Chassin - S Operative Strategy in General Surgery - An Expositive Atlas (2022)

Chassin’s
Operative
Strategy in
General
Surgery
an expositive atlas
Fifth edition
Carol E. H. Scott-Conner
Andreas M. Kaiser · Ninh T. Nguyen
Umut Sarpel · Sonia L. Sugg
Chassin’s Operative Strategy in General Surgery
Carol E. H. Scott-Conner • Andreas M. Kaiser
Ninh T. Nguyen • Umut Sarpel • Sonia L. Sugg
Editors
Chassin’s Operative Strategy

in General Surgery
An Expositive Atlas
Fifth Edition
Editors
Carol E. H. Scott-Conner Andreas M. Kaiser
Department of Surgery Department of Surgery
University of Iowa Carver College of Medicine Division of Colorectal Surgery
Iowa City, IA, USA City of Hope National Medical Center/
Comprehensive Cancer Center
Ninh T. Nguyen Duarte, CA, USA
Department of Surgery
University of California, Irvine Umut Sarpel
Orange, CA, USA Division of Surgical Oncology
Icahn School of Medicine at Mount Sinai
Sonia L. Sugg New York, NY, USA
Department of Surgery
University of Iowa Carver College of Medicine
Iowa City, IA, USA
ISBN 978-3-030-81414-4 ISBN 978-3-030-81415-1 (eBook)

https://doi.org/10.1007/978-3-030-81415-1
© Springer Nature Switzerland AG 2014, 2022

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For surgery residents everywhere
Umut Sarpel
Foreword to the Third Edition
Eight years have passed since the publication of the second edition of this atlas. During that
period, I retired from the practice of surgery and from the chairmanship of the Department of
Surgery at the New York Hospital Medical Center of Queens, concluding an exciting and stim-
ulating run of 34 years, the highlight of which was teaching several generations of residents the
intellectual and technical details of surgery. A vital component of this program was the atlas
Operative Strategy in General Surgery, the first edition of which was published in 1980. The
success of this work was due in large part to the fact that it was based on my day-to-day learn-
ing and teaching in the operating room. Having retired from the operating room, I felt that I
could not produce a quality, up-to-date product for the third edition of this work. Fortunately,
we were able to recruit an outstanding surgeon-teacher to edit the third edition.
Dr. Carol Scott-Conner, whom I taught when she was a resident in 1980, has the intellect,
teaching skills, and drive to have functioned as an author, surgeon, teacher, and Head of the
Department of Surgery at the University of Iowa. In editing this volume, she has reviewed each
chapter to make sure that the text and references are up to date. Although the previous editions
were the work of a single author (me), it is a fact that surgery and medical science have
advanced so rapidly that it is no longer feasible for a single author to write a comprehensive
surgical text like this one. Consequently, 13 prominent surgeons have each contributed a chap-
ter that reviews and analyzes recent advances in the fields of the contributor’s special expertise.
Eight new operations have been added, most of which are laparoscopic procedures. In addi-
tion, 77 operations from my last edition, having proven themselves worthy by the test of time,
are included in this volume, together with the meticulous operating room illustrations by
Caspar Henselmann. Many of these procedures are complex, such as esophagectomy, total
colectomy with ileoanal pouch, and pancreatoduodenectomy. Special attention has been paid
to emphasize in the drawings the detailed teaching points that will make these operations safe
for the patient.
I hope that our combined efforts have produced an atlas that you will find useful.
New York, NY, USA Jameson L. Chassin, MD
vii
Preface to the Fifth Edition
The year was 1979. I was a fourth-year surgical resident at New York University, sent for a
2-month rotation to the (then) Booth Memorial Medical Center. Many university programs
have a similar rotation: residents are sent to an outlying affiliated hospital for a couple of
months of intensive bread-and-butter surgery and an experience of what life is like in the real
world of private practice. Jim Chassin, his associates Jim Turner and Kenny Rifkind, and the
Booth Memorial residents welcomed me and shared their busy surgical practice with me. My
notes from the time indicate I scrubbed on a wide variety of cases, many with Jim Chassin. The
procedures were the very operations described in this text, and I hear his voice coaching me as
I read his words.
Surgical staplers were just coming into common use that year. My university program had
not yet adopted these devices, reasoning that residents need to learn how to suture before using
staplers. Thus, it was from Jim Chassin that I learned how to do a low anterior resection with
a circular stapled anastomosis. He reinforced his instructions with copies of the typed manu-
scripts of the relevant chapters from a book he was writing, complete with rough sketches by
his artist. When the first volume of the first edition of Chassin’s Operative Strategy in General
Surgery came out, I bought it and literally wore out my copy. The second volume followed in
due course, and eventually a second edition. I recommended the book to untold numbers of
residents.
It was thus with a sense of the circle coming around to full closure that I undertook the
editorship of the third edition upon Dr. Chassin’s retirement from that role. Searching through
my files, I found original manuscript copies with my handwritten notes from that 1979
rotation.
Eighteen years have now passed since that third edition was published. A fourth edition fol-
lowed, and now I am proud to release the fifth edition.
This fifth edition is a major revision that strives to remain faithful to the purpose and tone
of Dr. Chassin’s original text. Four section editors—Andreas M. Kaiser, MD; Ninh T. Nguyen,
MD; Umut Sarpel, MD; and Sonia Sugg, MD—have brought specialized expertise to appropri-
ate parts. All of the art is new, created specifically for this edition. Color is used throughout,
and color photographs have been added.
The purpose of this volume remains, as it was so eloquently stated by Frank C. Spencer,
MD, in the foreword to the first edition, to serve “all clinical surgeons, both those in training
and those in surgical practice” by “specifically discussing the conceptual basis of the operation
as well as the strategy that will help the surgeon avoid common pitfalls … the operative tech-
nique is then described step by step.”
As an academic surgeon, I am struck by how frequently a resident will comment “I’ve never
even seen one of these” when we embark upon certain formerly common operations, such as
an open common bile duct exploration. For this new generation of surgeons, I’ve included
most of the procedures that were in previous editions. Those that are rarely used are labeled
Surgical Legacy Technique, for that is what this book is—the legacy of a master surgeon: an
extraordinary surgeon and a kind and gentle man I have been privileged to scrub with and to
have as a friend. I hope that you will still hear his voice speaking through these pages.
ix
x Preface to the Fifth Edition
This work could not have been completed without the wise counsel of Richard Hruska, my
editor; the skilled assistance of Margaret Burns, developmental editor; and the loving support
of my husband, Dr. Harry Conner. My patients, students, residents, and coworkers continue to
teach and inspire me.
Iowa City, IA, USA Carol E. H. Scott-Conner, MD, PhD

Contents
Part I General Principles

Andreas M. Kaiser
1 Concepts and Strategies of Surgery �� 3

Andreas M. Kaiser and Carol E. H. Scott-Conner
Developing a Concept�� 3
Establishing Strategy �� 4
Making the Operation Easy �� 4
Further Reading �� 5
2 Mechanical Basics of Operative Technique �� 7
Constantine P. Spanos and Carol E. H. Scott-Conner
Introduction�� 7
Before You Scrub �� 7
Preoperative Verification Process�� 8
Importance of Surgeon’s Foot and Body Position �� 8
Use of Instruments �� 11
Scalpel�� 11
Metzenbaum Scissors�� 12
Electrocautery as a Cutting Device�� 12
Forceps�� 12
Needle Holder�� 12
Hemostat�� 13
3 Incision, Exposure, Closure�� 15
Constantine P. Spanos, Andreas M. Kaiser, and Carol E. H. Scott-Conner
Achieving Exposure�� 15
Incisions for Abdominal Surgery �� 16
Avoiding Wound Dehiscence and Hernia�� 17
Operative Technique for a Midline Incision�� 18
Making the Incision �� 18
Open Surgery �� 18
Port Insertion During Laparoscopic Surgery �� 19
Closure of Midline Incision �� 20
Modified Smead-Jones Technique �� 20
Standard Running Closure �� 20
Interrupted Closure�� 20
Skin Closure�� 20
xi
xii Contents
4 Dissecting and Suturing�� 23

Constantine P. Spanos, Andreas M. Kaiser, and Carol E. H. Scott-Conner
Art of Dissecting Planes�� 23
Sewing Technique�� 24
Use of a Needle Holder�� 24
Selection of Needle�� 24
Size of Bite�� 24
Distance Between Sutures�� 25
Size of Suture Material�� 25
Continuous Versus Interrupted Sutures�� 25
How Tight the Knot?�� 25
Catching Both Walls of Intestine with One Pass of the Needle Holder�� 25
Types of Stitches�� 26
Simple Everting Skin Stitch�� 26
Vertical Mattress (Stewart) Stitch�� 26
Continuous Subcuticular Stitch�� 27
Skin Staples�� 27
Simple Interrupted Fascial Stitch�� 27
Continuous Simple Over-and-Over Stitch �� 28
Smead-Jones Stitch�� 28
Horizontal Mattress Stitch �� 28
Hemostatic Figure-of-Eight Stitch�� 29
Single-Layer Bowel Anastomosis�� 29
Seromuscular Lembert Stitch�� 29
Cushing Stitch�� 29
Halsted Stitch �� 30
Continuous Locked Stitch�� 30
Connell Stitch�� 30
Technique of Successive Bisection�� 31
Intestinal Anastomoses�� 31
One Layer or Two?�� 31
End-to-End or End-to-Side Technique?�� 31
Sutured or Stapled Anastomosis?�� 32
Suture Material�� 32
Absorbable Sutures�� 32
Plain Catgut�� 32
Chromic Catgut�� 32
Polyglycolic Synthetics�� 32
Nonabsorbable Sutures�� 33
Natural Nonabsorbable Sutures �� 33
Synthetic Nonabsorbable Braided Sutures�� 33
Synthetic Nonabsorbable Monofilaments�� 33
Monofilament Stainless Steel Wire�� 33
Knot-Tying Technique �� 33
5 Surgical Stapling: Principles and Precautions�� 37
Erik R. Noren and Sang W. Lee
Characteristics of Staples�� 37
Surgical Stapling Technology�� 37
Linear Stapling Device�� 37
Linear Cutting Stapling Device�� 37
Circular Stapling Device�� 39
Contents xiii
Tissue Properties of the Stapled Anastomosis �� 39

Causes of Failure Following Stapled Anastomosis�� 40
Ischemia �� 40
Tension�� 40
Tissue Quality�� 40
Instrument Failure�� 40
Technical Error�� 40
Microbiology�� 41
Patient Factors�� 41
Stapled vs. Hand-Sewn Anastomosis�� 41
Reducing Anastomotic Complications in Practice�� 41
Hemostasis �� 41
Intraoperative Leak Testing�� 42
Perfusion Testing�� 42
Summary�� 42
6 Control of Bleeding�� 43
Morgan Schellenberg and Kenji Inaba
General Principles of Resuscitation �� 43
Control of Hemorrhage�� 43
Thoracic Hemorrhage�� 43
Upper Mediastinum and Pulmonary Hilum�� 43
Lung Parenchymal Injuries�� 44
Abdominal Hemorrhage�� 44
Abdominal Aorta, IVC, and Their Branches�� 44
Zones of the Retroperitoneum �� 44
Medial Visceral Rotations�� 45
Solid Abdominal Viscera�� 45
Spleen and Kidney �� 45
Liver �� 45
Pelvic Hemorrhage�� 46
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)�� 46
Extremity and Junctional Hemorrhage�� 47
Techniques to Achieve Hemostasis�� 47
Hemostat and Ligature�� 47
Tying in Continuity�� 47
Suture Ligation�� 47
Clips �� 47
Staplers�� 48
Electrocautery�� 49
Ultrasonic Shears �� 50
7 Management of the Contaminated Operation�� 51
Rahila Essani, Donald C. LaSeur, and Andreas M. Kaiser
The Challenge�� 51
Preoperative Considerations�� 52
Timing of Surgery�� 52
Resuscitation Before Surgery�� 52
Antibiotic Management �� 52
Preoperative Imaging �� 52
Intraoperative Considerations�� 53
Supportive Measures and Fluid Management�� 53
xiv Contents
Importance of Surgical Skills and Technique�� 53

Source Control �� 53
Containing the Contamination �� 54
Wound Irrigation�� 54
Other Considerations �� 54
Postoperative Considerations�� 55
Wound Closure�� 55
Wound Care�� 55
8 Damage Control Laparotomy �� 57
James M. Bardes and Kenji Inaba
Indications�� 57
Damage Control Strategy and Decision-Making �� 57
Damage Control Laparotomy in Trauma �� 57
Damage Control Management of Selected Injuries �� 58
Damage Control in Nontrauma�� 60
Temporary Closure of the Open Abdomen�� 60
Postoperative Management and Return to the Operating Room�� 61
9 Mechanical Basics of Laparoscopic Surgery �� 63
Sarah M. Popek and Zoë O. Jones
Ergonomics and Operating Room Design �� 63
Equipment�� 63
Setup and Trouble Shooting�� 65
Access to Abdomen�� 65
Laparoscopic Hemostasis and Energy Sources�� 67
Hemostatic Products and Adjuncts�� 67
Tissue Approximation�� 68
Pitfalls and Danger Points�� 70
Access Injuries �� 70
Hypotension �� 71
Hemorrhage�� 72
Hypoxia�� 72
Postoperative Bowel Obstruction�� 72
Laparoscopy in Pregnancy �� 73
Preoperative Considerations�� 73
Intraoperative Considerations�� 73
Laparoscopy in Previous Abdominal Surgery�� 73
10 Rational Use of Drains�� 77
Kulmeet K. Sandhu
Purpose of Drains�� 77
Various Drains and Their Pros and Cons �� 77
Penrose Drain�� 77
Polyethylene or Rubber Tube Drain�� 77
Silicone Tube Drain �� 78
Sump Suction Drains �� 78
Closed Suction Drain �� 78
Gauze Packing �� 78
Prevention of Drainage Tract Infection�� 78
Management of Intraperitoneal Sepsis�� 79
Contents xv
Percutaneous Drainage of Abdominal Abscesses with Computed Tomography

or Ultrasound Guidance �� 79
Negative Pressure Wound Therapy (NPWT) �� 79
Other Indications and Methods of Drainage�� 79
Abscess�� 79
Blood and Serum�� 79
Bile�� 80
Pancreatic Secretions �� 80
Anastomosis�� 80
11 Illustrated Glossary of Surgical Instruments�� 81
Erik R. Noren and Andreas M. Kaiser
12 Surgical Documentation, Informed Consent, and Operative Note�� 89
Andreas M. Kaiser
Defining Value of Documentation�� 89
Elements of Surgical Documentation�� 89
Provider Chart Entry�� 89
Informed Written Consent �� 89
Operative Note �� 90
Operative Note �� 90
Teaching Documentation �� 91
References�� 91
Part II Esophagus
Ninh T. Nguyen
13 Concepts in Esophageal Surgery�� 95

Olugbenga T. Okusanya and James D. Luketich
Gastroesophageal Reflux Disease and Type I Paraesophageal Hernia�� 95
Anti-reflux Operations �� 96
Wrap Choice�� 97
Alternatives to Traditional Surgery�� 97
Paraesophageal Hiatus Hernia �� 98
Achalasia�� 99
Esophageal Perforation�� 101
Esophageal Diverticulum�� 102
Cricopharyngeal Diverticulum�� 103
Epiphrenic Diverticulum�� 104
Barrett’s Esophagus �� 105
Workup of Esophageal Cancer�� 105
Esophagectomy�� 106
Choice of Esophagectomy Technique�� 107
Anastomotic Leakage�� 108
References�� 109
14 Laparoscopic and Thoracoscopic Ivor Lewis Esophagectomy�� 115
Simon R. Turner, Daniela Molena, and Virginia R. Litle
Preoperative Preparation�� 115
Abdominal Phase �� 116
Thoracic Phase �� 116
xvi Contents
Documentation�� 116
Operative Strategy�� 116
Abdominal Tumor Dissection, Lymphadenectomy,
and Mobilization of the Gastric Conduit �� 116
Abdominal Adjunct Procedures �� 116
Thoracic Resection�� 116
Thoracic Anastomosis�� 117
Operative Technique�� 117
Position and Incisions for the Abdominal Phase�� 117
Laparoscopic Lymphadenectomy and Gastric Mobilization �� 117
Pyloric Drainage and Feeding Jejunostomy�� 118
Transhiatal Dissection and Creation of the Gastric Conduit�� 119
Positioning for the Thoracic Phase�� 119
Thoracoscopic Dissection�� 120
Esophagogastric Anastomosis�� 120
Postoperative Care �� 122
Complications�� 122
Anastomotic Leak�� 122
Tracheoesophageal Fistula (TEF)�� 122
Conduit Necrosis�� 123
Chylothorax�� 123
Paraconduit Herniation�� 123
Cardiopulmonary Complications �� 123
Avoiding Postoperative Complications�� 123
Anastomotic Leak and Stricture�� 123
Tracheoesophageal Fistula (TEF)�� 124
Thoracic Duct Injury�� 124
Paraconduit Herniation�� 124
Pyloric Complications�� 124
15 Transhiatal Esophagectomy�� 127
Arjun Pennathur, Peter F. Ferson, and Rodney Landreneau
Patient Selection�� 127
Contraindications �� 128
Pitfalls�� 128
Patient Preparation and Initial Steps�� 129
Abdominal Phase: Laparoscopy/Laparotomy�� 130
Cervical Phase�� 131
Transhiatal Mediastinal Dissection�� 131
Preparation of the Gastric Conduit and Transposition to the Neck �� 132
Cervical Esophagogastric Anastomosis �� 134
Handsewn Anastomosis �� 134
Construction of Anastomosis with an EEA Stapler �� 134
Contents xvii
Total Mechanical Stapling with Modified Collard Technique �� 135

Hybrid Stapling Approach �� 135
Hemorrhage�� 137
Tracheal Tear�� 137
Pleural Complications�� 137
Chylothorax�� 137
Nerve Injury �� 137
Anastomotic Leaks�� 138
Splenectomy�� 138
16 Laparoscopic Heller Myotomy for Achalasia�� 141
Jeffrey E. Quigley and Keith R. Scharf
Workup�� 141
Preoperative Nutrition and Optimization�� 141
Pitfalls and Dangers �� 141
Pseudoachalasia �� 141
Incomplete Myotomy�� 141
Bleeding �� 141
Esophageal Perforation�� 141
Vagal Injury�� 142
Gastroesophageal Reflux �� 142
Division of the Short Gastric Vessels and Mobilization of the Fundus �� 142
Mobilization of the Esophagus and Removal of the Esophageal Fat Pad�� 142
Esophageal Myotomy Down to the Submucosal Layer Carried
Down onto the Gastric Cardia�� 142
Anti-reflux Procedure�� 142
17 Endoscopic Stent for Management of Esophageal Leaks�� 147
Eugene Kahn and Shaun Daly
Preoperative Assessment�� 147
Length and Diameter�� 148
Shape�� 148
Material�� 148
Coating�� 148
Positioning �� 148
Antibiotics�� 148
Documentation Basics �� 149
xviii Contents
18 Laparoscopic Nissen Fundoplication for Gastroesophageal

Reflux Disease�� 151
Michael N. Tran and Marcelo W. Hinojosa
Room Setup, Trocar Placement, and Exposure of the Hiatus�� 152
Dissecting the Hiatus �� 153
Mobilizing the Esophagus�� 155
Closure of the Hiatus �� 155
Construction of the Fundoplication �� 155
19 Laparoscopic Magnetic Augmentation of the Lower Esophageal Sphincter�� 159
James M. Tatum and John C. Lipham
Room Setup and Trocar Placement�� 160
Exposure of the Hiatus�� 160
Dissecting the Hiatus �� 160
Closure of the Hiatus �� 161
Identification and Dissection of the Posterior Nerve �� 161
Sizing of the LINX Device�� 161
Placing and Securing the Linx Device�� 162
Closure �� 162
Postoperative Complications�� 162
20 Laparoscopic Paraesophageal Hernia Repair�� 165
Nabeel R. Obeid and Aurora D. Pryor
Reduction/Dissection �� 166
Diaphragmatic Repair�� 167
Reconstruction �� 167
Short-Term Complications�� 170
Bleeding �� 170
Abscesses �� 170
Contents xix
Pneumothorax�� 170
Cardiac Arrhythmias�� 170
Long-Term Complications �� 170
Dysphagia�� 170
Recurrence �� 170
Gastroparesis�� 170
21 Laparoscopic Collis Gastroplasty�� 173
Mohan K. Mallipeddi and Miguel A. Burch
22 Endoscopic Antireflux Procedures �� 177
Jason Samarasena, David Lee, and Kenneth Chang
Nonablative Radiofrequency Therapy (Stretta) �� 177
Transoral Incisionless Fundoplication (TIF)�� 178
23 Peroral Endoscopic Myotomy for Achalasia �� 183
Paul D. Colavita and Kevin M. Reavis
Mucosal Injuries and Tears of the Mucosotomy�� 184
Endoscopic Measurements�� 185
Submucosal Tunnel�� 185
Circular Myotomy�� 186
Mucosotomy Closure �� 186
Gastroesophageal Reflux Disease (GERD) �� 187
xx Contents
Part III Stomach and Duodenum

Ninh T. Nguyen and Umut Sarpel
24 Concepts in Surgery of the Stomach and Duodenum�� 191

Sean P. Harbison and Daniel T. Dempsey
Operation for Morbid Obesity �� 191
Operation for Gastric Cancer �� 192
Subtotal Versus Total Gastrectomy�� 192
Extent of Lymphadenectomy �� 193
EUS and Diagnostic Laparoscopy �� 193
Laparoscopic Gastrectomy�� 193
Gastrointestinal Stromal Tumors (GISTs) �� 193
Surgery for Peptic Ulcer�� 194
Operation for Perforated Peptic Ulcer �� 194
The Role of Vagotomy in Peptic Ulcer Surgery�� 195
The Choice of Drainage Operation�� 196
The Role of Resection in Peptic Ulcer Surgery �� 196
Reconstruction after Distal Gastrectomy �� 196
Billroth I Versus Billroth II�� 196
Billroth II Versus Roux-En-Y�� 196
Other Reconstruction Options�� 197
Operation for Obstructing Peptic Ulcer �� 197
Operation for Bleeding Peptic Ulcer�� 197
Operation for Nonhealing Peptic Ulcer �� 197
Operation for Postoperative Recurrent Ulcer or Marginal Ulcer�� 198
Gastrostomy and Duodenostomy�� 199
Gastrostomy �� 199
Duodenostomy �� 199
Stapling the Stomach and Duodenum�� 199
Pulmonary Problems�� 200
Anastomotic Leak�� 200
Wound Problems�� 200
Pancreatitis�� 201
Early Gastric Stasis�� 201
Dumping Syndrome �� 201
Diarrhea�� 201
Bile Reflux Gastritis�� 202
Chronic Gastric Stasis and Roux Syndrome�� 202
Metabolic Problems after Gastric Operation �� 203
25 Truncal Vagotomy: Surgical Legacy Technique�� 207
Avoiding Esophageal Trauma�� 207
Avoiding Splenic Trauma�� 207
Preventing Incomplete Vagotomy�� 207
Hiatus Hernia �� 209
Contents xxi

Incision and Exposure�� 209
Left (Anterior) Vagal Trunks�� 209
Identification of the Right (Posterior) Vagus �� 209
Suture of Crural Musculature�� 210
26 Proximal Gastric Vagotomy: Surgical Legacy Technique�� 211
Exposure�� 211
Prevention of Hematoma and Injury to Gastric Lesser Curve �� 211
Preserving Innervation of the Antrum�� 211
Adequacy of Proximal Vagotomy�� 211
Postoperative Gastroesophageal Reflux�� 212
Identification of Right and Left Vagal Trunks�� 212
Identification of Crow’s Foot �� 212
Dissection of the Anterior Nerve of Latarjet�� 213
Dissection of Posterior Nerve of Latarjet�� 214
Repair of the Lesser Curvature�� 214
27 Pyloroplasty (Heineke-Mikulicz and Finney), Operation
for Bleeding Duodenal Ulcer: Surgical Legacy Technique�� 217
Control of Bleeding�� 217
Choice of Pyloroplasty�� 217
Kocher Maneuver�� 218
Pyloroduodenal Incision for Heineke-Mikulicz Pyloroplasty �� 218
Emergency Procedure for Bleeding Ulcer �� 218
Heineke-Mikulicz Pyloroplasty �� 219
Stapling�� 219
Finney Pyloroplasty �� 221
Reversal of Pyloroplasty or Gastrojejunostomy�� 222
xxii Contents
28 Gastrojejunostomy�� 223
Malini D. Sur
Operative Technique: Open�� 224
Incision�� 224
Freeing the Greater Curvature�� 224
Preparing the Jejunal Limb�� 224
Open Handsewn Technique�� 224
Open Stapled Technique�� 225
Operative Technique: Laparoscopic�� 226
Access�� 226
Preparation of the Jejunal Limb�� 226
Gastrojejunal Anastomosis: Laparoscopic Stapled Technique�� 226
29 Partial Gastrectomy�� 229
Ashley E. Russo, Carol E. H. Scott-Conner, and Vivian E. Strong
Type of Resection�� 229
Choice of Reconstruction�� 230
Duodenal Stump Leak�� 230
Splenic Trauma�� 230
Gastric Wedge Resection �� 230
Minimally Invasive Wedge Resection�� 230
Equipment�� 230
Laparoscopic Setup and Positioning�� 231
Operative Steps�� 231
Entry and Port Placement�� 231
Tumor Localization and Entry into Lesser Sac�� 231
Tumor Mobilization and Resection, Specimen Extraction, and Closure �� 231
Robotic Gastric Wedge Resection�� 231
Open Wedge Resection�� 234
Intragastric Resection�� 234
Distal Gastrectomy with Billroth I or II Reconstruction �� 234
Open Distal Gastrectomy�� 234
Division of Left Gastric Vessels�� 235
Division of Stomach�� 236
Duodenal Dissection�� 236
Division of Duodenum�� 236
Billroth I Gastroduodenal Anastomosis �� 236
Billroth II: Closure of Duodenal Stump�� 239
Duodenal Closure with Surgical Staples�� 239
Contents xxiii
Billroth II Gastrojejunal Anastomosis, Handsewn�� 240

Billroth II Gastrojejunal Anastomosis, Stapled �� 241
Drainage and Closure�� 245
Duodenal Fistula�� 245
Gastric Outlet Obstruction �� 245
Afferent Loop Obstruction and Afferent Loop Syndrome�� 245
Dumping Syndrome �� 245
Marginal Ulcer �� 245
30 Perforated Duodenal Ulcer�� 247
Sharmila Dissanaike and Carol E. H. Scott-Conner
Perforated Duodenal Ulcer�� 247
Incision�� 248
Identification of Perforation�� 248
Patch Repair of Perforation�� 248
Abdominal Closure�� 248
31 Laparoscopic Plication of Perforated Duodenal Ulcer �� 251
Edwin Onkendi
Potential Pitfalls and Dangers Points�� 251
Documentation Tips �� 251
Securing the Omental Patch�� 253
Omental Onlay Patch after Primary Closure�� 253
Omental Plug Technique�� 253
Omental Radial Patch Technique �� 253
Testing the Integrity and Security of the Perfortion Repair �� 253
Role of EGD�� 254
32 Enteral Access�� 255
Mariela Rivera and Henry Schiller
Percutaneous Gastrostomy�� 255
Surgical Gastrostomy�� 255
Jejunostomy �� 255
xxiv Contents

Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement �� 256
Stamm Gastrostomy�� 257
Witzel Jejunostomy�� 259
33 Distal Gastrectomy with D2 Nodal Dissection�� 261
Hisakazu Hoshi
Extent of Resection�� 261
Pancreatico-Splenectomy, Splenectomy�� 263
Blood Supply to Residual Gastric Pouch�� 263
Duct of Santorini�� 265
Resection�� 265
Omentectomy and Infrapyloric Nodal Dissection �� 265
Dissection of Suprapyloric Nodes �� 265
Division of the Duodenum�� 266
Hepatic Artery Node Dissection�� 266
Celiac Axis Dissection and Division of Left Gastric Vessels�� 266
34 Total Gastrectomy�� 269
Hisakazu Hoshi
Exposure�� 269
Esophageal Anastomosis�� 269
Prevention of Reflux Alkaline Esophagitis�� 270
Extent of the Operation�� 270
Exploration and Determination of Operability�� 270
Omentectomy, Lymph Node Dissection, and Division of Duodenum�� 271
Splenic Nodal Dissection without Splenectomy�� 271
Dissection of the Esophagocardiac Junction: Vagotomy �� 271
Preparation of the Roux-En-Y Jejunal Segment�� 272
End-to-Side Sutured Esophagojejunostomy�� 272
End-to-Side Stapled Esophagojejunostomy�� 273
Roux-En-Y Jejunojejunostomy�� 274
Sutured Version�� 274
Stapled Version�� 276
Modifications of Operative Technique for Patients with Benign Disease �� 276
Contents xxv

35 Management of Gastrointestinal Stromal Tumor of the Stomach�� 279
Eugene J. Won and Brian R. Smith
Preoperative Preparation. �� 279
Operative Strategy and Management �� 279
Operative Strategy and Technique �� 281
Laparoscopic Wedge Resection �� 281
36 Exposure of the Third and Fourth Portions of the Duodenum�� 283
Natasha Leigh and Benjamin Golas
Incision�� 284
Liberation of Right Colon�� 284
Liberation of Small Bowel Mesentery �� 284
Intraoperative Endoscopy�� 284
Resection of Duodenum�� 284
Closure �� 285
Minimally Invasive Approach�� 285
37 Laparoscopic Sleeve Gastrectomy�� 287
John Morton and Jamie Dutton
Relative Contraindications�� 287
Preoperative Optimization to Enhance Effectiveness
and Decrease Complications�� 287
Avoiding Operative Bleeding�� 288
Avoiding Postoperative Stenosis and Leak�� 288
Positioning and Port Placement �� 288
Mobilization of the Stomach�� 289
Creation of the Sleeve�� 289
xxvi Contents
Leak Test�� 289

38 Laparoscopic Roux-en-Y Gastric Bypass�� 291
Katherine M. Meister and Stacy A. Brethauer
Preoperative Examination�� 291
Trocar Placement �� 292
Division of the Jejunum and Creation of Jejunojejunostomy�� 292
Creation of the Gastric Pouch�� 294
Creation of the Gastrojejunostomy�� 295
Avoiding Complications�� 296
Late Complications�� 296
39 Laparoscopic Reoperative Bariatric Surgery�� 299
Giulio Giambartolomei, Emanuele Lo Menzo, Samuel Szomstein,
and Raul J. Rosenthal
Abdominal Entry and Initial Exposure�� 300
Adhesiolysis�� 300
Left Liver Lobe Mobilization�� 301
Diaphragmatic Hiatus Exposure�� 301
Operative Technique (Step by Step)�� 301
Patient Positioning and Trocar Placement �� 301
Exploration�� 301
Critical Anatomy Exposure�� 302
Gastroesophageal Junction Mobilization�� 302
Types of Reoperations�� 303
40 Endoscopic Intragastric Balloon�� 307
Camila B. Ortega, Alfredo D. Guerron, and Dana Portenier
Contents xxvii
Placement�� 308
Diagnostic Endoscopy �� 308
Insertion of the Uninflated Balloon�� 308
Confirmatory Endoscopy �� 308
Balloon Filling �� 308
Endoscopic Reevaluation �� 309
Removal �� 309
Diagnostic Endoscopy �� 309
Balloon Deflation �� 309
Removal of the Balloon System�� 309
Minor Complications �� 310
Major Complications �� 310
Part IV Small Intestine and Appendix

Andreas M. Kaiser
41 Concepts in Surgery of the Small Intestine and Appendix�� 313

Naelly Saldana Ruiz and Andreas M. Kaiser
Diagnostics�� 313
Nonsurgical Treatments �� 314
Surgical Tools�� 314
Perioperative Management�� 314
Diseases�� 315
Small Bowel Obstruction �� 315
Small Bowel Tumors�� 315
Crohn’s Disease �� 316
Appendicitis �� 317
Small Bowel Diverticula�� 317
Mesenteric Ischemia�� 317
Gastrointestinal Bleeding from Small Bowel�� 318
Trauma �� 318
42 Small Bowel Resection and Anastomosis �� 321
Open Versus Laparoscopic Technique �� 322
Successful Bowel Anastomosis Requirements�� 322
Contraindications to Anastomosis�� 323
Small Bowel Anastomosis by Suturing�� 323
Access and Incision�� 323
Division of Mesentery and Bowel Resection�� 323
Open Two-Layer Anastomosis�� 323
xxviii Contents
Open One-Layer Anastomosis �� 326

Closure of Mesentery�� 326
Small Bowel Anastomosis Using Stapling Technique �� 326
43 Enterolysis for Intestinal Obstruction�� 329
Open Versus Laparoscopic Technique �� 329
Timing of Intervention �� 330
Dissection�� 330
Bowel Decompression �� 330
Adhesion Prevention�� 330
Access, Incision, and Bowel Mobilization�� 330
Approach to Dense Adhesions �� 331
Early Re-laparotomy�� 332
Operative Intestinal Decompression�� 332
Repair of Damage to Bowel Wall�� 333
Closure �� 333
44 Baker Tube Stitchless Plication: Surgical Legacy Technique�� 335
45 Appendectomy (Open, Laparoscopic)�� 337
Matthew Zelhart and Andreas M. Kaiser
Possible Indications �� 337
Laparoscopic Appendectomy�� 338
Contents xxix

Creating a Window�� 340
Division of the Meso-appendix�� 340
Division of Appendix Base�� 341
Specimen Removal�� 341
Management of the Retrocecal Appendix�� 342
Closure �� 343
Open Appendectomy�� 343
Incision�� 343
Delivery of Appendix�� 344
Division of Meso-Appendix�� 344
Division of Appendix and Ligation/Inversion of Appendiceal Stump�� 344
Closure of Incision�� 346
46 Management of Appendicostomy for Malone Antegrade
Continence Enema (MACE)�� 349
Abigail K. Zamora and Andreas M. Kaiser
Primary Indication for MACE Procedure�� 349
Indications for Secondary MACE Management�� 349
Evaluation and Preparation�� 350
Decision-Making�� 350
Definition of Access�� 350
Closure of Appendicostomy�� 351
Preoperative Marking�� 351
Anesthesia and Positioning�� 351
General Considerations�� 351
MACE Creation: Open Approach�� 351
MACE Creation: Laparoscopic Approach �� 352
ACE Creation in Absence of Appendix �� 352
Revision for Appendicostomy Stricture�� 352
Appendicostomy Takedown�� 352
47 Management of Enterocutaneous and Enteroatmospheric Fistulas �� 355
Kazuhide Matsushima and Demetrios Demetriades
Definitions and Classifications�� 355
Delineate Fistula Anatomy and Manage Any Intra-abdominal Infections�� 355
Reduce and Divert Fistula Output�� 355
Optimize Metabolic and Nutritional Status �� 357
xxx Contents

Anesthesia, Positioning, and Instruments�� 358
Incision and Entering the Abdominal Cavity�� 358
Abdominal Exploration, Adhesiolysis, and Resection of Enteric Fistulas�� 359
Abdominal Wall Closure�� 359
48 Stricturoplasty in Crohn’s Disease �� 361
Gregory K. Low and Andreas M. Kaiser
Access and Exploration�� 362
Heineke-Mikulicz Stricturoplasty�� 362
Finney Stricturoplasty�� 362
Isoperistaltic Side-to-Side Stricturoplasty �� 363
Wound Closure and Reconstruction�� 365
49 Placement of Feeding Tube Jejunostomy�� 367
Kulmeet K. Sandhu
Mobilization of the Small Bowel and Purse-String Placement�� 367
Feeding Tube Placement and Securing the Jejunum to the Abdominal Wall�� 367
Open Placement of Feeding Jejunostomy Tube�� 368
Laparoscopic Placement of Feeding Jejunostomy Tube�� 369
50 Creation of Ileostomy (Loop, End)�� 373
Marjun P. Duldulao and Andreas M. Kaiser
Choice of Procedure and Site�� 374
Access�� 374
Proper Ileostomy Configuration�� 374
Contents xxxi

End Ileostomy Creation �� 375
Preoperative Selection of Ileostomy Site �� 375
Incision and Creation of a Passage�� 375
Fashioning the Ileal Mesentery�� 377
Exteriorization and Closure of Mesenteric Gap�� 377
“Brooking” the Ileostomy (Eversion and Mucocutaneous Fixation)�� 377
Loop Ileostomy Creation �� 377
Incision and Creation of a Passage�� 377
Exteriorization and Proper Orientation�� 377
“Brooking” of the Afferent Limb�� 378
51 Closure of Loop Ileostomy�� 381
Incision�� 382
Fascial Dissection�� 383
Peritoneal Dissection �� 383
Stapled Resection and Anastomosis of Ileostomy �� 383
Hand-Sewn Closure of Enterotomy �� 384
Closure of Abdominal Wall�� 384
Management of Skin Wound�� 385
52 Management of Problems Related to an Existing Continent Ileostomy �� 387
Difficult Stoma Intubation �� 389
Management During Non-related Surgeries or Incapacitation�� 389
Considerations for Unrelated Abdominal Surgery�� 389
Acute Pouch Surgery �� 389
Chronic Pouch Dysfunction�� 389
Endoscopic Pouch Decompression�� 390
Pouchoscopy�� 390
Pouch Revision�� 390
xxxii Contents
Part V Large Intestine

Andreas M. Kaiser
53 Concepts in Surgery of the Large Intestine �� 395

Andreas M. Kaiser
Diseases�� 398
Colorectal Polyps �� 398
Colorectal Cancer�� 399
Colon Cancer �� 400
Rectal Cancer �� 400
Hereditary Cancer Syndromes �� 402
Carcinomatosis�� 402
Colorectal Cancer Superimposed on Inflammatory Bowel Disease�� 402
Anal Cancer �� 403
Diverticulitis�� 403
Large Bowel Obstruction �� 404
Fistulization (Bladder, Vagina, Skin) �� 405
Lower GI Bleeding�� 406
Ischemia �� 406
Inflammatory Bowel Disease �� 406
Ulcerative Colitis �� 406
Crohn Disease�� 407
Indeterminate Colitis�� 407
C. difficile Colitis and Other Colitides�� 407
Volvulus �� 408
Pelvic Floor Dysfunction and Organ Prolapse�� 408
Stoma Creation and/or Takedown�� 409
54 Minimally Invasive Surgery (MIS) in Colorectal Surgery �� 413
Sarah M. Popek, Rodrigo Rodriguez, and Andreas M. Kaiser
Implementation and Benefits of MIS�� 413
How Is MIS Approach Different From Open Surgery? �� 413
Minimally Invasive Surgery (MIS) Platforms�� 414
Conventional Laparoscopic Surgery (CLS) �� 414
Hand-Assisted Laparoscopic Surgery (HALS)�� 415
Three-Dimensional Laparoscopic Surgery�� 416
Single Incision Laparoscopic Surgery (SILS) �� 416
Robotic Surgery �� 416
Strategies About Selection of the Surgical Approach�� 417
Challenges�� 418
Training Aspects�� 418
Conclusion �� 418
55 Endoscopic Techniques for Colorectal Lesions �� 421
Anna Skay and Jacques Van Dam
Contents xxxiii

Polyp Detection�� 421
Dye-Assisted Chromocolonoscopy�� 421
New Colonoscope Technology�� 422
Endoscopic Mucosal Resection �� 424
EMR Technique �� 424
Recurrent or Remaining Adenoma�� 424
Perforation�� 425
Tattoo Placement�� 425
Endoscopic Submucosal Dissection�� 425
Colonic Stent Placement�� 425
56 Right and Extended Right Hemicolectomy (Open, Laparoscopic) �� 427
Localization of Target Lesion�� 427
Surgical Approach�� 428
Extent of the Resection�� 428
Vascular Transection�� 428
Colon Mobilization�� 428
Colon Resection �� 428
Operative Approach and Incisions �� 431
Minimally Invasive Surgery�� 431
Open Approach�� 431
Identification of the Ureter�� 431
Division of the Ileocolic Vessels�� 433
Division of the Middle Colic Vessels�� 434
Mesentery and Omentum Roundup �� 434
Division of Ileum and Colon�� 435
Ileo-colonic Anastomosis�� 435
Hand-Sewn End-to-End �� 435
Stapled Functional End-to-End Anastomosis�� 436
Stapled Isoperistaltic Side-to-Side Anastomosis �� 438
xxxiv Contents
57 Sigmoid Resection and Left Hemicolectomy (Open, Laparoscopic) �� 443

The Difficult Reach�� 446
Technique of Anastomosis �� 446
Division of the Inferior Mesenteric Artery Pedicle�� 448
Medial to Lateral Approach �� 449
Lateral to Medial Approach �� 451
Splenic Flexure Mobilization�� 451
Division of the Middle Colic Vessels�� 452
Mesentery and Omentum Roundup �� 452
Division of the Bowel�� 452
Stapled End-to-End Anastomosis�� 453
Hand-Sewn End-to-End �� 455
Reversed Stapled Circular Stapler Anastomosis�� 455
58 Discontinuous Colon Resection (Hartmann Procedure)�� 459
Acute�� 459
Elective�� 459
Bowel Control and Decompression �� 460
Contents xxxv

Incision�� 461
Division of the Inferior Mesenteric Artery Pedicle�� 462
Division of Mesentery and Bowel�� 462
Hartmann’s Pouch Versus Mucous Fistula�� 462
End Colostomy�� 463
59 Total Mesorectal Excision/Low Anterior Resection (Open, Laparoscopic)�� 465
Kyle G. Cologne, Anthony J. Senagore, and Andreas M. Kaiser
Oncologic Extent of Resection�� 466
Mesorectal Dissection�� 467
Avoiding Collateral Damage�� 467
Prevention of Anastomotic Complications�� 468
Technique of Anastomosis �� 469
Indications for Diverting Stoma (Colostomy or Ileostomy)�� 469
Initial Colorectal Mobilization�� 471
Identification of the Ureters �� 472
Division of the Blood Supply (IMA Pedicle, Mesentery) �� 472
Proximal Bowel Transection�� 473
Splenic Flexure Mobilization�� 473
Pelvic and Presacral Dissection �� 473
Pelvic Hemostasis�� 475
Distal Rectal Transection �� 476
Irrigation of Rectal Stump �� 476
Double Stapled Anastomosis (Abdominal and Perineal Access)�� 476
Hand-Sewn Colo-anal Anastomosis (Perineal Access)�� 477
Reversed Stapled Circular Stapler Anastomosis (Abdominal Access)�� 477
xxxvi Contents
Variations of Colo-anal Anastomosis (To Improve Short-Term Function)�� 478

Pitfalls, Danger Points, and Troubleshooting Stapled Anastomoses �� 478
60 Abdominoperineal Resection (Open, Laparoscopic)�� 481
Kyle G. Cologne, Sean J. Langenfeld, and Andreas M. Kaiser
Extent of the Perineal Resection�� 482
Abdominal Phase �� 482
Colostomy�� 482
Perineal Dissection�� 482
Pelvic Defect Management�� 483
Abdominal Dissection and Colostomy Creation�� 484
Cylindrical Abdominoperineal Resection (Malignant)�� 485
Abdominal Part�� 485
Management of Pelvic Floor�� 487
Abdominoperineal Resection (Benign)�� 487
Abdominal Part�� 488
Closure of the Perineal Wound�� 488
Abdominal Wound Closure�� 488
Colostomy�� 489
61 Multivisceral Resections (Pelvic Exenteration)�� 491
Anesthesia and Patient Positioning�� 492
Operative Phases�� 492
Incision and Exploration�� 492
Peritoneal Incision and Identification of the Ureters �� 493
Contents xxxvii
Ligation of the Inferior Mesenteric Artery�� 493

Proximal Division of the Sigmoid Colon�� 493
Pelvic Dissection�� 493
Posterior Pelvic Dissection�� 493
Lateral Pelvic Sidewall Dissection�� 493
Anterior Dissection�� 494
Distal Transection Versus Abdomino-Perineal Resection�� 494
Harvest of VRAM Flap and Abdominal Wall Reconstruction�� 494
Urinary Reconstruction�� 494
Creation of Intestinal Stoma�� 495
Wound Closure and Reconstruction�� 495
62 (Sub-)Total Colectomy with Ileostomy or Ileo-Rectal
Anastomosis (Open, Laparoscopic)�� 497
Kyle G. Cologne, Theodor Asgeirsson, and Andreas M. Kaiser
Emergency �� 497
Staged�� 497
Elective�� 497
All�� 497
Elective�� 497
Emergency �� 498
General�� 498
Bowel Manipulation�� 498
Extent and Steps of the Resection�� 498
Anastomosis Versus Ileostomy�� 499
Evacuation of Stool�� 500
Mobilization and Resection �� 500
Total Colectomy�� 500
Distal Bowel Transection �� 501
Anastomosis Versus Ileostomy�� 502
Ileo-Rectal (Ileo-Sigmoid) Anastomosis�� 502
End Ileostomy�� 502
Ileostomy and Mucous Fistula �� 502
Drains�� 503
xxxviii Contents
63 Proctocolectomy with Ileal Pouch-Anal Anastomosis

(IPAA) or End Ileostomy (Open, Laparoscopic)�� 505
Kyle G. Cologne, Anthony J. Senagore, and Andreas M. Kaiser
Indications for Proctocolectomy�� 505
Contraindications for Pouch Creation�� 505
Extent and Steps of the Resection�� 506
Terminal Ileal Dissection �� 507
Rectal Dissection �� 507
Continence Factors�� 507
Constructing the Ileal Reservoir (Pouch)�� 508
Technique of Pouch-Anal Anastomosis �� 508
Indications for Diverting Ileostomy�� 508
Mobilization and Resection �� 509
Total Colectomy�� 509
Proctectomy �� 509
Constructing the Ileal Reservoir (J-Pouch)�� 510
Ileoanal Anastomosis �� 511
Pitfalls, Danger Points, and Troubleshooting Stapled Anastomoses �� 512
Loop Ileostomy�� 512
64 Cecostomy: Surgical Legacy Technique�� 515
Tube Cecostomy�� 516
Skin-Sutured Cecostomy �� 516
Incision�� 516
Exploration of Cecum�� 516
Cecal Fixation�� 516
Mucocutaneous Suture�� 516
Contents xxxix
65 Creation of Transverse Colostomy (Loop, Prasad-Type)�� 519

Constantine P. Spanos and Andreas M. Kaiser
Choice of Procedure�� 520
Access�� 520
Diversion of Fecal Stream�� 520
Incision�� 521
Identification and Exteriorizing of Transverse Colon�� 521
Choice of Bridge�� 522
Maturation of Colostomy�� 523
Prasad-Type Colostomy �� 523
66 Laparoscopic Versus Open Creation of Sigmoid Colostomy
(Loop, Prasad-Type, End) �� 525
Choice of Procedure and Site�� 526
Access�� 526
Type of Fecal Diversion �� 526
Incision, Identification, and Mobilization of the Sigmoid Colon�� 526
Open—Through Laparotomy�� 526
Open—Through Colostomy Site Only�� 527
Laparoscopic�� 527
Stoma Orientation�� 529
Abdominal Wall Reinforcement (Hernia Prevention)�� 529
Choice of Bridge�� 529
Maturation of Colostomy�� 529
Loop Colostomy�� 529
Prasad-Type Colostomy �� 529
End Colostomy�� 530
67 Closure of Temporary Loop Colostomy or Ileostomy�� 531
xl Contents

Incision�� 532
Fascial Dissection�� 532
Peritoneal Dissection �� 533
Strategies for the Difficult Dissection�� 533
Bowel Anastomosis�� 533
Resection with Stapled Side-to-Side (Functional End-to-End)
Simple Closure of Antimesenteric Bowel Wall Opening�� 534
Resection and End-to-End Anastomosis�� 535
Resection and Isoperistaltic Side-to-Side Anastomosis�� 535
Closure of Abdominal Wall�� 535
Management of Skin Wound�� 535
68 Hartmann Reversal (Open, Laparoscopic)�� 537
Kasim L. Mirza and Andreas M. Kaiser
Decision to Offer Hartmann Reversal�� 538
Choice of Approach: Open Versus Laparoscopic�� 538
Laparoscopic Access�� 539
Open Access�� 539
Colonic Mobilization �� 539
Rectal Stump Mobilization�� 539
Diverting Fecal Stream�� 539
Open Hartmann Reversal �� 540
Laparoscopic Hartmann Reversal�� 541
69 Surgeries for Large Bowel Obstruction �� 543
Joseph Nunoo-Mensah, Vita Klimasauskiene, and Andreas M. Kaiser
Stenting�� 543
Non-resective Approach (Stent, Diverting Stoma)�� 544
Resection�� 544
Conservative Management�� 544
Decision for Surgery�� 544
Contents xli
Choice of the Platform �� 544

Specific Considerations for the Stated Options Are as Follows�� 545
Setup and Patient Positioning�� 545
Colonic Stenting�� 546
Creation of Colostomy�� 546
Discontinuous Resection with Creation of a Stoma�� 547
Segmental or Subtotal Resection �� 547
Segmental Resection with Intraoperative Colonic Lavage and Anastomosis�� 547
70 Surgery for Colonic Fistula to Bladder, Vagina, or Skin�� 551
Decision for Surgery�� 552
Definitive Surgery�� 552
Access�� 552
Diversion�� 552
Access�� 552
Definitive Bowel Resection�� 553
Management of the Other Organ �� 553
Malignant �� 553
Benign�� 553
Diversion�� 554
71 Abdominal Repair of Rectal Prolapse and Pelvic Organ Descent (Open,
Laparoscopic) �� 555
Joongho Shin, Gregory K. Low, and Andreas M. Kaiser
Concept of the Repair�� 555
Rectal Mobilization�� 556
Posterior �� 556
Anterior�� 556
Avoiding Collateral Damage�� 556
Selection of Implant�� 557
xlii Contents

Posterior Rectal Mobilization and Fixation �� 558
Posterior Rectopexy with Mesh (Wells)�� 558
Posterior Suture Rectopexy (without Implant)�� 559
Legacy Procedure: Ripstein Rectopexy (Obsolete) �� 560
Ventral Mesh Rectopexy�� 560
Segmental Colon Resection with Rectopexy �� 561
Multicompartmental Resuspension�� 561
Part VI Anus, Rectum, and Pilonidal Region

Andreas M. Kaiser
72 Concepts in Surgery of the Anus, Rectum, and Pilonidal Region �� 565
Rachel Hogen and Andreas M. Kaiser
Anatomy and Physiology�� 565
Anorectal Examination�� 566
Imaging�� 566
Functional Testing�� 566
Management�� 567
Clinical Conditions�� 568
Anorectal Pain�� 568
Hemorrhoids�� 568
Anal Fissure �� 568
Anorectal Suppurative Diseases�� 569
Pilonidal Disease�� 570
Hidradenitis Suppurativa�� 570
Rectal Prolapse�� 570
Anorectal Stricture �� 570
Functional Disorders�� 571
Anorectal Skin Pathology�� 571
73 Office Procedures for Internal Hemorrhoids (Sclerotherapy,
Infrared Coagulation, and Rubber Band Ligation)�� 573
Contents xliii

Sclerotherapy �� 574
Infrared Coagulation�� 574
Rubber Band Ligation�� 575
74 Excisional Hemorrhoidectomy (Ferguson, Milligan-Morgan, Whitehead)�� 577
Joseph Nunoo-Mensah, Vita Klimasauskiene, and Andreas M. Kaiser
Considering Alternative Pathologies�� 578
Avoiding Anal Stenosis�� 578
Achieving Hemostasis�� 578
Avoiding Fecal Incontinence �� 578
General Setting�� 579
Positioning and Setup�� 579
Local Anesthetic Block�� 579
Excisional Hemorrhoidectomy�� 579
Ferguson Technique (Closed Wounds)�� 579
Milligan-Morgan Technique (Open Wounds)�� 581
Whitehead Hemorrhoidectomy�� 581
75 Stapled Hemorrhoidectomy/-opexy�� 583
Placement of the Retractor and Reduction of Prolapse �� 584
Purse-String Suture Placement and Transection of the Rectal Mucosa�� 584
Stapler Sets and Instruments�� 584
Placement of the Retractor and Reduction of Prolapse �� 585
Purse-String Suture Placement and Transection of the Rectal Mucosa�� 585
Inspection for Hemostasis and Removal of Retractor �� 587
xliv Contents
76 Doppler-Guided Hemorrhoidal Artery Ligation�� 589

Selection of the Treatment Method�� 590
Doppler-Guided Ligation�� 590
Mucopexy�� 591
77 Surgical Management of Anorectal Abscess and Fistula�� 593
Choice of Anesthesia�� 594
Localizing Fistula Tracts�� 594
Preserving Fecal Continence�� 594
Combining Fistula Surgery with Drainage of Anorectal Abscess�� 594
Anorectal Infections in Crohn’s Disease and Leukemia�� 595
Perianal and Ischioanal Abscess�� 595
Intersphincteric Abscess�� 595
Supralevator Abscess �� 596
Anorectal Fistula�� 596
Fistulotomy Versus Seton Placement �� 599
Endorectal Advancement Flap (ERAF) �� 600
Insertion of Fistula Plug�� 600
Ligation of Intersphincteric Fistula Tract (LIFT)�� 600
More Extensive Surgeries�� 600
78 Rectovaginal Fistula Repair�� 603
Rahila Essani and Andreas M. Kaiser
Timing of the Repair�� 604
Immediate Symptom Control�� 604
Contents xlv
Common Local Rectovaginal Repairs �� 604

Radical Local Repair Operations �� 604
Abdominal Approach �� 604
Perineal Approaches�� 604
Endorectal Advancement Flap (ERAF) �� 605
Episioproctotomy with Layered Closure �� 606
Perineal Access and Muscle Interposition �� 606
Miscellaneous Perineal Approaches�� 606
79 Rectourinary Fistula Repair �� 609
Immediate Symptom Control�� 609
Perineal Local Rectourinary Repair�� 610
Abdominal Local Rectourinary Repair�� 610
Abdominal and Abdomino-perineal Resection�� 610
Perineal Approach�� 610
Transanal Access�� 610
Parasacral-Transsphincteric Access (York-Mason)�� 610
Perineal Access and Muscle Interposition �� 610
80 Lateral Internal Sphincterotomy with/Without Fissurectomy
for Chronic Anal Fissure �� 613
Goal of Surgery�� 614
Optional Steps�� 614
Closed Sphincterotomy�� 614
xlvi Contents
Open Sphincterotomy�� 615

Fissurectomy and Removal of the Sentinel Pile and/or
Hypertrophic Anal Papilla�� 615
Concomitant Hemorrhoidectomy�� 615
81 Anoplasty for Anal Stenosis�� 617
Andreas M. Kaiser
Mucosal Advancement Flap�� 618
Anocutaneous Advancement Flap (V-Y Plasty)�� 618
Fluids�� 618
Wound Care�� 618
Regular Diet �� 618
Stool Management �� 618
Pain Management�� 618
82 Perineal Operations for Rectal Prolapse�� 621
Altemeier Procedure�� 622
Delorme Procedures�� 622
Thiersch Procedure: Pitfalls and Danger Points�� 622
Choice of Procedure�� 622
Patient Positioning �� 622
Anesthesia�� 622
Operative Tactics�� 622
Perineal Proctosigmoidectomy (Altemeier Procedure) �� 622
Mucosal Sleeve Resection with Muscular Cuff Plication (Delorme Procedure)� 623
Thiersch Operation (Surgical Legacy Procedure)�� 623
Altemeier Procedure: Perineal Proctosigmoidectomy �� 623
Delorme Procedure: Mucosal Sleeve Resection with Muscular Plication�� 625
Thiersch Operation (Surgical Legacy Procedure)�� 626
Contents xlvii
83 Operations for Pilonidal Disease�� 629

Abscess Drainage Without Excision�� 630
Excision of Sinus Pits with Lateral Drainage�� 630
Primarily Wide Open Excision with/Without Marsupialization�� 630
Excision with Primary Closure�� 631
Excision with Flap Closure�� 631
84 Overlapping Sphincteroplasty�� 633
Meara Dean and Massarat Zutshi
Timing of the Repair�� 634
Technical Considerations �� 634
Measuring the Results�� 634
Persistent Incontinence�� 634
General Setting�� 634
Incision�� 635
Mobilization�� 635
85 Sacral Nerve Stimulation for Fecal and Urinary Incontinence �� 639
Phase 1 �� 640
Phase 2 �� 640
xlviii Contents

Phase 1 �� 641
Plan Incision�� 641
Localizing the Foramina�� 641
Confirming Needle Position�� 641
Introducing Wire, Dilator, and Lead�� 642
Phase 2 �� 643
Removing the Temporary External Lead Extension�� 643
Connecting the Lead to the Neurostimulator �� 643
86 Transanal Local Excision of Rectal Lesions (TEMS, TAMIS, TAE)�� 645
Christine Hsieh and Andreas M. Kaiser
Depth of Excision�� 646
Choice of the Platform �� 646
Transanal Excision (TAE)�� 646
Transanal Endoscopic Microsurgery (TEMS) �� 647
Transanal Minimally Invasive Surgery (TAMIS)�� 647
Transanal Total Mesorectal Excision (taTME)�� 647
Patient Positioning �� 647
Anal Block �� 648
Surgical Excision �� 648
Transanal Excision�� 648
Transanal Endoscopic Microsurgery (TEMS) �� 649
Transanal Minimally Invasive Surgery (TAMIS)�� 649
Specimen Handling�� 649
Part VII Hepatobiliary Tract

Umut Sarpel
87 Concepts in Hepatobiliary Surgery�� 655

Umut Sarpel and H. Leon Pachter
Biliary Surgery�� 655
Biliary Colic and Cholecystitis�� 655
Cholecystitis During Pregnancy�� 656
Cholecystitis in the Hospitalized Patient �� 656
Cholecystectomy�� 656
Contents xlix
Intraoperative Cholangiography�� 657

Use of Drains �� 657
Iatrogenic Biliary Injury�� 657
Choledocholithiasis and Cholangitis�� 658
Ductal Drainage Procedures�� 658
T-Tube Management�� 659
Gallbladder Carcinoma�� 659
Cholangiocarcinoma�� 659
Hepatic Surgery�� 660
Hepatocellular Carcinoma �� 660
Colorectal Liver Metastases�� 660
Hepatic Trauma�� 661
Concepts in Liver Resection�� 661
Determining Resectability �� 662
Postoperative Management�� 663
88 Open Cholecystectomy�� 665
Shanel B. Bhagwandin and Umut Sarpel
Anomalies of the Extrahepatic Bile Ducts�� 665
Avoiding Injury to the Bile Ducts�� 667
Inadvertent Ligation of the Hepatic Artery�� 669
Avoiding Hemorrhage�� 669
Cholangiography�� 670
Common Errors of Operative Cholangiography�� 670
Decompressing the Gallbladder�� 671
Management of the Difficult Cystic Duct�� 671
Subtotal Cholecystectomy �� 671
Conversion to Open Cholecystectomy After Failed
Laparoscopic Cholecystectomy �� 672
Incision�� 672
Dissecting the Cystic Duct�� 673
Cystic Duct Cholangiography�� 673
Ligating the Cystic Artery�� 673
Dissecting the Gallbladder Bed �� 673
89 Laparoscopic Cholecystectomy�� 677
Cindi Sulzbach and Randall Zuckerman
Choledocholithiasis�� 677
l Contents

Avoiding Bleeding �� 677
Preventing Bile Duct Damage�� 678
Aberrant Anatomy�� 679
Ensuring Good Exposure �� 679
Intraoperative Cholangiography�� 680
Conversion to Open Cholecystectomy�� 680
Initial Inspection of the Peritoneal Cavity �� 680
Insertion of Secondary Trocar Cannulas�� 680
Dissecting the Gallbladder to Expose the Cystic Duct�� 681
Cystic Duct Cholangiogram�� 682
Removing the Gallbladder �� 683
Needle or Trocar Damage�� 684
Insufflation-Related Complications �� 684
Bile Duct Damage: Injury of Common and Hepatic Ducts �� 684
Bile Leak�� 686
Intraoperative Hemorrhage from Cystic Artery �� 686
90 Open and Laparoscopic Common Bile Duct Exploration�� 689
Juliane Bingener, Michael G. Sarr, and Carol E. H. Scott-Conner
Avoiding Postoperative Pancreatitis�� 690
CBD Perforations�� 690
Locating and Removing Biliary Calculi�� 690
Open CBD Exploration: Operative Technique�� 692
Cholangiography�� 692
Choledochotomy Incision�� 693
Choledochoscopy�� 693
Transduodenal Sphincterotomy/Sphincteroplasty for Impacted Stones�� 694
Checking for Ampullary Stenosis�� 695
Insertion of the T-Tube�� 695
Completion Cholangiogram�� 696
Laparoscopic CBD Exploration: Operative Technique�� 696
Bile Leak and Bile Peritonitis�� 698
Postoperative Acute Pancreatitis�� 698
Increasing Jaundice�� 698
Hemorrhage (Hemobilia) �� 698
Residual CBD Stone Postoperatively�� 698
Early Postoperative Treatment �� 698
Subsequent Postoperative Treatment �� 699
Contents li
91 Sphincteroplasty�� 701
Renganaden Sooppan and Charles J. Yeo
Duodenotomy�� 701
Preventing Duodenal or CBD Leak �� 701
Identifying and Protecting the Pancreatic Duct �� 702
Closure of Duodenotomy�� 702
Incision and Exploration�� 702
Mobilization of the Gallbladder and Kocher Maneuver�� 702
Location of the Ampulla of Vater and Duodenotomy�� 702
Mucosal Resection of Periampullary Adenoma�� 703
Bile Duct Sphincteroplasty�� 703
Pancreatic Ductoplasty and Septotomy �� 704
Completing the Cholecystectomy and Closing the Duodenotomy�� 705
Drainage and Abdominal Closure�� 705
Postoperative Acute Pancreatitis�� 705
Duodenal Leak and Fistula�� 705
Intraoperative and Postoperative Hemorrhage�� 706
92 Choledochoduodenostomy: Surgical Legacy Technique�� 707
Size of Anastomotic Stoma�� 707
Location of the Anastomosis�� 707
Preventing the Sump Syndrome�� 708
Incision�� 708
Choledochoduodenal Anastomosis�� 708
Alternative Method of Anastomosis�� 709
93 Transduodenal Diverticulectomy�� 713
lii Contents
Incision�� 713
Duodenotomy and Diverticulectomy �� 714
Closure and Drainage�� 714
94 Hepatic Resection�� 717
Wen-Liang Fang and Carlos U. Corvera
Anatomic Basis for Liver Resection�� 717
Anatomic Liver Resections�� 719
Principles of Safe Liver Resection�� 719
Parenchymal Transection �� 719
Vascular Control�� 720
Preservation of Bile Ducts �� 720
Wedge (Nonanatomic, Subsegmental, or Peripheral) Resection �� 721
Anatomic Oriented Segmental Resections�� 721
Resection of Segments 2 and 3 (Left Lobectomy/Left Lateral Sectionectomy)�� 722
Anatomic Right Hepatectomy (Right Hepatic Lobectomy)�� 723
Anatomic Left Hepatectomy (Left Hepatic Lobectomy)�� 726
Laparoscopic Liver Surgery�� 727
Special Equipment �� 727
Laparoscopic Left Lateral Sectionectomy �� 729
Totally Laparoscopic Right Lobectomy�� 730
Hand-Assisted Laparoscopic Right Hepatectomy �� 732
Part VIII Pancreas
Umut Sarpel
95 Concepts in Surgery of the Pancreas�� 737

Divya Sood and Rebekah R. White
Surgical Anatomy�� 737
Trauma �� 737
Acute Pancreatitis�� 737
Diagnosis�� 738
Treatment �� 738
Chronic Pancreatitis �� 738
Diagnosis�� 738
Treatment of Chronic Pancreatitis �� 738
Choice of Operation�� 739
Drainage Procedures�� 739
Resection Procedures �� 739
Nerve Ablation �� 739
Contents liii
Adenocarcinoma of the Pancreas�� 740

Diagnosis�� 740
Imaging�� 740
Determination of Resectability�� 740
Local Invasion�� 740
Distant Metastasis�� 741
Treatment �� 741
Operative Management�� 741
Neoadjuvant Therapy �� 741
Islet Cell Tumors�� 742
Cystic Neoplasms of the Pancreas �� 742
Complications of Pancreatic Surgery�� 743
96 Partial Pancreatoduodenectomy�� 745
Joseph J. Kim, Umut Sarpel, and Daniel M. Labow
Assessment of Pathology to Determine Resectability �� 746
Avoiding and Managing Intraoperative Hemorrhage�� 746
Vascular Resections �� 746
Avoiding and Managing Postoperative Hemorrhage �� 746
Avoiding Leakage from the Pancreatojejunal Anastomosis�� 747
Diagnostic Laparoscopy�� 747
Kocherization of the Duodenum�� 748
Dissection of Portal Vein and Superior Mesenteric Vein �� 748
Cholecystectomy�� 749
Dissection of the Porta Hepatis�� 749
Antrectomy�� 751
Dissection and Division of Proximal Jejunum�� 752
Division of Pancreas�� 752
Dissection of Uncinate Process�� 753
Reconstruction Techniques�� 754
Hepaticojejunal Anastomosis�� 755
Pancreaticojejunal Anastomosis�� 755
Pancreaticojejunal Anastomosis by Invagination�� 758
Insertion of Drains �� 758
Gastrojejunostomy �� 758
Pylorus Preservation�� 759
Closure �� 760
97 Total Pancreatoduodenectomy�� 763
Yael Feferman and Umut Sarpel
Benign Conditions �� 763
liv Contents
Premalignant Conditions�� 763

Malignant Conditions�� 763
Laparoscopic Exploration�� 764
Incision�� 764
Mobilization of Pancreatic Head, Determination of Resectability�� 764
Cholecystectomy and Hilar Dissection�� 764
Mobilizing the Distal Pancreas�� 765
Antrectomy/Pylorus-Preserving Procedure �� 766
Mobilizing the Duodenojejunal Junction�� 766
Freeing the Uncinate Process�� 767
98 Distal (Left) Pancreatectomy�� 769
Brendan P. Lovasik and David A. Kooby
Laparoscopic Distal Pancreatectomy �� 769
Open Distal Pancreatectomy�� 773
Borderline Resectable Neoplasms �� 774
Radical Antegrade Pantreatico-Splenectomy�� 774
Distal Pancreatectomy with Celiac Axis Resection (DP-CAR, Appleby) �� 774
Robotic Distal Pancreatectomy�� 775
99 Operations for Pancreatic Pseudocyst �� 777
Nicholas J. Zyromski
Background/Natural History�� 777
Operative Indications �� 777
Preoperative Preparation and Perioperative Considerations�� 779
Operative Strategy and Technique �� 781
Cyst-Enterostomy�� 781
Cystogastrostomy�� 781
Roux-en-Y Cystojejunostomy �� 782
Resection�� 783
Pancreatic Head Resection�� 783
External Drainage�� 783
Follow-Up�� 783
Pearls�� 783
Contents lv
100 Pancreaticojejunostomy for Chronic Pancreatitis�� 785

Faik G. Uzunoglu and Jakob R. Izbicki
Exposure�� 787
Incising the Pancreatic Duct�� 788
Pancreatic Head Resection�� 790
V-Shape Resection of the Body and Tail �� 790
Roux-en-Y Reconstruction�� 790
Part IX Spleen
Umut Sarpel
101 Concepts in Splenic Surgery �� 795

Prashant Sinha and H. Leon Pachter
Splenectomy for Disease�� 795
Perioperative Evaluation�� 795
Autoimmune Thrombocytopenic Purpura �� 796
Recurrent Symptoms After Splenectomy for Hematologic Disease�� 796
Choice of Surgical Approach: Open Versus Laparoscopic Procedure �� 796
Technical Considerations for Safe Laparoscopic Splenectomy�� 797
Laparoscopic Management of Splenic Cysts�� 797
Splenic Trauma�� 797
Nonoperative Splenic Salvage �� 798
Nonoperative Management of Splenic Trauma �� 798
Prognostic Indicators of Failure of Nonoperative Management�� 798
Follow-Up Imaging�� 798
Laparoscopy for the Management of Splenic Trauma�� 800
102 Open Splenectomy for Disease�� 803
Carl Winkler and Umut Sarpel
Choice of Approach: Open or Laparoscopic?�� 803
Avoiding Intraoperative Hemorrhage�� 803
Preventing Postoperative Hemorrhage�� 804
Avoiding Pancreatic Injury�� 804
Avoiding Trauma to the Stomach�� 804
Preventing Postoperative Sepsis�� 804
Accessory Spleen �� 804
Incision�� 804
Ligating the Splenic Artery�� 804
lvi Contents
Exposing the Spleen�� 805

Mobilizing the Spleen�� 805
Ligating the Splenic Vessels�� 805
Achieving Hemostasis and Searching for Accessory Spleens �� 806
Imbricating the Greater Curvature of Stomach�� 806
103 Operations for Splenic Trauma�� 809
Carina Biggs
Preparation �� 809
Pitfalls�� 809
Decision for Splenectomy or Repair of Spleen�� 809
Exposure for Splenectomy�� 810
Mobilization of the Spleen�� 810
Temporary Control of Hemorrhage�� 810
Identification of the Splenic Injury�� 811
Removal of the Spleen �� 811
Techniques for Splenic Preservation�� 811
Iatrogenic Injuries�� 812
104 Laparoscopic Splenectomy�� 815
Manish Parikh and H. Leon Pachter
Preoperative Evaluation and Preparation �� 815
Special Consideration: Splenomegaly (>11 cm)�� 817
Laparoscopic Management of Splenic Cysts�� 819
Part X Hernia Repairs, Operations for Necrotizing Faciitis,

Drainage of Subphrenic Abscess
105 Concepts in Hernia Repair, Surgery for Necrotizing Fasciitis,

and Drainage of Subphrenic Abscess �� 825
Mark C. Horattas and Ileana K. Horattas
Selection of Anesthesia�� 826
Perioperative Antibiotics�� 826
Groin Hernia Repair�� 826
Primary Repair �� 827
Contents lvii
Prosthetic Mesh Repair�� 827

Laparoscopic Technique�� 827
Repair of Femoral Hernia�� 828
Repair of Recurrent Inguinal Hernia�� 828
Repair of Large Ventral Hernias�� 828
Necrotizing Fasciitis�� 829
Subphrenic Abscess �� 829
106 Shouldice Repair of Inguinal Hernia �� 831
Evgeny V. Arshava and Michael Alexander
Local Anesthesia and Incision �� 833
Inguinal Repair�� 836
The First Line of the Repair�� 836
The Second Line of the Repair�� 839
The Third and Fourth Lines of Repair �� 840
Complete Groin Repair Technique for Femoral Hernia�� 841
Closure of Superficial Layers�� 842
Infection �� 843
Hemorrhage�� 843
Testicular Atrophy and Hydrocele �� 843
Injury to Bladder and Bowel�� 843
Chronic Postoperative Pain�� 843
Ejaculatory Dysfunction (Dysejaculation)�� 844
Urinary Retention�� 844
Hernia Recurrence �� 844
107 Cooper’s Ligament (McVay) Repair of Inguinal Hernia �� 845
Making the Relaxing Incision�� 846
Inserting Cooper’s Ligament Sutures�� 846
Closing the External Oblique Aponeurosis�� 847
lviii Contents
108 Mesh Repair of Inguinal Hernia�� 849

Incision�� 849
Dissection and Identification of Direct and Indirect Sacs�� 849
Placement of Patch�� 850
Closure �� 851
109 Laparoscopic Inguinal Hernia Repair: Transabdominal
Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) Repairs�� 853
Muhammed Ashraf Memon and Robert J. Fitzgibbons Jr
Patient Position and Room Setup: TAPP or TEP�� 854
TAPP Approach�� 854
Placement of Mesh�� 856
Peritoneal Closure�� 856
Bilateral Hernias�� 856
TEP Approach�� 857
Vascular Injuries�� 857
Urinary Retention, Urinary Infection, Hematuria�� 857
Bladder Injury�� 858
Nerve Injury �� 858
Vas Deferens and Testicular Complications�� 858
Complications Related to the Mesh �� 858
Recurrence of the Hernia �� 858
Osteitis �� 859
Wound Infection�� 859
110 Operations for Recurrent Inguinal Hernia�� 861
Kent C. Choi and Carol E. H. Scott-Conner
Operative (Management) Strategy �� 861
Internal Ring Left Too Wide�� 862
Inadequate Reconstruction of the Inguinal Floor�� 862
Defect at Pubic Tubercle�� 862
Failure to Suture Transversalis Fascia or Transversus Arch�� 862
Failure to Excise Sac�� 862
Contents lix
Use of Absorbable Sutures�� 862

Subcutaneous Transplantation of Cord�� 862
Femoral Recurrence Following Inguinal Hernia Repair�� 862
Recurrent Indirect and Direct Inguinal Hernia�� 863
Choice of Approach �� 863
Selecting the Optimal Technique for Repair of Recurrent Inguinal Hernia�� 863
Technique of Dissection�� 863
Avoiding Testicular Complications�� 864
Inguinal Approach�� 864
Repairing Recurrent Hernia Following Previous Halsted Operation
Without Opening the Inguinal Canal �� 864
Dissecting the Inguinal Canal�� 865
Repairing a Localized Defect in the Inguinal Floor�� 865
Prosthetic Mesh Repair�� 865
Abandoning the Anterior Approach �� 865
Preperitoneal Approach Using Mesh Prosthesis (Surgical Legacy Technique)�� 866
Suturing the Mesh�� 866
Closing the Abdominal Incision�� 867
111 Femoral Hernia Repair �� 869
Patrick W. McGonagill, Kent C. Choi, and Carol E. H. Scott-Conner
Inguinal Approach�� 869
Low Groin Approach �� 869
Preperitoneal Approach�� 870
Low Groin Approach for Left Femoral Hernia�� 870
Low Groin Approach Using Prosthetic Mesh “Plug”�� 872
Preperitoneal Approach for Right Femoral Hernia (Nyhus)�� 872
Incision�� 872
Mobilizing the Hernial Sac�� 873
Suturing the Hernial Ring�� 873
112 Operations for Large Ventral Hernia�� 875
Ariel P. Santos
lx Contents

Occult Wound Dehiscence �� 876
Large Drain Exit Site at the Fascia�� 876
Failure to Close Laparoscopic Trocar Sites Adequately�� 876
Transverse Versus Vertical Incision�� 876
Suturing Technique�� 876
Type of Suture Material �� 876
Size of Tissue Bites�� 877
Suture Tension�� 877
Intercurrent Disease �� 877
Tissue Integrity�� 878
Tension During Repair�� 878
Role of Prosthetic Mesh�� 878
Types of Synthetic Prosthetic Material�� 878
Biologic Mesh (Biomesh)�� 880
Myocutaneous Flap�� 880
Separation of Components�� 880
Elective Ventral Hernia Repair�� 880
Dissecting the Hernial Sac �� 880
Resecting the Hernial Sac�� 882
Mesh Repair of Ventral Hernia�� 882
Sandwich Repair�� 883
Onlay Patch Mesh Repair�� 883
113 Laparoscopic Ventral Hernia Repair �� 887
Peter Nau
Patient Positioning and Preparation of the Defect �� 888
Sizing the Mesh�� 889
Management of the Fascial Defect�� 890
114 Operations for Infected Abdominal Wound Dehiscence,
Necrotizing Fasciitis, and Intraabdominal Abscesses�� 893
Ariel P. Santos
Operative Strategy: Infected Abdominal Wall and Dehiscence �� 893
Local Exploration�� 894
Wide Debridement �� 894
Managing the Abdominal Wall Defect�� 894
Contents lxi
Repeat Laparotomy for Recurrence of Abdominal Sepsis�� 895

Management of Intestinal Stomas and Fistulas �� 896
Marsupialization and Open Abdomen Management�� 896
Intraabdominal Abscesses�� 896
Approaches to Abscess Drainage�� 896
Percutaneous Drainage�� 896
Lateral and Subcostal Extraperitoneal Approach�� 898
Laparoscopy�� 899
Laparotomy�� 901
Extraserous Approach�� 902
Extraserous Subcostal Drainage of Right Subphrenic Abscess
(Surgical Legacy Technique) �� 902
Laparotomy for Subphrenic and Abdominal Abscesses�� 902
Postoperative Care After Abscess Drainage�� 904
Part XI Breast and Melanoma

Sonia L. Sugg
115 Concepts in Breast Surgery�� 907

Sonia L. Sugg, Sophia L. Fu, and Carol E. H. Scott-Conner
Breast Cancer �� 907
Epidemiology�� 907
Breast Cancer Risk�� 907
Breast Cancer Screening�� 907
Imaging Modalities�� 908
Breast Biopsy: Obtaining a Tissue Diagnosis�� 908
Management of Common Benign Breast Lesions �� 908
Nipple Discharge�� 908
Breast Abscess �� 909
Benign Breast Mass or Cyst�� 909
Breast Lesions on CNB That May Require Excision�� 909
Breast Malignant Diseases�� 910
Ductal Carcinoma In Situ (DCIS)�� 910
Paget’s Disease of the Breast �� 911
Invasive Breast Cancer�� 911
Inflammatory Breast Cancer�� 912
Surgical Treatment of Breast Cancer �� 912
Considerations Prior to Surgery�� 912
Is the Patient a Surgical Candidate?�� 912
Is the Patient a Candidate for Breast Conservation?�� 912
Surgery First or Neoadjuvant Treatment Followed by Surgery? �� 912
Is the Patient a Candidate for Omitting SLN Biopsy?�� 913
Will the Patient Require Postmastectomy Radiation? �� 913
Are There Indications for Genetic Counseling?�� 913
The Role of Shared Decision-Making �� 913
Surgical Treatment of the Breast�� 913
lxii Contents
Breast Conservation Therapy (BCT) �� 913

Mastectomy�� 914
Lymph Node Surgery �� 915
Adjuvant Systemic Therapy�� 916
Treatment of Local Recurrence�� 916
Metastatic Disease �� 917
Breast Problems in Men�� 917
116 Excision of Benign Palpable Breast Mass�� 921
Choice of Incision�� 922
Local Anesthesia�� 922
Repair�� 923
117 Excision of Ducts, Operations for Breast Abscess�� 925
Emily L. Albright
Excision of Ducts�� 925
Physical Examination�� 925
Ductography�� 925
Ductal Endoscopy�� 925
Operations for Breast Abscess �� 925
Single Duct Excision Versus Total Duct Excision �� 926
Strategic Approach to Breast Abscesses�� 926
Prevention of Skin Necrosis with Ductal Excision�� 926
Single Duct Excision�� 926
Incision�� 926
Identification and Excision�� 926
Closure �� 926
Total Duct Excision�� 927
Incision�� 927
Excising the Ductal System �� 927
Simple Breast Abscess �� 929
Recurring Subareolar Abscess/Lactiferous Duct Fistula �� 929
Contents lxiii
118 Lumpectomy for Breast Cancer �� 931

Ingrid Lizarraga
Localization�� 931
Incision�� 932
Extent of Excision, Orienting the Specimen and Additional Margins�� 932
Closure �� 933
Special Techniques�� 933
Intraoperative Radiation Therapy�� 933
Oncoplastic Lumpectomy�� 933
Basic Lumpectomy�� 933
Techniques for Localization�� 934
Palpation-Guided Lumpectomy �� 934
Wire-Localized Lumpectomy�� 934
Ultrasound-Guided Lumpectomy�� 935
Lumpectomy Using Implanted Localization Marker�� 935
119 Mastectomy: Simple (Total), Modified, and Classical Radical�� 937
Sequencing the Operation�� 938
Simple Versus Modified Radical Mastectomy �� 938
Modified Radical Mastectomy�� 938
Radical Mastectomy�� 938
Incision and Skin Flaps�� 939
Thickness of Skin Flap�� 939
Alternative Incisions for Mastectomy�� 939
Avoiding Dog Ears�� 940
Axillary Lymph Node Anatomy for Breast Surgeons�� 940
Clearing the Pectoral Fascia�� 942
Axillary Dissection: Unroofing the Axillary Vein�� 942
Axillary Vein Dissection�� 943
Radical Mastectomy�� 944
Irrigation and Closure�� 945
Ischemia of Skin Flap�� 946
Seromas�� 946
Lymphedema�� 946
lxiv Contents
120 Skin and Nipple Sparing Mastectomy�� 947

Sonia L. Sugg, Cynthia Lee, and Iryna Chesnokova
Skin Sparing Versus Nipple Sparing Mastectomy �� 947
Axillary Lymph Nodes�� 948
Extent of Mastectomy�� 948
Incision and Skin Flaps�� 949
Skin Flap Techniques �� 949
Visualization�� 949
Incisions �� 950
Develop the Skin Flaps (Anterior) �� 951
Skin Sparing Mastectomy�� 951
Nipple Sparing Mastectomy�� 952
Release the Breast from the Chest Wall (Posterior)�� 952
Finishing the Mastectomy�� 953
Ischemia of Skin Flap�� 953
Ischemia of Nipple�� 953
121 Sentinel Lymph Node Biopsy and Axillary Staging for Breast Cancer�� 955
Lillian Erdahl and Carol E. H. Scott-Conner
Sentinel Lymph Node Biopsy�� 955
Axillary Node Dissection�� 957
Targeted Axillary Dissection�� 957
Axillary Reverse Mapping �� 958
Axillary Node Dissection�� 960
122 Concepts in Melanoma�� 963
Leah Kathryn Winer and Jeffrey J. Sussman
Diagnosis�� 963
Risk Factors �� 963
Biopsy�� 963
Staging �� 964
Primary Lesion: Wide Local Excision (WLE)�� 964
Contents lxv
Management of the Regional Lymph Nodes �� 964

Adjuvant Therapy�� 966
In-Transit Melanoma�� 966
Metastatic Disease �� 967
123 Wide Local Excision and Sentinel Lymph Node Biopsy for Melanoma �� 969
Carlos H. F. Chan and Hisakazu Hoshi
Wide Local Excision�� 969
Biopsy�� 970
124 Axillary Lymphadenectomy for Melanoma�� 975
J. E. Maxwell and Sonia L. Sugg
Incision�� 975
Exposing the Axillary Contents �� 976
Clearing the Axillary Vein�� 976
Dissecting the Chest Wall�� 977
Subscapular Space �� 977
125 Superficial and Deep Groin (Femoroinguinal and Pelvic) Dissection �� 979
Hisakazu Hoshi
Preoperative Evaluation �� 979
Preventing Wound Infection and Wound Dehiscence�� 979
Reducing Incidence of Lymphedema�� 980
lxvi Contents
Indications for Deep Groin Dissection and Exposure�� 980

Adequacy of Nodal Dissection�� 980
Dissection in the Femoral Triangle�� 981
Supra Inguinal Ligament Dissection�� 981
Deep Groin (Pelvic) Dissection �� 981
Sartorius Muscular Flap�� 983
Skin Closure and Drainage�� 983
Part XII Thyroid, Parathyroid, and Adrenal, Parotidectomy,

and Tracheal Procedures
Sonia L. Sugg
126 Concepts in Thyroid, Parathyroid, and Adrenal Surgery�� 987

Janice L. Pasieka
Thyroid�� 987
Benign Thyroid Disease�� 987
Hyperthyroidism�� 987
Multinodular Goiter �� 988
Thyroid Carcinoma�� 989
Ultrasound, Fine-Needle Aspiration, and Molecular Testing�� 989
Surgical Treatment of Thyroid Cancer�� 989
Well-Differentiated Thyroid Cancer�� 989
Medullary Thyroid Cancer�� 990
Parathyroid �� 990
Primary Hyperparathyroidism �� 991
Secondary and Tertiary Hyperparathyroidism �� 991
Parathyroidectomy �� 992
Adrenal�� 992
Adrenal Incidentalomas �� 993
Primary Aldosteronism�� 993
Cushing’s Syndrome�� 994
Pheochromocytoma/Paraganglioma�� 994
Surgical Approaches to the Adrenal Gland�� 994
127 Thyroidectomy �� 997
Geeta Lal
Preserving the Superior Laryngeal Nerve�� 997
Identification and Preservation of Recurrent Laryngeal Nerve�� 998
Preserving Parathyroid Glands�� 999
Intraoperative Preparation�� 999
Identification and Ligation of the Isthmus and Middle Thyroid Vein�� 1000
Contents lxvii
Dissecting the Superior Pole and Superior Parathyroid Gland�� 1000

Identification of Inferior Pole Vessels�� 1001
Identification of the Recurrent Laryngeal Nerve and Inferior Parathyroid
Gland�� 1001
Reimplantation of Parathyroid Glands�� 1002
Subtotal Thyroid Lobectomy �� 1002
Total Thyroid Lobectomy�� 1002
Partial Thyroid Lobectomy�� 1002
Closure �� 1003
Minimally Invasive Thyroidectomy �� 1005
128 Neck Dissection for Thyroid Cancer�� 1007
Maheshwaran Sivarajah and Rebecca S. Sippel
Scarring Due to Prior Surgery�� 1008
Nerve Injuries�� 1008
Injury to the Thoracic Duct�� 1008
Seroma �� 1008
Central Compartment Neck Dissection �� 1010
Lateral Compartment Neck Dissection�� 1011
129 Parathyroidectomy�� 1015
Sonia L. Sugg
Curing the Disease �� 1016
Preserving the Recurrent Laryngeal Nerve�� 1016
Preserving the Superior Laryngeal Nerve�� 1017
Preserving Normal Parathyroid Tissue�� 1017
Identify Crossing of the Inferior Thyroid Artery
and the Recurrent Laryngeal Nerve �� 1017
Identifying Inferior and Superior Parathyroids�� 1018
Resecting the Adenoma�� 1018
Biopsying Normal Parathyroid�� 1018
Subtotal Parathyroidectomy�� 1018
Total Parathyroidectomy with Autotransplantation �� 1018
Sequence for an Unfound Parathyroid Gland�� 1018
Closure �� 1019
lxviii Contents
Reoperation�� 1019
Posterior Approach�� 1019
130 Minimally Invasive Parathyroidectomy�� 1021
Philip M. Spanheimer and Sonia L. Sugg
Indications and Preoperative Preparation�� 1021
Intraoperative PTH Monitoring (IOPTH)�� 1022
Preserving the Recurrent Laryngeal Nerve�� 1022
131 Open Adrenalectomy �� 1025
James R. Howe
Operative Technique: Right Adrenalectomy�� 1027
Left Adrenalectomy �� 1029
132 Laparoscopic Adrenalectomy�� 1033
Emily E. K. Murphy and Tracy S. Wang
Special Considerations�� 1033
Preoperative �� 1034
Intraoperative �� 1034
Postoperative�� 1034
Transabdominal Approach �� 1035
Retroperitoneoscopic Approach�� 1037
Special Circumstances �� 1038
Contents lxix
133 Parotidectomy�� 1041

Locating and Preserving the Facial Nerve �� 1041
Exposing the Posterior Margin of the Parotid Gland�� 1043
Locating the Facial Nerve�� 1043
Dissecting Facial Nerve Branches �� 1044
Removing Deep Lobe of Parotid Gland (When Indicated)�� 1044
134 Cricothyroidotomy�� 1047
Jennifer Shanklin and Kathleen Romanowski
Indication �� 1047
135 Tracheostomy �� 1051
Carol E. H. Scott-Conner and K. Shad Pharaon
Operative Technique: Formal Tracheostomy �� 1052
Endotracheal Tube �� 1052
Identifying the Tracheal Rings�� 1052
Checking the Tracheostomy Equipment�� 1053
Opening the Trachea�� 1053
Inserting the Tracheostomy Tube�� 1054
Closure �� 1054
Percutaneous Tracheostomy�� 1054
Procedure �� 1055
Index�� 1059
Contributors
Emily L. Albright, MD Department of Surgical Oncology, University of Iowa,

Iowa City, IA, USA
Michael Alexander, MD Department of Surgery, Shouldice Hospital, Thornhill, ON, Canada
Evgeny V. Arshava, MD, FACS Department of Surgery, University of Iowa Carver College
of Medicine, Iowa City, IA, USA
Theodor Asgeirsson, MD Department of Colorectal Surgery, West Michigan Surgical
Specialists, Greenville, MI, USA
James M. Bardes, MD Department of Surgery, Division of Trauma, Acute Care Surgery and
Surgical Critical Care, Los Angeles County - USC Medical Center, Los Angeles, CA, USA
Shanel B. Bhagwandin, DO, MPH Department of Surgery, Division of Surgical Oncology,
Jupiter Medical Center Physician, Group, Jupiter, FL, USA
Carina Biggs, MD, FACS Trauma Medical Director, St. Mary’s Hospital, Waterbury, CT, USA
Juliane Bingener, MD Department of Surgery, Mayo Clinic, Rochester, MN, USA
Stacy A. Brethauer, MD Section of Laparoscopic and Bariatric Surgery, Department of
Surgery, Cleveland Clinic, Cleveland, OH, USA
Miguel A. Burch, MD Department of Surgery, Cedars-Sinai Medical Center, Los Angeles,
CA, USA
Carlos H. F. Chan, MD, PhD Department of Surgery, Surgical Oncology and Endocrine
Surgery, University of Iowa, Iowa City, IA, USA
Kenneth Chang, MD H. H. Chao Comprehensive Digestive Disease Center, University of
California Irvine, Orange, CA, USA
Iryna Chesnokova, MD Department of Surgery, RWJPE Steeplechase Breast Specialists,
Somerville, NJ, USA
Kent C. Choi, MD, MS Department of Surgery, Roy J. and Lucille A. Carver College of
Medicine, University of Iowa, Iowa City, IA, USA
Paul D. Colavita, MD Division of GI and Minimally Invasive Surgery, Carolinas Medical
Center, Charlotte, NC, USA
Kyle G. Cologne, MD Department of Surgery, Division of Colorectal Surgery, Keck School
of Medicine of the University of Southern California, Los Angeles, CA, USA
Carlos U. Corvera, MD, FACS Department of Surgery, University of California, San
Francisco, San Francisco, CA, USA
Shaun Daly, MD Department of General Surgery, University of California Irvine Medicine
Center, Costa Mesa, CA, USA
lxxi
lxxii Contributors
Jacques Van Dam, MD, PhD USC Digestive Health Center, Department of Medicine, Keck
School of Medicine, University of Southern California, Los Angeles, CA, USA
Meara Dean, MD Department of Colorectal Surgery, Digestive Disease & Surgery Institute,
Cleveland Clinic Foundation, Cleveland, OH, USA
Demetrios Demetriades, MD, PhD Department of Surgery, Division of Trauma and Acute
Care Surgery and Surgical Critical Care, Los Angeles County – USC Medical Center, Los
Angeles, CA, USA
Daniel T. Dempsey, MD Department of Gastrointestinal Surgery, Penn Medicine, Perelman
Center for Advanced Medicine, Philadelphia, PA, USA
Sharmila Dissanaike, MD Department of Surgery, Texas Tech University Health Sciences
Center, Lubbock, TX, USA
Marjun P. Duldulao, MD Department of Surgery, Division of Colorectal Surgery, Keck
School of Medicine of the University of Southern California, Los Angeles, CA, USA
Jamie Dutton, MD Department of Surgery, Northwest Medical Center, Bentonville, AR,
USA
Lillian Erdahl, MD Department of Surgery, Roy J. and Lucille A. Carver College of Medicine,
University of Iowa, Iowa City, IA, USA
Rahila Essani, MD Department of Surgery, Texas A&M University, Baylor Scott and White
Health Care, Temple, TX, USA
Wen-Liang Fang, MD, PhD Division of General Surgery, Department of Surgery, Taipei
Veterans General Hospital, Taipei, Taiwan
Yael Feferman, MD Division of Surgical Oncology, Department of Surgery, Icahn School of
Medicine at Mount Sinai, New York, NY, USA
Peter F. Ferson, MD Department of Cardiothoracic Surgery, University of Pittsburgh,
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Robert J. Fitzgibbons Jr, MD, FACS Division of General Surgery, Department of Surgery,
Creighton University School of Medicine, Omaha, NE, USA
Sophia L. Fu, MD Department of Oncology, Good Samaritan Hospital Medical Center, West
Islip, NY, USA
Giulio Giambartolomei, MD The Bariatric and Metabolic Institute, Cleveland Clinic Florida,
Weston, FL, USA
Benjamin Golas, MD Department of Surgery, Mount Sinai West Hospital, New York,
NY, USA
Alfredo D. Guerron, MD Department of Surgery, Division of Metabolic and Weight Loss
Surgery, Duke University Health System, Durham, NC, USA
Sean P. Harbison, MD Department of Gastrointestinal Surgery, University of Pennsylvania
Health System, Penn Gastrointestinal Surgery University City, Philadelphia, PA, USA
Marcelo W. Hinojosa, MD, FACS Department of Surgery, Division of Minimally Invasive
and Gastrointestinal Surgery, University of California Irvine Medical Center, Orange, CA,
USA
Rachel Hogen, MD Department of Surgery, Keck School of Medicine of the University of
Southern California, Los Angeles, CA, USA
Department of Surgery, Division of Colorectal Surgery, Keck School of Medicine of the
University of Southern California, Los Angeles, CA, USA
Contributors lxxiii
Mark C. Horattas, MD Department of Surgery, Northeast Ohio Medical University,

Rootstown, OH, USA
Department of Surgery, Cleveland Clinic Akron General, Akron, OH, USA
Ileana K. Horattas, MD Department of Surgery, Northeast Ohio Medical University,
Rootstown, OH, USA
Hisakazu Hoshi, MD Department of Surgery, Surgical Oncology and Endocrine Surgery,
James R. Howe, MD Department of Surgery, Surgical Oncology and Endocrine Surgery, Roy
J. and Lucille A. Carver University of Iowa College of Medicine, Iowa City, IA, USA
Christine Hsieh, MD Department of Surgery, Division of Colorectal Surgery, Keck School of
Medicine of the University of Southern California, Los Angeles, CA, USA
Kenji Inaba, MD, FACS Department of Surgery, Division of Trauma, Acute Care Surgery
and Surgical Critical Care, Los Angeles County - USC Medical Center, Los Angeles, CA, USA
Jakob R. Izbicki, MD Department of General-, Visceral- and Thoracic Surgery, University
Medical Center Hamburg-Eppendorf, Hamburg, Germany
Zoë O. Jones, MD Department of Surgery, University of New Mexico, Albuquerque, NM,
USA
Eugene Kahn, MD Department of General Surgery, University of California Irvine Medicine
Center, Costa Mesa, CA, USA
Andreas M. Kaiser, MD Department of Surgery, Division of Colorectal Surgery, City of
Hope National Medical Center/Comprehensive Cancer Center, Duarte, CA, USA
Joseph J. Kim, MD Division of Surgical Oncology, Department of Surgery, Icahn School of
Medicine at Mount Sinai, New York, NY, USA
Vita Klimasauskiene, MD, MMedb Faculty of Medicine, Vilnius University, Vilnius,
Lithuania
David A. Kooby, MD, FACS Emory Saint Joseph’s Hospital, Atlanta, GA, USA
Daniel M. Labow, MD Division of Surgical Oncology, Department of Surgery, Icahn School
of Medicine at Mount Sinai, New York, NY, USA
Geeta Lal, MD Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City,
IA, USA
Rodney Landreneau, MD Department of Cardiovascular-Thoracic Surgery, Penn Highlands
Healthcare, DuBois, PA, USA
Sean J. Langenfeld, MD Department of Surgery, University of Nebraska Medical Center,
Omaha, NE, USA
Donald C. LaSeur, MD Department of Surgery, Texas A&M University, Baylor Scott and
White Health Care, Temple, TX, USA
Cynthia Lee, MD Department of Surgery, University of Iowa Healthcare, Iowa City, IA,
USA
David Lee, MD, MPH H. H. Chao Comprehensive Digestive Disease Center, University of
Sang W. Lee, MD Department of Surgery, Division of Colorectal Surgery, Keck School of
lxxiv Contributors
Natasha Leigh, MD Department of Surgery, Mount Sinai West Hospital, New York, NY,
USA
John C. Lipham, MD Department of Surgery, Keck School of Medicine, University of
Virginia R. Litle, MD Department of Surgery, Boston Medical Center, Boston, MA, USA
Ingrid Lizarraga, MBBS Department of General Surgery, University of Iowa Hospitals and
Clinics, Iowa City, IA, USA
Brendan P. Lovasik, MD Department of Surgery, Emory University School of Medicine,
Atlanta, GA, USA
Gregory K. Low, MD Department of Surgery, University of Tennessee, Knoxville, TN, USA
James D. Luketich, MD Department of Cardiothoracic Surgery, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
Mohan K. Mallipeddi, MD Department of Surgery, Cedars-Sinai Medical Center, Los
Angeles, CA, USA
Kazuhide Matsushima, MD Department of Surgery, Division of Trauma and Acute Care
Surgery and Surgical Critical Care, Los Angeles County – USC Medical Center, Los Angeles,
CA, USA
J. E. Maxwell, MD Department of Surgery, Roy J. and Lucille A. Carver College of Medicine,
Patrick W. McGonagill, MD Department of Surgery, Roy J. and Lucille A. Carver College
of Medicine, University of Iowa, Iowa City, IA, USA
Katherine M. Meister, MD, FACS Section of Laparoscopic and Bariatric Surgery,
Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
Muhammed Ashraf Memon, FACS,FRACS,FRCSI,FRCSEd,FRCSEng Department of
Surgery, South East Queensland Surgery and Sunnybank Obesity Centre, Sunnybank, QLD,
Australia
Emanuele Lo Menzo, MD, PhD, FACS, FASMBS The Bariatric and Metabolic Institute,
Cleveland Clinic Florida, Weston, FL, USA
Kasim L. Mirza, MD Department of Surgery, Division of Colorectal Surgery, Keck School
of Medicine of the University of Southern California, Los Angeles, CA, USA
Daniela Molena, MD Department of Surgery, Memorial Sloan Kettering Cancer Center, New
York, NY, USA
John M. Morton, MD, MPH Bariatric and Minimally Invasive Surgery, Department of
Surgery, Yale School of Medicine, New Haven, CT, USA
Emily E. K. Murphy, MD Surgical Institute of South Dakota, Sioux Falls, SD, USA
Peter Nau, MD, MS Department of Surgery, Roy J. and Lucille A. Carver College of
Ninh T. Nguyen, MD Division of Gastrointestinal Surgery, University of California, Irvine,
Orange, CA, USA
Erik R. Noren, MD, MS Department of Surgery, Division of Colorectal Surgery, Keck
School of Medicine of the University of Southern California, Los Angeles, CA, USA
Joseph Nunoo-Mensah, BM, BS King’s College Hospital, London, UK
Contributors lxxv
Nabeel R. Obeid, MD Department of Surgery, University of Michigan Medical School,

Ann Arbor, MI, USA
Olugbenga T. Okusanya, MD Department of Surgery, Thomas Jefferson University,
Philadelphia, PA, USA
Edwin Onkendi, MB. ChB, FACS Department of Surgery, Texas Tech University Health
Sciences Center, Lubbock, TX, USA
Camila B. Ortega, MD Department of Surgery, Division of Metabolic and Weight Loss
Surgery, Duke University Health System, Durham, NC, USA
H. Leon Pachter, MD Department of Surgery, New York University School of Medicine,
New York, NY, USA
Manish Parikh, MD Department of Surgery, New York University School of Medicine, New
York, NY, USA
Janice L. Pasieka, MD, FRCSC, FACS Department of Surgery, Sections General Surgery
and Surgical Oncology, Faculty of Medicine, Cumming School of Medicine, University of
Calgary, Calgary, AB, Canada
Foothills Medical Center, Calgary, AB, Canada
Arjun Pennathur, MD, FACS Sampson Family Endowed Chair in Thoracic Surgical
Oncology, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
K. Shad Pharaon, MD Division of Trauma and Acute Care Surgery, Surgical Critical Care,
PeaceHealth Southwest Medical Center, Vancouver, WA, USA
Sarah M. Popek, MD Department of Surgery, University of New Mexico, Albuquerque, NM,
USA
Dana Portenier, MD Department of Surgery, Division of Metabolic and Weight Loss Surgery,
Duke University Health System, Durham, NC, USA
Aurora D. Pryor, MD, FACSFASMBS Department of Surgery, Stony Brook University
School of Medicine, Stony Brook, NY, USA
Jeffrey E. Quigley, DO Department of General Surgery, Loma Linda University Health,
Loma Linda, CA, USA
Kevin M. Reavis, MD, FACS Division of Minimally Invasive and GI Surgery, The Oregon
Clinic, Portland, OR, USA
Mariela Rivera, MD Department of Surgery, Mayo Clinic, Rochester, MN, USA
Rodrigo Rodriguez, MD Department of Surgery, University of New Mexico, Albuquerque,
NM, USA
Kathleen Romanowski, MD, FACS Department of Surgery, University of California, Davis
School of Medicine, Sacramento, CA, USA
Shriners Hospitals for Children, Sacramento, CA, USA
Raul J. Rosenthal, MD, FACS, FASMBS The Bariatric and Metabolic Institute, Cleveland
Clinic Florida, Weston, FL, USA
Ashley E. Russo, MD Department of Surgery, Memorial Sloan Kettering Cancer Center, New
York, NY, USA
lxxvi Contributors
Naelly Saldana Ruiz, MD Department of Surgery, Keck School of Medicine of the University
of Southern California, Los Angeles, CA, USA
Jason Samarasena, MD H. H. Chao Comprehensive Digestive Disease Center, University of
Kulmeet K. Sandhu, MD, MS, FACS, FASMBS Department of Surgery, Division of Upper
Gastrointestinal and General Surgery, Keck School of Medicine of the University of Southern
California, Los Angeles, CA, USA
Ariel P. Santos, MD, MPH, FACS, FCCM, FRCSC Department of Surgery, Texas Tech
University Health Sciences Center, Covenant Medical Center, Lubbock, TX, USA
Umut Sarpel, MD, FACS Division of Surgical Oncology, Department of Surgery, Icahn
School of Medicine at Mount Sinai, New York, NY, USA
Michael G. Sarr, MD Department of Surgery, Mayo Clinic, Rochester, MN, USA
Keith R. Scharf, DO Department of General Surgery, Loma Linda University Health, Loma
Linda, CA, USA
Morgan Schellenberg, MD, MPH Department of Surgery, Division of Trauma, Acute Care
Surgery and Surgical Critical Care, Los Angeles County - USC Medical Center, Los Angeles,
CA, USA
Henry Schiller, MD Department of Surgery, Mayo Clinic, Rochester, MN, USA
Carol E. H. Scott-Conner, MD, PhD Department of Surgery, University of Iowa Carver
College of Medicine, Iowa City, IA, USA
Anthony J. Senagore, MD, MS, MBA Kalamazoo, MI, USA
Jennifer Shanklin, MD Acute Care Surgery, University of Iowa Hospitals and Clinics, Iowa
City, IA, USA
Joongho Shin, MD Department of Surgery, Division of Colorectal Surgery, Keck School of
Prashant Sinha, MD Department of Surgery, NYU Langone Brooklyn Surgery Associates,
Brooklyn, NY, USA
Rebecca S. Sippel, MD, FACS Division of Endocrine Surgery, Department of Surgery,
University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
Maheshwaran Sivarajah, MD, MSc Acute Care Surgery, St.Barnabas Hospital, Bronx, NY,
USA
Anna Skay, MD USC Digestive Health Center, Keck School of Medicine, University of
Brian R. Smith, MD Department of Surgery, UC Irvine Medical Center, Orange, CA, USA
Divya Sood, MD Department of Surgery, University of California San Diego, La Jolla, CA,
USA
Renganaden Sooppan, MD Department of Surgery, Jefferson Pancreas Biliary and Related
Cancer Center, The Sidney Kimmel Medical College, Thomas Jefferson University,
Philadelphia, PA, USA
Philip M. Spanheimer, MD Department of Surgery, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
Constantine P. Spanos, MD, MBA Department of Surgery, Aristotelian University School of
Medicine, Thessaloniki, Greece
Contributors lxxvii
Vivian E. Strong, MD Gastric and Mixed Tumor Service, Department of Surgery, Memorial
Sloan Kettering Cancer Center, New York, NY, USA
Sonia L. Sugg, MD Department of Surgery, University of Iowa Carver College of Medicine,
Iowa City, IA, USA
Cindi Sulzbach, MD Department of Surgery, Pullman Regional Healthcare, Pullman,
Washington, USA
Malini D. Sur, MD Hepatopancreatobiliary Surgery and Surgical Oncology, Northside
Hospital Cancer Institute, Atlanta, GA, USA
Jeffrey J. Sussman, MD, FACS Department of Surgery, University of Cincinnati College of
Medicine, Cincinnati, OH, USA
Samuel Szomstein, MD, FACSFASMBS The Bariatric and Metabolic Institute, Cleveland
Clinic Florida, Weston, FL, USA
James M. Tatum, MD Department of Surgery, Keck School of Medicine, University of
Michael N. Tran, MD Department of Surgery, Division of Minimally Invasive and
Gastrointestinal Surgery, University of California Irvine Medical Center, Orange, CA, USA
Simon R. Turner Department of Surgery, Division of Thoracic Surgery, University of Alberta,
Edmonton, AB, Canada
Faik G. Uzunoglu, MD Department of General-, Visceral- and Thoracic Surgery, University
Medical Center Hamburg-Eppendorf, Hamburg, Germany
Tracy S. Wang, MD, MPH Section of Endocrine Surgery, Froedert & Medical College of
Wisconsin, Milwaukee, WI, USA
Rebekah R. White, MD Department of Surgery, University of California San Diego, La
Jolla, CA, USA
Leah Kathryn Winer, MD Department of Surgery, University of Cincinnati College of
Medicine, Cincinnati, OH, USA
Carl Winkler, MD Department of Surgery, The Valley Hospital, Ridgewood, NJ, USA
Eugene J. Won, MD Department of Surgery, UC Irvine Medical Center, Orange, CA, USA
Charles J. Yeo, MD, FACS Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
Abigail K. Zamora, MD Department of Surgery, Keck School of Medicine of the University
Matthew Zelhart, MD Department of Surgery, Tulane University, New Orleans, LA, USA
Randall Zuckerman, MD Department of Surgery, Pullman Regional Healthcare, Pullman,
Washington, USA
Massarat Zutshi, MD Department of Colorectal Surgery, Digestive Disease & Surgery
Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
Nicholas J. Zyromski, MD Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
Part I
General Principles
Andreas M. Kaiser
Concepts and Strategies of Surgery
1
Developing a Concept • Reflect on personal experience with complications and

deaths following the operation selected. This information
Successful surgery requires study, analysis, advance plan- is more relevant than are the results reported from some
ning, clear thinking, and technical skill. Brilliant execution renowned high-volume medical centers with expertise in
of the wrong operation or an operation at the wrong time can a particular operation. Superior results under their cir-
only lead to disaster. To achieve consistency and the best cumstances may not translate into equally successful out-
possible results for each surgical condition and a broad range comes in the hands of less-experienced surgeons.
of circumstances, the surgeon must develop a concept that Participation in national databases such as NSQIP (the
will rely on the skills but has to be based on a deep knowl- National Surgical Quality Improvement Project)
edge and analysis of the literature, the disordered physiol- (American College of Surgeons National Surgical Quality
ogy, and comprehension of the hypothesis underlying the Improvement Program 2011) as well as quality control
contemplated operation. Hesitance on one hand and blind efforts at your own hospital facilitates tracking results and
aggressiveness on the other hand should be avoided. compare them with national and local norms. The
To develop a valid concept, a surgeon must: American Board of Surgery requires such activities as
part of Maintenance of Certification (The American
• Build and maintain a solid knowledge foundation about Board of Surgery 2011).
the normal and pathologic physiology related to the target • Review postoperative complications and poor results.
condition as well as relevant comorbidities. When a complication or a death occurs, analyze the case
• Know the anatomy in general and specific alterations carefully. Grade the complications according to the
related to the individual patient. Clavien-Dindo classification (Table 1.1). Attempt to make
• Explore the relative merits of alternative operations and an objective appraisal of what went wrong: Was there
treatment options. poor judgment regarding the choice of operation? Was
• Analyze the operation selected for the problem at hand: there a delay? Was the diagnosis inaccurate? Was the
Are there valid data and/or evidence-based guidelines to assessment of the risk incorrect? Was there an error of
demonstrate that it can accomplish the desired goals? Is technique? Did the surgeon lack the technical expertise
the mortality rate for the procedure such that the benefit required to undertake the procedure?
outweighs the risk? Are there alternative treatments that • Keep records of morbidity and mortality (“M&M”) for
may offer lower morbidity and potential mortality? each operation. Frequent analysis of results increases the
• Should YOU do this operation? Or should you refer the database of the surgeon’s own experience. Knowledge the
patient to someone with more expertise? surgeon gains leads to self-renewal and improved perfor-
mance: Without it, the surgeon learns nothing from
experience.
A. M. Kaiser
• Persist in a lifetime study of the published literature in
Department of Surgery, Division of Colorectal Surgery, City of
Hope National Medical Center/Comprehensive Cancer Center, basic science and clinical surgery. Surgery has changed
Duarte, CA, USA and continues to change at such a rapid pace that even an
C. E. H. Scott-Conner (*) experienced surgeon who does not constantly follow a
Department of Surgery, University of Iowa Carver College lifelong learning may risk to suddenly offer outdated sur-
of Medicine, Iowa City, IA, USA gical care.
e-mail: carol-scott-conner@uiowa.edu
© Springer Nature Switzerland AG 2022 3

C. E. H. Scott-Conner et al. (eds.), Chassin’s Operative Strategy in General Surgery,
https://doi.org/10.1007/978-3-030-81415-1_1
4 A. M. Kaiser and C. E. H. Scott-Conner
Table 1.1 Clavien-Dindo classification of surgical complications

Grade Definition Comment
I Any deviation from the normal postoperative course Allowed therapeutic regimens are: drugs as
without the need for pharmacological treatment or antiemetics, antipyretics, analgetics, diuretics, and
surgical, endoscopic, and radiological interventions electrolytes and physiotherapy. This grade also
includes wound infections opened at the bedside
II Requiring pharmacological treatment with drugs other Blood transfusions and total parenteral nutrition are
than such allowed for grade I complications also included
III Requiring surgical, endoscopic, or radiological IIIa: not under general anesthesia
intervention IIIb: under general anesthesia
IV Life-threatening complication (including CNS IVa: single organ dysfunction (incl. dialysis)
complications) requiring IC/ICU-management IVb: multiple organ dysfunction
V Death of a patient
From Clavien et al. (2009), with permission
Establishing Strategy hours follow checklist procedures to assure safety before and
during a flight.
Establishing an operative strategy – advance planning of the Even more important is to do the easy steps of any oper-
approach and technical steps of the operation – is vital to the ation first. This practice often makes the next step easy. If
safety and efficiency of complex surgical procedures. The the surgeon continues to do easy steps, there may never be
operative strategy is what the surgeon ponders before sched- any difficult steps with which to contend. The reputation
uling the operation and what he should replay immediately for being a rapid operator is highly prized by some sur-
before the operation: What are the major steps of the proce- geons but often overrated. More important than speed –
dure? How should it be modified for this particular case? especially when good anesthesia and patient support
What are the known uncertainties and what are possible technology are available – are accuracy and delicacy of
uncertainties? Where are the potential pitfalls? How can they technique to ultimately leave behind a situation that has the
be avoided? What is plan B and/or the exit strategy? In some best chance for a favorable outcome. Nevertheless, time
ways, this exercise is similar to the visualization employed should not be wasted. A reduction in operating time is not
by highly skilled athletes. The thesis of this book is that by achieved merely by performing rapid hand motions. More
creating a strategy, the surgeon can increase the chance of important for an expeditious procedural flow are to not lose
success and reduce the incidence of operative misadventures sight of the target, to always think 2–3 steps ahead of the
and postoperative complications. current action, and to recognize when no real progress is
Anticipating and analyzing potential problems and dan- made. An operation can be expedited without sacrificing
ger points before an operation leads to success more surely safety only when thoughtful advance planning, anticipa-
than does frenzied activity in the operating room after the tion, and alert recognition of anatomic landmarks are com-
surgeon and patient are in deep trouble. Anticipation bined with efficiency of execution.
enhances the surgeon’s capacity for prompt decision making The surgeon in difficulty should stop cutting and start
in the operating room. thinking. Why is the step difficult? Poor exposure? Bad
working space? Bad light? Bloody field? Access and
approach (e.g., laparoscopic) not suited for this case? The
Making the Operation Easy good surgeon makes operations look easy because of good
operative strategy, rarely needing to resort to spectacular
The main goal of any successful operative strategy is to make maneuvers to extricate the patient from danger.
the operation easy by making it reproducible. The main goal The surgeon in real trouble should call for help from a
of this book is to show how to develop such strategy. Easy senior colleague or, if available, intraoperatively consult a
and reproducible operations are safe operations. A prime specialist in a specific area. Situations such as hemorrhage
requirement for making an operation simple is to obtain from the vena cava or laceration of the common bile duct are
good visualization and exposure with excellent light. Strategy best managed with the calming influence of an experienced
also means planning the sequence of an operation to clearly consultant who is not burdened by the guilt and anxiety of
identify and expose landmarks and vital structures early dur- having caused the complication.
ing the dissection to avoid damaging them. Surgeons can The chapters that follow in Part I discuss in detail the gen-
learn a lot from airline pilots who even after thousands of eral principles that underlie successful open and minimally
1 Concepts and Strategies of Surgery 5
invasive surgery. Subsequent sections work through the ana- Further Reading
tomic regions and operations that are the familiar terrain of
the general surgeon. The “concepts” chapter introduces each American College of Surgeons National Surgical Quality Improvement
section. The technical chapters that then follow deal with Program. 2011. http://www.acsnsqip.org/. Accessed 29 May 2017.
Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo clas-
specific standard surgical procedures. Some uncommon pro- sification of surgical complications – 5 year experience. Ann Surg.
cedures of more historical interest that are rarely used these 2009;250:187–96.
days have not been omitted, but labeled “legacy” material. In The American Board of Surgery. ABS MOC requirements. 2011. http://
each technical chapter, a discussion of the concept underly- home.absurgery.org/default.jsp?exam-mocreqs. Accessed 29 May
2017.
ing the operation and the operative strategy precedes the
description of each operative technique.
Mechanical Basics of Operative
Technique 2
Constantine P. Spanos and Carol E. H. Scott-Conner
Introduction Before You Scrub
Rare is the novice who has the inborn talent to accomplish all Before you scrub, ensure that any relevant radiographs are up
the mechanical manipulations of surgery with no more on the view screens in the operating room. Review the pro-
thought or analysis than the natural athlete gives to hitting a posed operation with your team and make sure that all instru-
ball. Most surgeons in training can gain much from analyz- ments, supplies, and equipment are available and in working
ing such basics of surgery as foot position, hand and arm order.
motion, and efficient use of instruments. This chapter Verify that the patient is in the appropriate position and
describes the basics as applied to open surgery. Please see that extremities and bony prominences are properly secured
Chap. 9 for a similar discussion of laparoscopic mechanics. and padded. If you plan to use a self-retaining retractor (such
Ergonomics, a science devoted to maximizing efficiency, is as the Bookwalter, Omni, or upper arm), check the relative
increasingly being applied to the operating room environ- position of the retractor post with the extremities, chest,
ment. Sound ergonomic principles such as those described head, and neck to avoid injury. Check the position of electro-
here help to diminish stress and the possibility of injury to cardiograph leads, ground pad for electrocautery, and any
the surgeon. other ancillary equipment to make certain that you have free
When considering the mechanics discussed here, remem- access to the surgical field. When operating on colorectal
ber that underlying all aspects of surgical technique are the cases, make one final assessment of accessible pathology by
fundamental principles articulated by Halsted, who empha- performing a digital rectal exam.
sized that the surgeon must minimize trauma to tissues by Position the lights. Most operations can be done with two
using gentle technique. Halsted also stressed the importance operating lights. These work best when brought in at 45°
of maintaining hemostasis and asepsis. angles from opposite sides to converge on the operative site.
This text has been written from the vantage point of the In the typical situation, the surgeon and first assistant will
right-handed surgeon. Left-handed surgeons face the deci- stand across the operating table from each other. The lights
sion of whether to learn to operate with the right hand or to may converge from above and below, so that neither surgeon
operate left-handed. Finding a left-handed mentor is nor first assistant’s head shadows the field. Make certain that
extremely helpful. The surgeon who operates with the left the “elbows” of the lights are positioned to allow the lights to
hand will need to reverse the instructions where be maneuvered easily and that the light handles are within
appropriate. easy reach of the operative team. As the operation progresses,
it is likely that the lights will be repositioned so that their
illumination continues to converge in the operative field.
When operating in the pelvis, use a headlight.
For minimally invasive procedures (laparoscopic, robotic,
TAMIS), check the appropriate position of the monitors.
C. P. Spanos
Department of Surgery, Aristotelian University School of Remember that surgeon – pathology – monitor should be in
Medicine, Thessaloniki, Greece one line. The same is true for the assistant who – if posi-
C. E. H. Scott-Conner (*) tioned on the opposite side of the table – should look at a
Department of Surgery, University of Iowa Carver College separate monitor.

https://doi.org/10.1007/978-3-030-81415-1_2
8 C. P. Spanos and C. E. H. Scott-Conner
Preoperative Verification Process needle is aimed toward the left foot. This is termed “forehand
suturing.” It allows the shoulder, arm, and wrist to occupy
Before surgery, the surgeon must mark the operative site in positions that are free of strain and permits the surgeon to
such a manner that the marks are visible after the patient is perceive proprioceptive sensations as the needle moves
prepped and draped. After draping, the entire team should through the tissues. Only in this way can the surgeon “feel”
pause and hold a “time-out” to verify patient identity, lateral- the depth of the suture bite. Combining this proprioceptive
ity and site, and nature of the procedure to be performed sense with visual monitoring of the depth of the needle bite
(American Academy of Orthopaedic Surgeons and American is the best way to ensure consistency when suturing. Because
Association of Orthopaedic Surgeons 2011). Another accurate placement of sutures through the submucosa is one
protocol used in hospitals throughout the world is the WHO of the most important factors during construction of an intes-
Guidelines for Safe Surgery checklist. The basic components tinal anastomosis, the surgeon must make every effort to per-
of the checklist are patient sign-in, timeout, and sign-out. Be fect this skill.
familiar with the protocol in use at your hospital and follow Forehand suturing maneuvers use the powerful biceps to
it carefully. move the hand from a pronated to a supinated position in a natu-
ral rolling motion. Backhand maneuvers require the surgeon to
begin from a supinated position and roll backward to return to a
I mportance of Surgeon’s Foot and Body pronated position. With practice, this action becomes smooth
Position but is not as easy or natural as forehand suturing. Whenever pos-
sible, establish your position relative to the field to allow fore-
A comfortable, relaxed stance enables the surgeon to spend hand suturing. When placing a running suture, begin at the
hours at the operating table without back or neck strain and farthest aspect of the suture line and sew toward yourself.
the accompanying muscle tremors. It is particularly impor- Figure 2.1 illustrates the proper foot position of the surgeon
tant to keep the shoulders and elbows relaxed. The novice inserting Lembert sutures during construction of an anastomo-
surgeon commonly tenses and elevates the shoulders and sis situated at right angles to the long axis of the body. To
elbows. A relaxed posture is facilitated by dropping the oper- insert sutures backhand, the needle is directed toward the sur-
ating table a few inches. The tense posture is often accompa- geon’s right foot. If only a few backhand sutures are needed, it
nied by a tendency to hunch over the field, bringing the face is not necessary to change position. If an entire row of sutures
close in a natural attempt to concentrate. This crouching pos- requires backhand suturing, however, consider reversing your
ture makes it difficult for assistants to see, may cause shad- position relative to the surgical field so the row may be placed
ows in the operative field, and in the extreme circumstance in the more natural forehand manner.
may even compromise sterility by allowing instruments to
touch the surgeon’s mask. Tension in the shoulders and fore-
arms also makes it difficult to hold instruments steady and
potentiates tremor. Poor elbow posture may eventually cause
epicondylitis.
When deciding which side of the operating table is the
“surgeon’s side,” consider which side allows you to most
L
easily use you right arm and hand to reach into the area of
pathology. For every activity involving the use of hands and
arms, there is a body stance that allows the greatest efficiency
of execution. For example, the right-handed professional
R
who uses a baseball bat, tennis racket, wood chisel, or golf

club places the left foot forward and the right foot 30–50 cm
to the rear; the right arm and hand motion are then directed
toward the left foot.
It may help to stand at one side or the other of the table
and imagine moving your right arm into the field of the
pathology. This exercise will generally convince you that one
side offers advantages over the other. When in doubt, stand
facing the anticipated pathology.
Similarly, for the greatest efficiency when suturing, the
surgeon assumes a body position such that the point of the Fig. 2.1
2 Mechanical Basics of Operative Technique 9
Some maneuvers require a backhand motion. For instance, Some surgeons do not have a highly developed proprio-
cutting by scalpel is properly performed with a backhand ceptive sense when they use the backhand suture. Therefore,
motion directed toward the surgeon’s right foot (Fig. 2.2). whenever feasible they should avoid this maneuver for sero-
Similarly, when electrocautery is used as a cutting instru- muscular suturing. This is almost always possible if the sur-
ment, it is commonly drawn toward the right foot in a man- geon rearranges the direction of the anastomosis or assumes
ner analogous to using a scalpel. In contrast, when using a body stance that permits optimal forehand suturing. This is
scissors the point of the scissors should be directed toward sometimes termed “reversing the field.” Consider reversing
the surgeon’s left foot. The proper foot position for inserting the field whenever you find yourself in a mechanically awk-
Lembert sutures in an anastomosis oriented in a line parallel ward situation.
to the long axis of the body is shown in Fig. 2.3. The method of changing body position so all sutures
can be placed with a forehand motion is illustrated in
Fig. 2.4, which shows Cushing sutures being inserted into
an esophagogastric anastomosis, with the surgeon stand-
ing on the left side of the patient. When the needle is
passed through the gastric wall from the patient’s left to
right, the surgeon’s left foot is planted close to the operat-
ing table along the left side of the patient’s abdomen. The
L
surgeon’s right foot is placed more laterally. When the

suture is passed from the patient’s right to left, on the pos-
terior aspect of the esophageal wall, the surgeon’s right
R
foot is placed alongside the operating table. The surgeon’s

body faces the patient’s feet, and the surgeon’s left foot is
somewhat lateral to the right foot (Fig. 2.5). This position-
ing directs the point of the needle toward the surgeon’s
left foot at all times.
A similar change in body stance is illustrated in Figs. 2.6
and 2.7, where Cushing sutures are being inserted into a low-
lying colorectal anastomosis. Of course, if the surgeon chose
to use the Lembert-type suture for an esophagogastrostomy
or a coloproctostomy, a single stance would be efficient for
the entire anastomosis.
Fig. 2.2
L R
L R
Fig. 2.3 Fig. 2.4

R L
L R
Fig. 2.5
Fig. 2.7
R L
L
R
Fig. 2.6 Fig. 2.8
Figures 2.8 and 2.9 illustrate insertion of Lembert sutures Figure 2.10 illustrates closure of an upper vertical midline
for the final layer of a gastrojejunal anastomosis, showing abdominal incision. Figure 2.11 shows a lower midline inci-
the foot position of the surgeon who is standing on the sion with the surgeon standing at the patient’s right side.
patient’s right side, compared with a position on the patient’s Although it is true that some surgeons are able to accom-
left side. plish effective suturing despite awkward or strained body
R
L
R L
Fig. 2.9 Fig. 2.11
Use of Instruments
Learn the names of the instruments that you will be using.

Chapter 11 provides an illustrated glossary of some common
instruments. Recognize that common terminology may dif-
fer, and it is not rare for an instrument to go by one name in
one hospital and another in a different hospital (particularly
in another geographical region).
With rare exceptions, all surgical instruments used for
soft tissue dissection should be held with fingertip pressure
L R rather than in a tight, vise-like grip. A loose grip is essential
if the surgeon is to perceive proprioceptive sensations as the
instrument is applied to the tissue. A relaxed grip also helps
avoid fatigue, which contributes to muscle tremors. This
requirement applies whether the instrument used is a scalpel,
forceps, needle holder, or scissors.
Scalpel
Fig. 2.10 When making the initial scalpel incision in the skin, the sur-
geon can minimize tissue trauma by using a bold stroke
and hand positions, it must be emphasized that during sur- through the skin and subcutaneous fat. It requires a firm grip.
gery, as in athletics, good form is an essential ingredient for In most other situations, however, the scalpel should be held
producing consistently superior performance. gently between the thumb on one side of the handle and the
other fingers on the opposite side. Long, deliberate strokes set for “coagulation,” considerable heat may be generated,
with the scalpel are preferred. Generally, cutting is best done causing the fat to boil. Excessive tissue trauma contributes to
with the belly of the scalpel blade, as it enables the surgeon postoperative wound infection.
to control the depth of the incision by feel as well as by On the other hand, transection of muscle bellies (e.g., dur-
vision. The scalpel is a particularly effective instrument ing a subcostal or thoracic incision) may be accomplished
when broad surface areas are to be dissected, as during radi- efficiently when the electrocautery is set for “coagulation” or
cal mastectomy or inguinal lymphadenectomy. “blend” current. This setting provides good hemostasis and
In such situations as an attempt to define the fascial ring appears not to injure the patient significantly. Occasionally,
surrounding an incisional hernia, the surgeon can clear over- the peritoneum and ligaments in the paracolic gutters are
lying adherent fat rapidly from broad areas of fascia using a somewhat vascular secondary to inflammation. Electrocautery
scalpel. The efficiency of knife dissection is greatly enhanced can be used here to divide these normally “avascular”
when the tissues being incised are kept in a state of tension, structures.
which can be brought about by traction between the sur- In many areas, such as the neck, breast, and abdominal
geon’s left hand and countertraction by the first assistant. wall, it is feasible to cut with electrocautery, now set for
The surgeon must always be alert to the nuances of anat- “cutting,” without causing excessive bleeding. To divide a
omy revealed by each scalpel stroke, especially if a structure small blood vessel, change the switch from “cutting” to
appears in an unexpected location. This is not possible if the “coagulation” and occlude the isolated blood vessel by elec-
surgeon is in the habit of making rapid, choppy strokes with trocautery. Carefully performed, this sequence of dissection
the scalpel, like a woodpecker. Rapid, frenzied motions do seems not to be damaging. If the incidence of wound infec-
not afford sufficient time for the surgeon’s brain to register tions, hematoma, or local edema is increased using this tech-
and analyze the observations made during the dissection. nique, the surgeon is overcoagulating the tissues and not
Nor do they allow sufficient time for feedback to control the isolating the blood vessels effectively.
hand motions. Slow, definitive, long sweeping strokes with
the scalpel make the most rapid progress and yet allow
enough time to permit activation of cerebral control mecha- Forceps
nisms and prevent unnecessary damage.
Care must be taken to avoid unnecessary trauma when apply-
ing forceps to body tissues. As with other instruments, hold
Metzenbaum Scissors the forceps gently. It is surprising how little force needs be
applied when holding the bowel with forceps while inserting
The round-tipped Metzenbaum scissors are valuable because a suture. If the imprint of the forceps appears on the wall of
they serve a number of essential functions. Closed, they are the bowel after the forceps have been removed, it is a clear
an excellent tool for dissection. They may be inserted behind warning that excessive force was applied when grasping the
adhesions or ligaments to elevate and delineate planes of dis- tissue.
section before dividing them. Properly held, with the fourth With the goal of avoiding unnecessary trauma, when
finger and thumb in the two rings and the index finger and selecting forceps, recognize immediately that “smooth” and
middle finger extended along the handle, this instrument “mouse-toothed” forceps are contraindicated when handling
serves as an extension of the hand when detecting sensations delicate tissue. Applied to the bowel, smooth forceps require
and provides the surgeon with information concerning the excessive compression to avoid slipping. In this situation,
density, pliability, and thickness of the tissue being dissected. Debakey-type forceps do not require excessive compression
As with other instruments, this proprioceptive function is to prevent tissue from slipping from the forceps’ jaws. For
enhanced if the hand grasps the instrument gently. more delicate dissection, the Brown-Adson-type forceps are
even more suitable. This instrument contains many tiny
interdigitating teeth, which allow the surgeon to hold deli-
Electrocautery as a Cutting Device cate tissues with minimal force.
Some surgeons prefer to use electrocautery, set for the “cut-

ting” current, for such maneuvers as elevating skin flaps dur- Needle Holder
ing mastectomy or incising subcutaneous fat. Transecting fat
with a cutting current makes hemostasis only partially effec- Match the size and weight of the needle holder to the size of
tive but minimizes tissue trauma. In fact, the “cutting” cur- the needle and suture. For example, do not use a delicate nee-
rent, which is a continuous low-voltage output, results in a dle holder to manipulate the heavy needle and suture used for
predictable zone of coagulation with higher quality and con- fascial closure. Similarly, a heavy needle holder is too cumber-
sistency than with the “coagulating” current. If the current is some to allow accurate suturing of bowel or blood vessels.
Ideally, needle holders are paired so the scrub assistant is load- less time if large bites of tissue are grasped by large hemo-
ing one with a suture while the surgeon is suturing. stats than if small, accurate bites are taken. On the other
It should be obvious that a curved needle must be inserted hand, with small bites many bleeding points can be rapidly
with a circular motion to avoid a tear at the site of the nee- controlled by electrocautery rather than ligature, a technique
dle’s point of entry into the tissue. The needle point should that is especially helpful during such operations as those for
“attack” the tissue at a right angle. It requires a rotatory radical mastectomy.
motion of the surgeon’s wrist, which in turn is aided by The choice between straight- and curve-tipped hemostats
proper body stance and relaxed shoulder and elbow posi- is a matter of personal preference, as either may be applied
tions. Stability is enhanced if the elbow can be kept close to with equal accuracy. Curve-tipped hemostats make it some-
the body. Many novices tend to ignore the need for this rota- what easier to bring a ligature around the back and tip of the
tory wrist motion, especially when the suture line is in a clamp for tying. The manner in which the curved hemostat is
poorly accessible anatomic location. They tend to insert a applied differs depending on whether the vessel is to be cau-
curved needle with a purely horizontal motion of the needle terized or tied. The hemostat should be applied points down
holder, causing a small laceration at the entrance hole. This and then lifted clear of all adjacent tissue to cauterize the
may pose a problem when suturing vascular grafts, leading vessel. It should be applied points up if the vessel is to be
to increased hemorrhage from the suture line. An expert sur- tied.
geon is a “needle-pusher” rather than a “needle-puller”; this Whenever possible, small Halsted or Crile hemostats
facilitates loading the needle holder with maximum effi- should be employed. For deeper vessels (e.g., the cystic
ciency when continuous suturing is required. artery), Adson clamps provide more handle length combined
Using the same hand grip throughout the suturing with delicate jaws. Hemostats vary in the length of the ser-
sequence enhances the surgeon’s capacity to detect proprio- rated segment. Some are fully serrated, whereas others are
ceptive impulses from the needle holder. It is difficult to serrated only at the distal portion. Only the serrated portion
sense the depth of the needle bite accurately if the surgeon’s of the clamp grasps tissue.
fingers are sometimes in the rings of the instrument’s handle Occasionally it is more efficient to use a single, large
and at other times are not. For gastrointestinal suturing, Kelly hemostat to grasp a large pedicle containing a number
where proprioception is of great importance, we prefer a grip of vascular branches than to cause additional bleeding by
with the thumb in one ring and the ring finger in the other, dissecting each small branch away from the pedicle. An
steadying the handle with the extended index and middle example is ligation of the left gastric artery-coronary vein
fingers. pedicle along the lesser curvature of the stomach during gas-
With practice, a delicate needle holder may be palmed, tric resection. A right-angled Mixter clamp is useful for
that is, manipulated, opened, and closed without placing the obtaining hemostasis in the thoracic cavity and when divid-
thumb or ring finger through the rings. It requires facility and ing the vascular tissue around the lower rectum during the
practice and should not be attempted by the novice, who is course of anterior resection.
apt to find it necessary to put the thumb and finger into the In all cases, the preferred hand grip for holding hemostats
rings to open and close the needle holder after palming the is identical with that for holding the needle holder and scis-
needle holder to place the stitch. This sequence is awkward, sors. When the hemostat has a curved tip, the instrument
increases tissue trauma, and significantly slows suture should be held so the tip curves in the same direction in
placement. which the surgeon’s fingers flex.
Although most suturing is accomplished using a needle
holder with a straight shaft, some situations require a needle
holder whose shaft is angled or curved (e.g., for low colorec- Further Reading
tal and some esophagogastric anastomoses). In both
instances, inserting the suture with a smooth rotatory motion American Academy of Orthopaedic Surgeons, American Association
of Orthopaedic Surgeons. Joint Commission (JC) Guidelines.
may not be possible unless a curved needle holder such as Guidelines for implementation of the universal protocol for the pre-
the Stratte or Finochietto is used. vention of wrong site, wrong procedure, and wrong person surgery.
http://www3.aaos.org/member/safety/guidelines.cfm. Accessed 8
Oct 2011.
Munro MG. Fundamentals of electrosurgry part I: principles of radio-
Hemostat frequency energy for surgery. In: Feldman LS, Fuchshuber PR,
Jones DB, editors. The SAGES manual on the fundamental use of
Ideally, a hemostat is applied to a vessel just behind the point surgical energy (FUSE). New York: Springer; 2012. p. 15–60.
of bleeding, and the bite of tissue is no larger than the diam- World Alliance for Patient Safety. WHO guidelines for safe surgery.
Geneva: World Health Organization; 2008.
eter of the vessel. Obtaining hemostasis may seem to take
Incision, Exposure, Closure
3
Constantine P. Spanos, Andreas M. Kaiser,
and Carol E. H. Scott-Conner
Achieving Exposure with fiberoptic lighting. This provides optimal visualization

of the deep pelvis.
Many dangerous surgical mishaps occur because the opera- Once the extent of pathology has been determined, there
tive exposure is inadequate. The first step toward obtaining are advantages to using a fixed retractor. For small abdomi-
good exposure is to make a well-planned incision of suffi- nal incisions where simple retraction of the abdominal wall
cient length. The second step during abdominal surgery is to is all that is required, a Balfour retractor may suffice. Place
pack the intestines away from the area of operation. If a dis- moist laparotomy pads under the blades to help minimize
section requires exposure of a large portion of the abdominal tissue trauma and to avoid slippage of the blades. For thora-
cavity, such as for left hemicolectomy or excision of an cotomy and thoracoabdominal incisions, a Finochietto
abdominal aortic aneurysm, it may be necessary to exterior- retractor is excellent for separating the ribs.
ize the small intestine for the duration of the dissection. The A often more efficient form of retraction is to place a
third step is retraction of the wound edges. wound protector system which comes in different sizes and
Retraction of the wound edges may be accomplished by consists of two plastic rings connected with a tube of thin
simple retractors, such as the handheld Richardson (see plastic: The internal ring is inserted into the abdomen; after
Chap. 11 for illustrations of various retractors and other assuring that no small bowel is trapped, the outer ring is
instruments), or by fixed retractors, such as the simple rolled over until there is a tight fit. This method often pro-
Balfour or the more complex but adaptable Omni-track. vides excellent exposure while keeping the wound moist and
In the initial exploration phase of an operation, simple protected.
retractors are extremely useful because they can rapidly be More complex fixed retractors are anchored in some way
moved as needed to explore various quadrants of the abdo- to the operating table and thus provide very constant expo-
men and identify the extent of the pathology. Richardson sure. These vary from the simple “chain” retractor to fancy
retractors are used to retract the skin, subcutaneous fat, and systems such as the Omni and Bookwalter. The “chain”
musculofascial layers of the abdominal wall. Harrington or retractor (Fig. 3.1) is an inexpensive improvisation that per-
heart-shaped retractors may be used to gently retract and mits insertion of a retractor blade underneath the lower end
expose deeper structures. St. Marks retractors are ideal for of the sternum or underneath either costal margin. It may
exposure in the deep pelvis. These may be modified to use seem primitive in comparison with modern systems but can
be adapted to the humblest operating room in the most diffi-
cult circumstances and remote locations. The retractor (the
third blade of a Balfour-type system works well) is attached
C. P. Spanos to an ordinary link chain, which can be purchased in a hard-
Department of Surgery, Aristotelian University School of
ware store. The anesthesiologist attaches a curved steel post
borrowed from the gynecologic lithotomy stirrup set to the
A. M. Kaiser
side rail at the head of the operating table. When the post is
Hope National Medical Center/Comprehensive Cancer Center, adjusted to the proper height, the chain is fixed to a snap at
Duarte, CA, USA the tip. By rotating the post in the proper direction, the lower
C. E. H. Scott-Conner (*) end of the sternum and the thoracic cage can be retracted
Department of Surgery, University of Iowa Carver College forcefully cephalad and anteriorly to elevate the sternum by
of Medicine, Iowa City, IA, USA as much as 8–10 cm.

https://doi.org/10.1007/978-3-030-81415-1_3
16 C. P. Spanos et al.
Fig. 3.2
For most operations, a more complex system of self-

retaining retractors such as the Thompson, Omni (see Chap.
11), or Bookwalter is useful. This particular system chosen
depends on personal preference and availability. These
retractors attach to the operating table with a post and have a
large variety of components for retraction. These devices are
Fig. 3.1 more flexible during operation than is the upper hand
retractor.
This device is ideal for operations around the lower The primary aim of all fixed retractors is not to reduce the
esophagus, such as hiatus hernia repair. It does not require number of assistants in the operating room but to provide
purchase of new instruments other than 25–30 cm of chain. better and more stable exposure. One disadvantage of using
It may be installed when necessary without preparation, even a mechanical self-retaining retractor in the abdomen is that it
during an operation. It is also helpful for liberating the may inflict trauma if intense pressure is exerted against the
splenic flexure of the colon. Here the device is placed on the rectus muscles. Another injury may be to the femoral nerve
left side of the operating table, and the retractor is positioned when using self-retaining blades for retraction in the lower
to draw the left costal margin to the left, cephalad, and ante- abdominal quadrants and pelvis. This pressure can be less-
riorly, significantly improving exposure. Whenever exposure ened by using long incisions and padding the musculature
for operations on the biliary tract is difficult, applying the with moist gauze pads. A second potential disadvantage
“chain” retractor to the right costal margin can be of when deep blades are used to retract intra-abdominal viscera
benefit. is distortion of normal anatomy, which may make it difficult
A slightly more complex retractor that attaches to the for the surgeon to identify vital structures. If the field is dif-
operating table to improve upper abdominal exposure is the ficult to interpret, consider removing any fixed deep blades
upper hand retractor (Fig. 3.2). This device is a steel bridge and reassessing the exposure.
that is attached to both sides of the operating table and passes
across the patient at the midsternal level. Its height is set at
4–10 cm above the sternum, depending on the type of retrac- Incisions for Abdominal Surgery
tion desired. Two retractor blades can be attached to the steel
bridge, one of which may be used to elevate the lower ster- Although many surgeons have long believed that transverse
num in a manner similar to the “chain” retractor. A second incisions are stronger and have a lower incidence of dehis-
blade may be attached to the bridge to retract the liver for cence than midline incisions, this belief is false (see follow-
biliary tract surgery; this method sometimes eliminates the ing section). Some think that the upper transverse incision
need for a second assistant. interferes less with respiration than does the upper midline
3 Incision, Exposure, Closure 17
incision. Clinically, this does not appear to be important. A even minor degrees of occult dehiscence may result in a
long, vertical midline incision gives excellent exposure for postoperative incisional hernia.
all parts of the abdomen. It also provides flexibility, as exten- The major causes of wound disruption are as follows:
sions in either direction are simple to execute. Reoperation
for other pathology is simpler if the previous operation was • Inadequate strength of suture material, resulting in
performed through a midline incision rather than a parame- breakage
dian incision. Finally, the midline incision creates minimal • Suture material that dissolves before adequate healing has
inferences with abdominal wall blood supply, facilitating occurred (e.g., catgut)
subsequent creation of TRAM (transverse rectus abdominis) • Knots becoming untied, especially with some monofila-
flaps for reconstructive breast and other surgery. Creation of ments (e.g., nylon and Prolene)
ostomies is simpler because the surgical incision is not in • Sutures tearing through tissue
proximity to the stoma. Thus, a midline incision offers con-
siderable options for ancillary procedures. All these causes except the last are self-explanatory;
Splenectomy, splenic flexure resection, hiatus hernia suture tears are poorly understood by most surgeons. A stitch
repair, vagotomy, pancreatectomy, and biliary tract surgery tears tissue if it is tied too tightly or encompasses too little
are easily done with the aid of the “chain” or more sophisti- tissue. Although it is true that in some patients there appears
cated retractors. Whenever exposure in the upper abdomen to be diminution in the strength of the tissue and its resis-
by this technique is inadequate, it is a simple matter to extend tance to tearing, especially in the aged and extremely
the midline incision via median sternotomy or into a right or depleted individuals, this does not explain the fact that many
left thoracoabdominal approach. Yet another advantage of wound disruptions occur in healthy patients. The sutures
midline incisions is the speed with which they can be opened must hold throughout the initial phase of wound healing,
and closed. which lasts several weeks and involves softening of the col-
Despite these advantages, we often use a subcostal lagen around the wound edges. Recent randomized trials
approach for open cholecystectomy because a short incision with careful follow-up have shown that the actual incidence
provides direct exposure of the gallbladder bed. If the gall- of wound infection and hernia is much higher than previ-
bladder has already been removed and a secondary common ously suspected and there is still much to be learned about
duct exploration is necessary or a pancreaticoduodenectomy the best method of incisional closure.
is contemplated, a midline incision extending 6–8 cm below When the incision is disrupted following an uncompli-
the umbilicus provides excellent exposure and may be cated cholecystectomy in a healthy, middle aged patient with
preferred. good muscular development, there must be a mechanical
When considering whether an upper midline incision or explanation. Often the surgeon has closed the wound with
subcostal might provide better exposure, study the angle of multiple small stitches of fine suture material. Under these
your patient’s ribs. If the patient has a narrow chest with a circumstances, a healthy sneeze by a muscular individual
high xiphoid process (a rib cage like the high arches of a tears the sutures out of the fascia and peritoneum because the
gothic church), an upper midline may be better. The thickset muscle pull exceeds the combined suture-tissue strength.
individual with a wide costal angle may do better with a sub- If the problem, then, is to maintain tissue approximation
costal incision. during a sneeze or abdominal distension for a period of time
For the usual appendectomy, the traditional McBurney sufficient for even the depleted patient to heal, what is the
incision affords reasonable exposure, a strong abdominal best technique to use? Adequate bits of tissue must be
wall, and a good cosmetic result. It heals extremely well and included in each suture; the sutures must be placed neither
hernias are rare. Accomplishing the same exposure with a too close nor too far apart; and they must be tied securely in
vertical incision would require either a long midline or a a manner that approximates but does not strangulate the
paramedian incision or an incision along the lateral border of tissue.
the rectus muscle, which might transect two intercostal Unfortunately, there is as yet no consensus as to the best
nerves and produce some degree of abdominal weakness. technique. Several points appear to have emerged from recent
trials. First, a running suture of a heavy slowly absorbable
material (such as PDS) appears to have advantages. Second,
Avoiding Wound Dehiscence and Hernia suture length to incision length should approximate 4:1.
Many surgeons believe that a patient who is at increased
Wound dehiscence spans a spectrum from catastrophic evis- risk of wound dehiscence by virtue of malnutrition, chronic
ceration through occult dehiscence. Major wound disruption steroid therapy, or chronic obstructive pulmonary disease
is associated with significant postoperative mortality, and should have an abdominal incision closed with “retention
2 cm
3 cm
3 cm
Fig. 3.3
sutures” that go through the skin and the entire abdominal

wall. If retention sutures are used, they should be considered
an adjunct to good closure rather than a substitute for it.
Suture bridges protect the skin, and retention sutures tied
Fig. 3.4
loosely do not cut through the fascia. Retention sutures
should be used only when delayed healing is anticipated and
should be left in place until healing is complete, which often
is signaled by the previously snug retention sutures becom-
ing loose as the wound contracts.
The Smead-Jones suture, recently modified as a continu-
ous rather than interrupted technique, creates a row of inter-
nal retention sutures by taking bites through the fascia and
muscle layers but avoiding the skin (Figs. 3.3 and 3.4) and
provides an alternative to external retentions that may be
more palatable to the patient. Although this text describes the
interrupted Smead-Jones technique, some have used a simi-
lar running suture technique with great success.
Operative Technique for a Midline Incision
Making the Incision
Open Surgery
Hold a large gauze pad in the left hand and apply lateral trac-
tion on the skin; the first assistant does the same on the oppo-
site side of the incision. Use the scalpel with a firm sweep
along the course of the incision (Fig. 3.5). The initial stroke
should go well into the subcutaneous fat. Then reapply the
gauze pads to provide lateral traction against the subcutane-
ous fat; use the belly of the scalpel blade to carry the incision
down to the linea alba, making as few knife strokes as pos-
sible. In morbidly obese individuals, a strong pull by surgeon Fig. 3.5
and assistant will often “cleave” the fat along the bloodless (e.g., laceration of vena cava with massive bleeding or air
midline to the linea alba. The linea alba can be identified in embolism), remain hidden for a period during surgery (retro-
the upper abdomen by observing the decussation of fascial peritoneal hematoma), or become symptomatic only in the
fibers. It can be confirmed by palpating the tip of the xiphoid, postoperative period (bowel or bladder laceration).
which indicates the midline. Safe port insertion starts with a review of the past surgical
The former custom of discarding the scalpel used for the history and assessment of the external anatomy for scars,
skin incision (in the belief that it incurred bacterial contami- body habitus, etc. Mark the planed ports and their sizes on
nation) is not supported by data or logic and is no longer the patient’s skin. Decide which port should be inserted first
observed. Because subcutaneous fat seems to be the body and where the camera should be placed.
tissue most susceptible to infection, every effort should be The safest method for the first port is an open cut-down
made to minimize trauma to this layer. Use as few hemostats (Hasson technique). Use this approach if there is any ques-
and ligatures as possible; most bleeding points stop sponta- tion about adhesions from previous surgery or other risk con-
neously in a few minutes. Subcutaneous bleeders should be stellations (aortic aneurysm, splenomegaly, pregnancy).
electrocoagulated accurately and with minimal trauma. Incise the skin for the respective trocar size, and supported
Continuing lateral traction with gauze pads, divide the by retractors dissect to the fascia. Place Kocher clamps onto
linea alba with the scalpel. If the incision is to be continued the fascia and incise it with scissors or a scalpel. Continue
around and below the umbilicus, leave a 5- to 8-mm patch of through the deeper layers until you can grasp the peritoneum
linea alba attached to the umbilicus to permit purchase by a with two clamps. Again, open the peritoneum in controlled
suture during closure. Otherwise, a gap between sutures may fashion. There should be space to slide in the first trocar. If
appear at the umbilicus, leading to an incisional hernia. that is not the case, you are either still preperitoneal, or there
Open the peritoneum to the left of the falciform ligament. are significant adhesions. If you suspect the latter, you either
Virtually no blood vessels are encountered when the perito- proceed with a regular open incision or try the same cut-
neum is opened close to its attachment to the undersurface of down technique in a different location. Once the first port is
the left rectus muscle. Elevate the peritoneum between two inserted, the pneumoperitoneum can be created (maximum
forceps and incise it just above and to the left of the umbili- 15 mm Hg pressure). Insert the camera and assess the situa-
cus. Using Metzenbaum scissors, continue this incision in a tion. Insert the subsequent ports under visual control. Unless
cephalad direction until the upper pole of the incision is the adhesions appear to be prohibitive, develop a working
reached. If bleeding points are encountered here, electroco- space by lysing adhesions until sufficient exposure and the
agulate them. One trick to minimize bleeding when opening planned port layout have been achieved.
the peritoneum, especially in patients with a considerable If there are not adverse risk factors, alternative port inser-
amount of preperitoneal fat, is to push vessels in this layer tion strategies include the Veress needle technique and an
laterally by gently pinching it with the other hand before optical trocar insertion. For the Veress needle technique, per-
incising the peritoneum. form a mini stab wound in a safe location (e.g., infraumbili-
To protect the bladder from injury, be certain when opening cal, left upper quadrant). Insert the Veress needle to
the peritoneum in the lower abdomen to identify the prevesical “reasonable depth” until a double click is noted. In correct
fat and bladder. As the peritoneum approaches the prevesical position, injection of saline should be without resistance,
region, the preperitoneal fat cannot be separated from the peri- aspiration should get back a few air bubbles. Create the
toneum and becomes somewhat thickened and more vascular. pneumoperitoneum until 4 liters of CO2 has been insufflated.
If there is any question about the location of the upper margin Make a skin incision at the camera port (which may be dif-
of the bladder, note that the balloon of the indwelling Foley ferent from the Veress needle site). Grab the skin around it
catheter can be milked in a cephalad direction. It is easy to with two towel clamps and lift the abdominal wall for
identify the upper extremity of the bladder this way. It is not counter-traction and insert the camera port. That can be done
necessary to open the peritoneum into prevesical fat, as it does bluntly or with a 0-degree camera inside the optical port
not improve exposure. Rather, simply retract this fat in a cau- obturator. The latter system can on occasion also be used
dal direction. However, opening the fascial layer down to and without even creating the pneumoperitoneum first.
beyond the pyramidalis muscles to the pubis does indeed Explore the abdomen laparoscopically in all quadrants
improve exposure for low-lying pelvic pathology. and record any abnormality. Subsequently place the operat-
ing table with the patient in such position that the nontarget
ort Insertion During Laparoscopic Surgery
P structures (e.g., small bowel) fall away from the target loca-
Unsafe insertion of the ports may not only ruin the mini- tion. For a pelvic operation, a steep Trendelenburg position
mally invasive surgery plan but can be a threat to the patient’s would be needed, for an appendix or right colon a left tilt.
safety or life. Injuries can either become violently obvious See Chap. 9 for more details.
Closure of Midline Incision

Previous suture
Modified Smead-Jones Technique strongly elevated
by assistant
In the upper abdomen, it is unnecessary to include the perito-
neum or falciform ligament in the suture. Below the umbili-
cus there is no distinct linea alba, and the rectus muscle belly
is exposed. In this region include the peritoneum in the stitch. Bite is
Apply Allis clamps to the linea alba at the midpoint of the 3 cm
wide Allis clamp
incision, one clamp on each side. Below the umbilicus, the Allis
clamps should include a bite of peritoneum and of anterior fas-
cia. With no. 1 polydioxanone suture (PDS), encompass 3 cm of
tissue on each side of the linea alba; then take a small bite of the
Linea alba
linea alba, about 5 mm in width, on each side. This results in a
small loop within a large loop (Fig. 3.6). The purpose of the
small loop is simply to orient the linea alba so it remains in
apposition rather than one side moving on top of the other. Place Distance between
sutures is 2 cm
the small loop 5–10 mm below the main body of the suture to
help eliminate the gap between adjacent sutures. Insert the next
suture no more than 2 cm below the first. Large, curved Ferguson
needles are used for this procedure.
tandard Running Closure

S Fig. 3.6
Another popular method of closure is to perform a running
suture encompassing 1 cm of fascia tissue on each side of the Interrupted Closure
linea alba and progressing in 1 cm steps. Unless the abdominal For an interrupted closure, tie the sutures with at least four
wall is substantially altered in composition, thickness, or condi- square throws. Avoid excessive tension. Again, prelay the last
tion by disease or previous surgery, it is preferable to not per- few stitches without tying them, leaving enough space to
form full-thickness bites as traction will lead to necrosis of insert the remaining stitches under direct vision. Tie all the
incorporated muscle or fat and the running suture will get loose. remaining sutures.
Better is to only incorporate fascia without fat or muscle. In laparoscopic cases, any port larger than 5 mm should
Different suture materials can be used. A no. 1 monofilament be closed to the fascia to avoid herniation.
suture (PDS or Prolene) has the advantage that it can easily be
pulled tight even after a few bites. A few interrupted absorbable
sutures (Vicryl) can be placed in-between the running bites to Skin Closure
serve as internal retention sutures. With a running stitch, it may
be tempting to use a single length of suture for the entire inci- Typically the skin is closed for elective cases and many
sion, but it is far easier and safer to begin from the ends and urgent/emergency cases, unless there was a grossly infected/
finish in the middle. However, it is often better to begin the run- contaminated surgical site. In that situation, only the fascia is
ning sutures from the cephalad and caudad ends separately and closed but the skin left open. In all other situations, close the
finish at the midpoint of the incision (Fig. 3.6). However, avoid skin with interrupted 4–0 nylon vertical mattress sutures, a
“meeting” the running sutures at the umbilicus; this may cause continuous subcuticular suture of 4–0 polyglycolic (PG), or
some unpleasant irritation to the patient and lead to hernias at staples (Fig. 3.7).
the umbilical region. Do not tie the last few stitches, leaving Other special incisions such as the McBurney (see Chap.
enough space to insert the remaining stitch under direct vision. 45) and subcostal (see Chap. 94) incisions are found else-
In no case should the surgeon insert a stitch without seeing the where in this volume where the operations most commonly
point of the needle at all times. Tie all the remaining sutures. performed through these exposures are introduced.
Further Reading
Ceydelli A, Rucinski J, Wise L. Finding the best abdominal closure:
an evidence-based review of the literature. Curr Surg. 2005;62:220.
Ellis H, Bucknall TE, Cox PJ. Abdominal incisions and their closure.
Curr Probl Surg. 1985;22(4):1.
Harlaar JJ, Deerenberg EB, van Ramshorst GH, Lont HE, van der Borst
EC, et al. A multicenter randomized controlled trial evaluating the
effect of small stitches on the incidence of incisional hernia in mid-
line incisions. BMC Surg. 2011;11:20.
Jacobs HB. Skin knife-deep knife: the ritual and practice of skin inci-
sions. Ann Surg. 1974;179:102.
Lumsden AB, Colborn GL, Sreeram S, Skandalakis LJ. The surgical
anatomy and technique of the thoracoabdominal incision. Surg Clin
North Am. 1993;73:633.
Masterson BJ. Selection of incisions for gynecologic procedures. Surg
Clin North Am. 1991;71:1041.
Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound
complications after closure of midline incisions: a randomized con-
trolled trial. Arch Surg. 2009;144:1056.
Rahbari NN, Knebel P, Diener MK, Seidlmayer C, Ridwelski K,
Stoltzing H, Seiler CM, et al. Current practice of abdominal wall
closure in elective surgery – is there any consensus? BMC Surg.
2009;9:8.
Seller CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer
C, Franck A, Kieser M, et al. Interrupted or continuous slowly
absorbable sutures for closure of primary elective midline abdominal
incisions: a multicenter randomized trial. Ann Surg. 2009;249:576.
Wind GG, Rich NM. Laparotomy. In: Principles of surgical technique.
Baltimore: Urban & Schwarzenberg; 1987. p. 177–200.
Fig. 3.7
Dissecting and Suturing
4
Constantine P. Spanos, Andreas M. Kaiser,
Art of Dissecting Planes maneuver produces gentle traction on the tissue to be incised.
If the finger is visible through the adhesion, it can aid dissec-
Of all the skills involved in the craft of surgery, perhaps the tion. When encountering adhesions in the midline during a
single most important is the discovery, delineation, and sepa- redo laparotomy, upward traction on the abdominal wall
ration of anatomic planes. When this is skillfully accom- using Kocher clamps may facilitate their dissection and
plished, there is scant blood loss and tissue trauma is division.
minimal. The delicacy and speed with which dissection is If there is insufficient space for inserting the surgeon’s left
accomplished can mark the difference between the master index finger, often Metzenbaum scissors, with blades closed,
surgeon and the novice. The specific anatomic planes that can serve the same function when inserted underneath an
often represent the bloodless embryologic fusion planes are adhesion for delineation and division. This maneuver is also
described for each operation in the remainder of the book. useful when incising adventitia of the auxiliary vein during a
This chapter deals with general techniques for developing mastectomy. To do this, the closed Metzenbaum scissors are
these planes. inserted between the adventitia and the vein itself, they are
Of all the instruments available to expedite the discovery then withdrawn, the blades are opened, and one blade is
and delineation of tissue planes, none is better than the sur- inserted underneath the adventitia. Finally, the jaws of the
geon’s nondominant index finger. This digit is insinuated scissors are closed, and the tissue is divided. This maneuver
behind the lateral duodenal ligament during performance of is repeated until the entire adventitia anterior to the vein has
the Kocher maneuver, behind the renocolic ligament during been divided.
colon resection, and behind the gastrophrenic ligament dur- In many situations, a closed blunt-tipped right-angle
ing a gastric fundoplication. These structures can then be Mixter clamp may be used the same way as Metzenbaum
rapidly divided, as the underlying index finger is visible scissors for dissecting and delineating anatomic structures.
through the transparent tissue. Dissection of all these struc- Identification and skeletonization of the inferior mesenteric
tures by other techniques not only is more time consuming, artery or the cystic artery and delineation of the circular mus-
it is frequently more traumatic and produces more blood cle of the esophagus during cardiomyotomy are some uses to
loss. which this instrument can be put.
To identify adhesions between the bowel and peritoneum, The scalpel is the instrument of choice when developing
pass the nondominant index finger behind the adhesion. This a plane that is not a natural one, be it when elevating skin
flaps over the breast or dissecting dense abdominal adhe-
sions. When the scalpel is held at a 45° angle to the direction
C. P. Spanos of the incision (Fig. 4.1), it is useful for clearing fascia of
overlying fat.
More important, when the surgeon must cope with
A. M. Kaiser
advanced pathologic changes involving dense scar tissue,
Hope National Medical Center/Comprehensive Cancer Center, such as may exist when elevating the posterior wall of the
Duarte, CA, USA duodenum in the vicinity of a penetrating duodenal ulcer, the
C. E. H. Scott-Conner (*) scalpel is the only instrument that can divide the dense scar
Department of Surgery, University of Iowa Carver College accurately until the natural plane of cleavage between the

https://doi.org/10.1007/978-3-030-81415-1_4
vasculature. The rectal mucosa is such an example. Injection

of the aforementioned solution into the rectal mucosa/sub-
mucosa will provide hemostatic dissection during perineal
procedures for rectal prolapse and mucosectomy when per-
forming a coloanal or ileal-pouch anal anastomosis.
The surgeon who wants to perform accurate dissections is
greatly aided by a talent for quickly recognizing tissues and
structures as they are revealed by the scalpel or scissors. A
45˚
truly alert surgeon can promptly evaluate the structural char-
acteristics of a nerve, blood vessel, ureter, or common bile
duct, so each is identifiable at a glance, even before the struc-
ture is thoroughly exposed. An intimate knowledge of anat-
omy is required for the surgeon to always be two steps ahead
of the game and anticipate exactly where each structure will
appear even before it has been revealed by dissection.
Fig. 4.1
duodenum and pancreas is reached, beyond the diseased Sewing Technique

tissue.
The peanut sponge (Kutner dissector), a small, 1.5 cm Use of a Needle Holder
gauze sponge grasped in a long hemostat, is an appropriate
device for separating fat and areolar tissue from anatomic Smooth rotatory wrist action and the surgeon’s awareness of
structures. It should not be used to tear tissues while making what it feels like when a needle penetrates the submucosa of
a plane. After the peritoneum overlying the cystic duct and the bowel are important when suturing with a typical half-
artery has been incised, the peanut sponge can separate the circle needle on a needle holder (see Chap. 2).
peritoneum and fat from the underlying duct and artery. It is
similarly useful for elevating a thyroid lobe from its capsule.
After sharp dissection has exposed the major arteries during Selection of Needle
the course of a colon resection, the peanut sponge can be
used to skeletonize the vessels and sweep the lymphatic and The needle selected for any use should have the least possi-
areolar tissue toward the specimen. ble thickness commensurate with adequate strength to
A folded 10 × 10 cm gauze square grasped in a sponge achieve its purpose. Tapered-point needles are used to insert
holder (sponge-on-a-stick) has occasional application for sutures into soft tissue such as the fascia, fat, or gastrointes-
sweeping perirenal fat from the posterior aspect of the peri- tinal viscera. Cutting needles are used for the skin and occa-
toneum during lumbar sympathectomy. It is useful also for sionally for tough fibrous tissue such as breast. Use of a too
separating the posterior wall of the stomach from peripancre- delicate needle risks bending or breaking the needle. More
atic filmy peritoneal attachments. Because the use of a large often such damage is due to failure to follow the curve of the
sponge does not permit anatomic precision, small veins may needle as it passes through the tissue or placing the needle
be torn during this type of gross dissection; therefore, the too far back on the needle holder. Needles with a 5/8 circle
sponge’s applicability is limited to avascular planes. curvature are used in deep, confined anatomic regions such
In several instances, saline injection in tissue planes may as a port site closure or the anorectum. They can be used by
facilitate the dissection, especially in difficult cases where rotating the wrist with little or no lateral movement.
inflammation is encountered. One example is the injection of
saline between the gallbladder wall and the liver during open
or laparoscopic cholecystectomy for acute cholecystitis. This Size of Bite
may be of significant help during removal of the gallbladder
from its fossa in the liver bed. Another prime example is The width of the tissue enclosed in the typical seromuscular
endoscopic mucosal resection where the submucosal injec- suture varies between 4 and 6 mm, depending on the thick-
tion is crucial to elevate the lesion such that it can be encir- ness and consistency of the tissue involved. Hypertrophied
cled with a snare and removed without risk to damage the gastric wall requires a larger bite than the normally thin
muscularis and cause a perforation. colon. As discussed in Chap. 3, our version of the Smead-
Finally, hemostatic dissection may be aided by the injec- Jones closure includes a bite of abdominal wall 3 cm wide
tion of saline and dilute epinephrine in tissue layers with rich for the “internal retention suture” part of the closure. Thus,
4 Dissecting and Suturing 25
the size of the bite must be matched to the purpose of the When an end-to-end anastomosis of the GI tract is fash-
suture, the size of the suture, and the amount of force the ioned, a continuous circumferential suture has a risk to lack
suture line must withstand. elasticity and cause a narrowing of the lumen (until the
suture is dissolved). When an anastomosis is large, as with a
gastrojejunostomy, the use of two continuous layers of PG
Distance Between Sutures appears safe. If the lumen is very narrow, though, the anasto-
mosis should either be done with interrupted sutures or use a
The distance between bites for a typical approximation of the separate continuous suturing for each hemicircumference
seromuscular layer with interrupted Lembert sutures is with care to avoid narrowing. Reinforcing a first layer with
5 mm. When continuous mucosal or other sutures are used, seromuscular stitches in interrupted fashion avoids the pos-
the width of the bites and the distance apart should be sibility that the purse-string effect of continuous stitch would
approximately the same as those specified for interrupted narrow the lumen more.
stitches.
After one layer of sutures has been inserted, tentatively
test the degree of inversion that is required to allow the sec- How Tight the Knot?
ond layer to be inserted without tension. Invert as little tissue
as possible, consistent with avoiding tension. There is almost nothing more delicate than defining the
right tension on sutures, particularly when it comes to
suturing a hollow viscus. Too loose a suture will result in a
Size of Suture Material tissue dehiscence. But if the sutures are too tight, they risk
cutting into the tissue, which is aggravated by evolving
As there must never be any tension on an anastomosis in the bowel edema. This may cause ischemic necrosis at the
gastrointestinal tract, it is not necessary to use suture mate- bowel ends where good perfusion would be needed most.
rial heavier than 4-0 or 3-0. Failure to heal often is due to a In addition, an eroding bite that has been placed errone-
stitch tearing through the tissue; it is almost never due to a ously through the entire wall of the bowel into the lumen
broken suture. When two layers of sutures are used for an may open up a hole. Both scenarios result in the potentially
anastomosis in the gastrointestinal (GI) tract, the inner layer disastrous clinical picture of an anastomotic leak. Because
should be 5-0 or 4-0 PG. This layer provides immediate, considerable edema follows construction of an anastomo-
accurate approximation of the mucosa and, in some instances, sis, knots should be tied with tension sufficient only to pro-
hemostasis. vide apposition of the two seromuscular coats without
When taking large bites of tissue with considerable ten- blanching of the tissue.
sile strength, such as with the Smead-Jones closure of the Caution must be exercised when tying slippery suture
abdominal wall, heavier suture material is indicated. Here, materials such as PDS. Each knot may have the effect of a
1-0 PDS is suitable. Obviously, the size of the suture material noose that is repeatedly tightened with the tying of each
must be proportional to the strength of the tissues into which additional knot. Nylon sutures also exhibit excessive slip-
it is inserted and to the strain it must sustain. page; even when the first knot has been applied with proper
The ideal suture is the smallest possible that provides tension, and thus, each succeeding knot often produces fur-
high uniform tensile strength, the ability to hold the wound ther constriction. When nylon sutures in the skin have been
securely during the healing phase and then rapidly absorb, a tied with too much tension, marked edema, redness, and
consistent uniform diameter, sterility, pliability, knot secu- cross-hatching can be seen at the site of each stitch. The
rity, least amount of tissue reactivity, and predictability. same ill effects occur when intestinal sutures are made too
tight, but the result is not visible to the surgeon.
Continuous Versus Interrupted Sutures

atching Both Walls of Intestine with One Pass
C
The advantage of interrupted sutures is that failure of a single of the Needle Holder
stitch may not necessarily trigger a complete failure of the
entire closure or anastomosis. The advantage of the continu- Most surgeons who insert seromuscular sutures to approxi-
ous suture technique is not only that it is typically faster, mate two segments of intestine were taught to insert the
avoids multiple knots that on occasion can cause irritations Lembert suture through the intestine on one side of the
in skinny patients, but most importantly that the tissue ten- anastomosis. They then pick up the needle with the needle
sion is equally distributed. holder to take another Lembert stitch in the opposite wall of
the bowel. Occasionally, under ideal conditions, it is pos- Types of Stitches

sible to pass a needle of proper length through one side of
the intestine and then, without removing the needle holder, Simple Everting Skin Stitch
to pass the needle through the opposite wall before pulling
the thread through. The danger associated with this shortcut Eversion of the edges is desired when closing the skin.
is that one may traumatize the entrance wound made on the Consequently, the wrist should be pronated and the needle
side of the intestine through which the needle was first inserted so the deeper portion of the bite is slightly wider
inserted. This problem can occur as the surgeon moves the than the superficial portion (Fig. 4.4). When this stitch is
needle and the intestinal wall in a lateral direction to bring tied, the edges are everted (Fig. 4.5).
it closer to the opposing intestine, thereby making a small
tear at the entrance hole (Fig. 4.2). With proper technique,
this shortcut can be accomplished without undue trauma. Vertical Mattress (Stewart) Stitch
After the needle has been passed through the first segment
of the intestine, the surgeon should avoid any lateral move- With the classic Stewart method of skin suturing, eversion is
ment of the needle holder. Instead, the surgeon gently picks guaranteed by the nature of the vertical mattress stitch
up the opposing segment of intestine with a forceps and (Figs. 4.6 and 4.7). Neither of these two types of skin suture
brings this portion of bowel to the needle. Then, with a should be tied with excessive tension if cross-hatching is to
purely rotatory motion of the wrist, the surgeon allows the be avoided.
needle to penetrate the second side (Fig. 4.3). If the surgeon
is conscious of the need to avoid trauma and uses a rotatory
maneuver, there are situations in which this technique is Deep portion at
suture bite is wider
acceptable and efficient.
than superficial part
Tear at
point of
entry
Fig. 4.4
Fig. 4.2
Note
absence
of tear
Fig. 4.3 Fig. 4.5

Fig. 4.6
Fig. 4.8
Skin Staples
Skin staples can be applied with force just sufficient to achieve

approximation without producing cross-hatching of the skin.
Fig. 4.7 They allow good cosmetic results. Depending on the thickness
of the skin and the underlying structures, staples may be
placed 5–10 mm apart (Fig. 4.9). Align the skin edges to pro-
Continuous Subcuticular Stitch duce good apposition with slight eversion. When working
with a less-skilled assistant, it is preferable for the surgeon to
For the continuous subcuticular stitch, 4-0 PG may be align the edges and allow the assistant to place the staples.
employed on an atraumatic, curved, cutting needle. With
practice the surgeon may insert it rapidly and obtain a good
cosmetic result (Fig. 4.8). Because it is absorbable, there are Simple Interrupted Fascial Stitch
no sutures to remove postoperatively.
If preferred, a continuous 3-0 Prolene or nylon may be Interrupted fascia closure (Fig. 4.10) is almost never done,
used, with lead shot or an external knot fixing the stitch at not to say obsolete. Even McBurney and Pfannenstiel inci-
its points of origin and termination. This stitch should not sions are safely and more efficiently closed with running
be removed for 10–14 days following the operation. If a sutures. Exceptions are internal retention sutures that are
closure is very long, plan for several segments of not more placed in addition to a running suture. Or in patients with
than 7–8 cm length each to avoid suture breaks during fascial dehiscence and very poor quality of the abdominal
removal. wall, the sutures have a substantial risk of pulling through
the tissue. It may therefore be safer to close the fascia with

interrupted full-thickness bites (“mass closure”), supported
by placement of external retention sutures.
Continuous Simple Over-and-Over Stitch
The simple over-and-over continuous stitch (Fig. 4.11) is the

most common form of closure for the fascia, occasionally for
the peritoneum. The stitches should be placed about 1 cm
apart and incorporate 1 cm of fascia; muscle or fat tissue
should be largely avoided as they do not add strength and
allow the suture to cut through and get loose.
Smead-Jones Stitch
The Smead-Jones stitch is well suited for closure of major

abdominal incisions. It is, in essence, a buried “retention”
suture, as it encompasses in its large loop all layers of the
abdominal wall, except the skin. The large loop is followed by a
small loop, which catches only 4–5 mm of linea alba on each
side. The purpose of this small loop is to orient the abdominal
wall in perfect apposition. It is described in detail in Chap. 3.
Horizontal Mattress Stitch
Fig. 4.9 The horizontal mattress suture (Fig. 4.12) is occasionally

used to close fascia, for example, for larger than 5 mm lapa-
Fig. 4.10 Fig. 4.11

roscopic ports, and sometimes for ventral hernia repair. It lar and submucosal layers and a small amount of mucosa.
can also serve as a hemostatic stitch. When properly applied, it produces a slight inversion of the
mucosal layer upon approximation.
If it is passed into the lumen before emerging from the
Hemostatic Figure-of-Eight Stitch mucosal layer, it is identical with that described by Gambee,
whose technique was at one time applied to one-layer clo-
The classic hemostatic figure-of-eight stitch (illustrated in Chap. sure of the Heineke-Mikulicz pyloroplasty. Used in an inter-
3, Fig. 3.4) is used for occlusion of a bleeding vessel that has rupted or a continuous fashion, it is an excellent alternative
retracted into the muscle or similar tissue. If p ossible, the center to the Connell stitch for inversion of the anterior mucosal
of the bleeding is either grasped with forceps or an Allis clamp. layer of a two-layer bowel anastomosis. When used for con-
On either side of the bleeder, a sufficiently deep bite is taken. struction of a single-layer intestinal anastomosis, it should of
Upon tying, the bleeding should be encircled and subside. course be done only in interrupted fashion.
Single-Layer Bowel Anastomosis Seromuscular Lembert Stitch
Bowel anastomoses employing one layer of sutures have Perhaps the most widely used technique for approximating
become acceptable. An effective method for accomplishing the seromuscular layer of a bowel or gastric anastomosis is
inversion and approximation simultaneously is the use of the the Lembert stitch (Fig. 4.14). Catching about 5 mm of tis-
seromucosal stitch (Fig. 4.13), which catches the seromuscu- sue, it includes a bite of submucosa and emerges 1–2 mm
proximal to the cut edge of the serosa. It also has been used
for one-layer intestinal anastomoses. Under proper circum-
stances, it may be applied in a continuous fashion.
Cushing Stitch
The Cushing stitch is similar to the Lembert stitch, except it

is inserted parallel to the cut edge of the bowel at a distance
of 2–4 mm and catches about 5 mm of the seromuscular
bowel, including the submucosa. It is especially applicable
to seromuscular approximation for anastomoses in poorly
accessible locations, such as the low colorectal anastomosis.
The technique can be employed in interrupted (Fig. 4.15a) or
continuous fashion (Fig. 4.15b) and can be a good alternative
to the Connell stitch for inverting the anterior mucosal layer
of an anastomosis. The main difference between the Connell
stitch (see below) and a continuous Cushing suture is that the
former penetrates the lumen of the bowel, whereas the latter
passes only to the depth of the submucosal layer. The con-
tinuous Cushing suture is also much easier and more effi-
cient to accomplish than the Connell stitch.
Fig. 4.12
Fig. 4.13 Fig. 4.14

Fig. 4.17
Fig. 4.15
Fig. 4.18
Connell Stitch
The Connell suture was originally described as a technique

for performing a single-layer end-to-end anastomosis of the
Fig. 4.16 bowel. This suture has been used for many decades as the
method for inverting the anterior mucosal layer of a two-
layer bowel anastomosis. The stitch goes from the serosa
Halsted Stitch through all layers of intestine into the lumen (Fig. 4.18),
comes out through all the layers on the same side, and passes
The Halsted stitch (Fig. 4.16) is another variation of the over to the opposite segment of the bowel, where the same
Cushing stitch with a seromuscular depth. It provides excel- sequence takes place.
lent seromuscular approximation in a bowel anastomosis. Because it forms a loop on the mucosa, the Connell
The danger it shares with the Cushing stitch is that excessive stitch is slightly hemostatic, but one should not depend
tension can cause strangulation of a larger bite of tissue than entirely on it for that purpose. The suture is placed loosely
does the simple Lembert suture. to avoid purse-stringing the anastomosis and hence is inad-
equate to produce hemostasis for small arterial bleeders. As
the bowel is inverted, intraluminal bleeding does not remain
Continuous Locked Stitch visible to the surgeon and may go undetected. This is par-
ticularly common with the stomach, which has a rich sub-
A continuous locked stitch (Fig. 4.17) ensures hemostasis mucosal blood supply. Rather than rely on the Connell
during approximation. When hemostasis is not a problem, stitch, individually ligate the bleeding points or secure
some surgeons prefer to close this layer with a simple over- them with electrocautery.
and-over continuous stitch (see Fig. 4.11).
Technique of Successive Bisection prevent leakage. Although we have had good results with
one-layer techniques, we recommend that each surgeon
The technique we named “successive bisection” ensures master the standard two-layer technique before considering
consistently accurate intestinal anastomoses, especially the other.
when the diameters of the two segments are not identical. As
illustrated in Fig. 4.19, the first two stitches are inserted at
the mesenteric and the antimesenteric border. All subsequent End-to-End or End-to-Side Technique?
stitches are always placed in the middle of the two adjacent
sutures. This pattern is then repeated until the anastomotic In most situations, the end-to-end technique is satisfactory
layer is complete (Fig. 4.20). for joining two segments of bowel. If there is some disparity
in diameter, a spatulation by means of a Cheatle slit is per-
formed on the antimesenteric border of the narrower seg-
Intestinal Anastomoses ment of intestine to enable the two diameters to match each
other (Figs. 4.21 and 4.22).
One Layer or Two? If there is a large disparity in the two diameters (>1.5–
2.0 cm), the end-to-side anastomosis has advantages, pro-
Although abundant data confirm that an intestinal anasto- vided the anastomosis is not constructed in a manner that
mosis can be performed safely with one or two layers of permits a blind loop to develop. If the end-to-side anastomo-
sutures, to our knowledge there is no consistent body of sis is placed within 1 cm of the closed end of the intestine,
randomized data conclusively demonstrating the superior- the blind loop syndrome does not occur. Stapled closure of
ity of one or the other in humans. It is obvious that the one- the end segment is rapid and efficient. Alternatively, an iso-
layer anastomosis does not turn in as much intestine and peristaltic side-to-side anastomosis can be carried out.
consequently has a larger lumen than the two-layer anasto- There are two instances in which the end-to-side or side-
mosis. However, in the absence of postoperative leakage, to-end anastomosis are superior to the end-to-end procedure.
obstruction at the anastomotic site is rare except perhaps First, studies have suggested that for the esophagogastric
when the esophagus is involved. It seems reasonable, anastomosis following esophagogastrectomy, the incidence
though, to assume that if the seromuscular layer sutured by
the surgeon suffers from some minor imperfection the
mucosal sutures may compensate for the imperfection and
Cheatle
1 slit
Fig. 4.19
3
5
Fig. 4.20 Fig. 4.21

advantage, this rapidity is the result of an intense inflamma-

tory reaction that produces enzymes to digest the organic
material. Plain catgut is acceptable for ligating bleeding
points in the subcutaneous tissues and not for much else.
Electrocautery has largely rendered that application
unnecessary.
Chromic Catgut
Chromic catgut has the advantage of a smooth surface, which
permits it to be drawn through delicate tissues with minimal
friction. It thus may be good for splenorrhaphy or hepator-
rhaphy. Moisten the chromic catgut with saline and allow it
to soften for a few seconds before inserting the suture.
Chromic catgut generally retains its strength for about a
week and is suitable only when such rapid absorption is
desirable. It is completely contraindicated in the vicinity of
the pancreas, where proteolytic enzymes produce premature
absorption, or for closure of abdominal incisions and hernia
Fig. 4.22
repair, where it does not hold the tissues long enough for
adequate healing to occur.
of leakage, postoperative stenosis, and mortality is lower Chromic catgut is useful for approximating the mucosal
with the end-to-side technique. Second, an ultralow rectal layer during two-layer anastomosis of the bowel. For this
anastomosis may functionally benefit from an interruption of purpose, size 4-0 is suitable. Bear in mind that wound infec-
the peristaltic wave and possible increase of the reservoir. tion increases the rapidity of catgut digestion. Chromic cat-
gut has largely been supplanted by synthetic absorbable
sutures for the purpose.
Sutured or Stapled Anastomosis? Chromic catgut swells slightly as it absorbs water after
contact with tissue, with the knots becoming more secure. It
Gastrointestinal stapling techniques (see Chap. 5) have is used for some endoscopic pretied suture ligatures for this
become standardized, faster, and universally accepted where reason.
size and anatomy permit. When done by experienced sur- Similarly, hydrated chromic catgut suture become soft
geons, suturing and stapling can achieve equally good and thus may be preferred for splenorrhaphy or hepatorrha-
results. Some anastomoses are naturally easier to suture, for phy in trauma surgery, as it is less likely to cut through.
example, a choledochojejunostomy or a colo-anal anastomo-
sis, as opposed to a low colo-rectal anastomosis which is
much easier stapled. Another example would be the stapled Polyglycolic Synthetics
side-to-side functional end-to-end anastomosis which pro-
vides an easy way to create an ileocolonic anastomosis after Polyglycolic synthetic sutures (PG), such as Dexon or Vicryl,
right hemicolectomy because it eliminates the problems pre- are far superior to catgut because the rate at which they are
viously described for joining bowel of varying size. absorbed is much slower. About 20% of the tensile strength
Unquestionably, however, a hand-sewn anastomosis in one remains even after 15 days. Digestion of the PG sutures is by
or two layers can be constructed with any portion of the hydrolysis. Consequently, the proteolytic enzymes in an area
bowel. of infection have no effect on the rate of absorption of the
sutures. Also, the inflammatory reaction they incite is mild
compared to that seen with catgut. The chief drawback is that
Suture Material their surface is somewhat rougher than that of catgut, which
may traumatize tissues slightly when the PG suture material
Absorbable Sutures is drawn through the wall of the intestine. This characteristic
also makes tying secure knots somewhat more difficult than
Plain Catgut with catgut. However, these factors appear to be minor disad-
Plain catgut is not commonly used during modern surgery. vantages, and these products have made catgut an obsolete
Although its rapidity of absorption might seem to be an suture material for many purposes.
Nonabsorbable Sutures ynthetic Nonabsorbable Monofilaments

S
Monofilament synthetics such as nylon and Prolene are so
atural Nonabsorbable Sutures
N slippery and have such a strong “memory” (the tendency to
Natural nonabsorbable sutures, such as silk and cotton, have return to the original untied shape) that as many as six or
enjoyed a long period of popularity among surgeons the seven knots may be required. These and monofilament stain-
world over. They have the advantage of easy handling and less steel are the least reactive of all the products available.
secure knot tying. Once the knots are set, slippage is rare. On For this reason, 2-0 or 0 Prolene has been used by some sur-
the other hand, they produce more inflammatory reaction in geons for the Smead-Jones abdominal closure in the hope of
tissue than do the monofilament materials (stainless steel, eliminating suture sinuses. Because of the large number of
Prolene) or even the braided synthetics. Silk and cotton, knots, this hope has not been realized, but there are fewer
although classified as nonabsorbable, disintegrate in the tis- sinuses than when nonabsorbable braided materials are used.
sues over a long period of time, whereas the synthetic mate- Prolene size 4-0 on atraumatic needles has been used for the
rials appear to be truly nonabsorbable. Despite these seromuscular layer of intestinal anastomoses. Both Prolene
disadvantages, silk and cotton have maintained worldwide and various braided polyester sutures have achieved great
popularity mainly because of their ease of handling and sur- popularity for vascular surgery.
geons’ long familiarity with them. Because there are no
clear-cut data at this time demonstrating that anastomoses
performed with synthetic suture material have fewer compli- Monofilament Stainless Steel Wire
cations than those performed with silk or cotton, it is not yet
necessary for surgeons to abandon the natural nonabsorbable Monofilament stainless steel wire has many of the character-
sutures if they can handle them with greater skill. istics of an ideal suture material, but it is difficult to tie and
With the exception of the monofilaments, a major disad- has largely been abandoned except for closing median ster-
vantage of nonabsorbable sutures is the formation of chronic notomy incisions.
draining sinuses and suture granulomas. This problem is
especially marked when material larger than size 3-0 is used
in the anterior abdominal fascia or subcutaneous tissue. For Knot-Tying Technique
this reason, many surgeons do not use nonabsorbable sutures
above the fascia. The “three-point technique” for tying knots is important
when ligating blood vessels. The surgeon’s left hand grasp-
ynthetic Nonabsorbable Braided Sutures
S ing one end of the ligature, the vessel being ligated, and the
Synthetic braided sutures include those made of Dacron surgeon’s right hand grasping the opposite end of the ligature
polyester, such as Mersilene, Ticron (Dacron coated with are positioned in a straight line (Fig. 4.23a, b). If this is not
silicone), Tevdek (Dacron coated with Teflon), and Ethibond the case, as the surgeon’s hands draw apart when tightening
(Dacron with butilated coating). Braided nylon (Surgilon or the knot, they exert traction against the vessel. When tying
Nurolon) is popular in the UK. All these braided synthetic deep bleeding points, this traction tears the vessel at the point
materials require four or five knots for secure closure, com- of ligature and exacerbates bleeding. When tying a deep
pared to the three required of silk and cotton. structure, such as the cystic artery, the surgeon’s left index
finger should draw the deep end of the ligature deep to the
artery so the left index finger, the cystic artery, and the sur-
geon’s right hand always form a straight line.
Fig. 4.23
a
When using silk, three square throws provide adequate

security. With PG sutures, four throws are necessary. With
the various coated polyester sutures, four or five knots must
be tied. When using the synthetic materials, many prefer the
“surgeon’s knot” (Fig. 4.24) as a first throw.
For heavy monofilament suture material such as 0 or 1
Prolene, we have used modified fisherman’s 3-1-2 knot:
First, make a triple-throw “surgeon’s knot” (Fig. 4.25a) and
then square it with a single throw (Fig. 4.25b). Complete the
knot with the usual double-throw “surgeon’s knot”
(Fig. 4.25c). This knot seems to hold without slipping.
When tying a knot in a deep or poorly accessible location,
it is vital that the two-hand tying technique be used. For
superficial bleeding points in the skin and subcutaneous tis- Fig. 4.24
sues, one- or two-hand knots are efficacious.
a Further Reading
Ceydelli A, Rucinski J, Wise L. Finding the best abdominal closure:
an evidence-based review of the literature. Curr Surg. 2005;62:220.
Ellis H, Bucknall TE, Cox PJ. Abdominal incisions and their closure.
Curr Probl Surg. 1985;22(4):1.
Harlaar JJ, Deerenberg EB, van Ramshorst GH, Lont HE, van der Borst
EC, et al. A multicenter randomized controlled trial evaluating the
effect of small stitches on the incidence of incisional hernia in mid-
line incisions. BMC Surg. 2011;11:20.
Jacobs HB. Skin knife-deep knife: the ritual and practice of skin inci-
sions. Ann Surg. 1974;179:102.
Lumsden AB, Colborn GL, Sreeram S, Skandalakis LJ. The surgical
anatomy and technique of the thoracoabdominal incision. Surg Clin
North Am. 1993;73:633.
Masterson BJ. Selection of incisions for gynecologic procedures. Surg
Clin North Am. 1991;71:1041.
b Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound
complications after closure of midline incisions: a randomized con-
trolled trial. Arch Surg. 2009;144:1056.
Rahbari NN, Knebel P, Diener MK, Seidlmayer C, Ridwelski K,
Stoltzing H, Seiler CM, et al. Current practice of abdominal wall
closure in elective surgery – is there any consensus? BMC Surg.
2009;9:8.
Seller CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer
C, Franck A, Kieser M, et al. Interrupted or continuous slowly
absorbable sutures for closure of primary elective midline abdominal
incisions: a multicenter randomized trial. Ann Surg. 2009;249:576.
Wind GG, Rich NM. Laparotomy. In: Principles of surgical technique.
Baltimore: Urban & Schwarzenberg; 1987. p. 177–200.
Fig. 4.25
Surgical Stapling: Principles
and Precautions 5
Characteristics of Staples depending on device selection. An aligning pin isolates the

tissue to be stapled and ensures proper position of the anvil
Modern surgical staples are constructed of a titanium alloy and staple cartridge. In cases where a staple line longer than
and designed to mimic the biomechanical and physiologic can be accommodated comfortably with the pin in closed
effects of a sutured anastomosis on the tissue they are placed position is required, a linear cutting stapler is preferred.
into. Basic principles such as approximation without stran- Linear staplers appose tissues in eversion, such that the
gulation and gentle noncrushing tissue handling are carried mucosa of each side faces each other. Many surgeons choose
forward into the design of modern surgical staples and sta- to oversew or dunk the everted staple line to achieve serosal
plers. When applied correctly the tissue is entered perpen- apposition. The device finds application in multiple areas
dicular with straight staple prongs that are bent into a “B” including completion of an anastomosis by closure of the
configuration at the appropriate selected depth. As illustrated open end or enterotomies through which another stapling
in Fig. 5.1, selection of the proper staple load height to match device was inserted and fired.
the tissue thickness is essential and allows for perfusion of These staplers are only available for open surgery.
tissue distal to the staple line. Minimally invasive linear cutting stapling devices perform
this function during laparoscopic surgery.
Surgical Stapling Technology

Linear Cutting Stapling Device
The sections below describe the most common types of sta-
pling devices and their application. Product specifications The linear cutting stapler, often referred to as the gastrointes-
vary between manufacturers and each has unique names, tinal anastomosis or GIA stapler, applies two double-
sizes, and color coding systems for staple cartridges. staggered staple rows and utilizes a built in knife to divide
Familiarize yourself with the use of the particular devices between them. Staplers are available in various lengths
available at your institution, including stapler sizes, staple between and 55 mm and 100 mm depending on manufacture,
heights, and the recommended reloadable cartridge size for and utilize reloadable cartridges in staple heights that should
each tissue type. be matched to the tissue type. The technology finds common
application in dividing segments of bowel as well as in anas-
tomosis creation, including functional end-to-end and the
Linear Stapling Device gastrojejunostomy pictured in Fig. 5.2. A curved variation on
the cutting stapler is available for applications within the
The linear stapling device, often referred to as the transverse limited anatomic space of the pelvis.
anastomosis or TA stapler, applies a line of two staggered The minimally invasive or endoscopic linear cutting sta-
staple rows in lengths of 30 mm, 45 mm, 60 mm, or 90 mm pler devices apply two double-staggered or triple-staggered
staple rows depending on the manufacture. These feature
articulating joints for improved utility within a limited oper-
E. R. Noren · S. W. Lee (*) ating space and compression mechanisms to squeeze out tis-
Department of Surgery, Division of Colorectal Surgery, Keck
sue edema. Manual and powered stapling devices are
School of Medicine of the University of Southern California,
Los Angeles, CA, USA available.
e-mail: sangwl@med.usc.edu

https://doi.org/10.1007/978-3-030-81415-1_5
38 E. R. Noren and S. W. Lee
Fig. 5.1 4 mm
a
4.8 mm
Approximately
2 mm closed
Range of closure
b
4 mm
3.5 mm
Approximately
1.5 mm closed
Range of closure
5 Surgical Stapling: Principles and Precautions 39
Fig. 5.3
Fig. 5.2 issue Properties of the Stapled

T
Anastomosis
A “vascular” load, intended to be hemostatic, is available Surgical staplers must accommodate the unique physiologic
for these staplers. It may be used to divide the main vascular and biomechanical properties of gastrointestinal tissue.
organ pedicles (colon, kidney, spleen, and others), the mes- Within the layers of the intestinal wall are structural ele-
entery (e.g., during laparoscopic appendectomy), or rela- ments including a collagen matrix, muscular components to
tively small but difficult vessels (e.g., the right adrenal vein). facilitate motility, and the vascular conduits that allow tissue
Because of these features, many surgeons find them use- perfusion. The presence of multiple tissue elements with dif-
ful during open (as well as laparoscopic) surgery. fering purposes places conflicting demands on a surgically
created intestinal anastomosis.
The immediate requirement for a stapled anastomosis is
Circular Stapling Device to create a water tight mechanical seal between the two sides
of the anastomosis while maintaining adequate hemostasis
The circular stapling device, often referred to as the end- without causing tissue necrosis. These short-term functions
to-end or EEA stapler, applies a double staggered ring of are better accomplished as greater force is applied in com-
staples to join two luminal ends of tubular structures pression of the anastomosed tissues. Unfortunately, exces-
together. To accomplish this, the tissue is closed around a sive force application negatively impacts the potential for a
detachable anvil with a purse string suture and drawn into successful anastomosis beyond the immediate poststapling
the stapler head in an inverted position. Inspection of the period by choking off the microvascular perfusion necessary
divided ends of the anastomosed tissue, referred to as for tissue healing. Excessive compression predisposes to
“donuts” or “bagels,” confirms a successful full thickness anastomotic failure and stricture. As illustrated in Fig. 5.4,
anastomosis. Stapler heads are available in 21 mm, the ideal anastomosis results from optimal balance between
25 mm, 29 mm, 31 mm, and 33 mm depending on manu- adequate tissue compression to maintain a hemostatic seal
facturer. EEA staplers are primarily employed in anasto- without creating undue ischemia or tension.
mosis creation in esophageal and low pelvic colorectal Unfortunately, there is no single amount of force or sta-
surgery as pictured in Fig. 5.3. A specifically modified pler compression that is ideal for every application. Selection
circular stapling device is employed in the procedure for of stapling device and staple height should be individualized
prolapsed and hemorrhoids also known as stapled to each case, accounting for tissue type, thickness, tissue
hemorrhoidopexy. quality, and disease process.
Fig. 5.4
auses of Failure Following Stapled

C Tissue Quality
Anastomosis
Unhealthy tissue should not be depended upon to heal in a
Ischemia normal manner and therefore should not be incorporated into
an anastomosis. This includes highly inflamed tissue, as is
Perhaps the most important factor in successful healing of an found in diverticulitis and inflammatory bowel disease, as
anastomosis is adequate tissue perfusion. Ischemia is fre- well as the unfortunate circumstance of diffuse tumor
quently identified as a factor contributing to anastomotic involvement. Adjustments in technique and staple selection
dehiscence and leak. There are several methods for assessing should be made for patients with altered tissue quality as can
the adequacy of tissue perfusion at a potential resection mar- be seen in malnutrition, obstruction, or chronic inflammatory
gin and anastomosis location. Visual inspection is often the states.
first assessment, but alone may not be adequate. Palpation or
Doppler assessment of mesenteric pulse can supplement the
visual assessment but is also not a reliable indicator. Some Instrument Failure
surgeons elect to sharply divide the bowel or make a cut in an
epiploic appendage near the level in question. Brisk bleeding Although less common with adoption of disposable stapler
is reassuring in those cases. Newer technologies utilizing devices over reusable devices, misalignment of the jaws in a
fluorescence angiography to directly visualize perfusion to stapler can affect the relative orientation of the anvil to the
the anastomotic segment are increasingly being adopted in cartridge and result in improperly placed staples. For this
open and laparoscopic surgery. reason, it is important to inspect the staple line after stapler
deployment. Inspection will additionally reveal any staple-
line bleeding and verify adequate patency of the
Tension anastomosis.
Anastomosis placed under tension experiences a distracting

force that is an identified factor in breakdown and leak. Technical Error
Though less often an issue in small bowel and ileocolic anas-
tomoses, tension can be a challenge in pelvic anastomoses as Examples of errors in technique or judgment that can predis-
well as in esophageal and hepatobiliary reconstructive opera- pose to anastomotic failure include incorporation of the mes-
tions. Attempts to reinforce areas thought to be under tension entery or epiploic appendage, taking partial thickness bites
should not be considered as adequate and additional mobili- or partial thickness stapling, utilizing improper height sta-
zation pursued in order to relieve tension on the ples, strangulation of tissues, and attempting to bunch too
anastomosis. much tissue into the linear or linear cutting stapler. Avoid
5 Surgical Stapling: Principles and Precautions 41
excessive electrocautery application to staple lines as this Stapled vs. Hand-Sewn Anastomosis
may contribute to ischemic tissue breakdown. Additionally,
avoid placing staple lines in a manner that creates acute cor- The development and refinement of mechanical stapling
ners as these are at higher risk of becoming ischemic. Actions techniques and devices necessarily presented a fundamental
that impair the blood supply to the anastomosis or place it question to the general and gastrointestinal surgeon. Is a sta-
under tension as discussed above should be avoided. pled anastomosis superior to a well-constructed hand-sewn
anastomosis?
Over the subsequent decades, several investigations have
Microbiology sought to answer this question, but have failed to demon-
strate consensus superiority of one technique over the other.
Improvements in surgical technique and stapling technology In general, creation of a stapled anastomosis is accomplished
have not been entirely successful in preventing anastomotic with greater rapidity than a hand-sewn, but with higher
failure. The frustrating persistence of the problem has led equipment cost. There may be specific clinical or anatomic
many to conclude that additional factors must contribute to situations in which one method is preferred to the other, such
the pathogenesis of anastomotic breakdown, which has as use of a circular stapler for anastomosis in the low pelvis.
spurred investigation into the role played by the estimated Staplers are often favored in emergency surgery or when
100 trillion bacteria that comprise the human intestinal operating on the critically ill or unstable patient where there
microbiota in anastomotic healing. is a clear benefit to minimizing operative times. Some prac-
Surgical stress itself alters the composition of intestinal titioners may prefer the adaptability of sutures, to adjust
microbes, and methods of preoperative preparation, including placement and tension during creation of a hand sewn
fasting, oral antibiotics, and mechanical bowel preparation, anastomosis.
induce further alteration. Pathogenic strains of Enterococcus The decision to perform a stapled versus a hand-sewn
faecalis, Escherichia coli, and Pseudomonas aeruginosa anastomosis is, therefore, most appropriately determined by
with high collagenase activity have been identified in models the operating surgeon in each case, taking patient factors into
of inflamed and injured gastrointestinal tracts. The specific account, and utilizing their best clinical judgment.
pathophysiologic mechanism such bacteria may contribute
to anastomotic leakage remains to be fully defined. Further
investigations are needed to define optimal methods for educing Anastomotic Complications
R
counteracting the effects of harmful bacteria, as well as pre- in Practice
and postoperative regimens that enhance the protective capa-
bility of a healthy gut microbiome. Hemostasis
Selection of correct staple height for the tissue application

Patient Factors minimizes bleeding risk when creating a stapled anastomo-
sis. As previously described, staples that are too tall allow
Many factors that contribute to anastomotic failure are for incomplete hemostasis. Hemostasis is enhanced by
beyond control of the surgeon at the time of operation. The pausing once the stapler is closed on the tissue, prior to fir-
following factors increase the risk for anastomotic complica- ing the device. As demonstrated by Morita et al., allowing
tions and efforts aimed at elimination or minimizing their the stapler to compress the tissue minimizes edema and
impact should be undertaken prior to elective operations decreases excess mucosal tissue incorporated in the cut
when possible. staple line. In their study, utilizing an endoscopic linear
cutting stapler, a one-minute wait time was associated with
• Obesity a reduction in gross staple line bleeding compared to imme-
• Diabetes diate firing. Histologic examination of the compressed tis-
• COPD sue showed greater mucosal disruptions in the staple line
• Cigarette smoking when the device was immediately fired. The investigators
• Malnutrition found there was no bleeding difference between 20 s,
• Chemotherapeutic agents 1 min, and 3 min. Therefore, a short period of waiting
• Radiation therapy before firing the stapler should be considered. Refer to the
• Immunomodulators manufacturer recommendations for the suggested compres-
• Steroids sion period duration for the specific stapling devices avail-
• Inflammation (e.g., diverticulitis or inflammatory bowel able at your institution.
disease)
Intraoperative Leak Testing Summary
Intraoperative leak testing, performed with air or gas insuf- • Surgical staples are designed to mimic the biomechanical
flation, has become nearly routine practice for surgeons per- and physiologic effects of a sutured anastomosis on the
forming higher risk anastomoses such as gastric and low tissue they are placed into. A variety of stapler designs
pelvic. The completed anastomosis is submerged in saline allow for application to many different areas of surgery.
and an endoscope is used to insufflate the anastomosed • Causes of stapled anastomosis failure include ischemia,
lumen while the remainder of the bowel is manually tension, impaired tissue quality, equipment failure, micro-
occluded. The presence of bubbles in the saline bath indi- biology, and technical error by the surgeon.
cates the presence of a leak. Flexible endoscopy is often pre- • Patient factors are important causes of anastomotic failure
ferred, especially in left-sided colorectal anastomoses as it and should be optimized prior to surgery when possible.
provides superior visualization of the anastomosis for detec- • For most applications, superiority of hand-sewn com-
tion of ischemia, bleeding, vascularity, and distal tumor mar- pared to stapled anastomosis creation has not been estab-
gin for rectal cancer. lished. Determine the appropriate technique based on
It is important to note that finding an air-tight anastomosis each individual clinical situation.
on intraoperative leak testing does not guarantee the absence • To reduce the risk for postoperative anastomotic compli-
of postoperative anastomotic leak. However, positive leak cations, select the appropriate stapler and staple height,
testing does allow the operating surgeon the opportunity for apply the correct level of tissue compression, and opti-
immediate intervention to reduce the risk of septic postop- mize patient factors.
erative complications. Retrospective analysis of left-sided • Intraoperative leak testing and perfusion testing are addi-
colorectal anastomoses by Ricciardi et al. demonstrated that tional techniques to decrease the risk of postoperative
untested anastomoses had twice the clinical leak rate com- anastomotic failure.
pared to those in which an intraoperative test was performed
(8.1 vs. 3.8%). Encountering a positive intraoperative leak
test presents the opportunity for repair or revision of the
leaking anastomosis, as well as the opportunity to establish Further Reading
proximal diversion.
Choy PY, Bissett IP, Docherty JG, Parry BR, Merrie AE. Stapled versus
hand sewn methods for ileocolic anastomoses. Cochrane Database Syst
Rev. 2007;3:1–18. https://doi.org/10.1002/14651858. CD004320.pub2.
Perfusion Testing Guyton K, Alverdy JC. The gut microbiota and gastrointestinal surgery.
Nat Rev Gastroenterol Hepatol. 2017;14(1):43–54.
Perhaps the factor most frequently cited as contributing to Hunt SR, Silviera ML. Chapter 9. Anastomotic construction. In: The
ASCRS textbook of colon and rectal surgery. third ed. New York:
anastomotic failure is inadequate perfusion and ischemia, Springer International Publishing; 2016.
which has driven the development of novel technologies for Ishihara S, et al. Intraoperative colonoscopy for stapled anastomosis in
intraoperative assessment of tissue perfusion. Fluorescence colorectal surgery. Surg Today. 2008;38(11):1063–5.
angiography has been utilized successfully in plastic and Jafari MD, et al. Perfusion assessment in laparoscopic left-sided/ante-
rior resection (PILLAR II): a multi-institutional study. J Am Coll
reconstructive surgery to assess microperfusion in tissue Surg. 2015;220(1):82–92.
flaps, and there is interest in applying the technology to Morita K, et al. Effects of the time interval between clamping and lin-
assessment of intestinal perfusion prior to resection and ear stapling for resection of porcine small intestine. Surg Endosc.
anastomosis. In a recent multicenter prospective open-label 2008;22:750–6.
Naumann DN, et al. Stapled versus handsewn intestinal anastomosis
trial (PILLAR II), an endoscopic fluorescence imaging sys- in emergency laparotomy: a systemic review and meta-analysis.
tem (PINPOINT, Novadaq Technologies, Inc.) was utilized Surgery. 2015;157(4):609–18.
to assess tissue perfusion in left-sided colectomies and ante- Neutzling CB, et al. Stapled versus handsewn methods for colorectal
rior resections. The intraoperative assessment identified anastomosis surgery. Cochrane Libr. 2012;(2):CD003144.
Ricciardi R, et al. Anastomotic leak testing after colorectal resection:
diminished perfusion that resulted in alteration of the planned what are the data? Arch Surg. 2009;144(5):407–11.
resection margin in 8% of patients. There were no anasto- Shogan BD, et al. Do we really know why colorectal anastomoses leak?
motic failures identified after the margin was adjusted to bet- J Gastrointest Surg. 2013;17:1698–707.
ter perfused tissue. Additional investigation will be needed to
assess the overall significance of fluorescence angiography
in clinical practice.
Control of Bleeding
6
Morgan Schellenberg and Kenji Inaba
General Principles of Resuscitation Control of Hemorrhage
The management of a bleeding patient must involve close Thoracic Hemorrhage

communication between the surgical and anesthesia teams to
ensure proper resuscitation proceeds as control of bleeding is pper Mediastinum and Pulmonary Hilum
U
obtained. Massive transfusion of red blood cells must be Bleeding from the aortic arch, its branches, the superior vena
accompanied by infusion of platelets and clotting factors to cava (SVC), or its tributaries is best approached through a
avoid worsening coagulopathy. The two most common trans- median sternotomy in the operating room (OR). The left
fusion strategies for patients who require massive transfu- innominate vein is the first vessel encountered in the upper
sion are empiric transfusion of blood products in a 1:1:1 ratio mediastinum and can be divided if absolutely necessary
of packed red blood cells, fresh frozen plasma (FFP), and between suture ligatures in order to improve exposure to
platelets, titrated to the patient’s hemodynamics and the underlying injuries. Injuries to the subclavian, internal jugu-
achievement of hemostasis and viscoelastic testing-directed lar, or brachiocephalic vein should be repaired. For tempo-
transfusions. rary control prior to repair, place your finger or a vascular
With viscoelastic testing, a sample of the patient’s clamp over the injury. If primary repair is not possible
blood undergoes point of care analysis. Results are imme- because of the extent of injury or the presence of other, more
diately available and indicate which specific blood prod- urgent injuries, ligate the vein. Injuries to the SVC require
ucts (FFP, platelets, cryoprecipitate) the patient requires. repair.
This can be repeated throughout the resuscitation process. Injuries to the aortic arch and its branches can be very dif-
However, while increasing in its worldwide distribution, ficult to control because of high volume bleeding and chal-
viscoelastic testing is not universally available and can be lenging access. Begin by quickly achieving temporary
challenging to use in austere environments. For patients control with digital pressure and application of vascular
with rapid ongoing blood loss requiring high volume clamps while you plan your management strategy. The
transfusion, red blood cells, plasma, and platelets should injured innominate artery should be repaired or grafted if
be transfused in a 1:1:1 ratio. Once viscoelastic data possible, although ligation is generally well tolerated as the
returns, if available, transfusion can then be guided by the right subclavian artery will fill via backflow from the right
point of care testing. common carotid. Similarly, injuries to either common carotid
artery should be repaired or grafted unless the patient is
unable to tolerate this. For these patients, temporary shunts
should be positioned. The subclavian arteries should not be
ligated because of significant risk of limb loss. If the patient
is too unstable for repair or grafting, a temporary shunt
should be placed.
Patients with injuries to the pulmonary hilum frequently
die at the scene because of the massive blood loss that ensues
M. Schellenberg · K. Inaba (*)
Department of Surgery, Division of Trauma,Acute Care Surgery as well as the risk of air embolism and hypoxia that accom-
and Surgical Critical Care, Los Angeles County - USC Medical pany this type of injury. If you encounter this injury in the
Center, Los Angeles, CA, USA operating room, work with Anesthesia to initiate one-lung
e-mail: kenji.inaba@med.usc.edu

https://doi.org/10.1007/978-3-030-81415-1_6
44 M. Schellenberg and K. Inaba
ventilation of the noninjured lung to prevent the injured lung accomplished in the right upper quadrant by placing a hand
from obscuring your surgical field. Take down the inferior above the dome of the liver as far as possible posteriorly and
pulmonary ligament and gather the injured lung in your non- then tightly placing laparotomy pads above the liver. Packs
dominant hand. Identify the hilum and place a vascular are then placed below the liver as well, in order to accom-
clamp across it to control the bleeding. Next, pass a noncut- plish vectored packing, in which the liver is compressed
ting linear stapler across the hilum, dividing the primary from both sides to staunch bleeding.
bronchus, pulmonary artery, and pulmonary veins en masse. The left upper quadrant is packed in essentially the same
After firing the stapler but prior to releasing the hilar stump, manner, first placing the left hand behind the spleen to deliver
place two stay sutures to facilitate exposure in case there is it out of the splenic fossa and then placing packs both behind
bleeding after division. If the patient’s physiology allows, it and anterior to it. Care must be taken to prevent injury to the
is safer to ligate the hilar structures individually. However, spleen while doing so. The paracolic gutters are then packed
these patients are typically hemodynamically compromised bilaterally and intraperitoneal packs are placed into the pel-
due to large volume blood loss and it is important to be expe- vis. The four quadrants and the pelvis are then inspected
ditious. Be aware that pneumonectomy, particularly in a sequentially by taking down the packs and looking for
young patient, is very poorly tolerated due to the ensuing bleeding.
right heart strain.
ung Parenchymal Injuries

L Abdominal Aorta, IVC, and Their Branches
Operative management of parenchymal injuries to the lung is
rarely indicated because a chest tube to evacuate a pneumo- Zones of the Retroperitoneum
or hemothorax is typically sufficient. If the chest tube output The surgeon must be familiar with the zones of the retroperi-
exceeds 1.0–1.5 L immediately after placement, 200– toneum and medial visceral rotations. Hematomas of the ret-
300 cc/h for 3 consecutive hours, or if the patient becomes roperitoneum are divided into four zones. Zone I hematomas
hemodynamically unstable, the patient should be brought to are located in the midline from the aortic hiatus in the dia-
the OR. After performing an anterolateral thoracotomy, first phragm to the aortic bifurcation and reflect injury to the aorta
inspect the hilum for injury. Once that has been excluded, or its major branches or the inferior vena cava (IVC). All
assess the lung parenchyma and chest wall for bleeding. If Zone I hematomas, regardless of mechanism of injury, must
bleeding intercostal arteries are encountered, oversew them. be explored.
For injuries to the lung parenchyma, nonanatomic or wedge Zone II hematomas are lateral to Zone I and encompass
resections of the injured lung are the mainstay of surgical the kidney and its hilum bilaterally. Penetrating Zone II
management and can be quickly accomplished with a linear hematomas should generally be explored, unless the hema-
cutting stapler. These resections should be performed in a toma is lateral, small, and nonexpanding in a hemodynami-
manner that minimizes tissue loss and takes into account the cally stable patient. This is especially true if preoperative CT
radial blood flow to the periphery of the lung in order to pre- scan demonstrates injury to the kidney parenchyma only, as
vent ischemia to residual tissue. The remaining lung paren- leaving Gerota’s fascia intact can help preserve the kidney.
chyma should be tethered in place after lung reinflation using Blunt Zone II hematomas should not be explored unless they
two points of fixation to prevent lobar torsion. are pulsatile or expanding.
If a penetrating lung injury is found intraoperatively, a Zone III hematomas occur in the pelvis, below the aortic
tractotomy can be performed using a linear cutting stapler in bifurcation. Penetrating Zone III injuries should all be
order to expose the injury. Bleeding encountered along the explored. Blunt Zone III hematomas should not be explored
injury tract can then be oversewn or the injured segment can unless they are pulsatile or expanding. Methods of control-
be resected. This is well tolerated, especially in the young ling pelvic hemorrhage, including preperitoneal packing
trauma patient. and bilateral internal iliac artery ligation, are discussed in
Chap. 8.
Finally, Zone IV hematomas occur as a result of injury to
Abdominal Hemorrhage the retrohepatic IVC. These are extraordinarily difficult inju-
ries to control and repair. If you encounter an intact Zone IV
When large volume bleeding is encountered during a trauma hematoma at laparotomy, do not attempt to mobilize the liver
laparotomy, the first maneuver is to pack all four quadrants or enter the hematoma. Instead, pack the area tightly. This
off the abdomen. Routine packing is not required and if there will work in the majority of patients who arrive alive to hos-
is no blood, packing should not be performed. Packing is pital. If packing does not control the bleeding, the hematoma
6 Control of Bleeding 45
will need to be explored and the bleeding source controlled. Prior to performing a nephrectomy for a bleeding kidney,
This is described below in the section on liver injuries. it has been traditionally advocated that the surgeon palpate
the contralateral kidney to quickly assess its size, consis-
Medial Visceral Rotations tency, and shape. Practically, the decision to perform a
A right medial visceral rotation, also known as the Cattell- nephrectomy should not be based on palpation of the contra-
Braasch maneuver, allows for the exposure of the IVC, the lateral kidney alone but rather upon the extent of renal injury
right renal hilum, and the left renal vein. To perform a and overall patient condition. The injured kidney should be
Cattell-Braasch, for example, to explore a right-sided Zone I preserved whenever possible but renal salvage should never
hematoma, begin by rapidly mobilizing the right colon along take precedence over patient survival. For bleeding uncon-
the white line of Toldt. Next, take down the hepatic flexure trolled by packing, nephrectomy is the default treatment for
and Kocherize the duodenum. Finally, sweep the small bowel a patient in extremis.
upwards and to the left, and incise the peritoneum overlying
the small bowel mesentery from the right lower quadrant to Liver
the Ligament of Treitz. The viscera will now be mobilized The liver must be considered separately from other abdominal
completely off of the right side of the retroperitoneum. viscera for a number of reasons. First, its removal is neither
The management of injuries to the IVC depends on the expeditious nor compatible with life, although transplant for
location of the injury relative to the renal veins. Infrarenal severe hepatic trauma has been described. Second, its inflow
IVC injuries should be repaired primarily if the patient is and outflow vasculature are contained in two separate pedicles,
stable and repair can be accomplished with less than 50% unlike the spleen or kidney, which makes control of bleeding
narrowing of the IVC lumen. Otherwise, the injured infrare- more challenging. Third, its large size, protected position under
nal IVC should be ligated. The suprarenal IVC should be the right costal margin and diaphragm, and numerous ligamen-
repaired or, if the injury is destructive, shunted with delayed tous attachments can make liver injuries very difficult to access.
reconstruction. Retrohepatic IVC injuries are considered When an injury to the liver is encountered, the first
separately and are discussed further below. maneuver is vectored packing, as described above. For
A left medial visceral rotation, also known as the Mattox superficial bleeding, the packs should be removed and cau-
maneuver, exposes the abdominal aorta and its branches. To tery, FDA-approved topical hemostatic agents, or large chro-
perform it, mobilize the proximal sigmoid colon and left mic sutures with bites that incorporate the liver capsule for
colon. In the traditional Mattox maneuver, this plane is taken strength can be used for control. If there is an avulsed or
superiorly behind the left kidney, to rotate this medially with ischemic segment, nonanatomic resection should be per-
the viscera. However, if the kidney appears uninjured, leave formed. For thinner, peripheral areas, ultrasonic shears can
it in place and carry the plane of dissection anterior to the be used to help limit blood loss, but the finger fracture or
kidney, below the tail of the pancreas and the spleen. This crush and tie techniques are also options.
allows exposure of the aorta and its branches. The celiac Larger or deeper bleeding that is controlled after packing
trunk and inferior mesenteric artery can be ligated. The renal should be managed by damage control packing with contin-
arteries and superior mesenteric artery, however, must be ued resuscitation outside of the operating room. Attempts at
repaired or, in the case of the superior mesenteric artery, control for extensive liver injuries at the index operation even
bypassed. All injuries that cannot be ligated should be in the seemingly stable patient should be performed cau-
shunted. Injury to the aorta itself should be primarily repaired tiously. If there is a large raw surface area, placing a Vicryl
or grafted, depending on the extent of injury. If the patient is mesh sheet directly onto the liver before pack placement can
in extremis, temporary shunting is appropriate. facilitate later pack removal as the Vicryl can be left on the
liver surface and thereby help prevent clot disruption.
Angiography with embolization is a useful adjunct to pack-
Solid Abdominal Viscera ing and should be considered for any deep liver lacerations.
Bleeding from the liver that is not controlled with packing
Spleen and Kidney is a significant problem that requires an organized and expe-
Trauma to the spleen or kidney with bleeding resulting in ditious approach. Injuries to the retrohepatic IVC can present
hemodynamic instability is managed with removal of the in this manner. Before diving into the bleeding, gain expo-
injured organ. Splenorrhaphy or partial splenectomy can be sure by adding a right subcostal incision to the laparotomy.
attempted in young patients if the surgeon can perform those Depending on the anatomy of the injury, and especially if
techniques expeditiously and the patient’s hemodynamics total hepatic vascular isolation is needed, a median sternot-
are relatively normal with resuscitation. Otherwise, splenec- omy or right thoracotomy with division of the diaphragm
tomy is the preferred procedure for splenic bleeding in the may be required. Start by applying a Pringle maneuver. This
unstable patient. is performed by creating an opening in an avascular portion
ligation, and resuscitative endovascular balloon occlusion of

the aorta (REBOA). Although bilateral internal iliac artery
ligation and REBOA directly control arterial, not venous,
hemorrhage, they contribute to the cessation of venous bleed-
ing by diminishing the arterial inflow. Angioembolization is
an elective technique performed by IR to control pelvic
bleeding and is particularly suited for the hemodynamically
stable patient with a contrast blush noted on CT scan.
Because IR is not in-house at all times, one of the above
methods (preperitoneal packing, intraperitoneal packing
with bilateral internal iliac artery ligation, or REBOA) is
typically required to arrest pelvic bleeding in the unstable
Fig. 6.1 patient until IR is able to adjunctively perform angioemboli-
zation. For the techniques of preperitoneal packing and bilat-
of the hepatoduodenal ligament and then passing a finger eral internal iliac artery ligation, please refer to Chap. 8.
through the foramen of Winslow and up through this opening
in order to occlude the porta hepatis. The operator’s finger
can be replaced with a Satinsky clamp or a Rummel tourni- esuscitative Endovascular Balloon Occlusion
R
quet to free the surgeon’s hands. This is usually insufficient. of the Aorta (REBOA)
Proceed to get inflow and outflow control by cross-clamping
the aorta at the diaphragmatic hiatus and temporarily occlud- REBOA is a relatively new method of controlling bleeding
ing the infra- and suprahepatic IVC. The suprahepatic IVC is coming from below the diaphragm. The new REBOA cath-
most easily controlled in the chest, along its intrapericardial eter is inserted through a 7 Fr catheter that is inserted into
segment. the common femoral artery using a percutaneous Seldinger
Now that proper exposure and vascular exclusion have technique. This can be done with or without ultrasound
been achieved, tackle the bleeding. Mobilize the liver by guidance, depending on the availability of ultrasound and
dividing its ligamentous attachments and expose the injury. the ability to palpate a femoral pulse. If it has not yet been
If the injury can be visualized and controlled, repair it. If not, determined if the source of bleeding is abdominal or pelvic,
an atriocaval shunt can be considered. the balloon should be deployed in Zone I, the distal tho-
Penetrating liver injuries are best considered separately as racic aorta. This should be approximated prior to insertion
they typically create a tract through the liver parenchyma, in by measuring the catheter from the planned puncture site in
which the injured vasculature is much more difficult to the groin to the mid-sternum. If the source of bleeding is
access. If the tract is relatively superficial, perform a known to be pelvic, for example, in a patient who becomes
tractotomy using either ultrasonic shears, a linear cutting sta- unstable after a CT scan rules out other sources of hemor-
pler with a vascular load, or finger fracture. This will allow rhage, the REBOA should be placed in Zone III, immedi-
for direct visualization of the injured vessels and they can be ately above the aortic bifurcation, in order to mitigate the
directly oversewn. If the tract is deep within the liver paren- consequences of visceral malperfusion that result from
chyma, this is not feasible. The best option then is to insert occluding the aorta in Zone I. Zone III can be approximated
one or more Foley catheters into the injury and inflate the by measuring the catheter from the puncture site to the
balloons with saline to achieve tamponade (Fig. 6.1). These xiphoid process. Once the REBOA catheter is inserted to
can be left inflated until the patient is brought back for a the desired depth, the balloon is gently inflated with 8 cc in
second look and then slowly taken down. Often, with appro- Zone I or 2 cc in Zone III. An immediate improvement in
priate resuscitation and time, the tract will then be the patient’s hemodynamics should result. REBOA is not a
hemostatic. definitive treatment and should be used as a bridge to defin-
itive therapy and a resuscitative adjunct as blood product
transfusion continues. This will provide time for IR to
Pelvic Hemorrhage arrive to perform angioembolization, or will serve to tem-
porarily stabilize the patient for transport to the OR and
There are a number of operative techniques available to con- definitive control of bleeding. The balloon should continu-
trol pelvic bleeding. These include preperitoneal packing, ally be deflated to check the status of the resuscitation.
intraperitoneal packing with bilateral internal iliac artery When adequate, it can be left deflated.
Extremity and Junctional Hemorrhage silk (0–3.0, depending on the size of the vessel), to seal off
the vessel below the hemostat as the hemostat is removed
Bleeding from extremity wounds can typically be controlled (Fig. 6.2c–f). When ligating vessels surrounded by other tis-
with external pressure using gauze or laparotomy pads. sue, such as thickened mesentery, the “ease-and-squeeze”
When available, topical hemostatic agents are useful if pres- technique can be used to ensure the ties are secured tightly
sure alone is insufficient to halt the bleeding. If both of these around the vessel. With this technique, gently open the
techniques fail, a tourniquet should be applied. Prior con- hemostat but do not release the vessel and surrounding tissue
cerns about potential limb ischemia resulting from tourni- as the tie is placed. Close the hemostat around the tissue
quet use have not been confirmed in contemporary studies. again and secure a second tie around the vessel.
Preservation of life over limb remains the overall manage-
ment principle for extremity bleeding.
Junctional bleeding, occurring at the junction of the Tying in Continuity
extremities with the torso (i.e., axilla and groin), is challeng-
ing because of the inability to occlude inflow with a tourni- When dividing a larger artery or vein, such as the vessels in
quet. Although junctional tourniquets have been developed the splenic hilum or an injured common iliac vein (Fig. 6.3a),
and are used in certain circumstances in military popula- it is safer to ligate the vessel in continuity in order to achieve
tions, they have not reached widespread use either with the control of the vessel prior to dividing it. With this technique,
military or civilian population because of concerns about use a hemostat or right angle dissector to first free the vessel
visceral ischemic injury. If a junctional injury is encoun- of surrounding tissues. Pass the instrument below the vessel
tered, apply direct pressure to the wound with gauze or lapa- (Fig. 6.3b), and use a DeBakey or Tonsil to feed one end of a
rotomy pads as described for extremity injury. FDA-approved silk tie into the jaws of the instrument. Repeat this maneuver
local hemostatic agents designed to control junctional pene- such that two ties have been passed around the vessel
trating injuries are now also available and have been used (Fig. 6.3c). Secure the two ties (Fig. 6.3d), divide the vessel
with success at our center. between them using Metzenbaum scissors (Fig. 6.3e), and
Extremity and junctional vascular injuries are brought to cut the tails off the ties (Fig. 6.3f).
the OR for management. If the patient’s physiology allows, a
repair, graft, or bypass of the injury should be performed.
Ligation of the common femoral artery, superficial femoral Suture Ligation
artery, popliteal artery, or any area of the upper extremity
blood supply proximal to the brachial artery bifurcation For larger vessels, particularly if only a short length is acces-
should not be performed because of the substantial risk of sible or exposed, suture ligation is an excellent option. Place
limb ischemia and limb loss. Shunting should be used in the two hemostats around the vessel, as described above in
patients unable to tolerate definitive repair. Ligation of the “Hemostat and Ligature,” and divide the vessel using
deep femoral artery is generally well tolerated, and ligation Metzenbaum scissors. Instead of silk ties, use a silk suture
of arterial branches after the trifurcation of the popliteal with a tapered needle to transfix the vessel below the hemo-
artery is safe as long as one major trunk remains intact. stat before tying it off. This ensures the tie will not slip off
Similarly, ligation of one of the radial or ulnar arteries is well the vessel, as it may be apt to if a stump of 5 mm or more
tolerated. cannot be left on the end of the divided vessel.
Techniques to Achieve Hemostasis Clips
Hemostat and Ligature Metal clips in a wide range of sizes are an expedient method
of dividing vessels. With this technique, place clips proximal
Hemostats and ties can be used to divide bleeding vessels in and distal to the injured area on the vessel. Guide the vessel
most areas of the body. Place a hemostat on the vessel both into the heel of the clip and tightly squeeze the clip applier in
proximal and distal to the site of bleeding, with the jaws of order to properly place the clip. Clips are especially useful
the hemostats facing each other so that the tips of the instru- for small vessels, such as those in the neck. However, two
ment face up after the vessel is ligated (Fig. 6.2a). After important technical points must be made. With repeated tis-
applying the hemostats, divide the vessel with Metzenbaum sue handling, clips have a tendency to dislodge. Therefore,
scissors between the hemostats (Fig. 6.2b). Use ties, usually they are not suited for small branches coming off of viscera
a b c
d e f
Fig. 6.2
that are being mobilized (e.g., small duodenal branches dur- Staplers
ing a Kocher maneuver). The second point is that the vessel
must be cleared of surrounding tissues completely in order to Staplers with a vascular load can be used to divide vessels,
be effective. If a clip is applied around a vessel and its sur- sometimes en masse or with their mesentery depending on
rounding tissue, it is unlikely to obtain hemostasis and may the size of the vessel and stapler. If one side of the vessels to
be dislodged. be divided is immediately being removed from the patient as
a b c
d e f
Fig. 6.3
a specimen, a noncutting stapler can be used. For example, comes in two main forms, monopolar and bipolar cautery.
this is a useful method of dividing the distal pancreas after an Monopolar cautery is a tipped instrument that can be used
injury, or a pedicled viscera such as the lung at the pulmo- to divide tissue, much like a scalpel. It has two modes:
nary hilum. A linear cutting stapler can be used to quickly cutting and coagulation. On cutting mode, heating occurs
resect bowel and mesentery, especially if the patient is to be very rapidly and thus tissues are divided quickly with
left in discontinuity. minimal heat imparted to surrounding structures. This can
be useful, for example, to divide skin. Because of the
speed of tissue division, there is minimal hemostasis and
Electrocautery thus it is not a good option on highly vascular tissue. In
this situation, the coagulation mode is a better choice.
Electrocautery is an electrical current that passes through With coagulation, tissues are heated more slowly, which
tissues and generates heat, leading to coagulation. It allows for hemostasis of blood vessels before tissue divi-
sion. For increased precision with electrocautery, the Further Reading

bleeding vessel can be picked up and delivered gently into
the surgical field, off of underlying tissues, with DeBakey Bardes JM, Grabo D, Lam L, Tadlock MD, Strumwasser A, Inaba
K. Treatment algorithm and management of retrohepatic vena cava
forceps and then electrocautery can be applied to the tip
injuries. J Trauma. 2017;83(2):340–4.
of the instrument. Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA,
Bipolar cautery instruments have the appearance of for- Dubose JJ, Fox EE, Inaba K, Rodriguez CJ, Holcomb JB, Duchesne
ceps and heat tissue held between the two tines. It is espe- JC. Damage control resuscitation in patients with severe traumatic
hemorrhage: a practice management guideline from the Eastern
cially useful if cautery is to be used in proximity to critical
Association for the Surgery of Trauma. J Trauma. 2017;82(3):605–17.
structures, such as nerves. This makes bipolar cautery par- Chang R, Fox E, Greene TJ, Eastridge BJ, Gilani R, Chung KK,
ticularly useful for dissection and control of bleeding of DeSantis S, DuBose JJ, Tomasek JS, Fortuna GR, Sams VG, Todd
small vessels in the neck. SR, Podbielski JM, Wade CE, Holcomb JB, The NCTH Study
Group. Multicenter retrospective study of noncompressible torso
There are important limitations to the ability of electro-
hemorrhage: anatomic locations of bleeding and comparison of
cautery to control bleeding. First of all, it does not work well endovascular versus open approach. J Trauma. 2017;83(1):11–8.
if the tissue is wet. For example, cautery will be unable to Dubose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, Moore
achieve hemostasis if applied in a pool of blood. Second, L, Holcomb J, Turay D, Arbabi CN, Kirkpatrick A, Xiao J, Skarupa
D, Poulin N, AAST AORTA Study Group. The AAST prospective
cautery is only suited for hemostasis or division of small ves-
aortic occlusion for resuscitation in trauma and acute care surgery
sels, since it typically cannot seal vessels that are greater (AORTA) registry: data on contemporary utilization and outcomes
than 3 mm in diameter. Lastly, electrocautery should not be of aortic occlusion and resuscitative balloon occlusion of the aorta
used to obtain hemostasis of vessels that have a tendency to (REBOA). J Trauma. 2016;81(3):409–19.
Gonzalez E, Moore EE, Moore HB. Management of trauma-
retract into surrounding tissues as this can make bleeding
induced coagulopathy with thromboelastography. Crit Care Clin.
very difficult to control. For example, bleeding branches off 2017;33:119–34.
the pancreas should generally not be controlled with Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM,
electrocautery. del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ, Cotton
BA, Fabian TC, Inaba K, Kerby JD, Muskat P, O'Keeffe T, Rizoli
S, Robinson BR, Scalea TM, Schreiber MA, Stein DM, Weinberg
JA, Callum JL, Hess JR, Matijevic N, Miller CN, Pittet JF, Hoyt
DB, Pearson GD, Leroux B, van Belle G, PROPPR Study Group.
Ultrasonic Shears Transfusion of plasma, platelets, and red blood cells in a 1:1:1
vs a 1:1:2 ratio and mortality in patients with severe trauma: the
PROPPR randomized clinical trial. JAMA. 2015;313(5):471–82.
These devices use the friction generated from high-frequency Inaba K, Aksoy H, Seamon MJ, Marks JA, Duchesne J, Schroll R,
vibration between its jaws to heat the tissue contained within Fox CJ, Pieracci FM, Moore EE, Joseph B, Haider AA, Harvin JA,
them, thereby coagulating vessels in a coapted position. Lawless RA, Cannon J, Holland SR, Demetriades D, Multicenter
Shunt Study Group. Multicenter evaluation of temporary intravas-
They are a useful addition to the surgeon’s armamentarium
cular shunt use in vascular trauma. J Trauma. 2016;80(3):359–64.
to control bleeding as they can divide vessels larger than Linnebur M, Inaba K, Haltmeier T, Rasmussen TE, Smith J, Mendelsberg
those that can be safely divided by electrocautery (typically R, Grabo D, Demetriades D. Emergent non-image-guided resuscita-
up to 7 mm but dependent on the device). Ultrasonic shears tive endovascular balloon occlusion of the aorta (REBOA) catheter
placement: a cadaver-based study. J Trauma. 2016;81(3):453–7.
are an expeditious means of dividing vessels that would oth-
Matsushima K, Aiolfi A, Park C, Rosen D, Strumwasser A, Benjamin E,
erwise need to be divided using hemostats and ligatures, Inaba K, Demetriades D. Surgical outcomes after trauma pneumo-
such as the short gastric vessels or the small bowel mesen- nectomy: revisited. J Trauma. 2017;82(5):927–32.
tery, and of dividing highly vascular tissue such as liver Plackett TP, Barmparas G, Inaba K, Demetriades D. Transplantation for
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parenchyma.
Management of the Contaminated
Operation 7
Rahila Essani, Donald C. LaSeur, and Andreas M. Kaiser
Table 7.1 Wound classification

The Challenge
Wound class Descripton (and examples)
I: Clean Sterile field without inflamed or infected tissues,
Infectious complications after surgery remain a major cause no entry into the respiratory, GI, or GU tracts:
of morbidity and mortality and add tremendous cost to the Hernia repair
national healthcare bill. Primary infections are those present Mastectomy
before the surgery, are caused by the underlying disease, and Splenectomy
Vascular bypass
often represent the major indication to proceed with a surgi- II: Clean Entry into the respiratory, GI, or GU tract
cal intervention. But bacteria may also enter the surgical Contaminated without spillage:
field during clean operations and cause a secondary infection Small bowel/colon resection
that was not present at the onset. Whether or not the presence Cholecystectomy
Hysterectomy
of bacteria perpetuates the existing infection, initiates a new
III: Spillage (any) from respiratory, GI, or GU tracts,
clinically manifest infection, or can be suppressed and Contaminated tissue inflammation or necrosis, major break in
resolved is a complex process. It depends on a complex inter- sterile technique:
action of competing parameters that move the delicate bal- Cholecystectomy for cholecystitis
ance between bacterial virulence and host defense in one or Appendectomy
Ostomy (existing or new)
the other direction. The list is endless and among others Fresh penetrating wound
includes the microbiology and size of the bacterial inoculum IV: Dirty Existing clinical infection, bacteria present
(Table 7.1), antibiotic resistance profile, characteristics of before operation:
the disease (cancer versus “benign”) and the surgical field Abscess
Perforated viscus
(e.g., persistent disease or presence of foreign material), as Penetrating wound
well as general patient factors such as the hemodynamic sta-
bility and tissue perfusion, nutritional status, preexisting
comorbidities, and unrelated life expectancy.
The management of contaminated operations invariably eign bodies (e.g., hernia mesh, stones, retained sponge).
presents a great clinical challenge, as the surgeon needs to They also include procedures in which spillage occurs, for
optimize when and how to address the past and current example, during lysis of adhesions or when the gallbladder is
impacts in anticipation of passible future concerns. Examples perforated during laparoscopic cholecystectomy (with result-
of intrinsically dirty surgical fields include those resulting ing outpouring of bile and stones).
from a perforated hollow viscus (cancer, diverticulitis, peptic Postoperative complications may be local or systemic.
ulcer, appendicitis, etc.), gangrenous bowel, or infected for- The former are summarized as surgical site infections (SSI)
to include subcutaneous wound infection, fasciitis, abscess
formation, peritonitis, or enterocutaneous fistula formation.
R. Essani · D. C. LaSeur
Uncontrolled local infections may trigger a systemic immune
Department of Surgery, Texas A&M University, Baylor Scott and
White Health Care, Temple, TX, USA response syndrome (SIRS), sepsis, septic shock, multiorgan
failure, and death. Management should be directed toward
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of efficient source control, be it temporary (abscess drainage,
Hope National Medical Center/Comprehensive Cancer Center, diversion) or definitive (resection of inflamed organ). In
Duarte, CA, USA addition, the patient’s additional risk factors for infections
e-mail: akaiser@COH.org

https://doi.org/10.1007/978-3-030-81415-1_7
52 R. Essani et al.
and host defense mechanisms should be optimized. This guided by specific goals for lactic acid, mean arterial pres-
chapter reviews specific surgical strategies to address and sure, cardiac output, mixed venous oxygen saturation, and
potentially mitigate these risks. urine output. Ultimately, it remains the art of surgical judg-
ment to define when exactly to proceed.
Preoperative Considerations
Antibiotic Management
Timing of Surgery
Perioperative parenteral antibiotics tailored to the specifics
One of the most fundamental strategies is to determine of the planned intervention are considered standard of care
whether the emergency situation with a contaminated sur- for most elective surgeries and are limited to a 24-hour
gical field can be converted into an elective operation per- period. Active major infections require administration of
formed later under more controlled and favorable specific antibiotics in therapeutic intent. Current sepsis
circumstances. In absence of diffuse peritonitis, this con- response pathways recommend to start broad spectrum anti-
cept has proven extremely successful in the treatment of biotics within 1 hour of sepsis recognition. Even a small
perforated appendicitis with abscess as well as compli- delay in antibiotic therapy may increase morbidity and mor-
cated diverticulitis with abscess formation (modified tality rates. Sepsis or pre- and intraoperative findings of
Hinchey stages Ib and II). The historically only option of active infection or spillage of enteric contents justify longer
an open exploration, drainage of the abscess, and a antibiotics but must be stated to be therapeutic and not pro-
Hartmann resection with colostomy can often be averted phylactic. Cultures from the infected/contaminated fields as
by means of interventional radiology techniques well as results of blood and other cultures and the patient’s
(CT-guided percutaneous drainage) and broad-spectrum clinical course are helpful to dictate the transition from an
antibiotics. An elective resection with primary anastomo- “educated guess” of antibiotic choice to targeted and more
sis can be carried out more safely if it can be postponed for narrow antibiotic management.
at least 6 weeks to allow for resolution of the acute infec- In the postoperative period, assess the need for and appro-
tion, normalization of tissues and overall patient status, priateness of antibiotic coverage every day. Narrow the anti-
and routine workup procedures. biotics based on the bacterial sensitivities of each organism
isolated. Generally, antibiotics are continued for 7–10 days
after abdominal surgery for perforation or dead bowel.
Resuscitation Before Surgery However, longer courses may be required in patients with
immunosuppression or that have a slow clinical response.
Acute and chronic illness are frequently aggravated by meta- Consider using prophylactic antifungal therapy when a gas-
bolic and nutritional deconditioning, fluid and electrolyte trointestinal perforation is found.
imbalances including third-spacing, and compensatory
vasoconstriction, before hemodynamic and cardiopulmonary
instability evolve. Maximizing tissue perfusion and oxygen Preoperative Imaging
delivery forms the cornerstone of successful perioperative
resuscitation. Restitution of the circulatory volume and reso- Crossectional imaging (CT, ultrasound, MRI) is of undeni-
lution of the reactive peripheral vasoconstriction both are able importance for modern surgical strategies and decision
addressed with adequate fluid resuscitation. If successful, it making. It provides the tools for assessment and differential
results in higher PO2 in injured or inflamed tissue which has diagnosis and has the potential for alternative interventions.
a beneficial impact on bacterial resistance, collagen synthe- With few exceptions, CT scan with intravenous contrast and
sis, and epithelialization. (if appropriate) with enteral contrast is the single most useful
Rushing a patient to surgery is sometimes inevitable. modality for evaluating patients with acute abdominal pre-
However, if the circumstances of a necessary urgent or emer- sentations – even if an emergency surgery seems indicated
gency surgery allow, it is often advisable to invest a limited based on clinical criteria. The specifics of a patient’s condi-
period of upfront time (hours) to optimize the patient in a tion may limit that diagnostic modality and necessitate oth-
concerted effort. This includes, among others, hemodynamic ers, for example, in case of (pre-)renal failure or contrast
stabilization, fluid resuscitation, correction of electrolyte and allergies. If there is evidence for a contained abscess or
acid/base imbalances, and achieving normothermia. abscesses that appear accessible, consider image-guided per-
Unfortunately, a single marker to demonstrate adequacy of cutaneous drainage rather than surgery as a temporizing
resuscitation has not been found. Resuscitation should be measure.
7 Management of the Contaminated Operation 53
Intraoperative Considerations Source Control
Supportive Measures and Fluid Management It is crucial to quickly identify and isolate or eliminate the
source of contamination. This may require closing a perfora-
Continue goal-directed resuscitation in the operating room. In tion, draining abscesses, resecting a segment of bowel, or
team work with the anesthesiologist, swiftly initiate adequate creating an ostomy.
monitoring tools and vascular access. Maintenance of normo- Sometimes the source is obvious from the history, physi-
glycemia and normothermia (core temperature ≥ 35.5 °C) is cal examination, and preoperative imaging studies. Ruptured
critical in both elective and emergency surgeries and has been appendicitis with generalized peritonitis or a perforated duo-
associated with improved outcomes and lower incidence of denal ulcer would be examples of such situations. In other
surgical site infections. Both may be difficult to achieve in cases, the source will be obvious only at surgery. In very rare
septic patients and patients with major trauma. Patient warm- and frustrating cases, free intra-abdominal air may prompt
ing systems (e.g., Bair Hugger), raising the temperature in the and exploration, but no definite source can be identified (see
operating room, warming all intravenous and irrigation fluids, the end of this section).
and using warming circuits in the anesthesia machine may all A limited midline laparotomy allows for preliminary
be required to uphold normothermia. assessment. It can be extended in the direction of the pathol-
Continue appropriate fluid management intraoperatively ogy as needed. A full laparotomy is not wrong and achieves
and avoid under-resuscitation with hypovolemia and vaso- excellent exposure to all quadrants of the abdomen. However,
constriction, as well as fluid overload with bowel edema and it may not always be necessary. Circumstances and surgical
risk of abdominal compartment syndrome. Insensible losses skills are determined in the individual case whether a mini-
from the surgical field and injured tissues and measurable mally invasive approach (laparoscopy) would be appropriate
losses from bleeding, suction/drainage tubes need to be at least to start and potentially even address the pathology in
accounted for. The optimal fluid management strikes a bal- its entirety. Carefully separate fibrinous adhesions between
ance between (1) traditional fixed-volume algorithms, (2) loops of bowel and the abdominal wall. The color, texture,
restricted fluid therapy, and (3) goal-directed fluid therapy. content, and odor of peritoneal fluid will often give a definite
The latter is based on continuous dynamic monitoring of a clue as to the level of the perforation. Fluid that is not mal-
number of parameters including cardiac performance and odorous may signify a proximal perforation/injury (e.g., gas-
has been associated with decreased perioperative morbidity, tric or duodenal ulcer). Adhesions including tethering of the
possibly even mortality. omentum are often densest near the site of perforation.
Copious irrigation with warm saline, removal of fibrin and
debris, and packing the abdomen in quadrants will allow
Importance of Surgical Skills and Technique identification of the source.
When a definitive source is not immediately identified,
Anticipation, proactive strategy, knowledge, and meticulous use a systematic four quadrant examination. Visualize and
surgical technique constitute important principles that affect evaluate the upper digestive tract from gastroesophageal
postoperative results, including the ability to resolve the junction to proximal jejunum. Open the lesser sac to allow
acute illness and reduce the incidence of new or persistent inspection of the back of the stomach. Fill the abdomen with
postoperative infections. Experience is helpful but is not lim- warm saline and have the anesthesiologist inject air into the
ited to personal cases; it can in part be acquired from study stomach via the gastric tube. Gentle compression of the
and discussion as not every mistake in history needs to be proximal jejunum during the maneuver prevents the pumped-
repeated individually. Anatomy, tissues, and tissue planes are in air from distending all bowels. If there is a hole in-between,
often altered by inflammation, tumor, or trauma. bubbles should be evident; the negative predictive value of
Understanding the immediate and future goals and limita- this test is not perfect but reasonably high if a good disten-
tions is crucial. Gentle tissue manipulation using appropriate tion could be achieved without bubbling. Similarly approach
dissection tools and adequate hemostasis are important to the other quadrants and assess the entire small and large
avoid incremental damage (see Chap. 4). Solid search for intestine but also investigate genitourinary structures.
and attention to any enterotomies or other structural injuries When nothing is found during laparoscopy, convert to a
are part of any due diligence. Critical analysis of personal laparotomy. If still nothing is visible, close the abdomen and
outcomes and the literature in regular intervals is important continue antibiotics while awaiting results of cultures. Some
to maintain and improve standards. Participation in national surgeons will place closed suction drains near the most likely
improvement initiatives such as the National Surgical Quality source, for example, near the sigmoid colon if occult diver-
Improvement Program (NSQIP) is encouraged. ticular perforation is suspected.
54 R. Essani et al.
Fig. 7.2
Wound Irrigation
Irrigation is one of the tools to clean up the area of pathology

and surgical intervention and remove blood clots, enteric
Fig. 7.1
content, pus, or debris. Use of irrigation should be rational
and proportional to the needs in order to maximize its bene-
Containing the Contamination fit. Washout of the entire abdomen with copious amounts is
appropriate for diffuse purulent or feculent peritonitis.
Surgical access and sufficient exposure are inevitable neces- However, if an infection is contained in one area, you should
sities to address the pathology. Even under elective clean cir- avoid irritating so much that the contaminated irrigation fluid
cumstances, there is a potential for wound contamination. is propagated throughout the abdomen. It may be preferable
When there is evidence for an active infection or contamina- to apply a sequence of multiple small-volume irrigations and
tion of the surgical field, the danger is substantially larger immediate suctioning until the area looks clean.
and increases the risk of wound dehiscence and hernia Once the first layer of the incision has been closed, it is
formation. For that aspect, it is helpful to minimize the size advisable to irrigate the wound and again remove debris
of the incision(s) and to protect it/them from being exposed and isolated fat fragments prior to continuing with the clo-
to negative impacts by the target pathology. Laparoscopic sure. Pressure irrigation has been recommended by some
ports are less at risk the main incisions. For laparotomy inci- for select cases as it can be effective in removing fibrin
sions, traditional shielding of the wound with surgical towels plaques and debris as surrogate for contamination and bac-
is one option. More efficient and elegant, however, are a vari- teria. However, some tissues are too delicate and may suffer
ety of wound protector systems that have been associated tissue injury.
with decreased rates of surgical site infections. They come in It also remains a long fought controversy whether addi-
different sizes and consist of two semi-rigid plastic rings tion of antibiotics to the irrigation fluid results in any advan-
connected with a circumferential cylinder of elastic plastic tage when compared to saline alone. Various antibiotic
sheath. They allow simultaneously for retraction and 360 additives were suggested, such as cephalosporins, aminogly-
degree shielding of the wound such that the tissue moisture cosides, neomycin, bacitracin, and metronidazole. Overall,
is preserved and contact with bacterial contaminants mini- however, there is little evidence that it would reduce surgical
mized. These single-use systems are easily inserted by slip- site infection rates – not at last as the antibiotics are not
ping the inner ring into the open incision below the abdominal immediately bactericidal but require to be metabolized by
wall (Fig. 7.1). The outer ring is lifted up and turned over the microbes to initiate their action.
multiple times until sits snug on the skin while the elastic
sheath covers and retracts the abdominal wall structures in-
between (Fig. 7.2). Other Considerations
It makes intuitive sense to change grossly contaminated
gloves and remove dirty instruments from the field. A more Drains are used remove or prevent existing or accumulating
rigid policy requiring to routinely change gowns, gloves, and collections of pus, succus, or other body fluids (see Chap.
all instruments prior to abdominal wall closure has been sug- 10). At the end of a grossly contaminated surgery, it may be
gested but lacks any scientific evidence. Furthermore, such rational to leave a drain in proximity of the infected area or
measures interfere with the flow of the operation in general, in the dependent portions of the abdomen where contami-
and particularly when closure of the incision is not the last nated fluid would collect.
step but followed by subsequent dirty steps (e.g., stoma When the patient is unstable or a second look operation is
maturation). planned within a short period of time (e.g., to reassess areas
7 Management of the Contaminated Operation 55
of questionable perfusion), avoid any risky reconstruction. Wound Care

Either postpone it until the next intervention or carry the
bowel end out through an abdominal wall gap. Even if it is All wounds need to be monitored for signs of infection. The
not yet matured formally into a stoma, its presence can be specific care depends on whether they are closed or primarily
used as an indicator of tissue perfusion. or secondarily open. Closed wound care appears to be a mat-
Occasionally, it is necessary to pack and leave the abdo- ter of surgeon preference. Open wound care typically asks
men open and subsequently return for second looks. While for maintaining a moist environment by irrigation or wet
the value of multiple second looks may be questionable, clo- gauze dressings at least twice a day, covered with an absorb-
sure may become increasingly a challenge if not impossible. ing pad.
Management of an open abdomen needs to be individual- If a negative pressure wound therapy device is utilized,
ized. Using an open abdomen negative pressure system the dressing change reflects the needs of specific device
allows for rapid re-entry into the abdomen and can help used. In the most common scenario where the sponge lays
expedite fascial closure and prevent loss of domain (see over the fascia with the skin edges open, changes are sched-
Chap. 8). uled approximately every third day.
Postoperative Considerations Further Reading
Wound Closure Bjorck M, Bruhin A, et al. Classification--important step to improve

management of patients with an open abdomen. World J Surg.
2009;33(6):1154–7.
Primary wound closure during contaminated operations has Dellinger RP, Levy MM, et al. Surviving sepsis campaign: international
been associated with a nearly 40% wound infection rate, guidelines for management of severe sepsis and septic shock: 2012.
necessitating reopening of the wound. This complication Crit Care Med. 2013;41(2):580–637.
Howell MD, Davis AM. Management of Sepsis and Septic Shock.
can be prevented by closing the fascia only but leaving the JAMA. 2017;317(8):847–8.
skin primarily open after highly contaminated operations. Mihaljevic AL, Muller TC, et al. Wound edge protectors in open
The wound can either be managed until it heals by second- abdominal surgery to reduce surgical site infections: a systematic
ary intention, or a delayed postprimary closure after 4–6 review and meta-analysis. PLoS One. 2015;10(3):e0121187.
Morgan K, Mansker D, et al. Not just for trauma patients: damage
postoperative days may be envisioned and results in fewer control laparotomy in pancreatic surgery. J Gastrointest Surg.
wound infections and avoids large labor- and cost-intensive 2010;14(5):768–72.
wound care. Routine use of external retention sutures to Reid K, Pockney P, et al. Barrier wound protection decreases surgi-
reduce tension on the fascial closure is not recommended cal site infection in open elective colorectal surgery: a randomized
clinical trial. Dis Colon Rectum. 2010;53(10):1374–80.
unless a reclosure of a dehisced fascia with poor tissue Smith JW, Garrison RN, et al. Direct peritoneal resuscitation acceler-
quality is necessary. Negative pressure wound therapy ates primary abdominal wall closure after damage control surgery. J
(NPWT) is a newer modality for wound closure in a con- Am Coll Surg. 2010;210(5):658–64. 664–657
taminated field. It utilizes negative pressure through a Teleanu G, Iordache F, et al. Prognostic scoring systems-validation and
their utility in patients with abdominal sepsis in colon peritonitis. J
sponge to remove fluid and infectious material from the Med Life. 2014;7(1):84–9.
surgical incision. While its use may not necessarily acceler- Waibel BH, Rotondo MF. Damage control in trauma and abdominal
ate wound healing, it eliminates large and most wounds and sepsis. Crit Care Med. 2010;38(9 Suppl):S421–30.
facilitates the dressing changes from twice daily to once Waibel BH, Rotondo MF. Damage control for intra-abdominal sepsis.
Surg Clin North Am. 2012;92(2):243–57. viii
every 3 days.
Damage Control Laparotomy
8
James M. Bardes and Kenji Inaba
Indications dysmotility, and loss of domain are also complications of the

open abdomen. Despite these risks, the utilization of damage
The principles of damage control surgery, applied to criti- control principles has expanded for the most critically injured
cally injured patients that are too unstable to tolerate defini- patients who are unlikely to survive otherwise.
tive operative repair, are responsible for saving countless
lives. The central tenants of trauma surgery have always been
to: (1) control hemorrhage, (2) stop contamination, and (3) amage Control Strategy
D
perform definitive repair. There is, however, a subset of and Decision-Making
patients who are in physiological distress, or in whom the
injury burden is so great that an attempt to definitively repair The decision to make an operation a damage control proce-
all of their injuries would result in irreversible physiological dure is critical and must occur early while the patient is still
exhaustion. Any attempt to perform the definitive reconstruc- salvageable. Missing the signs that damage control is neces-
tion of all of these injuries would result in a cold, coagulo- sary will lead to the patient’s death. Experienced surgeons
pathic, and severely acidotic patient, ultimately leading to will often plan for damage control as a treatment option even
death. For these patients, the principles of damage control before leaving the trauma bay. Signs of critical physiologic
are to abbreviate the initial operation, performing only the stress should be an indication to proceed with a damage con-
procedures required to control bleeding and contamination. trol strategy. While exact indications are not available, hypo-
A temporary closure is performed at the end of the operation thermia (<35°), acidosis (pH < 7.2 or base deficit >8),
in order to facilitate reoperation and prevent abdominal com- coagulopathy, requirement for a massive transfusion
partment syndrome. The patient is then moved to the inten- (>10 units packed red blood cells), or hemodynamic instabil-
sive care unit (ICU) where metabolic abnormalities are ity are indicators of high risk. Good communication between
corrected and the patient is optimized to enhance their toler- the anesthesia and surgery teams is critical for recognizing
ance for further surgical stress. Once the physiologic these signs. Surgeon judgment is also important for recog-
derangements have been corrected, the patient is taken back nizing that the burden of injuries is large, even in a patient
to the operating room (OR) for definitive repair and abdomi- currently physiologically normal, or that the injuries are
nal closure. Initially described for laparotomy, these princi- beyond the surgeon’s skillset. For these patients, damage
ples can be applied to all regions of the body. Damage control control is an effective method of temporizing a patient and
principles can even be applied in the setting of nontraumatic, getting them to a higher level of care (Table 8.1).
emergency surgery.
While damage control has many benefits, there is morbid-
ity associated with its use due to the delay in abdominal wall Damage Control Laparotomy in Trauma
closure. Ventral hernia is a common complication after dam-
age control. Enterocutaneous fistula, gastrointestinal tract Damage control requires minimal additional infrastructure
and equipment if the facility is already equipped to care for
trauma patients. This includes temporary closure devices and
J. M. Bardes · K. Inaba (*)
Department of Surgery, Division of Trauma, Acute Care Surgery vascular shunts, both of which are inexpensive and widely
and Surgical Critical Care, Los Angeles County - USC Medical accessible. All operating rooms equipped to handle multisys-
Center, Los Angeles, CA, USA tem trauma will have standard trays readily available for
e-mail: kenji.Inaba@med.usc.edu

https://doi.org/10.1007/978-3-030-81415-1_8
58 J. M. Bardes and K. Inaba
Table 8.1 Indications for damage control surgery emergency department and extend through the operating
Signs of Physiologic Hypothermia (<35 °C), room, to the postoperative phase of care in the ICU.
Stress Acidosis (pH < 7.2 or base deficit >8)
Coagulopathy
Massive transfusion (>10 units packed red
blood cells) amage Control Management of Selected
D
Hemodynamic instability Injuries
Physician judgment Need for second look laparotomy
Large burden of injury Hollow viscus injuries are managed by rapid control of con-
Injuries beyond the surgeon’s skillset
Need for transfer to higher level of care tamination. Initially, place Babcock clamps across any perfo-
ration. For larger lacerations, use a running stitch to provide
temporary control. Ultimately, a linear cutting stapler is ideal
operations in the abdomen, chest, and peripheral vasculature. for damage control resection of the small bowel and colon.
Coordination between the operating room and the blood The mesentery is then resected with a bipolar energy device
bank should be prearranged in the event a massive transfu- or with clamps and ties. The bowel may then be left in dis-
sion is required. Ideally, this would include a satellite blood continuity until the patient is returned to the OR for defini-
bank with immediate access to universal donor blood and tive repair. If the patient’s physiology permits, even in a
plasma. Patients should have at least two large bore (14 or 16 damage control situation, a rapid stapled anastomosis can be
gauge) peripheral intravenous catheters placed. Central performed to restore continuity. This anastomosis can be re-
venous access is not mandatory. However, if central access is examined at the take-back operation.
used, large bore single lumen catheters should be used. Place The diaphragm requires repair during the index operation.
the patient on a warming blanket. Insert a Foley catheter. Repair the diaphragm quickly with a running monofilament
Prep the patient widely, from chin to knees, and table to table nonabsorbable suture in one layer. It is important to com-
laterally. Lastly, administer a dose of perioperative antibiot- plete this repair at the first operation to prevent retraction of
ics prior to incision. the muscle, to optimize pulmonary mechanics, and to pre-
Make a laparotomy incision from the xiphoid process to vent bowel strangulation. If the muscle retracts, this will
the pubis. The dissection down to the fascia is performed make future repair more difficult and may require mesh
quickly and with a knife. Bleeding is typically minimal in reconstruction. If the injury is complicated and requires
these moribund patients. Inform anesthesia prior to entering mesh reconstruction initially, or reattachment to the chest
the abdomen, as the loss of tamponade when the fascia is wall, a delayed repair may be considered.
opened can increase bleeding. Incise the fascia sharply and Injuries to the retroperitoneum are managed according to
enter the abdomen, complete the fascial opening with heavy the zone of injury, the mechanism of injury, and according to
mayo scissors, using a hand to protect the viscera under- the presence of a large, pulsatile, or expanding hematoma.
neath. Suction and remove blood clots from the abdomen to Zone I is the central zone and contains the great vessels and
improve exposure. An assistant should use a large hand held their visceral branches, the duodenum, and the pancreas. All
retractor to expose each quadrant, and if there is bleeding, zone I hematomas should be explored. Vascular injuries are
that quadrant should be packed. The abdomen is then discussed separately below. Injuries to the duodenum can be
explored systematically. Management of specific injuries in managed with temporary drainage alone at the initial opera-
the damage control setting is discussed below. tion. Small injuries may be amenable to primary repair.
The concept of damage control resuscitation has also Similarly, the pancreas can be managed with drain place-
been developed and is complementary to damage control ment. In the case of an obvious complete transection of the
laparotomy. Using these strategies in conjunction provides pancreas, use a stapler to resect the distal gland. The patient
the best opportunity for survival. Damage control resuscita- will likely not tolerate spleen preservation in the setting of
tion is guided by several principles. Allowing for a lower damage control.
blood pressure until hemostasis is achieved is important. Zone II includes the lateral portions of the retroperito-
Aggressive over-resuscitation, prior to achieving hemor- neum and contains the kidneys. Minor kidney injuries may
rhage control, only increases bleeding and transfusion be amenable to packing at the initial operation, with defini-
requirements. Once definitive hemorrhage control is tive repair or resection performed at the next operation. In
obtained, the patient can then be fully resuscitated. the event a severe renal injury is found, the kidney may need
Contemporary resuscitation strategies should minimize the to be removed. While it has been suggested that a contralat-
use of crystalloid solutions. Instead, the use of a balanced eral kidney be sought by palpation, this should never impact
transfusion with packed red blood cells, fresh frozen plasma, decision-making. Whether or not a contralateral kidney is
and platelets in a 1:1:1 ratio should be performed. These present, the surgeon should always try to preserve kidney
damage control resuscitation techniques should start in the mass. If the injury is destructive, or there is a vascular injury
8 Damage Control Laparotomy 59
requiring reconstruction, remove the injured kidney with the encountered, obtain proximal and distal control of the vessel
use of a linear stapler with vascular load or with ties. If the first. The decision to repair or ligate a vein can then be made.
patient’s condition permits, control the ureter separately and Large destructive injuries in a patient that is acidotic and
divide it distally. If the injury is isolated to the ureter, and the cold should be ligated quickly and the patient taken out of
patient will not tolerate repair, damage control drainage can the OR. In the damage control setting, most venous injuries
be performed by intubating and exteriorizing, or shunting, can be ligated. Notable exceptions to this include the supra-
the ureter. hepatic segment of the inferior vena cava, the portal vein,
Zone III of the retroperitoneum is the pelvis and contains bilateral internal jugular vein injuries, and the renal veins
the pelvic vessels, the bladder, and portions of the rectum. depending on where the vessel is ligated. The left renal vein
Penetrating hematomas require exploration. In penetrating can be ligated if collaterals through the left suprarenal vein
trauma, high volume hemorrhage is most likely from a and left inferior phrenic vein are intact. The right kidney
lacerated vessel. Vascular injuries are managed with either does not have collateral drainage. Therefore, if the right renal
reconstruction or ligation if it is isolated to the internal iliac vein requires ligation, the right kidney will be compromised.
or venous structures. In a damage control situation, shunting For these venous injuries, a shunt should be used to maintain
or ligation should be performed. Bleeding from the bone blood flow as described below. Arterial injuries, unlike
itself is best managed with packing. If a blunt injury is pres- venous injuries, rarely tolerate ligation. In the case of small
ent, there is likely an associated pelvic fracture. After blunt injuries, a simple suture repair can be performed. However,
injury, if the hematoma is not expanding or pulsatile, the ret- in the damage control setting, larger injuries typically require
roperitoneum should not be explored. Unroofing the hema- a longer time in the OR, and more blood loss, than the patient
toma in this case will eliminate the tamponade that has will tolerate. Vascular shunts can quickly restore continuity
controlled the bleeding. Hemodynamic instability may fol- of blood flow to an extremity or organ and allow exit from
low and controlling the bleeding is difficult since there is the OR. When placing a shunt, the injured artery should not
rarely a discrete bleeding vessel identified. However, if a be debrided at the initial operation. This is to preserve vessel
patient is hypotensive after pelvic injury, or the hematoma is length because the vessel will be debrided when the defini-
expanding or pulsatile, exploration is required. There are tive repair is done. If a bridge of tissue remains, it can be
multiple techniques to control pelvic hemorrhage. If the preserved if possible (Fig. 8.1). Several commercial shunts
patient has an open book pelvic fracture wrap the pelvis in a are available, such as the Argyle™, Sundt™, and Javid™
commercial binder or sheet. Orthopedic surgeons can rapidly shunts. For central vessels, temporary conduits such as a
place external hardware to stabilize the pelvis. Packing can chest tube can be used to improve size matching. Prior to
be done in one of two ways. First is preperitoneal packing. insertion, ensure adequate inflow and outflow through the
Make a 7–10 cm incision directly above the pubis. Carry the vessel, otherwise the shunt will thrombose. Local heparin
dissection down to the fascia and open the fascia sharply. can be used in the case of extremity shunting but is not nec-
Staying in the preperitoneal space, retract the bladder and essary for intra-abdominal or neck use. Systemic anticoagu-
place three laparotomy pads on either side of the space. Then lation can be used; however, it is not necessary in the damage
close the fascia and skin to provide additional tamponade. control setting. Select the largest shunt that will fit the vessel,
Another option for rapid control of pelvic hemorrhage is and insert it into the proximal end, avoiding any intimal dam-
transperitoneal packing and ligation of the internal iliac age or dissection. Flush the shunt by removing the proximal
arteries bilaterally. The aortic bifurcation is palpated and the control briefly (Fig. 8.2). Next, insert the shunt into the distal
common iliac arteries traced into the pelvis. Often the retro- vessel far enough to prevent bowing of the shunt. Secure the
peritoneum has been lacerated by the trauma, if not, open the
retroperitoneum with cautery. Dissect the common iliac
arteries until they bifurcate. The internal iliac arteries should
be identified and dissected with a long right angle clamp.
Pass vessel loops twice around the vessels and pull up to
occlude the vessel. Then secure the loops with a large clip.
Pulses should be confirmed in the femoral vessels to ensure
the external iliacs were not inadvertently occluded. The
entire area can then be packed. Pelvic bleeding is another
indication for postoperative angiography and embolization.
Again, early mobilization of this resource is important to
decrease hemorrhage.
Vascular trauma is one of the most common reasons why
damage control is required. When venous injuries are Fig. 8.1
Fig. 8.2
Fig. 8.3
Fig. 8.4
shunt in place with nonabsorbable ties. After tying down the

shunt at the end of the vessel, use the long ends of the suture temporary abdominal closure, a patient could still develop
to secure the shunt and prevent migration (Fig. 8.3). compartment syndrome. If recurrent signs exist, a bladder
Damage control techniques have been described for inju- pressure should be checked, or the dressing removed at the
ries to the liver and spleen. These are primarily options for bedside and reapplied.
hemorrhage control and are commonly used during damage
control procedures. For a detailed explanation of these tech-
niques, see Chap. 6, Control of Bleeding. Temporary Closure of the Open Abdomen
Temporary closure of the abdomen is a critical component of

Damage Control in Nontrauma damage control surgery. The ideal closure will allow contin-
uous drainage from the abdomen, prevent excessive fascial
Damage control techniques are commonly used in settings retraction, and will not cause injury to the bowel. A variety
such as mesenteric ischemia, infected pancreatic necrosis, of techniques have been developed for temporary closure,
and abdominal compartment syndrome. These patients often with vacuum devices performing the majority of closures
present under extreme physiologic stress due to their under- today. Older temporary closure techniques included skin
lying disease processes. In the setting of mesenteric ischemia only closures, towel clip closures, and devices that were
or abdominal sepsis, by obtaining just source control, the sewn to the fascia. These strategies have largely been aban-
patient can be rapidly returned to the ICU for resuscitation. doned due to the tissue damage they cause, as well as the
Definitive gastrointestinal tract reconstruction can occur propensity for skin only closures to cause abdominal com-
when the patient’s condition has improved. For abdominal partment syndrome.
compartment syndrome, opening the abdomen and perform- Commercial negative pressure devices exist for tempo-
ing a temporary abdominal closure will treat this life- rary closure (Fig. 8.4). Vacuum closure can also be per-
threatening condition, allowing the patients underlying cause formed without these commercial devices (Fig. 8.5).
to be managed. It is important to emphasize that even with a Fenestrate a sterile x-ray cassette cover and place it over the
8 Damage Control Laparotomy 61
Fig. 8.5
Fig. 8.7
Fig. 8.6
bowel (Fig. 8.6). Push the cassette cover all the way into the ostoperative Management and Return
P
gutters laterally, to the diaphragm superiorly and the pelvis to the Operating Room
inferiorly. Unfurl two rolls of gauze on top of the cassette
cover, with x-ray markers. Place a pair of 10Fr flat Jackson- Postoperatively, patients undergoing damage control surgery
Pratt drains on the gauze, with the drains exiting at the level should be admitted to the ICU. The principals of damage
of the xiphoid (Fig. 8.7). Then apply a large sterile dressing control resuscitation were discussed previously and should
over the abdomen (Fig. 8.8). Place the drains to low continu- be employed. Minimizing crystalloid resuscitation is critical
ous wall suction to continue decompression and drainage of to prevent severe bowel edema and difficulty closing the
the abdomen. This temporary vacuum closure requires mini- abdomen. Patients should return to the operating room for
mal equipment and is widely available. definitive repair of injuries, and closure, as soon as they are
become necessary. Closure of the abdomen as soon as pos-

sible is important to avoid fistula formation. Additional com-
plications from a prolonged open abdomen include loss of
domain making hernia repair difficult, gastrointestinal tract
dysmotility, malnutrition, and intra-abdominal abscess.
Some patients will require skin grafting to close a chroni-
cally open abdomen. Once fully healed and rehabilitated, a
component separation may be necessary to reestablish
abdominal wall domain.
Further Reading
Cotton BA, Reddy N, Hatch QM, LeFebvre E, Wade CE, Kozar RA,
Gill BS, Albarado R, McNutt MK, Holcomb JB. Damage control
resuscitation is associated with a reduction in resuscitation volumes
and improvement in survival in 390 damage control laparotomy
patients. Ann Surg. 2011;254(4):598–605.
Dubose J, Inaba K, Barmparas G, Teixeira PG, Schnüriger B, Talving
P, Salim A, Demetriades D. Bilateral internal iliac artery ligation as
a damage control approach in massive retroperitoneal bleeding after
pelvic fracture. J Trauma. 2010;69(6):1507–14.
Fig. 8.8 Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, Inaba K,
Bee TK, Fabian TC, Whelan J, Ivatury RR. AAST open abdomen
study group: open abdominal management after damage-control
fully resuscitated. Most will return within 24–48 hours. laparotomy for trauma: a prospective observational American
There is no minimum amount of time that must pass before Association for the Surgery of Trauma multicenter study. J Trauma
reoperation. Once the patient is normothermic, and their Acute Care Surg. 2013;74(1):113–22.
coagulopathy and metabolic acidosis have been corrected, Duchesne JC, Kimonis K, Marr AB, Rennie KV, Wahl G, Wells JE,
Islam TM, Meade P, Stuke L, Barbeau JM, Hunt JP. Damage con-
they should return to the operating room. trol resuscitation in combination with damage control laparotomy:
On return to the operating room, the abdomen is re- a survival advantage. J Trauma Acute Care Surg. 2010;69(1):46–52.
explored to ensure there were no missed injuries, and all Inaba K, Aksoy H, Seamon MJ, Marks JA, Duchesne J, Schroll R, Fox
definitive repairs completed if possible. A careful sweep for CJ, Pieracci FM, Moore EE, Joseph B, Haider AA. Multicenter
evaluation of temporary intravascular shunt use in vascular trauma.
retained lap pads and instruments should be performed, J Trauma Acute Care Surg. 2016;80(3):359–65.
including the use of radiofrequency identification systems if Roberts DJ, Ball CG, Feliciano DV, Moore EE, Ivatury RR, Lucas CE,
available, and an abdominal x-ray to confirm removal of all Fabian TC, Zygun DA, Kirkpatrick AW, Stelfox HT. History of the
foreign bodies. In some cases, the abdomen cannot be closed innovation of damage control for management of trauma patients:
1902–2016. Ann Surg. 2017;265(5):1034–44.
at the first take-back operation. In these cases, the vacuum Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris
closure should be reapplied. The patient should return to the PD, Brohi K, D’Amours S, Fabian TC, Inaba K, Leppäniemi
in OR in 24–48 hours after diuresis if possible. This may AK. Indications for use of damage control surgery in civilian trauma
need to be repeated several times before closure can be patients: a content analysis and expert appropriateness rating study.
Ann Surg. 2016;263(5):1018–27.
achieved. Even if the patient requires multiple return trips to Rotondo MF, Schwab CW, McGonigal MD, Phillips GR, Fruchterman
the OR, consider extubating the patient. An open abdomen TM, Kauder DR, Latenser BA, Angood PA. ‘Damage control’:
should not be considered a contraindication to extubation. an approach for improved survival in exsanguinating penetrating
If the patient’s abdomen is not fully closed by the second abdominal injury. J Trauma Acute Care Surg. 1993;35(3):375–83.
return to the operating room, a planned ventral hernia may
Mechanical Basics of Laparoscopic
Surgery 9
Sarah M. Popek and Zoë O. Jones
Ergonomics and Operating Room Design geon’s workplace injuries is referred to as cumulative trau-
matic disorders (CTDs). The following factors have been
Thoughtful room setup is crucial. The basic equipment con- identified as protective against CTDs: increasing age, number
sists of the laparoscopic tower (containing insufflator, light of years in practice, exercise, and awareness of operating
source, camera unit, recorder, and/or color printer), video room ergonomics. Factors related to increased injury and pain
monitors, electrosurgical unit, and adjunctive energy devices. include higher caseload, female gender, short stature, smaller
These must be well-positioned in relation to the operating glove size, and hand-assisted laparoscopic techniques.
table. If working in a small room, it may be advantageous to Nonphysiologic posture and long-term static posture are
position the operating table diagonally. latent ergonomic factors which should be taken into account
Ergonomics originates from the Greek ergon (labor) and when designing the layout of the operating room. Monitor loca-
nomos (law). It is an applied science concerned with the tion, working surface height, and placement of the surgical team
design and arrangement of a workspace to produce a safe and must be strategized before the start of the operation. To reduce
efficient interaction between people and tools. With growing neck and eye strain, monitors should be positioned 15 to 30
adoption of laparoscopic approaches to surgery, the impact of degrees below eye level, directly across from the working sur-
ergonomics on technique and surgeon fatigue has catalyzed geon and assistant (Fig. 9.1). To reduce shoulder and forearm
the development of a new field. Equipment setup impacts the pain, instruments should be at or below the level of the elbow
technical difficulty of a case as well as physician fatigue. The and elbow flexion should not exceed 45 degrees from horizon-
surgeon and assistants may experience eye strain and neck, tal. Forearms should be in a neutral position, midway between
shoulder, wrist, back, and hand pain and stiffness based on the pronation and supination. Wrists and fingers should be lightly
laparoscopic configuration. Thenar nerve damage, known as flexed. Feet should be hip width’s distance apart and weight
“laparoscopist’s thumb,” can result from handling laparo- should be distributed evenly on both feet. Knees should not be
scopic instruments. While the patient experiences the benefit locked. Static posture should be avoided in both the standing
of a minimally invasive approach, the surgeon may experience and seated positions. If there is height discrepancy between
cumulative deleterious effects which degrade performance. team members, the table height should be adjusted to the tallest
The adverse impact of compromised ergonomics on both person with shorter team members standing on a step.
surgeon technical capacity and well-being is an active topic of Long-term data on the impact of poor ergonomics and
research in the contemporary surgical literature. The field of cumulative traumatic disorders on technical performance
surgical ergonomics is aimed at raising awareness of ergo- and personal well-being are currently lacking.
nomic issues and educating surgeons on intraoperative pos- Musculoskeletal pain and neck and back injuries can result
tural techniques in both open and laparoscopic surgery. in temporary or permanent disability. Chronic pain has a sig-
General surgeons performing open and laparoscopic surgery nificant impact on quality of life and risk of burnout.
report that up to 87% experience musculoskeletal pain.
General surgeons reported neck, low back, and shoulder pain
as the most commonly affected areas. The mechanism for sur- Equipment
S. M. Popek (*) · Z. O. Jones Equipment setup occurs prior to transporting the patient to
Department of Surgery, University of New Mexico, the operating room. Laparoscopic surgery relies on tech-
Albuquerque, NM, USA nology in a way that open surgery does not: The completion
e-mail: spopek@salud.unm.edu

https://doi.org/10.1007/978-3-030-81415-1_9
64 S. M. Popek and Z. O. Jones
b c
Fig. 9.1
9 Mechanical Basics of Laparoscopic Surgery 65
and success of laparoscopic surgery is vulnerable to equip- the surgical case, from the quality of surgery to the environ-
ment failure, malfunction, or simply unfamiliarity with its ment within the operating room. The quality of the visual
preparation and use. Laparoscopic surgery has become image is comprised from several pieces of equipment (some-
commonplace and the basic equipment functionality often times known as the magnificent seven): light source, light
taken for granted. When there is a technical malfunction, cable, laparoscope, cameral head, video signal processor,
the surgical team can be completely incapacitated and video cable, and monitor. Any component can malfunction
require the a ssistance of a biomedical engineer. It behooves resulting in a suboptimal image. Once the light is function-
the surgeon to have a working knowledge of the basic ing at 100% protecting, the tip of the laparoscope from burn-
equipment. ing the drapes or starting a fire is critical.
Thoroughly check all equipment prior to beginning the White balancing removes unrealistic color casts to render
procedure. Confirm the insufflator and its alarm are function- white objects white on the screen. The camera is used to
ing, ensure two tanks of carbon dioxide are full and in the view a true white object outside of the abdominal or thoracic
room, the video monitors are functional and well positioned, cavity, such as a Ray-Tec or laparotomy sponge, so that red,
and that the light source is fully functional. Suction and ade- blue, and green signals can be adjusted to create pure white.
quate irrigation should be available and within reach to con- Likewise, the camera will need to be focused before each
nect to the suction irrigator. Use of equipment checklists, use. Focusing takes place extracorporeally and at a distance
such that created by SAGES/AORN, can lead to identifica- of five centimeters from a target object.
tion of missing equipment and have been shown to minimize In the past, each component of the video laparoscopic
preventable delays. setup was separate. Modern systems have evolved to incor-
porate high definition video systems and digital flat panel
displays. Unified systems allow control of all aspects of the
Setup and Trouble Shooting imaging system by the surgeon from a display panel accessed
via the laparoscopic camera. Integrated systems facilitate
Setup begins with patient positioning. Arms should be tucked collaboration with the ease of streaming and recording pro-
if access to the pelvis is anticipated. If the operation demands cedures. Color printers and USB image capture technology
reverse Trendelenburg, is a foot board needed? If the C-arm are connected to the laparoscopic tower. USB slots allow
is to be used, is the operating room table appropriately posi- hard disk drives (HDD) or flash drives to be used to capture
tioned? For modified lithotomy position as well as the supine images and video. Images can be routed to eyepieces or head
split leg position, thought must be given to additional drapes mount displays; this is used in 3D systems.
for the legs and to adequately securing the patient to the bed. The complexity of the laparoscopic equipment and depen-
The patient’s weight should be evenly distributed on the bed. dence on technology demands a degree of sophisticated tech-
The use of foot boards demands they are well-padded and nical capability by the surgeon not required in open surgery.
that the patient’s legs are secured at the knees with padded Troubleshooting guides are now available from surgical
straps. Preparation for placement of a nasogastric or orogas- societies such as the Society of American Gastrointestinal
tric tube and Foley catheter should also be thoughtfully and Endoscopic Surgeons (SAGES) and the American
made. Naso- or orogastric decompression aids visualization College of Surgeons (ACS) (Table 9.1).
and reduces the risk of injury to a large, distended stomach.
A Foley catheter should be placed if the operation is taking
place in the lower abdomen or if the operation has a long Access to Abdomen
expected length.
Next is consideration of the abdominal quadrant with the Initial access to the abdomen to establish pneumoperitoneum
anticipated pathology and should occur in advance of the is accomplished in one of three ways: use of a Veress needle,
surgical day. The surgeon stands facing the quadrant of inter- Hasson trocar, or optical entry (Fig. 9.2). The Veress needle
est with the video monitors positioned directly across from is the most commonly used method to establish pneumoperi-
and level with the surgeon’s gaze. For example, a surgeon toneum and is considered a closed method. The Hasson tech-
performing a laparoscopic sigmoidectomy will stand at the nique, utilizing the Hasson trocar, is an open method of
patient’s right side facing the left lower quadrant (Fig. 9.1c). initial trocar placement and creation of pneumoperitoneum.
Setup is often procedure-specific and is difficult to alter once The optical entry technique may be used with or without
the sterile procedure has begun. established pneumoperitoneum.
Poor visual imaging is one of the most troublesome chal- The Veress needle is a 14-gauge spring-loaded needle
lenges in laparoscopic surgery. If you can’t see, you can’t with a sharp exterior and blunt inner cannula. The inner can-
operate (safely). This leads to frustration on the part of the nula retracts when pressure is applied, allowing the sharp
surgeon and operating room team and impacts all aspects of needle to pierce the layers of the abdominal wall. The blunt
Table 9.1 Basic troubleshooting in laparoscopic surgery

Problem System/connection issue Setup issue Access/injury issue
Field yellow or Check RGB cable connection White balance outside of Spillage of bile, blood, enteric contents
discolored Low voltage abdomen
Sudden black out Disconnected camera or Tip of scope fully in contact with another object
monitor cable (inside or outside the abdomen)
Blown bulb fuse (use back up
light source)
Poor picture definition Camera not focused Obscured by fluids (clean camera and trocar;
irrigate and suction)
High pressure alarm Gas tap on Veress needle Veress needle obstructed
before insufflation closed, obstructing flow (flush with saline)
Gas tubing kinked
Vasovagal reaction Peritoneal irritation (desufflate, allow vitals to
recover)
CO2 embolism Gas in vessel or systemic absorption
(immediate desufflation, position in Trendelenburg
and left lateral decubitus)
Loss of working space Cessation of insufflation Trocar stopcocks open Inadequate muscle relaxation (inform anesthesia
(check connections, insufflator) (close stopcocks) team)
Gas canister empty (replace Excessive suctioning (cease suctioning, allow
canister) pneumoperitoneum to reestablish)
the abdominal cavity while holding it at its distal hub. Initial

resistance will be followed by two audible and palpable
“clicks,” representing passage through fascia and
peritoneum.
A saline drop test is performed with a 10 cc syringe
filled with 5 cc of saline. The first step is aspiration to
ensure no cloudy or grossly enteric contents or blood
returns, which would indicate bowel or vessel injury. If
aspiration is uneventful, saline is injected through the
Veress. Lack of resistance confirms intraperitoneal place-
ment. A final indication of intraperitoneal location is obser-
vation of the remaining saline after the syringe is removed:
Saline rapidly egressing into the abdominal cavity signals
correct placement. Insufflation tubing is connected to the
Veress and insufflation begun. Initial pressures should not
measure over 10 mm Hg if placement is intraperitoneal. If
Fig. 9.2
higher initial pressures are present, the Veress should be
removed and placement re-attempted. Once the desired
inner cannula is otherwise present and is exposed when the intraabdominal pressure (between 12 and 15 mm Hg) is
Veress is inside the peritoneal cavity, protecting the intraab- reached, the Veress needle is removed and a port placed
dominal organs from damage. through the incision.
Prior to Veress insertion, the spring load mechanism is The open entry, or Hasson technique, may be useful in
tested by pressing the tip of the needle onto a hard object patients who have a known surgical history and suspected
(either a knife handle, the mayo stand, or the surgeon’s adhesions. The Hasson trocar accommodates a 10 mm cam-
thumb nail). Patency of the needle is confirmed by flushing it era. Of note, Hasson entry is more technically difficult with
prior to use. obese patients. A supra- or infra-umbilical site is chosen and
Placement of the Veress needle begins with a stab incision a two to three centimeter incision is made. This is carried
placed preferentially in the supra- or infra-umbilical position down to expose the rectus fascia. The rectus fascia is sharply
(alternate locations discussed later in chapter). The umbili- incised to expose the peritoneum. The peritoneum is grasped
cus is grasped with the nondominant hand, a towel clamp, or with two hemostats or forceps and incised sharply. Visual
a Kocher clamp placed on the umbilical stalk and elevated inspection aids in confirming that the peritoneal cavity has
anteriorly. The Veress is directed through the incision into been entered. A finger is also inserted into the incision and
swept circumferentially, directly feeling for adhesions. ceps. Current passes through the active electrode to the
Vicryl sutures is placed in the fascial edges to anchor the return electrode, minimizing the path of the current beyond
Hasson trocar. The suture is left in place and can be used for the surgical field.
fascial closure after trocar removal at the termination of the Cut and coagulation are the two modes of electrical
operation. The Hasson trocar is placed directly into the peri- energy. Cutting current heats tissue rapidly, without time to
toneal cavity and secured in place by wrapping the fascial produce coagulation necrosis. Coagulation is used more fre-
sutures around it. The insufflation tubing is connected to the quently in laparoscopy and relies on a low frequency, high
trocar and the abdomen is insufflated as detailed above. voltage, pulsed waveform to denature proteins and coagulate
The optical entry technique (Optiview by Ethicon, tissue.
Surgiview by US Surgical) is a method that may be used The LigaSure (Covidien) and Enseal (Ethicon Endo-
alone or after Veress use. These trocars have transparent, Surgery) are bipolar tissue and vessel sealing devices. Both
rounded tips, and an optical obturator that allows for the devices are approved to seal vessels up to 7 mm in diameter.
laparoscope to be placed into the trocar and obturator while The devices automatically regulate the level of energy used
the surgeon directly views the entry of the trocar through based on the resistance of the tissue being divided.
layers of the abdominal wall. This is often used after cre- Additionally, these instruments may also be used to cut and
ation of pneumoperitoneum with the closed Veress tech- bluntly dissect tissue, minimizing frequent instrument
nique. It may also be used prior to pneumoperitoneum by changes during surgery.
simply retracting the umbilicus anteriorly. This method of Ultrasonic energy is also widely utilized in laparoscopy.
abdominal access is arguably faster compared to both Veress Tissue destruction is achieved through high frequency
and Hasson techniques. Recent data has demonstrated a mechanical vibration which causing friction and creating
similar complication profile, making this a reasonable alter- heat to disrupt tissues. Three effects can be achieved: cavita-
native technique. The optical trocar is not needed during tion, coaptation or coagulation, and cutting. Cavitation,
placement of additional trocars, as these are placed under which is produced by intracellular fluid evaporation, aids in
direct visualization. separating tissue planes. Coaptation and coagulation occur
Placement of secondary, or working, trocars is procedure as a result of mechanical energy transfer to tissues that lique-
specific and their location dictated by the anatomical loca- fies and denatures hydrogen bonds. Denatured colloidal pro-
tion of the operation. The size is determined by the caliber of teins now form a gel. This is insoluble and is able to “seal”
the instruments to be passed through each trocar. The sur- vessel walls. Cutting is produced in the sharp blade mode.
geon should triangulate the area of interest and consider the The Harmonic scalpel (Ethicon Endo-Surgery) is a widely
working ports as if they are his or her right and left hands. used ultrasonic scalpel. Ultrasonic devices produce less lat-
Being cognizant of the distance between trocars during eral spread of energy to surrounding tissues.
placement is also essential. Studies have been able to demonstrate the benefit of
advanced hemostatic devices in laparoscopy, namely reduced
hemorrhage and operative time, at the detriment of cost.
aparoscopic Hemostasis and Energy
L Bipolar sealing and ultrasonic devices are costly and may
Sources require advanced knowledge of their use in comparison to
standard bovie electrocoagulation.
Electrical and ultrasonic energy devices play an essential
role in laparoscopic hemostasis. Both modalities cause ther-
mal destruction of tissues. Nonenergetic sources, such as Hemostatic Products and Adjuncts
laparoscopic clip appliers and staplers, are also useful; how-
ever, it is the laparoscopic energy device that is the work Bleeding in laparoscopy has a different impact on visibility
horse of hemostasis. than in open surgery: Minor bleeding will absorb light and
Electrical energy is arguably the most cost-effective and limit visibility in the operative field. Uncontrolled arterial
familiar modality. Bovie electrocautery and the LigaSure bleeding may prompt conversion to an open procedure; how-
(Covidien) device employ electrical energy. An electrosur- ever, less hemodynamically significant uncontrolled venous
gical unit is connected to both an active and return elec- oozing may also be cause for opening due to obliteration of
trode. Monopolar and bipolar electrosurgery differ in the the laparoscopic view. Suturing and energy devices comprise
path of the current. Monopolar devices act as the active elec- the first-line for hemostasis in laparoscopy as in open sur-
trode and return current through a return electrode, often gery. Hemoclips and linear staplers employ titanium to
referred to as a “grounding pad,” on the patient. Bipolar secure vessels and are readily available and easy to use. The
devices utilize an active and return electrode that are in laparoscopic equipment may limit some mechanical means
direct apposition to one another, such as each tine of a for- of hemostasis, such as the size of instruments used to provide
tamponade or the ability to quickly and effectively suture. sheet, NuKnit, and in fibrillar form that may be applied in
The surgeon must gauge his/her technical skills to determine thin tufts or layers or as a rolled pad. Foreign body and gran-
management of bleeding. ulomatous reactions have been described with their use.
The first step, as with open surgery, is to apply direct pres- Fibrin sealants are comprised of fibrinogen and thrombin
sure. During laparoscopic cholecystectomy, for example, and have been in use since the 1970s. They are both hemo-
venous bleeding from the liver bed may be temporarily con- static and adhesive. Factor VIII or bovine-derived antifibri-
trolled by using a grasper to press the gallbladder firmly nolytic agents, aprotinin or tranexamic acid, may be added to
against the bleeding site. This affords the surgeon time to stabilize the clot. A cross-linked insoluble fibrin clot forms
decide upon the next step in management. once fibrinogen and thrombin components are mixed. Tisseel
Adjunct topical hemostatic agents have a role in laparos- (Baxter Healthcare) and Evicel (Ethicon) are two commonly
copy as they do in open surgery. Factors inherent to laparos- used fibrin sealants. Human thrombin is more commonly uti-
copy, such as the size of the trocar being used, impact the use lized in comparison to bovine thrombin, which is potently
of these agents. Hemostatic agents may be used to address immunogenic. There is a risk of bloodborne pathogen trans-
venous ooze. If brisk arterial bleeding is unable to be con- mission with use of human plasma. Antifibrinolytic agents
trolled mechanically, conversion to open is indicated. The carry a risk of anaphylaxis or hypersensitivity. Risk of intra-
delivery of topical agents has evolved to be effectively vascular thrombosis increases with the amount of thrombin
employed laparoscopically. For example, often a tipped in any given preparation.
syringe or gun applicator is used via the trocar.
Gelatin products have the capacity to absorb many times
their weight in fluid and swell, which causes mechanical Tissue Approximation
tamponade. Gelfoam (Pharmacia & Upjohn) and Surgifoam
(Johnson & Johnson) both come in sponge form and can be The basis of tissue approximation is suturing and knot tying.
applied laparoscopically if this is cut into small pieces or Laparoscopic suturing is an advanced skill and requires a
ground into a powder. The gelatin matrix provides an archi- degree of technical ability that is largely unrelated to experi-
tecture for clot formation, but does not act upon the coagula- ence in open suturing and knot tying techniques. Studies
tion cascade. Gelatin products are absorbed in 4–6 weeks. have demonstrated that completion of a dedicated course,
Collagen agents utilize purified bovine collagen to cause such as Fundamentals of Laparoscopic Surgery (FLS), and
platelet contact activation and stimulation of the collagen cas- simulated practice significantly improve skill and facility.
cade. Platelet aggregation causes thrombus in the interstices of Because of the operative field magnification on the monitors,
the material and creates a physiologic platelet plug. Sponge, coordinated motion requires significant concentration and
flour, and sheet forms are available: Actifoam (Bard Davol), much slower movements. Movements performed at the same
EndoAvitene (Bard Davol), and Avitene (Bard Davol) are speed as they are during open surgery will lack precision and
examples. Collagen products are absorbed within 3 months. safety.
FloSeal Matrix (Baxter Healthcare) and SurgiFlo As with other aspects of laparoscopic surgery, ease and
(Ethicon) are gelatin products mixed with thrombin to pro- success of the procedure are influenced by setup. Ports are
duce both mechanical and pharmacologic effects on hemor- best placed in a triangulated fashion in relationship to the
rhage. Alternatively, gelfoam may be soaked in thrombin to tissue and to reproduce the arrangement of the surgeon’s
augment hemostasis. Both gelatin and collagen hemostatic hands with the camera in between these ports where the eyes
products may cause formation of granulomatous masses and naturally are between the hands. Suture needs to be short
their animal or human derivation makes them immunogenic. (10–15 cm in length) and bright white or dyed for easy visi-
A wide spectrum of allergic reactions can occur ranging bility. Needles are often tapered and cutting to facilitate pas-
from hypersensitivity to anaphylaxis. sage through tissues, as the length of laparoscopic instruments
Cellulose products comprise a third popular category of decreases the force that may be applied to the needle driver.
agents derived from wood pulp. The material swells once in In-line, coaxial handles and self-righting drivers are tools
contact with liquid and resorbs over a period of weeks. that may be used to facilitate suturing (Fig. 9.3a-c). Tissue
Oxidized or oxidized regenerated cellulose is thought to feedback is reduced, due to the length of the instruments and
affect coagulation in several ways, including interaction with inability to directly touch structures, making visual cues
proteins, activation of intrinsic and extrinsic pathways, and more important. The needle is observed passing through the
due to their low pH. The acidic environment makes them tissue and hand motions may be adjusted to allow it to pass
bactericidal. These products are not animal-derived and are smoothly and atraumatically.
absorbed in one to two weeks for oxidized regenerated and Both interrupted and running suturing may be performed
three to four weeks for oxidized cellulose. Surgicel (Ethicon) laparoscopically. Knots may be tied intracorporeally or
is a well-known cellulose product and is available in a fabric extracorporeally. Intracorporeal knot tying requires a high
a b
Fig. 9.3 (a–c). (From Scott-Conner CEH (ed), The SAGES manual: fundamentals of laparoscopy and GI endoscopy. New York: Springer-Verlag,
1999, with permission)
degree of concentration and practice to master. Less suture is turer have demonstrated reduced operative time using
used and square knots are made. An instrument tie is created EndoStitch.
within the abdominal cavity by making a c-shaped loop V-loc (Covidien) is a bidirectionally barbed suture and
around the instrument in the nondominant hand. The tail of has been utilized in open and laparoscopic procedures,
the suture is grasped with the nondominant hand, pulling the designed to function without knots. The bidirectional barbs
short tail through the loop, and the first throw is laid down. in the suture seat it within tissue along the length of its use
The second throw of the square knot is made by reversing the and it does not backslide. It is available in both absorbable
direction of the c-shaped loop and using the other hand to and nonabsorbable material. Because of the barbs, tensile
grasp the short end and pull it through the loop (Figs. 9.4a-d strength is reduced in comparison to nonbarbed suture; the
and 9.5). tensile strength of 0 barbed suture is comparable to 2–0 non-
In extracorporeal knot tying, slip knots are tied outside barbed suture. The V-loc obviates the need for knot tying in
the abdominal cavity and then slid (“pushed”) down toward laparoscopic surgery.
the tissue using a knot pusher. Roeder’s knot is a method of The Endoloop (Ethicon) is another method of tissue
sliding knot that may be used in laparoscopic surgery. After approximation or hemostasis that may be employed in lapa-
a single throw is created, one of the ends is wrapped around roscopic procedures and can be used as an alternative to a
the loop of suture three times, then passed through the loop. stapler in laparoscopic appendectomy or to hemoclips in
The looped suture must be stacked evenly before being slid laparoscopic cholecystectomy. It may also be used addi-
down toward the tissue with a knot pusher (Fig. 9.6). tively, for example, after placement of clips on a cystic duct.
The EndoStitch (Covidien) device was created to improve The Endoloop is a pretied suture loop, and typical suture
the ease of laparoscopic suturing by automating needle pass- material is vicryl or PDS. The pretied suture loop must be
ing between instruments. A short, straight needle is passed able to be passed over the tissue to be ligated. The ends of
between two jaws of the instrument and is able to be toggled suture are encased in a plastic tube with a distal score. The
to each jaw. This allows the needle to be placed into tissue, scored end is cracked, allowing the ends of suture to be
the jaws closed, and the needle passed through the tissue to pulled as the plastic tube is directed toward the tissue to be
the other jaw. When the jaws are then opened, the needle has ligated, pushing the pretied knot down. Once the pretied knot
passed through the tissue and is attached to the opposite jaw has been secured, the plastic tube is removed and the long
and the next stitch ready to be taken. Studies by the manufac- ends of suture are cut intracorporeally.
Fig. 9.4 (a–d). (From

a b
Scott-Conner CEH (ed), The
SAGES manual:
fundamentals of laparoscopy
and GI endoscopy. New York:
Springer-Verlag, 1999, with
permission)
Make C-loop
with ight hand.
Wrap
with
right
hand.
c d
Grab short
tail...
Lay down
first flat knot.
... and pull

through
Pitfalls and Danger Points access to the abdominal cavity result from bleeding or perfo-
ration of vessels and organs. Insufflation of carbon dioxide
Laparoscopy relies on pneumoperitoneum, which places the into any structures other than into the peritoneal space may
body under distinct physiologic stress, different from that of result in hypercapnea or hypotension.
an open procedure. Most patients tolerate this stress well, Once the abdomen in insufflated, the following principles
making laparoscopic procedures such as appendectomy and are followed to avoid injury: do not angle the Veress or optiv-
cholecystectomy the standard of care. If the patient does not iew trocar toward the midline during initial placement, place-
tolerate insufflation or becomes unstable during any part of ment under direct vision (Fig. 9.7), transillumination of the
the procedure, the surgeon must pause the operation and con- abdominal wall to visualize and avoid large vessels, use of
sider the cause. Communication with the anesthesia team is the smallest diameter cannula possible, and creation of the
paramount. If hemodynamic or respiratory instability occurs skin incision slightly larger than the diameter of the trocar to
during insufflation, it is best to stop insufflation, evacuate the minimize force needed to pass the trocar.
pneumoperitoneum, and convert to an open procedure. Major vascular injury carries a 15% mortality and occurs
Intraoperative causes of death from laparoscopy are most more commonly in a thin patient. Injuries to retroperitoneal
commonly related to anesthesia, followed by vascular injury, vessels, such as the distal aorta, right common iliac vein, or
and lastly bowel injury. inferior vena cava, can occur before, during, and after insuf-
flation. The incidence is higher with the Veress needle in
comparison to with optical trocar entry. Major vascular
Access Injuries injury should be suspected if there is sudden hypotension
during insufflation, or a dramatic fall in end tidal carbon
Access injuries include both injuries sustained from Veress dioxide, as this could represent CO2 embolization.
needle or open access as well as complications from nonin- Minor vascular injury is associated with a 2.5% mortality
traperitoneal insufflation of carbon dioxide. Access injuries rate and is most commonly due to inferior epigastric injury.
can lead to hypercarbia, carbon dioxide embolus, bleeding, Transillumination of the abdominal wall to visualize large
and urgent conversion to midline laparotomy. Injuries during vessels minimizes this risk. Identification of an injury to the
Fig. 9.5 (From Scott-Conner a b

CEH (ed), The SAGES
manual: fundamentals of
laparoscopy and GI Wrap with left hand.
endoscopy. New York: Make C-loop Grab short tail...
with left hand
Springer-Verlag, 1999, with
permission)
... and pull

through.
Lay second flat knot

to complete square knot.
inferior epigastric vessels is best performed at the end of the sweeping the bowel away to aid operative field exposure may
case during trocar removal. This allows identification of contribute to lack of identification. If a bowel injury is sus-
hematomas or hemorrhage following trocar removal. pected at the time of surgery and conversion to an open pro-
Omental vessels, and less commonly mesenteric vessels, cedure is performed, leave the cannula in place to aid
may also cause hemorrhage if injured during Veress needle identification of injury site. Careful attention should be paid
or trocar placement. If major or minor vessel injury is sus- to the patient’s postoperative complaints and vital signs.
pected and hemorrhage is unable to be controlled, leave the
trocars in place while conversion to an open procedure is
performed: The trocars will provide tamponade and facilitate Hypotension
identification of the injury site once the patient is opened.
Bowel injury differs from vascular injury in that it is less Hemorrhage, CO2 embolus, tension pneumothorax, and
likely to be identified at the time of surgery and may present hypercarbia causing dysrhythmias can all lead to hypoten-
postoperatively with peritonitis. This is the third most com- sion during laparoscopic surgery. In general, hypercarbia is
mon cause of death from laparoscopic surgery and multiple rare, and hyperventilation can be employed by the anesthesia
studies have shown the incidence (0.04 to 0.3%) to correlate team to reduce it.
with surgeon experience. Mortality rates correspond to tim- Gas embolus may occur if carbon dioxide is insufflated
ing of identification of the injury. A bowel injury identified directly into a vessel, or operations which require transec-
days or weeks after the operation has a higher morbidity and tion of venous sinusoids are cut, such as during laparoscopic
mortality than an enterotomy identified and repaired at the liver resection. Aspiration with the Veress needle as
initial surgery. Bowel injury can be caused by Veress needle, described above prior to carbon dioxide insufflation helps to
primary trocar placement, secondary trocar placement, blunt avoid this complication. Clinically significant gas emboli
dissection, electrocoagulation, and graspers. Small bowel, are rare, with reported incidences ranging from 0.0012% to
colon, and stomach may be injured. Normal peristalsis or 0.5%. The mortality rate is 28% with a significant embolus.
Fig. 9.7
operative length, and has the ability to obscure the operative

field. Lower abdominal trocar sites are located lateral to the
rectus sheath and the abdominal wall transilluminated to
delineate the course of the inferior epigastric and other ves-
sels prior to trocar placement. Umbilical puncture sites
should be avoided in cirrhotic patients with known caput
medusae. Sutures placed into the abdominal wall can be used
to control hemorrhage from access sites.
Fig. 9.6 Hypoxia
Hypoxia may be caused by compression of the lungs by

A gas embolus is best identified by transesophageal echo- pneumoperitoneum. Patients with considerable pulmonary
cardiogram. Suspicion should arise with a sudden elevation disease are not candidates for laparoscopy as they will not
followed by an abrupt fall in end tidal CO2, unexplained tolerate a restrictive decrease in lung expansion.
hypotension, and hypoxia. Management is focused on pre-
vention of further gas entry: insufflation should cease imme-
diately and pneumoperitoneum evacuated. Place the patient Postoperative Bowel Obstruction
in the left lateral decubitus position with steep head down,
hyperventilate the patient, and obtain central venous access While the incidence of postoperative ileus is less with lapa-
for the purpose of aspirating the gas embolus. Utilize fluid roscopic surgery than with open surgery, the development of
administration, inotropes, and vasopressor medications as a mechanical postoperative bowel obstruction should trigger
indicated. Cardiopulmonary resuscitation may be required. thought of a Richter’s-type hernia, which have an incidence
Tension pneumothorax is rare, but may also be a cause of of 0.77% to 3%. This occurs when the negative pressure
unexplained hypotension. This is more commonly seen with upon port removal draws or sucks a portion of intestine into
foregut procedures where the working area is near the esoph- the incision. The difference between the external atmo-
ageal hiatus. spheric pressure and a higher intraabdominal pressure is aug-
mented to create more suction when the valves of the trocars
are closed upon removal. Valves should be opened prior to
Hemorrhage cannula removal. Using the smallest diameter cannula pos-
sible, removal under visualization, and closing the fascia of
Major and minor vascular injury are discussed above. Less all port sites greater than 5 mm reduce the risk of bowel
clinically significant bleeding is an annoyance, may add to entrapment in trocar sites.
Laparoscopy in Pregnancy technique is preferred by many surgeons as it provides an

opportunity to visualize the uterus prior to trocar placement.
Laparoscopy is the standard of care in the management of The left subcostal area may also be used to avoid the gravid
common emergent surgical conditions, notably appendici- uterus. Fundal height is estimated as at the pubic symphysis
tis and cholecystitis, and this holds true in the pregnant at 13 to 14 weeks, halfway between the symphysis and the
patient. One in 500 to 635 women will undergo nonobstet- umbilicus at 16 weeks, and at the umbilicus at 20 weeks. It
rical surgery during pregnancy. Gestational age and trimes- approaches the xiphoid at 36 to 40 weeks.
ter are important considerations for operative planning; Trocar placement for a cholecystectomy is typically with
however, laparoscopy may be performed safely in any the initial port in a supraumbilical position and two ports in
trimester. their usual positions in the right upper quadrant. Trocar
The beneficial outcomes of laparoscopic procedures, placement for appendectomy or diagnostic laparoscopy var-
including decreased hospital stay, decreased postoperative ies more, as the location of the inflammatory process may be
pain, and decreased use of narcotics, are also seen in preg- closer to the gravid uterus. The ideal working port placement
nant patients. The decreased demand for postoperative nar- will vary depending on the location of the appendix. During
cotics benefits the fetus by decreasing fetal respiratory the first trimester, no adjustments to port locations are
depression caused by narcotics. needed. In the second or third trimesters, a supraumbilical or
subxiphoid access point is preferred, followed by placement
of additional ports dictated by the location of the appendix.
Preoperative Considerations Often, this will necessitate right and left lower quadrant
working ports in the second trimester and two right-sided
Laparoscopy in the pregnant patient requires thoughtfulness ports in the third trimester.
toward the physiologic changes of pregnancy, including ane- The use of carbon dioxide to establish pneumoperitoneum
mia, increased tidal volume, increased oxygen requirement, creates concern of maternal and fetal acidosis. This has been
and increased cardiac output. Avoiding complications to the observed in animal studies without any detectable long term,
fetus, such as preterm labor and spontaneous abortion, is a deleterious outcome. Significant maternal or fetal acidosis from
goal linked to providing care for the mother and reducing her carbon dioxide pneumoperitoneum has not been demonstrated
mortality risk from acute surgical conditions. The fetus is in humans. Some sources recommend maintaining intraabdom-
most vulnerable to spontaneous abortion in the first trimes- inal pressure as low as possible, less than 12 to 15 mm Hg, as
ter, while the risk of preterm labor increases in the third long as adequate visualization can be maintained.
trimester. Pregnancy predisposes to lower extremity venous stasis
An obstetric consultation is recommended by and hypercoagulability due to increased levels of fibrinogen
SAGES. Intraoperative fetal monitoring may be used. If and factors VII and XII. Laparoscopic procedures have a
intraoperative monitoring is not used, fetal heart tones should decreased risk of thromboembolic events. Venous thrombo-
be documented pre- and postoperatively. embolic events occur with 0.1 to 0.2% frequency in preg-
The first trimester uterus is amenable to the supine posi- nancy. Sequential compression devices are sufficient for
tion; however, the left lateral decubitus or partial left lateral intraoperative prophylaxis.
decubitus position must be used in the second and third tri-
mesters. After the first trimester, the gravid uterus places
pressure on the inferior vena cava, decreasing venous return Laparoscopy in Previous Abdominal Surgery
to the heart, thereby decreasing cardiac output. This can
cause maternal hypotension and placental hypoperfusion. Laparoscopy may be attempted after previous abdominal
surgery. Initially any type of previous abdominal surgery was
considered a contraindication to laparoscopy; however, this
Intraoperative Considerations is no longer the case. There are specific concerns when
embarking on laparoscopy in the setting of prior abdominal
Intraoperative concerns around the safety of laparoscopy in surgery, specifically the risk of bleeding, visceral injury, and
pregnancy include the risk of uterine and fetal injury and conversion to an open procedure. These concerns stem from
fetal acidosis from pneumoperitoneum. the presence of intraabdominal adhesions, which occur at a
Abdominal access and additional trocar placement must variable rate of 30–90% after abdominal surgery. The pres-
be altered and adjusted for uterine size and fundal height. All ence, severity, and location of adhesions vary from patient to
access techniques, including the optical trocar and the Veress patient, with no accurate way to predict these factors. Both
needle, are safe to use in a pregnant patient. The Hasson patient factors (obesity, number, and complexity of prior
abdominal surgeries) and surgeon factors (surgeon comfort, or other instruments, and the surgeon should maintain a
technical expertise) contribute to the success rate with a lapa- high index of suspicion for bowel injury during the post-
roscopic approach. operative course.
In the last 5 years, the data demonstrates both the pres-
ence and absence of a statistical difference between laparo- Acknowledgments This chapter was contributed by Carol E. H. Scott-
scopic procedures in the virgin abdomen in comparison to Conner, MD, PhD, in the previous edition.
previous abdominal surgery in terms of morbidity, mortality,
and conversion rates. Common to all studies is the lack of
data to suggest that operative time is longer in the setting of Further Reading
previous abdominal surgery. Previous midline laparotomy,
laparoscopic adhesiolysis, and previous intestinal resection Ahmad G, Gent D, et al. Laparoscopic entry techniques. Cochrane
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cites Crohn’s disease and proctectomy as independent risk quantitative study of the time and motion of laparoscopic surgeons
factors for conversion to an open procedure. in live surgical environments. Surg Endosc. 2016;30(11):5068–76.
Patient selection is key to success. The planned opera- Antoniou SA, Antoniou GA, et al. Blunt versus bladed trocars in lapa-
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surgery is away from the site of the planned operation, as is a new learning curve? Dis Colon Rectum. 2013;56(6):786–96.
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tion can usually be performed with ease. Attention should factors for intra- and postoperative complications in 1316 elective
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As a rule, laparoscopic access should be gained well la Chapelle CF, Swank HA, et al. Trocar types in laparoscopy. Cochrane
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below the left costal margin in the midclavicular line, is Lyons SD, Law KS. Laparoscopic vessel sealing technologies. J Minim
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The optical entry technique may also be employed. If Marcovich R, Del Terzo MA, et al. Comparison of transperitoneal lapa-
roscopic access techniques: Optiview visualizing trocar and Veress
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the surgeon must decide if it is safer to proceed with an oncological resections. Updates Surg. 2017;69(3):339–44.
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Rational Use of Drains
10
Kulmeet K. Sandhu
Purpose of Drains radiopaque sheet of rubber. It has the advantage of being

inexpensive. It is also successful in encouraging fibrosis, so
Drains permit purulent material, blood, serum, lymph, bile, it forms a well-established tract within 8–10 days. Penrose
pancreatic juice, and intestinal contents to escape from the drains are also used for retraction, for example, when the
body. They form a walled-off passageway that leads from the esophagus is retracted during hiatal hernia repair. It has
source of infection or fluid buildup to the outside. This pas- many disadvantages as well. This is a completely passive
sageway, or tract, must persist long enough to ensure com- drain, and fluid exits around the drain by capillary action and
plete evacuation of the collection, and then allow collapse of gravity. Ideally, the drain is placed to create a dependent tract
the cavity with healing from the inside out. Drains can work through which fluid escape may be aided by gravity. If the
passively (gravity-dependent) or actively (suction-surgeon does not take pains to bring the drain out in a straight
dependent) and can be an open system or closed system. The line, without wrinkles, stagnant pools of serum can accumu-
risk of infection is considered to be lower for a closed system late around the wrinkled areas of the drain. After the drain is
drain. removed, the patient may have a 24-hour increase in tem-
In the presence of a discrete abscess, the need for and perature of as much as 1 °C. More fundamentally, the passive
purpose of a drain is obvious and not controversial, as its drain does not empty a cavity; it simply permits secretions to
therapeutic benefits are clear. In most other situations, the overflow from the abdomen to the outside. It is not particu-
drain acts as a prophylactic measure to prevent accumulation larly effective in evacuating oozing blood before a clot forms.
of undesirable products or as an early marker of anastomotic There is no good method by which the depth of the wound
leak. Because it is a foreign body, the drain also has the para- can be irrigated with this type of drain as there is when a tube
doxical effect of potentiating infection. In addition to infec- or sump type is used.
tion, drains can also cause bleeding and possible hernia Finally, the most significant disadvantage to the Penrose
development. When and how a drain should be used for pro- drain arises from the fact that it requires a 1- to 2-cm stab
phylactic purposes has long been a source of controversy. wound in the abdominal wall, which permits retrograde pas-
Controlled trials have significantly decreased the indications sage of pathogenic bacteria down into the drain tract. It also
for “prophylactic” drainage. creates a sizable fascial opening that may be the site of sub-
sequent hernia formation.
Various Drains and Their Pros and Cons

Polyethylene or Rubber Tube Drain
Penrose Drain
These are also passive drains but are tubular and more rigid
The Penrose drain is a soft drain of various dimensions. It than the Penrose drain. Both polyethylene and rubber tube
has the shape of a flattened cylinder and is made of a thin, drains establish tracts to the outside, as they are mildly irri-
tating and stimulate adhesion formation. They effectively
evacuate air and serum from the pleural cavity and bile from
K. K. Sandhu (*)
Department of Surgery, Division of Upper Gastrointestinal and the common bile duct (a chest tube, or a T-tube, would be
General Surgery, Keck School of Medicine of the University of examples of such drains). Drainage tract infection following
Southern California, Los Angeles, CA, USA the use of tube drains is less common in this drain type.
e-mail: kulmeet.sandhu@med.usc.edu

https://doi.org/10.1007/978-3-030-81415-1_10
78 K. K. Sandhu
Among the disadvantages of rubber and polyethylene rated silicone or polyethylene catheters attached to a sterile
tubes is that they become clogged with clotted serum or plastic container, the source of continuous suction. It is a
blood unless they are large. Large tubes, however, are unsuit- closed system, and the catheters are brought out through
able for placement deep in the abdominal cavity for long puncture wounds. These drains have replaced other drains
periods of time, as there is danger of erosion through an adja- for most applications. Patient mobility is unimpaired, as the
cent segment of intestine, resulting in an intestinal fistula. plastic container is easily attached to the patient’s attire. The
These drains are, therefore, primarily used in selected appli- depths of the wound can be irrigated with an antibiotic solu-
cations such as pleural space drainage and biliary tract drain- tion by disconnecting the catheter from the suction device
age as noted above. and instilling the medication with a sterile syringe.
Closed suction drains are commonly used in a clean field,
such as at axillary node dissection sites to prevent seroma
Silicone Tube Drain formation. They should be removed as soon as possible to
prevent bacterial entry.
Silicone or Silastic tubes are less reactive than are other Some closed suction drains contain multiple perforations.
types of drain. They are less prone to become plugged as a In time, tissues are sucked into the fenestrations, and tissue
result of clotting serum. Because of the soft texture of sili- ingrowth may even occur. This makes removal difficult
cone, erosion into the intestine is uncommon. (occasionally to the point of requiring relaparotomy), and
A disadvantage of silicone drains is their lack of reactiv- most surgeons are reluctant to leave a fenestrated closed suc-
ity; hence, there is minimal fibrous tract formation. This les- tion drain in the abdomen for more than 10 days. Fluted
son was learned when Silastic T-tubes were (briefly) used in (channel-type) suction drains are also available and avoid
the common bile duct, and their removal often resulted in this potential complication.
bile peritonitis because a firm fibrous channel had not been
established between the bile duct and the outside.
Gauze Packing
Sump Suction Drains When a gauze pack is inserted into an abscess cavity and is
brought to the outside, the gauze, in effect, serves as a drain.
Generally constructed of silicone or polyethylene tubing, Unless the packing is changed frequently, this system has the
sump drains must be attached to a source of continuous disadvantage of potentiating sepsis by providing a foreign
suction. They effectively evacuate blood and serum, espe- body that protects bacteria from phagocytosis. Management
cially if suction is instituted in the operating room, so the of pancreatic abscesses by marsupialization and packing is
blood is evacuated before it clots. The sump allows air to an example of this technique. Daily dressing changes keep
enter as suction is applied, much as a sump nasogastric tube the packing fresh.
continuously aspirates air. This air intake channel can also
be used for instillation of an antibiotic solution when indi-
cated. If used regularly, fluid instillation prevents obstruc- Prevention of Drainage Tract Infection
tion of the drain due to coagulation of serum or secretions.
Drainage tract infections with sumps are uncommon even Retrograde transit of bacteria from the patient’s skin down
though unsterile, bacteria-laden air is drawn into the depths into the drainage tract is a source of postoperative sepsis and
of the patient’s wound by the continuous suction. A major may even follow clean operations. When a polyethylene
disadvantage of sump drains is the requirement that the sump or a silicone closed suction catheter is brought through
patient be attached permanently to a suction device, thereby a puncture wound of the skin, it is easy to suture it in place
impairing mobility. These drains are predominately used and minimize or eliminate the to-and-fro motion that encour-
for very difficult abscesses, such as those associated with ages bacteria to migrate down the drain tract. On the other
peripancreatic sepsis, where other drains tend to stop hand, when a latex drain is brought out through a 1- to 2-cm
working. stab wound in the abdominal wall, there is no possibility of
eliminating the to-and-fro motion of the drain or retrograde
passage of bacteria into the drainage tract. Consequently,
Closed Suction Drain when latex or gauze drains are required for an established
abscess, the surgeon must accept the added risk of retrograde
These are the most common drains used in current practice. contamination with bacteria despite sterile technique when
The closed suction drain consists of one or two multiperfo- dressings are changed.
10 Rational Use of Drains 79
Management of Intraperitoneal Sepsis with overlying fenestrated plastic covering which is cut to fit
inside the peritoneal cavity and cover the abdominal con-
When managing intraperitoneal sepsis, a distinction must be tents. This is covered with a second sponge, sized to the
made between an isolated abscess (e.g., around the appen- abdominal wound. An adherent dressing and, finally, tubing
dix) and multiple abscesses involving the intestines accom- that connects to a portable suction device are placed over the
panied by generalized peritonitis. With the latter type of sponges. This method provides drainage of the peritoneal
sepsis, the presence of fibrin and necrotic tissue prevents cavity while protecting its contents. Fluid flows from the
adequate phagocytosis and perpetuates sepsis. abdominal cavity into a disposable collection canister. The
When an abscess has developed rigid walls that do not col- negative pressure can be set, and the therapy can be continu-
lapse after evacuation of pus, large drains must be inserted to ous or intermittent. Care must be taken to correctly place the
establish a reliable tract to the outside. Sometimes, a rigid dressing and choose suitable settings as complications such
abscess cavity requires 2–5 weeks to fill with granulation as bleeding, bowel erosion, or fistula formation may occur.
tissue. It is not safe to remove the drains until injecting the This is discussed further, with illustrations, in Chap. 8.
abscess with an aqueous iodinated contrast medium has pro-
duced a radiograph demonstrating that the cavity is no longer
significantly larger in diameter than the drainage tract. If this Other Indications and Methods of Drainage
is not done, the abscess may rapidly recur. For rigid-walled
abscesses of this type, several large latex drains should be Abscess
inserted together with one or two sump drains. Some surgeons
place an additional straight 10F catheter for intermittent instil- For abscesses of the extremities, trunk, or perirectal area, the
lation of dilute antibiotic solution. At least one drain is left in important step is to unroof the abscess by making a cruciate
place until the sinogram shows that the abscess cavity has incision so the tract does not close before all the pus has been
essentially disappeared. Care should be taken that none of the evacuated. An unroofing procedure is adequate for superfi-
rigid drains comes into contact with the intestine or stomach, cial abscesses, and any type of temporary drain is sufficient.
as intestinal fistulas can be a serious complication. When the danger exists that the superficial portion of the
tract might close before deep healing takes place, insertion of
gauze packing is indicated. The packing is then changed
ercutaneous Drainage of Abdominal
P often enough to keep it from blocking the egress of pus.
Abscesses with Computed Tomography or
Ultrasound Guidance Blood and Serum
The presence of blood, serum, or fibrin in a perfectly sterile
Treatment of abdominal abscesses underwent a revolution- area is not dangerous to the patient, although the operative
ary change during the 1990s owing to the demonstrated effi- field is never completely sterile following any major opera-
cacy of percutaneous drainage by the interventional tion. For this reason, postoperative puddles of blood or serum
radiologist. In the case of most abdominal abscesses, the in combination with even a small number of bacteria can
skilled radiologist can find a safe route along which to insert result in abscess formation because the red blood cell impairs
a drainage catheter that evacuates the pus without a need to antibacterial defenses. With the low colorectal anastomosis,
perform laparotomy for drainage. This has led to a signifi- accumulated serum or blood in the presacral space, together
cant decrease in the number of surgical drains placed during with secondary infection and abscess formation, may result
the index operation. This technology is especially welcome in anastomotic breakdown. For these reasons, strenuous
in the critically ill patient who may not tolerate a major efforts should be exerted to eliminate bleeding during any
operation. abdominal operation. If these efforts must be supplemented
by some type of drainage, the ideal method is to insert one or
two multiperforated Silastic drains, which are brought out
Negative Pressure Wound Therapy (NPWT) through puncture wounds in the abdominal wall and attached
to a closed suction system.
Negative pressure therapy is commonly used for abdominal Closed suction drainage is extremely effective following
incisions, both acute and chronic. In the setting of emergency radical mastectomy or regional lymph node dissections of
surgery with severe abdominal sepsis, where a second look the neck, axilla, or groin. Small-diameter tubing is accept-
may be required or abdominal compartment syndrome is a able. This technique has also been employed successfully
concern, the abdomen can be left open and NPWT applied. following abdominoperineal proctectomy with primary clo-
This system often consists of a sterile abdominal sponge sure of the perineal floor and skin.
80 K. K. Sandhu
Bile structing the anastomosis or eliminating it from this stage of

the operation.
Because bile has an extremely low surface tension, it tends to When treating Crohn’s disease accompanied by extensive
leak through tiny defects in anastomoses or through needle cellulitis, some surgeons believe the inflamed areas should
holes. It is essentially harmless if a passageway to the out- be drained. In reality, cellulitis or contamination, such as
side is established. A sump drain or closed suction system might follow a perforated duodenal ulcer, does not benefit
works well for this purpose. Silastic tubes are contraindi- from drainage. It is well established that the peritoneal cavity
cated whenever the formation of a fibrous tract to the outside as a whole cannot be drained.
for the bile is desirable, especially with use of a T-tube in the If complete hemostasis cannot be achieved in the vicinity
common bile duct, as previously noted. of an anastomosis, there may be some merit to inserting a
silicone closed suction drain for a few days to prevent pool-
ing of blood next to the anastomosis, provided the drain does
Pancreatic Secretions not come into direct contact with the suture line. In truth,
there is no substitute for excellent hemostasis.
It is not dangerous for pure pancreatic juice to drain into the
abdominal cavity, as is evident in patients who have pancre- Acknowledgments This chapter was contributed by Carol E. H. Scott-
atic ascites or a fistula. If the pancreatic secretion is activated Conner MD, PhD in the previous edition.
by the presence of bile, duodenal contents, or pus, however,
trypsinogen is converted to trypsin and the adjacent tissues
are subjected to a raging inflammatory reaction. Recently Further Reading
constructed adjacent anastomoses may be digested and
destroyed. Eventually, hemorrhage from retroperitoneal Cheng Y, Xia J, et al. Prophylactic abdominal drainage for pancreatic
surgery. Cochrane Database Syst Rev. 2016;10:CD010583.
blood vessels ensues. Dann GC, Squires MH 3rd, et al. Value of Peritoneal Drain Placement
Consequently, it is important to evacuate bile and pancre- After Total Gastrectomy for Gastric Adenocarcinoma: A Multi-
atic secretions. This is accomplished by inserting a long plas- institutional Analysis from the US Gastric Cancer Collaborative.
tic catheter into the pancreatic duct in the tail of the pancreas. Ann Surg Oncol. 2015;22(Suppl 3):S888–97.
Diener MK, Tadjalli-Mehr K, et al. Risk-benefit assessment of closed
The catheter is brought through the segment of jejunum to intra-abdominal drains after pancreatic surgery: a systematic
which the duct is anastomosed. Then, it is brought through a review and meta-analysis assessing the current state of evidence.
jejunostomy opening to an outside drainage bag. Unless the Langenbeck's Arch Surg. 2011;396(1):41–52.
tube is accidentally displaced, it conveys all pancreatic secre-Gurusamy KS, Koti R, et al. Routine abdominal drainage versus no
abdominal drainage for uncomplicated laparoscopic cholecystec-
tions from the abdominal cavity. In addition, a suction cath- tomy. Cochrane Database Syst Rev. 2013;9:CD006004.
eter is inserted in the vicinity of the anastomosis, between Gurusamy KS, Samraj K. Routine abdominal drainage for uncom-
the tail of the pancreas and the jejunum. Many surgeons rou- plicated open cholecystectomy. Cochrane Database Syst Rev.
tinely drain pancreatic staple lines or suture lines (e.g., after 2007;2:CD006003.
Gurusamy KS, Samraj K, et al. Routine abdominal drainage for
distal pancreatectomy or pancreaticojejunostomy) with uncomplicated liver resection. Cochrane Database Syst Rev.
closed suction drains. 2007;3:CD006232.
Huttner FJ, Probst P, et al. Meta-analysis of prophylactic abdominal
drainage in pancreatic surgery. Br J Surg. 2017;104(6):660–8.
Lobaton T, Guardiola J, et al. Comparison of the long-term outcome of
Anastomosis two therapeutic strategies for the management of abdominal abscess
complicating Crohn’s disease: percutaneous drainage or immediate
If anastomotic breakdown occurs, the presence of a drain surgical treatment. Color Dis. 2013;15(10):1267–72.
may not prevent generalized peritonitis. If the surgeon Puleo FJ, Mishra N, et al. Use of intra-abdominal drains. Clin Colon
Rectal Surg. 2013;26(3):174–7.
believes there is significant risk of anastomotic failure, the Schein M. To drain or not to drain? The role of drainage in the contami-
anastomosis should be taken apart and re-done, or else both nated and infected abdomen: an international and personal perspec-
ends should be exteriorized and reconnected at a second- tive. World J Surg. 2008;32(2):312–21.
stage operation. The surgeon must not fall into the trap of Shrikhande SV, Barreto SG, et al. Post-operative abdominal drainage
following major upper gastrointestinal surgery: single drain versus
fuzzy thinking, which would permit acceptance of an anasto- two drains. J Cancer Res Ther. 2013;9(2):267–71.
mosis that might be less than adequate, rather than recon-
Illustrated Glossary of Surgical
Instruments 11
Introduction
In the operating room, an efficient workflow with smooth

sequences of movements between the surgeon and the oper-
ating technician depends on proper commands. You must be
familiar with the names of common instruments.
This chapter provides a photographic guide for identify-
ing some of the commonly used open and laparoscopic sur-
gical instruments. It should be noted though that instrument
naming may considerably vary from institution to institution.
It pays to learn and use the terminology of the operating
room suite in which you practice, even if it differs from that
with which you have been familiar (Figs. 11.1, 11.2, 11.3,
11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, 11.12,11.13,
11.14, 11.15, 11.16, 11.17, 11.18, 11.19, 11.20, 11.21, 11.22,
11.23, 11.24, 11.25, 11.26, 11.27, 11.28, 11.29, 11.30, 11.31,
11.32, 11.33, 11.34, 11.35, 11.36, 11.37, 11.38, 11.39, and
11.40).
Fig. 11.1 Hemostatic clamps: Kelly, straight and curved
E. R. Noren
Los Angeles, CA, USA
A. M. Kaiser (*)
Hope National Medical Center/Comprehensive Cancer Center,
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_11
82 E. R. Noren and A. M. Kaiser
Fig. 11.2 Hemostatic clamps: Reinhoff, Kelly, Tonsil (left-to-right)
Fig. 11.4 Clamps: Kocher, Lahey, Allis, Babcock (left to right)
Fig. 11.5 Sponge-stick (top), Foerster ringed forceps (bottom)

Fig. 11.3 Right angle clamps
11 Illustrated Glossary of Surgical Instruments 83
Fig. 11.8 Forceps (top to bottom): Russian, Gerald, Debakey, Bonney,

Adson
Fig. 11.6 Doyen noncrushing bowel clamp
Fig. 11.7 Needle drivers
Fig. 11.9 Scissors (top to bottom): Straight Mayo, Curved Mayo,

Metzenbaum
Fig. 11.10 Vascular clamps: Satinsky (left), Debakey (right) Fig. 11.13 St Mark’s pelvic retractor
Fig. 11.11 Hand-held retractors: Richardson
Fig. 11.14 Small retractors (top to bottom): Right Angle, USA (a.k.a.
Army-Navy), Goulet
Fig. 11.12 Hand-held retractors: Dever

Fig. 11.15 Self-retaining retractor: Weitlander
Fig. 11.18 Curettes in multiple sizes
Fig. 11.16 Self-retaining retractor: Gelpy
Fig. 11.19 Anal retractors: Chelsea-Eaton anal retractor (a.k.a. anal

bullet retractor)
Fig. 11.17 Suction tips (top to bottom): Poole, Yankauer, Andrews-

Pynchon (A-P)
Fig. 11.23 Linear cutting stapler (a.k.a. GIA)
Fig. 11.20 Anal retractors: Hill-Ferguson retractor
Fig. 11.24 Non-cutting linear stapler 90 mm (a.k.a. TA)
Fig. 11.21 Fistula probes, multiple types Fig. 11.25 Circular stapler (a.k.a. EEA)
Fig. 11.22 Drains: Blake (left), Bulb suction (center), Jackson-Pratt Fig. 11.26 Circular sizers (25 mm, 28 mm, 31 mm)
(Right)
Fig. 11.27 Stapled hemorrhoidopexy set (a.k.a. PPH): circular stapler,

anal retractor (transparent), obturator (white), suture anoscope, suture
threader
Fig. 11.30 Laparoscopic trocars with obturator removed (5 mm,

12 mm)
Fig. 11.28 Advanced energy device: ultrasonic shears
Fig. 11.31 Veress needle
Fig. 11.29 Advanced energy device: bipolar tissue sealing device
Fig. 11.32 Hasson trocar

Fig. 11.37 Laparoscopic powered stapler
Fig. 11.33 Laparoscopic shears
Fig. 11.38 Laparoscopic ultrasonic shears (Harmonic® HD, Ethicon

US, LLC)
Fig. 11.34 Laparoscopic instruments (top to bottom): Maryland dis-

sector, Grasper with teeth, Babcock, shears
Fig. 11.39 Specimen retrieval bag
Fig. 11.35 Laparoscopic needle holder
Fig. 11.40 Bookwalter retractor system
Fig. 11.36 Laparoscopic clip appliers

Surgical Documentation, Informed
Consent, and Operative Note 12
Andreas M. Kaiser
Table 12.1 Defining the values of documentation

Defining Value of Documentation Area of value Comment
Continuity of Communication/sharing/transfer of
Appropriate documentation is an integral part of delivering care information, understanding of case details,
health care to our patients and adds enormous value on a treatment planning, development of surgical
number of different levels (Table 12.1). While often maligned strategy
Cost saving Cost control
as an undue administrative burden to the physicians, it should
Avoiding unnecessary repetition of previously
be recognized that good documentation is our friend as well done steps/procedures
as our “protective insurance,” while poor, incomplete, or Reimbursement You can only bill if it is documented and
altered documentation can easily turn into our worst enemy. indicated
In complex or decentralized cases that require either simulta- Litigation Good report: Deflect risks, minimizes room for
speculation and interpretation
neous or sequential involvement of different physicians
Harmful report: Not or untimely done, lacking
(potentially working in different locations), availability and essential details, altered later without clearly
study of current and past records serves as means to com- marking changes as amendment
municate and transfer information and greatly facilitates Quality control/ Analysis of outcomes
continuity of care, the development of a treatment concept, Research
and a surgical strategy.
letter) that summarizes in broad terms or with specific details

Elements of Surgical Documentation the treatment plan, the rationale and timeline for the recom-
mendation, as well as the discussion with the patient. Not
Excellent surgical technical judgment and skills still remain only does such a well-crafted document allow other directly
the foundation of success. However, modern surgery has or peripherally involved providers (e.g., referring physician)
become a lot more complex in more ways than just those due to be brought up to date. Equally important, it may in the
to the technology revolution. We are as specialists dependent case of a litigation carry a protective capacity of the same or
on many others and vice versa held accountable to high stan- higher magnitude than the official informed consent, particu-
dards. Solid surgical documentation is the vehicle to success larly if it clarifies the discussed goals, limitations, possible
and relies on the following three pillars. outcomes in detail that allow the patient to understand the
choices and set realistic expectations.
Provider Chart Entry

Informed Written Consent
Before the operation, the surgeon should sign off on an
explanatory note (consultation note, progress note, provider Most people consider this to be the only legal document to
confirm the patient’s understanding of the plan and willing-
ness to proceed with a specific intervention. In that sense, it
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of should list the procedure(s), alternatives, benefits, and risks.
Hope National Medical Center/Comprehensive Cancer Center, The type and format of the informed consent and the extent
Duarte, CA, USA and detail of contained information, however, are by no

https://doi.org/10.1007/978-3-030-81415-1_12
90 A. M. Kaiser
means standardized and vary substantially from one institu- (b) The surgeon is the attending who takes the main respon-
tion to another. Regardless though, and in order to avoid an sibility and primary or supervision decision-making role
unpleasant surprise in front of a lawyer, it is strongly recom- during the case. In a complex case that requires two or
mended that the surgeon in fact reads and knows what the more primary surgeons to conjointly be involved, they
respective consent document states. act and bill as co-surgeons, unless their respective com-
ponents are not necessarily connected but simply happen
during the same anesthesia. If an attending surgeon acts
Operative Note as assistant and intends to bill for his assisting role, the
note has to state that there was no qualified resident
This document should be considered to be the “executive available to assist.
summary” of the events, steps, and immediate results of a (c) The preoperative diagnosis describes the medical condi-
surgical intervention. While it should cover a number of ele- tion for which the procedure is being performed.
ments, it should strike a balance between too little and too (d) The postoperative diagnosis states whether the operative
much detail. A brief postoperative note is generated immedi- findings were supportive of or different from the preop-
ately at the end of the procedure and serves as a preliminary erative diagnosis and list other important incidental find-
document until the official operative note is dictated/tran- ings (e.g., previously unknown liver cirrhosis, or
scribed or computer-generated and accessible in the chart. carcinomatosis).
(e) The name of the procedure labels the operation or lists
the main independent portions of the case, either with
Operative Note immediate display of current procedural terminology
(CPT) codes or in such clarity that it can easily be used
The official operative note can be generated in a number of for coding and subsequent billing purposes. If the CPT
different ways, for example, dictated and transcribed, self- code is affected by size or complexity (e.g., size of split-
typed, or using computer-module guided structured creation thickness skin graft), give these details here.
with stepwise prompting of key information to be entered. (f) The indication section is a crucial part of the operative
Following a standard format best assures that all of the essen- note. It should reflect the provider chart entry and sum-
tial information be included. It is crucial to strike a balance marize the reasoning and thought process to justify pro-
between thoroughness and excessive length with unneces- ceeding with the particular operation at the particular
sary details. The following elements should be included in time rather than considering other surgical or non-
every operative note: surgical options. In order to assign the appropriate
diagnosis- related group for hospital inpatient billing
• Date of the procedure purposes, it is relevant to mention significant comorbidi-
• Team: Surgeon, co-surgeon(s), assistants ties. It should document that the situation was discussed
• Preoperative diagnosis with the patient (or other authorized decision-makers)
• Postoperative diagnosis with explanation of the procedure along with goals, limi-
• Name of the procedure and major components thereof tations, possible outcomes, alternatives, benefits, and
• Indication for the procedure risks. Last but not least, it confirms that an informed
• Description of the procedure consent was obtained and who from the patient’s side
• Postoperative condition and family was involved.
• Plan These statements in this section primarily serve at
documenting the decision-making process and potential
risk constellations but may quickly move into the center
(a) An accurate operative note should be promptly dictated of interest if a case is being audited for billing issues or
or generated within 24 hours. Later dictation may not scrutinized in peer review or malpractice litigation.
only be below the professional standard of care but also (g) The description of the procedure represents the core of
represent a deviation from hospital bylaws and require- the operative note and documents the relevant findings
ments of accreditation organizations (The Joint and surgical steps with a sufficient level of detail to
Commission). More important though is the reality that allow for easily conceptualizing what was done and
even the best of memory may fade quickly when it why. While the exact execution of the report is a matter
comes to relevant intraoperative details. Hence, the more of personal style, the section should be concise, accu-
delayed a report is, the more vulnerable it becomes to rate, and honest, but avoid excessive wordiness for irrel-
inquisitive speculation by lawyers should a case become evant aspects. It should address all aspects and findings
part of a litigation. that are important for the current intraoperative choices,
12 Surgical Documentation, Informed Consent, and Operative Note 91
Table 12.2 Elements of “Description of the procedure” namic stability, status of vital organ functions, ability to
Detail Comment extubate, estimated blood loss and transfusions, urine
Position Supine, modified lithotomy, output, etc. The patient’s destinations (recovery room,
prone, prone-jackknife, etc. intensive care unit, etc.) have to be delineated.
Access and incision type Open, MIS, endoscopic
(i) Plan and/or recommendation: Some details about the
Intraoperative findings Target pathology
Altered anatomy, adhesions
postoperative care need to be spelled out, for example,
Unexpected findings the impact of the pathology report on the further man-
Dissection Planes, distance from relevant agement, antibiotic use beyond 24-hour prophylaxis
structures (therapeutic intent), need for scheduled second look or
Pertinent structures identified Nerves, vascular structures, follow-up operations, timing, and criteria for future
and protected ureters, ducts, etc.
stoma takedown.
Anatomic location of pathology
Vascular structures present,
resected, left behind
Specimen resected R0, R1, R2, margins Teaching Documentation
Extent and viability of For example, length of residual
structures/tissues left behind small or large bowel after How to prepare an appropriate operative note is rarely taught
resection
or instructed to the surgical residents. The quality of reports
Configuration, type and Stapled or handsewn
technique, and assessment of End-to-end, end-to-side, side to shows a wide range and can be optimized through teaching.
anastomoses side, functional end vs. Such need was identified and addressed by a book titled
isoperistaltic Operative Dictations in General and Vascular Surgery, coed-
Testing: air-leak test, perfusion ited by Carol Scott-Conner and Jamal J Hoballah (2011),
fluoroscopy
which has served as a companion to Chassin’s textbook. This
Implants/prosthesis Specifics, size, type
Stoma Segment, location, type (loop, has been a very useful educational resource to the surgical
end, catheter) residents in training as a quick reference guide prior to per-
Complications Surgical: collateral injury forming a surgical procedure or in preparation for the certi-
Systemic fying part of the American Board of Surgery examination.
Closure With/without implant
Type and completeness of
closure
Drains and tubes Type, size, location References
Completeness of counts (or Sponge, needle, instruments
X-ray confirmation) Hoballah JJ, Scott-Conner CEH, editors. Operative dictations in gen-
Condition Hemodynamic stability eral and vascular surgery. 2nd ed. New York: Springer Science +
Urine output Business Communication; 2011.
Estimated blood loss Maniar RL, Sytnik P, Wirtzfeld DA, Hochman DJ, McKay AM,
Transfusions Yip B, Hebbard PC, Park J. Synoptic operative reports enhance
documentation of best practices for rectal cancer. J Surg Oncol.
Wound classification I, II, III, IV
2015;112(5):555–60.
Maniar RL, Hochman DJ, Wirtzfeld DA, McKay AM, Yaffe CS, Yip
B, Silverman R, Park J. Documentation of quality of care data for
decisions, and steps, the extent of the surgery (what was colon cancer surgery: comparison of synoptic and dictated operative
removed, what was left behind), and the ultimate out- reports. Ann Surg Oncol. 2014;21(11):3592–7.
Melton GB, Burkart NE, Frey NG, Chipman JG, Rothenberger DA,
come (Table 12.2). Adverse events can occur during an Vickers SM. Operative report teaching and synoptic operative
operation in the best of hands. They should be described reports: a national survey of surgical program directors. J Am Coll
in a neutral nonjudgmental fashion (e.g., do not call a Surg. 2014;218(1):113–8.
collateral injury “inadvertent,” as it would be interpreted Parrish AB, Sanaiha Y, Petrie BA, Russell MM, Chen F. Examining
the quality of rectal cancer operative reports in teaching institu-
as “careless”). Attempts at covering them up or avoid- tions: is there an opportunity for resident education? Am Surg.
ance of describing them and clarifying how they were 2016;82(10):1023–7.
managed can reflect negatively on the surgeon when the Zwintscher NP, Johnson EK, Martin MJ, Maykel JA, Rivadeneira DE,
case is being reviewed. Serur A, Steele SR. Surgical residents and the adequacy of dictated
operative reports. J Surg Res. 2012;177(2):211–6.
(h) The patient’s intra- and postoperative condition should
be described in a short statement with regard to hemody-
Part II
Esophagus
Ninh T. Nguyen
Concepts in Esophageal Surgery
13
Olugbenga T. Okusanya and James D. Luketich
astroesophageal Reflux Disease and Type

G lifestyle changes related to GERD. Specifically, ask about
I Paraesophageal Hernia their uses of antacid medications (prescribed, over the coun-
ter, or homemade), changes in their diet, or GERD-related
In the normal configuration, the true gastroesophageal junc- physiologic maneuvers such as repetitive empty swallowing.
tion (GEJ) is demarcated by the transition from squamoco- Also, ask about general bowel function including regularity
lumnar to glandular tissue in the distal esophagus. This is of defecation, history of constipation, narcotic use, and espe-
seen at or below the level of the diaphragmatic pinch (visible cially a history of bloating. Also, note the patient’s general
during endoscopy when the patient “sniffs” to contract the physical condition, recent weight changes, current weight,
diaphragm and compress the esophagus at that level). This body mass index (BMI), and previous abdominal surgeries.
transition is visible on standard white light endoscopy, with Typically, patients who present to a surgeon have been
the normal esophageal mucosa appearing a light pink, and previously evaluated by another provider. Proton pump
the gastric mucosa a deeper red appearance. In concert with inhibitors (PPI) have revolutionized the medical treatment of
lower esophageal sphincter (LES) tone, the configuration of GERD. These medications are generally well tolerated and
the proximal stomach at the Angle of His, and the relative significantly ameliorate the symptoms of GERD in most
constriction of crus muscle around the esophagus, gastric patients, so much so that patients who present with typical
contents are contained in the stomach though there is a small symptoms are often started on PPI therapy empirically and
and expected amount of physiologic gastroesophageal reflux those whose symptoms resolve are maintained on PPI ther-
less than 4% of the time. In gastroesophageal reflux disease apy without further workup. Recent research into PPIs has
(GERD), any one of these components can be disrupted lead- indicated some associations with clostridium difficile infec-
ing to the pathologic exposure of the esophagus to acidic tion, osteoporosis, and other long-term health problems (Loo
gastric contents. et al. 2011; Kwok et al. 2011; Sherwood et al. 2015). Patients
Key to the detection and treatment of GERD is the careful who have persistent symptoms on maximal twice a day PPI,
and detailed questioning of each patient about their symp- who do not want to continue to take medications, or who
toms. The terms heartburn and regurgitation are so often and have had GERD-related complications including anemia,
colloquially used that patients will often acknowledge or dis- aspiration pneumonia, and or interstitial pulmonary fibrosis
miss symptoms based on the presumption of what they think should be considered for surgical therapy. For patients who
those terms mean. Precise questioning regarding typical are morbidly obese and have GERD, bariatric surgery, spe-
symptoms (retrosternal post-prandial chest pain, volume cifically a Roux-en-Y gastric bypass, can be an effective
acid regurgitation, or dysphagia) and atypical symptoms weight loss and anti-reflux surgery.
(chronic cough, globus, volume salivation, odynophagia) Paraesophageal hernias (PEH) represent a spectrum of
should be a priority. Ask about self-directed interventions or diseases in which GERD can be intermingled. A type I PEH
is somewhat of a misnomer and is better thought of as a slid-
ing hiatal hernia. As such, the esophagus and proximal stom-
O. T. Okusanya
Department of Surgery, Thomas Jefferson University, ach slide up into and out of the chest while one wall of the
Philadelphia, PA, USA hernia is made of the peritoneal lining over the herniated
J. D. Luketich (*) stomach. Small sliding hiatal hernias are quite common, and
Department of Cardiothoracic Surgery, University of Pittsburgh if the patient is asymptomatic no further therapy is war-
Medical Center, Pittsburgh, PA, USA ranted. The degree of symptomatology of a sliding hiatal
e-mail: luketichjd@upmc.edu

https://doi.org/10.1007/978-3-030-81415-1_13
96 O. T. Okusanya and J. D. Luketich
hernia is strongly correlated to the severity of the patient’s mative, especially in patients whose other studies are
GERD. Though these hernias can be small, the severity of equivocal, or who present with inconsistent atypical
the GERD they can cause should not be underestimated. symptoms, and it is essential in patients who have had
Small sliding hiatal hernias and GERD often exist separately, prior foregut surgery of any kind to assess the function of
but if they exist together or warrant surgical therapy, the the vagal nerves (Schuchert et al. 2010).
approach is largely the same.
A typical workup consists of an esophagogastroduode-
noscopy (EGD) preferably performed by the operating sur- Anti-reflux Operations
geon, a barium swallow, a pH study, while the patient is off
medical therapy, esophageal manometry, and if clinically Anti-reflux operations are functional in nature as their goal
indicated a gastric emptying study. is to improve the patient’s symptoms and quality of life.
The challenge, therein, is to do so without rendering harm
• EGD: First and foremost is to exclude another esophageal or leaving a patient in a worse state than they were in before
pathology as the cause of the patient’s symptoms. EGD surgery. In simple terms, replacing a valve that is “too
also allows the surgeon to confirm the presence of GERD- loose,” with a valve that is “too tight” may well address the
related phenomena such as Barrett’s esophagus, esopha- GERD but could leave a patient with recalcitrant dyspha-
gitis, stricture, or malignancy. Lastly, the size and location gia, gas bloat, and unmanageable flatulence. As such, small
of a hernia can be directly ascertained as well as any gas- errors can lead to unmanageable clinical outcomes. We
tric pathology. often make the comparison of a surgeon doing colon resec-
• Barium swallow: The barium swallow is inexpensive and tions, lung resections, gallbladder removals, etc., which
gives a detailed delineation of the esophageal anatomy. It may be perfectly fine, but can they routinely perform a
can effectively give clues regarding the presence of stric- functional ileoanal anastomosis? Again, small errors may
tures and motility disorders. It also can delineate other lead to a lifetime of incontinence or the requirement for a
significant mechanical pathologies such as esophageal colostomy. Similarly, how many cardiac surgeons can
diverticula. safely and effectively perform a mitral valve replacement,
• pH study: Wireless capsule-based pH studies form the likely many, but how many can do a functional repair of the
foundation of the workup for anti-reflux operations due to mitral valve? Far less, and thus we caution all surgeons to
the relative clarity of the information provided. The consider the anti-reflux operations as functional recon-
Bravo™ pH monitoring system (Medtronic, Minneapolis structions, and thus, the surgeon should be properly trained
MN) is a wireless sensing probe placed 5 cm proximal to and should have a detailed knowledge of their own out-
the gastroesophageal junction during endoscopy, and data comes. We see many patients operated upon by less experi-
are collected and transmitted over 48 hours. It is well tol- enced surgeons who wind up with inferior results. Some
erated by most patients. A DeMeester score for each day label the patients “psychotic” or “problem patients” when
is calculated and then averaged. A score above 14.72 is their new symptoms absolutely did not exist before the
considered positive for pathologic acid exposure (Johnson anti-reflux operation and now they are miserable, but the
and Demeester 1974). surgeon is unwilling to acknowledge their operation may
• Manometry: High-resolution manometry gives detailed be the cause of such a dysfunctional state.
information about the esophagus’s contractile profile. Laparoscopy has changed the fundamental approach to
These results should be interpreted with caution as mod- these operations. Now the vast majority of these cases are
erate or severe reflux itself can cause some abnormalities done minimally invasively (laparoscopic or robotic-assisted).
in motility. Manometry is largely used to determine the However, the tenants of any anti-reflux operation are clear.
type of fundoplication to be done or if an operation should
be done at all, although many surgeons acknowledge that 1. Vagal preservation.
in the absence of clinical dysphagia, significant abnor- 2. Maintenance of crural integrity and careful repair.
malities in the manometric results may not ultimately 3. Extensive intrathoracic esophageal mobilization.
influence their plan of care. We believe the manometry 4. Re-establishment of “normal” anatomy in terms of the
does contribute to our decision-making regarding the type location of a tension-free GE junction 2–3 cm below the
of wrap, and how we counsel patients and families in level of the diaphragm.
regard to the expected outcomes and potential side effects 5. Precise identification of the GE junction, that is, the true
of a fundoplication. location of where the striated esophageal musculature
• Gastric emptying study: In patients who present with sig- meets the serosal layer of the gastric cardia. We find this
nificant bloating, advanced diabetes, or other concerning virtually impossible to precisely locate without mobiliz-
gastrointestinal maladies, an emptying study can be infor- ing and rolling the fat pad from the patients left to right,
13 Concepts in Esophageal Surgery 97
carefully creating a plane parallel to the lie of the anterior be 2 cm long and easily permit the passage of the shaft of an
vagus nerve. instrument next to the esophagus inside the wrap. In a patient
6. A well-created and positioned fundoplication. with symptoms of significant bloating or evidence of esopha-
geal dysmotility, a near Nissen is performed where the wrap
We approach these operations using a 5–6 port technique is posteriorly directed but approximately only 300–320
with the operating surgeon on the patient’s right side and the degrees around the esophagus. Many surgeons choose a Dor
patient in steep reverse Trendelenburg position. The opera- (180-degree anterior wrap) or Toupet (180-degree posterior
tion begins with a careful and precise placement of the lapa- wrap) for a number of reasons. Some centers still prefer the
roscopic ports to best position the surgeon and assistant(s) to Belsey Mark IV (240-degree posterior transthoracic wrap)
accomplish the operation efficiently and safely. The initial approach as it does not require intra-abdominal access and
assessment is to determine the degree of hiatal hernia that is can be used as a salvage in complicated cases.
present; to fully accomplish this, the pars flaccida is opened It is clear that the completeness of the wrap and its tight-
and the right crus is dissected away from the hiatal contents. ness are related to the degree of undesirable symptoms
Take care not to strip the peritoneum from the crus and do patients experience postoperatively including bloating and
not expose bare striated muscle. This plane is carried anteri- dysphagia. However, it is also clear that the more complete
orly watching for the left anterior vagus nerve. Next, the pos- the wrap, the more effective the acid exposure control. Early
terior aspect of the esophagus is dissected. At a minimum, postoperative patients often have symptoms of early satiety,
perform circumferential dissection of the intrathoracic dysphagia, diarrhea, and flatus due to the decrease in gastric
esophagus up to the level of the inferior pulmonary veins. reservoir, the more rapidly emptying stomach, and normal
The short gastric vessels are divided as needed for a fundo- postoperative swelling. These are generally mild and should
plication, and then the gastric fat pad is mobilized to visual- resolve within a few weeks. Postoperative bloating is to be
ize the gastroesophageal junction. In order to wrap the expected and is worse in patients with bloating symptoms
esophagus, there must be 3 cm of tension-free intra-abdomi- preoperatively. Dysphagia can often be managed conserva-
nal esophagus. The crura are closed starting posteriorly using tively and can even be resolved with judicious and serial
a heavy braided suture while maintaining the normal ley of dilation. However, persistent or new symptoms warrant
the esophagus. Lastly, the wrap of choice is performed. In investigation as they may indicate a technical complication.
the obese patient (BMI > 35), a discussion should be had We recommend an immediate postoperative barium swallow
about a Roux-en-Y gastric bypass being performed as the to ensure a satisfactory appearance and also as a reference
reflux operation. A gastric bypass is an excellent ant-flux for future comparison. Ultimately, surgeon judgment is cru-
operation and has the bonus of being a bariatric operation as cial to delivering a satisfactory result. It should be noted in
well (Jones Jr. et al. 1991; Awais et al. 2008; Raftopoulos the era of significant narcotic prescriptions that patients on
et al. 2004). However, the surgeon or center performing these chronic narcotic medications may have great difficulty in
operations should have experience with these techniques as achieving a satisfactory clinical outcome. The main issues
it has its own unique set of challenges and it is imperative we have experienced are gastroparesis, chronic nausea, and
that a careful and complete hernia reduction and crural repair chronic constipation. These patients should be carefully
be performed (if a hernia is present) prior to creating the gas- counseled about the potential negative effects of an anti-
tric pouch. reflux wrap on these symptoms. If it is possible to lower
doses and or wean completely off, this should be
considered.
Wrap Choice
There are several choices for a fundoplication. The particular Alternatives to Traditional Surgery
choice is often dictated by surgeon preference and practice.
For a Nissen fundoplication, the degree of wrap should be There are several alternatives to traditional anti-reflux sur-
dictated by patient’s manometry and preoperative symptoms. gery. One such therapy is magnetic sphincter augmentation
A classic Nissen is a posterior-directed 360-degree wrap (MSA) by the implantation of the Food and Drug
using both the anterior and posterior parts of the stomach. Administration (FDA)-approved LINX ® Device (Torax
The term “floppy” Nissen popularized by Donahue includes Medical, Shoreview MN). The LINX is a small flexible
the use of a 50 French bougie in the esophagus at the time of band of titanium beads with magnetic cores. The device is
wrap and a 16 French dilator on the stomach (Donahue et al. implanted laparoscopically after dissection of the phreno-
1977). We use a 54 French bougie and include a partial- esophageal ligament and mobilization of the anterior vagus
thickness bite of the esophagus in our wraps. We aim to make nerve. The device is sized to the esophagus and then placed
the wrap floppy and not too snug or tight. The wrap should around it in a 360-degree fashion with a locking clasp mech-
anism. The core principle is that the device increases pres-

sure at the LES preventing reflux but when a food plus
passes antegrade the magnetic force of the beads is over-
come and the bolus is allowed to pass into the stomach.
Several studies have shown MSA to be effective at reducing
GERD symptoms and improving patients’ GERD quality of
life (Bonavina and Attwood 2016; Ganz et al. 2016).
Propensity matched studies have suggested similar if not
superior results to Nissen fundoplication (Reynolds et al.
2015). However, mechanical erosion of the device into the
lumen of the esophagus has been reported, and the device is
currently only being implanted in patients with very small
hiatal hernias (Asti et al. 2017). We have implanted this
device in over 100 patients with excellent outcomes in over Fig. 13.1
85% of cases.
Transoral incisionless fundoplication (TIF) is an endo-
scopic procedure performed with the EsophyX™ Despite the emergence of multiple new approaches to
(EndoGastric Solutions, Inc., Redmond WA, United States) anti-reflux procedures, surgical fundoplication remains the
device. In short, a stapling device is introduced through the gold standard for non-medical therapy for GERD. These
GEJ, while an endoscope is retroflexed. The stomach is fixed other methodologies are yet to demonstrate a long-term
to the GEJ while being plicated and rotated using pairs of safety and efficacy profile but warrant continued study and
full-thickness tacking anchors. It creates a 3–5 cm valve that development.
is anywhere between 200 and 300 degrees around.
Randomized trials and prospective trials indicate that TIF is
able to improve patients’ symptoms and decrease PPI usage. Paraesophageal Hiatus Hernia
The long-term durability of these results is in question
(Huang et al. 2017). Anywhere between 3% and 10% of Type III and IV PEHs represent a unique disease condition.
patients experience a significant complication including In type III PEH, the GEJ and the proximal stomach have
pneumothorax, bleeding, or abscess (Wendling et al. 2013). passed through a widened hiatus and are now fixed in the
Long-term follow-up indicates that the rate of PPI use intrathoracic position (Fig. 13.1). In a type IV (Giant PEH),
increases overtime and that TIF is not as cost-effective as more than 50% of the stomach and/or other intra-abdominal
Nissen fundoplication (Funk et al. 2015). Currently, we are organs are intrathoracic. Most patients, when questioned
not using this approach in our own practice. carefully, are symptomatic. In extreme cases, patients can
Stretta therapy is the endoscopic use of radiofrequency present with gastric volvulus, enteric ischemia, and be in
energy to augment the LES. The therapy is catheter based extremis. A wide range of symptoms can exist between these
using the Stretta System (Curon Medical Inc., Sunnyvale, two states including intermittent obstructive symptoms, nau-
Calif., United States) which has four nitinol needles that are sea, early satiety, regurgitation, chronic cough, GERD,
injected at 5 mm intervals above and below the GEJ, thus recurrent pneumonias, anemia from Cameron’s ulcers, bloat-
producing 56 lesions. The needles are at the depth of the ing, dyspnea, or chest and abdominal discomfort. It is clear
muscular level of the esophagus and heated to 85 °C, while that when these hernias are fixed in the urgent or emergent
the mucosa is actively cooled with water. The exact mecha- setting, patients do poorly with a mortality of at least three
nism of augmentation is unclear though it is believed that times that of a patient getting an elective repair (Tam et al.
this therapy causes hypertrophy of the esophageal muscle 2017a). In patients who present with major obstructive epi-
and augmentation of the LES. Individual studies on Stretta sodes, early decompressive EGD with the placement of a
have shown improvement in patient GERD symptoms, nasogastric tube can temporize the majority of patients,
decrease in PPI use, and overall esophageal acid exposure allowing a semi-elective operation to be performed (Awais
(Liang et al. 2015). However, at least two major systematic and Luketich 2009). Careful observation of these patients
reviews and meta-analyses have had conflicting results. after decompression is critical as they may display signs of
Specifically, these studies differed in their endpoints and recurrent strangulation or ongoing malperfusion. If on EGD
methodology (Lipka et al. 2015; Fass et al. 2017). Currently, there is frank necrosis or ongoing ischemia, then operative
we are considering using the Stretta approach for complex intervention at that time is a must to salvage the patient.
redo situations where a true anatomic defect cannot be For the patient undergoing elective repair, we favor a bar-
identified. ium swallow, pulmonary function tests, cardiac risk stratifi-
cation, and preoperative EGD by the operating surgeon as a Much like anti-reflux surgery, there are key principles that
standard workup. CT is optional, and it can be helpful in must be followed for a successful repair of a PEH (Nason
defining the type IV hernia, but generally this does not affect et al. 2012).
the operative plan to a significant degree; thus, we only use
CT scanning selectively. We generally encourage medically • Preservation of the peritoneal lining over the crus
fit patients to undergo elective repair as the morbidity and • Vagal nerve preservation
mortality for non-elective repairs, even in experienced hands, • Complete intrathoracic mobilization of the hernia sac
are too high. Even frail patients can tolerate a careful laparo- • Circumferential mobilization of the proximal stomach
scopic complete sac dissection and complete repair. In our and esophagus
series of more than 600 patients, we have been able to limit
30-day mortality to less than 2% despite increasing comor- With experience, all these aims can be met minimally
bidities in these patients (Luketich et al. 2010; Ballian et al. invasively. Direct reduction of the hernia by manipulation of
2013; Nason et al. 2008). the stomach can cause significant gastric injury. An initial
As many as 20% of these patients will experience GERD anterior approach that mobiles the hernia sac from the medi-
if an anti-reflux procedure is not performed (Allen et al. astinum routinely and safely reduces all the hernia contents.
1993). However, due to the mechanical changes from fixa- Careful attention must be paid to the location of the pleura,
tion in the chest and a short esophagus, these patients will pericardium, vagus, aorta, and thoracic duct.
often require an esophageal lengthening procedure in order The use of mesh to reapproximate the hiatus is a widely
to perform an intra-abdominal fundoplication (Horvath et al. debated issue among surgeons. The long-term benefit to
2000). As such a careful questioning of the patients as to mesh has not been clearly shown though there is some data
their most concerning or prominent symptom is key. The use to support that it reduces the rate of early hernia recurrence
of manometry in these patients is debated as positioning a (Tam et al. 2016). To avoid excessive tension, a left pleural
manometry catheter in these patients may be technically dif- catheter can be placed at the time of surgery to induce a con-
ficult to get accurate LES measurement. However, esopha- trolled pneumothorax which greatly aids in adding “floppi-
geal body peristaltic assessment is generally very doable and ness” to the left hemidiaphragm allowing a tension-free
can be helpful in planning the operation. In most patients reapproximation of the crura. Currently, we use mesh in less
with GERD symptoms, we favor complete esophageal mobi- than 5% of our cases, generally when the integrity of the
lization, and if needed a lengthening via Collis gastroplasty, crura is in question (Tam et al. 2017b). Others suggest that
followed by fundoplication. The routine use of Collis gastro- using relaxing incisions in the lateral diaphragm to aid in a
plasty is not associated with worse outcomes, and it can eas- tension-free reapproximation of the crura, we have not found
ily be performed laparoscopically or robotically (Fig. 13.2) this necessary in the majority of cases, especially when using
(Nason et al. 2011; Luketich et al. 2000). In the older frail the controlled left-sided pneumothorax (Greene et al. 2013).
patients especially those with isolated mechanical symp-
toms; intrathoracic dissection, reduction, and gastropexy
may be acceptable. Achalasia
Achalasia is an esophageal motility disorder characterized

by a non-relaxing LES, often in conjunction with hypomotil-
ity in the rest of the esophagus. High-definition manometry
has led to the definition of three subtypes of achalasia: type
1, minimal esophageal pressurization, type II with pan pres-
surization, and type II with spasm and spastic contraction.
Barium swallow often shows a dilated esophagus with sig-
nificant stasis and a smooth tapering at the GEJ. In extreme
cases, one may observe a sigmoidal appearance and a mega-
esophagus. In these advanced cases, a simple myotomy will
likely fail in many, leaving esophagectomy as the best
approach when other lesser measures fail (Schuchert et al.
2009) (Fig. 13.3). EGD is a critical diagnostic tool to first
rule out malignancy or other causes of esophageal compres-
Fig. 13.2 sion leasing to pseudo-achalasia. EGD typically shows mild
in the best series, has a perforation rate of 4–11%, which

frequently requires urgent surgical intervention. Even if ini-
tial is successful, up to 50% of patients treated with dilation
are not doing well at long-term follow-up (Campos et al.
2009). Because of this and the risk of perforation, many cen-
ters choose laparoscopic or endoscopic approaches over
pneumatic dilation as the first and hopefully definitive repair.
An alternative or adjunct to balloon dilation of the LES is the
injection of botulinum toxin injection. First reported in the
1990s, an intersphincteric injection of 80 units of botulinum
toxin was able to generate a 40% decrease in LES pressures
with results that were sustained in short-term follow-up
(Pasricha et al. 1995). However, the results are generally not
durable and usually dissipate within a year. Furthermore,
surgical interventions have been shown to have worse out-
comes after botulinum injection (Smith et al. 2006).
The gold standard for the current therapy for achalasia is
laparoscopic Heller myotomy (LHM) (Kilic et al. 2009a).
Because the dilated proximal esophagus may contain signifi-
cant amounts of food or liquid, anytime a patient with acha-
lasia is to be anesthetized, it is important that they only
consume a clear liquid diet for a few days before the case.
Induction is done with rapid sequence induction. Have a
bronchoscope ready to avoid aspiration and quickly clear the
airways if it occurs. Once the case begins, the anterior por-
tion of the esophagus is mobilized to expose the distal esoph-
Fig. 13.3
agus and to mobilize the anterior vagus nerve away from the
myotomy. The longitudinal and circular fibers of the esopha-
gus are split 5–10 cm proximal to the GEJ and 3 cm distal
onto the stomach. The bulging mucosa should be visible.
Most surgeons perform a Dor fundoplication to prevent the
development of GERD as the point of this operation is to
disrupt the LES. Randomized studies have shown that Dor
fundoplication in addition to myotomy was far superior to
myotomy alone in terms of the incidence of postoperative
GERD (Richards et al. 2004). Some have postulated that
other fundoplications may have a better profile but differ-
ences between the type of fundoplication used and outcomes
are not clearly established (Rawlings et al. 2012).
Transmucosal myotomy was first described in the 1980s
(Ortega et al. 1980). Per oral endoscopic myotomy (POEM)
gained popularity in the late 2000s as an alternative to surgi-
cal therapy for achalasia (Schaheen et al. 2018). POEM is an
endoscopic therapy usually performed by surgeons or gastro-
Fig. 13.4 enterologists. The submucosa at least 10 cm from the GEJ is
injected and raised away from the muscular layer often using
esophageal candidiasis, and there is usually a characteristic a methylene blue containing solution. This area is incised,
“pop” as the scope passes through the GEJ. Manometry and a submucosal tunnel is created down beyond the
remains the gold standard for diagnosis. GEJ. Then using a cautery blade, the muscular fibers starting
Currently, there are a number of therapeutics available for 3 cm distal to the mucosal entry are split down to 2 cm
the treatment of achalasia. Many patients are seen by a gas- beyond the GEJ, thus creating a partial-thickness myotomy
troenterologist and may have had balloon dilation as a first (Fig. 13.4). Subsequently, the mucosal defect is clipped or
intervention. However, aggressive pneumatic dilation, even sewn back together. In one of the largest studies of POEM
with 300 patients, efficacy was 98% (Onimaru et al. 2013). obtain adequate drainage in any of these cases to avoid the
Complications included bleeding, full-thickness esophageal development of fulminant mediastinitis which leads to the
perforation, mediastinitis, pneumothorax, and the develop- patient’s death. Debridement of devitalized or soiled tis-
ment of reflux in over 50% (most serious complications are sue is also a necessity. Small, self-draining perforations
actually quite uncommon). There are no randomized control may be observed, but this requires significant judgment
trials comparing POEM to Heller with or without fundopli- and careful clinical monitoring.
cation. However, a recent meta-analysis showed that proba- • Supportive care: Patients with full-thickness perforations,
bility of improvement of dysphagia was statistically higher with mediastinal soilage, will often be quite ill and even
for POEM at both 12 and 24 months through both techniques in extremis, they will require antibiotics, urinary catheter
had a greater than 90% probability. Rates for GERD by pH and monitoring, volume resuscitation and ionotropic sup-
probe were 11% for Heller and 47% for POEM. POEM port as needed, and selective intubation to withstand the
patients also stayed in the hospital 1 day longer than LHM septic shock associated with this condition. These sup-
(Schlottmann et al. 2017). The question of which therapy portive measures must be urgently administered and, in
will ultimately prove to be best is unclear, but as time and most cases, patients should be in the operating room suite
experience grow it will likely become more clear what the as soon as possible.
role of each modality will be. For the current era, it is clear • Antibiotics: Broad-spectrum antibiotics including fungal
that many patients are choosing POEM, when given the coverage is key and must be administered as early as pos-
option. sible when perforation is even suspected. Cultures should
be taken liberally but regardless, broad-spectrum antibiot-
ics should be started, possibly tapered later, and followed
Esophageal Perforation judiciously.
• Lung expansion: The lung may have a dense fibrous peel
The majority of esophageal perforations are iatrogenic depending on the age of the perforation and will need to
(Brinster et al. 2004). They can occur at almost any level of be decorticated, so it may expand and obliterate any
the esophagus. Modern adjuncts especially the development potential empyema space.
of self-expanding covered stents have given surgeons more
options for management. Surgical dictum states that perforations less than
Esophageal perforation is a true surgical emergency. If 24 hours old may be primarily repaired, and those greater
left untreated, true full-thickness perforations can be fatal. It than 48 hours should be drained. However, with advances
has been clearly documented that the mortality doubles if in critical care and surgical judgment, those dogmas should
therapy is delayed for more than 24 hours (Brinster et al. be respected but not considered law. Traditional therapy
2004). The management of perforations has several goals for an intrathoracic perforation would be a left or right tho-
(Abbas et al. 2009). racotomy depending on the level of the perforation, open-
ing and debridement of the posterior mediastinum, wide
• Early identification: Patients often present with a history drainage, and establishment of enteral access. If the tissues
of instrumentation, foreign body ingestion, prolonged around the esophagus can be debrided back to a healthy
wretching, or vomiting. The presence of a pleural effu- area, then primary repair with a local flap (intercostal mus-
sion, pneumothorax, pneumomediastinum, or pneumo- cle, pleura, mediastinal fat, omentum) can be used as a but-
peritoneum should trigger a computed tomography (CT) tress. If this is to be done, a myotomy must be performed
scan with oral and intravenous contrast which will often proximally and distally around the site to ensure all the
clinch the diagnosis. A barium swallow is still the gold perforated mucosa is debrided and closed. In patients with
standard test and should be obtained liberally. achalasia, a separate myotomy at the level of the GEJ
• Localization: Imaging may be able to clearly identify the should also be performed. In the case of extensive chronic
location of the perforation but EGD will also be able to soilage, debridement alone with drainage and the optional
localize the perforation. Though there may not be a clear placement of an esophageal T tube can be used to create a
defect, there are often stigmata indicating the level of per- controlled fistula that scars down and closes over time.
foration. When the patient is stable, we prefer to have a Repair of significantly damaged esophageal tissue may not
barium swallow and CT scans prior to going to the operat- be possible, and in these cases, resection or a covered stent
ing suite. may need to be considered.
• Control of soilage: Perforations may perforate locally and In the case of perforation at the level of GEJ, it may be
spontaneously drain back into the esophagus, drain into necessary to perform a laparotomy or laparoscopic explora-
contained cavities in the mediastinum, or be free flowing tion of the abdomen to control soilage at that level or to com-
into the mediastinum or pleural space. It is critical to plete the esophageal repair. This may also be necessary in
order to place a surgical gastrostomy for gastric decompres- exploration and drainage (Freeman et al. 2007; Blackmon
sion to decrease reflux and a feeding jejunostomy for enteral et al. 2010). Propensity matched analysis of this approach
access. showed decreased ICU stay, total stay, days to oral intake,
Patients are often perforated during an EGD because they morbidity, and enteral nutrition after discharge but no differ-
have an abnormal esophagus which predisposes them to ence in mortality in this well-selected population. Stent
injury. The condition of the native esophagus is an important migration is a common problem with up to 20% of these
determinant as one evaluates and creates a plan for perfora- patients having a migration episode that required adjustment
tion management. For example, in the setting of a severely (Freeman et al. 2015; Ong and Freeman 2017). Recently,
strictured esophagus, with fibrosis, narrowing, and esophagi- esophageal metal clips have become popular and can be used
tis, even early repair may not be an option. On the other to help stabilize stent placement. Stents are far less likely to
hand, when the native esophagus is deemed to be repairable, migrate when used for obstructing esophageal cancers where
primary repair with drains and buttressing can work well in the lumen of the esophagus is quite narrow. It is clear that
the right patient. In patients with significant damage to the injuries in the proximal esophagus, injuries across the GEJ,
native esophageal wall, or with significant local tissue necro- and injuries longer than 6 cm are all at high risk for stent-
sis, esophagectomy may be the best therapy for perforation. based management failure (Freeman et al. 2012). In a center
This decision requires shrewd surgical judgment as a balance with experience and with patients who have limited intratho-
between the patient’s current state of illness, the degree of racic perforations and minimal soilage, this approach cer-
their underlying esophageal pathology, and their ability to tainly has appeal. However, surgeons would be wise to
tolerate esophagectomy. In an extremely ill patient, an intra- consider that this approach is on the spectrum of conserva-
thoracic esophagectomy, washout, spit fistula, surgical gas- tive management, and these patients much be watched
trostomy, and delayed reconstruction can be a lifesaving closely for signs of uncontrolled sepsis and if so, traditional
pathway when simple repair and/or stenting is not feasible. surgical therapy should be the next step.
Cervical perforation with extravasation generally man-
dates a neck exploration down to the level of the thoracic
inlet. Depending on the expertise of the thoracic surgeon, it Esophageal Diverticulum
may be advisable to collaborate with an otolaryngology col-
league on cervical work. Debridement and wide drainage of Esophageal diverticula can occur at any level of the esopha-
perforation in the neck with the placement of feeding access gus. They are broadly classified as traction or pulsion diver-
are often sufficient to control significant perforations. Minor ticula. False diverticula do not involve all layers of the
perforations, with no significant extravasation, and good pri- esophageal wall and tend to occur with mechanical forces
mary closure can also be performed depending on the con- leading to an outpouching of mucosa between the muscular
figuration and nature of the defect. Dilation after the layers of the esophageal wall. Pulsion diverticulum is most
esophagus scars down is usually necessary. For perforations often found proximal to the upper esophageal sphincter
at or just below the cricopharyngeus, placement of a (UES) and is referred to as Zenker’s diverticulum. At the
Montgomery salivary stent can help limit the soilage and lower end of the esophagus, epiphrenic diverticula may
promote healing. For pharyngeal perforations, wide drainage occur related to motility disorders. These are generally
is the therapy; primary closure may not be possible or advis- believed to be a result of proximal contractions pressing
able. In the setting of neck or cervical spine hardware, post- against a relatively unyielding distal sphincter. Patients may
cervical spine stabilization, collaboration with orthopedic present with a range of symptoms including dysphagia,
surgery or neurosurgery is important. In the case of delayed regurgitation, abdominal discomfort, weight loss, aspiration
erosion of hardware into the pharynx or proximal cervical events, or odynophagia. The location and type of the diver-
esophagus, if the stabilization hardware has been present for ticulum dictate therapeutic options (Fernando et al. 2005;
any significant time, there may be enough ossification to Macke et al. 2015).
allow hardware removal, without compromising spine stabil- True full-thickness, diverticula in most cases, are traction
ity. That is a judgment call made by orthopedic or neurosur- diverticula. They arise in a delayed fashion in the location of
gery consultants. extra-esophageal inflammatory processes, such as lymphad-
Self-expanding covered esophageal stents can be placed enitis. As healing occurs, the periesophageal tissues retract
to prevent or minimize continuing soilage from esophageal and can cause a weakness in the esophageal wall leading due
perforations. Many groups have had success treating perfora- to a full-thickness outpouching. Traction diverticulum is
tions with hybrid approaches that combine an endoscopic small and found incidentally in the mid-esophagus, and ther-
placement of a covered stent and a percutaneous feeding apy may not be needed. In some cases, long-standing true
tube followed by a video-assisted thoracoscopy (VATS) diverticulum may enlarge, leading to a wide mouth diverticu-
lum, that may be present with no apparent motor disorder. It the pre-cervical fascia and cricopharyngeus. Deep to the
is our belief that some of these diverticula are related to prior omohyoid, we prefer to use bipolar cautery when needed for
inflammatory processes, but in rare circumstances, the diver- hemostasis as injury to the left recurrent nerve can occur.
ticulum can enlarge sufficiently to cause symptoms requiring The diverticulum is identified and retracted upward and
surgery. carefully separated from the musculature of the esophagus.
The development of stapling technology has made the
removal of the diverticulum somewhat easier, and some pre-
Cricopharyngeal Diverticulum fer to staple or transect the diverticulum at its base, avoiding
narrowing of the true lumen. Small- to mid-sized diverticula
A cricopharyngeal diverticulum, otherwise known as a are frequently suspended superiorly and posterior to the
Zenker’s diverticulum, occurs just above the cricopharyngeal proximal esophagus and sewn to the prevertebral fascia.
muscle. Typically, the outpouching is directed posterolateral Care should be taken to avoid having the pexy suture tra-
through a weakness in the muscular wall through Killian’s verse the wall of the diverticulum and become contaminated
triangle. It is believed that high upper esophageal sphincter by pouch contents, as there are reports of infectious compli-
(UES) pressures pushing against an unrelenting cricopharyn- cations following pexy, which are thought to be due to this
geus cause this diverticulum. This historical hypothesis puts etiology. Larger diverticulum may need to be resected as
forth the concept that there is a discoordinated pharyngeal previously described. Given that this is a motility-related
contraction wave against the cricopharyngeus. While this has condition, it is critical to perform a 2-cm myotomy proximal
been common dogma, there is some evidence to support that and distal to the diverticulum. The integrity of the resected
GERD may play a role in the development of this disorder area is tested via on-the-table flexible endoscopy with insuf-
(Sasaki et al. 2003). The hypothesis is that a weakened LES, flation, and a drain may be left if there is concern about a
which results in GERD into the mid- to upper esophagus, potential delayed leak. Once a barium swallow confirms no
leads to cricopharyngeal spasm to prevent or minimize the leak on post-op day 1, the patient can resume oral intake. It
risk of oropharyngeal reflux. Clinically, this can manifest as is important to consider the possibility of laryngeal penetra-
globus or water brash, and in some cases even pulmonary tion and/or frank aspiration developing after or existing
soilage. Therefore, the unrelenting cricopharyngeus is actu- before the procedure. If there are any concerns over this, we
ally trying to more or less control free flow of refluxate into first perform a modified barium swallow; if present this may
the pharynx, and potentially the airway. Over time, this is require a delay in oral intake and speech therapy. We typi-
hypothesized to lead to the occurrence of a cricopharyngeal cally start with full liquids and advance to soft diet and then
bar and ultimately a Zenker’s diverticulum. Again, this is not regular diet over a 1- to 2-week period. Although this is a
a universally accepted hypothesis, but in our practice, we fre- disease of the elderly and frail, in whom significant comor-
quently see evidence of GERD in the majority of patients bidities can be expected, most tolerate the procedure well.
with a Zenker’s. The general rule is that we treat whichever More than 90% of patients have resolution of their symp-
problem area seems to be responsible for the majority of toms (Peracchia et al. 1998). Transoral repair requires a sur-
symptoms. One might think that if the two are related, that gical team with a high level of confidence in their endoscopic
early treatment of GERD might minimize the occurrence of skills and in dealing with esophageal pathology. Patients
a Zenker’s diverticulum, but it is somewhat uncommon and must be able to extend their neck to some degree, be able to
difficult to predict with GERD patient might ultimately open their jaws to allow placement of the Weerda scope and
develop a Zenker’s. We have noted, for the most part, that to have a diverticulum that is large enough to accommodate
performing a cricopharyngeal myotomy only rarely leads to the anvil of the endoscopic stapler. Due to the requirement
worsening water brash or unopposed oropharyngeal reflux of direct stapler placement in the diverticulum, the divertic-
and the need for subsequent surgical repair to address the ulum must be at least 3 cm, or very close to that. Thus, in the
weakened LES. office, it is important to examine the patient, check for neck
There are two main approaches to this disease: open cer- mobility and the ability of the patient to widely open their
vical myotomy with diverticulectomy or pexy and transoral jaw. Any concerns here should lead one to be concerned that
stapling repair. Historically, there were some proponents of you may not be able to perform the transoral stapling safely.
diverticulectomy alone without a myotomy, and currently The easier cases generally involve a diverticulum that is at
most surgeons, including our group, believe that the myot- least 3 cm in size, in a patient with reasonable cervical neck
omy (open or stapled) is an essential part of the treatment. motion, and the ability to widely open their jaws. Removal
Open repair is carried out much like any neck dissection for dentures, rather than native teeth or dental implants, are an
esophageal disease. An incision in the left neck is made, and additional favorable feature. This eliminates the risk of
careful dissection is carried down through the platysma; the chipping the upper incisors or implants by contact with the
omohyoid is divided and the dissection is continued down to rigid metal Weerda scope.
In the OR, the patient should be treated as an aspiration Epiphrenic Diverticulum

risk. It is not uncommon to see a diverticulum full of debris
and foul-smelling material; thus, careful anesthetic induc- Intrathoracic diverticulum of the distal esophagus
tion and avoidance of aspiration are important. The first (epiphrenic) is usually of the pulsion type and as such is false
step is a flexible EGD; this should allow for careful inspec- diverticulum. They can cause a wide array of symptoms, and
tion of the size and shape of the diverticulum. At this time, most will require resection and myotomy. Small diverticula
the surgeon should irrigate and clean out any debris that (less than 2–3 cm) may be treated laparoscopically. The
may be present in the diverticulum. It is critical to perform advantage of the laparoscopic approach is that it provides a
this step carefully as it is easy to engage and immediately great view for completing the distal myotomy and a partial
perforate the diverticulum. We frequently pass a simple wrap if desired.
guidewire down the true lumen of the esophagus, which Larger epiphrenic diverticula may require a right chest
may be a helpful guide during the early passage of the approach. This can be done open or through a VATS
Weerda scope. The rigid Weerda scope is placed into the approach. We have performed the majority of these through
esophagus and stabilized to the Mayo tray with the stabiliz- the right chest with a distal myotomy onto the GE junction.
ing bar. Once the scope is in proper location, there are two The best way to determine if the distal myotomy is adequate
adjustments to make on the scope, the first opens the distal is to perform an on-the-table EGD before and after the diver-
ends of the rigid scope. The superior one is somewhat lon- ticulectomy and myotomy. If there is concern that there is
ger and resembles the tip of a #3 three Miller blade laryn- continued restriction distal to the diverticulectomy staple
goscope. This tip should enter the true esophageal lumen. line, it is important to continue with the myotomy further
Once this is in place, one can open the two blades, with the onto the stomach. This may require a laparoscopy depending
lower slightly shorter blade being in the actual body of the on the circumstances. Performing a wrap can be potentially
diverticulum. If the correct anatomic location is present, problematic as many of these patients have a co-existing
one should now have a good view of the cricopharyngeal motility disorder, and thus wraps may lead to significant dys-
muscle, appearing as a bar on the horizontal plane. The sta- phagia. In our experience, we have performed the diverticu-
bilizing bar can help to control the Weerda scope’s move- lectomy and myotomy at the first operation and then if
ment and improve visualization of the muscular bar between symptomatic GERD is not satisfactorily treated with medi-
the true lumen and the diverticulum. At this time, the guide- cations and dietary modifications, and we would consider a
wire is no longer needed and it is removed from the field. partial wrap at a second operation. For the most part, most
Next, we place a traction suture through the muscular bar patients will not need the wrap in our experience.
using the Endostitch ™ (Covidien). This stitch serves as a Some surgeons advocate approaching all epiphrenic
traction-like suture to minimize distal migration of the diverticula laparoscopically because of the ability to
muscular bar as the endoscopic stapler is closed upon it and remove the diverticulum and perform the distal myotomy
fired. We place the stapler under direct vision, using a 5 mm with relative ease. Also, advocates of this approach also
endoscope placed just outside of the Weerda scope. This point out that if a partial wrap is desired, it can be per-
can be a very technically challenging procedure, to place formed in the same setting. We have found over time that
the scope in an atraumatic fashion, avoid chipping the teeth, exposing all of the diverticulum down to its base and get-
avoiding overextension of a frail patient’s cervical spine ting a perfect resection is best achieved through a right
and avoiding trauma to the esophageal and diverticular VATS approach followed by a laparoscopic phase if needed
lumen. Once fired, the blade between the staple lines (Abbas et al. 2009). We favor a five-port technique similar
divides the muscular septum and creates a common channel to what we use for minimally invasive esophagectomy
between the diverticulum and the true lumen effectively (MIE). The posterior mediastinal pleura is opened and the
restoring continuity. A second stapling may be needed for esophagus exposed; care is taken to spare the major vagal
larger diverticula, and we frequently use the Nd:Yag laser trunks. The diverticulum is identified and lifted, and the
to extend the staple line “V” 1–2 mm. Diverticulum larger base of the defect is identified by dissecting away the sur-
than 6 cm should be considered for open resection as this rounding muscle layers of the esophagus. The diverticulum
technique does not excise the diverticulum but rather incor- almost always has a relatively narrow neck and then mush-
porates it into the lumen of the true esophagus. Many stud- rooms out. It is important that the stapling device be placed
ies have shown comparable outcomes with both approaches across the neck, so as to not retain a residual diverticulum
(Morse et al. 2007; Van Abel et al. 2016; Bonavina et al. body buried in the muscular layers. The vagal nerves should
2012; Weksler et al. 2010). There are limited data to sug- be identified early and protected. The placement of a 54
gest that smaller diverticula (<3 cm) benefit more from the French bougie will greatly aid in dissection and stapling,
open approach but there are no large-scale randomized tri- helping to avoid compromise of the true esophageal lumen.
als on this topic (Gutschow et al. 2002). Before transection of the diverticulum, we use this as a
handle for cephalad retraction, so the myotomy can be car- to the esophagus is believed to cause the transformation as
ried down through the LES onto the gastric cardia. The somewhat of a “protective” mechanism. Non-dysplastic
diverticulum can now be resected at the narrowest point at Barrett’s, though a finding associated with GERD, has an
its base using a reticulating endoscopic stapler from a low exceeding low chance of progressing to cancer in many long-
port to ensure a perfect angle when completing the diver- term follow-up studies. Dysplastic Barrett’s, low-grade or
ticular stapled resection. A careful inspection for leaks is high-grade, has a 0.1 to as high as 3% annual risk of develop-
performed, and then the muscle layers over the diverticular ing cancer (Spechler 2003; Rastogi et al. 2008). Historically,
resection are gently reapproximated while the layers over low-grade dysplastic Barrett’s was treated with observation,
the myotomy are left open. If there is residual distal esoph- and high grade was treated with esophagectomy. However,
ageal narrowing from LES muscle, we perform a laparo- the development of radiofrequency ablation (RFA) and endo-
scopic continuation of the myotomy and in some cases a scopic mucosal resection (EMR) has changed the paradigm
partial Dor fundoplication. It is clear that an incomplete of treatment.
myotomy or poor endoscopic stapler placement results in In patients with low-grade dysplasia, surveillance or RFA
more staple line leaks which is the major morbidity of this ablation are acceptable options. It is critical that four-quad-
operation and must be avoided (Chan et al. 2017). Our rant biopsies are performed every 1 cm to confirm the diag-
15-year experience with a minimally invasive approach nosis and rule out more advanced disease. In patients with
showed excellent results and no thirty -day mortality high-grade dysplasia, biopsies are equally important.
(Macke et al. 2015; Kilic et al. 2009b). However, the goal is to rule out the possibility of cancer. If
It is important to note that not all mid- to lower esopha- biopsies have been performed and are negative, it is reason-
geal diverticula are epiphrenic in location, and thus may have able to proceed with RFA ablation with the understanding
a different etiology. The classic epiphrenic diverticulum is that there may be undetected carcinoma. For patients with
just that it is truly “epi” phrenic and may times actually any mucosal abnormality or nodularity within a field of high-
touching the diaphragm as it enlarges. When you obtain a grade Barrett’s, EMR should be performed as both diagnos-
barium swallow, you observe a classic “birds’ beak,” narrow- tic and potentially therapeutic intervention with RFA
ing of the distal esophagus. On endoscopy, there is a classic afterward to ablate the rest of the Barrett’s.
“pop,” and a manometry shows a marked motor disorder. But In patients with a known diagnosis of an esophageal can-
what of the somewhat more proximal large esophageal diver- cer confined to the muscular layer (T1a) with no signs of
ticulum, with a wide mouth, and no apparent narrowing of lymphatic or distant spread, EMR is an acceptable therapeu-
the esophagus distal to the diverticulum whatsoever (either tic strategy (Ell et al. 2000). This is also with the caveat that
by barium esophagram or by endoscopy)? In this situation, the tumor is less than 2 cm, the resected specimen is removed
the esophagus distal to the diverticulum is “wide open,” and in one piece, and there is no lymphovascular invasion or poor
many patients will at best have a non-specific motor disorder differentiation on path. TIb (into but not through the submu-
or will even have normal manometry. In these cases, one cosal layer) lesions are an indication for esophagectomy due
should suspect the etiology and thus the treatment may be to the greater than 20% rate of lymph node metastasis
different. Here, we have had good success with simple diver- (Newton et al. 2017; Pech et al. 2014; Pennathur et al. 2010).
ticulectomy by dissection and stapling. When the endoscope
shows absolutely no distal narrowing, and motor studies are
normal, we do not routinely perform a long myotomy onto Workup of Esophageal Cancer
the stomach in these select cases. We believe some of these
are the result of unusual mediastinal inflammation and are Esophageal cancer rates in the Western world have been on
thus “true” traction diverticula that simply enlarged over the rise with more than 17,000 new cases every year (Siegel
time rather than true epiphrenic diverticula. The clues to sus- et al. 2017). In North America, the histology of this cancer
pect this are listed above and include relatively wide-mouthed has rapidly shifted toward adenocarcinomas and away from
diverticulum, not in the true epiphrenic location, no narrow- squamous cell cancers. Risk factors for the development of
ing distally on barium swallow, no distal pop on endoscopy, adenocarcinoma include male gender, GERD, and obesity.
and no classic motor disorder. As the histology has changed so has the typical location of
these cancers as now more tumors are found in the distal
esophagus and at the GEJ than in the mid- or upper
Barrett’s Esophagus esophagus.
Patients often present with progressive dysphagia to sol-
Intestinal metaplasia of the normal squamous columnar dis- ids and liquids. EGD and biopsy will confirm the diagnosis.
tal esophagus defines Barrett’s esophagus. Barrett’s is EGD is critical for several reasons. First, the exact location
strongly linked to GERD as the pathologic exposure of acid and extent of the tumor must be carefully documented. Any
Barrett’s and its extent should also be documented. The • Negative margins: A preoperative and an on-the-table
ability to traverse the tumor and assess the stomach’s involve- EGD allows the surgeon to understand the anatomy of the
ment are important details. Diagnostic biopsy should get tumor and plan the appropriate operative strategy in order
enough tissue for molecular testing. Routine workup includes to obtain a negative proximal and distal margin. If the
positron emission tomography with computer-aided tomog- tumor or Barrett’s esophagus extends more proximal than
raphy (PET/CT), an EGD with endoscopic ultrasound, pul- typical, we consider a McKeown esophagectomy (neck,
monary function tests, and a standard cardiovascular risk thoracic, and abdominal fields). Meticulous surgical tech-
workup. For patients with advanced tumors, we perform a nique to remove the esophagus, with a generous proximal
laparoscopic staging procedure with EGD by the primary and distal margin (greater than 5 cm in most cases) and an
surgeon, to directly evaluate the distal esophagus, stomach, aggressive nodal and surrounding tissue resection, yields
lymph node basins, liver, and peritoneum for disease, and negative margins in the majority of cases.
place a port for chemotherapy (Mehta et al. 2017). If a patient • Lymph node clearance: Lymph node clearance is a critical
requires it, esophageal dilation and or feeding jejunostomy part of this operation not only for the staging information
placement can be performed for enteral nutrition. For patients gained but also to obtain an R0 resection. We resect the
with tumors in the mid- or proximal esophagus, bronchos- left gastric nodal basin down to the base of this artery,
copy is also performed at this time to rule out airway then along the superior border of the pancreas and splenic
involvement. artery, cephalad to include all periesophageal nodes and
In patients with node-positive disease or whose TNM T tissues along the plane of the aorta, and the right and left
stage is 3 or greater (tumor into the adventitia), neoadju- pleura laterally, and along the pericardium superiorly all
vant therapy is indicated (Al-Batran et al. 2017). There from the abdomen. In the chest, we continue these planes
remains debate about the ideal neoadjuvant regimen to include the entire subcarinal lymph node packet, along
between chemotherapy and chemoradiation therapy for the pericardium, left atrium, and always up to and just
esophageal adenocarcinoma (Deng et al. 2017). For patients above the level of the azygous vein. There are data to sup-
with minimal nodal disease and a non-bulky, resectable port accurate staging, lower local recurrence rates, and
carcinoma without frank invasion of the diaphragm or peri- improved outcomes with increased number of harvested
aortic fat plane, we prefer neoadjuvant chemotherapy due nodes (Hsu et al. 2013; Groth et al. 2010).
to our low rate of local recurrence with our current aggres- • Tension-free anastomosis with a well-vascularized neo-
sive surgical resection. For most advanced squamous cell esophagus: The standard neoesophagus is created using
cancers, it is clear that neoadjuvant chemoradiation for the stomach and is based on the right gastroepiploic
advanced disease improves survival (Shapiro et al. 2015). arcade. This conduit can be created to be long and straight
with the appropriate application of stapling devices and
with minimal handling of the conduit, the submucosa vas-
Esophagectomy cular plexus can be left undisturbed. For an intrathoracic
anastomosis, mobilization of the stomach to the level of
Esophagectomy is now a much less morbid and mortal oper- the first portion of the duodenum is usually sufficient, but
ation than it was historically. Operative mortality of less than for a high intrathoracic anastomosis or a cervical anasto-
5% should be expected in centers of excellence. In our center mosis, it may be necessary to perform a formal
and other selected centers of high-volume surgery, mortality Kocherization of the duodenum. The goal of antral mobi-
rates of just under 1% have been achieved (Luketich et al. lization is to allow the pylorus to easily reach the level of
2012, 2015). Operations can typically be carried out mini- the right crus in a tension-free manner.
mally invasively, with an overnight ICU stay, and a total hos-
pital stay of under 1 week for low-risk cases. Early ambulation Some other technical details such as the exact manner in
is the norm, and nasogastric tubes can be removed as early as which the anastomosis is formed, the need for a pyloric empty-
postoperative day 1 with enteral feeding started on postop- ing procedure, the routine need for feeding jejunostomy place-
erative day 1. We obtain a barium esophagram on post-op ment, or the routine use of an omental flap are debated and
day 3 to assess not only anastomotic integrity but to assess often fall to surgeon preference. Some surgeons particularly in
the lie of the conduit and to serve as a baseline for compari- Asia advocate a three-field lymphadenectomy where a neck
son of future films. Patients are routinely discharged tolerat- dissection is also performed. This approach can increase the
ing a limited oral diet (2–3 ounces every 2–3 hours) with the number of lymph nodes resected but also increases the morbid-
remaining protein and caloric requirement being delivered ity with no proven benefit in terms of oncologic outcomes (Uc
by cycled evening and nighttime enteral feeds. et al. 2014). Given the location and histology of most of the
Regardless of the approach, there are key principles to tumors seen in Europe and the Americas, we do not routinely
esophagectomy. perform a three-field dissection.
mobilized back toward the pylorus ensuring that the gastro-

epiploic arcade remains in view and undisturbed. The entire
conduit can be created using a “no-touch” technique. All
adhesions behind the stomach and pylorus are lysed. When
the pylorus can easily meet the right crus in a tension-free
fashion, then mobilization is generally sufficient. We perform
a Heineke–Mikulicz pyloroplasty laparoscopically, although
recent trends in other centers question the need for this.
Currently, a randomized controlled trial of pyloroplasty ver-
sus no pyloroplasty using a 2.8–3.0 cm diameter conduit is
underway in our institution. The conduit is created based on
the greater curvature of the stomach using well-spaced and
angled 45 mm staple fires often starting with a vascular load
for some of the inserting vessels of the right gastric artery on
Fig. 13.5 the lesser curve. Keeping tension on the very tip conduit
toward the left upper quadrant and the new gastric reservoir
toward the right lower quadrant simplifies this step and allows
Choice of Esophagectomy Technique us to create a straight 3-cm-wide conduit (Fig. 13.5). The con-
duit is then tacked to the specimen, and a feeding jejunos-
There are a variety of options for esophagectomy. Given our tomy is placed. For the thoracic portion, we again use a
experience with a wide variety of techniques, we strongly five-port technique with the option of placing a high anterior
favor a minimally invasive (totally thoracoscopic and laparo- almost axillary sixth port (5 mm) to assist with the anvil
scopic) Ivor Lewis Esophagectomy (MIE). There are several manipulation during the circular stapler anastomosis.
reasons for our choice (Luketich et al. 2012; Levy et al. Dissection starts with the mobilization of the inferior pulmo-
2012): nary ligament, and then the medial portion of the esophagus
is dissected away from the pericardium, inferior pulmonary
• Most patients are presenting with distal esophageal or vein, and the subcarinal area and the posterior mediastinum.
GEJ tumors which does not require resecting the more Great care must be taken when working around the posterior
proximal cervical esophagus to obtain a negative margin. membranous airway especially when mobilizing the subcari-
• Surgical experience in the cervical esophageal region has nal lymph node packet which is prone to bleeding. Above the
decreased in recent years in terms of experience during level of the azygous mobilization stays on the esophagus to
general surgery training and thoracic training; thus, if it is limit any potential nerve injury, and the vagus is also tran-
not needed oncologically, one has to question the value of sected at this level. Lateral mobilization is carried out next,
going to the neck. and aortoesophageal perforators and small lymphatics are
• By creating the anastomosis in the upper chest, the recur- clipped. The conduit is then brought into the chest, and the
rent nerves are essentially spared in over 98% of cases, posterior dissection of the esophagus down to the level of the
thus minimizing this morbidity. contralateral pleura is carried out all the way up to the level of
• By not bringing the new gastric conduit to the neck, the the anastomosis which should be two to three centimeters
surgeon is generally able to resect the most ischemic part above the azygous if suitable. A utility thoracotomy is made
of the proximal gastric conduit leading to a lower anasto- (5–6 cm) with no rib spreading, the esophagus is transected,
motic leak rate. and the specimen is removed through this incision with a
• This operation yields excellent nodal count and low local wound protector in place. The anvil of a 28 mm circular sta-
recurrence compared to trans hiatal approaches. pler is sutured into the proximal esophagus with two purse
strings (Fig. 13.6). We strongly prefer the placement of at
Typically, we begin with a laparoscopic phase that utilizes least 28 mm anvil to prevent stricture formation. The circular
five working ports and a liver retractor. The esophagus at the stapler is then introduced through the access incision and the
hiatus is mobilized from the crura to assess resectability. The anastomosis made after a decision on exactly where to exit
left gastric artery and vein are skeletonized and divided at the the posterior wall of the new conduit. This allows the surgeon
base using a vascular stapler. The short gastric vessels are to resect the tip of the conduit, and frequently 6–10 cm is
divided, and the right gastroepiploic arcade is preserved as removed and also serves as an additional gastric final
the greater curve is mobilized while harvesting an omental margin.
flap based on one or two perforators if the patient has received Following the anastomosis, an NG tube is passed under
neoadjuvant radiotherapy. The stomach is then completely direct vision and taped in place with the tip above the dia-
Transhiatal esophagectomy is performed most frequently

open with mobilization of the stomach and creation of the
conduit. Then, the esophagus is bluntly, usually manually,
dissected away from the posterior mediastinum. A cervical
neck incision is made, and the esophagus is identified; the
dissection is carried blindly in a caudad fashion to meet up
with the fingertips of the hand coming up from the abdomen.
The esophagus is transected in the neck, and the conduit is
brought up to this level for anastomosis. Many centers per-
form this operation very well but due to concerns over its
oncologic value, and the lack of need to remove the most
proximal cervical esophagus, we do not perform it routinely
(Omloo et al. 2007; Urba et al. 2001). Overall, the prepon-
Fig. 13.6
derance of data does not clearly support one approach to
esophagectomy over another.
phragm. We then remove all ports and irrigate the chest with Tabularized stomach remains the conduit of choice due to
antibiotic solution, and clean app port sites. The camera is the ease of use and reliability. Whole stomach conduits have
reinserted, and we place 10 French Jackson-Pratt (JP) drains fallen out of favor due to higher rates of reflux and thoracic
posterior and lateral to the anastomosis. At this time, the redundancy, stasis, reflux, and dysphagia (Zhang et al. 2015).
conduit is inspected, and there should be no redundancy or Colonic interposition historically was the conduit of choice
excess conduit in the chest; the staple line should be directed in children for benign conditions, and it remains a second
directly up in the right chest, and the gastroepiploic arcade option for esophageal replacement in adults. Colonic inter-
along with a rim of omental fat is positioned between the position should be preceded by colonoscopy to rule out
conduit and the airway. At this time, if an additional omental malignancy or stricture and a contrast-enhanced study of the
flap was harvested, it is positioned around the anastomosis abdomen and pelvic to rule out any vascular abnormalities.
and gently sutured in place. We then place a 28F chest tube The colonic conduit can be based on the right or the left
and inject the intercostal nerves with a bupivacaine with epi colonic vessels. A pedicled colonic conduit is then anasto-
solution. After turning the patient supine, and before the mosed to the cervical esophagus and to the remnant stomach
endotracheal tube is manipulated, the oropharynx is suc- or the limb of a Roux-en-Y. Lastly, a colo-colonic anastomo-
tioned clean and irrigated by the surgical team to avoid the sis restores enteric continuity. For most patients, a pedicled
aspiration of any esophageal contents backwashed into the jejunal interposition is a third and usually final choice for
mouth during the case. In most cases, we prefer to extubate esophageal conduit when the other options have been
in the OR, longer cases, or frail patients may require an exhausted. However, it is popular at many centers and for
overnight ventilator support at the judgment of the surgical some is a second choice of conduit before colon. The narrow
and anesthesia team. nature of the jejunum can allow it to function in a similar
The postoperative care continues to evolve in the mini- manner to the native esophagus. There are some data to sup-
mally invasive era with shorter hospital stays. Our current port that these conduits are at least not inferior to gastric con-
practice is to remove the NG tube on post-op day 1 and begin duits but these are in highly specialized centers with a robust
enteral feedings, in a cycled fashion on post-op day 1. The experience (Stephens et al. 2015; Blackmon et al. 2012).
surgical and nursing team strives for a discharge home on There are some significant technical challenges to this opera-
postoperative day 6. tion, and it also requires a microvascular anastomosis. There
In our series of the first 1000 MIE patients, the mortality of is a significant learning curve with this technique. However,
this approach was less than 1% with an anastomotic leak rate in some specialized centers good outcomes can be achieved.
of 4% (Luketich et al. 2012). In a multicenter trial for MIE,
the operative mortality was slightly higher at 2.9%, while the
leak rate was 8.6% and the local recurrence rate was 6.7% at Anastomotic Leakage
a median follow-up of 40 months (Luketich et al. 2015). MIE
has also at least equal if not improved 30- and 90-day mortali- In order to perform esophagectomy, a clear and routine path-
ties, hospital stay, morbidity rate, and oncologic value as way must be established to appropriately treat esophageal
compared to open (Mitzman et al. 2017; Kauppila et al. 2017; leakage. It is failure to rescue that causes the majority of
Biere et al. 2012). MIE has also been adapted to the robotic mortality in this operation. If patients develop fulminant sep-
platform by us and others with good short-term results sis and acute respiratory distress syndrome, salvage becomes
(Okusanya et al. 2017; Sarkaria et al. 2016). exceedingly difficult.
The first step in treating leaks is to do everything possible Gastric tip or conduit necrosis resulting in a leak must be
to avoid them. Meticulous attention must be paid to the han- managed on an individual basis. Management may be simi-
dling and quality of the conduit. The anastomosis must be lar to the above algorithm, if the area of necrosis is small and
tension-free and well perfused. Lastly, expert hands must be well drained. Larger or progressive necrosis of the conduit
available at all points of the operation. Beyond this, the most may require to take down of the conduit, resection of necrotic
important step in managing a leak is to recognize it early. In material, and creation of a cervical spit fistula with delayed
any post-esophagectomy patient, mild hypotension, tachy- reconstruction. Patients with progressive or large areas of
cardia, atrial fibrillation, tachypnea, fever, increased pain, necrosis tend to present sooner in the postoperative course
and elevated lactate levels can be early signs of leakage and and have clearer clinical signs of decompensation than a
should prompt evaluation. For patients with a neck anasto- patient with a non-necrotic leak. If EGD shows conduit
mosis, any sign of erythema, fullness, or unusual drainage necrosis, then the surgeon has to make a judgment call based
from the neck incision is worrisome. Often, simply opening on the visual exam, the condition of the patient, and other
the neck incision at the bedside is sufficient to control the factors, but if the judgment is that healing is unlikely and the
leak in this transhiatal group. However, one must make sure necrosis is significant, the conduit should be taken down and
that the leak is not draining down into the mediastinum. the patient should be placed in discontinuity. This can be a
Patients with a thoracic anastomosis may present with clini- lifesaving maneuver but obviously is a very big step. Gastric
cal signs noted above or with frank bilious effluent into a conduits can be salvaged and once back in the abdominal
perianastomotic drain. Apart from appropriate fluid resusci- cavity, the amount of conduit resected may require some
tation and institution of broad-spectrum antibiotics, first- degree of observation and again, surgical judgment. However,
line diagnostics include a barium esophagram which is salvaging as much conduit as possible can make delayed
frequently done early in the post-op period in the current reconstruction much easier. In this scenario, a bipolar exclu-
era. Because of this, the barium study performed early may sion (cervical esophagostomy, gastric tip resection, and gas-
not show a subsequent leak that may occur later. However, trostomy) should not be viewed as a failure but as a lifesaving
we feel that the early barium esophagram provides other maneuver.
important information and does pick up some leaks, and Other strategies for leak management with viable con-
thus we perform this early (post-op day 3) in all patients. If duits may include the placement of esophageal stents. Stent
a leak is present at the early barium study, it may be small placement can be achieved in a select population. However,
and go directly to the JP drain. If this is the case, aggressive about 30% of patients will fail stent-based management of
measures may not be needed. For all chest leaks, even when intrathoracic anastomotic leaks (Schaheen et al. 2014).
well drained we do initiate antibiotics and then assess the Stents are prone to migration especially in an environment
situation further. We generally perform a chest CT to evalu- where there may not be significant compression. Lastly,
ate for any collections, empyema, or mediastinitis. Next stents in the context of a leak and infection may provide a
patients are taken to operating room for an EGD. The goal nidus for fistula formation to the airway or aorta which are
of the EGD is to determine the extent of the gastric tip devastating complications. Recently, endoluminal vacuum
breakdown, the overall viability of the conduit, and the sponge therapy for treating leaks has become popular (Pines
extent of the leak. If the leak is small, with good viable gas- et al. 2017). The data on this technique are still emerging and
tric tip, save for a small, less than 1 cm breakdown, we gen- have not gained widespread consensus.
erally dilate gently with a 54 Fr savory and adjust the drain,
frequently backing it up slightly so the tip is just in view.
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Laparoscopic and Thoracoscopic Ivor
Lewis Esophagectomy 14
Simon R. Turner, Daniela Molena, and Virginia R. Litle
Indications radiation-induced esophagitis, resulting in poor oral intake.

Nutritional status should be assessed and optimized.
Esophagectomy via right thoracoscopic and laparoscopic Endoscopic palliation of malignant dysphagia with stents or
approach is indicated for carcinoma of the distal esophagus ablation may be required to minimize aspiration risk, which
and gastroesophageal junction. would delay oncologic treatment. Such intervention may
improve nutritional status. Pretreatment laparoscopically
placed feeding tubes may also be indicated depending on
Preoperative Preparation oral caloric intake.
Patients should also be encouraged to maintain a healthy
Preoperative preparation of any patient prior to esophagec- exercise regimen consisting of at least daily walking, as well
tomy requires a comprehensive, multidisciplinary approach, as smoking cessation. Many esophageal cancer patients have
involving medical and radiation oncologists and nutritionists multiple comorbidities due to related conditions such as obe-
as appropriate. Most patients who undergo esophagectomy sity in adenocarcinoma patients and smoking and alcohol
do so as treatment for primary malignancy. Both adenocarci- use in squamous cell carcinoma patients. A thorough history
nomas and squamous cell carcinomas should be staged and physical must address all of these issues, and referrals
appropriately using endoscopic biopsies, endoscopic ultra- should be made to relevant consulting medical services for
sound, and positron emission tomography-computed tomog- diagnosis and optimization of preoperative risk factors of
raphy (PET-CT). Many patients undergoing esophagectomy poor outcome. Ultimately, though, it is the surgeon’s respon-
for malignancy will receive neoadjuvant chemoradiation. sibility to assess a patient’s suitability for a given operation,
The response to therapy should be assessed by reviewing rel- especially one as complex and potentially morbid as esopha-
evant imaging studies, blood tests, and the patient’s symp- gectomy. Discussion at a multidisciplinary tumor board is
toms and functional status. Any interruptions of therapy or often helpful in making these decisions.
complications such as cytopenias or infections should be The operating surgeon should personally perform endos-
noted. Although ideally esophagectomy should be done copy preoperatively to assess the proximal and distal extents
between 4 and 8 weeks from the end of neoadjuvant treat- of the tumor, the proximal extent of any Barrett’s esophagus,
ment, it is important to be sure that the patient has fully and involvement of the gastric cardia.
recovered from their preoperative therapy prior to undertak- On the day before surgery, the patient should be on a clear
ing resection. Dysphagia and/or odynophagia may result liquid diet and the surgeon may consider a half bottle of
from either the patient’s underlying disease process or from magnesium citrate. Enhanced recovery after surgery (ERAS)
programs may include additional preoperative regimens such
as a carbohydrate beverage and selective anti-inflammatory
S. R. Turner
Department of Surgery, Division of Thoracic Surgery, University agents.
of Alberta, Edmonton, AB, Canada
D. Molena
Department of Surgery, Memorial Sloan Kettering Cancer Center,
New York, NY, USA
V. R. Litle (*)
Department of Surgery, Boston Medical Center, Boston, MA, USA
e-mail: Virginia.litle@bmc.org

https://doi.org/10.1007/978-3-030-81415-1_14
116 S. R. Turner et al.
Pitfalls and Danger Points Operative Strategy
Abdominal Phase Laparoscopic and thoracoscopic Ivor Lewis esophagectomy,

also known as minimally invasive esophagectomy (MIE),
• Establishing pneumoperitoneum in patients with multiple consists of two major phases: the abdominal and the thoracic
previous operations or abdominal infections phase. These can be subdivided as follows.
• Injury to the branches of the celiac axis (including a
replaced left hepatic artery), aorta, inferior vena cava, or
pancreas during celiac lymphadenectomy Abdominal Tumor Dissection,
• Injury to the right gastroepiploic artery arcade, which is Lymphadenectomy, and Mobilization
the sole blood supply of the conduit of the Gastric Conduit
• Injury to the spleen or short gastric vessels
• Excess or careless manipulation of the stomach, damag- MIE begins with laparoscopy. A thorough examination is
ing submucosal vascular channels vital for perfusing the performed to rule out advanced disease at the hiatus, celiac,
proximal extent of the conduit peritoneum, and liver. Resection begins with division of the
• Inadequate division of the gastrocolic ligament, predis- lesser omentum and a complete lymphadenectomy along the
posing to paraconduit hernia formation by allowing the celiac artery. The entire gastrocolic ligament is divided next,
colon to be pulled up into the chest taking care to preserve the right gastroepiploic artery yet
• Inadvertent entry into the pleural spaces during transhia- mobilizing the pedicle at its origin. This step is important to
tal dissection, resulting in pneumothorax, hypotension, obtain adequate mobility of the gastric conduit into the chest
and hypoxia and avoid tension on the anastomosis. Short gastric arteries
are divided to free the greater curve. Division of the gastro-
colic ligament toward the pylorus helps prevent colonic her-
Thoracic Phase niation into the chest. The esophagus is then mobilized at the
hiatus as the last step to reduce loss of CO2 insufflation into
• Perforation of the membranous airway, especially of the the chest. Transhiatal dissection is then performed to com-
left mainstem bronchus during subcarinal lymph node pletely mobilize the distal esophagus and also remove the
dissection paracardiac lymph nodes, which are difficult to reach thora-
• Injury to the aorta or the small aorto-esophageal branches coscopically via the right chest. The gastric conduit is tubu-
• Injury to the thoracic duct or its small branches larized with the Endo GIA. The conduit is not yet completely
• Inadvertent entry into the left pleural space resulting in divided from the specimen, allowing easy delivery of the
left pleural effusion or pneumothorax conduit into the chest later on.
• Injury to the right or left recurrent laryngeal nerves during
paratracheal dissection
• Twisting of the conduit as it is delivered into the chest Abdominal Adjunct Procedures
• Performance of the anastomosis under tension or in an
area of poor perfusion, predisposing to anastomotic In addition to the oncologic resection and mobilization of the
leak gastric conduit, the abdominal phase also entails perfor-
mance of a pyloric drainage procedure with a pyloroplasty or
Botox injection. A feeding jejunostomy is placed in the left
Documentation abdominal wall with a standard percutaneous technique.
• Findings on preoperative endoscopy, including proximal

and distal extent of the tumor and any Barrett’s esopha- Thoracic Resection
gus, appearance of the stomach and pylorus
• Extent of lymphadenectomy performed in both the abdo- The esophagus is mobilized from the hiatus to above the azy-
men and chest gous vein, which is divided. Care is taken to stay wide
• Pyloric drainage procedure performed, if any enough to encompass periesophageal lymph nodes and pro-
• Assessment of the conduit prior to anastomosis, including vide a radial margin, while avoiding the thoracic duct, aorta,
perfusion assessment with fluorescence when available and airways. Clips are used liberally posteriorly to minimize
• Location and type of anastomosis the risk of postoperative chylothorax. A subcarinal lymph
• Location of chest drains placed node dissection is performed.
14 Laparoscopic and Thoracoscopic Ivor Lewis Esophagectomy 117
Thoracic Anastomosis
The conduit is delivered into the chest by gently pulling

cephalad on the esophagus, taking care to avoid excess trac-
tion and to maintain the correct orientation. After finally
dividing the specimen from the conduit, the conduit perfu-
sion is assessed using fluorescence imaging when available
and a suitable location for creation of the anastomosis is
selected. An end-to-side anastomosis is performed using a
circular stapler. The anastomosis is secured to the superior
mediastinal pleura and buttressed with omentum between
airway and anastomosis. Sutures are placed between the con-
duit and the hiatus to reduce the risk of paraconduit hernia-
tion with colon.
Operative Technique
osition and Incisions for the Abdominal

P
Phase
General anesthesia is induced with a double-lumen endotra-

cheal tube, two large bore IVs, a radial arterial line, and uri-
nary catheter. If the patient has not had a recent upper
endoscopy prior to surgery, perform this after anesthesia is
induced. Take care to avoid excess insufflation which makes
laparoscopy more challenging. Decompress the stomach and
place an oro- or nasogastric tube and keep it on suction.
Position the patient supine on a beanbag, with both arms out. Fig. 14.1
Use a footboard. Gradually introduce steep reverse
Trendelenburg position, used during laparoscopy to aid in
visualization of the upper abdomen, to avoid sudden camera operator stands to the patient’s right below the pri-
hypotension. mary surgeon.
Make a 10 mm incision just underneath the left costal
margin in the mid-clavicular line. We use a 10 mm optical
trocar with a 0-degree camera to gain entry to the perito- aparoscopic Lymphadenectomy and Gastric
L
neum. Once entry is visualized, and pneumoperitoneum is Mobilization
established change the camera to a 45-degree scope and
place all remaining ports under direct vision. Place a second Dissection begins with division of the gastrohepatic liga-
10 mm port in the midline just below the falciform ligament. ment. Replaced left hepatic arteries are not uncommon and
Place a third 10 mm port in the right flank. Place a 5 mm port should be preserved if possible. Continue the division of the
in the right upper quadrant such that instruments will have an ligament superiorly until reaching the right crus. Then carry
easy trajectory under the liver and falciform ligament and the dissection down the right crus toward its base and then
toward the hiatus. Finally, place an optional 5 mm port in the inferiorly overlying the celiac artery and its branches.
left upper quadrant. Identify the left gastric, splenic, and common hepatic artery
Place a Nathanson liver retractor via a 3 mm incision just and perform a complete lymphadenectomy of their associ-
below the xiphoid and elevate the left lobe of the liver ated nodes (Fig. 14.2). The superior aspect of the pancreas is
(Fig. 14.1). The surgeon stands on the right side of the patient visualized as this dissection is carried leftward. Once all
with a grasper in the left hand and Harmonic scalpel (Ethicon, nodes are swept upward along the left gastric vessels and
Somerville, NJ) in the right. The mobilization of the greater into the specimen, divide the left gastric artery and vein near
curvature of the stomach is done by the surgeon standing on their origin using a stapler. Retract the stomach to gain access
the patient’s left. The first assistant stands at the patient’s left to the celiac artery nodes found between the left gastric
and uses a grasper in each hand to assist with retraction. The artery stump and the base of the diaphragmatic crus.
Fig. 14.2 Fig. 14.3
Attention then returns to the hiatus. Carry the dissection the pylorus is freely mobile, and the colon is completely free
previously begun on the right crus across the apex of the of the stomach and proximal duodenum. At this point, the
hiatus and down the left crus toward the angle of His. Take pylorus will nearly reach the hiatus. A Kocher maneuver is
care to preserve the fibers of the crura while staying wide not required and discouraged as excessive duodenal mobility
enough to ensure an adequate radial margin. Muscle of the may result in herniation of the duodenum into the chest with
crura may be taken as a margin if there is concern for bulky folding of the gastric conduit.
disease in this area. Avoid extensive dissection via the hia-
tus and do not completely encircle the esophagus at this
time in order to avoid causing a pneumothorax early in the Pyloric Drainage and Feeding Jejunostomy
procedure.
Next, gently retract the stomach anteriorly and to the right, The decision of whether to perform a pyloric drainage pro-
exposing the gastrocolic ligament. Visualize the right gastro- cedure is individualized to the patient based on the endo-
epiploic artery and preserve it. This is crucial, as this will be scopic appearance of the pylorus at the time of preoperative
the blood supply to the anastomosis (Fig. 14.3). Staying well gastroscopy. If the pylorus is widely patent at baseline, no
away from this artery, divide the gastrocolic ligament, pro- drainage procedure is necessary. If not, inject 100 units of
ceeding along the greater curve toward the fundus. Eventually, Botox in 5 cc of sterile saline into the muscle of the pylorus
the right gastroepiploic artery terminates, though there are using a transabdominal needle or perform a laparoscopic
sometimes horizontal collaterals with one or two short gastric pyloroplasty. Next, place the patient level for the laparo-
arteries which should be preserved. Above this level, it is safe scopic jejunostomy placement. Grasp the colon and lift it
to stay closer to the stomach, and doing so allows the short superiorly and identify the ligament of Treitz. Select a
gastric arteries to be divided with a long stump on the splenic mobile, proximal loop of jejunum and elevate it to the
side in case of bleeding. Take care not to injure the spleen as abdominal wall in the left mid-abdomen. Place four sutures
division of the gastrosplenic ligament continues toward the in a diamond pattern surrounding the planned jejunostomy
previous dissection along the left crus. It is generally easiest site. Sequentially bring each suture through the abdominal
for the assistant standing at the patient’s left to divide the last wall with the Carter-Thompson fascial closure device and
attachments holding the fundus. Often, posterior attachments secure it loosely with a hemostat (Fig. 14.4). Use a
of the stomach to the retroperitoneum are encountered and Seldinger technique to perform a percutaneous jejunos-
must also be divided, and posterior gastric arterial branches tomy. Take care to ensure the tube is advanced intralumi-
may also be identified and divided. nally and in an antegrade fashion. Once a sufficient length
Once the fundus is completely mobilized, continue the of tube has been inserted, tie the four anchoring sutures
division of the gastrocolic ligament caudally toward the externally within the subcutaneous layer, securing the jeju-
pylorus. It is important to fully divide these attachments num to the anterior abdominal wall. Place one anti-torsion
between the distal stomach and the colon to reduce tension suture a few centimeters distal to the jejunostomy to reduce
on the anastomosis and to avoid predisposing the patient to risk of bowel torsion. Lastly, secure the tube to the skin
colonic herniation via the hiatus. This step is complete once with non-absorbable suture.
ranshiatal Dissection and Creation

T
of the Gastric Conduit
Place the patient back in reverse Trendelenburg and dissect

the esophagus transhiatally. Completely encircle the distal
esophagus at the level of the hiatus and pass a ½ inch Penrose
drain around it, securing the drain with a locking clip to cre-
ate a mobile handle (Fig. 14.5). Using the drain to aid in
retraction, perform a transhiatal dissection as high as is fea-
sible, about to the level of the inferior pulmonary vein. Keep
periesophageal lymph nodes, including nodes anteriorly
along the pericardium, with the specimen. If a pneumothorax
occurs at this point, it is important to ensure having a wide
pleural opening to avoid entrapment of air within the chest
and tension physiology. If hemodynamic instability is noted,
it is important to communicate with the anesthesia team.
Decreasing the intra-abdominal insufflation pressure
(8–10 mmHg can be adequate), increasing the airway pres-
sure, and taking the patient off steep Trendelenburg are use-
ful maneuvers that resolve the problem in most cases.
Fig. 14.4
Placement of a chest tube is almost never required.
Select a location on the lesser curve just proximal to the
pylorus to begin tubularization. Withdraw the oro- or naso-
gastric tube to avoid incorporation into the staple line.
Communicate clearly with the anesthesiologist about the
tube. Use serial firings of the endostapler to tubularize the
conduit and begin dividing it from the specimen, proceeding
superiorly toward the fundus. The conduit should be 4–5 cm
in width. Take care to keep the staple line as straight as pos-
sible by stretching the stomach from the tip of the fundus
(Fig. 14.6). Stop the staple line approximately 3 cm proximal
to the fundus so that the specimen and conduit can later be
delivered into the chest together in the proper orientation.
Finally, pass the Penrose drain around through the hiatus
where it will later be retrieved via the chest. Remove the liver
retractor and all ports after ensuring hemostasis. Close all
Fig. 14.5
port sites in the standard fashion.
Positioning for the Thoracic Phase
Position the patient for the thoracic phase in the left lateral
decubitus position leaning slightly forward on a beanbag,
with an axillary roll and arm support and with the table
flexed. Achieve lung isolation is achieved. Enter the chest
under direct visualization with an optical trocar in the sev-
enth intercostal space in the posterior axillary line. Place a
10 mm camera port in the ninth intercostal space just poste-
riorly to the first port. Place an additional 10 mm port in the
fourth or fifth intercostal space in the mid-axillary line. A
5 mm port is placed in the seventh intercostal space between
the scapula and the spine (Fig. 14.7). Chest insufflation with Fig. 14.6
CO2 at a pressure of 8 mmHg helps exposure by flattening
Fig. 14.8
use it as a retraction handle. Then completely dissect the

esophagus out of its bed in the mediastinum, proceeding
superiorly toward the level of the azygous vein. Take care to
avoid injury to the membranous airways. Lymphatic branches
coming from the thoracic duct and arterial branches from the
aorta must be identified and liberally clipped. Perform a sub-
carinal nodal dissection, again taking care not to injure or
devascularize the airway (Fig. 14.9).
Esophagogastric Anastomosis
Extend the dissection of the esophagus beneath the pleura

around 2 cm superiorly past where the pleura was divided
at the level of the azygous vein. The preserved pleura will
Fig. 14.7 act as a buttress for the eventual anastomosis. Use a linear
stapler to divide the esophagus at the desired level for the
anastomosis, after confirming that the oro- or nasogastric
the diaphragm, collapsing the lungs toward the anterior tube and esophageal temperature probe have been removed.
mediastinum, and decreasing the mediastinal movement At this time, ask the anesthesiologist to advance an oral
from the contralateral ventilation. anvil for the circular stapler (Orvil, Medtronic, Minneapolis,
MN) until the tip of the tubing can just be seen at the proxi-
mal staple line. Grasp the staple line on both sides and kept
Thoracoscopic Dissection horizontal (Fig. 14.10). Use cautery to create a small open-
ing just above the center of the staple line and pass the anvil
Divide the inferior pulmonary ligament and dissect its asso- through.
ciated lymph nodes. Incise the mediastinal pleura anterior to Gently pull the distal esophagus upward, delivering the
the esophagus, heading superiorly to the level of the azygous specimen and the conduit into the chest. Take care to avoid
vein. Divide the vein using a vascular stapler (Fig. 14.8). excess traction and any twisting of the conduit. The staple
Dissection then proceeds inferiorly by dividing the pleura line of the conduit should be oriented to the patient’s right
posterior to the esophagus. Take care not to stray too wide and be totally straight (Fig. 14.11). At this point, if available,
from the esophagus as this risks injury to the aorta and the assess the conduit using fluorescence imaging using a pro-
thoracic duct. As the dissection is carried inferiorly, the tran- prietary camera such as the Pinpoint system (Novadaq,
shiatal dissection performed via the abdomen is eventually Ontario, Canada). The anesthesiologist administers dilute
encountered and the Penrose drain identified. Grasp this and indocyanine green intravenously. Within minutes fluores-
cence can be seen within the conduit. The speed of fluores- mosis in an area of good conduit perfusion with no tension,
cence appearance and any areas of demarcation are noted to leaving the greater curvature vessels on the tracheal side of
identify regions of poor perfusion in the conduit. If a demar- the anastomosis in order to protect the airways in case of
cation is noted, mark the area and endeavor not to use this leak. The fat pad containing the vessels provides a nice but-
region for the creation of the anastomosis and to resect this tress between airway and anastomosis to reduce risk of gas-
portion of the stomach after the anastomosis is performed. trobronchial fistula. After the stapler is removed, transect the
Then divide specimen from the conduit using a linear sta- opened proximal end of the conduit with a linear stapler,
pler, taking care to maintain an adequate margin and leave making sure the anastomosis and the gastric staple line are at
enough room for insertion of the circular stapler to form an least 1–2 cm apart to avoid ischemia (Fig. 14.13). At this
end-to-side esophagogastric anastomosis (Fig. 14.12). Place point, allow the anastomosis to retract under the superior
the specimen in a retrieval bag and send it for intraoperative mediastinal pleura and tack it in place with absorbable
pathologic assessment of the proximal and distal margin. sutures. Buttress the vertical staple line of the conduit with
Once these are determined to be negative, perform the anas- omentum or pericardial fat, separating it from the airway
tomosis. Grasp the proximal tip of the conduit and open the (Fig. 14.14). Advance a nasogastric tube under direct vision.
staple line with cautery, wide enough to allow insertion of Place a single chest tube re-expand the lung. Close the inci-
the circular stapler. Insert the stapler and perform the anasto- sions in the standard fashion.
Fig. 14.9
Fig. 14.11
Fig. 14.10 Fig. 14.12

discharge. Patients are encouraged to ambulate 1 mile per

day and use incentive spirometry hourly. Careful attention is
paid to any unexpected deviation from the clinical course,
such as fever, cough, or arrhythmia, which may signal a
more serious complication such as anastomotic leak or pneu-
monia. In the absence of complications, most patients are
discharged by around the seventh day. The diet is slowly
advanced as an outpatient, and tube feeds are weaned as oral
calorie intake improves. The jejunostomy can usually be
removed at the first outpatient follow-up appointment
2 weeks following discharge.
Complications
Anastomotic Leak
Fig. 14.13 Prevention of anastomotic leak relies on meticulous surgical

technique in the creation of a tension-free anastomosis with
adequate blood supply, negative margins, and no distal
obstruction. Even with good technique, however, the risk of
leak remains. The presentation may range from subclinical
to fulminant. Any aberration in vital signs such as tachycar-
dia, fever, arrhythmia, or elevation of the white cell count
should raise suspicion of a leak. Chest tube output should be
carefully observed to rule out the presence of bile, air, or pus.
If a leak is suspected, contrast radiography, ideally a CT of
the chest with oral and IV contrast, should be performed and
esophagoscopy should be considered. Depending on the
severity of the leak and the stability of the patient, manage-
ment options include keeping the patient NPO and on antibi-
otics, placement of a covered esophageal stent, placement of
radiologically guided chest drains, and operative repair and
Fig. 14.14 drainage either by thoracoscopy or thoracotomy. Some phe-
nomena related to esophageal leak, with their own presenta-
tions and management, are described below.
Postoperative Care
Patients are extubated in the operating room and monitored Tracheoesophageal Fistula (TEF)
in the post-anesthetic care unit overnight. The nasogastric
tube is kept to suction, and the patient is kept NPO. Tube TEF may occur when there is an undrained leak from the
feeds are initiated as early as postoperative day one. The anastomosis or the linear staple line of the conduit that
nasogastric tube is removed by the third or fourth postopera- erodes into the airway or may arise as a delayed result of
tive day, depending on the output and provided the conduit is injury to the membranous airway. In either case, the classic
not distended on chest X-ray. Contrast esophagram is not presentation is of an intractable cough, worst after swallow-
reliable to identify or rule out a subclinical anastomotic leak ing, that eventually progresses to pneumonitis and pneumo-
and is not routinely performed. The patient resumes a diet, nia as the lung is soiled with oral and enteric contents and
starting with clear fluids, on around the fifth postoperative more commonly presents on postoperative day 3 or 4. Quick
day. The chest tube is removed once a chyle leak has been recognition is vital to preventing severe pulmonary sequelae.
ruled out, typically by the third or fourth postoperative day. Antibiotics are started empirically early on. The diagnosis
Throughout the recovery period strict attention is paid to should be confirmed and the extent of the fistula evaluated
fluid balance. Most patients require diuresis starting on with both bronchoscopy and esophagoscopy. Covered stents
around the third postoperative day and often continued up to in the conduit are usually more effective to control the fi
stula,
especially if the conduit was tubularized. When a large stom- follow-up imaging, should be individualized depending on
ach is used as a conduit, it is hard to stop the gastric juice the size of the hernia, the patient’s comorbidities, and their
from draining behind the stent into the airway. When the fis- oncologic prognosis. Observation is appropriate in some
tula is not controlled, the best option involves right thora- cases.
cotomy, and repair of the airway with a viable tissue buttress.
If the patient is stable, the conduit may be repaired; however,
if there is an associated anastomotic leak or extensive inflam- Cardiopulmonary Complications
mation, it is wise to return the conduit to the abdomen along
with the creation of a cervical esophagostomy. In the unsta- The most common complications after esophagectomy are
ble patient, the thoracic portion of the conduit should simply not technical but, rather, involve the pulmonary system. MIE
be resected. Delayed reconstruction with interposed subster- reduces these complications compared with open surgery but
nal gastric conduit, colon, or free jejunal graft is performed does not eliminate them entirely. Atelectasis should be pre-
several months after the patient has recovered. vented with aggressive ambulation and use of incentive spi-
rometry. ERAS protocols may reduce these complications. If
it occurs, chest physiotherapy and liberal bedside bronchos-
Conduit Necrosis copy are added to help prevent progression to pneumonia.
The most frequent cardiac complication is atrial fibrillation,
One of the most dramatic complications that can occur fol- which can usually be managed with rate control medications,
lowing esophagectomy is necrosis of the conduit. This typi- though prolonged arrhythmia warrants anticoagulation.
cally occurs in a delayed fashion several days postoperatively Myocardial infarction and pulmonary emboli also occur and
as the right gastroepiploic arterial supply ultimately fails. are managed in the usual fashion.
Patients present with a clinical picture of sepsis. Urgent
endoscopy is performed to confirm the diagnosis, and the
conduit must be resected via thoracotomy. Diversion with Avoiding Postoperative Complications
delayed reconstruction is required.
Anastomotic Leak and Stricture
Chylothorax Anastomotic leak is one of the most morbids of the common

complications of any esophagectomy and remains a stubborn
Because the thoracic duct and its branches are difficult to challenge for esophageal surgeons. The higher rate of esoph-
visualize and run in close proximity to the esophagus, chylo- ageal leaks compared with other anastomoses relates, at least
thorax may occur after any esophagectomy, carrying a sig- in part, to the gastric conduit perfusion. To transpose the
nificant morbidity and mortality rate. This complication can stomach either in the chest or the neck, all vascular supply
be prevented by staying within the correct plane of dissection needs to be divided and its main perfusion is based on a sin-
and rigorously clipping all the small lymphatic branches that gle arterial supply originating distally (the right gastroepi-
are encountered. If chylothorax does occur, about half of all ploic artery), while the anastomosis is created proximally, in
cases will stop with expectant management consisting of an area of the stomach perfused entirely by submucosal
keeping the patient NPO and on parenteral nutrition. The microcirculation. In keeping with basic surgical principles,
remainder will need further intervention, which may consist the anastomosis must be fashioned in an area of optimal per-
of bedside pleurodesis, thoracic duct embolization, or fusion, without tension and without distal obstruction.
ligation. Ensuring good blood supply entails fastidiously preserving
the right gastroepiploic artery and gentle handling of the
conduit itself. Correct orientation is maintained to avoid tor-
Paraconduit Herniation sion of the conduit during its transposition. Prior to creating
the anastomosis, perfusion is assessed using fluorescence
Herniation of the colon or small bowel may occur in the imaging (or color and Doppler signal), and an optimal loca-
immediate postoperative period or months to years following tion is selected (Fig. 14.15). Tension is minimized by placing
surgery. In order to prevent this problem, the gastrocolic the anastomosis just above the azygous vein and by fully
ligament is completely divided and care is taken not to widen dividing the gastrocolic ligament distally and mobilizing the
the hiatus excessively. Acute and/or symptomatic hernias right gastroepiploic pedicle at its origin. The anastomosis is
should be managed operatively, which can generally be anchored to the superior mediastinal pleura to counteract the
accomplished via a laparoscopic approach. The management effect of gravity. Distal obstruction is relieved by selective
of asymptomatic hernias, such as those detected on routine performance of a pyloric drainage procedure by injecting
path of the thoracic duct. Prophylactic ligation of the duct

has not consistently been shown to reduce postoperative chy-
lothorax, but if injury to the duct or its branches is suspected,
the duct should be ligated just above the hiatus. Intraoperative
fluorescence imaging may be useful to help delineate the
anatomy of the duct to aid in its preservation or ligation,
though it is not routinely necessary.
Paraconduit Herniation
Herniation of the colon and small bowel into the chest via the
hiatus can occur in either an acute or delayed fashion. A pre-
disposition for this complication is created when the gastro-
colic ligament is not completely divided distally toward the
pylorus. This tends to pull the colon up with the conduit,
possibly leading to herniation. Instead, the ligament must be
fully divided such that the colon is totally free of the conduit.
Avoidance of excessive widening of the hiatus during tran-
shiatal dissection and the placement of sutures securing the
conduit to the hiatus after forming the anastomosis further
Fig. 14.15
reduces this risk.
Botox into the muscle of the pylorus (or a pyloromyotomy or

pyloroplasty), and an NgT is placed intraoperatively to keep Pyloric Complications
the conduit decompressed. Anastomotic stricture is generally
a result of leak or ischemia, and so avoidance of leak will The pylorus is a source of two contrasting types of complica-
also prevent most stricture formation. tions. When the pylorus is not patent, patients may suffer
from poor conduit emptying and feeding intolerance.
Conversely, if the pylorus is widely patent, patients are pre-
Tracheoesophageal Fistula (TEF) disposed to bile reflux and aspiration as well as dumping
syndrome. There continues to be debate about the utility of
Avoidance of injury to the membranous airways, including pyloric drainage procedures. We feel that the use of Botox is
the trachea and left and right mainstem bronchi, is para- ideal, as it temporarily allows free drainage of the conduit as
mount in preventing TEF. Caution is exercised when using function gradually improves postoperatively and patients
energy devices near the airway, particularly during the sub- learn to accommodate their new anatomy. Over time the
carinal node dissection. It is helpful to ensure that the bron- effect wears off and chronic bile reflux, aspiration, and
chial cuff of the double-lumen endotracheal tube is not dumping syndrome are prevented as pyloric function eventu-
overinflated, which can predispose the left mainstem airway ally resumes.
to injury. Bronchial artery branches supplying the airway
should be preserved to prevent ischemia. The anastomosis
and longitudinal staple line of the conduit are buttressed with Further Reading
omentum or pericardial fat to separate them from the airway,
as often an undrained anastomotic leak is the cause of the Grimm JC, Valero V, Molena D. Surgical indications and optimization
of patients for resectable esophageal malignancies. J Thorac Dis.
fistula. 2014;6:249–57.
Litle VR, Buenaventura PO, Luketich JD. Minimally invasive resection
for esophageal cancer. Surg Clin North Am. 2002;82:711–28.
Thoracic Duct Injury Luketich JD, Pennathur A, Franchetti Y, et al. Minimally invasive
esophagectomy: results of a prospective phase II multicenter trial-
the eastern cooperative oncology group (E2202) study. Ann Surg.
The thoracic duct has an inconsistent course and is often dif- 2015;261:702–7.
ficult to visualize, especially in obese patients or after neoad- Mungo B, Lidor AO, Stem M, Molena D. Early experience and lessons
juvant radiation, placing it at risk for injury during esophageal learned in a new minimally invasive esophagectomy program. Surg
Endosc. 2016;30:1692–8.
mobilization in the chest. Care is taken not to stray outside of Pennatur A, Awais O, Luketich JD. Technique of minimally invasive
the periesophageal plane of dissection and into the expected Ivor Lewis esophagectomy. Ann Thorac Surg. 2010;89:S2159–62.
Sarkaria IS, Rizk NP. Robotic-assisted minimally invasive esophagec- Takeuchi T, Miyata H, Ozawa S, et al. Comparison of short-term out-
tomy: the Ivor Lewis approach. Thorac Surg Clin. 2014;24:211–22. comes between open and minimally invasive esophagectomy for
Sarkaria IS, Rizk NP, Finley DJ, et al. Combined thoracoscopic and esophageal cancer using a nationwide database in Japan. Ann Surg
laparoscopic robotic-assisted minimally invasive esophagectomy Oncol. 2017:1821–7.
using a four-arm platform: experience, technique and cautions Urschel JD. Esophagogastrostomy anastomotic leaks complicating
during early procedure development. Eur J Cardiothorac Surg. esophagectomy: a review. Am J Surg. 1995;169:634–40.
2013;43:e107–15. Wang H, Shen Y, Feng M, et al. Outcomes, quality of life, and sur-
Shah SP, Xu T, Hooker CM, et al. Why are patients being readmit- vival after esophagectomy for squamous cell carcinoma: a propen-
ted after surgery for esophageal cancer? J Thorac Cardiovasc Surg. sity score-matched comparison of operative approaches. J Thorac
2015;158:472–85. Cardiovasc Surg. 2015;149:1006–14.
Sihag S, Kosinski AS, Gaissert HA, et al. Minimally invasive versus Zhang J, Wang R, Liu S, et al. Refinement of minimally invasive esoph-
open esophagectomy for esophageal cancer: a comparison of early agectomy techniques after 15 years of experience. J Gastrointest
surgical outcomes from The Society of Thoracic Surgeons National Surg. 2012;16:1768–74.
Database. Ann Thorac Surg. 2016;101:1281–8.
Transhiatal Esophagectomy
15
Arjun Pennathur, Peter F. Ferson,
and Rodney Landreneau
Introduction Indications
There are several approaches to esophageal resection, with The transhiatal approach for esophagectomy is applicable
the two primary approaches being a transhiatal approach and for selected patients with benign diseases (e.g., achalasia and
a transthoracic approach. Over the past several years, refine- esophageal stricture) and for resection of tumors of the distal
ment of the operative techniques and advances in anesthesia, esophagus and gastroesophageal junction. This approach is
critical care, and perioperative management have improved not generally used for proximal thoracic esophagus and high
the perioperative outcomes of esophagectomy. This chapter mid-esophageal tumors. In patients requiring a laryngophar-
primarily focuses on open transhiatal esophagectomy. Many yngectomy, a transhiatal approach may be used for esopha-
of the technical details described are based on Dr. Mark gectomy. The stomach is the preferred organ to use as a
Orringer’s refinement and extensive experience with tran- replacement conduit because of its rich blood supply, mobil-
shiatal esophagectomy. ity, length to reach the neck, and the need for one unique
anastomosis. Transhiatal resection is safe and well
tolerated.
Preoperative Preparation
Patient Selection Preoperative Preparation
Appropriate patient selection is critical to optimize surgical Ideally, at least 2–3 weeks before surgery, the patient should
results and must include risk assessment and accurate stag- start pulmonary physiotherapy and stop smoking. The
ing. Patients with esophageal cancer are thoroughly staged patient’s nutritional status needs to be evaluated and opti-
with endoscopic ultrasound and positron emission tomogra- mized as soon as possible. If weight loss and nutritional
phy (PET) scanning. In addition, we also utilize minimally depletion are severe, consideration should be given to sup-
invasive laparoscopic staging. Risk assessment for esopha- plemental feedings. In some instances, a feeding jejunos-
gectomy includes both cardiac evaluation and pulmonary tomy tube may be considered. Although colonic evaluation is
evaluation. not routinely required, patients with a history of gastric dis-
eases or surgery should have their colon evaluated for its
suitability as a replacement conduit in case stomach interpo-
sition is not feasible. We generally use a full-bowel prepara-
tion prior to surgery. In patients with a history of significant
A. Pennathur (*)
mesenteric or visceral vascular disease and patients with
Sampson Family Endowed Chair in Thoracic Surgical Oncology,
Department of Cardiothoracic Surgery, University of Pittsburgh prior resection, consideration is also given to obtaining a
Medical Center, Pittsburgh, PA, USA computed tomography (CT) angiogram for vascular
P. F. Ferson evaluation.
Department of Cardiothoracic Surgery, University of Pittsburgh,
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
R. Landreneau
Department of Cardiovascular-Thoracic Surgery, Penn Highlands
Healthcare, DuBois, PA, USA

https://doi.org/10.1007/978-3-030-81415-1_15
128 A. Pennathur et al.
Pitfalls and Danger Points Pitfalls
Contraindications Some of the specific pitfalls during the various phases of the
operation are summarized below.
The transhiatal approach for esophagectomy is not gener-
ally used for proximal thoracic esophagus and high-to- 1. Anesthesia Induction.
mid-esophageal tumors. Bronchoscopic evidence of (a) Patients with an obstructed esophagus (e.g., dilated
tracheobronchial invasion during preoperative or intraop- tortuous sigmoid esophagus) or severe reflux are at
erative assessment is a contraindication for transhiatal high risk of aspiration. In these patients, a clear liquid
esophagectomy. The most critical assessment is in the diet for few days prior to surgery, rapid sequence
operating room, with the surgeon’s palpation through the intubation, and cricoid pressure during intubation
hiatus, to assess for esophageal and determine if the resec- may reduce the risk of aspiration.
tion is safe and feasible. Firm adhesion of the esophagus to 2. Abdominal phase.
the aorta or the tracheobronchial tree, either from direct (a) Avoid injury to the right gastroepiploic arcade by
tumor invasion or dense adhesions, contraindicates a tran- identifying the arcade early in the procedure. The
shiatal esophagectomy. right gastroepiploic artery is critical for preservation
There are circumstances where caution is warranted in of the gastric conduit.
patients with benign or malignant disease. (b) Minimize any trauma to the stomach.
(c) Caution is warranted during mobilization of large or
1. Caustic injury. There may be extensive adhesions in the giant paraesophageal hernia during mobilization of
mediastinum in patients with caustic esophageal injury, the stomach. Avoid gastric trauma and inadvertent
and also injury to the stomach precluding its use as a injury to the gastroepiploic arcade during omental
conduit. mobilization in patients with gastric volvulus.
2. Achalasia. In patients with a tortuous sigmoid mega- (d) Ligation of the short gastric vessels close to the stom-
esophagus, being treated with esophagectomy, caution is ach may result in ischemic necrosis of the stomach.
warranted. In these patients, since there is an increase in Ligate these vessels 1–2 cm from the gastric wall.
collateral blood vessels in a tortuous esophagus, there is Avoid undue traction on the stomach or omentum
an increased risk of bleeding with a transhiatal approach. and splenic capsular tear.
Prior esophageal myotomy may expose the esophageal (e) During mobilization of the celiac axis, avoid injury to
mucosa to the aorta and left lung, causing adhesions, and the aorta and other celiac branches (e.g., hepatic
this could complicate the transhiatal dissection. The artery). Avoid ligation of an aberrant left hepatic
dilated sigmoid esophagus that deviates also increases the artery arising from the left gastric artery.
chances of entry into the pleural spaces. Esophageal dila- (f) Evaluation of stomach as a conduit. During endos-
tion may extend high in the chest to near the thoracic copy, evaluate for tumor extension into the cardia
inlet, and this proximal dilation may make mobilization or the stomach, which may preclude use of the
of the cervical esophagus difficult. stomach or necessitate a different surgical approach,
3. Salvage esophagectomy. Caution is essential in patients such as an Ivor Lewis anastomosis in the chest. In
who are candidates for salvage esophagectomy, particu- addition, evaluate the stomach for other disease
larly several months after definitive chemoradiation. The processes that may make the stomach unsuitable as
risk profile is higher regardless of approach in these com- a conduit, such as caustic injury, previous gastric
plex patients, and the dense adhesions may increase the resection, previous antireflux surgery, multiple fun-
risk of transhiatal approach. doplications, and bariatric surgery (e.g., sleeve
4. Portal hypertension. Portal hypertension increases the gastrectomy).
risk of bleeding. (g) Avoid too wide or too narrow a hiatus at the conclu-
5. PET-CT scan findings. Some authors have utilized the sion of the operation.
findings of the PET-CT scan to select patients for tran- 3. Cervical phase.
shiatal esophagectomy. Patients with bulky subcarinal (a) Avoid hyperextension injury during positioning of
PET-positive lymph nodes may be better approached with the neck.
a transthoracic approach with mediastinal lymph node (b) Avoid recurrent nerve injury.
dissection under direct visualization. 4. Transhiatal mediastinal dissection.
15 Transhiatal Esophagectomy 129
(a) Avoid cardiac displacement and compression, which • Details of the neck dissection including dissection of the
can cause hemodynamic instability. esophagus and preservation of the recurrent laryngeal
(b) Be attentive for bleeding due to injury to the azygos nerve (RLN)
vein, aortic collaterals, or aorta. • Details of the transfer of the conduit in the proper orienta-
(c) Avoid injury to the thoracic duct with subsequent tion to the neck
chylothorax. • Details of the technique of anastomosis
(d) Avoid entry into the pleural spaces with • Details of drains and chest tubes
pneumothorax. • Any intraoperative complications and management
(e) Avoid injury to the trachea.
5. Creation of gastric conduit.
(a) Avoid trauma of the gastric conduit. Operative Strategy
(b) Avoid creation of a very narrow conduit, which may
compromise the blood supply to the conduit. The surgery is performed in a sequential fashion that starts in
6. Transposing the conduit to neck. the abdomen with initial evaluation of the tumor and its
(a) Maintain proper orientation when transposing the resectability, evaluation of the esophagus and its mobility,
conduit to the neck. evaluation of the stomach, gastric mobilization, and lymph
7. Cervical esophagogastric anastomosis. node dissection. Other components of the abdominal portion
(a) Avoid tension at the anastomosis. of the procedure are the performance of a pyloric drainage
(b) During a handsewn anastomosis, it is important to procedure and placement of a feeding jejunostomy tube. We
include the mucosa and submucosa incorporating the then move on to the neck and mobilize the proximal esopha-
muscularis mucosa in the anastomosis. gus. Transhiatal, mediastinal mobilization of the esophagus
(c) Avoid distension of the stomach and use nasogastric is then performed in a systematic fashion to mobilize the
tube drainage. posterior, anterior, and lateral attachments of the esophagus;
this combines both a transhiatal approach through the abdo-
men and a cervical approach. The gastric conduit is then
Documentation fashioned, the specimen is resected, the conduit is transposed
to the neck, and the cervicogastric anastomosis is con-
Please refer to the AMA CPT codes for the most recent codes structed. The neck and abdomen are then closed.
for documentation of the procedure. Key aspects that we
include in the operative note are as follows.
Avoiding Postoperative Complications
• History and staging information in patients with malig-
nant disease including TNM stage and overall stage Avoidance of postoperative complications starts with appro-
• Preoperative treatment (enrollment in clinical trial proto- priate patient selection, optimal preoperative preparation of
cols, use of neoadjuvant treatment, chemotherapy and the patient, attention to the details of the operative technique,
radiation dose, whether this is a salvage avoidance of the pitfalls detailed in other sections of the
esophagectomy) chapter, and optimizing postoperative care. Early recogni-
• Esophagogastroduodenoscopy (EGD) findings including tion and management of complications is also an important
extent of tumor, involvement of the cardia, and suitability factor in improving outcomes. Although we will discuss
of stomach as conduit some of the important complications and avoidance of these
• Bronchoscopy findings documenting the absence of tra- in this chapter, the reader is referred to a more detailed dis-
cheobronchial involvement cussion of the postoperative complications of esophageal
• Findings in the abdominal phase of the operation includ- reconstructions found in an excellent chapter by Dr. Alex
ing metastases, extent of lymph nodal disease, extent of G. Little, which is included in the Further Reading list.
lymph node dissection, details of fashioning of the gastric
conduit, the size of the gastric conduit, preservation of the
key blood supply—the right gastroepiploic artery—and in Operative Technique
some patients the right gastric artery
• Performance of a pyloric drainage procedure Patient Preparation and Initial Steps
• Placement of a feeding tube
• Description of the transhiatal dissection including attempt Intra-arterial blood pressure is typically monitored continu-
at nodal dissection ously, and two large-bore intravenous catheters should be
placed in the patient. This is important because hemody- Generally, during mobilization, we leave a few centimeters
namic instability is associated with mediastinal dissection of omentum next to the vessels to avoid injury to the arcade.
and compression of the heart, which causes impaired dia- While the first assistant retracts the colon, dissection is
stolic filling and potential estimated blood loss between started where the right gastroepiploic artery terminates
0.5 L and 1 L. An epidural catheter can be considered for through an avascular portion of the omentum toward the
better postoperative pain control and, consequently, better spleen. The transition between the short gastric vessels and
postoperative pulmonary function. A single-lumen endotra- the gastroepiploic arcade is identified to avoid injuries to the
cheal tube is normally used for ventilation, unless the patient right gastroepiploic artery. In addition, as the short gastric
has a history of prior esophageal surgery or in upper or vessels are divided, care is taken to avoid the spleen. It is
middle-third esophageal tumors, which may necessitate tho- prudent to avoid extensive retraction of the stomach, which
racoscopy or thoracotomy. In these patients, a double-lumen can cause injury to the short gastric vessels and splenic cap-
endotracheal tube is used. We routinely use a sequential sular injury. Larger vessels should be ligated separately; the
compression device for deep-vein thrombosis prophylaxis. ultrasonic scalpel or other energy devices (e.g., Ligasure)
EGD is routinely performed at the beginning of the opera- may be useful for safely transecting the short gastric vessels.
tive procedure under general anesthesia. This allows the sur- Alternatively, the short gastrics can be controlled with a long
geon to confirm the location of the tumor and the margins of right-angle clamp and placement of 2-0 silk ties. Ligation of
resection, evaluate the stomach as the conduit, and review the short gastric vessels too close to the stomach may result
the surgical approach. Retroflexion is regularly performed to in delayed ischemic necrosis of the stomach, so they should
evaluate the gastroesophageal junction and cardia to assess be ligated at least 1–2 cm away from the stomach. Greater
any tumor extension in this area, evaluate the extent of resec- curve mobilization is completed by dividing the gastrocolic
tion necessary to obtain clear margins, and ensure appropri- ligament, the posterior gastric artery, and the posterior gas-
ate selection of the conduit. It is prudent to avoid excessive tric attachments. The fundus attachments to the diaphragm
air insufflation during the preoperative endoscopy. are divided. The greater curve is thus mobilized from the left
Bronchoscopy is also routinely performed to exclude airway crus to the pylorus. With complete mobilization of the greater
invasion in patients with mid- and proximal esophageal curvature, the peritoneum overlying the hiatus is incised, and
tumors. esophagus is encircled with a Penrose drain to apply
The patient is positioned supine with the head extended traction.
and turned to the right with a shoulder roll. Prophylactic anti- We begin mobilizing the lesser curvature by making an
biotics are administered as per protocol. The skin prepara- incision in a flimsy or transparent area of the gastrohepatic
tion includes the neck, the anterior and lateral chest up to the omentum with the electrocautery or an ultrasonic scalpel.
mid-axillary line, and the whole abdomen. The arms are The gastrohepatic omentum is then divided toward the right
extended during the positioning. crus. The stomach is gently retracted toward the left of the
patient, which facilitates dissection of the left gastric vessels.
The left gastric vessels are identified. Since there are ana-
Abdominal Phase: Laparoscopy/Laparotomy tomic variations in the vascular supply, it is important to rec-
ognize the celiac trunk and its branches and identify any
We prefer the start of the procedure with laparoscopy to rule aberrant left hepatic artery before division of the left gastric
out any unsuspected advanced disease, such as distant metas- vessels. In patients with esophageal cancer, the lymph nodes
tases. We also carefully examine the stomach for scarring or in the celiac axis and the left gastric artery are swept toward
any other evidence of prior disease. In the absence of metas- the specimen. The left gastric vessels can be divided with a
tases, we proceed with the abdominal portion of the proce- mechanical stapling device or suture ligatures close to its ori-
dure. Here, we describe an open transhiatal approach. The gin to the celiac axis. In patients with an aberrant hepatic
procedure begins with a midline incision starting from the artery, the left gastric artery is ligated and divided distal to its
xiphoid process and extending to the umbilicus. A retractor origin. The lesser curve is thus mobilized. We prefer to pre-
(Thompson or Book Walter retractor) is placed to help with serve the right gastric artery, although this is not essential.
exposure. We start by dividing the triangular ligament for Once the stomach is completely mobilized, the duodenum
mobilization of the left hepatic lobe. The upper hand retrac- is mobilized from its retroperitoneal location, with a gener-
tor blade is useful to retract the left lobe of the liver and is ous Kocher maneuver. With an adequate Kocher maneuver,
placed to help with exposure. The mobilization of the stom- the pylorus should be able to be displaced from its usual
ach is started typically in the omentum at the midpoint of the position to the right upper quadrant.
greater curvature. It is critical to handle the stomach gently In summary, it is critical to preserve both the arterial sup-
and with care. It is best to identify the gastroepiploic arcade ply and the venous drainage of the gastroepiploic arcade. In
early in the dissection and carefully preserve the arcade. addition, full mobilization of the stomach requires careful
division of the posterior attachments of the stomach, attach- tors are not placed deep against the tracheoesophageal
ments to the colon, and a Kocher maneuver. This will allow groove to avoid injury to the RLN. A Weitlander retractor
the stomach to attain its maximal cephalad reach for perfor- can be placed superficially retracting the superficial sterno-
mance of a neck anastomosis. cleidomastoid muscle and superficial strap muscle medially.
The use of a pyloric drainage procedure has been debated The inferior thyroid artery is identified and divided with care
in the literature. Our approach is to generally perform a taken to preserve the RLN. Trauma is also avoided to the
pyloric drainage procedure (pyloromyotomy or pyloro- main vagus nerve laterally. The middle thyroid vein is usu-
plasty) to avoid the possibility of delayed gastric emptying ally ligated and divided. Once the prevertebral fascia is
after vagotomy. We start by placing 2-0 silk stay sutures at reached, blunt dissection with an index finger is performed
the most superior and inferior aspects of the pylorus. With posterior to the esophagus as far caudal as possible.
traction on the stay sutures, the serosa and muscle across the Next, we develop a plane between the trachea and the
pylorus are transversally scored with the electrocautery for anterior surface of the esophagus. Care must be taken to
1.5–2 cm. This is done with fine-tipped electrocautery start- avoid injuring the posterior membranous trachea during this
ing at the gastric side and extending to the duodenal side by mobilization. We start with sharp dissection, staying poste-
about 0.5–1 cm. The dissection continues until the submu- rior to the RLN. Fingers must be kept closely applied to the
cosa bulges out. The pyloromyotomy is then covered with wall of the esophagus. Once the anterior and posterior tho-
adjacent omentum, or a pyloroplasty can be performed. racic esophagus is mobilized, we gently encircle it with a
The phrenoesophageal membrane at the hiatus is divided rubber drain and maintain an upward traction. With this
as the crura of the diaphragm are opened anteriorly. The maneuver, the esophagus can be fully mobilized from the
gastroesophageal junction, which was encircled with a
mediastinum up to the carina. In rare circumstances, when
Penrose drain, is used as a handle. With downward traction the upper third of the thoracic esophagus is firmly attached to
on the Penrose drain, the right hand can be used to enter the the posterior membranous trachea, either because of a tumor
diaphragmatic hiatus to perform further dissection of the or an inflammatory reaction, a partial median sternotomy
lower esophagus. We open the diaphragm and enlarge the might be necessary to provide good access and direct vision.
diaphragmatic opening. Long, narrow, Lemmon extra-deep
Deaver retractors (Teleflex Inc.) are placed through the hia-
tus to allow visualization in the mediastinum and dissection. Transhiatal Mediastinal Dissection
At this point, it is important to ensure that the esophagus is
free from the pericardium, aorta, prevertebral fascia, and the When we begin mediastinal dissection, we coordinate with
tracheobronchial tree. The surgeon’s assessment of the the anesthesiologist for close monitoring for hemodynamic
mobility of the esophagus is critically important. Fixation instability. Most of the esophagus can be mobilized through
precludes resection, and if the procedure is deemed unsafe, the abdomen, with division of the mediastinal attachments
the surgeon should not hesitate to convert to a transthoracic under direct vision, which allows the placement of clips in
resection. The abdominal phase of the operation is concluded the blood vessels surrounding the esophagus. Placing the
with the placement of a jejunostomy tube. Generally, a 14F patient in the reverse Trendelenburg position can aid in the
jejunostomy tube is placed 20–30 cm from the ligament of exposure. The major vagal trunks are divided as the esopha-
Treitz. We use the Wetzel technique to place this jejunos- gus is dissected from the pleura and pericardium. When dis-
tomy tube. Abdominal pack is placed in the lower section is technically difficult, the direct exposure of the
mediastinum. esophagus is facilitated by small retractors in the diaphrag-
matic hiatus. The esophagus can be mobilized circumferen-
tially and dissected routinely up to the level of the pulmonary
Cervical Phase veins and to the subcarinal area. In patients with firm adhe-
sions that cannot be safely separated from the mediastinal
We begin the cervical phase of the transhiatal esophagec- structures, the surgeon should not hesitate to change surgical
tomy by exposing the cervical esophagus through the left approach from transhiatal to a transthoracic approach with a
side of the neck. A 5-to-8-cm oblique incision is made along right thoracotomy. The esophagus along with the mass is pal-
the anterior border of the left sternocleidomastoid muscle, pated through the hiatus to evaluate the mobility of the
starting from the sternal notch to the level of the cricothy- esophagus in the mediastinum. Transhiatal esophageal mobi-
roid, which marks the cricopharyngeus. The omohyoid mus- lization is then performed in a systematic fashion, with pos-
cle is identified and divided between silk sutures; the fascia terior, anterior, and lateral mobilization of the esophagus
is then divided. The sternocleidomastoid muscle and carotid (Fig. 15.1). One hand is inserted from the abdomen through
sheath are retracted laterally, and the thyroid and larynx are the diaphragmatic hiatus posterior to the esophagus and
retracted medially. During this phase, it is critical that retrac- advanced superiorly along the prevertebral fascia. The cervi-
riorly. The surgeon’s hand is then advanced, palm downward,

through the hiatus, to dissect the anterior esophagus superi-
orly. The esophagus is retracted superiorly toward the left,
and through the cervical incision, two fingers with the pal-
mar aspect on the esophagus are used to dissect inferiorly on
the anterior esophagus. It is particularly important to keep
the fingers on the esophagus behind the trachea and avoid
injury to the membranous trachea and the azygos vein.
Inferiorly, the esophagus is dissected away from the pericar-
dium. After anterior mobilization, lateral mobilization of the
esophagus is performed. The cervical esophagus is retracted
superiorly and elevated out of the mediastinum. The lateral
attachments are dissected and divided; 5–8 cm of the upper
esophagus is mobilized. The surgeon places his or her hand
through the hiatus, palm down, and holds the esophagus
between the index and middle fingers against the preverte-
bral fascia. The remaining attachments are lysed, with a
downward motion from the superior mediastinum. If needed,
the long, narrow retractors are placed through the hiatus, and
denser attachments can be divided under direct vision. At the
subcarinal level, posterior pressure is exerted against the
esophagus, thereby sweeping it away from the pericardium.
The esophagus can usually be mobilized completely in this
fashion. If inappropriate blunt dissection is performed, the
carina and left bronchus are vulnerable to injury. The azygos
vein is also at risk. Occasionally, a partial upper sternal split
may be needed to allow for direct visualization to divide the
remaining attachments in the subcarinal or subaortic area.
Frequent assessment of blood pressure with an arterial line
Fig. 15.1 and constant communication with the anesthesiologist are
essential in avoiding prolonged hypotension.
Once the esophagus is completely free, from the hiatus to
cal esophagus is retracted anteriorly to the right, and a half- the neck, we withdraw the nasogastric tube proximally to the
sponge stick is advanced inferiorly toward the abdomen, level of the cricopharyngeus. The esophagus is then divided.
posterior to the esophagus along the prevertebral fascia. The Depending on the technique of the planned anastomosis, this
esophagus is thus mobilized posteriorly off the prevertebral division may be performed obliquely from anterior to poste-
fascia, so that the hand inserted from the abdomen through rior, so that the anterior end is longer than the posterior end.
the hiatus meets with the half-sponge on a stick placed This division is done about 8 cm distal to the cricopharyn-
through the cervical incision. This completes the posterior geal muscle with a GIA™ stapling device (Medtronic). It is
dissection of the esophagus. The surgeon’s hand is kept pos- useful to have more length here, particularly in patients with
teriorly in the mediastinum close to the spine to minimize distal or gastroesophageal junction tumors where the proxi-
pressure against the heart and prevent prolonged hypoten- mal margin may not be a concern. Any excess length can be
sion. A gentle upward traction is applied on the rubber drain resected later during the anastomosis.
encircling the cervical portion of the esophagus. Again, blunt
dissection is carried out keeping the fingers directly against
the esophagus in the midline. At the completion of the poste- Preparation of the Gastric Conduit
rior dissection, a suction catheter is placed to evacuate the and Transposition to the Neck
blood.
The anterior mobilization of the esophagus is also per- The stomach and esophagus are placed on the anterior
formed from both the abdominal and cervical incisions with abdominal wall to perform the partial proximal gastrectomy.
the fingers always directed against the anterior esophagus to The whole stomach or a tubularized stomach can be used as
avoid injury to the posterior membranous wall of the trachea. a conduit. The proximal lesser curve of the stomach, includ-
The Penrose drain encircling the esophagus is retracted infe- ing the proximal branches of the left gastric artery along with
Fig. 15.2
the lymph nodes (Figs. 15.2 and 15.3), can be included in the
resection in patients with malignancy. To start this resection
and fashion the gastric conduit, traction is placed at the high-
est point of the gastric fundus and also at the lowest point of
the antrum so the stomach is stretched. A GIA stapler is Fig. 15.3
applied in the lesser curve toward the gastric fundus, so the
cardia and proximal stomach are resected. We allow a 5–6 cm
distal margin to the tumor to obtain adequate margins. The inserted into the mediastinum can be used to assess bleeding.
specimen is removed, and the margins are sent for frozen Mediastinal packing is a prudent step and helps with hemo-
section examination. With each application of stapler, cepha- stasis. The packs are subsequently removed, and mediasti-
lad traction should be applied to the fundus, and the stomach num is inspected through the hiatus with narrow retractors.
is lengthened progressively, thereby maximizing the upward In patients with pleural entry, chest tubes should be inserted.
reach of the conduit. With most of the lesser curvature We routinely place bilateral thoracostomy tubes.
removed, the stomach is untethered, and the fundus is fully We oversew the staple line with continuous Lembert
mobilized. This allows the stomach to be mobilized without suturing of 4-0 polypropylene. This is interrupted in the mid-
excessive tension, and the stomach becomes a more tubular dle, and it is important to avoid creating a “purse-string,”
structure instead of a large reservoir. It is critical not to nar- which will limit the cephalad mobility of the conduit. The
row the conduit too much, however, because this will com- gastric conduit, placed over the anterior chest wall, should be
promise the blood supply of the fundus. We preserve as much able to reach the neck and remain viable and healthy. The
of the stomach as possible, although a tubular stomach with- mediastinal packs are removed, and the mediastinum is again
out excessive narrowing of the conduit can be used. Even inspected closely to make sure hemostasis is adequate.
with a gross 5 cm margin beyond the tumor, the gastric con- The next step is the transposition of the gastric conduit
duit is long enough to reach the cervical esophagus through across the mediastinum to the neck. It is important to main-
the posterior mediastinum or the substernal route. In patients tain the proper orientation of the gastric conduit, with the
with benign disease, more stomach can be preserved, also lesser curve staple line toward the patient’s right. Marking
saving the collateral circulation to the fundus. The surgical sutures can be placed, if needed, to assist in orientation. The
specimen with the esophagus and the stomach is pulled surgeon’s entire forearm is passed through the diaphragmatic
through the abdomen. A careful inspection of the posterior esophageal hiatus to ensure an adequate mediastinal tunnel
mediastinum should then be performed. A suction catheter for the new conduit. The conduit is placed in a sterile laparo-
scopic cover bag. This is attached to a large Penrose drain anterior wall of stomach is brought up to the neck, the staple
placed from the neck to the abdomen through the mediasti- line is rotated slightly medially, away from the proposed site
num. The stomach is gently pushed rather than pulled of the anastomosis. Three to four cm of the stomach lies
through the hiatus, while the Penrose drain is gently pulled. above the proposed site of the anastomosis. The esophagus is
This avoids direct handing of the stomach and minimizes then divided at the appropriate site, and the specimen is sent
trauma to the stomach. The retractors in the hiatus and those for analysis as the final esophageal margin. Full-thickness
retracting the liver are withdrawn as the conduit is trans- 3-0 silk stay sutures may be placed to allow for esophageal
posed. The stomach is delivered above the clavicles to the retraction, if needed. The esophagus is retracted superiorly,
neck. Generally, there should be 4–5 cm of stomach above and two silk sutures are placed at the apex of the gastric con-
the clavicle after mobilization to the neck. This is a direct duit and the muscular layer of the esophagus a few centime-
path, through the original esophageal bed in the posterior ters above the proposed site of the anastomosis. This brings
mediastinum, and does not require resection of the clavicle. the esophagus into position, so it is resting on the anterior
During the transfer of the conduit to the neck, it is critical to wall of the stomach. A 1.5–2 cm linear incision is made in
maintain the orientation. The whole conduit should be pal- the stomach to match the diameter of the esophagus. The
pated to assure proper orientation and positioning without contents are suctioned out. Initially, the posterior seromuscu-
torsion. When the gastric fundus appears in the cervical lar layer sutures are performed. We then place interrupted
wound, it is gently grasped while the surgeon’s hand inserted horizontal mattress 3-0 silk sutures of about 5 mm from the
from the abdomen gently pushes the stomach upward, mak- site of the anastomosis approximating the posterior wall of
ing sure no twisting occurs. Every effort is made to minimize the esophagus to the anterior seromuscular layer of the stom-
trauma to the mobilized stomach being used to replace the ach. All sutures are placed first, and then subsequently tied.
esophagus. The plastic bag and Penrose drain are removed. This sets up the next step to complete the posterior layer
The abdomen is again inspected. The hiatus is re- of the anastomosis. Interrupted 3-0 or 4-0 polydioxanone,
approximated with non-absorbable sutures so that only three full-thickness sutures are placed. The esophageal mucosa
fingers can pass alongside the stomach. Subsequently, tends to retract, and it is critical to include the mucosa and
sutures are placed to approximate the gastric conduit to the submucosa, incorporating muscularis mucosa of the esopha-
crus to help prevent a paraconduit hernia. In addition, some gus and stomach, with these sutures. Several interrupted
surgeons have suggested that a pexy of the tenia coli from the sutures, 3 mm apart, incorporating about 5 mm thickness
leading point of the transverse colon to the undersurface of from the anastomotic margin are used to complete the back
the costal margin can be performed to prevent herniation. wall of the anastomosis. The corner sutures are tied, and the
The conduit is inspected to make sure it appears viable, with sutures are cut long and secured with a hemostat. Inverting
no compromise with a narrow hiatus. Abdominal hemostasis sutures are used around the corner, and the anterior inner
is ensured prior to beginning the cervical esophagogastric layer is then completed in similar fashion using 3-0 polydiox-
anastomosis. anone suture making sure that the mucosa and submucosa
are incorporated. We then place anterior interrupted simple
(or horizontal mattress) 3-0 silk sutures approximating the
Cervical Esophagogastric Anastomosis anterior wall of the esophagus to the seromuscular layer of
the stomach. This completes the anastomosis. The anastomo-
The next step is the cervical esophagogastric anastomosis. sis is checked with air insufflation through a nasogastric
Several techniques have been described for the esophagogas- tube. A muscle flap to protect the anastomosis has been sug-
tric anastomosis, both handsewn or with mechanical staplers. gested by some authors and can be considered. A nasogastric
The surgeon should be familiar with several methods of tube is passed, placed above the pylorus, and secured.
anastomosis, because a different method may have to be uti-
lized depending on the circumstances. Here, we describe our onstruction of Anastomosis with an EEA Stapler
C
techniques for a handsewn anastomosis, a total mechanical When stapling the cervical esophagogastric anastomosis, a
stapled anastomosis using the GIA and TA™ staplers, and an circular end-to-end anastomotic (EEA) stapler can be uti-
end-to-end anastomosis. lized. After division of the cervical esophagus, we place a
purse-string suture in the distal esophagus. Stay sutures may
Handsewn Anastomosis be placed to aid in the placement of the stapler anvil. A
When handsewn, we utilize a two-layer anastomosis and 25–28 mm EEA anvil is placed in the proximal esophagus
construct an end-to-side cervical esophagogastric anastomo- and secured with a purse-string suture. We generally add a
sis. The esophagus had previously been stapled, and we gen- second purse-string suture to make sure that the edges are
erally leave a longer length of the esophagus during that circumferentially well approximated around the anvil. Since
stapling, which is tailored during the anastomosis. After the the fundus of the stomach is the most ischemic portion of the
Esophagus
Gastric tube
Excess stomach
trimmed and closed
Fig. 15.5
most ischemic area, as part of the conduit may help in mini-

mizing leaks.
Fig. 15.4 otal Mechanical Stapling with Modified Collard

T
Technique
conduit, we plan the anastomosis so as to discard the fundal A modified Collard technique can also be used for the anas-
tip. We open the tip of the fundus, and the contents are suc- tomosis when the stomach is not tubularized. This anastomo-
tioned out. The internal aspect of the conduit is inspected to sis should be away from the gastric staple line used during
make sure there is no bleeding. The lubricated EEA stapler is construction of the conduit. In this technique, the posterior
then advanced into the gastrostomy. The exact location of the wall of the esophagus and the stomach are approximated,
anastomosis is based on the length of stomach that is needed, and an Endo GIA stapler is used to construct a side-to-side,
the margins required, and the surgeon’s assessment of the functional end-to-end anastomosis (Fig. 15.6a, b). Allis
vascularity of the conduit and the ideal location of the anas- clamps are used to line up the residual edges of the defect,
tomosis. The tip of the EEA then pierces the stomach along and a TA stapler is then used to approximate this defect
the greater curvature at the selected location and is carefully (Figs. 15.6c, d and 15.7). We place a #10 Jackson-Pratt drain
docked to the anvil (Fig. 15.4). Care is taken not to pull on in the neck. It is important to secure these drains well.
the anvil as the EEA stapler is deployed. It is important at
this stage for the surgical team to pay close attention to avoid ybrid Stapling Approach
H
tension in the anastomosis and intervening tissue (e.g., fat) Alternatively, a side-to-side stapled cervical anastomosis
that may cause incomplete rings during the anastomosis. We with a linear Endo GIA II 30-3.5 stapler can be utilized as
carefully fire the EEA stapler, and a stapled anastomosis described by Orringer. In brief, after the anterior wall of
between the end of the esophagus and the side of the gastric stomach is brought up to the neck, the staple line is rotated
conduit is completed. The surgeon inspects the rings, ensures slightly medially, away from the proposed site of the anasto-
that they are complete, and sends this for pathological evalu- mosis. Three to four cm of the stomach lies above the pro-
ation. The redundant portion of the fundus, through which posed site of the anastomosis. The esophagus had previously
the EEA stapler was placed, is then excised with a reticulat- been stapled obliquely, so that their anterior end is longer
ing Endo GIA stapler (Fig. 15.5). Importantly, this staple line than the posterior end. The esophagus is then divided at the
should not be placed too close to the EEA anastomotic staple appropriate site, and the specimen is sent for analysis as the
line. A nasogastric tube is placed across the anastomosis and final esophageal margin. After performing the anterior gas-
secured. In patients in whom a narrow gastric tube is con- trotomy, two stay sutures are placed to align the esophagus
structed, avoiding using the tip of the fundus, which is the and the stomach. The stapler is inserted with the thinner anvil
a b
c d
Fig. 15.6 (b–d) (From Schuchert et al. 2010, with permission.)
into the stomach and closed. Before firing, two suspension

sutures are placed on either side of the anastomosis. Once
fired, a nasogastric tube is placed, and the anterior anastomo-
sis can be completed in two layers with monofilament
sutures. The cervical wound is closed over a drain.
Hemostasis is ensured in the abdomen, and the abdominal
wound is closed.
Postoperative Care
After transhiatal esophagectomy, the patients are usually

extubated in the operating room or in the intensive care
unit. A chest X-ray is obtained in the recovery room. We
monitor patients in the ICU overnight. As soon as possible,
Fig. 15.7 respiratory physiotherapy is resumed, and ambulation is
encouraged. Early ambulation is a key factor in postopera- Orringer reported an incidence of 1% in his series. Patients at
tive care. risk include patients with preoperative radiation therapy,
The use of a feeding jejunostomy permits early postoper- prior mediastinitis, or tumors with firm fixation to the poste-
ative discontinuation of intravenous feedings, greater ease in rior tracheal wall. Upon identifying an airway laceration, the
ambulation and early patient care, and nutritional endotracheal tube should be guided under direct broncho-
supplementation, if necessary, following the discharge from scopic vision distal to the tear to avoid loss of large ventila-
the hospital. Jejunostomy tube feeding is usually started on tory volume. Ideally, after the completion of the
postoperative day 2 or 3, via slow infusion and, if well toler- esophagectomy, the tear can be primarily repaired. The tech-
ated, can be progressively increased. The chest tubes are nique of tracheal repair is dependent on the site of the injury.
removed, as per usual protocol, when drainage decreases, if In upper tracheal tears, a partial sternotomy offers direct
there is no air leak, and no chylous leak is evident when the visualization. However, extensive tears involving the carina
patient is on jejunostomy tube feeding. We obtain a contrast or main bronchus should be approached by the right
swallow evaluation between postoperative days 5 and 7, to thoracotomy.
evaluate for a leak and evaluate gastric emptying, and subse-
quently remove the nasogastric tube. We start clear liquids
after the swallow study and slowly advance the diet. Pleural Complications
Intraoperative pleural entry is a minor complication, easily

Complications managed with immediate chest tube insertion. This occurs in
25–75% of patients. In a study by Gurkan and colleagues of
Hemorrhage 148 patients who underwent transhiatal esophagectomy,
44.6% of the patients had pneumothorax.
One of the greatest concerns over the use of transhiatal esoph-
agectomy has centered on the lack of direct visualization dur-
ing the mediastinal dissection and consequently the risk of Chylothorax
increased blood loss and potentially catastrophic bleeding.
The use of long narrow retractors through the hiatus for direct Chylothorax has been reported in approximately 1% of
visualization and control of vessels decreases the chances of patients after transhiatal esophagectomy. Chest tube drain-
bleeding. This complication is rare and, when it occurs, is usu- age greater than 200–400 ml per shift for more than 48 hours
ally related to injury of larger vessels such as the azygos vein should lead one to suspect thoracic duct injury. The milky
and the aorta. Most of the arteries that nourish the esophagus aspect of the fluid with high levels of triglycerides or the
originate directly from the aorta, divide into fine branches, and presence of chylomicrons in the pleural effusion confirms
then penetrate the muscular wall to form an extensive inter- the diagnosis. Nonoperative treatment using tube thoracos-
connecting submucosal network. When these small vessels are tomy and a reduced-fat diet with administration of medium-
torn, massive hemorrhage is rare and unusual. If the point of chain triglycerides or total parenteral nutrition is typically
bleeding cannot be identified, the mediastinum should be used as initial conservative treatment. However, some sur-
packed, and volume resuscitation started. If the bleeding con- geons advocate aggressive management by early surgical
tinues, the procedure is converted to a thoracotomy. The aver- repair via transthoracic ligation of the thoracic duct.
age bleeding for transhiatal esophagectomy has been 500 mL Prolonged or massive drainage of chyle may perpetuate seri-
to 1000 mL but has importantly decreased as surgeons become ous nutritional deficits and lymphocyte depletion, both of
more proficient with the procedure. Maintaining the plane of which may promote or magnify the effects of perioperative
dissection immediately on the muscular wall of the esophagus infective complications. When there is persistent high chy-
is key to reduce bleeding. Patients with tumors fixed to the lous drainage and no improvement with conservative man-
aorta or periesophageal tissues should not undergo this proce- agement, we prefer an early initial attempt at thoracic duct
dure. In Orringer’s landmark series of over 2000 patients who embolization. If this is not successful, surgical ligation of the
underwent transhiatal esophagectomy, less than 1% of patients thoracic duct should be performed.
required a thoracotomy for bleeding control.
Nerve Injury
Tracheal Tear
RLN injury can be a devastating complication after esopha-
Tracheal tear is another major intraoperative complication gectomy, not only because it causes hoarseness but also
with a lower rate of occurrence in experienced hands. because of impaired swallowing and secondary pulmonary
aspiration. Paresis of the RLN is linked to placement of Splenectomy

retractors in the tracheoesophageal groove and usually
resolves within weeks. Several series have reported an inci- Incidental splenectomy, secondary to traction injury and
dence of RLN injury of 9% after transhiatal esophagec- bleeding, has been required in about 3% of patients. A care-
tomy, while Dr. Orringer reported RLN injury in only 1% ful dissection around the greater curvature is the only mea-
of the patients in his series, demonstrating that surgeon sure that can prevent this injury. It is important to avoid a
experience plays a major role in avoiding this traction injury with excessive retraction of the stomach.
complication. In summary, it is important to pay detailed attention to the
technical aspects of the operation. Over the past several
years, refinement in the operative techniques and advances in
Anastomotic Leaks anesthesia, critical care, and perioperative management have
improved the perioperative outcomes of esophagectomy.
The incidence of anastomotic leak reported in the literature Transhiatal esophagectomy can be performed safely, with
varies from 13% to 20%. Although the relative merits of low mortality and good long-term function.
handsewn versus stapled approaches and single-layer versus
multilayer closures have been debated, there is no definitive
evidence that suggests that any anastomotic technique is Further Reading
associated with superior results. In Dr. Orringer’s large
series, cervical anastomotic leak occurred in 13% of patients, Collard JM, Romagnoli R, Goncette L, Otte JB, Kestens PJ. Terminalized
semi mechanical side-to-side suture technique for cervical esopha-
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prior operation at the gastroesophageal junction. This com- Devaney EJ, Iannettoni MD, Orringer MB, Marshall B. Esophagectomy
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Ercan S, Rice TW, Murthy SC, Rybicki LA, Blackstone EH. Does
tal esophagectomy is rare. esophagogastric anastomotic technique influence the outcome
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Laparoscopic Heller Myotomy
for Achalasia 16
Jeffrey E. Quigley and Keith R. Scharf
Preoperative Preparation Pitfalls and Dangers
Workup Pseudoachalasia
All patients should undergo a workup consisting of upper Malignancy of the esophagus or esophagogastric junction
endoscopy, esophagram, and esophageal manometry prior can mimic symptoms and imaging findings of achalasia. A
to surgery. Contrast esophagogram will show tapering or high index of suspicion must be maintained when dysphagia
“bird’s beak” appearance of the lower esophagus and can has been present less than 6 months or in patients greater
demonstrate esophageal dilation if present. Upper endos- than 60 years of age. All patients with the diagnosis of acha-
copy is necessary to evaluate for malignancy causing lasia should undergo endoscopy. Endoscopy allows for visu-
extrinsic compression of the esophagus causing obstruc- alization and biopsy of suspicious lesions. Computed
tion, known as pseudoachalasia. Biopsies can be per- tomography (CT) scans of the chest, abdomen, and pelvis,
formed of any suspicious lesions seen on endoscopy. with oral and intravenous contrast, may show an obstructing
Esophageal manometry is the “gold standard” for diagno- mass or metastatic disease. Endoscopic ultrasound may also
sis of achalasia and will show aperistalsis of the esophagus be helpful to rule out malignant obstruction.
and incomplete relaxation of the lower esophageal
sphincter.
Incomplete Myotomy
Preoperative Nutrition and Optimization The myotomy should start 6 cm proximal to the gastroesoph-
ageal (GE) junction and carry onto cardia of the stomach
Laboratory evaluation includes transthyretin and albumin 2–3 cm or until the obstruction is relieved as demonstrated
levels. Malnourished patients may be provided with high- by intraoperative endoscopy.
calorie nutritional supplement shakes. Patients who are
unable to tolerate even liquids may require total paren-
teral nutrition until nutritional markers improve. Solid Bleeding
foods are discontinued at least 4 days prior to surgery, and
we recommend clear liquid diet 48 hours prior to surgery The proximal stomach muscle is more vascular than that of
to prevent accumulation of food debris within the the esophagus; while bleeding is usually minimal, bleeding
esophagus. is more likely to occur while making the myotomy at or
below the gastroesophageal junction.
Esophageal Perforation
J. E. Quigley · K. R. Scharf (*)
Department of General Surgery, Loma Linda University Health,
Loma Linda, CA, USA As the myotomy is carried distal toward the gastroesopha-
e-mail: KScharf@llu.edu geal junction, the mucosa becomes thinner resulting in a

https://doi.org/10.1007/978-3-030-81415-1_16
142 J. E. Quigley and K. R. Scharf
higher chance of perforation. The transition from esophagus The stomach can then be readily retracted medially or folded
to stomach is marked by change in the direction of the sero- on itself to gain exposure of the left crus and posterior esoph-
sal muscle fibers. If a mucosal perforation is made, then it is agus. In addition, mobilization of the fundus reduces tension
closed with absorbable interrupted suture and buttressed on the fundoplication performed at the end of the procedure.
with omentum or stomach such as a Dor fundoplication. If a Toupet fundoplication is going to be performed, com-
plete retroesophageal dissection will need to be done.
Vagal Injury
obilization of the Esophagus and Removal
M
The anterior vagus nerve should be identified and preserved of the Esophageal Fat Pad
during mobilization of the esophagus and creation of the
myotomy. The myotomy is made to the right and parallel to To ensure an adequate length of myotomy, the esophagus
the vagus nerve. Injury to vagus nerve(s) can result in delayed must be mobilized for about 8 cm into the mediastinum. The
gastric emptying. phrenoesophageal ligaments and anterior mediastinal attach-
ments are divided using the advanced energy device. Gentle
sweeping maneuvers can be used on the areolar connective
Gastroesophageal Reflux tissues of the mediastinum. Posterior dissection of the medi-
astinum is not always necessary unless a hiatal hernia is pres-
Gastroesophageal reflux is common after Heller myotomy, ent. Downward retraction on a Penrose drain around the
and an anti-reflux procedure such as a Dor or Toupet fundo- gastroesophageal junction brings the esophagus down into
plication should be performed. Previous studies have shown the abdomen and assists with lateral and medial retraction
worsening reflux when Heller myotomy was performed during mediastinal dissection. The esophageal fat pad is
alone without an anti-reflux component. A 360 fundoplica- often removed as it sits above the gastroesophageal junction
tion is typically not necessary and may produce obstructive and stands in the way of the myotomy.
symptoms, especially in the setting of esophageal dilation.
The choice between Dor and Toupet fundoplication is
dependent on the surgeon. The benefit of performing a Dor sophageal Myotomy Down to the Submucosal
E
is that it does not require posterior esophageal dissection Layer Carried Down onto the Gastric Cardia
and disruption of the entire phrenoesophageal ligament.
The other benefit is that it can cover the esophageal mucosa The myotomy is made anteriorly on the esophagus 6 cm
in case a small perforation is not detected. The benefit of a proximal to the gastroesophageal junction and carried dis-
Toupet fundoplication is that it can help keep the myotomy tally in a longitudinal direction toward the gastroesophageal
open, as a Dor if too tight could lead to scarring and junction. The hook electrocautery or ultrasonic dissecting
obstruction. shears are used to divide the longitudinal and circular mus-
cular layers of the esophagus. Our preference is to use the
hook electrocautery for the myotomy. The myotomy is then
Documentation carried through the GE junction 2–3 cm onto the stomach.
The muscular layers of the cardia are more adherent to the
• Presence and size of hiatal defect and whether repair was mucosa and more vascular than the esophagus. The serosal
done and oblique muscular layers of the stomach are divided first,
• Myotomy length in total and then the muscular layers are divided until the gastric
• Endoscopy and leak test results mucosa is visualized. A lighted esophageal bougie is very
• Type of fundoplication: Anterior (Dor) or posterior helpful for visualization of the mucosal layer.
(Toupet)
Anti-reflux Procedure
Operative Strategy
An anti-reflux procedure consisting of a Dor or Toupet fun-
ivision of the Short Gastric Vessels
D doplication should be performed to prevent gastroesopha-
and Mobilization of the Fundus geal reflux. If a Dor is performed, an anterior partial
fundoplication can be achieved by suturing fundus to the cut
An important step, usually performed first, is division of the edge of the myotomy covering the esophageal mucosa. If a
short gastric vessels along the proximal greater curvature. Toupet fundoplication is chosen, complete retroesophageal
16 Laparoscopic Heller Myotomy for Achalasia 143
dissection is necessary, and the fundus is brought posterior to

the esophagus and sutured to the cut edge of the myotomy.
• Intraoperative and postoperative sequential compression

devices
• Postoperative chemical deep vein thrombosis (DVT)
prophylaxis
• Integration of enhanced recovery protocols
• Early ambulation
• Multimodal pain therapy to minimize need for opioid-
based pain medications
Operative Technique
The patient is placed in the supine position on top of an anti-

slip pad or beanbag as the bed will be repositioned into a
steep reverse Trendelenburg position. After placement of
monitors and induction of general endotracheal anesthesia,
the upper and lower extremity pressure points are padded,
the patient is strapped in at the hips, and the chest and Fig. 16.1
sequential compression devices are placed on the calves. A
split leg position is used with the legs strapped in two loca- Division of short
tions. Preoperative antibiotics are administered prior to the gastric vessels
incision.
The abdomen is prepped and draped in the usual fashion.
Initial pneumoperitoneum is achieved using a Veress needle
at Palmer’s point: left mid-clavicular line, two fingerbreadths
inferior to the rib. A saline meniscus test is performed, and
opening pressure is checked before high flow carbon dioxide
is insufflated to a set pressure of 15 cm H2O. The initial port
is placed about 15 cm below the xiphoid and to the right
using the Optiview trocar technique (Fig. 16.1). A 10-mm
30-degree laparoscope is used. The peritoneal cavity is sur-
veyed, and the site of the Veress needle placement is visual-
ized. Under direct vision, two ports are placed in the left Fig. 16.2
upper quadrant and one port is placed in the right upper
quadrant. The falciform ligament can be taken down using coagulating shears along with the proximal one-third of the
the advanced bipolar or ultrasonic dissector if it is exceed- greater curvature (Fig. 16.2). First, the lesser sac is entered
ingly redundant. distally by tenting up the stomach and the omentum and
A Nathanson liver retractor is placed through a 5-mm entering between them. The dissection is kept a few millime-
incision in the epigastrium. The retractor is positioned to ters from the stomach to avoid thermal injury. Using medial
elevate the left lobe of the liver anterior–superior with the retraction of the stomach and lateral retraction of the omen-
blunt edge just above the crus. Care is taken to avoid placing tum, the dissection is carried proximally until the fundus is
it in a sulcus as this can lead to a laceration. The retractor can mobilized and the left crus is fully visualized. Blunt dissec-
be stabilized using a support system attached to the operating tion or energy use directly on the spleen is also avoided as
table such as a Bookwalter post. This will achieve visualiza- this can lead to retraction of the vessels and difficult
tion of the hiatus. bleeding.
The gastric fundus is mobilized by dividing the short gas- The gastrohepatic ligament is then entered and divided
tric vessels and gastrosplenic ligament using the ultrasonic using the ultrasonic coagulating shears, and care is taken to
preserve accessory and replaced hepatic vessels until the the gastroesophageal junction as it is important for the myot-
right crus is visualized. The phrenoesophageal membrane is omy to extend onto the stomach for 3 cm. At this point, a
opened anteriorly. Using blunt dissection, a window is cre- lighted 50 F dilator may be placed transorally into the esoph-
ated in the avascular plane between the esophagus and the agus which acts to stiffen the esophagus for the myotomy,
crura. An instrument is placed through the window from and the light provides contrast for the dissection of the fibers
right to left, and a ½” Penrose drain is passed behind the from the submucosal layer. Use of a lighted dilator at this
esophagus and used as a retractor for the esophagus. Gentle point in the procedure is the surgeon’s preference. The dila-
inferior traction brings the gastroesophageal junction further tor should be placed only by an experienced anesthesia staff
down into the abdomen. The esophagus is then dissected member or part of the surgical team. The dilator is advanced
from its mediastinal attachments anteriorly up to 8 cm above slowly and under laparoscopic visualization until the tip is
the gastroesophageal junction in preparation for the myot- well within the stomach. The dilator should advance
omy (Fig. 16.3). If a hiatus hernia is present, it should be smoothly without any resistance. The length should be at
closed with interrupted permanent 2-0 sutures posterior to least 6 cm on the esophagus and 3 cm on the gastric cardia.
the esophagus, but the repair should be loose so as not to The myotomy is then marked using the tip of the hook cau-
cause any narrowing or obstruction in the esophagus tery parallel to the anterior vagus and measured.
(Fig. 16.4). The myotomy is started on the esophagus, 6 cm proximal
The anterior vagus is then identified so that it can be pre- to the gastroesophageal junction. The longitudinal and then
served. The esophageal fat pad is dissected from the esopha- circular muscular fibers of the esophagus are divided using
gus using the ultrasonic device. This allows visualization of the hook electrocautery until the smooth submucosal layer is
encountered (Fig. 16.5). Attention must be paid to dividing
both layers of muscular fibers of the esophagus and avoiding
Esophageal mobilization injury to the mucosa (Fig. 16.6).
The myotomy is then carried onto the stomach, extending
3 cm below the gastroesophageal junction and slightly
Fig. 16.3
Division of
circular layer
Cruroplasty
Fig. 16.5
Lighted bougie
Fig. 16.4 Fig. 16.6

16 Laparoscopic Heller Myotomy for Achalasia 145
Toupet fundoplication Dor fundoplication
Fig. 16.8
Fig. 16.7
The liver retractor, Penrose drain, and ports can then be

toward the lesser curvature. Hook electrocautery is used to removed under direct visualization. Ports of 12 mm or greater
divide the serosal and oblique muscular layers first for the are closed at the fascial level with 0 suture. The skin is closed
entire 3 cm gastric section, and then carefully work down to with absorbable 4-0 suture and dermal glue or other
the muscularis and then the mucosa. Bleeding of the muscle dressings.
edges is more likely in the muscular gastric cardia and can be
addressed with pressure, using the jaws of a grasper, or brief
bursts of electrocautery. Cautery should not be applied Postoperative Care
directly to or near the mucosa.
After adequate length of myotomy has been achieved, the Clear liquid diet can be started once the patient reaches the
esophageal and gastric mucosa is inspected for injuries. If a medical–surgical unit. Diet is typically advanced to soft diet
mucosal perforation is noted, it should be repaired with 4-0 on postoperative day 1. Most patients are discharged on post-
interrupted absorbable suture using intra-corporeal suturing. operative day 1.
The bougie, if used, is withdrawn and a flexible video endo-
scope inserted into the esophagus. Insufflation is applied,
preferably with carbon dioxide, to evaluate for areas of resid- Complications
ual narrowing or unrecognized mucosal injury. Proximal or
distal extension of the myotomy or division of residual fibers • Esophageal perforation
may be required. Mucosal bulging should be noted if an ade- • Persistent dysphagia
quate myotomy was performed. The scope should easily • Incomplete myotomy
pass from the esophagus into the stomach. • Gastroesophageal reflux
Attention is then turned to performing an anti-reflux pro- • Injury to vagus nerves
cedure which should be done in all cases. A Toupet fundopli-
cation, or partial posterior wrap, is our preferred approach
(Fig. 16.7). However, a Dor fundoplication, or partial ante-
rior wrap, is often used in cases in which the mucosa was Further Reading
perforated as it acts as a patch for the repair (Fig. 16.8). The
esophagus is retracted anteriorly with the Penrose drain. The Afaneh C, Finnerty B, Abelson J, Zarnegar R. Robotic-assisted Heller
myotomy: a modern technique and review of outcomes. J Robot
gastric fundus is grasped on the greater curvature marked by Surg. 2015;9:101–8.
short gastric vessels, and it is then passed from left to right Andolfi C, Fisichella P. Laparoscopic Heller myotomy and Dor fundo-
behind the esophagus. The fundus is sutured using nonab- plication for esophageal achalasia: technique and perioperative man-
sorbable 2-0 suture (Ethibond) to the right side of the myot- agement. J Laparoendosc Adv Surg Tech A. 2016;26(11):916–20.
Donohue PE, Schleisinger PK, Sluss KF, et al. Esophagocardio-
omy with three interrupted sutures. On the left the proximal myotomy—floppy Nissen fundoplication effectively treats achala-
fundus may be sutured to the left myotomy in an interrupted sia without causing esophageal obstruction. Surgery. 1994;116:719.
fashion as well. If a Dor fundoplication is performed, the Ellis FH. Esophagectomy for achalasia: who, when, and how much?
fundus is brought anteriorly, and the proximal aspect is Ann Thorac Surg. 1989;47:334.
Ellis FH Jr. Oesophagomyotomy for achalasia: a 22 year experience. Br
sutured to the left side of the myotomy and the tip of the J Surg. 1993;80:882.
fundus is sutured to the right side of the myotomy.
Grimes K, Inoeu H. Per oral endoscopic myotomy for achalasia: a achalasia: an 8-year experience with 168 patients. Ann Surg.
detailed description of the technique and review of the literature. 1999;230:4.
Thorac Surg Clin. 2016;25(2):147–62. Pellegrini C, Wetter LA, Patti M, et al. Thorascopic esophagomyotomy:
Henderson RD, Ryder DE. Reflux control following myotomy in dif- initial experience with a new approach for the treatment of achala-
fuse esophageal spasm. Ann Thorac Surg. 1982;34:230. sia. Ann Surg. 1992;216:296.
Kashiwaqi H, Omura N. Surgical treatment for achalasia: when should Rawlings A, Soper N, Oelschlager B, Swanstrom L, Matthews B,
it be performed and for which patients? Gen Thorac Cardiovasc Pellegrini C, Pierce R, Pryor A, Martin V, Frisella M, Cassera M,
Surg. 2011;59:389. Brunt L. Laparoscopic Dor verus Toupet fundoplication following
Murray GF, Battaglini JW, Keagy BA, et al. Selective application of Heller myotomy for achalasia: results of a multicenter, prospective,
fundoplication in achalasia. Ann Thorac Surg. 1984;37:185. randomized-controlled trial. Surg Endosc. 2012;26:18–26.
Orringer MB, Stirling MC. Esophageal resection for achalasia: indica- Skinner DB. Myotomy and achalasia. Ann Thorac Surg. 1984;37:183.
tion and results. Ann Thorac Surg. 1989;47:340. Tatum R, Pellegrini C. How I do it: laparoscopic Heller myotomy
Patti M, Pellegrini C, Horgan S, Arcerito M, Omelanczuk P, Tamburini with Toupet fundoplication for achalasia. J Gastrointest Surg.
A, Diener U, Eubanks T, Way L. Minimally invasive surgery for 2009;13:1120–4.
Endoscopic Stent for Management
of Esophageal Leaks 17
Eugene Kahn and Shaun Daly
Indications give an additional 50 mL of per oral (PO) contrast on the

exam table immediately before the exam. Placement of an
The most common cause of an esophageal perforation is iat- esophageal stent is commonly performed under general
rogenic. Patients undergoing upper endoscopic procedures anesthesia but could be placed under moderate conscious
are at the greatest risk for an iatrogenic perforation. sedation. All appropriate preparations should be taken to pre-
Additional indications for placement of an esophageal stent pare for possible blood loss or perforation during dilation if
are benign perforations, malignant perforations, traumatic indicated. Placement can be completed with endoscopy
perforations, and caustic perforations. Esophageal stents are alone or may require the aid of fluoroscopy.
becoming more frequently used in controlling contamination
for esophageal anastomotic leaks. It is important to note that
all indications for the stenting of esophageal anastomotic Pitfalls and Danger Points
leaks are off-label and have not been approved by the Food
and Drug Administration (FDA) for this use. When placing an esophageal stent, take care to avoid
Esophageal stents have been validated and approved in excessive manipulation of the endoscope which could
both the palliation of malignant dysphagia and for improving extend the perforation. Similarly, avoid excessive insuffla-
enteral nutrition in patients with strictures due to esophago- tion (which can also worsen the leak). Take care to place
gastric cancers. They have also been used for managing an esophageal stent that is of appropriate length to cover
benign esophageal diseases such as strictures due to caustic the esophageal perforation with adequate overlay, but
ingestion, gastroesophageal reflux disease, radiation, post- avoid placing the stent too proximal as this may cause
surgical changes, perforations, fistulas, and leaks (Figs. 17.1 intolerable symptoms. Excessive radial force from a stent
and 17.2). Patients with large leaks, disproportionate destruc- that is too large in diameter can lead to esophageal wall
tion or necrosis, and non-viable anastomoses are not appro- necrosis and breakdown.
priate candidates for esophageal stenting. Other
contraindications include those too ill to undergo Esophago
gastro duodenoscopy (EGD), life expectancy less than Operative Strategy
30 days, and coagulopathy.
Self-expanding esophageal stents are categorized by their
base material and include plastic stents, metal alloy stents,
Preoperative Assessment and bare-metal stents (Fig. 17.2). They are described as
being partially covered or fully covered. Manufacturers of
Preoperative confirmation of esophageal leaks is diagnosed esophageal stents that are currently approved for use in the
with a water-soluble esophogram or alternatively a computed United States include Boston Scientific, Cook Medical,
tomography with oral contrast (Fig. 17.1). We routinely will EndoChoice, Merit Medical Endotek, and Taewoong Medical
Co. Manufacturer differences in stents include shape, the
strength of the radial forces which help the stent maintain
E. Kahn · S. Daly (*)
position, and the types of coating material on the stents.
Department of General Surgery, University of California Irvine
Medicine Center, Costa Mesa, CA, USA Differences also include the individual properties within the
e-mail: shaund@uci.edu

https://doi.org/10.1007/978-3-030-81415-1_17
148 E. Kahn and S. Daly
Shape
Esophageal stent shapes vary among manufactures; however,

the primary purpose for the shape of the esophageal stent is
to prevent migration once deployed in the esophagus. Shapes
include the dog bone shape (Taewoong Medical), progres-
sive step flared ends (Boston Scientific), outer metal struts
(Alveolus), and anti-migration ring (Hradec Kralove).
Material
Today, most esophageal stents are constructed with nitinol

(nickel-titanium alloy). Other materials include stainless
steel, silicone, or plastics such as polyester.
Fig. 17.1
Coating
Esophageal stents may be fully covered, partially covered, or

bare metal. For the purpose of esophageal stenting for esoph-
ageal leaks, a fully covered esophageal stent is recommended
to exclude the leak and to help facilitate retrieval.
Positioning
The esophageal stent needs to extend 3 cm above and 3 cm

below the perforation site. The minimal distance from the
upper esophageal sphincter and the top of the stent should be
1–2 cm (but patient may become symptomatic at these
lengths due to the sensory innervation of this region). The
distal end of the stent should be at least 3 cm above the hia-
tus. Avoid excessive pressure against the esophageal wall or
conduit if post-esophagectomy, thus avoiding the risk of
ischemia and/or erosion. If repositioning of the esophageal
Fig. 17.2
stent is required once deployed, a rat-tooth endoscopic for-
ceps can be used to grasp the retrieval suture at either the
stent that assist in radiological visualization to improve accu- proximal or distal stent and facilitate manipulation of the
racy of placement. stent into correct position. An improperly deployed or posi-
tioned esophageal stent should be removed immediately
because the risk of subsequent complications outweighs any
Length and Diameter benefits.
An esophageal stent placed for an esophageal leak should be

greater than 21 mm in diameter at the non-flared portion to Antibiotics
assist with maximizing sealing success. A stent length of
12–15 cm is optimal because these longer esophageal stents Broad-spectrum antibiotics to cover gram-negative and aero-
have a lower incidence of migration. bic bacteria in addition to fungal coverage are
recommended.
17 Endoscopic Stent for Management of Esophageal Leaks 149
Documentation Basics esophageal defect. The endoscopic examination proceeds to

the stomach, and a full assessment is performed including
After placement of an esophageal stent, thorough and com- intubation of the pylorus and visualization of the first portion
plete documentation is essential. The size of the esophageal of the duodenum. Retroflex the scope to completely assess
stent placed should be documented, both the diameter and the gastroesophageal junction.
the length of the esophageal stent. The distance the esopha- Once a complete endoscopic examination is performed,
geal stent was placed from the incisors should be docu- pass a guidewire through the working port of the endoscope.
mented in the procedure note as well as if the stent was Under direct visualization, pass it distal to the perforation
secured in place with a suture or clip. It is important to also and into the stomach so that a generous length of the guide-
document the defect size and location from the incisors. A wire curls in the stomach. Next, withdraw the endoscope
full esophagogastroduodenoscopy examination should be while simultaneously advancing the guidewire through the
completed and documented in the medical record. working port to avoid withdrawing it into the endoscope. The
goal is to leave the guidewire in position after removing the
scope, the endoscope. Calculate the total length of the esoph-
Operative Technique ageal defect using the documented proximal and distal mea-
surements previously determined. Allow 2–3 cm of additional
Selection of appropriate patients is crucial for successful coverage beyond the extent of the esophageal defect both
treatment of esophageal leaks with esophageal stents. proximally and distally. This overlap is mandatory.
Patients should be fasting for 6 hours from solids and 2 hours Esophageal stents can be placed within 1–2 cm of the cri-
from liquids. This is often not feasible because these patients copharyngeus muscle; however, this often leads to stent
most commonly are undergoing emergent esophageal stent intolerance. If needed, esophageal stents can also be placed
placement for esophageal leaks for which they are acutely ill. across the gastroesophageal junction and into the proximal
We prefer general anesthesia with endotracheal intubation in stomach. Often a 12-cm stent is sufficient to cover most
these patients because it allows for a more extensive assess- esophageal defects with appropriate overlay. A fully cov-
ment of the esophageal defect and allows the surgeon to per- ered, 18-mm-diameter stent with a proximal and distal flare
form any number of procedures which may be required in is commonly used. The flares of the esophageal stent are
addition to placement of the esophageal stent. Endotracheal designed to lower stent migration rates. If there is particular
intubation should be completed with a rapid sequence concern for stent migration, a single anchor suture can be
protocol. endoscopically placed at the proximal edge of the esopha-
Before starting the procedure, ensure that the endoscope geal stent. If an esophageal stricture is present, balloon dila-
is working properly with regard to the light source, the work- tion may be necessary at the time of stent placement.
ing port, the suction port, and the insufflation port. Make Lubricate the tip of the esophageal stent and place it over
sure you have enough CO2 in the tank to complete the proce- the guidewire using the Seldinger technique. Advance the
dure. Several esophageal stent sizes and lengths need to be stent over the guidewire under direct visualization. The dis-
readily available, and the proper guidewire is available. tance from the proximal edge of the esophageal defect previ-
Compression stockings should be applied and broad- ously determined and documented is used to place the
spectrum antibiotics initiated if the patient is not currently esophageal stent. The distance to the proximal edge is
receiving proper antibiotic coverage. The esophageal stent recalled, and 3 cm is subtracted from this length. Place the
will be placed under direct endoscopic guidance with or proximal edge of the esophageal stent at the calculated dis-
without the aid of fluoroscopy, based upon surgeon prefer- tance under direct visualization. Deploy the esophageal stent
ence and stent used. Place a bite block, lubricate the end of under direct visualization. After the deployment, remove the
the endoscope, and advance it to the posterior pharynx. device and guidewire. Advance the endoscope down the
Suction the posterior pharynx and identify and traverse the esophagus and verify that the esophageal stent is in proper
upper esophageal sphincter. position. Suction the stomach and esophagus of all debris
Carefully insufflate the esophagus with CO2 and advance and remove the endoscope.
the endoscope down until the defect is identified. Suction the The patient is extubated and transferred to recovery for
area free of purulence, mucoid material, and/or debris. Note post-anesthesia monitoring. A post-esophageal stent place-
the proximal and distal extent of the perforation and document chest radiograph is completed in recovery to document
ment the distance from the incisors. If the perforation can be positioning of the esophageal stent.
traversed and the extraluminal cavity visualized, the cavity If the esophageal leak is secondary to a perforated esoph-
can be suctioned of any foreign material. Copious irrigation ageal malignancy, the technique of esophageal stent place-
and suctioning are required to visualize the edges of the ment remains identical to the above procedure except that the
150 E. Kahn and S. Daly
proximal and distal margins of the tumor are used for place- migration is the most common early and late complication
ment rather than the esophageal defect edges. and has an incidence rate of 7–75%. Bowel perforation can
be a serious consequence of stent migration. A small amount
of bleeding can occur after placement of an esophageal stent,
Postoperative Care but major bleeding is a rare event occurring in less than 1%
of cases. Perforation extension can be seen with the place-
The patient should be monitored with aspiration precautions ment of an esophageal stent or after placement due to erosion
and started on a proton pump inhibitor if the stent spans of the stent. Erosion can also lead to a fistula between the
across the lower esophageal sphincter. A post-procedure esophagus and the trachea pericardium or the aorta.
chest plain film can be used to document stent placement and
positioning. A chest radiograph can then be used to ensure
non-migration of the esophageal stent should there be any Further Reading
change in patient status (Fig. 17.2). Enteral feeds should be
instituted immediately after esophageal stent placement, Castano R. Endoscopic techniques for gastrointestinal stenting: when
and how to stent, how to manage complications, stent selection and
either through the use of a gastrostomy or jejunostomy tube. costs. Rev Col Gastroenterol. 2012;27(1):Bogota.
The patient may start oral feeds once cleared by a speech D’Cunha J. Esophageal stents for leaks and perforations. Semin Thorac
pathologist and have undergone an esophogram demonstrat- Cardiovasc Surg. 2011;23(2):163.
ing containment of the esophageal leak; this is typically per- D’Cunha J, et al. Esophageal stents for anastomotic leaks and perfora-
tions. J Thorac Cardiovasc Surg. 2011;142:39–46.
formed by the third post-placement day. Esophageal stents Dai Y, et al. Esophageal stents for leaks and perforations. Semin Thorac
should be reevaluated in 14 days for removal or exchange as Cardiovasc Surg. 2011;23:159–62.
determined by the degree of healing of esophageal defect. Kozarek R, et al., editors. Self-expandable stents in the gastrointestinal
tract. New York: Springer Science and Business Media; 2013.
Hindy P, et al. A comprehensive review of esophageal stents.
Gastroenterol Hepatol (N Y). 2012;8(8):526–34.
Complications
Complications experienced after placement of an esophageal

stent include chest pain, dysphagia, globus, gastroesopha-
geal reflux symptoms, and post-placement fevers. Stent
Laparoscopic Nissen Fundoplication
for Gastroesophageal Reflux Disease 18
Michael N. Tran and Marcelo W. Hinojosa
Indications • Tension pneumothorax from entry into the mediastinal

pleura and injury to lung
• GERD symptoms refractory to medical therapy • Tight fundoplication
• Patients intolerant of pharmaceutical therapy
• Patients with complications of GERD such as esophageal
strictures, Barrett’s esophagus, esophageal bleeding, and/ Documentation
or erosive esophagitis
• Patients with extraesophageal manifestations of GERD • Intraabdominal esophageal length
such as aspiration, recurrent pneumonias, chronic bron- • Identification of vagus nerves
chitis, and laryngitis in whom additional studies strongly • Presence of hiatal hernia and size
suggest aspiration of refluxate into the airway • Intraoperative endoscopy findings
• Use of mesh and type of mesh if used
• Type of fundoplication
• Preoperative workup Operative Strategy

–– Esophageal manometry, pH study, upper gastrointesti-
nal imagining study, and esophagogastroduodenoscopy We perform laparoscopic Nissen fundoplication in the
–– Preoperative Nothing by mouth (NPO) after midnight majority of patients with gastroesophageal reflux. A partial
–– Chemical Venous thromboembolism (VTE) prophy- fundoplication, such as a Toupet or Dor fundoplication, is
laxis in the preoperative area reserved for patients with severe esophageal dysmotility or
–– First-generation cephalosporin for antibiotic aperistalsis. The key points of the operation are as follows:
prophylaxis The hiatus is exposed by elevating the left lobe of the liver
–– Nasogastric tube decompression if needed without dividing its attachments. The gastrophrenic ligament
and short gastric vessels are divided, and the esophagus is
exposed and mobilized by incising the gastrophrenic liga-
Pitfalls and Danger Points ment on the left side. The gastrohepatic ligament is then
divided, and circumferential esophageal mobilization is
• Esophageal injury completed and extensive mediastinal dissection is performed.
• Gastric injury The extensive dissection necessitates the need for approxi-
• Splenic injury mation of the crura. A fundoplication is then constructed and
• Vagus nerve injury gastropexy performed.
• Bleeding

M. N. Tran · M. W. Hinojosa (*)
Department of Surgery, Division of Minimally Invasive and
Gastrointestinal Surgery, University of California Irvine Medical Herniation through the hiatal opening can be minimized by
Center, Orange, CA, USA minimizing tension on the hiatal closure and on the subse-
e-mail: hinojosm@uci.edu

https://doi.org/10.1007/978-3-030-81415-1_18
152 M. N. Tran and M. W. Hinojosa
quent fundoplication. Adequate division of the short gastric

vessels and the posterior attachments of the proximal stom-
ach, as well as adequate mediastinal dissection of the esoph-
agus to ensure that adequate intraabdominal esophageal
length can help to prevent this. When reapproximation of the Monitor
crura leads to undo tension of the hiatal closure, a relaxing
incision can be performed on the right diaphragm and cov-
ered with biologic or biosynthetic mesh. Special attention
and care must be paid at the time of mediastinal dissection to
avoid pleural injury or tear. Inadvertent pleural entry can be
treated by immediate closure or widening of the defect so as
to allow for equilibration of the two cavities. Pleural entry Monitor
rarely necessitates the placement of chest tube. Vagus nerve
injury can be avoided with early identification of the nerve
and careful dissection. Esophageal and gastric injury can be
minimized by using a Penrose drain around the esophagus
for retraction. Splenic injury can potentially be avoided by
avoiding forceful retraction of the upper short gastric ves-
sels. A medial-to-lateral approach while taking down the
upper short gastric arteries can help facilitate dissection off
the spleen with less tension. The fundoplication should feel
“floppy” to prevent too tight of fundoplication and subse-
quent dysphagia and gas bloat. A slipped wrap may be pre-
vented by placing gastropexy sutures securing the top of the
fundoplication to the lateral aspects of the esophagus and to
the left and the right crus. Additional sutures are placed as
necessary to the undersurface of the diaphragm to secure the
position of the fundoplication and prevent it from sliding. If
the patient has severe ineffective esophageal motility or
aperistalsis of the esophagus, a partial posterior 270-degree
fundoplication (Toupet) is performed instead of a 360-degree Fig. 18.1
fundoplication (Nissen).
(Fig. 18.2). Obtain pneumoperitoneum using a Veress nee-

Operative Technique dle followed by placement of a 12-mm optical trocar. By
placing this port close to the costal margin, closure is usu-
oom Setup, Trocar Placement, and Exposure
R ally not needed as the defect retracts above the costal mar-
of the Hiatus gin. Position a 5-mm camera port at 10–12 cm from the
costal margin in a line that is 2–3 cm to the left of the umbi-
Place the patient in the supine position with legs spread on a licus. Use a 30-degree angled laparoscope for adequate
split leg table secured with an anti-slip pad. Alternatively, a visualization deep in the mediastinum. Place an additional
modified lithotomy positioning with a beanbag can be used 5-mm port for the assistants’ right hand along the left ante-
or a supine position. Position the monitors at the head of the rior axillary line near the costal margin. Place a Nathanson
table with the primary monitor directly in the midline over liver retractor through a stab incision just to the left of mid-
the head of the operating table. The surgeon and assistant line high in the epigastrium. Alternatively, place a paddle
initially stand on either side of the patient for the initial entry retractor through a 5-mm or 12-mm port in the right upper
into the abdomen and port placement. Once the ports are in quadrant at the anterior axillary line (Fig. 18.3). Finally,
position, the surgeon then moves between the legs for the place a 5-mm working port in the right upper quadrant just
remainder of the operation. The assistant’s position is on the medial to the midclavicular line for the surgeon’s left hand.
patient’s left side (Fig. 18.1). Take care to avoid placing this port too close to the liver
Begin port placement with the left upper quadrant port, retractor as this can make it difficult to perform the right-
placed at the costal margin along the midclavicular line sided mediastinal dissection.
18 Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease 153
a b
Fig. 18.2
Dissecting the Hiatus vessels by releasing the spleen and prevents undo tension
when taking down the superior-most short gastric vessels,
We begin on the left side by first dividing the phrenogastric thus minimizing potential splenic injury. Then mobilize the
ligament to expose the posterior left crus (Fig. 18.4). This is gastric fundus by dividing the proximal short gastric vessels
done by gentle downward retraction of the gastric fat pad by and posterior attachments of the proximal stomach. Liberal
the surgeon and the fundus of the stomach by the assistant. mobilization of the greater curvature will help to minimize
This facilitates division of the superior-most short gastric tension on the subsequent fundoplication and may make pos-
Fig. 18.4
Fig. 18.3
Fig. 18.5
terior hiatal mobilization easier. Once the base of the left

crus is exposed, slight retraction of the stomach helps expose serve the artery by isolating and gently retracting it during
the phrenoesophageal ligament. Incise the phrenoesophageal dissection. Ultimately, the fundoplication will lie cephalad to
ligament at the base of the left crus with an energy device. the artery. Continue the previous right-sided division of the
Next divide the phrenoesophageal ligament anteriorly phrenoesophageal ligament from anterior to the base of the
beyond the 12 o’clock position and posteriorly beyond the 6 right crus to meet the left side dissection. Develop a “win-
o’clock position. If there is a hiatal hernia, take care to incise dow” posterior to the gastroesophageal junction by dissect-
all of the layers of the phrenoesophageal ligament to avoid ing the base of the right crus and proceeding under the
leaving sac behind and making hiatal dissection more esophagus to the previously exposed left crus. Place a
difficult. Penrose drain behind the esophagus and use it to provide
Next, divide the gastrohepatic ligament (Fig. 18.5) to caudal and lateral retraction during the mediastinal dissec-
expose the right crus. One must pay close attention as an tion. The Penrose drain may be sutured to itself in a loop or
accessory left hepatic artery may be present in the gastrohe- tied together with an end loop to provide a “handle” for
patic ligament (Fig. 18.6). If this is the case, take care to pre- retraction (Fig. 18.7).
accessory left hepatic artery
Fig. 18.8
Fig. 18.6
Fig. 18.9
Fig. 18.7
Closure of the Hiatus

Mobilizing the Esophagus
Close the hiatus posteriorly in an interrupted fashion, with
Identify the esophagus by its orientation, light pink to reddish- each successive suture progressing anteriorly from the poste-
pink color, longitudinal muscle striations, and overlying rior confluence of the left and right crus. Use the Penrose
vagus nerve. A lighted bougie, endoscope, or n asogastric tube drain to aid in retraction and exposure of the crus during the
may be passed and used to elevate and transilluminate the closure. Leave a small gap to avoid overtightening of the hia-
esophagus if it proves difficult to identify. tus, which may cause postoperative dysphagia (Fig. 18.10).
Normally, an extensive hiatal and mediastinal esopha- On rare occasions, anterior sutures may also be needed to
geal dissection is performed to ensure at least 3 cm of reapproximate the hiatus. When a large hiatal hernia is
length of intraabdominal esophagus. Perform this dissec- encountered, hiatal closure may be difficult due to tension. In
tion with a combination of blunt and energy dissection these cases, we perform a right-sided diaphragmatic relaxing
(Fig. 18.8). In patients with severe pulmonary diseases incision and reinforce the hiatal closure and cover the relax-
such as idiopathic pulmonary fibrosis or other pulmonary ing incision with a biologic or biosynthetic mesh.
issues, we try to minimize mediastinal dissection and only
mobilize the esophagus enough to position the gastro-
esophageal junction 3 cm below the hiatus (Fig. 18.9). Construction of the Fundoplication
While the goal is to always perform a tension-free fundo-
plication and deep mediastinal dissection it is also Place a stay suture at 3 cm below the GE junction and 2 cm
extremely important to minimize damage to mediastinal away from the greater curvature on the posterior aspect of
pleura and to keep the mediastinal portion of the operation the stomach (Fig. 18.11). This stitch will serve as a marker to
short in these patients. help identify the exact place in the posterior wall of the fun-
Fig. 18.12
Fig. 18.10
Fig. 18.13
injury to the anterior vagus. Typically, three interrupted

sutures are all that is needed to create the 3-cm-length fundo-
plication (Fig. 18.13).
As the fundoplication is completed, three coronal sutures
Fig. 18.11
are placed. First, suture the right side of the fundoplication to
dus that should come behind the GE junction and reach the the lateral esophagus and right crus. Similarly, on the left
right side of the esophagus. Using the marking suture, par- side suture the posterior aspect of the fundoplication to the
tially pass the fundus with the suture behind the posterior left crus and left lateral aspect of the esophagus. Additionally,
window behind the esophagus. Then from the right side, place a suture to the undersurface of the diaphragm to secure
identify the suture, and grasp and pull the fundus behind the the position of the fundoplication and prevent it from sliding.
esophagus. This should pass easily. Bring additional fundus The completed fundoplication should lie easily below the
over from the left side to meet the portion that had been diaphragm (Fig. 18.11). The suture line of the fundoplication
passed behind it. The ends of the wrap should meet easily lies at the 10 o’clock position (Fig. 18.14).
and feel floppy. Additionally, a “shoeshine” maneuver may In patients with aperistalsis or severe ineffective esopha-
be performed to ensure that the wrap is floppy. Place the first geal motility of the esophagus, we perform a partial posterior
gastro-gastric suture (Fig. 18.12). 270-degree fundoplication after closing the crura, rather than
Introduce a 52 French bougie and construct a 3 cm fundo- a full 360-degree fundoplication.
plication over the bougie. This is done by suturing the right Once the fundoplication is complete, perform esophago-
(posterior aspect of the fundus) and the left (anterior aspect gastroscopy to examine the esophagus and stomach and
of the fundus) gastric flaps together without suturing the thoroughly evaluate the fundoplication in terms of its shape,
wrap to the esophagus to prevent inadvertent trapping or position, and tightness (Fig. 18.15).
diet for 2 weeks, and then finally with resumption of a nor-

mal diet thereafter. The patient is followed up at 2–3 weeks,
and thereafter, follow-up is tailored to patient needs, includ-
ing continued nutritionist input.
Complications
• Herniation of viscera through the hiatal opening

• Early hiatal hernia recurrence
• Esophageal or gastric perforation
• Pleural injury or tear
• Pneumothorax
• Dysphagia
• Gas bloat
• Slipped wrap
• Vagus nerve injury
Esophagus
Wrap Further Reading
Fig. 18.14 Byrne JP, Smithers BM, Nathanson LK, Martin I, Ong HS, Gotley
DC. Symptomatic and functional outcome after laparoscopic reop-
eration for failed antireflux surgery. Br J Surg. 2005;92:996.
Crespin OM, Yates RB, Martin AV, et al. The use of crural relaxing inci-
sions with biologic mesh reinforcement during laparoscopic repair
of complex hiatal hernias. Surg Endosc. 2016;30(6):2179–85.
Draaisma WA, Rijnhart-de Jong HG, Broeders IA, Smout AJ, Furnee
EJ, Grooszen HG. Five-year subjective and objective results of
laparoscopic and conventional Nissen fundoplication: a randomized
trial. Ann Surg. 2006;244:34.
Hinojosa MW, Pellegrini CA. Surgical and endoscopic approaches to
GERD. In: Raghu Meyer KC, Raghu G, editors. Gastroesophageal
reflux and the lung. New York: Springer Science+Business Media;
2013. p. 249–66.
Horgan S, Pohl D, Bogett D, et al. Failed antireflux surgery, what have
we learned from reoperations? Arch Surg. 1999;134:809–17.
Morgenthal CB, Shane MD, Stival A, et al. The durability of laparo-
scopic Nissen fundoplication: 11 year outcomes. J Gastrointest
Surg. 2007;11:693.
Oelschlager BK, Quiroga E, Parra JD, et al. Long-term outcomes
after laparoscopic antireflux surgery. Am J Gastroenterol.
2008;103(2):280–7.
Fig. 18.15 Ohnmacht GA, Deschamps C, Cassivi SD, et al. Failed antireflux sur-
gery: results after reoperation. Ann Thorac Surg. 2006;81:2050.
Paulina TP, Salminen PT, Hiekkanan HI, et al. Comparison of long-
Postoperative Care term outcome of laparoscopic and conventional Nissen fundoplica-
tion: a prospective randomized study with an 11-year follow up.
Ann Surg. 2007;246:201.
Patients are started on liquids on postoperative day 0. A Schauer PR, Meyers WC, Eubanks S, et al. Mechanisms of gastric and
trained nutritionist evaluates each patient postoperatively esophageal perforations during laparoscopic fundoplication. Ann
and provides dietary guidance. If the patient is able to toler- Surg. 1996;223:43.
Varin O, Velstra B, De Sutter S, Ceelen W. Total versus partial fun-
ate liquids without issues they are discharged. Average hos- doplication in the treatment of gastroesophageal reflux disease: a
pital stay is 1–2 days. The patients are kept on a full liquid meta-analysis. Arch Surg. 2009;144:273.
diet for 2 weeks, followed by a pureed diet for 2 weeks, soft
Laparoscopic Magnetic Augmentation
of the Lower Esophageal Sphincter 19
James M. Tatum and John C. Lipham
Preoperative Preparation device must accomplish two objectives: (1) to reduce and
secure the lower esophageal sphincter into an intra-abdominal
• Indications: Gastroesophageal reflux disease is defined position and adequately approximate the diaphragmatic
by abnormal pH testing in patients who seek an alterna- crura and (2) to augment the strength of the anatomic LES by
tive to continuous acid suppression therapy for disease the dynamic external compression provided by the MSA
management. device. Initial descriptions of MSA surgery failed to ade-
quately emphasize the importance of accomplishing both
objectives to achieve a durable and efficacious antireflux
Pitfalls and Danger Points procedure.
We advocate complete hiatal dissection and obligatory
• Contraindications tightening of the diaphragmatic hiatus during surgery.
–– Titanium allergy After this is accomplished, attention is turned to appropri-
–– Body mass index (kg/m2) >35 ately placing the MSA device securely at the gastroesoph-
–– Esophageal or gastric varices ageal junction (GEJ) by dissecting a plane between the
–– Distal esophageal dysmotility posterior vagus nerve and the esophageal body, with care
• Esophageal injury taken to adequately dissect soft tissue from the anterior
• Violation of pleural peritoneum esophageal wall prior to placement of an appropriately
• Injury to the posterior vagus nerve sized MSA device. Diligent attention to these principles
• Failure to recognize and reduce hiatal hernia allows the MSA procedure to be an option for patients
• Failure to adequately tighten diaphragmatic crura with or without a hiatal hernia of any size. The MSA pro-
• Improper sizing of device vides a durable and safe alternative to fundoplication sur-
• Failure to adequately clear fat from anterior esophagus gery while maintaining the ability to vomit and pass gas
through the GEJ. It also provides the patient the benefits of
early discharge home.
Operative Strategy
The LINX device allows the surgeon to laparoscopically Documentation Basics

place a collar of small magnets around the lower esophageal
sphincter (LES). Appropriately sized and positioned, this • Document the identification and preservation of the pos-
collar of magnets prevents reflux while opening to allow terior vagus nerve.
bolus transport. After bolus transit, the magnets of the LINX • Description of hiatal dissection and closure.
reapproximate and restore competence to the LES. Antireflux • Details of sizing procedure and measurement of implanted
surgery using the magnetic sphincter augmentation (MSA) device.
J. M. Tatum · J. C. Lipham (*)

Department of Surgery, Keck School of Medicine, University of
e-mail: John.Lipham@med.usc.edu

https://doi.org/10.1007/978-3-030-81415-1_19
160 J. M. Tatum and J. C. Lipham
Operative Technique tal hernia and the tendency for MSA failure in the presence
of even a small unreduced hiatal hernia. Careful inspection
Room Setup and Trocar Placement of the hiatus is aided by gentle downward traction on the
body of the stomach with a large atraumatic retractor. Our
Place the patient in low lithotomy. Tuck both arms, place preferred instrument of dissection throughout the procedure
a Nissen strap around each leg, secure sequential com- is the harmonic scalpel.
pression devices, and place each leg into a padded lithot- Begin hiatal dissection by opening the pars flaccida.
omy stirrup. Keep the legs in a neutral position, at the hips The hepatic branch of the posterior vagus nerve is taken
(spread apart at an angle) to facilitate the surgeon operat- with impunity, a variation of our initial descriptions of the
ing between the patient’s legs. Place monitors at the head dissection where preservation of the hepatic branch of the
of the bed in clear line of sight of both surgeon and the nerve was advocated. If encountered, an accessory left
assistant. hepatic artery can be compressed to occlusion with an
We place an initial 5-mm optical insertion trocar without atraumatic grasper while the left lobe of the liver is
insufflation into a virgin abdomen, approximately 2 cm observed. Any change in perfusion mandates preservation
superior and 2 cm to the left of midline with a 0° scope. of the artery; otherwise when encountered it is ligated and
Patients with prior midline abdominal surgery or relevant divided. Open the peritoneum over the right crus, as near
history will have the initial trocar placed as deemed appro- the decussation of the right and left crura as possible, with
priate by the surgeon. In addition, the position of the initial cautery on scissors. Next, complete blunt and sharp dis-
trocar varies based on body habitus, with a more cephalad section of peritoneum and phrenoesophageal membrane
site necessary in patients with a higher BMI. Insufflate the in a clockwise fashion around the crura as far as easily
abdomen, exchange the 5-mm 0° laparoscope for a 5-mm achieved, usually to 1 o’clock. With the assistant retract-
30° viewing scope, and place the patient in steep reverse ing the stomach medially, dissect in the same fashion
Trendelenburg for the remainder of the procedure. Introduce from as low as possible on the left crura superiorly. With
an 8-mm trocar through the left upper quadrant, along the the stomach is then retracted laterally toward the patient’s
midclavicular line two fingerbreadths inferior to the costal left, careful dissection inferior to the esophagus is com-
margin. This 8-mm trocar facilitates the later introduction of pleted with the creation of a retroesophageal window.
the MSA device. Next, place a 5-mm trocar in the right upper Pass a Penrose drain through this window and secure it
quadrant at the midclavicular line 2 cm inferior to the costal around the esophagus, so that it can be grasped by the
margin. Introduce a Nathanson hook liver retractor through a assistant. Retraction on the Penrose facilitates exposure
trocar stab wound directly below and leftward enough of the and traction of the esophagus allowing completion of the
xiphoid to avoid the falciform ligament coursing along the hiatal dissection and resection of any hernia sack, if nec-
midline. Finally, place an additional 5-mm port approxi- essary. At least 3 cm of esophagus should be easily pulled
mately 5 cm caudal and 3 cm lateral to the 8-mm port for the into the abdomen. Continue the dissection of the intratho-
assistant. racic esophagus to facilitate adequate intra-abdominal
length. If necessary, consider a Collis gastroplasty; how-
ever, we have not found this necessary (Fig. 19.1).
Exposure of the Hiatus
Position the Nathanson retractor such that the left lobe of the
liver is retracted superiorly and laterally to provide clear
visualization of diaphragm medial to the liver, exposing the
adjacent right crura hiatus. This exposure is necessary to
allow hiatal dissection, paraesophageal hernia reduction, and
crura approximation as well as facilitating device
placement.
Dissecting the Hiatus
Complete dissection of the GEJ has become standard in our

practice given the poor sensitivity and reliability of video-
esophagography or endoscopy for the diagnosis of small hia-
Fig. 19.1
19 Laparoscopic Magnetic Augmentation of the Lower Esophageal Sphincter 161
A lipomatous collection of fat is frequently encountered tunnel, anterior the vagus nerve, and around the esophagus.
at the anterior GEJ, particularly in obese men, and should be This can be the same Penrose as previously used to encircle
completely dissected and removed at this stage. the esophagus during hiatal dissection and closure.
Closure of the Hiatus Sizing of the LINX Device
After reduction of any hiatal hernia and resection of the sack, Torax medical has a proprietary device which is necessary
approximate the right and left crura with 2 to 3 figure-of- for device sizing. The instrument consisted of a floppy pis-
eight 0-braided absorbable sutures to create a snug hiatal ton, tipped with a magnet, that extends from a hard-plastic
opening. The opening should only allow the easy passage of housing. Place the device along the course of the previously
a single blunt grasper through the hiatus. Alternatively, per- placed Penrose drain. The hard-plastic housing is fixed on a
form this closure with the aid of 48–60 Bougie in place (Fig. long tool that is inserted through the right upper abdominal
19.2). 5-mm trocar. The floppy magnet-tipped piston is extended
and wraps itself around the esophagus, loosely attaching by
means of magnetism to a metal band on the rigid plastic
I dentification and Dissection of the Posterior housing—making a loop (Fig. 19.4). To obtain the optimal
Nerve size, we utilize two visual cues. A ratchet torque device in
After the hiatal portion of the procedure, the posterior vagus

nerve must be identified as it courses from the posterior to
right side of the intra-abdominal esophagus. The vagus nerve
is white in appearance and might be mistaken for fat. The
nerve is taut and has a density and character like that of the
vas deferens. Once identified, select a site approximately
2 cm proximal to the GEJ and gently hook the nerve with a
Maryland grasper, pulling it away from the body of the
esophagus. Develop a passage between the nerve and the
esophageal body by gentle and precise dissection with the
closed scissors and closed Maryland (Fig. 19.3). The passage
between the vagus and esophageal body must only be large
enough for the grasper to easily fit through. Then, pass a
grasper between the posterior vagus nerve and the esophagus
from medial to lateral and through the retroesophageal tun-
nel. Pass a Penrose that is placed into the left grasper with the
surgeon’s right hand, and then retracted medially through the Fig. 19.3
Fig. 19.2 Fig. 19.4

162 J. M. Tatum and J. C. Lipham
the tool’s handle is gently retracted backward, tightening the Closure

sizing loop. The first visual cue is when the sizing loop rests
comfortably around the esophagus, without compression of Remove trocars under direct visualization as the abdomen is
the tissue. The second visual cue is obtained by continuing to desufflated with the aid of a Valsalva maneuver provided by
ratchet down the sizing loop until the magnets separate and the anesthesiologist. The fascia may be closed at the sur-
the sizing loop opens. Three sizes above this loop separation geon’s discretion. Port site skin incision is closed with sub-
measurement are usually the appropriate size and should cor- cuticular absorbable monofilament sutures and Tegaderm.
relate with the first visual cue—where the sizing loop rested No additional dressings are placed.
comfortably around the esophagus without compression.
The two sizing methods are then compared. If they do not
correlate, the larger size is utilized for device selection. A Postoperative Care
window on the devices handle indicates the size of the
esophagus throughout this process. Repeat the measuring The nasogastric tube is removed in the operating room if it
procedure twice to ensure correct measurement. was not removed after initial decompression of the stomach.
Patients who underwent repair of a large hiatal hernia are
admitted overnight. Other patients are routinely discharged
Placing and Securing the Linx Device home the day of surgery. All patients are instructed to
advance from clear to full liquid diet immediately postopera-
Remove the sizing device, leaving the Penrose drain. Then tively and regular diet as tolerated.
bring the MSA device into the abdomen through the 8-mm Immediate postoperative dysphagia is the most common
trocar. There is looped suture at each end of the device, side effect of MSA placement. Incidence and speed of reso-
allowing it to be grasped with the laparoscopic graspers. Pass lution are reduced in patients who can take multiple (6) small
the device i from lateral to medial around the esophagus in meals per day for the first month postoperatively. Persistent
the same fashion as the Penrose drain was initially placed. dysphagia often requires a short course of oral steroids, and
Leave the Penrose drain in place, ends free, during insertion the most persistent cases of dysphagia often resolve after 2–3
to aid in its passage through the retroesophageal tunnel. Then balloon dilations to 18 mm.
bring the free ends of the MSA device together, taking care
not to capture loose tissue between the two joining magnets.
Gentle agitation of the two magnets with a grasper will Postoperative Complications
prompt coupling which can be confirmed by observing the
magnetic junction for proper alignment as described by the • Displacement of MSA device into unreduced paraesopha-
manufacturer. Next, remove the Penrose drain and snip the geal hernia.
looped sutures free from the device (Fig. 19.5). • Erosion of MSA into esophagus.
• Dysphagia.
• Esophageal perforation.
Further Reading
Asti E, Siboni S, Lazzari V, Bonitta G, Sironi A, Bonavina L. Removal
of the magnetic sphincter augmentation device. Ann Surg.
2017;265:941.
Bonavina L, Saino G, Bona D, Sironi A, Lazzari V. One hundred con-
secutive patients treated with magnetic sphincter augmentation for
gastroesophageal reflux disease: 6 years of clinical experience from
a single Center. J Am Coll Surgeons. 2013;217:577.
Ganz RA, Peters JH, Horgan S, Bemelman WA, Dunst CM,
Edmundowicz SA, et al. Esophageal sphincter device for gastro-
esophageal reflux disease. N Engl J Med. 2013;368:719–27.
Ganz RA, Edmundowicz SA, Taiganides PA, Lipham JC, Smith CD,
DeVault KR, et al. Long-term outcomes of patients receiving a mag-
netic sphincter augmentation device for gastroesophageal reflux.
Fig. 19.5 Clin Gastroenterol Hepatolo. 2016;14:671.
19 Laparoscopic Magnetic Augmentation of the Lower Esophageal Sphincter 163
Louie BE, Farivar AS, Shultz D, Brennan C, Vallières E, Aye Smith CD, DeVault K, Buchanan M. Introduction of mechanical
RW. Short-term outcomes using magnetic sphincter augmentation sphincter augmentation for gastroesophageal reflux disease into
versus Nissen fundoplication for medically resistant gastroesopha- practice: early clinical outcomes and keys to successful adoption. J
geal reflux disease. Ann Thorac Surg. 2014;98:498. Am Coll Surgeons. 2014;218:776.
Reynolds JL, Zehetner J, Wu P, Shah S, Bildzukewicz N, Lipham Tatum JM, Samakar K, Bowdish ME, Mack WJ, Bildzukewicz N,
JC. Laparoscopic magnetic sphincter augmentation vs laparoscopic Lipham JL. Videoesophagography vs. Endoscopy for Prediction
Nissen fundoplication: a matched-pair analysis of 100 patients. J of Intraoperative Hiatal Hernia Size. Am Surg. [Accepted for
Am Coll Surgeons. 2015;221:123. Publication January 15, 2017].
Rona KA, Reynolds J, Schwameis K, Zehetner J, Samakar K, Oh P, Torax Medical. Linx for life: indications, safety and warnings. Torax
et al. Efficacy of magnetic sphincter augmentation in patients with Medical Corporation. http://www.linxforlife.com/abridged-
large hiatal hernias. Surg Endosc. 2016;31:2096. statement. Accessesd 9/20/2017.
Skubleny D, Switzer NJ, Dang J, Gill RS, Shi X, de Gara C, et al. Warren HF, Brown LM, Mihura M, Farivar AS, Aye RW, Louie
LINX® magnetic esophageal sphincter augmentation versus Nissen BE. Factors influencing the outcome of magnetic sphincter augmen-
fundoplication for gastroesophageal reflux disease: a systematic tation for chronic gastroesophageal reflux disease. Surg Endosc.
review and meta-analysis. Surg Endosc. 2016;31:3078. 2018;32(1):405–12.
Laparoscopic Paraesophageal Hernia
Repair 20
Nabeel R. Obeid and Aurora D. Pryor
Preoperative Preparation particularly if mucosal abnormalities are found on contrast

studies. pH monitoring study is usually unnecessary for larger
Begin with a thorough history and physical examination. hernias, as it is unlikely to change surgical management, but
Symptoms of paraesophageal hernia (PEH) may include could help with elucidating symptoms for smaller hernias.
dysphagia, regurgitation, early satiety, chest or epigastric Identify any major comorbidities and optimize these
abdominal pain, chronic cough, or shortness of breath. Many before elective repair. Most notably, a history of coronary
times, the patient has already undergone a preliminary artery disease, particularly with cardiac stents, heart failure,
workup for cardiopulmonary etiology, as it is common to arrhythmia, or change in angina symptoms or reduced exer-
misdiagnose the symptoms of PEH as that of angina. Physical cise tolerance, should prompt a formal cardiology evaluation
examination and laboratory analysis are usually unrevealing. for preoperative optimization. Many times, this will include
Some asymptomatic patients may be diagnosed on chest an electrocardiogram, echocardiogram, and/or stress testing
X-rays obtained for an unrelated problem. to determine the severity of disease and if any coronary inter-
Diagnostic workup includes an upper gastrointestinal vention is indicated. For patients with coronary stents on
series (UGIS) to evaluate the patient’s anatomy and to diag- dual antiplatelet therapy, it is now the authors’ routine prac-
nose the presence of a PEH (Fig. 20.1). Anatomic features tice for elective surgery to maintain the patient on aspirin
that should be noted include the location of the gastroesopha- 81 mg in the perioperative period to decrease the risk of in-
geal junction, the amount of stomach (and possibly small stent thrombosis while holding other agents, such as clopido-
bowel or colon) herniated into the thoracic cavity, shortening grel, until 24–48 hours after surgery, when the risk of
of the esophagus, and passage of oral contrast (or lack thereof postoperative hemorrhage has decreased substantially.
to suggest gastric volvulus). Many of these patients will Pulmonary complaints often accompany larger PEH. A
already have had a computed tomography (CT) scan when pulmonology evaluation may be deemed appropriate for
referred to the surgeon. CT can further characterize the her- patients with severe symptoms, or chronic obstructive pulmo-
nia. It allows for a greater appreciation of the extent of the nary disease, especially for patients on home O2 therapy, as
defect and herniated contents, including identifying the spe- well as poorly controlled asthma. Recent hospitalizations for
cific type of hiatal hernia (Table 20.1). Additional workup pulmonary exacerbations should also prompt an evaluation,
may also include esophageal manometry testing to assess for which may include spirometry testing and adjustment of med-
baseline dysmotility which will aid in performing the appro- ications. Given the post-prandial discomfort that many patients
priate surgical repair. Endoscopic evaluation is helpful to with PEH experience, it is not uncommon for these patients to
assess for esophagitis, Barrett’s esophagus, gastritis, ulcer- present with malnutrition and weight loss. This should be eval-
ation, and to rule out other pathologies such as a neoplasm, uated and, if severe, may require preoperative nutritional opti-
mization in the form of enteral or parenteral nutrition.
N. R. Obeid
Department of Surgery, University of Michigan Medical School,
Ann Arbor, MI, USA Pitfalls and Danger Points
e-mail: obeidn@med.umich.edu
A. D. Pryor (*) • Attempting to reduce the stomach and/or other contents
Department of Surgery, Stony Brook University School of without fully mobilizing the hiatus and dissecting the her-
Medicine, Stony Brook, NY, USA nia sac circumferentially, which can result in tissue injury
e-mail: aurora.pryor@stonybrookmedicine.edu

https://doi.org/10.1007/978-3-030-81415-1_20
166 N. R. Obeid and A. D. Pryor
d ifferent portions of the stomach (failure to perform con-

firmatory maneuvers such as the “shoeshine” test)
• Performing a fundoplication that is too tight, resulting in
early postoperative dysphagia
• Performing a fundoplication that is too loose, resulting in
slippage of the wrap
• Placing the fundoplication on the proximal stomach
instead of on the distal esophagus
Documentation
It is important to describe in great detail the size and shape

of the hiatal defect, as well as to list all organs that are her-
niated into the mediastinum. The surgeon should specifi-
cally state that the sac was fully dissected and reduced, and
Fig. 20.1 comment on the extent of mediastinal dissection and esoph-
ageal mobilization. The operative report should also spec-
Table 20.1 Classification of hiatal hernias ify the identification and preservation of both vagus nerves.
Type Description
The final length of intra-abdominal esophagus should be
I Sliding hiatal hernia, migration of the GEJ above the stated. If the length is inadequate despite maneuvers,
level of diaphragm describe the esophageal lengthening procedure performed
II True PEH, GEJ remains in the normal anatomic position (most commonly a transabdominal Collis gastroplasty, i.e.,
with herniation of gastric fundus wedge fundectomy), including the staple type and height
III Combination of type I and II used. If the hiatal closure is difficult, the addition of and
IV Herniation of another abdominal organ along with the
location of any relaxing incisions should be documented. If
stomach
mesh is used for reinforcement of the hiatal closure or
GEJ, gastroesophageal junction; PEH, paraesophageal hernia
bridging a relaxing incision, this should be noted, including
the type of mesh, relationship to the esophagus, and method
• Stripping the peritoneum from muscle fibers of the crura of fixation. For the fundoplication, the surgeon should spe-
adjacent to the hiatus, making the crural repair less sturdy, cifically state the size of bougie used for calibration, if
and placing the patient at potentially higher risk for applicable. Any maneuvers carried out to ensure proper
recurrence fundoplication technique (stand-alone or shoeshine tests)
• Inadequate or incomplete identification of the vagus nerves should be stated. Finally, if intraoperative endoscopy is per-
• Unrecognized pleural violation with resultant formed, the findings should be described.
pneumothorax
• Inadvertent ligation of a replaced or accessory left hepatic
artery in the gastrohepatic ligament Operative Strategy
• Incomplete mediastinal dissection and esophageal mobi-
lization leading to inadequate length of intra-abdominal Reduction/Dissection
esophagus
• Failure to recognize and manage a short esophagus that The key to successful repair of a paraesophageal hernia is the
can lead to wrap herniation or recurrence complete dissection and reduction of the hernia sac out of the
• Performing a primary crural repair under excessive ten- mediastinum. The minimally invasive approach provides a
sion, raising the risk for failure of the repair (consider the clear view, with magnification and excellent exposure of the
use of a relaxing incision or mesh in this circumstance) mediastinal structures. The hernia sac must be separated
• Performing an anterior crural repair that causes kinking of from the crura circumferentially in the proper avascular
the esophagus plane, on the medial edge of the crura. Once this is done, the
• Placing synthetic mesh that abuts the esophagus, which sac is grasped and retracted inferiorly to provide tension in
has a higher risk of erosion or chronic stricture order to facilitate the esophageal mobilization. Reducing the
• Twisting or improper orientation of the fundoplication sac is the safest way to reduce the stomach itself. This dissec-
(short gastrics should line the outer edges with the ante- tion is complete when the esophagus is mobilized to provide
rior stomach against the posterior esophagus) or wrapping 2–3 cm of intra-abdominal length and when the hiatus is free
20 Laparoscopic Paraesophageal Hernia Repair 167
of any attachments. The vagus nerves must be identified and at the conclusion of the procedure, assess the integrity of
preserved during this step. the fundoplication.
Diaphragmatic Repair Operative Technique
With the hiatus fully dissected and esophagus mobilized, the Place the patient in supine position on the operating room table,
hiatal hernia repair can begin. This is typically performed place sequential compression devices on the lower extremities,
posteriorly, beginning at the base of the crura. Approximation and abduct the upper extremities at 90 degrees. Use a footboard
of the crura can be done with interrupted sutures in a simple, to stabilize the patient for steep reverse Trendelenburg position-
figure-of-eight, or mattress configuration, with or without ing. Foley catheterization is not routinely performed.
pledgets. The repair continues until there is no longer a gap Gain access into the peritoneal cavity with a Veress needle
in the hiatus, with the esophagus abutting the diaphragm cir- technique in the left upper quadrant, and insufflate the abdo-
cumferentially and readily accommodating a blunt-tip men with carbon dioxide gas to a pressure of 15 mmHg.
grasper. Mesh reinforcement or relaxing incisions may be Once the abdomen is insufflated, we use a 5-mm optical tro-
performed on occasion, depending on the adequacy of pri- car with a 5-mm/30-degree laparoscope that is used to gain
mary repair. If mesh is used, it should not abut nor encircle entry. Final port configuration includes a 5 mm left upper
the esophagus. quadrant, 5 mm paramedian, 12 mm right mid-clavicular
line, 5 mm right upper quadrant, and 5 mm right anterior
axillary line trocar, which is used for the liver retractor.
Reconstruction Position the patient in steep reverse Trendelenburg in order
to maximize the exposure to the upper abdomen. The operat-
The final phase of the repair is reconstruction with a fundo- ing surgeon stands on the patient’s right side, with the assis-
plication. Depending on the patient’s symptoms and workup, tant, who also operates the camera, on the patient’s left side.
this is either a complete (Nissen) or partial (usually Toupet) We begin with reduction of any additional organs back
fundoplication. The short gastric vessels are usually stretched into the peritoneal cavity, followed by division of the short
out by the hernia and divided easily during hernia mobiliza- gastric vessels along the greater curvature of the fundus,
tion, thus avoiding unwanted tension. The posterior, proxi- working proximally toward the hiatus. Divide the hernia sac
mal fundus is identified, grasped, and brought back through and expose the crural muscles on the central edge of the hia-
the retroesophageal window, maintaining proper orientation. tus. As the dissection approaches the base of the left crus, put
The fundoplication is sutured into place on the distal esopha- traction on the hernia sac, not the stomach. It is important to
gus, approximately 2 cm in length. A gastropexy suture is be in the correct plane during the dissection of the sac to
placed from the posterior portion of the fundoplication to the avoid bleeding and damage to mediastinal structures as well
cruroplasty at the hiatus. If the fundus has remodeled over as to maintain the integrity of the crura. This dissection is
time, however, a standard wrap may not be possible, and carried out circumferentially from left to right moving ante-
alternatives, such as Dor fundoplication or less formal partial riorly. Complete the dissection from an approach on the
fundoplication, should be employed. patient’s right side, beginning with division of the transpar-
ent portion of the gastrohepatic ligament and dividing the
tissues toward the diaphragm. Take care to recognize and
Avoiding Postoperative Complications preserve any accessory or replaced left hepatic artery.
There are typically an anterior and a posterior portion of the
• Dysphagia: For patients with an element of dysmotility hernia sac. These usually intersect at the 10 o’clock and 5
on preoperative testing, a partial wrap should be per- o’clock positions on the hiatus. An awareness of this anatomy
formed to decrease the risk of dysphagia. facilitates dissection. Identify the base of the right crus, and
• Delayed gastric emptying: Identification and preservation complete the hiatal dissection in the avascular plane by joining
of both vagus nerves are crucial. with the dissection of the sac performed previously. The authors
• Pneumothorax: During mediastinal dissection and esoph- generally do not excise the hernia sac, unless it is felt that the
ageal mobilization, one must take care to identify the excess tissue is obscuring or preventing an appropriate repair.
pleural lining and avoid violation. At this time, extend the dissection into the mediastinum to
• Performing an endoscopy intraoperatively can clarify mobilize the esophagus. This is done with a combination of
anatomy, ensure proper location of the gastroesophageal blunt dissection and electrosurgery, taking care to avoid ther-
junction to confirm adequate intra-abdominal length, and, mal injury to the esophagus. Carefully identify and preserve
the vagus nerves. They typically run parallel to the esopha- there is tension. The sutures should be placed catching vari-
gus, but their path may be altered with significant shifting of able muscle fibers to distribute the forces of closure. Rarely,
mediastinal structures with larger hernias. This dissection an anterior suture may be placed for a wide anterior compo-
continues superiorly in the mediastinum, as well as circum- nent to the hiatus. At the conclusion of the repair, the esopha-
ferentially, until at least 2.5–3 cm of intra-abdominal esophagus should be loosely abutting the diaphragmatic tissues
geal length, without tension, is achieved. This maneuver is circumferentially. It should be possible to gently slide the
best performed with the assistant’s grasper retracting the closed tip of a blunt grasper between esophagus and hiatus.
esophagus anterolaterally against the left crus in order to If the crural tissues are attenuated, consider mesh reinforce-
expose the mediastinum (Fig. 20.2). If, despite these efforts, ment, placed so as not to abut the esophagus. If the closure
there is inadequate intra-abdominal length, the surgeon can cannot be completed without significant tension, consider
perform an esophageal lengthening procedure. The authors’ using a relaxing incision, typically on the right, but alterna-
preference is for a transabdominal Collis gastroplasty (wedge tively on the left. Bridge the relaxing incision with perma-
fundectomy) using a 60 mm linear stapler (3.5 mm staple nent mesh. Relaxing incisions should leave around a
height or purple cartridge) to perform the initial, oblique centimeter of tissue that can support both the crural closure
staple fire, followed by another 60 mm linear staple fire and the mesh. The incision should parallel the hiatus and
beginning from this point and extending superiorly toward may only need to be partially through the diaphragm to pro-
the gastroesophageal junction against a 56 Fr bougie. vide adequate mobility. The right crus is preferred as liver
The retroesophageal window should now be clearly dis- will abut the repair in this area, and there is less vascularity
sected and the base of both crura visible. Reapproximate the and innervation.
hiatus posteriorly with interrupted 0 nonabsorbable suture Based on preoperative manometry results, patients with
(Fig. 20.3). Figure-of-eight or mattress sutures can help if intact motility will undergo a Nissen fundoplication, while
those with any element of dysmotility are likely to have a
Toupet fundoplication. . Pass the left-hand grasper of the
operating surgeon through the retroesophageal window and
visualize the tip in the left upper quadrant, avoiding inadver-
tent injury to the spleen. The assistant grasps the greater cur-
vature at the proximal fundus and retracts slightly medially
in order to expose the posterior wall of the stomach, which is
grasped by the surgeon’s left-hand grasper and pulled back
through the retroesophageal window to the right of the
esophagus. In the correct configuration, the posterior wall of
the fundus should be against the esophagus, with the short
gastric vessel stumps marking the outer border of the wrap.
Several maneuvers are performed at this time to ensure
proper fundoplication configuration. The first is the stand-
alone test, where the surgeon’s left hand is removed from
grasping the fundus that was pulled through in order to dem-
Fig. 20.2
onstrate that this stomach will not retract back toward the left
side. Then, the two edges of the fundoplication should be
grasped by the surgeon’s two graspers, and an attempt should
be made to reach these edges toward the abdominal wall to
demonstrate laxity, and the ability to wrap around the esoph-
agus without tension. The final maneuver is the shoeshine
test, where the two edges of the fundoplication are moved
back and forth in synchrony to demonstrate that they are part
of the same portion of fundus being used for the wrap and to
confirm that the esophagus is being wrapped (Fig. 20.4).
Perform the fundoplication with 2-0 nonabsorbable
sutures. A 54 to 60 French bougie may be used. For a Nissen
fundoplication, the sutures are placed through stomach on
one side, through the anterior wall of the esophagus (avoid-
ing the anterior vagus nerve), and through the contralateral
Fig. 20.3 stomach before being tied. This is performed two more
Fig. 20.4 Fig. 20.6
Postoperative Care
Patients are recovered in the post-anesthesia care unit in the

immediate postoperative period. An aggressive anti-emetic
regimen is paramount to avoid nausea and retching, which
may disrupt the repair. Ondansetron and metoclopramide
are used routinely in a scheduled, alternating fashion in the
authors’ practice. Patients are observed in a regular floor
bed with telemetry and started on a full liquid diet.
Postoperative pain is controlled with acetaminophen and
ibuprofen, with narcotic medication for breakthrough pain.
Early ambulation is encouraged, along with incentive spi-
rometry. Home medications, including proton pump inhibi-
Fig. 20.5 tors (PPIs), are restarted on the first postoperative day. The
patient is discharged once tolerating the full liquid diet,
times, approximately 1 cm above and 1 cm below the middle ambulating, voiding spontaneously, and pain controlled,
suture, for a total fundoplication length of 2 cm. The inferior which is generally within 24 hours of surgery, often on the
suture is stomach to stomach only. For a Toupet fundoplica- night of surgery. Dietary counseling is crucial, and a list of
tion, the edges of the fundoplication are sutured to the sides approved and non-approved items is given to the patient
of the esophagus using a 2-0 nonabsorbable suture, leaving a upon discharge, with instructions to self-advance the diet as
strip of unwrapped esophagus (partial fundoplication/wrap). tolerated to soft foods over the course of the subsequent
The most proximal sutures incorporate the diaphragm 3 days. Patients are seen in 2–3 weeks in the outpatient set-
(Fig. 20.5). In the final step, a gastropexy is performed, ting for their first postoperative visit, at which time symp-
where the posterior aspect of the fundoplication is sutured to toms are re-evaluated, wounds are examined, pathology
the hiatal closure using a 2-0 nonabsorbable suture. The final reviewed (if applicable), and dietary choices are reinforced.
configuration for a Toupet fundoplication is shown in PPIs are stopped at this time.
Fig. 20.6.
Intraoperative endoscopy is routinely performed to evalu-
ate the final configuration of the complete or partial fundo- Complications
plication. Upper endoscopy may also be deployed if there is
difficulty in identifying certain anatomic landmarks, such as The overall morbidity after laparoscopic paraesophageal
the gastroesophageal junction to ensure adequate intra- hernia repair is low with excellent long-term results.
abdominal esophageal length. Generally, complications following paraesophageal hernia
Withdraw the trocars in the usual fashion, and close the repair can be divided into short- and long-term
fascia for trocars greater than 10 mm. complications.
Short-Term Complications Long-Term Complications
Bleeding Dysphagia
Early postoperative hemorrhage is likely due to bleeding Postoperative dysphagia is not uncommon but generally
from short gastric arteries at the splenic hilum. This can be improves over the course of the first few months. For patients
due to incomplete hemostasis during mobilization of the with persistent or new-onset dysphagia, further workup is
greater curvature of the stomach. Iatrogenic splenic injury, required. An UGIS is useful to evaluate for any obstruction.
most commonly capsular tear, can also result in significant This could be due to a stricture (from devascularization or
hemorrhage. While not common, early postoperative bleed- from inflammatory adhesions related to mesh placement), a
ing causing hemodynamic instability or a transfusion fundoplication that is too tight, or a recurrence of the hiatal
requirement is an indication for re-exploration and control of hernia.
hemorrhage.
Recurrence
Abscesses A distinction must be made between radiographic and symp-
Intra-abdominal sepsis is unusual after minimally invasive tomatic recurrence of a paraesophageal hernia. The former is
paraesophageal hernia repair. The most likely etiology would not infrequent over long-term follow-up, while the latter is
be an inadvertent gastrostomy or esophagectomy from trau- much less common. Recurrence is multifactorial, with risk
matic handling of tissue, resulting in spillage of luminal con- factors such as a large hiatal hernia, attenuated crura, hiatal
tents and subsequent abscess formation. This can generally repair with tension, shortened esophagus, incomplete esoph-
be treated with antibiotics and percutaneous drainage. ageal mobilization, and uncontrolled retching or vomiting.
Instability or persistent leakage could require re-exploration Recurrence can also occur due to wrap dehiscence, leading
or stenting. to a lack of intra-abdominal bolster and re-herniation.
Pneumothorax Gastroparesis
Pleural violation during mediastinal dissection may result in Delayed gastric emptying may present with post-prandial
a pneumothorax. This complication varies in the degree of nausea, intolerance of oral intake, or bloating. Other diagno-
clinical significance, especially since the insufflation gas is ses should be entertained, such as symptomatic cholelithia-
carbon dioxide, which is readily reabsorbed. Generally, an sis. If initial workup is negative, a gastric emptying scan is
asymptomatic patient can be managed expectantly. useful to evaluate for gastroparesis. This scenario is likely
Intraoperatively, a red-rubber catheter can be used through a related to irritation or injury to the vagus nerve(s) during
trocar to decompress the chest at the time of hiatal closure. esophageal mobilization and excision of the hernia sac.
This is combined with a large breath and intraoperative Delayed gastric emptying, once diagnosed, is initially treated
removal. However, if there are signs of postoperative hypo- with pro-motility agents, such as metoclopramide or erythro-
tension or respiratory distress, a chest X-ray may be per- mycin. If such measures are ineffective, a pyloroplasty may
formed to evaluate for a pneumothorax and, if present in a be performed to promote more rapid drainage.
symptomatic patient, may require a thoracostomy tube for
decompression.
Further Reading
Cardiac Arrhythmias
It is not uncommon for a patient to experience transient Alicuben ET, Worrell SG, DeMeester SR. Impact of crural relaxing
incisions, Collis gastroplasty, and non-cross-linked human dermal
arrhythmia in the acute postoperative period, most com- mesh crural reinforcement on early hiatal hernia recurrence rates. J
monly atrial fibrillation. This is likely due to the manipula- Am Coll Surg. 2014;219:988–92.
tion in the mediastinum and electrolyte imbalance. Telemetry Andolfi C, Plana A, Furno S, Fisichella PM. Paraesophageal hernia and
is often employed for the first 12–24 hours in order to moni- reflux prevention: is one fundoplication better than the other? World
J Surg. 2017;41(10):2573–82.
tor for such arrhythmias. Management consists of fluid Antoniou SA, Pointner R, Granderath FA, Köckerling F. The use of bio-
resuscitation or diuresis, depending on fluid status, electro- logical meshes in diaphragmatic defects - an evidence-based review
lyte repletion, and the use of beta-blockers or anti-arrhythmic of the literature. Front Surg. 2015;2:56.
agents. Cohn TD, Soper NJ. Paraesophageal hernia repair: techniques for suc-
cess. J Laparoendosc Adv Surg Tech A. 2017;27:19–23.
Cole W, Zagorski S. Intramural gastric abscess following laparo- esophageal hiatal hernias—is a fundoplication needed? A random-
scopic paraesophageal hernia repair. Endoscopy. 2015;47(Suppl 1 ized controlled pilot trial. J Am Coll Surg. 2015;221:602–10.
UCTN):E227-8. Müller-Stich BP, Kenngott HG, Gondan M, Stock C, Linke GR, Fritz
Crespin OM, Yates RB, Martin AV, Pellegrini CA, Oelschlager BK. The F, Nickel F, Diener MK, Gutt CN, Wente M, Büchler MW, Fischer
use of crural relaxing incisions with biologic mesh reinforcement L. Use of mesh in laparoscopic paraesophageal hernia repair: a meta-
during laparoscopic repair of complex hiatal hernias. Surg Endosc. analysis and risk-benefit analysis. PLoS One. 2015;10:e0139547.
2016;30:2179–85. Mungo B, Molena D, Stem M, Feinberg RL, Lidor AO. Thirty-day
El Khoury R, Ramirez M, Hungness ES, Soper NJ, Patti MG. Symptom outcomes of paraesophageal hernia repair using the NSQIP data-
relief after laparoscopic paraesophageal hernia repair without mesh. base: should laparoscopy be the standard of care? J Am Coll Surg.
J Gastrointest Surg. 2015;19:1938–42. 2014;219:229–36.
Jones R, Simorov A, Lomelin D, Tadaki C, Oleynikov D. Long-term Oleynikov D, Jolley JM. Paraesophageal hernia. Surg Clin North Am.
outcomes of radiologic recurrence after paraesophageal hernia 2015;95:555–65.
repair with mesh. Surg Endosc. 2015;29:425–30. Reynolds JL, Zehetner J, Bildzukewicz N, Katkhouda N, Lipham JC. A
Lebenthal A, Waterford SD, Fisichella PM. Treatment and controver- durable laparoscopic technique for the repair of large paraesopha-
sies in paraesophageal hernia repair. Front Surg. 2015;2:13. geal hernias. Am Surg. 2016;82:911–5.
Lidor AO, Steele KE, Stem M, Fleming RM, Schweitzer MA, Marohn Schlottmann F, Strassle PD, Farrell TM, Patti MG. Minimally invasive
MR. Long-term quality of life and risk factors for recurrence surgery should be the standard of care for paraesophageal hernia
after laparoscopic repair of paraesophageal hernia. JAMA Surg. repair. J Gastrointest Surg. 2017;21:778–84.
2015;150:424–31. Schlottmann F, Strassle PD, Patti MG. Laparoscopic paraesophageal
Müller-Stich BP, Achtstätter V, Diener MK, Gondan M, Warschkow R, hernia repair: utilization rates of mesh in the USA and short-term
Marra F, Zerz A, Gutt CN, Büchler MW, Linke GR. Repair of para- outcome analysis. J Gastrointest Surg. 2017;21(10):1571–6.
Laparoscopic Collis Gastroplasty
21
Mohan K. Mallipeddi and Miguel A. Burch
• All patients require medical clearance prior to surgery,

Indications and prior operative notes should be obtained for any revi-
sional surgery.
• This procedure is a useful adjunct to hiatal hernia repair
with fundoplication, applied in cases where the esopha-
gus is too short to reach comfortably below the dia- Pitfalls and Danger Points
phragm. The primary indication is to reduce axial tension
when maximal mediastinal esophageal mobilization is • Major technical risks include (1) esophageal perforation,
insufficient. (2) an overly narrow or wide Collis segment, (3) fundopli-
• In children, the gastroplasty can be used to facilitate cation placed too high or low on the esophagus or gastric
reconstruction in esophageal atresia. tube, (4) leak, (5) hemorrhage secondary to injuring an
accessory/replaced left hepatic artery, inferior phrenic
artery, branches of the left gastric artery, short gastric ves-
Preoperative Preparation sels, aorta, inferior vena cava, and inferior pulmonary
vein, (6) laceration of the spleen or liver, and (7) inadver-
• Most patients will require, at minimum, an upper GI content vagotomy.
trast series for dynamic characterization of esophageal –– The surgeon must understand the expected locations
and gastric anatomy and function, manometry to deter- and anatomic relationships of these various hazards.
mine the fundoplication most likely to be tolerated, and Most vascular structures are to be avoided, but the
endoscopy to identify mucosal lesions and facilitate short gastric vessels must be divided using an appro-
biopsy. priate ligating device. Care should be taken when dis-
–– In addition to workup for reflux, patients should be secting and dividing the sack off the gastroesophageal
evaluated for dysphagia, delayed gastric emptying, fat pad as the anterior vagus nerve is often encountered
and foregut cancer as these will alter management. here.
–– Ulcerative esophagitis should be medically treated for • Inadequate visualization, exposure, or experience may
3–6 weeks and then reevaluated with endoscopy. necessitate conversion to open surgery.
Ameliorating esophagitis to at least Los Angeles • The surgeon should convey the risk of aspiration during
Classification (LA) grade A or B prior to surgery will intubation to the anesthesiologist.
facilitate periesophageal dissection.
–– The most reliable predictor of a short esophagus (i.e.,
<2 cm intraabdominal length) requiring gastroplasty is Documentation
a stricture. Other predictors reported in the literature
are the presence of a type III hiatal hernia or a hernia • Document the extent of mediastinal dissection either in
>5 cm. terms of distance (e.g., 6–10 cm) or landmarks (e.g., to
the inferior pulmonary vein); also, include the fate of the
hernia sack (e.g., divided and sent to pathology); finally,
M. K. Mallipeddi (*) · M. A. Burch account for the vagi (e.g., both vagal trunks were seen and
Department of Surgery, Cedars-Sinai Medical Center, preserved).
e-mail: mohan.mallipeddi@cshs.org

https://doi.org/10.1007/978-3-030-81415-1_21
174 M. K. Mallipeddi and M. A. Burch
• Document the intraabdominal length of native esophagus completion of esophagogastroscopy, the endoscope should
(e.g., 1 cm) as well as the combined length with the Collis pass through the fundoplication with minimal resistance and
segment (e.g., 3 cm). without twists or turns. In retroflexion, the fundoplication
• Document the bougie type and size used (e.g., 56 Fr should create a nipple valve adherent to the endoscope.
tapered tip).
• Document the distance between the crura and the way
they are reapproximated (i.e., use of mesh, pledgets, and Operative Technique
relaxing incision).
• Document that the fundus is wrapped around the neo- The abdomen can be accessed by the surgeon’s preferred
esophagus without tension (standalone test), and the method, including the Veress needle, Hasson technique, or
orientation of the fundoplication with the Collis staple optical trocar. Take care with the final port placement as
line directed inferiorly. these must allow adequate access to the hiatus and mediasti-
num for dissection, hiatal hernia repair, and fundoplication
as well as the gastroplasty (Fig. 21.1). A 12 mm port in the
Operative Strategy midclavicular line of the right upper quadrant is optimal for
stapler insertion. A Nathanson liver retractor positioned from
Originally described by JL Collis in 1957 for “hiatus hernia the subxiphoid region will be out of the way and easy to
with short esophagus,” the original Collis gastroplasty was adjust. Exposure is greatly enhanced by placing the patient
done through a thoracotomy incision. The laparoscopic mod- in steep reverse Trendelenburg.
ification described here allows the stomach to be used to Sharply enter the pars flaccida adjacent to the caudate
lengthen the esophagus in a similar manner, but the opera- lobe of the liver and identify a thin white peritoneal line
tion is done through the abdomen under laparoscopic along the internal aspect of the right crus. Much like the
guidance. white Line of Toldt, this white line should serve as the dis-
The split leg and low lithotomy positions allow the sur- section margin for the hiatus. With large hernias, this line
geon to operate comfortably in line with the anatomy and
leave room for the assistant on either side of the patient. The
operation can also be done with the patient supine and arms
abducted. The hiatus is exposed and the distal esophagus and
proximal stomach are dissected in the usual fashion. The
intraabdominal esophagus is then measured, and Collis gas-
troplasty is considered if it is less than 2 cm.
The short gastric vessels are divided. A 56 French bougie
is passed into the esophagus. A segment of greater curvature
is removed by firing an articulating stapler perpendicular to
the bougie, and then parallel to the bougie. This creates a
tubular segment of stomach that serves as a neoesophagus
and effectively produces a greater intraabdominal length.
There are four tenets of a good operation. Maximal
Dissection: The esophagus should be circumferentially dis- Liver retractor
sected to the inferior pulmonary vein or as high as safely 5
5
possible. Hernia Sack Resection: The sack must be reduced 12
10
entirely from the mediastinum; this includes medial mobili-
zation of the epiphrenic fat pad to visualize the gastroesoph-
ageal junction. The sack should be excised to mitigate the
risk of recoil and symptomatic seroma formation. Crural
Closure: If a tension-free primary closure with interrupted,
nonabsorbable suture cannot be accomplished, adjuncts
(e.g., a relaxing incision followed by onlay of mesh over the
reapproximated hiatus and incision) should be utilized.
Appropriate Fundoplication: The fundoplication, whether
partial or complete, must encompass the neoesophagus,
rather than sit below it, to avoid creating a gastric reservoir
that can dilate and cause dysphagia and esophagitis. On Fig. 21.1
21 Laparoscopic Collis Gastroplasty 175
may not be appreciable until the sack is reduced into the cephalad parallel to the bougie toward the angle of His to
abdomen. Sharply enter and develop this plane of mostly excise a narrow wedge of fundus (Fig. 21.3a–b). Perform a
avascular areolar tissue “up and around” the hiatus using a leak test.
combination of blunt and sharp dissection (e.g., with an Once the gastroplasty is completed, approximate the
ultrasonic dissector) – the occasional bridging vessel will crura posterior to the esophagus with the bougie in place.
need to be sealed and divided. To complete the left-sided dis- When separated by less than 5 cm, primary closure with
section, divide the short gastric vessels along the proximal nonabsorbable suture has excellent results. For larger
portion of the greater curvature. Identify and preserve both gaps, there are data to suggest that absorbable mesh rein-
of the vagal trunks. If the pleura is violated during the dissec- forcement mitigates the risk of recurrence. However,
tion, nothing is required unless sufficient CO2 is insufflated mesh should never be used to merely span the gap; rather,
to produce signs of a tension capnothorax, in which case a for large gaps make a relaxing incision in the tendinous
chest tube should be inserted. Continue to further reduce the portion of the diaphragm between the right crus and infe-
hernia sack and contents into the abdomen as the dissection rior vena cava to allow the crura to be approximated.
progresses. Finally, divide the hernia sack at the level of the Then, cover/reinforce the hiatus and relaxing incision
gastroesophageal fat pad. with the mesh.
Once maximal hiatal and mediastinal dissection have Lastly, perform a complete or partial posterior fundopli-
been completed, measure and note the length of tension-free cation. Pay special attention to the fundal staple line and
intraabdominal esophagus (i.e., distance from hiatus to gas- relative position of the neoesophagus. Pass the staple line
troesophageal junction [GEJ]). If this measurement is less posterior to the neoesophagus and orient it inferiorly
than 2 cm, a neoesophagus (created by the gastroplasty) (Fig. 21.4). Secure the fundoplication with permanent suture
must make up for the difference. The position of the GEJ can as high as possible on the neoesophagus. The fundoplication
be ascertained with concurrent use of endoscopic transillu- is otherwise executed as in routine cases (see Chap. 18).
mination and laparoscopy. Mark the point along the lesser
gastric curvature at which there is at least 3 cm of intraab-
dominal (neo)esophagus with a clip. Then, pass a 56 Fr bou- Postoperative Care
gie into the stomach to avoid encroaching onto the GEJ and
esophagus during the gastroplasty. • Routine use of a nasogastric tube for decompression is
There are numerous reported methods for performing a not required; however, vomiting and retching must be pre-
Collis gastroplasty. Our preferred method is a variant of the empted or aggressively treated. One option is to schedule
wedge technique. An articulating linear stapler (1.5–2.0 mm around-the-clock antiemetics (e.g., ondansetron) and rap-
staple height) is first fired perpendicular to the greater curva- idly wean off intravenous narcotics.
ture, 2–2.5 cm lateral to the GEJ, and starting along the bou- • For uncomplicated cases, postoperative antibiotics are not
gie at the level of the previously placed clip. This seemingly required.
backwards fire is accomplished by folding the greater curva- • An upper GI series with water-soluble contrast should be
ture into the stapler. This staple line may require additional obtained before discharge to characterize the gastroplasty
fires to reach the mark (Fig. 21.2a–b). Then, fire the stapler and fundoplication as a baseline for later comparison.
a b
Fig. 21.2
176 M. K. Mallipeddi and M. A. Burch
a b
Fig. 21.3
not promptly recognized and treated. Small, contained

leaks can be managed with stenting, antibiotics, and
drainage, whereas free perforation often necessitates
reoperation.
• As noted above, if the neoesophagus is trapped above the
fundoplication, it will dilate and cause dysphagia; even
the small amount of acid it secretes can cause esophagitis.
In such patients, proton pump inhibitor therapy may pro-
vide sufficient relief, but surgical repositioning of the fun-
doplication is necessary for severe or refractory symptoms.
Additionally, dysphagia may signal whether the Collis
segment is overly narrow or wide. If it is too narrow, treat-
ment entails a myotomy. If it is too wide, treatment entails
Fig. 21.4 revision of the gastroplasty.
• A liquid diet should be started on the ward and advanced

to a soft, then regular, diet over the span of 1–2 weeks on
an outpatient basis. Patients can be discharged once they Further Reading
can tolerate a full liquid diet.
Collis JL. An operation for hiatus hernia with short oesophagus.
Thorax. 1957;12(3):181–8.
Gastal OL, et al. Short esophagus: analysis of predictors and clinical
Complications implications. Arch Surg. 1999;134(6):633–6. discussion 637–8
Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: patho-
• Hiatal hernia repair and fundoplication can be compli- physiology, incidence, presentation, and treatment in the era of lapa-
roscopic antireflux surgery. Ann Surg. 2000;232(5):630–40.
cated by obstruction, gas bloat, dysphagia, and recur- Jobe BA, Horvath KD, Swanstrom LL. Postoperative function follow-
rence/failure. Please see the pertinent sections of Chaps. ing laparoscopic collis gastroplasty for shortened esophagus. Arch
18 and 20 on Nissen fundoplication and hiatal hernia Surg. 1998;133(8):867–74.
repair, respectively. Johnson AB, Oddsdottir M, Hunter JG. Laparoscopic Collis gastro-
plasty and Nissen fundoplication. A new technique for the manage-
• A unique concern when including the gastroplasty is sta- ment of esophageal foreshortening. Surg Endosc. 1998;12:1055.
ple line leak. If not detected intraoperatively during the Terry ML, Vernon A, Hunter JG. Stapled-wedge Collis gastroplasty for
leak test, this typically manifests as tachycardia, tachy- the shortened esophagus. Am J Surg. 2004;188:195.
pnea, fever, and/or leukocytosis. Septic shock may arise if
Endoscopic Antireflux Procedures
22
Jason Samarasena, David Lee, and Kenneth Chang
Indications Pitfalls and Danger Points
Patients may be considered candidates for one of these pro- • Patients with large hiatal hernias (>3 cm) are poor candi-
cedures if they have gastroesophageal reflux disease (GERD) dates for endoscopic antireflux therapies. Consider surgi-
and: cal hiatal hernia repair with fundoplication instead.
• Failure to respond to medical therapy portends poorer
• A contraindication to medical therapy, or response to antireflux procedures. First evaluate for alter-
• Concerns regarding the long-term side effects of the pro- native causes of their symptoms, including hypersensitive
ton pump inhibitor (PPI) class of medications, and esophagus and functional heartburn.
• Do not qualify for because of previous surgery or • Achalasia or incomplete lower esophageal sphincter
comorbidities (LES) relaxation in response to swallow must be excluded
• Refuse surgical options for the treatment of GERD before considering treatment due to the risk of worsening
these conditions following therapy.
Operative Strategy
• Diagnostic esophagogastroduodenoscopy (EGD) to eval-
uate for structural abnormalities, such as hiatal hernia and At the time of this writing, there are currently two endo-
presence of gastroesophageal junctional weakness (Hill scopic antireflux procedures in use: Stretta nonablative
grading system), and to characterize the presence of radiofrequency therapy and the EsophyX transoral incision-
sequelae of GERD, such as esophagitis, Barrett’s esopha- less fundoplication (TIF). Appropriate patient selection is
gus, or strictures/rings. critical for determining the success of each of these
• For nonerosive reflux disease, further testing with Bravo procedures.
wireless pH monitoring or 24-hour ambulatory pH moni-
toring is recommended to confirm the presence of patho-
logic reflux. Nonablative Radiofrequency Therapy (Stretta)
• High-resolution esophageal manometry testing should be
performed to rule out the presence of achalasia or other During the Stretta procedure, small needle electrodes are
esophageal motility disorders. used to engage the muscle layer near the GEJ and cardia with
the assistance of an inflatable balloon. Radiofrequency (RF)
energy is then used to produce small localized burns, which,
properly placed, increase the stiffness of the distal esophagus
preventing reflux.
In our opinion, optimal candidates for Stretta are patients
with small (<2 cm) hiatal hernias, who have typical GERD
J. Samarasena · D. Lee · K. Chang (*) symptoms, have nonerosive reflux disease (NERD), are at
H. H. Chao Comprehensive Digestive Disease Center, University least partially responsive to PPI therapy, and are predomi-
of California Irvine, Orange, CA, USA nantly upright refluxers. It is thought that the Stretta proce-
e-mail: kchang@uci.edu

https://doi.org/10.1007/978-3-030-81415-1_22
178 J. Samarasena et al.
dure increases gastric yield pressure, prevents the triggering potential complications from the procedure should be
of transient lower esophageal sphincter (LES) relaxations, noted as well.
and decreases gastroesophageal junction compliance. The
Stretta procedure can be repeated if need be and does not
preclude a patient from any alternative interventions, such as
adjunctive PPI use, further endoscopic therapy, or antireflux Operative Technique
surgery. Novel emerging applications for Stretta include
patients who have undergone prior fundoplication that is los- onablative Radiofrequency Therapy (Stretta)
N
ing efficacy, or patients who have undergone bariatric sleeve The Stretta system (Mederi Therapeutics, Greenwich, CT) is
gastrectomy having resultant reflux. comprised of a four-channel radiofrequency (RF) generator
(Fig. 22.1) and single-use RF energy catheters (Fig. 22.2). At
the start of the procedure, position the patient in a left lateral
Transoral Incisionless Fundoplication (TIF) decubitus position. Place the return electrode pad on the
patient’s right mid-scapular region, off the midline.
The TIF procedure is designed to create full-thickness plica- First perform a standard esophagogastroduodenos-
tion, reconstructing a partial fundoplication with valve copy (EGD) procedure, with careful inspection and mea-
approximately 3 cm in length, and occupying approximately surement to confirm the location and depth of the patient’s
200–300 degrees of circumference. squamocolumnar junction (SCJ). Place a guidewire
The ideal candidate for TIF are those with typical GERD through the SCJ through the stomach and into the pylo-
symptoms, with at least partial response to PPI therapy. They rus. Introduce the Stretta procedure catheter over the
must have normal esophageal motility by manometric test- guidewire into the esophagus, and advance it to 1 cm
ing. While experience with TIF in patients with hiatal her- proximal to the SCJ. On the generator, switch from
nias as large as 5 cm have been described, typically hiatal “Standby” to “Ready” mode. Attach suction to the cath-
hernia sizes of <2 cm have been associated with better out- eter. Next, use the syringe and pressure release valve (to
comes, presumably due to better ability to reduce the hiatal prevent overinflation) to inflate the balloon basket assem-
hernia during the TIF procedure. Additionally, GE junction bly. Four nitinol needle electrodes (22 gauge, 5.5 mm)
weakening of Hill grade I and II are amenable to TIF, but Hill are then extended fully into the muscular layer of the
grade III and IV are typically too wide to allow for adequate esophageal wall (Fig. 22.3). Pressing on the foot pedal
tightening during TIF. then engages the RF generator to deliver pure sine-wave
Patients with a hiatal hernia with >2 cm, diaphragmatic energy (465 kHz, 2 to 5 watts per channel, and 80 volts
hiatus greater than 2 cm wide or Hill Grade 3 or 4 may be maximum at 100 to 800 ohms) into the lower esophageal
candidates for concomitant TIF (c-TIF). In this case, the sphincter muscle for 60 seconds, resulting in a thermal
patient undergoes a hiatal hernia reduction with crural repair reaction (Fig. 22.4).
followed by a TIF procedure. This may be a promising tech- Following this treatment cycle, retract the needles and
nique for those patients reluctant to have a nissen fundoplica- deflate the balloon. Pull the catheter back to 25 cm, rotate the
tion because there may be a more favorable side effect
profile, however further studies are still needed to establish
this.
Documentation
• Clinical symptoms, including duration and responses (if

any), to medical management.
• Diagnostic EGD findings, including:
–– Presence and length of hiatal hernia.
–– Gastroesophageal junction Hill grade.
• Esophageal manometry and ambulatory pH monitoring
results.
• Counseling regarding the risks, benefits, and alternatives
to the procedure, along with discussion regarding the Fig. 22.1 (© 2020 Restech / Mederi-RF, LLC)
22 Endoscopic Antireflux Procedures 179
Fig. 22.4
Fig. 22.2 (© 2020 Restech / Mederi-RF, LLC)

Fig. 22.5
Repeat this entire process at three additional levels: at

0.5 cm above the SCJ, at the SCJ, and 0.5 cm below the SCJ
up the esophagus. Then, remove the guidewire and advance
the catheter into the stomach. Inflate the balloon to 25 mL
and withdraw it until it is snug to the hiatus. Extend the nee-
dles and complete a 60-second treatment cycle. Next, retract
the needles, advance the catheter into the stomach, and rotate
it 30 degrees to the right. Pull back against the hiatus again,
and complete another treatment cycle. Finally, perform a
third treatment cycle at 30 degrees to the left of the original
treatment cycle.
For the last treatment level, advance the catheter into the
Fig. 22.3 stomach and inflate the balloon to 22 mL. Withdraw the cath-
eter until the balloon is again snug at the hiatus. A similar
catheter 45 degrees to the right, and then readvance it back pattern of three treatment cycles is again performed at this
into position 1 cm from the SCJ. Reinflate the balloon, and level (Fig. 22.6).
extend the needles as before. RF energy is delivered to four Throughout the procedure, there is constant chilled irriga-
additional points (Fig. 22.5). The thermal reaction of the section of water (not saline) applied to the esophageal and car-
ond treatment cycle is shown, offset by 45 degrees from first diac mucosa to prevent undesirable complications of mucosal
cycle. injury, such as ulcerations or strictures.
Fig. 22.6
Fig. 22.7 (Esophyx Z courtesy of EndoGastric Solutions, Inc.,

Following completion of the procedure, deflate the bal- Redmond, WA, USA)
loon and remove the catheter. We recommend a postproce-
dure EGD to carefully inspect the treatment sites and to
confirm no immediate complications related to the
procedure.
ransoral Incisionless Fundoplication (TIF)

T
The TIF procedure is performed using the EsophyX Z device
(EndoGastric Solutions, Redmond, WA). It is designed to
create full-thickness serosa-to-serosa plications and recon-
struct valves approximately 3 cm in length and 200 to 300
degrees in circumference (Fig. 22.7). The device consists of
an 18-mm-diameter frame through which a standard endo-
scope can be introduced; a handle with controls; tissue
invaginator consisting of side holes positioned at the distal
end of the frame to which external suction can be applied; Fig. 22.8
the tissue mold, which pushes tissue against the chassis of
the device; a helical retractor, which is advanced into the tis- lubricant over the distal end of the endoscope and the distal
sue and allowed for the retraction of the tissue between the two-thirds of the EsophyX Z device. Place this inside the
tissue mold and the chassis; two stylets, which puncture the patient’s oral cavity and advance it into the stomach using
plicated tissue and tissue mold, and over which polypropyl- direct visualization with the endoscope.
ene H-shaped fasteners can be deployed; and a cartridge, Insufflate the stomach, and position the endoscope in ret-
which holds 20 fasteners. roflexion. Under direct visualization, advance the EsophyX
Prior to the start of the procedure, it is helpful to first per- Z device into the stomach, and rotate it to align the back of
form a diagnostic EGD examination to measure the length the tissue mold to the lesser curve of the stomach. Then,
from the patient’s incisors to the Z-line as well as the dia- retract the endoscope into the distal aspect of the chassis and
phragmatic pinch, and note any anatomical abnormalities close the tissue mold (Fig. 22.8). Readvance the endoscope
and verify that the stomach is free of food contents. If there into the stomach retroflex it to visualize the EsophyX Z
is any question about the compatibility of the endoscope, the device and the gastroesophageal junction.
endoscopy compatibility tool can be used to verify whether If there is a small hiatal hernia, the device can be with-
the diameter of the endoscope will be compatible with the drawn back into the distal esophagus, where suction is
EsophyX Z. applied to engage the distal esophageal mucosa. The device
Next, liberally coat the endoscope with lubricant, and can then be advanced to bring the herniated stomach back
place the lubricant over the Esophyx Z device endoscope below the diaphragm.
seal. Insert the endoscope through the seal, and advance it Next, advance the helical retractor until it is in contact
until the endoscope tip extends approximately 10–15 cm with tissue just below the squamocolumnar junction, and
beyond the distal tip of the EsophyX Z device. Then, reapply rotate the helical retractor control clockwise to engage tissue
22 Endoscopic Antireflux Procedures 181
Fig. 22.10
Fig. 22.9
(Fig. 22.9). Advance the mold and retractor by 1 cm, and

open the mold slightly to release the retractor from the tissue
mold. Then, withdraw the entire device to a level such that
the proximal blue segment is above the GE junction. This
“sets” the device so that the two stylets will exit the device
approximately 1.5 cm proximal to blue segment.
While desufflating the stomach, pull the retractor down
maximally (this excursion length will determine the length
of the neovalve). With retraction, tissue of the gastric fundus
lesser curve side is pulled in between the tissue mold and the
chassis. Once fully retracted (around 3 cm), begin rotation
Fig. 22.11
toward the lesser curve using a counterclockwise motion.
This will result in a clockwise rotation on the monitor. It is a
combination of retraction and rotation that will optimize the curve. Repeat these steps, taking two plications at each
wrap. Typically, since we routinely place three plications in position.
each corner (posterior and anterior), we prioritize retraction After these 10 plications (3 posterior, 3 anterior, and 2
in the first one to two plications and prioritize rotation in the greater curve), which results in 20 fasteners deployed, assess
last plication. Once fully retraced and rotated, lock the retrac- whether further plications are necessary. Typically, an addi-
tor, and then lock the tissue mold. tional 0–3 bites are performed for visual satisfaction. The
Turn on the invaginator suction at this point to couple the appearance should be of a tight wrap with 2- to 3-cm-long
esophagus with the device. Reinsufflate the stomach and valve as pictured in Fig. 22.11.
readvance the scope and device to the initial length of the GE
junction, which ensures that the stylets do not fire into and
through the diaphragm muscles. Load and fire the fasteners Complications
by depressing the safety button and squeezing the trigger
(Fig. 22.10). Overall, the rates of complications from these endoscopic
At this time, the fasteners can be reloaded, and the antireflux procedures are very low. The most common post-
invaginator turned off. Rotate the device out of the corner, procedural complaints are typically mild and self-resolve
unlock the retractor, and open the tissue mold. Repeat this without additional intervention required. However, there
sequence for the second and third plication into the poste- have been case reports of serious adverse events described
rior corner. After three plications, open the tissue mold and with each of these procedures.
remove the helical retractor. The device is then rotated to
the anterior corner, and an additional three plications are
performed here. Nonablative Radiofrequency Therapy (Stretta)
Then, position the device at the 5 o’clock and 7 o’clock
positions. Here, the main goal is retraction (no rotation at Typical postprocedure complaints include dyspepsia, tran-
these positions) to gain additional length at the greater sient epigastric or chest pain, dysphagia, odynophagia, and
low-grade fevers. These will typically self-resolve. Early Transoral Incisionless Fundoplication (TIF)
experience with Stretta also reported rare cases of esopha-
geal perforation and aspiration pneumonia, although with Typical postprocedure complaints include sore throat, epi-
changes in protocol and equipment since 2002, no serious gastric and chest pain, dysphagia, nausea, and left shoulder
adverse events have been reported to the FDA. Rare cases of pain that can last up to 1 month. Due to the more aggressive
ulcerative esophagitis following this procedure and gastropa- tissue manipulation of TIF, more perforations have been
resis have been reported. reported, including a case report of esophageal perforation
with bilateral empyema. Significant bleeding following TIF
requiring blood transfusion has been reported, as well as fail-
Postoperative Care ure of TIF, necessitating either repeat procedure or laparo-
scopic Nissen fundoplication.
• Admit for overnight observation.
• Start clear liquid diet for first 24 hours, then advance to
full liquid diet for next 24 hours, then soft diet for 2 weeks. Further Reading
• Keep on IV pantoprazole 40 mg twice daily during over-
night observation; then, transition to oral PPI twice daily Bell RC, Cadière GB. Transoral rotational esophagogastric fundoplica-
tion: technical, anatomical, and safety considerations. Surg Endosc.
until seen in outpatient clinic. 2011;25(7):2387–99.
• Keep on IV Zosyn during overnight observation for pro- Hummel K, Richards W. Endoscopic treatment of gastroesophageal
phylaxis, then transition to oral liquid Augmentin for reflux disease. Surg Clin North Am. 2015;95(3):653–67.
5 days. Hopkins J, Switzer NJ, Karmali S. Update on novel endoscopic thera-
pies to treat gastroesophageal reflux disease: a review. World J
• Pain/nausea control as needed. We prescribe liquid acet- Gastrointest Endosc. 2015;7(11):1039–44.
aminophen and liquid acetaminophen/codeine as needed. Witteman BP, Conchillo JM, Rinsma NF, et al. Randomized con-
• Patients should crush all medications or use liquid prepa- trolled trial of transoral incisionless fundoplication vs. proton pump
rations for 1 month after treatment. inhibitors for treatment of gastroesophageal reflux disease. Am J
Gastroenterol. 2015;110(4):531–42.
• Follow up clinic visit in approximately 4 weeks.
Peroral Endoscopic Myotomy
for Achalasia 23
Paul D. Colavita and Kevin M. Reavis
Preoperative Preparation durally. Laparoscopic myotomy with hernia repair and par-
tial fundoplication is recommended in these patients.
The typical test to evaluate dysphagia is an upper gastroin- When a patient is a candidate for POEM, the authors’
testinal (UGI) series or an esophagram, which often demon- practice is to place patients on a clear liquid diet for 24 hours
strates a “bird’s beak” tapering of the distal esophagus in prior to the procedure. Oral antifungal treatment is recom-
patients with achalasia. Progressive dilatation and tortuosity mended to clear the esophagus of yeast. The authors typi-
of the esophagus are frequently demonstrated in later stages cally prescribe 500,000 units of nystatin QID for 7 days
of the disease. The diagnosis of achalasia requires confirma- before surgery. A single dose of first-generation cephalospo-
tion by manometry, preferably high-resolution manometry rin is given within 30 minutes of mucosal incision (mucoso-
(HRM). Endoscopy is important to rule out pseudoachalasia tomy), and a single dose of dexamethasone (10 mg) is given
from an obstruction, and endoscopic ultrasound can be con- intravenously in the preoperative holding area to minimize
sidered when suspicion for malignancy causing obstruction mucosal edema in order to facilitate closure of the mucosot-
is high. Endoscopy frequently appears normal in early stages omy at the end of the case. The procedure requires endotra-
of the disease, as dilation of the esophageal body may not cheal intubation and general anesthesia; it most commonly
have occurred, but esophagitis from stasis and/or yeast occurs in the operating room to allow for close monitoring
esophagitis may be present. A timed barium swallow (TBS) and potential surgical intervention if necessary.
provides objective data on esophageal emptying and is com- Recommended equipment is contained in Table 23.1.
monly used before and as follow-up after treatment for acha-
lasia. TBS involves ingestion of 200 mL of oral contrast,
with radiographs taken at baseline and then 1, 2, and 5 min- Pitfalls and Danger Points
utes after ingestion. The height and width of the barium col-
umn at each time period are recorded. Inadvertent mucosal injuries, including burns and small
There are no current absolute contraindications to peroral punctures, can occur in up to 25% of cases during an endos-
endoscopic myotomy (POEM), except inability to tolerate copist’s initial experience; these can usually be treated with
general anesthesia. End-stage “sigmoid” achalasia and those endoscopic clips or sutures. Other options include stents,
with prior interventions (Botox injections, dilatation, or prior endoloops, or fibrin sealant. Full-thickness perforations
myotomy) were once felt to be relative contraindications; resulting in direct exposure of the esophageal lumen to the
however, the safety and efficacy of the procedure in these surrounding mediastinal adventitia or peritoneal cavity are
situations are now well established. The authors do consider very rare, but must be recognized and repaired at the time of
a large hiatal hernia to be a relative contraindication to the procedure. Mucosotomy dehiscence and postoperative
POEM due to the likely development of GERD postproce- bleeding are also rare and can often be controlled
endoscopically.
Capnoperitoneum, capnomediastinum, and capnothorax
P. D. Colavita
Division of GI and Minimally Invasive Surgery, Carolinas Medical are fairly common side effects of the procedure. Due to the
Center, Charlotte, NC, USA rapid absorption of carbon dioxide used during insufflation,
K. M. Reavis (*) these issues rarely require intervention. When these are
Division of Minimally Invasive and GI Surgery, The Oregon symptomatic, sterile needle decompression of the perito-
Clinic, Portland, OR, USA neum can be performed. The authors typically insert a Veress
e-mail: kreavis@orclinic.com

https://doi.org/10.1007/978-3-030-81415-1_23
184 P. D. Colavita and K. M. Reavis
Table 23.1 POEM equipment list (specific vendor for select devices) needle at the level of umbilicus to decompress the capnoperi-
General setup toneum, if ventilatory compromise develops during the
Video tower: (Olympus) 190/180 series, CV/CLV-190/180 procedure.
HDTV compatible
Endoscope: (Olympus)GIF-HQ190, GIF-H180J, or GIF-H180
use CO2 insufflation; patient in supine position
CO2 regulation unit (Olympus UCR); adapter for wall gas-DISS Documentation
(Olympus: MAJ-1085)
Low-flow tubing (Olympus: MAJ-1742) use with UCR An appropriate operative note should include measurements
Flushing pump (Olympus: OFP-2 or ESG-100) use with from a reference point, typically the tip of the overtube.
GIF-H180J Record the site of proximal high pressure zone,
Large pitcher/small pitcher
squamocolumnar junction, the mucosotomy site, as well as
Lifting solution: 1 mL indigo carmine diluted in 500 mL
normal saline with epinephrine 1:1000 1 mg/mL
the start and end of the myotomy. The number of clips used
10 cc controlled syringes for mucosotomy closure, when applicable, can also be
Wash towels—Grip of endoscope included. The location of myotomy on the circumference of
Alcohol swabs—Camera cleaning; toothbrushes—Cleaning the esophageal lumen is also important. The authors prefer a
needle knives trajectory in line with the anterior lesser curvature of the
Wire bucket—Temporary storage of endoscopic wired devices stomach (“2-o’clock position”), although posterior
(merit: Wire buckets K12T-017788 or ring basins RM01)
(6-o’clock) is also well described. When performed, imped-
Measurement
Data sheet
ance planimetry measurements before and after myotomy
Overtube (Apollo) are helpful to determine adequacy of the myotomy and
Mucosotomy should be recorded.
Generator/ground pad (Boston Scientific: Endostat III; or
Olympus: ESG-100 or ERBE VIO 300D); recommended setting
“Mucostomy: 60 cut; tunnel: 60 spray; Myotomy: 40 spray” Operative Strategy
Active cord (Olympus MAJ-860)
Injection needle (Olympus NM-400 L-0423 or NM-400 U-0423;
or Boston Scientific M00518310) The purpose of esophagomyotomy for achalasia is to divide
Needle knife: Boston Scientific M00545840 the hypertrophied obstructing circular muscle fibers.
Balloon: Boston Scientific M00550450 Conventional open or laparoscopic myotomy requires full
ERBEJET 2 (ERBE 10150-000) and ERBEJET 2 Pump mobilization of the esophagus and the division of longitudi-
Cartridge (ERBE 20150-300) nal muscle fibers simply to access the surgical site. POEM
HybridKnife, T-Type I-Jet, or I-type I-jet (ERBE 20150-260 or reverses the access procedure by using a proximal mucosot-
20,150-261)
omy to enter the submucosal plane in which the circular
Tunnel
Dissecting caps: Soft (Olympus D-201-12,704 or D-201-11,804);
muscle fibers can be seen and divided. These fibers are then
hard (Olympus MH-588) angled (Olympus MAJ-Y0173) divided under direct visualization. When a satisfactory myot-
Hemostatic graspers (Olympus FD-411UR or FD-411LR) or omy has been achieved, the mucosotomy is closed, as are
(Boston Scientific FD-411UR) any tears in the mucosa.
Triangle tip knife (Olympus KD-640 L) There are five steps to POEM: (1). endoscopic measure-
HybridKnife, T-Type I-Jet, or I-type I-jet (ERBE 20150-260 or ments, (2). saline lift/mucosotomy, (3). submucosal tunnel-
20,150-261)
ing, (4). circular myotomy, and (5). mucosotomy closure.
Myotomy
Insulated tip knife (Olympus KD-610 L)
L hook (Olympus KD-620LR)
HybridKnife, T-Type I-Jet, or I-type I-jet (ERBE 20150-260 or Avoiding Postoperative Complications
20,150-261)
Closure ucosal Injuries and Tears of the Mucosotomy
M
Clip: As mentioned previously, mucosal injuries can occur in up to
Large (Boston Scientific resolution clip or resolution 360 clip
25% of cases during the learning curve. These typically
(M00522610 or M00521230))
Large (cook instinct clip DHC-7-230)
occur during myotomy, when the knife’s arc is extended too
Small (Olympus quick clip HX-201UR-135 L or EZ clip far and the mucosa is burned in the submucosal tunnel.
HX-201LR-135LA) Careful and meticulous control of the endoscope and endo-
Suture: scopic knife are paramount to avoid these injuries. When this
Overstitch generation 2 (Apollo) pitfall occurs, simple endoscopic clips or sutures are most
Requires dual-channel scope (Olympus 2 T-160) commonly used to close the inadvertent mucosotomy at the
23 Peroral Endoscopic Myotomy for Achalasia 185
end of the procedure in order to avoid leak into the submuco-

sal tunnel postoperatively.
Excess traction from overly forceful dissection (endo-
scopic bowing) can cause the mucosotomy to tear and elon-
gate. Forced pressure with the dissecting cap or excessive
twisting of the endoscope can contribute. These factors often
come into play when the submucosal plane becomes tight at
the esophagogastric junction due to the thickened lower
esophageal sphincter musculature, the curve from the esoph-
agus to the stomach along the lesser curve, and the diaphrag-
matic impression. Progressive lifting and dissection will
eventually permit passage of the endoscope into the gastric
submucosal plane, allowing the operator to avoid excessive
pressure and twisting. When the mucosotomy is torn, addi-
tional clips or sutures must be used to close the submucosal
tunnel to avoid leak postoperatively. Maintaining the same
operative position and ensuring the circular fibers remain
visually parallel to the end of the cap will prevent spiraling Fig. 23.1
of the tunnel.
Operative Technique
Endoscopic Measurements
An esophageal length overtube is commonly placed at the

beginning of the case. This reduces the risk of oropharyngeal
trauma and also provides stability to the endoscope, creating
less tension at the mucosotomy site. Anatomic landmarks are
measured in reference to the overtube. The length of the
myotomy can be determined using intraoperative impedance
planimetry using EndoFlip® (Crospon, Galway, Ireland).
For achalasia types 1 and 2, a short myotomy is planned,
with the start of the myotomy 3 cm proximal to the high
pressure zone. For achalasia type 3, a longer myotomy is per-
Fig. 23.2
formed to include the entire spastic segment. This can be
measured from HRM or impedance planimetry. This long
endoscopic myotomy can be extended from a few centime- mucosotomy using a hook or triangle-tip (TT) cautery device
ters below the cricopharyngeus to the gastric cardia. with cutting current (Fig. 23.2).
The distal extent of myotomy is not measured, but can be
determined by performing retroflexion in the stomach and
placing a tattoo with nondilute methylene blue 2 cm distal to Submucosal Tunnel
the esophagogastric junction, along the line of planned
myotomy (Fig. 23.1, 2-o’clock position, anterior lesser Fit the endoscope with a vented, taper, or angled dissection
curve). cap. Then, insert it through the mucosotomy into the submu-
Saline Lift and Mucosotomy. cosal plane. If insertion is difficult, use a 15 mm biliary
The site for the mucosal incision should be 3–4 cm proxi- extraction balloon to elevate the edges of the mucosa. Instill
mal to the planned myotomy. Again, the authors prefer the lifting solution to perform hydrostatic dissection through the
anterior lesser curve position (“2-o’clock position”) for the extraction balloon. After initial hydrostatic dissection, sepa-
myotomy. Perform the saline lift by injecting a dilute methy- rate the esophageal mucosa and submucosa from the under-
lene blue saline solution, with or without epinephrine (“lift- lying circular muscle fibers using cautery (Fig. 23.3). Use
ing solution”), into the submucosal space. Use a 23-gauge cautery to continue the submucosal tunnel distally. Repeat
endoscopic injection needle. Create a longitudinal 1.5 cm hydrodissection whenever necessary to create additional
Fig. 23.3
Fig. 23.4
space for tunneling, typically every 2–3 centimeters. Large

bridging vessels are occasionally encountered and must be Mucosotomy Closure
controlled or avoided. The authors prefer a coagulator
grasper and soft cautery. Difficult bleeding can be controlled Once myotomy is complete, close the mucosotomy using
with direct pressure by advancing the dissecting cap and endoscopic clips or endoscopic sutures. First address any
holding the endoscope in place. Identify the distal extent of mucosal burns or perforations and then close the mucosot-
the dissection by encountering the tattoo placed previously omy from distal to proximal.
or by visualizing the transition from orderly esophageal ves-
sels to the submucosal palisades characteristic of the gastric
submucosal plane. Finally, a retroflexed view in the stomach Postoperative Care
can confirm mucosal blanching caused by the tunnel extend-
ing across the GEJ. The patient is made NPO after the procedure. A water-
soluble contrast esophagram is performed on postoperative
day 1, followed by 7 days of a pureed diet, and then a regular
Circular Myotomy diet. The pureed diet is instituted so that the endoscopic clo-
sure is not prematurely traumatized. The hospital length of
Begin the myotomy at the measurement from step 1 and pro- stay is typically 1 day, opiate pain management is rarely nec-
ceed antegrade to allow the dissecting cap to place tension on essary, and patients usually return to regular activity within
the muscle fibers. The myotomy consists of division of the the week. Postoperative testing is not mandatory, but endos-
circular muscle fibers using an Endocut current. Once the copy and pH testing are highly recommended to detect iatro-
circular fibers are divided, the longitudinal muscle fibers are genic GERD at 6–12 months postoperatively as these patients
readily visible (Fig. 23.4). The longitudinal fibers can be have compromised lower esophageal sensory input and are at
thin. The muscle fibers are often split due to the pressure of risk for the development of peptic strictures over time if left
the dissecting cap, which will reveal mediastinal structures without surveillance. Timed barium swallow at this interval
beyond the intact esophageal adventitia. This “mediastinal can also be used to demonstrate objective improvement after
exposure” is common and would be produced during open or POEM. Due to the increased risk of squamous cell carci-
laparoscopic/thoracoscopic myotomy approaches. It requires noma in achalasia patients, screening endoscopies are rec-
no intervention if the overlying mucosa is intact. ommended every 3–5 years.
Continue the myotomy distally, dividing the circular
fibers between the submucosal tunnel and the longitudinal
fibers, well onto the gastric wall as confirmed by the previ- Complications
ously placed tattoo and/or confirmation by retroflection.
Impedance planimetry can be performed to ensure an Mucosal injuries, burns, or inadequate mucosotomy closure
increase in the compliance of the lower esophageal sphincter can result in a leak contained within the dissection tunnel.
and increase in cross-sectional area (Fig. 23.5). When patients are not clinically ill, these can often be
23 Peroral Endoscopic Myotomy for Achalasia 187
Fig. 23.5
observed with NPO status and repeated esophagram symptoms of reflux have normal acid exposure; the authors,
24–48 hrs later. When patients are symptomatic, endoscopic therefore, recommend postoperative pH testing in all patients
stents can be considered if the esophagus is of normal caliber to identify those with increased acid exposure after POEM,
with mindfulness that the myotomized esophagus is at risk and consideration of lifelong antacid medication use or
for tension-induced ischemia and necrosis. A full-thickness selective endoscopic or laparoscopic fundoplication in this
leak into the mediastinum with clinical sequela requires subset of patients.
intervention. Similar to a clinically relevant contained leak,
external source control via drainage with internal diversion
(with stents, NPO status, or surgical diversion) along with Further Reading
appropriate antimicrobial coverage is indicated.
Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diag-
nosis and management of achalasia. Am J Gastroenterol.
2013;108(8):1238–49. quiz 1250
Gastroesophageal Reflux Disease (GERD) Kahrilas PJ, Bredenoord AJ, Fox M, et al. The Chicago classification
of esophageal motility disorders, v3.0. Neurogastroenterology
POEM does not facilitate surgical fundoplication at the time and motility: the official journal of the European Gastrointestinal
Motility Society. 2015;27(2):160–74.
of myotomy, but the intact phrenoesophageal ligaments and Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy
the preservation of the longitudinal esophageal muscle fibers (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265–71.
are believed to reduce the incidence of GERD after Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E, Swanstrom
POEM. Approximately 10–40% of patients will demonstrate LL. A comparative study on comprehensive, objective outcomes of
laparoscopic Heller myotomy with per-oral endoscopic myotomy
symptoms of reflux after POEM, which is similar to rates (POEM) for achalasia. Ann Surg. 2014;259(6):1098–103.
after surgical myotomy. Objective testing demonstrates Sharata AM, Dunst CM, Pescarus R, et al. Peroral endoscopic myotomy
higher rates of acid exposure after POEM, though many of (POEM) for esophageal primary motility disorders: analysis of 100
these patients are asymptomatic. There may be technique- consecutive patients. J Gastrointest Surg. 2015;19(1):161–70; dis-
cussion 170.
specific effects on iatrogenic GERD based on location of Ren Z, Zhong Y, Zhou P, et al. Perioperative management and treatment
myotomy (2-o’clock vs. 6-o’clock) and division of the longi- for complications during and after peroral endoscopic myotomy
tudinal fibers. Up to 50% of patients with post-POEM, (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg
GERD can be asymptomatic, and up to 44% of patients with Endosc. 2012;26(11):3267–72.
Stavropoulos SN, Brathwaite CE, Iqbal S, et al. 509 P.O.E.M. Familiari P, Gigante G, Marchese M, et al. EndoFLIP system for the
(PerOral Endoscopic Myotomy), a U.S. Gastroenterologist intraoperative evaluation of peroral endoscopic myotomy. United
Perspective: Initial 2 Year Experience. Gastrointestinal European Gastroenterol J. 2014;2(2):77–83.
Endoscopy.75(4):AB149. Bechara R, Ikeda H, Inoue H. Peroral endoscopic myotomy: an evolv-
Hungness ES, Sternbach JM, Teitelbaum EN, Kahrilas PJ, Pandolfino ing treatment for achalasia. Nat Rev Gastroenterol Hepatol. 2015.
JE, Soper NJ. Per-oral endoscopic Myotomy (POEM) after the Talukdar R, Inoue H, Reddy DN. Efficacy of peroral endoscopic myot-
learning curve: durable long-term results with a low complication omy (POEM) in the treatment of achalasia: a systematic review and
rate. Ann Surg. 2016;264(3):508–17. meta-analysis. Surg Endosc. 2014.
Hungness ES, Teitelbaum EN, Santos BF, et al. Comparison of Miller HJ, Neupane R, Fayezizadeh M, Majumder A, Marks JM. POEM
perioperative outcomes between peroral esophageal myotomy is a cost-effective procedure: cost-utility analysis of endoscopic and
(POEM) and laparoscopic Heller myotomy. J Gastrointest Surg. surgical treatment options in the management of achalasia. Surg
2013;17(2):228–35. Endosc. 2016.
Schneider AM, Louie BE, Warren HF, Farivar AS, Schembre DB, Aye Docimo S, Jr., Mathew A, Shope AJ, Winder JS, Haluck RS, Pauli
RW. A matched comparison of per Oral endoscopic Myotomy EM. Reduced postoperative pain scores and narcotic use favor per-
to laparoscopic Heller Myotomy in the treatment of achalasia. J oral endoscopic myotomy over laparoscopic Heller myotomy. Surg
Gastrointest Surg. 2016;20(11):1789–96. Endosc. 2016.
Part III
Stomach and Duodenum
Ninh T. Nguyen and Umut Sarpel

Concepts in Surgery of the Stomach
and Duodenum 24
Sean P. Harbison and Daniel T. Dempsey
Operation for Morbid Obesity conversion to duodenal switch. Preoperative, intraoperative,

and postoperative care by a multidisciplinary experienced
Most patients with BMI > 40 (or BMI > 35 with weight- bariatric team optimize outcomes and maximize patient
related comorbidities) cannot sustain significant weight loss safety.
with a diet and exercise program, whereas the long-term ben- Pulmonary embolism, cardiac events, and anastomotic
efits of bariatric surgery are clear (Arterburn et al. 2015; leak are the most common causes of postoperative death,
Adams et al. 2017; Mehaffey et al. 2016). Thus, these patients now a relatively rare event following bariatric surgery.
should be considered for referral to a multidisciplinary bar- Perioperative thromboembolic prophylaxis must be meticu-
iatric surgery center for evaluation. Surgical weight loss lous, and patients at highest risk for complications can be
options include vertical sleeve gastrectomy (Peterli et al. considered for preoperative removable vena caval filter,
2017), Roux-en-Y gastric bypass (RYGBP), adjustable gas- though there is no clear evidence that the benefits of filters
tric band, and duodenal switch or biliopancreatic diversion outweigh the risks in bariatric surgery (Rowland et al. 2015).
(BPD), although adjustable banding is waning in popularity Though randomized trials are lacking, many surgeons
(Lazzati et al. 2017) and many centers do not perform increase subcutaneous heparin dose in the heaviest patients,
BPD. All these operations can be performed laparoscopi- and routinely administer postdischarge, low molecular
cally with improved outcomes and patient satisfaction when weight heparin for a few weeks (Bartlett et al. 2015), though
compared to the open approach. The operative mortality risk admittedly there is some risk and little data demonstrating
for sleeve gastrectomy and gastric bypass is below 0.5% and the effectiveness of this practice in preventing fatal pulmo-
varies directly with the extent of comorbidities. Some cen- nary embolism. Preoperative cardiac and pulmonary assess-
ters have formed in-house preoperative review panels to ment should be liberally utilized before bariatric surgery.
assess the risk-benefit ratio of bariatric surgery in the highest Intraoperative testing of gastric anastomosis or staple
risk patients and to guide preoperative evaluation and man- lines is routine, nevertheless, staple-line/anastomotic leak
agement in this group. may complicate sleeve gastrectomy and RYGBP. After
Selection of the appropriate operation for the individual appropriate imaging and resuscitation, clinical signs of sep-
patient requires experience and judgment. For example, the sis should prompt early reoperation to ensure adequate drain-
technical challenges of performing RYGBP in someone with age, absence of staple-line ischemia, enteral feeding access
BMI approaching 70 may push one toward sleeve gastrec- distal to leak, and if possible patch or closure of the leak.
tomy; reflux esophagitis favors gastric bypass rather than This can often be done laparoscopically provided the initial
sleeve gastrectomy or gastric band; and inadequate weight operation was also performed laparoscopically. Small leaks
loss after a technically sound RYGBP can be treated with without sepsis may sometimes be managed nonoperatively if
drainage is adequate. Small staple-line leaks usually close
with NPO and nutritional support. Chronic leaks often
S. P. Harbison (*)
require surgical revision; simple restapling or resuturing (or
Department of Gastrointestinal Surgery, University of
Pennsylvania Health System, Penn Gastrointestinal Surgery endoscopic clipping) usually does not work. Other options to
University City, Philadelphia, PA, USA manage staple-line leak or stricture after sleeve gastrectomy
e-mail: sean.harbison@pennmedicine.upenn.edu include stenting, conversion to Roux-en-Y gastric bypass,
D. T. Dempsey Roux patch of chronic leak, and total gastrectomy (El-Sayes
Department of Gastrointestinal Surgery, Penn Medicine, Perelman et al. 2017). Salvage options for chronic anastomotic leak or
Center for Advanced Medicine, Philadelphia, PA, USA

https://doi.org/10.1007/978-3-030-81415-1_24
192 S. P. Harbison and D. T. Dempsey
stricture after RYGBP include resection and reanastomosis; priate for curative resection. Palliative resection should be
if the initial gastric pouch is small, this means esophagojeju- avoided except for otherwise unmanageable bleeding or
nostomy. During provisional operation after sleeve gastrec- obstruction, though endoscopic gastrostomy placement, gas-
tomy or RYGBP, if a Roux limb is anastomosed to a proximal trojejunostomy, or stenting should be considered for patients
gastric pouch, care should be taken to avoid retained antrum with obstruction and incurable disease. The standard opera-
physiology, since this may result in marginal ulceration. This tion for gastric adenocarcinoma of the body or antrum is
can happen if there is a trivial parietal cell mass in continuity “radical subtotal gastrectomy,” which includes a distal gas-
with an intact antrum, resulting in continuous uninhibited trectomy, removal of associated lymphoid tissue, and
antral gastrin secretion. In the setting of the associated removal of the lesser and greater omentum. For lesions close
chronic hypergastrinemia, even a small proximal gastric to the GE junction, some distal esophagus is usually removed.
pouch may make enough acid to result in marginal ulceration
of the Roux limb.
Other procedure-specific complications can occur. Subtotal Versus Total Gastrectomy
Bleeding from the staple lines is a known event. Band slip-
page or herniated stomach through the band can be a surgical Routine total gastrectomy for distal gastric adenocarcinoma
emergency since gastric necrosis may ensue. These patients is unnecessary and should be avoided provided that adequate
present with acute abdominal pain and abnormal imaging. margins and lymphadenectomy are not compromised. When
Band erosion into the stomach typically is handled with elec- compared to subtotal resection, the operative mortality is
tive band removal and drainage. Stricture or torsion of the higher, the cancer-free survival no better, and the quality of
proximal gastric tube may complicate sleeve gastrectomy. life inferior with total gastrectomy (Bozzetti et al. 1999;
Internal hernia, anastomotic stricture (either GJ or enteroen- Roukos et al. 1995; Robertson et al. 1994; Lee et al. 2016).
terostomy), and marginal ulcer can complicate RYGBP. Since Both the nutritional and social consequences of total gastrec-
some of these complications may require emergency opera- tomy can be quite disabling (Lee et al. 2016). If at least 30%
tion (e.g. lap band with herniated stomach; internal hernia of the proximal stomach remains, continuity should be
with RYGBP; and perforation or bleeding marginal ulcer), it restored with Billroth II gastrojejunostomy. However, if the
is important to consider early CT scan in any bariatric sur- remnant is small, the anastomosis will be too close to the GE
gery patient with acute abdominal pain. It is also important junction, and bile reflux with esophagitis will ensue.
that the covering surgeon be prepared to deal with these sur- Therefore, usually after subtotal gastrectomy for cancer,
gical emergencies (Bradley 3rd et al. 2015). Finally, each continuity is reestablished with Roux-en-Y gastrojejunos-
bariatric operation has a specific set of possible long-term tomy. The addition of a Braun enteroenterostomy between
complications, nutritional and otherwise. Iron, B12, and cal- the afferent and efferent limbs of the Billroth II may divert
cium deficiencies are less common with sleeve gastrectomy most of the bile from the proximal stomach, but it may not.
or lap band than with RYGBP and duodenal switch. A Billroth I reconstruction should be avoided in cases of gas-
tric malignancy because of the risk of recurrence at the duo-
denal margin (usually the margin with the least tumor
Operation for Gastric Cancer clearance).
Cancers of the proximal third of the stomach are treated
Adenocarcinoma of the stomach may extend submucosally with total gastrectomy (preferred) or proximal gastrectomy.
much farther than is appreciated on gross examination. Early The proximal margin for a gastric adenocarcinoma should be
metastasis is usually to regional lymph nodes, but the lym- >5 cm, and thus, lesions along the lesser curve and linitis
phatic drainage of the stomach is extensive and often unpre- plastica often require total gastrectomy. Both total gastrec-
dictable. These facts support a generous gastric resection for tomy and proximal subtotal gastrectomy give equal cure
treatment of gastric cancer judged to be clinical stage T2 or rates, but the latter can be associated with poor remnant
greater. Ideally, the resection encompasses 5 cm of normal function, including debilitating bile esophagitis, especially if
gastric tissue proximal and distal to the gross tumor, though pyloroplasty is added (Harrison et al. 1997). We prefer total
a lesser margin may be acceptable for smaller tumors or gastrectomy for proximal gastric cancer, though occasion-
tumors of the intestinal subtype. The goal of resection for ally we have used a proximal gastrectomy with esophago-
gastric cancer is removal of all gross tumor (an R-0 resec- gastrostomy without pyloroplasty in patients with a poor
tion) with negative microscopic margins and an adequate prognosis. A better option for reconstruction following prox-
lymph node dissection (>15 nodes). Frozen section analysis imal gastric resection may be isoperistaltic jejunal interposi-
is important for the intraoperative confirmation of negative tion (Henley loop) between the esophagus and distal stomach
margins. En bloc resection of involved adjacent organs but this increases the number of anastomoses, and is rarely
(spleen, colon, tail of pancreas, and left lateral liver) is appro- used (Aronow et al. 1995). By far, the most common recon-
24 Concepts in Surgery of the Stomach and Duodenum 193
struction following total gastrectomy is end-to-side Roux- experienced hands, some patients with T1b tumors can be
en-Y- esophagojejunostomy. We favor the construction of managed with endoscopic submucosal resection. T2N0
some sort of jejunal reservoir since some published studies patients may be considered for resection without chemother-
show better nutritional status and quality of life with pouch apy. However, patients with tumors staged as T3 or higher, or
reconstruction compared to straight esophagojejunostomy N1 or higher by EUS should be considered for preoperative
(Gertler et al. 2009). The J-pouch is easy to construct and chemotherapy with or without radiation. Diagnostic laparos-
functions well. copy should be performed prior to resection in patients with
advanced gastric cancer. Visceral or peritoneal metastases or
positive peritoneal cytology mean that the patient is incur-
Extent of Lymphadenectomy able by surgery alone. Thus, resection should not be per-
formed in these patients unless tumor bleeding or obstruction
There is near universal agreement that, when performing a is otherwise unmanageable, which is unusual. Some patients
formal gastrectomy for adenocarcinoma of the stomach, can be restaged and relaparoscoped after chemotherapy or
more than 15 lymph nodes must be removed and assessed chemoradiation. If the cytology has normalized, curative
pathologically. While it is generally acknowledged in this resection can be considered (Mezhir et al. 2010).
situation that the more lymph nodes removed the better
(Smith et al. 2005), the role of extended lymph node dissec-
tion for gastric cancer remains controversial (Degiuli et al. Laparoscopic Gastrectomy
2016). A D1 dissection removes the level N1 perigastric
lymph nodes (lesser and greater curvature, suprapyloric and Clinical trials from Asia and Europe suggest that the opera-
infrapyloric, right and left crural, i.e., stations 1–6), while a tive morbidity and mortality with laparoscopic/robotic gas-
D2 dissection also removes N2 level nodes along the left gastrectomy for gastric cancer, in select patients, are comparable
tric, common hepatic, celiac, and splenic arteries (stations to open operation (Honda et al. 2016; Brenkman et al. 2017).
7–11). Splenectomy and distal pancreatectomy are no longer Lymph node counts and long-term survival are also not dif-
routinely performed as part of D2 gastrectomy, as this has ferent for the laparoscopic and open operations. Surgeons
been shown to increase perioperative morbidity without hoping to duplicate these results should be mindful that in
improving the cure rate. The extent of gastric resection is published trials, the surgeons are usually very experienced
generally the same for D1 and D2 resections for distal gastric with laparoscopic gastrectomy for cancer, and the body habi-
tumors (70% distal gastrectomy) and for proximal gastric tus of the average patient in published trials is probably more
tumors (total gastrectomy). Randomized clinical trials, favorable for laparoscopic operation than many Western
including the well-known MRC (Cuschieri et al. 1996; patients with the same disease.
Cuschieri et al. 1999) and Dutch trials (Bonenkamp et al.
1999; Hartgrink et al. 2004), and two meta-analyses (Jiang
et al. 2013; El-Sedfy et al. 2015) have shown no survival Gastrointestinal Stromal Tumors (GISTs)
advantage for D2 lymphadenectomy and all have shown
higher morbidity with D2 resection. However, two more Gastrointestinal stromal tumors (GISTs) arise from the inter-
recent studies, one a 15-year follow-up of the Dutch trial stitial cells of Cajal, and though they may occur anywhere in
(Songun et al. 2010) and one a Cochrane analysis (Mocellin the GI tract, they are found most commonly in the stomach
et al. 2015), suggest that D2 resection may improve long- (Kingham and DeMatteo 2009; Keung and Raut 2017).
term cancer-specific survival. Though not required by NCCN Almost all GISTs (95%) express KIT (CD117) and over 85%
guidelines, D2 resection should be strongly considered for have detectable activating KIT mutations, which make these
potentially curable gastric cancer patients who are not high tumors uniquely responsive to tyrosine kinase inhibitors
surgical risk. such as imatinib, sunitinib, and regorafenib. Most GISTs
without detectable KIT mutations have mutations in
PDGFRA. There are three histologic GIST subtypes: spindle
EUS and Diagnostic Laparoscopy cell (70%), epithelioid (20%), and mixed (10%). Initial clini-
cal evaluation usually includes endoscopy, EUS with deep
We think that endoscopic ultrasound (EUS) and staging lapa- needle biopsy for standard histologic and immunohisto-
roscopy should be part of the clinical evaluation for most chemical analysis, and CT scan. All GISTs >2 cm, and those
patients with gastric cancer (Ajani et al. 2016). Nonulcerated with symptoms, for example, bleeding, should be resected.
moderately or well-differentiated tumors confined to the Surgical treatment is resection with negative margin; wide
mucosa (Tis and T1a), as identified by EUS, can be consid- margins and lymphadenectomy are unnecessary. For patients
ered for endoscopic mucosal resection (Han et al. 2016). In with completely resected nonmetastatic disease, risk of
recurrence is related to tumor size (<2 cm lowest; then, the is the obvious exception), acid/peptic damage to the gastro-
risk increases based on size: 2–5 cm, 5–10 cm, >10 cm), duodenal mucosa is the mechanism of injury common to all
mitotic activity (risk lower if <5 mitoses per 50 high power peptic ulcers (Calam and Baron 2001). Cheap, relatively
fields), and site of origin (risk higher for nongastric sites of safe, and effective suppressors of gastric acid secretion are
origin). Patients at intermediate or high risk of recurrence now readily available (proton pump inhibitors and H2 block-
should be treated with adjuvant imatinib (Balachandran and ers). Clearly, these developments together with advances in
DeMatteo 2014; Ho and Blanke 2011). Very large primary therapeutic endoscopy account for the current reality that the
GISTs that appear marginally resectable on presentation large majority of operations for peptic ulcer disease today
may shrink considerably with neoadjuvant imatinib, which are done urgently or emergently for complications (perfora-
may also make gastric GISTs near the GE junction or pylo- tion, obstruction, and bleeding in order of decreasing fre-
rus amenable to margin negative wedge resection rather than quency) (Lee and Sarosi Jr 2011). These facts also have
formal segmental resection. One-thirds of patients have met- some important implications for the surgeon:
astatic disease to the liver or peritoneum on presentation.
Patients with metastatic GIST should be treated with tyro- 1. Beware of the patient with intractable or nonhealing pep-
sine kinase inhibitors. In some patients, this may lead to tic ulcer disease. This should be a rare indication for oper-
tumor shrinkage and allow meaningful tumor debulking. ation in the modern era. If helicobacter is eradicated,
Patients who experience disease progression or intolerable NSAIDs and aspirin are avoided, smoking is eliminated,
side effects on imatinib are treated with next-generation and acid suppressed, then virtually all peptic ulcers
tyrosine kinase inhibitors sunitinib or regorafenib. should heal. Thus, nonhealing peptic ulcer implies either
Sophisticated mutational analysis may be useful in patients noncompliance and/or malignancy and/or an unusual eti-
with unresponsive tumors. ology of the ulcer (e.g., motility disorder) or symptoms
Gastric GISTs are most commonly treated with wedge (e.g., visceral hypersensitivity). Today, patients with
resection, but larger tumors may require subtotal or rarely abdominal symptoms and a demonstrable nonhealing
total gastrectomy. Concomitant intraoperative endoscopy benign peptic ulcer may be just as difficult to cure with
may be helpful during laparoscopic resection, particularly operation as they are with medication. Since an ill-
for smaller endophytic tumors. Wedge resection for GIST conceived ulcer operation can easily result in chronic
located near the GE junction or pylorus can result in symp- weight loss of 10% or greater, asthenic patients with non-
tomatic luminal narrowing or obstruction, and placement of healing ulcer are particularly problematic.
a bougie can ensure patency of the lumen. Wedge resection 2. Postoperative recurrent peptic ulcer or marginal ulcer-
for lesser curvature GIST may vagally denervate the antrum ation is more easily treated today than in the distant past
and pylorus, resulting in gastric stasis. While many smaller because (as indicated above) we have both a better under-
lesions are amenable to laparoscopic gastric wedge resection standing of ulcer pathophysiology and a better medical
(Xiong et al. 2017), it is important not to compromise onco- treatment armamentarium. Thus, prevention of ulcer
logic principles just to avoid an open operation. Furthermore, recurrence has become a weaker argument for a larger
injudicious laparoscopic wedge resection of gastric GIST initial ulcer operation.
may result unnecessarily in a distorted and dysfunctional 3. Patients with peptic ulcer disease severe enough to merit
gastric remnant. hospitalization or surgical consultation, and all peptic
Duodenal GISTs are usually treated by segmental duode- ulcer patients who require NSAIDs and/or aspirin, or in
nal resection or wedge resection. Lesions some distance whom smoking cannot be eliminated, should be treated
from the ampulla can be excised with negative margins with with long-term maintenance PPI (unless vagotomy is per-
a full- thickness piece of the involved duodenal wall. formed). Empiric helicobacter therapy should also be
Reconstruction options include primary repair or anastomo- considered (Vaduganathan et al. 2016; Yazbek et al.
sis and Roux duodenojejunostomy. Proximal duodenal 2015).
GISTs may require distal gastrectomy.
Operation for Perforated Peptic Ulcer

Surgery for Peptic Ulcer
Perforation is by far the most common indication for operation
It is now generally recognized that most peptic ulcers are for peptic ulcer nowadays (Soreide et al. 2015). The 90-day
caused by Helicobacter pylori infection, NSAID use (includ- operative mortality rate may be as high as 30% and reoperation
ing aspirin), smoking, and/or stress. While acid hypersecre- is required in up to 25% of patients for persistent or recurrent
tion alone, in the absence of one or more of these factors, perforation, abdominal sepsis, or, more commonly, wound
rarely causes peptic ulceration (Zollinger-Ellison syndrome problems after open operation (Hasselager et al. 2016). A lapa-
roscopic approach to repair is, thus, desirable whenever possi- 1. Patients may be less willing to take long-term PPI because
ble. The choice of operation depends on the location of the of recent observational studies suggesting an association
ulcer, the condition of the patient, and whether a definitive ulcer of chronic PPI use with a variety of medical problems
operation is desirable. Patients with major premorbid medical including kidney disease, cardiac disease, and Alzheimer’s
illness, shock, or delayed diagnosis of perforation are probably disease (Vaezi et al. 2017). Avoidance of vagotomy in
best treated with omental patch closure (Graham patch) alone favor of lifelong PPI may, thus, be a flawed strategy in
(Boey et al. 1982). Even low-risk patients with perforated duo- some patients.
denal or gastric ulcer do well with patch closure if the etiologic 2. Vagotomy is quite efficacious in suppressing gastric acid
agents (helicobacter, NSAIDs, aspirin, and smoking) can be secretion, and PPIs may not be any more effective at
eliminated (Ng et al. 2000). Laparoscopic closure of perforated decreasing gastric acid. Parietal cell vagotomy decreases
peptic ulcer and peritoneal washout is an excellent alternative to basal gastric acid output by 50–80% and decreases stimu-
laparotomy (Wilhelmsen et al. 2015). Perforated gastric ulcers lated (peak) gastric acid output by 80–90% (Cohen et al.
should be biopsied to rule out malignancy. Consideration can be 1993). Truncal vagotomy should be comparable.
given to mucosal biopsy (if accessible) in all perforated peptic Similarly, regular dosing with proton pump inhibitors can
ulcers to evaluate for helicobacter infection. maintain gastric luminal pH above 4 for 80–90% of a
Good operative candidates with perforated duodenal ulcer continuously monitored 24-h time period, but in some
and a chronic ulcer history, especially those who have failed patients this occurs only at higher dose levels (Rohss
medical management, may be considered for definitive ulcer et al. 2010).
operation such as patch closure of the perforation and proximal 3. Neither chronic PPI therapy nor vagotomy is without
gastric vagotomy (Jordan and Thornby 1995). This approach complications. Medication side effects, fundic gland pol-
not only fixes the acute process but also provides long-term pro- yps, dosage compliance, and cost are recognized prob-
tection from recurrence with minimal side effects. If there is lems with PPIs, while technical and postvagotomy
extensive scarring of the pyloric region, patch closure with trun- complications are acknowledged problems with vagot-
cal vagotomy and gastrojejunostomy should be considered. If omy. Parietal cell vagotomy is very safe, but it is time
pyloric scarring is not extensive, the perforation may be incor- consuming and perhaps less effective in inexperienced
porated into a pyloroplasty and truncal vagotomy added. hands. Truncal vagotomy is quicker but may be associ-
Definitive operation for perforated gastric ulcer is distal gastrec- ated with diarrhea, or dumping due to the concomitant
tomy or wedge resection, usually without vagotomy. All the drainage procedure, or gastroparesis. Technical compli-
above operations for perforated peptic ulcer can be done laparo- cations of either operation include bleeding, esophago-
scopically by the experienced surgeon. gastric perforation, and incomplete vagotomy.
4. In the pre-Helicobacter, pre-PPI era, the addition of
vagotomy was shown to significantly improve the clinical
The Role of Vagotomy in Peptic Ulcer Surgery outcomes in patients requiring closure of perforated duo-
denal ulcer (Boey et al. 1982; Jordan and Thornby 1995),
Between 1993 and 2006, the use of vagotomy in peptic ulcer but in the modern era results of simple closure of perfo-
operation decreased by about 70% (Wang et al. 2010). While rated duodenal ulcer are very good provided that helico-
the reasons for this are myriad (evolving surgeon experience bacter infection is treated (Ng et al. 2000). But not all
and initiative, ready availability of medical acid suppression, patients requiring ulcer surgery have helicobacter infec-
overenthusiasm for the pathophysiologic primacy of helico- tion, and many patients will be noncompliant with the
bacter, fear of postvagotomy side effects, etc.), there can be treatment or will have treatment-resistant infection or
little doubt that the preponderance of operations performed will have other important pathophysiologic factors like
in the USA today for peptic ulcer disease omits vagotomy. NSAIDs and smoking. Given the modern clinical context,
The decision to add truncal or proximal gastric (parietal cell) it may be acceptable to surgically treat many peptic ulcer
vagotomy to an ulcer operation is a risk/benefit analysis patients without vagotomy. However, in the stable good-
(Lagoo et al. 2014). It is nearly impossible to perform this risk patient requiring operation for peptic ulcer disease,
analysis in an evidence-based fashion since essentially all vagotomy should be considered in patients with ulcer
the prospective clinical trials of ulcer surgery were per- chronicity, failure of medical treatment, and noncompli-
formed in the pre-Helicobacter, pre-PPI era (Harbison and ance. It seems unwise to rely on medical treatment alone
Dempsey 2005). But the following should be considered (e.g., antibiotics for helicobacter, chronic PPI, avoidance
before abandoning vagotomy altogether as an important part of NSAIDs and aspirin, and no smoking) in all these
of the ulcer surgeon’s armamentarium. patients.
The Choice of Drainage Operation Reconstruction after Distal Gastrectomy
The most common indications for a drainage procedure in illroth I Versus Billroth II
B
the intact stomach are truncal vagotomy and gastric outlet Following distal gastrectomy for benign disease, gastroin-
obstruction, sometimes benign but usually malignant. In the testinal continuity can be reestablished by gastroduodenos-
setting of vagotomy, both pyloroplasty and gastrojejunostomy (Billroth I) or gastrojejunostomy (Billroth II).
tomy are equally effective drainage operations. The major Functionally, these operations give equally good results.
advantages of the pyloroplasty are that it does not require an The advantage of the Billroth I is the avoidance of a duode-
anastomosis with attendant possible complications, and that nal stump and other possible complications of Billroth
perhaps a leak might be more easily managed with drainage II. Theoretically, there may also be a lower incidence of
and gastric suction, since it is proximal to the entry of bile recurrent ulceration with Billroth I anastomosis since the
and pancreatic juice. The major advantages of the gastrojeju- duodenum is likely more resistant to acid than the small
nostomy are that it is easily reversible (unlike pyloroplasty) intestine. The advantage of the Billroth II is ease of con-
and does not interfere with duodenal stump closure if subse- struction and the requirement for less mobilization. The
quent gastrectomy is required; previous pyloroplasty can amount of chronic postoperative enterogastric reflux is
make duodenal stump closure problematic. Possible compli- similar for the two operations. Gastroduodenostomy should
cations of gastrojejunostomy include marginal ulcer, afferent be avoided when malignancy is the indication for gastrec-
or efferent loop obstruction, intussusception, and “circus tomy, particularly when the duodenal margin is close to the
movement” of duodenal contents. The risk of marginal ulcer- tumor. Both Billroth I and II arrangements should be
ation is probably decreased by a technically sound vagotomy avoided in the setting of a small gastric pouch since bile
or chronic PPI therapy. Obviously, if the indication for a esophagitis is a risk. When doing a Billroth II operation, we
drainage procedure in the intact stomach is gastric outlet always position the tip of the NG tube into the afferent limb
obstruction, pyloroplasty is usually not an option. to prevent early postoperative duodenal distention. Extra
side holes may be cut to ensure gastric drainage. We prefer
to staple the duodenal stump and do not oversew the staple
The Role of Resection in Peptic Ulcer Surgery line but routinely cover the staple line with healthy
omentum.
Between 1993 and 2006, the number of gastrectomies for
peptic ulcer decreased by 50% (Wang et al. 2010). Distal illroth II Versus Roux-En-Y
B
gastric resection is a good surgical option for low-risk The major advantage of Roux-en-Y reconstruction after
patients with distal gastric ulcer or gastric outlet obstruction distal gastrectomy is the avoidance of enterogastric reflux
from gastric and/or duodenal ulcer. Gastric ulcers should of bilious duodenal contents, which can cause bile reflux
always be biopsied to rule out malignancy, and admittedly gastritis and esophagitis. The Roux limb should be at least
the ultimate biopsy is gastric resection to include the ulcer. 45 cm and preferably 60 cm long to ensure the absence of
Typically, duodenal ulcers do not require biopsy, but duode- bile in the gastric pouch. The Roux anastomosis may also
nal cancer can masquerade as duodenal ulcer disease and we be safer than a Billroth II, since if leak occurs at the gas-
have operated on two patients with a preoperative diagnosis trojejunostomy, it does not discharge duodenal contents
of obstructing duodenal ulcer disease who on exploration into the peritoneal cavity. There are, however, several dis-
required a Whipple operation for duodenal cancer. This advantages to Roux reconstruction. Compared to Billroth
remote possibility should be kept in mind by the surgeon II gastrojejunostomy, Roux-en-Y reconstruction requires
who opts for laparoscopic proximal gastric vagotomy and another anastomosis (enteroenterostomy), and early post-
gastrojejunostomy to treat obstructing duodenal ulcer. In the operative problems with this anastomosis could increase
emergency situation, distal gastric resection can be consid- the risk of duodenal stump disruption and gastrojejunos-
ered for perforated gastric ulcer or bleeding peptic ulcer, but tomy leak. Also, the Roux gastrojejunostomy is more sus-
if possible it should be avoided in unstable and high-risk ceptible to marginal ulceration than the Billroth II due to
patients. In the nonemergent situation, gastric resection is a the complete lack of duodenal contents in the vicinity of
tempting option to treat thin patients with peptic ulcer the gastrojejunostomy. Also, the motility of the Roux limb
because it is not a difficult operation in the nonobese patient. is deranged, which may lead to delayed gastric emptying.
However, resection should be avoided in these patients, if Because of these last two observations, it is unwise to uti-
possible, because of postoperative nutritional side effects lize the Roux reconstruction in the presence of a large gas-
and/or weight loss. tric remnant.
Other Reconstruction Options high-risk group in whom endoscopic treatment of bleeding

ulcer should be considered and surgical consultation
There are two alternatives to Roux reconstruction, which obtained. Operation should be strongly considered in patients
also decrease the risk of bile gastritis and bile esophagitis. requiring transfusion of four or more units of blood, espe-
The Braun modification of the Billroth II adds an anastomo- cially in patients who have exhibited hemodynamic instabil-
sis between the afferent and efferent limbs, theoretically ity or who have high-risk ulcers (e.g., deep posterior duodenal
allowing bilious duodenal contents to go from the former to ulcer and deep lesser curvature gastric ulcer with either vis-
the latter without having to enter the stomach (Vogel et al. ible vessel or brisk active bleeding). Though bleeding is by
1994). The rarely performed Henley loop reestablishes far the most common peptic ulcer complication requiring
gastrointestinal continuity with the interposition of a 40 cm hospitalization, the use of advanced endoscopic techniques
isoperistaltic isolated segment of jejunum between the gas- to control bleeding ulcer has increased dramatically over the
tric remnant proximally and the duodenum distally (Aronow last two decades and this has decreased both the need for
et al. 1995). operation and the mortality of bleeding peptic ulcer (Wang
et al. 2010; Calvet et al. 2004). Today operation for bleeding
peptic ulcer is much less common than operation for perfora-
Operation for Obstructing Peptic Ulcer tion and less common than operation for obstructing ulcer.
During operation for bleeding peptic ulcer, the first concern
Gastric outlet obstruction (GOO) secondary to peptic ulcer should be localization and management of the bleeding ulcer
disease is typically not a surgical emergency. Fluid resuscita- site. For bleeding duodenal lesions, this is most often accom-
tion, nasogastric decompression, acid suppression, and H. plished via a longitudinal duodenotomy, which may be
pylori treatment are the mainstays of medical therapy. An extended through the pylorus. The bleeding duodenal ulcer is
attempt at endoscopic balloon dilation may yield initial suc- controlled with nonabsorbable sutures. For posterior pene-
cess, but recurrent obstruction is common (Yusuf and Brugge trating bleeding duodenal ulcer involving the gastroduodenal
2006). The operative choices for GOO are vagotomy and artery and its branches, multiple deep sutures are often nec-
drainage (we prefer laparoscopic proximal vagotomy (PGV) essary. The quintessential U stitch might be helpful. Vigorous
and gastrojejunostomy (GJ)), or vagotomy and antrectomy. irrigation and gentle suction abrasion of the bleeding site
These operations were equally effective in a small random- assure the surgeon that hemostasis has been secured. In the
ized clinical trial (Csendes et al. 1993). The advantage of hemodynamically unstable patient, in whom definitive oper-
PGV and GJ is that it can be done laparoscopically quite ation is not planned, the duodenotomy and pylorotomy may
easily. Furthermore, the GJ is easily reversible, and does not be closed either longitudinally or as a pyloroplasty.
interfere with subsequent gastrectomy if necessary. The dis- Alternatively, a proximal gastric or truncal vagotomy should
advantage of PGV and GJ is that a proximal duodenal or be considered in the hemodynamically stable patient
distal gastric cancer may be missed. The advantage of vagot- (Schroder et al. 2014). Although one might consider truncal
omy and antrectomy is the very low ulcer recurrence rate and vagotomy with antrectomy for bleeding duodenal ulcer in
the fact that tissue is sent to pathology for analysis. This the stable good risk patient, this operation can create a prob-
operation is usually well tolerated in the patient who was lematic duodenal stump, and it carries a much higher periop-
well nourished or obese prior to the development of gastric erative risk in this patient population than in the elective
outlet obstruction, though the operative mortality risk is setting. For bleeding gastric ulcer, high-risk or unstable
probably two or three times higher than vagotomy and patients are best treated with biopsy and oversewing or
drainage. wedge resection. Stable low-risk patients can be treated with
distal gastrectomy to include the bleeding lesion. The addi-
tion of vagotomy to distal gastrectomy for gastric ulcer has
Operation for Bleeding Peptic Ulcer traditionally been considered unnecessary, but it might
decrease the risk of marginal ulcer in patients at high risk for
More than half of the patients admitted to the hospital with recurrent ulcer (smokers and NSAID users).
upper GI bleeding have bleeding peptic ulcer (Laine 2016).
These patients are treated with fluid resuscitation, PPI infu-
sion, EGD, and if necessary, blood transfusion. Risk stratifi- Operation for Nonhealing Peptic Ulcer
cation is important to help identify the 25% who are most
likely to continue bleeding or to rebleed; essentially all Operation for nonhealing peptic ulcer should be done reluc-
bleeding ulcer deaths occur in this group. Hypotension or tantly and only after careful evaluation of the patient, and
shock, hematemesis, endoscopic stigmata of recent hemor- deliberation with both the patient and gastroenterologist.
rhage, and ongoing transfusion requirement identify this While a nonhealing peptic ulcer may be associated with an
undiagnosed malignancy, more commonly it indicates pecu- should be needed infrequently nowadays as an elective treat-
liar physiology and/or a noncompliant patient, both of which ment for intractable duodenal ulcer, given the rarity of this
herald a suboptimal surgical outcome. problem in the modern era. Obviously prior to embarking on
Gastric ulcers: Type I gastric ulcers are located in the these procedures, the surgeon should consider the irrevers-
body of the stomach close to the angularis incisura and are ibility of both pyloroplasty and antrectomy.
not associated with high acid output. Types II and III gastric
ulcers have a duodenal (II) or prepyloric (III) component and
thus are surgically treated more like duodenal ulcers. Type peration for Postoperative Recurrent Ulcer or
O
IV gastric ulcer is relatively uncommon and occurs high on Marginal Ulcer
the lesser curvature close to the gastroesophageal (GE) junc-
tion. Elective surgery for nonhealing type I gastric ulcer In the modern era, the most common cause of marginal
should be preceded by an appropriate biopsy to rule out ulceration is RYGBP (Sverden et al. 2016). Thus, nowadays
occult carcinoma. Historically, the elective operation of most marginal ulcers do not represent recurrent peptic ulcer
choice has been distal gastrectomy to include the ulcer with after ulcer operation.
reconstruction in a Billroth I or Billroth II fashion. Data from When evaluating patients with recurrent peptic ulcer fol-
the pre-Helicobacter, pre-PPI era showed a mortality rate for lowing an ulcer operation or with a marginal ulcer following
this elective operation around 2% with a recurrent ulcer rate some other gastric operation, for example, RYGBP, the dif-
of about 4%. This compared favorably to a 20% recurrence ferential diagnosis includes:
rate following vagotomy and drainage. Proximal gastric
vagotomy with excision of the ulcer yielded lower morbidity 1. Large parietal cell mass: Examples of this include the
and mortality and a recurrence rate in the range of 4–15% patient who had a hemigastrectomy and Roux recon-
(Harbison and Dempsey 2005; Emas et al. 1994). Obviously, struction without vagotomy for gastric ulcer, where gas-
excision of a lesser curve ulcer can be challenging and may tric pH testing on acid suppressive treatment shows
denervate the antrum and pylorus, thwarting the “highly persistently low pH and UGI shows a large gastric rem-
selective” vagotomy. Type IV gastric ulceration poses a chal- nant. Another example would be the patient who had a
lenge because of its relation to the GE junction. Ideally, the truncal vagotomy and gastrojejunostomy, but the vagot-
ulcer is resected in continuity with a distal gastrectomy and omy is incomplete. Adequacy of vagotomy can be
reconstruction with gastroduodenostomy (Pauchet opera- assessed by measuring serum pancreatic polypeptide
tion) or Roux-en-Y esophagogastrojejunostomy (Csendes during sham feeding; an increase in PP with sham feed-
operation). Other options include vagotomy and drainage ing suggests incomplete vagotomy. Finally, a large pari-
with biopsy or excision of the ulcer, or biopsy of the ulcer etal cell mass causing recurrent ulceration may be seen
followed by distal gastric resection. Total gastrectomy for in the patient who had a Roux-en-Y gastric bypass for
benign gastric ulcer should be avoided, and it must be recog- severe obesity and the proximal pouch is large, and/or
nized that any type of distal gastric resection can be nutri- the patient develops a gastrogastric fistula (assessed by
tionally problematic in the chronically thin patient. EGD and UGI).
Duodenal ulcers: Elective surgery for intractable or non- 2. Hypergastrinemia: Causes include retained antrum,
healing duodenal ulcer should be rare. The surgical options which is out of continuity with the proximal stomach, or
include proximal gastric vagotomy (PGV), truncal vagotomy a gastrinoma. If the gastrin level increases with secretin
with drainage procedure, or vagotomy and antrectomy. Any infusion (positive secretin stimulation test), this suggests
elective surgery for an intractable duodenal ulcer must have gastrinoma (Mendelson and Donowitz 2017).
low morbidity. In the pre-Helicobacter, pre-PPI era, clinical 3. Smoking.
data showed that, compared to other surgical options, PGV 4. NSAID or aspirin use.
had the lowest postoperative morbidity and mortality rate 5. Persistent or recurrent helicobacter infection.
while providing an acceptably low recurrence rate when per- 6. Ischemia of the jejunal limb. This is more common in
formed electively for intractable duodenal ulceration Roux-en-Y gastrojejunostomy, particularly gastric
(Harbison and Dempsey 2005; Millat et al. 2000). But in the bypass.
modern era, PGV is likely no better than PPI, and most sur- 7. Stump cancer may present as recurrent ulcer disease
geons are not experienced with the operation. PGV remains years after the first ulcer operation.
a consideration, however, in patients in need of safe acid sup- 8. Noncompliance: Many patients referred to the surgeon
pression who cannot afford, tolerate, or comply with chronic with recurrent or marginal ulcer are noncompliant with
PPI treatment. Truncal vagotomy (TV) and drainage or TV prescribed PPIs, continue to smoke, and/or continue to
and antrectomy are associated with higher postoperative use NSAIDs or aspirin. This is an important point, since
morbidity and mortality rates than PGV. These operations continued noncompliance predicts another recurrent
ulcer after revisional operation. On the other hand, good and the lack of suture fixation of the stomach to the abdomi-
compliance usually predicts success with revisional oper- nal wall. Laparoscopic gastrostomy provides direct visual-
ation and may even obviate the need for revisional ization as well as a method of suture fixation but is more
operation. invasive. Open gastrostomy is the most invasive but may be
the only option in certain patients with prior abdominal sur-
In addition to assessing ongoing compliance with medical gery. The Stamm gastrostomy is the most commonly used
treatment, prior to reoperating on the patient for recurrent open method. This can be done under local anesthesia and
peptic ulcer or marginal ulcer, the surgeon should review the sedation in many patients. Options for tube type include sim-
prior operative notes and pathology reports. Workup should ple mushroom or Foley balloon catheter, commercially avail-
include upper GI series, upper endoscopy, gastric emptying able gastrostomy catheter, button gastrostomy, and GJ tubes,
scan, tests for helicobacter, and serum gastrin level. Other which allow gastric drainage and transpyloric enteral feed-
tests to consider include secretin stimulation test to rule out ing. The Janeway gastrostomy creates a permanent mucosa-
gastrinoma as a cause of hypergastrinemia, urine nicotine lined gastrocutaneous fistula, obviating the need for a
level, serum salicylates, and sham feeding to evaluate com- continuous indwelling tube; however, leakage and skin irri-
pleteness of vagotomy (serum pancreatic polypeptide tation can be problematic and, appropriately, it is performed
response or gastric acid secretory response is assessed). infrequently.
Consultation or even better comanagement with an experi-
enced gastroenterologist is important, and infectious dis-
eases consultation to confirm helicobacter eradication can be Duodenostomy
helpful.
Surgical options for recurrent peptic ulcer depend upon A tube is positioned in the duodenum for decompression,
the original operation. Options include thoracoscopic vagot- usually to protect a tenuous duodenal suture line. The safest
omy, takedown of loop gastrojejunostomy if gastric outlet is way to accomplish this is via a 14 F or 16 F jejunal tube
intact, distal gastric resection to include the gastrojejunal placed in a retrograde Witzel fashion with the tip in the
anastomosis and recurrent ulcer, conversion of Roux-en-Y to descending duodenum and the jejunostomy site sutured to
Billroth II (not advisable with small gastric remnant), and the abdominal wall. Alternatively, a duodenostomy tube may
subtotal or near-total gastrectomy with Roux reconstruction. be placed in a Stamm fashion into the lateral duodenum or
Reoperation for recurrent ulcer after hemigastrectomy or into the end of the duodenal stump. A closed suction drain is
marginal ulcer after Roux-en-Y gastric bypass can be chal- placed nearby. If it is not possible to obtain apposition
lenging because of involvement of adjacent structures such between the duodenal tube site and the abdominal wall, the
as pancreas, celiac artery branches, spleen, liver, colon, and/ site should be covered with omentum. Lateral duodenostomy
or bypassed stomach. Preoperative evaluation often underes- tubes (especially balloon or mushroom catheters) can create
timates the extensiveness of the inflammatory process. problems early in the postoperative period if inadvertently
During revision of gastric bypass for marginal ulceration, if dislodged.
part of the bypassed stomach is resected, it is important that
some parietal cell mass be left in continuity with the antrum.
Otherwise, unremitting antral gastrin secretion ensues since Stapling the Stomach and Duodenum
there is no luminal acid (the shut-off signal for gastrin secre-
tion) in the antrum. Complete resection of the bypassed Most gastric and duodenal resections in the USA utilize sta-
stomach to include the antrum is preferable to this situation. pling instruments, typically “GIA,” “TA,” and “EEA”
devices. In this era of six-sigma manufacturing, “surgeon
failure” (i.e., pilot error) is far more common than “stapler
Gastrostomy and Duodenostomy failure.” For safe application, it is important to adhere to cer-
tain principles:
Gastrostomy
1. Choose the appropriate staple size for the tissue. If the
Gastrostomy tubes may be placed endoscopically (percuta- staples are too big, excessive staple-line bleeding can
neous endoscopic gastrostomy or PEG), radiologically, lapa- occur or rarely leakage of air and GI contents through
roscopically, or in a conventional open fashion. Each method the intact staple line. If the staples are too small, they
has its unique advantages and limitations. PEG is a relatively will not go full thickness through both walls and the
simple method that can be performed outside the operating staples will not form correctly. This results in staple-line
room and does not require general anesthesia. The limitation failure and leak. It is probably better to use a staple size
of this method lies in the blind nature of the tube insertion that is too big than one that is too small. It is also impor-
tant to recognize that occasionally the tissue (usually the 10. When performing a Roux gastrojejunostomy with the
stomach in a reoperative situation) is simply too thick “EEA” device, care must be taken not to catch the back
for any stapler, and hand sewing in this situation is the wall of the jejunum, which results in a stenotic or
best option. obstructed efferent limb.
2. Similar staplers made by different companies can have
subtle differences. The surgeon who has been using one
company’s stapler for 10 years cannot assume that she Postoperative Complications
knows exactly how to use the other company’s similar
stapler. There are subtle differences in how the instrument Pulmonary Problems
is designed to function, and when changing stapler sup-
plier, the surgeon must take it upon herself to become Atelectasis is probably the most common complication after
familiar with the new instrument before using it in the gastric operation. Adequate analgesia, incentive spirometry,
operating room. and early ambulation help minimize this problem.
3. Allow the stapling instrument to compress the tissue for Pneumonia is a less common but feared complication
a few seconds prior to firing the instrument. after gastric surgery. Predisposing factors are atelectasis,
4. Heavy braided suture material in the vicinity of the anas- vomiting, and preexisting lung disease. Pulmonary embo-
tomosis may snag the “EEA” stapler, making it difficult lism is unusual with current prophylactic practices but should
to remove after firing without disrupting the fresh be considered in any postoperative patient with shortness of
anastomosis. breath, chest pain, or unexplained fever and tachycardia.
5. Firing the GIA on top of an existing parallel staple line
or suture line may result in the knife catching the exist-
ing staples or sutures, resulting in disruption and leak. Anastomotic Leak
This is why when stapling across an existing staple line
with a GIA, it is best to position the stapler so that the A suture line leak following a gastric or duodenal operation
knife hits the existing line at an angle greater than 45°. can create a potentially fatal situation. These problems typi-
6. There are no good data to support or refute the practice cally manifest by the fifth or sixth postoperative day and are
of oversewing staple lines. We do not do this routinely, associated with increasing abdominal pain, fever, distension,
but we always gently abrade the TA staple line looking and/or leukocytosis. These findings should prompt an aggres-
for bleeders that are handled with gentle discreet cautery sive diagnostic evaluation including contrast CT scan, or
or suture ligature. Gastrografin upper gastrointestinal (GI) series. Although
7. When tissue is resected with the “GIA” device, the spec- small leaks can sometimes be managed nonoperatively with
imen staple line should be inspected. If the specimen a strategically placed drain, reoperation should not be
staple line is incompetent, the patient staple line may delayed in the deteriorating patient with sepsis. Operative
also be bad. strategies focus on drainage, since repeat resection and anas-
8. When feasible, staple lines in the stomach and duode- tomosis have a high complication rate and are ill advised.
num should be tested intraoperatively. The simplest Irrigation and drainage of the peritoneal cavity, decompres-
method is air insufflation via NG tube and distention of sion of the leaking segment (e.g., duodenostomy or gastros-
the submerged staple lines, which should be airtight. tomy), closure or intubation of the leak (or both), and feeding
Instillation of methylene blue and intraoperative endos- jejunostomy are important aspects of surgical management.
copy are other useful methods to confirm staple-line If the initial operation was laparoscopic, sometimes an ade-
integrity. quate reoperation can be accomplished laparoscopically.
9. Staple-line bleeding into the lumen can be problematic
and rarely can be life threatening. This usually occurs
after a GIA- or EEA-type anastomosis. Prior to closure Wound Problems
of the common channel after a GIA anastomosis, the
lumen should be inspected for excessive hemorrhage Wound infection, dehiscence, and herniation can occur after
and bleeders controlled. Following EEA gastrojejunos- major gastric operations. This is one obvious advantage of
tomy, intraoperative endoscopy should be performed if the laparoscopic/robotic approach. Wound problems are
excessive staple-line hemorrhage is suspected (copious commonly interrelated in that infection predisposes to dehis-
bleeding from EEA insertion site, or luminal distention, cence and hernia formation. Wound infection is related to
or copious blood from NG tube). Bleeders can be con- intraoperative contamination, and the concentration of bacte-
trolled with endoscopic cautery or full-thickness laparo- ria in luminal contents is increased in the setting of acid sup-
scopic or open suture. pression, gastric cancer, and obstruction. Appropriate use of
prophylactic antibiotics and good surgical technique are patients can be nursed through the first 3 months postopera-
important preventative measures. Pulmonary disease, tively, reoperation is often unnecessary and GI function
abdominal distension, obesity, infection, malnutrition, and returns to normal. Reoperation should, thus, usually be
steroid therapy have all been shown to increase the incidence delayed for at least 3 months (preferably 6 months) after the
of wound problems, and these risk factors are not unusual in first operation unless a high-grade or complete mechanical
patients having stomach operations. obstruction has been demonstrated in the small intestine.
This may be due to a process that predisposes to small bowel
strangulation (e.g., herniation through the transverse meso-
Pancreatitis colon or proximal adhesive small bowel obstruction) and
should be operated on promptly if there is significant abdom-
Pancreatitis following gastroduodenal operation is generally inal pain.
caused by operative trauma to the gland itself or to the major
or minor papilla. Either of the papillae can be injured during
aggressive dissection of the postbulbar duodenum. More Dumping Syndrome
commonly, the more proximal minor papilla is occluded or
transected. This is usually a self-limited problem unless the Clinically significant dumping occurs in 5–10% of patients
patient has pancreas divisum. Occasionally, a duodenal after pyloroplasty, pyloromyotomy, or distal gastrectomy
stump leak is misdiagnosed as pancreatitis. Postoperative (Berg and McCallum 2016). The symptoms are thought to be
pancreatitis does not require invasive treatment except in a result of the abrupt delivery of a hyperosmolar load into the
cases of infected necrotizing pancreatitis or persistent pan- small bowel. It is usually due to ablation of the pylorus, but
creatic fistula. decreased gastric compliance with accelerated emptying of
liquids (e.g., after PGV) is another accepted mechanism.
“Early” dumping syndrome occurs about 15–30 min after a
Early Gastric Stasis meal when the patient typically becomes diaphoretic, weak,
light-headed, and tachycardic. These symptoms may be ame-
Occasionally in the hospitalized patient who is recovering liorated by recumbence or saline infusion. Abdominal pain
from gastric surgery, the nasogastric tube “cannot be or cramping is common. Diarrhea often follows. A variety of
removed” because of persistent nausea and vomiting. aberrations in GI hormone levels have been observed in
Usually, the gastric outlet is anatomically patent in these patients with dumping. Medical therapy for early dumping
patients and gastric emptying improves with time, but some- syndrome consists of dietary management and, if necessary,
times this can be a few weeks. The etiology of delayed gas- somatostatin analog (octreotide). “Late” dumping occurs
tric emptying is poorly understood. If the patient is otherwise 2–3 h after a meal and represents a form of postprandial
doing well, the first step is TPN and continued NG drainage hypoglycemia. It is the rare patient with dumping symptoms
via suction, or preferably via gravity if tolerated. Promotility who requires an operation. Most patients improve with time
agents may or may not be helpful. Alternative methods of (months and even years), dietary management, and medica-
gastric intubation and alimentation can be considered, and tion. The results of remedial operation for dumping are vari-
are clearly preferable to a major reoperation during the first able and unpredictable. A variety of surgical approaches
6 weeks postoperatively when the inflammatory response in have been described, none of which works consistently well.
the surgical field may be intense. Reoperation during this Options include simple takedown of the gastrojejunostomy if
early postoperative period is often difficult, hazardous, and the antrum and pylorus are intact and patent, or conversion of
usually unnecessary. Laparoscopic-assisted jejunal feeding Billroth I or Billroth II into a Roux-en-Y configuration, tak-
tube placement can be considered, and if an adequate gastric ing advantage of the slowing effect of the typically abnormal
remnant remains, a decompressing gastrostomy can some- Roux motility (Miedema and Kelly 1991). Whether Roux-
times be placed laparoscopically or endoscopically. en-Y proximal duodenojejunostomy (i.e., duodenal switch
Sometimes another smaller tube or the long end of a GJ tube procedure) would benefit the rare patient with disabling
can be advanced into the jejunum for enteral feeding. In dumping following pyloroplasty is unclear.
patients with a small gastric remnant, where a Stamm gas-
trostomy technique is impossible because the stomach will
not reach the abdominal wall, a decompressing gastric tube Diarrhea
can be passed retrograde through the jejunal efferent limb
(using a Witzel technique), and another (distal) tube may be Truncal vagotomy is associated with clinically significant
placed antegrade as a Witzel feeding jejunostomy. Both tube diarrhea in 5–10% of patients (Raimes et al. 1986). It occurs
sites are sutured to the peritoneum at the exit sites. If these soon after operation and is usually not associated with other
symptoms, a fact that helps distinguish it from dumping (see emptying problems compared to the other operations for bile
above). The diarrhea may be a daily occurrence or it may be reflux, but controlled data are lacking. Primary bile reflux
more sporadic and unpredictable. This syndrome may be a gastritis (i.e., no previous operation) is rare and may be
cause of diarrhea associated with jejunal feedings after treated with duodenal switch operation, essentially an end-
esophagectomy. Possible mechanisms include intestinal dys- to-end Roux-en-Y to the proximal duodenum. The Achilles’
motility and accelerated transit, bile acid malabsorption, heel of this operation is, not surprisingly, marginal ulcer-
rapid gastric emptying, and bacterial overgrowth (Malchow- ation. Thus, it should be combined with proximal gastric
Moller et al. 1986). Some patients with postvagotomy diar- vagotomy and/or chronic acid suppressive medication.
rhea respond to cholestyramine, and in others codeine or
loperamide is useful (Davis and Ripley 2017).
Chronic Gastric Stasis and Roux Syndrome
Bile Reflux Gastritis Gastric stasis following operation on the stomach may be
due to gastric motor dysfunction or mechanical obstruction
Following ablation or resection of the pylorus, most patients (Schirmer 1994; Forstner-Barthell et al. 1999; Speicher et al.
have bile in the stomach on endoscopic examination along 2009). The gastric motility abnormality may have been pre-
with some degree of gross or microscopic gastric inflamma- existent and unrecognized by the operating surgeon.
tion (Ritchie Jr 1986; Malagelada et al. 1985). Attributing Alternatively, it may be secondary to deliberate or uninten-
postoperative symptoms to bile reflux is, therefore, problem- tional vagotomy or resection of the dominant gastric pace-
atic as most asymptomatic patients also have bile reflux. It is maker. An obstruction may be mechanical (e.g., anastomotic
generally accepted that a small subset of patients have the stricture, marginal ulcer, efferent limb kink from adhesions
clinical syndrome referred to as bile reflux, or alkaline reflux, or constricting mesocolon, or a proximal small bowel
and gastritis. These patients present with nausea, bilious obstruction) or functional (e.g., retrograde peristalsis in a
vomiting, epigastric pain, and some evidence of excess Roux limb). The latter situation is referred to as the Roux
enterogastric reflux. Curiously, symptoms often develop syndrome (Schirmer 1994; Vogel and Woodward 1989).
months or years after the initial operation. The differential Chronic gastric stasis presents with vomiting (often of
diagnosis includes afferent or efferent loop obstruction, gas- undigested food), bloating, epigastric pain, and weight loss.
tric stasis, small bowel obstruction, and gastric stump cancer. Evaluation includes esophagogastroduodenoscopy (EGD),
Plain abdominal radiography, upper endoscopy, upper GI upper gastrointestinal series, gastric emptying scan, and gas-
series, abdominal CT scans, and gastric emptying scans are tric motility testing. Once mechanical obstruction has been
helpful for evaluating these possibilities. Bile reflux may be ruled out, medical treatment is successful in most cases of
quantitated with gastric analysis or more commonly scintig- motor dysfunction that follows previous gastric surgery. It
raphy (bile reflux scan). Remedial operation eliminates the consists of dietary modification and promotility agents.
bile from the vomitus and may improve the epigastric pain, Intermittent oral antibiotic therapy may be helpful for treat-
but it is quite unusual to render these patients completely ing bacterial overgrowth with its attendant symptoms of
asymptomatic, especially if they are narcotic dependent. Bile bloating, flatulence, and diarrhea. Severe chronic gastropare-
reflux gastritis after distal gastric resection may be treated by sis following vagotomy and drainage may be treated with
Roux-en-Y gastrojejunostomy (Ritchie Jr 1986; Malagelada subtotal (75%) gastrectomy. Billroth II anastomosis with
et al. 1985), Henley loop (Aronow et al. 1995), or Billroth II Braun enteroenterostomy may be preferable to Roux-en-Y
gastrojejunostomy with Braun enteroenterostomy (Vogel reconstruction since recurrent gastric stasis attributable to
et al. 1994). To eliminate bile reflux, the Roux limb or Henley the Roux syndrome is theoretically avoided. If gastric stasis
loop should be at least 45 cm long, and a Braun enteroenter- is felt to be related to recurrent or marginal ulcer, this usually
ostomy should be placed at a similar distance from the stom- responds to medical therapy. Endoscopic dilation is occa-
ach. Excessively long jejunal limbs may be associated with sionally helpful. Gastroparesis following subtotal gastric
obstruction or malabsorption. All operations for bile reflux resection is best treated with near-total (95%) or total gastric
gastritis can result in marginal ulceration and, thus, are com- resection and Roux-en-Y reconstruction. Gastric pacing is
bined with distal gastrectomy if a large gastric remnant promising, but it has not achieved widespread clinical use-
exists. If generous gastrectomy has already been done at a fulness in the treatment of postoperative gastric atony (Navas
previous operation, the Roux or Braun operations may be et al. 2017).
attractively simple. Vagotomy is usually not added since the The Roux syndrome seems to be more common in patients
benefits of decreased acid secretion may be outweighed by with a generous gastric remnant. Truncal vagotomy has also
vagotomy-associated dysmotility in the gastric remnant. The been implicated. Medical treatment consists of promotility
Roux operation may be associated with an increased risk of agents. Surgical treatment consists of paring down the gas-
tric remnant. If gastric motility is severely disordered, a 95% gastric bypass for morbid obesity. It also occurs in up to one-
gastrectomy should be done. The Roux limb should be third of patients who have had a vagotomy or gastric resec-
resected if it is dilated and flaccid, and if doing so does not tion. Iron deficiency is the most common cause, but vitamin
put the patient at risk for short bowel problems. B 12 or folate deficiency also occurs. Of course, patients who
Gastrointestinal continuity may be reestablished with another have had a total gastrectomy will all develop life-threatening
Roux, or a Henley isoperistaltic isolated jejunal loop inter- vitamin B 12 deficiency without supplementation.
posed between the small gastric remnant and the duodenum. Bone disease: Abnormalities of calcium and vitamin D
While some patients with severe gastric stasis problems fol- metabolism can contribute to metabolic bone disease in
lowing gastric surgery can be helped with near-total or total patients following gastric surgery. Calcium absorption
gastrectomy, many patients remain significantly symptom- occurs primarily in the duodenum, which is bypassed with a
atic (Visick 3 or 4), and most have chronic nutritional prob- gastrojejunostomy, distal gastric resection, or gastric bypass.
lems (Schirmer 1994; Forstner-Barthell et al. 1999; Speicher Fat malabsorption due to bacterial overgrowth or inefficient
et al. 2009; Vogel and Woodward 1989). digestion can significantly affect absorption of vitamin D, a
fat-soluble vitamin. The problems usually manifest as pain
or fractures years after the gastric operation. Musculoskeletal
Metabolic Problems after Gastric Operation symptoms should prompt a study of bone density. Dietary
supplementation of calcium and vitamin D may be useful for
There are a variety of chronic nutritional and metabolic preventing these complications. Routine skeletal monitoring
problems that are not uncommon after gastric operation of patients at high risk (e.g., elderly men and women; post-
(Davis and Ripley 2017; Harju 1990; Hu et al. 2013; Ichikawa menopausal women) may prove useful for identifying skel-
et al. 2002; Ledoux et al. 2014). Given the surge in bariatric etal deterioration that with appropriate treatment can be
surgery in the last 20 years, most patients with one or more arrested.
of these problems nowadays have had previous bariatric sur-
gery, but these issues can also significantly compromise
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Truncal Vagotomy: Surgical Legacy
Technique 25
Indications Avoiding Esophageal Trauma
Truncal vagotomy is rarely indicated as an adjunct to man- The best way to avoid trauma to the esophagus is by per-
agement of refractory duodenal ulcer disease or during performing most of the esophageal dissection under direct
formance of other procedures (see Chap. 24). vision. Forceful, blind finger dissection can be dangerous.
After the peritoneum overlying the abdominal esophagus is
incised (Figs. 25.1, 25.2, and 25.3), the crural musculature
Preoperative Preparation should be clearly exposed. The next vital step in this sequence
is to develop a groove between the esophagus and the adjoin-
• See Chap. 24. ing crux on each side. This should be done under direct
vision using a peanut dissector (Fig. 25.4). Only after the
anterior two-thirds of the esophagus has been exposed, is it
Pitfalls and Danger Points permissible to insert an index finger and encircle the
esophagus.
• Esophageal trauma
• Splenic trauma
• Inadequate vagotomy Avoiding Splenic Trauma
• Disruption of esophageal hiatus with postoperative hiatal
hernia; gastroesophageal reflux Splenic trauma can be prevented by avoiding any traction
that draws the stomach toward the patient’s right. Such trac-
tion may avulse the splenic capsule because of attachments
Operative Strategy between the omentum and the surface of the spleen.
Consequently, all traction on the stomach should be applied
Part of the strategy is to consider alternatives. Most patients on the lesser curvature side and directed toward the patient’s
who come to truncal vagotomy have failed intensive medical feet. Avulsion of a portion of the splenic capsule, in the
management and developed a severe complication of their absence of gross disruption of the splenic pulp, does not
peptic ulcer disease, such as upper gastrointestinal bleeding. require splenectomy. Application of topical hemostatic
Even then, all nonoperative methods of bleeding control are agents and pressure may control bleeding satisfactorily.
typically exhausted before surgery is undertaken.
Laparoscopic and thoracoscopic versions of vagotomy
have been described. Because most of these are done under Preventing Incomplete Vagotomy
urgent/emergent conditions, only the open version is
described here. In most cases of recurrent marginal ulcer, it turns out that the
posterior vagal trunk has not been divided. This trunk is gen-
erally the largest trunk encountered. The surgeon’s failure to
C. E. H. Scott-Conner (*) locate the posterior vagus suggests inadequate knowledge of
Department of Surgery, University of Iowa Carver College the anatomy of the posterior vagus. The right (posterior)
of Medicine, Iowa City, IA, USA vagal trunk is frequently 2 cm or more distant from the right

https://doi.org/10.1007/978-3-030-81415-1_25
208 C. E. H. Scott-Conner
Fig. 25.3
Fig. 25.1
Fig. 25.2
Fig. 25.4
lateral wall of the esophagus. It is often not delivered into the
field by the usual maneuver of encircling the esophagus with arrives several days after the operation can serve as a test of the
the index finger. If the technique described below is carefully surgeon’s ability to identify nerves visually. The surgeon may
followed, this trunk is rarely overlooked. be surprised to find that four or five specimens of nerve have
To improve tissue recognition skills, the surgeon should been removed during a complete truncal vagotomy. Frozen
place each nerve specimen removed from the vicinity of the section examination is helpful but not conclusive because it
esophagus into a separate bottle for histologic examination. cannot prove that all the vagal nerve branches have been
Each bottle should have a label indicating the anatomic area removed. The surgeon must gain sufficient skill at identifying
from which the nerve was removed. The pathology report that nerve trunks to be certain no significant nerve fiber remains.
25 Truncal Vagotomy: Surgical Legacy Technique 209
Hiatus Hernia Identification of the Right (Posterior) Vagus
Significant hiatal hernia following vagotomy occurs in no The posterior vagal trunk often is situated 2–3 cm lateral and
more than 1–2% of cases. This percentage can probably be posterior to the right wall of the esophagus. Consequently, its
reduced if the surgeon repairs any large defects seen in the identification requires that when the surgeon’s right index fin-
hiatus after the dissection has been completed. ger encircles the lowermost esophagus, proceeding from the
patient’s left to right, the fingernail should pass over the ante-
rior aorta. The finger should then go a considerable distance
Documentation Basics toward the patient’s right before the finger is flexed. The fin-
gernail then rolls against the deep aspect of the right branch
• Findings of the crural muscle. When this maneuver is completed, the
right trunk, a structure measuring 2–3 mm in diameter, is con-
tained in the encircled finger to the right of the esophagus
Operative Technique (Fig. 25.6). Its identification may be confirmed in two ways.
First, look for a major branch going toward the celiac gan-
Incision and Exposure glion. Second, insert a finger above the left gastric artery near
Make a midline incision from the xiphoid to a point about

5 cm below the umbilicus. The incision can be extended into
the xiphocostal junction if necessary. Elevate the sternum
8–10 cm by means of an upper hand or Thompson retractor.
Elevate the upper half of the operating table about 10°. Place
fixed retractors to elevate the left lobe of cephalad. In rare
instances, the triangular ligament must be incised, and the
left lobe of the liver retracted to the patient’s right for expo-
sure (see Chap. 18). If vagotomy is being performed as an
adjunct to suture ligation of a bleeding duodenal ulcer, take Left vagus
time to reposition the retractors and optimize exposure of the nerve
esophageal hiatus.
Using long DeBakey forceps and long Metzenbaum scis-
sors, incise the peritoneum overlying the abdominal esopha-
gus (Figs. 25.1, 25.2, and 25.3). Next identify the muscles of
the right and left branches of the crux. Use a peanut dissector
to develop a groove between the esophagus and the adjacent Fig. 25.5
crux, exposing the anterior two-thirds of the esophagus
(Fig. 25.4). At this point, insert the right index finger gently
behind the esophagus and encircle it.
Left (Anterior) Vagal Trunks

Right vagus
In our experience, whereas the posterior trunk often exists as nerve
a single structure in the abdomen, the anterior vagus divides
into two or more trunks in more than 50% of cases. The main
left trunk generally runs along the anterior wall of the lower
esophagus, and the other branches may be closely applied to
the longitudinal muscle of the anterior esophagus. The major
nerve branches may be accentuated by caudal traction on the
stomach, which makes the anterior nerves prominent against
the esophagus. After applying hemostatic clips, remove seg-
ments from each of the anterior branches (Fig. 25.5). Any
suspicious fibers should be removed with forceps and sent to
the pathology laboratory for analysis. Fig. 25.6
placed to approximate the muscle bundles behind the esoph-

agus, taking care to leave a gap of one fingerbreadth between
the esophagus and the newly constructed hiatus. No attempt
at fundoplication or any other antireflux procedure needs to
be undertaken unless the patient had symptoms or other evi-
dence of gastroesophageal reflux and esophagitis before the
operation. Check hemostasis before going on to the gastric
resection or drainage procedure, if not already performed.
Postoperative Care
• See Chap. 27.
Complications
Fig. 25.7 • Operative perforation of the esophagus: This injury must

be carefully repaired with two layers of interrupted
sutures. If additional exposure is needed, do not hesitate
the lesser curvature of the stomach, and draw the left gastric to extend the abdominal incision into the left sixth or sev-
vessel in a caudal direction. This applied traction causes it to enth intercostal space. For additional security, when
be more readily palpable as a stout cord. The right trunk repairing a low esophageal tear, cover the suture line with
rarely divides in the abdomen above the level of the esopha- gastric wall by performing a Nissen fundoplication.
gogastric junction. It is relatively common for this trunk to be • Postoperative gastric stasis: Because this complication is
“left behind” when the esophagus is encircled. Thus, if the unpredictable and difficult to manage, a drainage proce-
trunk cannot be found on the esophagus, check the soft tis- dure such as pyloroplasty or gastrojejunostomy is gener-
sues posterior to the esophagus. ally done with truncal vagotomy.
Apply a long Mixter clamp to the nerve, place hemostatic
clips above and below the clamp, and remove a 2–3 cm seg-
ment of nerve and submit it for histologic study. Rotate the Further Reading
esophagus and inspect the posterior wall. At the conclusion
of this step, the lower 5 cm of esophagus should be cleared Bonanno A, Tieu B, Dewey E, Husain F. Thoracoscopic truncal vagot-
omy versus surgical revision of the gastrojejunal anastomosis for
of all nerve fibers. One should see only longitudinal muscle recalcitrant marginal ulcers. Surg Endosc. 2018 Aug 21 (epub ahead
throughout its circumference (Fig. 25.7). of print).
Donohue PE. Parietal cell vagotomy versus vagotomy-antrectomy:
Ulcer surgery in the modern era. World J Surg. 2000;24:264–9.
Lagoo J, Pappas TN, Perez A. A relic or still relevant: the narrowing
Suture of Crural Musculature role for vagotomy in the treatment of peptic ulcer disease. Am J
Surg. 2014;2017(1):120–6.
If the hiatus admits two or more fingers alongside the esoph- Roberts JP, Debas HT. A simplified technique for rapid truncal vagot-
agus, one or two sutures of 0 cotton or Tevdek should be omy. Surg Gynecol Obstet. 1989;168:539.
Proximal Gastric Vagotomy: Surgical
Legacy Technique 26
Indications sternum elevates the sternum and draws it in a cephalad

direction.
Peptic ulcer disease refractory to medical management, see
Chap. 24.
revention of Hematoma and Injury to Gastric
P
Lesser Curve
Hematomas in the region of the gastrohepatic ligament along
• Esophagogastroduodenoscopy to confirm the diagnosis. the lesser curve of the stomach increase the difficulty of
• Carefully consider all alternatives, including intensive identifying the terminal branches of the nerve of Latarjet.
medical management and laparoscopic vagotomy. Furthermore, rough dissection and hematomas in this area
may damage the deserosalized muscle along the lesser curve
to such an extent that necrosis may occur. This rare compli-
Pitfalls and Danger Points cation is preventable if dissection is performed gently.
Resuturing the peritoneum produces inversion of the desero-
• Hematoma of gastrohepatic ligament salized portion of the lesser curve and helps prevent
• Incomplete vagotomy perforation.
• Damage to innervation of pyloric antrum
• Injury to spleen
• Necrosis or perforation of lesser curvature of stomach Preserving Innervation of the Antrum
The anterior and posterior nerves of Latarjet terminate in a

Operative Strategy configuration resembling the foot of a crow. This crow’s foot
portion maintains innervation of the antrum and pylorus and
Exposure ensures adequate emptying of the stomach.
Part of the operative strategy must include evaluation of all

alternatives, including intensive medical management and Adequacy of Proximal Vagotomy
truncal vagotomy with drainage. Even in the best hands, dur-
ing the period of time when ulcer surgery was common, this Hallenbeck et al. demonstrated that the incidence of recur-
operation carried a significant failure rate. rent postoperative ulcer dropped markedly when they
The visibility of the area around the lower esophagus is extended the dissection so the lower esophagus was com-
greatly enhanced if the Thompson or the upper hand retrac- pletely freed of any vagal innervation. This required meticu-
tor is attached so the blade underlying the lower border of the lous removal of all nerve branches reaching the lower 5–7 cm
of the esophagus and the proximal stomach. Grassi noted
that one reason the proximal vagotomy technique fails is that
C. E. H. Scott-Conner (*)
surgeons sometimes overlook a branch leading from the pos-
Department of Surgery, University of Iowa Carver College
of Medicine, Iowa City, IA, USA terior vagus nerve to the posterior wall of the upper stomach.
e-mail: carol-scott-conner@uiowa.edu He named it the “criminal nerve.” If all the vagal nerve

https://doi.org/10.1007/978-3-030-81415-1_26
branches that enter the distal esophagus or proximal stomach wall of the aorta, and curve it anteriorly along the posterior
are divided, interruption of the criminal nerve is included in aspect of the right side of the diaphragmatic crux, entering
the dissection. the operative field adjacent to the right crux. As a result of
this maneuver, the index finger almost invariably contains
both vagal trunks in addition to the esophagus. The right
Postoperative Gastroesophageal Reflux vagus generally is considerably larger than the left and is
almost always a single trunk. The left (anterior) vagus can
Extensive dissection in the region of the esophagogastric be identified generally at the right anterior surface of the
junction may produce or exacerbate gastroesophageal reflux. lower esophagus. Separate each vagal trunk gently from the
Patients with preoperative gastroesophageal reflux should esophageal wall, pulling the vagal trunk toward the right
undergo an antireflux procedure at completion of the proxi- and the esophagus to the left. Encircle each vagal trunk
mal gastric vagotomy. A posterior gastropexy (see Chap. 21) with a Silastic loop, brought out to the right of the
or a Nissen fundoplication (see Chap. 18) may be done. The esophagus.
choice of procedure depends on the experience of the sur-
geon and the operative findings.
Identification of Crow’s Foot
Documentation Basics Pass the left index and middle fingers through an avascular
area of the gastrohepatic omentum and enter the lesser sac.
• Findings. This enables the nerves and blood vessels along the lesser
curvature of the stomach to be elevated and put on stretch.
The anterior nerve of Latarjet, which is the termination of the
Operative Technique left vagus trunk as it innervates the anterior gastric wall, can
be seen through the transparent peritoneum adjacent to the
Incision and Exposure lesser curvature of the stomach. It intermingles with terminal
branches of the left gastric artery, which also go to the lesser
With the patient supine, elevate the head of the operating curvature. As the nerve of Latarjet reaches its termination, it
Table 10–15°. Make a midline incision from the xiphoid to a divides into four or five branches in a configuration that
point 5 cm below the umbilicus. Place fixed retractors to resembles a crow’s foot. These terminal branches innervate
elevate the sternum, and the left lobe of the liver above the the distal 6–7 cm of the antrum and pylorus and should be
esophageal hiatus. On rare occasions, this exposure is not preserved (Figs. 26.1 and 26.2a).
adequate, and the triangular ligament of the left lobe of the
liver may have to be divided with the left lobe retracted to the
patient’s right.
Identification of Right and Left Vagal Trunks L. vagus n.
Hepatic branches
Expose the peritoneum overlying the abdominal esophagus, of I. vagnus n.
and transect it transversely using long Metzenbaum scissors
Ant. nerve of
and DeBakey forceps. Extend the peritoneal incision to Latarjet
uncover the muscular fibers of the crura surrounding the L. gastric a.
esophageal hiatus (Figs. 26.1, 26.2, and 26.3). Separate the
Line of division
anterior two-thirds of the circumference of the esophagus of branches of
from the adjacent right and left crux of the diaphragm using ant. nerve of
scissors and peanut-sponge dissection under direct vision Latarjet
(Fig. 26.4). Then, encircle the esophagus with the right index
finger.
The right (posterior) vagus nerve is frequently 2 cm or
more away from the esophagus. To avoid leaving the poste-
rior vagus behind, pass the finger into the hiatus at the
groove between the left branch of the crux and the left mar-
gin of the esophagus. Pass the fingernail along the anterior Fig. 26.1
26 Proximal Gastric Vagotomy: Surgical Legacy Technique 213
a b
Fig. 26.2
Dissection of the Anterior Nerve of Latarjet in each hemostat. To preserve the innervation of the antrum,
the hemostats must be applied close to the gastric wall so as
After identifying the crow’s foot, insert a Mixter right-angle not to injure the main trunk of the nerve of Latarjet. Take
clamp underneath the next cephalad branch of the nerve and great care not to tear any of these small blood vessels, as they
the accompanying blood vessels (Fig. 26.2b). This branch is tend to retract and form hematomas in the gastrohepatic liga-
6–7 cm cephalad to the pyloric muscle. After the clamp has ment obscuring the field of dissection. This is a particular
broken through the peritoneum on both sides of these struc- hazard in obese patients. Avoid trauma to the musculature of
tures, divide them between Adson hemostats and carefully the gastric wall, as this area of the lesser curvature is not
ligate with 4–0 silk (Fig. 26.2c). Alternatively, each branch protected by a layer of serosa.
may be double ligated before being divided. Repeat the same Continue dissection of the anterior layer of the gas-
maneuver many times, ascending the lesser curvature of the trohepatic ligament until the main trunk of the left vagus
stomach and taking care not to include more than one branch nerve is reached. Retract this trunk toward the patient’s
right by means of the umbilical tape. At the conclusion

of the dissection, the left vagus nerve should be com-
pletely separated from the wall of the esophagus for a
distance of 6–7 cm above the esophagogastric junction.
Any small nerve branching from the vagus nerve to this
portion of the esophagus should be divided. In this fash-
ion, all the branches from the left vagus to the stomach
are interrupted, with the exception of those innervating
the distal antrum and pylorus. Preserve the hepatic
branch of the vagus trunk also because it leaves the left
vagus and goes to the patient’s right on its way to the
liver.
Dissection of Posterior Nerve of Latarjet
Delineate the posterior leaflet of the gastrohepatic omentum as

it attaches to the posterior aspect of the lesser curvature of the
stomach. Again, the crow’s foot should be identified and pre-
served. Each branch of the left gastric artery and vein, together
with each terminal branch of the posterior nerve of Latarjet,
should be individually isolated, double clamped, divided, and
Fig. 26.3
ligated (Fig. 26.3). Take care to make this division close to the
gastric wall to preserve the main nerve of Latarjet. Continue this
dissection in a cephalad direction until the previously identified
right vagal trunk can be seen alongside the distal esophagus.
When this dissection has been properly completed, it becomes
evident that the right vagus nerve and the gastrohepatic ligament
are situated far to the right of the completely bare lesser curva-
ture. Now dissect away the posterior aspect of the esophagus
from the posterior vagus nerve for a distance of 7 cm above the
esophagogastric junction so no branches from this trunk can
reach the stomach by way of the distal esophagus.
Pay special attention to the criminal nerve of Grassi, which is
a branch of the posterior vagal trunk passing behind the esopha-
gus to the posterior wall of the gastric cardia. If the surgeon’s
left hand can be passed between the freed vagal trunks and the
distal esophagus as well as the gastric fundus, it helps to ensure
that the extent of the dissection has been adequate. In addition,
carefully inspect the longitudinal muscle fibers of the distal
esophagus. Any tiny fibers resembling nerve tissue should be
divided or avulsed from the musculature throughout the circum- Fig. 26.4
ference of the lower 7 cm of esophagus (Fig. 26.4).
Postoperative Care
Repair of the Lesser Curvature
Continue nasogastric suction and intravenous fluids for 48 h.
Use interrupted 4–0 silk Lembert sutures to approximate the At the end of this time, the patient generally is able to be
peritoneum over the gastric musculature, thereby reperitone- advanced to a normal diet. Usually, the postoperative course
alizing the lesser curvature (Fig. 26.5). Close the abdominal is uneventful, and undesirable postoperative gastric sequelae,
incision in the usual fashion, without drainage. such as dumping, are distinctly uncommon.
26 Proximal Gastric Vagotomy: Surgical Legacy Technique 215
Complications Further Reading
• Recurrent ulceration: Inadequate vagotomy results in Casas AT, Gadacz TR. Laparoscopic management of peptic ulcer dis-
recurrent ulceration. ease. Surg Clin N Am. 1996;76:515.
Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard
• Necrosis: Unique to proximal gastric vagotomy is necro- R. Laparoscopic highly selective vagotomy. Br J Surg. 1994;81:554.
sis of the lesser curvature. Although rare (0.3% of all Donohue PE. Parietal cell vagotomy versus vagotomy-antrectomy:
proximal gastric vagotomy operations), it is often fatal. It ulcer surgery in the modern era. World J Surg. 2000;24:264–9.
probably results from trauma or hematoma of the gastric Grassi G. Special comment: anatomy of the “criminal branch” of the
vagus and its surgical implications. In: Nyhus LM, Wastell C, edi-
wall in an area that lacks serosa. Prevention requires accu- tors. Surgery of the stomach and duodenum. Boston: Little, Brown;
rate dissection assisted by reperitonealization of the lesser 1977. p. 61.
curvature by suturing (Fig. 26.5). Treatment requires Hallenbeck GA, Gleysteen JJ, Aldrete JS. Proximal gastric vagotomy:
early diagnosis and resection. effects of two operative techniques on clinical and gastric secretory
results. Ann Surg. 1976;184:435.
Jordan PH Jr, Thornby J. Parietal cell vagotomy performed with fundo-
plication for esophageal reflux. Am J Surg. 1997;173:264.
Lagoo J, Pappas TN, Perez A. A relic or still relevant: the narrowing
role for vagotomy in the treatment of peptic ulcer disease. Am J
Surg. 2014 Jan;2017(1):120–6.
Temple MB, McFarland J. Gastroesophageal reflux complicating
highly selective vagotomy. Br J Surg. 1975;2:168.
Valen B, Halvorsen JF. Reperitonealization of the lesser curve in proxi-
mal gastric vagotomy for duodenal ulcer. Surg Gynecol Obstet.
1991;173:6.
Wilkinson JM, Hosie KB, Johnson AG. Long-term results of highly
selective vagotomy: a prospective study with implications for future
laparoscopic surgery. Br J Surg. 1994;81:1469.
Fig. 26.5
Pyloroplasty (Heineke-Mikulicz
and Finney), Operation for Bleeding 27
Duodenal Ulcer: Surgical Legacy
Technique
Indications Control of Bleeding
Pyloroplasty is now primarily used in patients undergoing Expose the ulcer through a generous gastroduodenotomy.
emergency surgery for massive hemorrhage from duodenal This incision begins on the distal antrum, crosses the pylo-
ulcer, when other methods of control (e.g., endoscopic) have rus, and continues several centimeters down onto the duode-
failed. A vagotomy may be added if the patient has been non- num. The bleeding site must be positively identified. If the
compliant with medical therapy (see Chaps. 25 and 26). ulcer is not seen, determine whether blood is coming from
proximal or distal and extend the incision as needed. In case
of doubt, do not hesitate to insert a gloved finger into the
Preoperative Preparation stomach and palpate for the ulcer crater.
The arterial anatomy of the stomach is shown in Fig. 27.1.
• Nasogastric suction. The most common situation is a posterior duodenal ulcer
• Esophagogastroduodenoscopy (endoscopic control of eroding into the gastroduodenal artery. Occasionally, a gas-
hemorrhage is frequently possible, obviating the need for tric ulcer erodes into the left or right gastric artery, the gas-
operation). troepiploic arcade, or (rarely) posteriorly into the splenic
• Perioperative antibiotics. artery. Identify the bleeder and suture ligate it.
• Resuscitation.
• Close communication with the blood bank.
Choice of Pyloroplasty
Pitfalls and Danger Points Even if fibrosis and inflammation of the duodenum are pres-
ent—as may be with severe ulcer disease—in most cases, a
• Suture line leak Heineke-Mikulicz pyloroplasty is feasible. When the duode-
• Inadequate lumen num appears too inflexible to allow performance of this pro-
• Failure to control hemorrhage cedure, or when the gastroduodenotomy has extended too
long to allow easy transverse closure, the Finney pyloro-
plasty or gastrojejunostomy should be elected. The latter two
Operative Strategy operations, although slightly more complicated than the
Heineke-Mikulicz, ensure production of an adequate lumen
Although laparoscopic techniques have been described, an for gastric drainage. Because the gastroduodenal incision is
open surgical approach remains the fastest and most certain optimally positioned slightly differently for the two types of
approach to this life-threatening problem. An upper midline pyloroplasty, it is ideal to decide which type is to be per-
incision gives rapid and excellent access. formed before the incision is made. In the emergency situa-
tion, this consideration is secondary to the need for swift,
adequate exposure.
University of Iowa Carver College of Medicine, University of
Iowa, Iowa City, IA, USA

https://doi.org/10.1007/978-3-030-81415-1_27
Fig. 27.1
Documentation Basics yloroduodenal Incision for Heineke-Mikulicz

P
Pyloroplasty
• Findings, including location of ulcer and appearance.
• Nature of pyloroplasty. Make a 5 cm incision across the lower antrum, pyloric
• Vagotomy or not? If so, which type? sphincter, and proximal duodenum, with the incision cen-
tered on the pyloric muscle (Fig. 27.2). Apply Babcock
clamps to the cephalad and caudad cut ends of the pyloric
Operative Technique sphincter, and draw them apart to open the incision. Transfix
any bleeding points with 4–0 PG or PDS suture ligatures or
Kocher Maneuver with careful electrocoagulation. Close the incision trans-
versely, providing a patulous lumen for gastric drainage.
In most cases, pyloroplasty requires a Kocher maneuver to
provide maneuverability of the tissues: Grasp the peritoneum
lateral to the duodenum with forceps and make an incision in Emergency Procedure for Bleeding Ulcer
this peritoneal layer. Alternatively, in many patients, the sur-
geon’s index finger may be insinuated behind the common The longitudinal incision across the pylorus and into the
bile duct and portal vein, pointing toward the ampulla of proximal 3 cm of the duodenum described above generally
Vater. The finger then slides toward the patient’s right. provides good visualization of a posterior duodenal ulcer
Overlying the fingertip is not only a thin layer of peritoneum that has eroded into the gastroduodenal artery (Fig. 27.2).
but also an avascular lateral duodenal ligament that attaches If you do not see an ulcer crater, ascertain whether the
the duodenum to the underlying retroperitoneal structures. blood is coming from proximal or distal and extend the inci-
Incise the peritoneal layer with scissors or electrocautery, sion as needed for adequate exposure. In a difficult situation,
and then, stretch the lateral duodenal ligament with the fin- do not hesitate to insert your gloved finger into the incision
gertip and divide it similarly. and carefully palpate for an ulcer crater.
27 Pyloroplasty (Heineke-Mikulicz and Finney), Operation for Bleeding Duodenal Ulcer: Surgical Legacy Technique 219
Fig. 27.4
ligation of the gastroduodenal artery. Pluck the thrombus

from the lumen of the ulcerated artery to determine if hemor-
rhage control is complete.
The incision in the stomach and duodenum is then closed
as a pyloroplasty. If the incision is relatively short, as shown
in Fig. 27.2, a Heineke-Mikulicz closure is appropriate. A
longer incision, or a fibrotic duodenum, may require closure
by a Finney pyloroplasty. Both are described in the sections
that follow. A Kocher maneuver greatly facilitates closure
Fig. 27.2
and should be done, if not previously completed.
Heineke-Mikulicz Pyloroplasty
Sutures.
Use one layer of sutures to prevent excessive tissue inver-
sion. Most techniques call for a through-and-through suture.
As the gastric wall is much thicker than the duodenal wall, it
is difficult with this technique to prevent eversion of mucosa
between the sutures. Consequently, we prefer deep “seromu-
cosal” sutures (see Fig. 4.13) or interrupted Lembert sutures
of 4–0 silk. Insert the first suture at the midpoint of the suture
line (Fig. 27.5). Proceed with the closure from one corner to
the midpoint and then from the other corner to the midpoint,
inverting just enough of the seromuscular coat to prevent
outpouching of mucosa between the sutures (Figs. 27.6 and
27.7).
Then, suture omentum loosely over the pyloroplasty. This
prevents leakage from the one-layer suture line and adhe-
Fig. 27.3
sions between the suture line and the undersurface of the
liver, which may cause angulation and partial obstruction.
As previously noted, the most common source of duode-
nal ulcer bleeding is posterior erosion into the gastroduode- Stapling
nal artery (Fig. 27.1). Transfix this artery with 2–0 silk Instead of suturing the pyloroplasty incision as described
sutures proximal and distal to the bleeding point. Place a above, apply Allis clamps to the incision, approximating the
third suture on the pancreatic side and deep to the bleeding tissues in eversion, mucosa to mucosa. Then, apply a
point (Figs. 27.3 and 27.4) to occlude a hidden posterior 55/4.8 mm linear stapling device to the everted tissues just
branch of the gastroduodenal artery. This branch, generally, deep to the line of Allis clamps (Fig. 27.8) and fire it. Excise
the transverse pancreatic artery, may produce retrograde redundant tissue with a scalpel, lightly electrocoagulate the
bleeding following apparently successful proximal and distal everted mucosa, and remove the stapler. Carefully inspect
Fig. 27.7
Fig. 27.5
Fig. 27.8
the staple line to be sure satisfactory B formation has been

carried out (Fig. 27.9). Control bleeding points by conserva-
tive electrocoagulation or 4–0 PG sutures. Place omentum
over this stapled closure.
Fig. 27.6
27 Pyloroplasty (Heineke-Mikulicz and Finney), Operation for Bleeding Duodenal Ulcer: Surgical Legacy Technique 221
Fig. 27.9
Fig. 27.10
Finney Pyloroplasty
Unlike the anterior midline gastroduodenotomy incision pre-

viously described, for the Finney pyloroplasty, the gastro-
duodenal incision is kept close to the greater curvature side
of the stomach and the pancreatic side of the proximal duo-
denum (Fig. 27.10) to avoid excessive tension on the anterior
suture line. Ideally, the first row of sutures is placed before
the incision is made.
Insert a layer of interrupted 4–0 silk Lembert sutures to
approximate the greater curvature of the stomach to the
superior portion of the proximal duodenum. Place these
sutures fairly close to the greater curvature of the stomach
and to the junction of the duodenum and pancreas. Continue
this suture line for a distance of 5–6 cm from the pylorus
(Fig. 27.10).
When the sutures have been tied, make an inverted
U-shaped incision along a line 5–6 mm superficial to the
suture line (Fig. 27.10). Carry this incision through the full
thickness of the pyloric sphincter. After the incision has been
made, the mucosal surface of both the gastric antrum and Fig. 27.11
duodenum can easily be seen.
Begin the mucosal suture at the inferior surface of the
divided pyloric sphincter. Pass a needle armed with 3–0 incision is reached. Close the anterior seromuscular layer
atraumatic PG through the full thickness of stomach and by means of interrupted 4–0 silk Lembert sutures
duodenum at the pyloric sphincter and tie it (Fig. 27.11). (Fig. 27.13). At the conclusion, the lumen should admit two
Continue the suture in a caudal direction as a continuous fingers.
locked stitch until the lowermost portion of the incision is
reached. Then, pass the needle from inside out on the stom-
ach side. Approximate the anterior mucosal layer by means Postoperative Care
of a continuous Connell or Cushing suture (Fig. 27.12),
which should be terminated when the cephalad end of the • Administer nasogastric suction for 1–3 days.
Complications
Complications following this operation are rare, although

delayed gastric emptying occurs occasionally, as does suture
line leakage. Dumping symptoms may occur.
Reversal of Pyloroplasty or Gastrojejunostomy
About 1–2% of patients, who have undergone truncal vagot-

omy and pyloroplasty or gastrojejunostomy, develop severe
symptoms of dumping, diarrhea, or bilious vomiting of such
severity that surgical correction may be indicated.
Reconstruction of the pylorus is required in rare circum-
stances. Martin and Kennedy described reconstruction of the
pylorus in nine patients who underwent a Heineke-Mikulicz
pyloroplasty and three with a Finney pyloroplasty. There was
marked improvement in three-fourths of the patients, whose
complaints were dumping and diarrhea.
One can surgically reverse a pyloroplasty by reopening
the transverse incision, identifying both cut ends of the
Fig. 27.12
pyloric sphincter, reapproximating the sphincter by inter-
rupted sutures, and closing the incision in a longitudinal
direction, thereby restoring normal anatomy.
Further Reading
Berne CJ, Rosoff L. Peptic ulcer perforation of the gastroduodenal
artery complex. Ann Surg. 1969;169:141.
Lee CS, Sarosi GA Jr. Emergency ulcer surgery. Surg Clin North Am.
2011;91:1001.
Ohmann C, Imhof M, Roher HD. Trends in peptic ulcer bleeding and
surgical treatment. World J Surg. 2000;24:282.
Reuben BC, Stoddard G, Glasgow R, et al. Trends and predictors for
vagotomy when performing oversew of acute bleeding duodenal
ulcer in the United States. J Gastrointest Surg. 2007;11:22.
Smith BR, Wilson SE. Impact of nonresective operations for com-
plicated peptic ulcer disease in a high-risk population. Am Surg.
2010;76:1143.
Wang YP, Richter JE, Dempsey DT. Trends and outcomes of hospital-
izations for peptic ulcer disease in the United States, 1993 to 2006.
Ann Surg. 2010;25:51.
Zelickson MS, Bronder CM, Johnson BL, Camunas JA, Smith DE,
et al. Helicobacter pylori is not the predominant etiology for peptic
ulcers requiring operation. Am Surg. 2001;77:1054.
Fig. 27.13
Gastrojejunostomy
28
Malini D. Sur
• Duodenal or gastric outlet obstruction when endoscopic • Anastomotic bleeding

stenting is not feasible • Anastomotic obstruction
• Reconstruction in patients undergoing distal gastrectomy • Delayed gastric emptying
or pancreaticoduodenectomy • Bile reflux
Preoperative Preparation Operative Strategy
Patients with malignant gastric outlet obstruction are intially Gastrojejunostomy is utilized in diverse clinical settings.
managed with nasogastric tube decompression and hydra- Gastrojejunostomy is most commonly performed as the recon-
tion. Although a survival benefit for parenteral nutrition in structive procedure in patients undergoing distal gastrectomy or
the palliative setting is unclear, perioperative parenteral standard pancreaticoduodenectomy. In isolation, diverting gas-
nutrition may be consideration for nutritional optimization trojejunostomy may be performed as a palliative measure in
prior to surgery. Imaging workup should include computed patients who have duodenal or gastric outlet obstruction where
tomography with oral contrast administration. An upper GI resection is not indicated. In patients with poor performance sta-
series may be useful when axial imaging is insufficient for tus, poor life expectancy, ascites, or hostile abdomen, alterna-
the diagnosis of a mechanical obstruction. Endoscopy is use- tives such as palliative endoscopic stenting or venting tube
ful for confirmation of the diagnosis if this is needed, and for gastrostomy should be considered instead. Multidisciplinary
assessment of the feasibility of duodenal stent placement. consultation with an advanced endscopic team and a dedicated
Duodenal stenting can be limited by angulation and is opera- palliative care service is strongly encouraged.
tor dependent; it should generally be avoided if the risk of Several reconstructive techniques have been described:
failure and/or perforation is deemed high, or if an advanced anterior versus posterior gastrotomy, antecolic versus retro-
gastroenterology team is unavailable. Finally, multidisci- colic, isoperistaltic versus anteperistaltic, handsewn versus
plinary discussion including the primary surgeon, gastroen- stapled, and open versus laparoscopic or robotic methods.
terology, medical oncology, and palliative care is essential to Some surgeons advocate fashioning the gastrojejunostomy
determining whether surgical relief of the obstruction on the posterior wall of the stomach because it may allow
through gastrojejunostomy is indicated and in line with the better drainage in the dependent position. There is a lack of
patient’s goals and values. consensus as to the optimal modality, and the approach
should be tailored to the individual patient and surgeon expe-
rience. For technical simplicity, we prefer an anterior,
antecolic, isoperistaltic, handsewn gastrojejunostomy along
the greater curvature of the body of the stomach.
Delayed gastric emptying is common after gastrojejunos-
M. D. Sur (*) tomy, and its etiology is not well understood. There are no
Hepatopancreatobiliary Surgery and Surgical Oncology, Northside proven strategies to prevent or treat this complication. In
Hospital Cancer Institute, Atlanta, GA, USA patients with apparent delayed gastric empyting, it is impor-
e-mail: malini.sur@northside.com

https://doi.org/10.1007/978-3-030-81415-1_28
224 M. D. Sur
tant to first rule out an obstruction at the anastomosis with an

upper GI study or endoscopy. Once patency is confirmed,
prokinetics may be useful in initiating normal gastric func-
tion. The time to recovery can be highly variable, and in
some patients delayed gastric emptying may take weeks to
resolve. Rarely, re-operation for surgical revision, conver-
sion to Roux-en-Y gastrojejunostomy, or creation of a Braun
anastomosis, may be indicated.
Documentation Basics
• Assessment for metastatic disease and ascites

• Location of gastrotomy on anterior or posterior gastric
wall
• Retrocolic or antecolic position of jejunal limb
• Anastomotic technique
Fig. 28.1
Operative Technique: Open
Incision
Make an upper midline incision from the xiphoid to the

umbilicus. Explore the abdomen.
Freeing the Greater Curvature
Identify the location on the stomach for the anastomosis.

Typically, mobilization of the stomach is not necessary for
an anterior gastrojejunostomy, although ligation of the short
gastric vessels can provide greater laxity to the stomach if
needed. The greater omentum may be released along the
region of the planned anastomosis to facilitate its placement
in a dependent portion of the stomach, if desired.
Fig. 28.2
Preparing the Jejunal Limb
muscular layers of the stomach and jejunum for a length of
Retract the transverse mesocolon superiorly and identify the about 5 cm. Keep the initial suture tag long and clamped.
ligament of Treitz. Pass the first mobile loop of jejunum in an When the line is complete, protect the needle (Fig. 28.1).
antecolic fashion, positioning the bowel so that it runs from Next, place clean towels around the field. Using electrocau-
the patient’s left to right in an isoperistaltic fashion. The jeju- tery, make a 5 cm gastrotomy and, opposite this, a 5 cm jeju-
notomy should be planned no further than about 15 cm from notomy along the antimesenteric border. Using 3–0 vicryl,
the ligament of Treitz. begin the inner, continuous, posterior layer by taking a full-
thickness bite through the gastric and jejunal walls at the
midpoint of the incision. Allow the assistant to place a simi-
Open Handsewn Technique lar stitch about 2 mm away. The free ends may be tied
together and one needle protected. Begin a continuous
Begin the posterior, outer layer with an interrupted or con- suture, penetrating both mucosal and seromuscular layers
tinuous Lembert stitch with 4–0 silk. Approximate the sero- (Fig. 28.2). Come around one corner and begin the anterior
28 Gastrojejunostomy 225
Fig. 28.3
Fig. 28.5
made with electrocautery opposite this. The inner layer is

fashioned as above with a continuous absorbable suture. The
anterior, outer layer is created with additional 4–0 silk
Lembert sutures. Finally, the remaining gastric staple line is
inverted with interrupted Lembert sutures and a U-stitch of
4–0 silk is placed at the angle of sorrows where the gastric
Fig. 28.4 staple line meets the gastrojejunostomy. PDS suture is an
acceptable alternative for the inner layer.
suture line. You may convert to a continuous Connell type
stitch, inverting the bowel wall. Allow the assistant to do the
same with the second needle. The two sutures should meet Open Stapled Technique
anteriorly near the midline and be tied to each other
(Fig. 28.2). Finally, continue the outer suture with a sero- Identify the proximal jejunum and bring it to an antecolic
muscular bites to fashion the anterior, outer layer (Fig. 28.3). position as described above. Using electrocautery, make an
Tie down to the starting suture tag. The anastomosis should enterotomy on the antimesenteric side of jejunum at a point
admit two fingers (Fig. 28.4). 12–15 cm from the ligament of Treitz. Then, make a gas-
In patients undergoing gastrojejunostomy as a reconstruc- trotomy along the greater curvature of the stomach at a point
tive procedure following partial gastrectomy, the inferior about 10 cm from the pylorus. Insert one arm of an 80 mm
portion of the gastric staple line is typically incorporated into cutting linear stapling device into the jejunum and one arm
the anastomosis. A posterior, outer layer of interrupted 4–0 into the stomach (Fig. 28.5). Align the jejunum so its
silk Lembert sutures is created. The inferior gastric staple antimesenteric border is parallel to the stapler and lock the
line is removed, creating the gastrotomy. The jejunotomy is device. Check the proposed gastrojejunal staple line to
226 M. D. Sur
phoid region to allow placement of a laparoscopic liver

retractor to help retract a large left lateral segment.
Preparation of the Jejunal Limb
Using atraumatic graspers, retract the transverse mesocolon

superiorly and identify the ligament of Treitz. Pass the first
mobile loop of jejunum in an antecolic fashion, positioning
the bowel so that it runs from the patient’s left to right in an
isoperistaltic fashion. The jejunotomy should be planned no
further than about 15 cm from the ligament of Treitz.
astrojejunal Anastomosis: Laparoscopic

G
Fig. 28.6
Stapled Technique
ensure that the mesentery is free and no tissue other than Identify the proximal jejunum and bring it to an antecolic
stomach and jejunum is included. Fire the stapler and remove position as described above. Place a seromuscular stay suture
it. of 4–0 silk through the jejunum and then through the stom-
Apply Allis clamps to the anterior and posterior termina- ach wall in the region of the planned enterotomy, about
tions of the staple line. Inspect the staple line carefully for 12–15 cm from the ligament of Treitz, and planned gastrot-
bleeding, and control any bleeding point by cautious electro- omy, about 10 cm from the pylorus. Tie this down intracor-
coagulation or insertion of absorbable suture ligatures in a poreally and keep end long for retraction. Now lifting up on
figure-of-8 fashion. this suture tag with a grasper, use hook electrocautery to
Approximate the remaining defect in the anastomosis in make an enterotomy on the antimesenteric side of the jeju-
an everting fashion by applying several Allis clamps, taking num. Then, make a gastrotomy along the greater curvature of
care to ensure that the entire cut edge sits above the ends of the stomach at a point. Insert one arm of a laparoscopic
the clamps. Apply a 90 mm linear stapler immediately below 60 mm cutting linear stapling device into the jejunum and
the Allis clamps. Fire the stapler, excise the redundant tissue one arm into the stomach. Align the jejunum so its antimes-
sharply, and remove the stapling device. Mucosal bleeding enteric border is parallel to the stapler and lock the device.
may be controlled with pinpoint electrocautery. The anasto- Check the proposed gastrojejunal staple line to ensure that
mosis should admit two fingers without difficulty. Place a the mesentery is free and no tissue other than stomach and
4–0 seromuscular Lembert suture to fix the stomach to the jejunum is included. Fire the stapler and remove it. Inspect
jejunum on the right lateral margin of the newly stapled the staple line to ensure hemostasis. Now use a 3–0 absorb-
anastomosis (Fig. 28.6). able suture to close the gastroenterotomy in a continuous
fashion.
Operative Technique: Laparoscopic

Postoperative Care
Access
Nasogastric suction is not mandatory, but may be indicated
In setting of a distended stomach, establish pneumoperito- in select patients with a distended, aperistaltic stomach from
neum via an open technique in the supraumbilical region. If chronic gastric outlet obstruction.
the stomach is adequately decompressed, a Veress needle or
optical trocar may be used. The abdomen is insufflated to
12–15 mmHg. Three additional ports are placed in the left Complications
upper quadrant, left mid-abdomen, and right mid-abdomen.
Either the right mid-abdomen or the supraumbilical port may Gastric bleeding is a rare complication, and can typically
be upsized to allow placement of the laparoscopic stapler. If be controlled by endoscopic approaches. Anastomotic
necessary, an additional incision may be made in the subxi- leakage is unusual due to the robust healing of the stomach
28 Gastrojejunostomy 227
and small bowel. Anastomotic obstruction can occur if Further Reading

there is edema or kinking of the efferent limb; thus, the
surgeon should make certain that the anastomosis is not Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema
PD. Stent versus gastrojejunostomy for the palliation of gastric out-
angulated. Upper endoscopy with intubation of the limbs let obstruction: a systematic review. BMC Gastroenterol. 2007;7:18.
may help to alleviate this; however, reoperation may be Nagaraja V, Eslick GD, Cox MR. Endoscopic stenting versus opera-
necessary in cases of persistent complete obstruction. At tive gastrojejunostomy for malignant gastric outlet obstruction-a
times, an apparently satisfactory gastrojejunostomy is ana- systematic review and meta-analysis of randomized and non-
randomized trials. J Gastrointest Oncol. 2014;5(2):92–8.
tomically normal but fails to empty well. Once patency is Zhang LP, Tabrizian P, Nguyen S, Telem D, Divino C. Laparoscopic
confirmed, prokinetics may be useful in initiating normal gastrojejunostomy for the treatment of gastric outlet obstruction.
gastric function. JSLS. 2011;15(2):169–73.
Partial Gastrectomy
29
Ashley E. Russo, Carol E. H. Scott-Conner,
and Vivian E. Strong
Indications Operative Strategy
• Gastrointestinal stromal tumors of the stomach (GISTs) In the modern era of proton pump inhibitors, far fewer gas-
• Premalignant lesions / polyps not amenable to endoscopic trectomies are performed than in the past. As a result, cur-
removal rently, the most common indication for gastrectomy is to
• Direct extension into the stomach (e.g., pancreatic mass, resect malignancy, such as gastric adenocarcinoma, carci-
renal mass, etc.) noid tumors, or gastrointestinal stromal tumors. For gastric
• Dieulafoy lesion cancer and most carcinoids, a lymphadenectomy is a critical
portion of the operation, and is described extensively in a
dedicated chapter. This chapter focuses on partial gastrec-
Preoperative Preparation tomy without lymphadenectomy, as indicated for: gastroin-
testinal stromal tumors (GISTs); en bloc resection of direct
• See Chap. 28. invasion into the stomach from a separate primary; and pre-
malignant lesions not amenable to endoscopic removal.
Pitfalls and Danger Points

Type of Resection
• Duodenal stump leak
• Anastomotic leak The oncologic resection of a gastric GIST does not require
• Splenic trauma wide margins (as opposed to for gastric adenocarcinoma),
• Poor gastric emptying and thus, less extensive resections which preserve GI conti-
• Gastric outlet obstruction nuity can typically be performed. Often these lesions are
• Postgastrectomy syndromes exophytic and/or pedunculated, and can be resected with a
simple wedge of the stomach. When performing a wedge
resection of the proximal stomach, it is critical to confirm
that the resection will not narrow the lumen of the GE junc-
tion. Wedge resections which remove a large segment of the
body of the stomach can be fraught with poor postoperative
gastric emptying; thus, care to avoid “shark-bite” resections
A. E. Russo which grossly distort the gastric body or leave a bilobed
Department of Surgery, Memorial Sloan Kettering Cancer Center,
stomach. Especially, for endophytic or broad-based GISTs, it
New York, NY, USA
e-mail: russoa2@mskcc.org is often better to enter the stomach, excise the lesion from
within, and suture the defect closed, rather than to attempt
University of Iowa Carver College of Medicine, University of resection of the lesion with the stomach intact. See also
Iowa, Iowa City, IA, USA Chap. 35 on Management of GI Stromal Tumors of the
e-mail: carol-scott-conner@uiowa.edu Stomach for additional details.
V. E. Strong
Gastric and Mixed Tumor Service, Department of Surgery,
Memorial Sloan Kettering Cancer Center, New York, NY, USA

https://doi.org/10.1007/978-3-030-81415-1_29
230 A. E. Russo et al.
Choice of Reconstruction Documentation Basics
If the resection requires a distal gastrectomy, there are three • Findings

basic ways to reconstruct the upper gastrointestinal tract: • Extent of resection
Billroth I, Billroth II, and roux-en-Y. Each reconstruction • Reconstruction
has its pros and cons, and the selection is made depending on
the extent of resection performed. A Billroth I reconstruction
can only be performed in cases of limited gastric resection, Operative Technique
which allows the gastric remnant to reach the duodenal
stump without tension. The Billroth II reconstruction allows Gastric Wedge Resection
for larger resections; the reconstruction avoids tension by
creating a duodenal stump and an end-to-side gastrojejunos- Indications
tomy. The Roux-en-Y reconstruction is most appropriate for The most common indication for local wedge resections is
subtotal or total gastrectomies: it diverts bile from the gastric gastrointestinal stromal tumors (GISTs), though the tech-
remnant and avoids the potential problem of bile reflux gas- niques described here can be applied for other appropriate
tritis, but adds another anastomosis to the equation and may indications as well. GISTs can occur anywhere along the GI
lead to delayed gastric emptying. This chapter describes the tract, with approximately half occurring in the stomach.
Billroth I and Billroth II reconstructions. The Roux-en-Y Surgical resection is indicated for symptomatic GISTs or
reconstruction is covered in Chap. 38. GISTs larger than 2 cm. The goal of any GIST operation is to
achieve complete resection (R0 or R1) without tumor disrup-
tion. Radical resection with lymphadenectomy is not required
Duodenal Stump Leak since nodal metastases are rare. The development of thera-
peutic agents that suppress tumor growth by inhibiting tyro-
The stomach is a robust organ with low leak rates, thus, most sine kinase receptor activity has dramatically improved
of the serious postoperative complications of gastric surgery outcomes for GIST and has redefined the role for surgery.
involve failure of the duodenal stump closure. This compli- Surgery remains the only potential curative therapy for
cation usually results from persistent efforts to dissect the patients with primary, localized, and resectable GIST.
duodenum away from the pancreas – potentially devascular-
izing it, or oversewing of the duodenal stump – which fre- inimally Invasive Wedge Resection
M
quently only creates tissue tearing. A normal duodenum Laparoscopic or robotic assisted partial gastrectomy is fre-
should not leak if there is no downstream obstruction, and quently possible. Patient selection for minimally invasive
does not typically need to be oversewn. However, a duodenal gastric resection is critical. Ideal candidates for minimally
stump that is edematous or fibrosed due to tumor involve- invasive surgery are those with minimal comorbidities,
ment or chronic ulcer disease is higher risk. If there is any smaller tumors, pedunculated tumors, and those without a
doubt about the security of the duodenal stump suture line, history of intraabdominal adhesions. This section will
insert a catheter into the duodenum for postoperative decom- describe the technique using a GIST as an example lesion.
pression. It provides a valuable safety valve and prevents dis-
ruption of the duodenal suture line in most instances. Equipment
In addition to the typical laparoscopic setup, including
appropriate equipment for entry into peritoneal cavity
Splenic Trauma depending on access preference, special instruments for gas-
tric wedge resections include:
Traction on the greater curvature of the stomach can result in
a tear of the splenic capsule, or an avulsion of a short gastric • Nathanson liver retractor with an anchoring device
vessel. Minor capsular injuries can generally be managed by • Energy device such as ultrasonic scalpel, Sonosurg,
direct pressure over a sheet of topical hemostatic agent. Ligasure, etc.
However, avulsion of a short gastric vessel can leak to brisk • Endo-GIA stapler with stapling loads for stomach (purple
hemorrhage and requires definitive control and ligation. This load, 45 mm)
complication is best avoided by providing excellent visual- • Laparoscopic needle holder
ization of the area and gentle tissue handling. • Sterile extraction bag
29 Partial Gastrectomy 231
aparoscopic Setup and Positioning

L After identifying the location of the GIST, visualize the
Position the patient supine on a split-leg operating table with transverse colon by lifting the greater omentum in the cepha-
foot pads. Beanbag devices can be helpful for stabilization of lad direction. Enter the lesser sac by dissecting the omentum
the patient during the procedure. The patient’s arms may be from the top of the transverse colon toward the splenic flex-
tucked or placed on arm boards. Pad all pressure points ure (Fig. 29.3). Take care to avoid injury to the transverse
including the elbows and hands. Secure the patient to the mesocolon during this step. Continue the dissection until the
table with safety straps. Place the legs and feet in Velcro- posterior wall of the stomach can be visualized. Then, grasp
secured foot pads to avoid sliding during the reverse the posterior wall of the stomach using a bowel grasper and
Trendelenburg positioning necessary for the operation. retract it anteriorly and to the right in. This should allow you
Access to the mouth should be readily available in order to to identify and ligate the necessary short gastric vessels using
perform intraoperative endoscopy if needed. Video monitors a Ligasure. Then, retract the stomach toward the left upper
are placed at the head of the bed (Fig. 29.1). The stability of quadrant to continue the omental dissection from below.
the patient setup may be tested prior to starting the operation Continue the mobilization of the greater curvature up to the
by temporarily placing the patient in steep reverse level of the proximal resection margin.
Trendelenburg.
umor Mobilization and Resection, Specimen

T
Operative Steps Extraction, and Closure
ntry and Port Placement

E After adequate mobilization of the stomach, the GIST
Place a Veress needle in the left upper quadrant and establish must be lifted in preparation for resection. If the GIST is
pneumoperitoneum. Place a 12 mm trocar in the midline large or exophytic, grasp it gently with bowel graspers and
above the umbilicus and insert a laparoscope. Carefully lift it before introducing the stapler. Take extreme care to
inspect the peritoneal cavity. Under direct visualization, avoid rupturing the capsule of the tumor. If marking
place two 5 mm ports to triangulate with the stomach. We stitches were placed during endoscopy, grasp these instead
typically use three ports for a laparoscopic gastric wedge (Fig. 29.4). Introduce an Endo-GIA purple loaded stapler
resection, but if the size or location of the tumor warrants with seam guard attached into the peritoneal cavity and
additional working ports, then five trocars may be used as position it under the base of the GIST (Figs. 29.5 and
well. A five-trocar setup typically consists of four 5 mm 29.6). Close the stapler and inspect both sides of the staple
ports and one 12 mm port in the right periumbilical position. line to ensure only desired tissue will be removed with the
After placement of the trocars, inspect the abdomen for the transected specimen. Prior to transection, check the area of
presence of any intraabdominal adhesions that may preclude stomach within the stapler to ensure that the entire GIST is
safely continuing the procedure laparoscopically. captured in specimen. The specimen is then transected
Place a Nathanson liver retractor via a 3 mm stab skin intact.
incision made in the middle of the subxiphoid position and Place the specimen into a sterile endocatch bag (Fig. 29.7)
use it to retract the left lobe of the liver. Secure this in place and remove it via the umbilical port site (Fig. 29.8). Then,
with a stationary retractor arm attached to the side of the bed. reintroduce the 12 mm trocar and laparoscope through the
Place the patient in steep reverse Trendelenburg position. umbilical port site to check for hemostasis along the staple
line. Fully inspect the peritoneal cavity and remove all tro-
umor Localization and Entry into Lesser Sac
T cars under direct visualization prior to removal of the cam-
Prior to resection, the location of the GIST must be con- era. Desufflate the abdomen and remove the camera. Close
firmed. If a GIST is large and exophytic, localization may be the fascia at the specimen extraction site with 0 vicryl ties.
done by simple visualization of the extraluminal surface of Close the skin at all port sites with 4–0 monocryl and
the stomach. If the GIST is small or largely intraluminal, dermabond.
endoscopy should be performed to aid in localization
(Fig. 29.2). If endoscopy is used, particularly in the case of
small intraluminal GISTs, two seromuscular marking Robotic Gastric Wedge Resection
stitches should be placed laparoscopically on the extralumi-
nal surface of the stomach to mark the proximal and distal Robotic gastric wedge resection follows almost all of the
extent of the mass. This will ensure that the GIST is success- same principles as a laparoscopic gastric wedge resection.
fully removed without disruption during the planned resec- The advantages of the robotic platform over laparoscopy are
tion. These marking stitches can also be helpful later in the that the camera provides three-dimensional, high-definition,
operation, as they can be gently lifted with laparoscopic stable, and magnified views of the operative field. The
instruments to help position the linear stapling device around robotic instruments are able to articulate and provide seven
the portion of the mobilized stomach that will be resected. degrees of freedom, which aid in facilitating difficult dissec-
Fig. 29.1
Fig. 29.2 Fig. 29.5
Fig. 29.3
Fig. 29.6
Fig. 29.4
Fig. 29.7
Open Wedge Resection
Open wedge resection follows the same steps as detailed

above, but is facilitated by the ability to locate smaller lesions
by direct palpation of the stomach.
Intragastric Resection
Intragastric resection may also be performed for GISTs since

some tumors protrude endophytically into the gastric lumen.
One technique for this involves trocar placement directly into
the lumen of the stomach under endoscopic visualization. The
gastric lumen itself is insufflated and the endoscope is used to
provide visualization throughout the duration of the proce-
dure. After resection of the GIST, the gastric wall defect is
closed with laparoscopic needle drivers and endoscopically
passed sutures. The specimen is removed orally. This tech-
nique works best for lesions near the gastroesophageal junc-
tion or those on the posterior wall of the proximal stomach.
Alternatively, the surgeon can perform a gastrotomy,
resect the tumor from the gastric lumen, close the gastros-
tomy, and remove the specimen from the abdomen using an
endocatch bag.
istal Gastrectomy with Billroth I or II

D
Fig. 29.8 Reconstruction
Distal gastrectomy can also be performed open or using min-

tions and suturing as compared to laparoscopy. In terms of imally invasive techniques, depending on the expertise of the
robotic setup, an important step to note is that the bed must surgeon. We describe the open technique below.
be placed in 45 degrees of reverse Trendelenburg prior to
docking the robot (Fig. 29.9). Port placement follows a simi-
lar general principle as in laparoscopy, however, ports are Open Distal Gastrectomy
typically placed at least 8 cm apart for robotic resections, and
at a further distance from the target lesion. The dissection Incision and Exposure
and mobilization of the tumor follows the same steps as in The incision should be midline, from the xiphoid to a point
laparoscopy. During a robotic gastric wedge resection, above the umbilicus. Enter the lesser sac between the stom-
another option for resection of the GIST is via robotic endo- ach and the transverse colon. Isolate the branches going from
scopic shears or hook cautery. The defect can, thus, be tai- the gastroepiploic arcade to the greater curvature of the
lored to the lesion and easily closed in two layers using stomach, then ligate and divide each. Continue this process
robotic needle drivers, thus, avoiding the need for staplers. up along the greater curve of the stomach until the halfway
Robotic suturing is an effective method for primarily closing point between the pylorus and the diaphragm is reached
a defect of any size or location and is fairly straightforward (Fig. 29.10). Divide the avascular attachments between the
given the added degrees of freedom provided by the articu- back wall of the antrum and the pancreas to allow full mobi-
lating robotic instruments. lization of the stomach.
Fig. 29.9
Next, dissect the distal segment of the gastroepiploic ivision of Left Gastric Vessels
D
arcade from the antrum. Perform this dissection with care, as Select a point on the lesser curvature about halfway between
a number of fragile veins in the vicinity of the origin of the the esophagogastric junction and the pylorus. This point
right gastroepiploic vessels are easily torn. Completion of serves as a reasonably good approximation of the upper mar-
this dissection frees the entire distal half of the gastric greater gin of the antral mucosa. Next, ligate the adjacent vascular
curvature. bundle using a Ligasure or two ties on the proximal and dis-
tal side (Fig. 29.11a and b), making sure to preserve supply gastric pouch (Fig. 29.12). Place another Allen clamp oppo-
of the left gastric artery to the remnant stomach. site the stapler and divide the gastric tissue flush with the
stapler. Lightly electrocauterize the gastric mucosa before
Division of Stomach removing the stapling device (Fig. 29.13a).
This is accomplished by applying Allen clamps for a dis-
tance of 3–4 cm at an angle of 90° to the greater curvature of
the stomach. The amount of stomach in the Allen clamp Duodenal Dissection
should equal the width of the gastrojejunal or gastroduodenal
anastomosis to be performed in a subsequent step. Identify, ligate, and divide the right gastric artery (Fig. 29.14).
After the gastric wall has been incised midway between Apply traction to the specimen in an anterior direction to
these two clamps, fire a linear stapler at a somewhat cepha- expose the posterior wall of the duodenum and the anterior
lad angle to close the lesser curvature portion of the residual surface of the pancreas. No more than 1.5 cm of the posterior
duodenal wall should be freed from the underlying pancreas.
Division of Duodenum
Apply an Allen clamp immediately distal to the pylorus, and

transect the duodenum flush with the clamp (Fig. 29.15).
Before passing off the specimen, remove the clamp and inspect
the distal end of the specimen to ascertain that a rim of duode-
nal mucosa has been removed. This ensures that there is no
remaining antral mucosa left behind in the duodenal stump.
Billroth I Gastroduodenal Anastomosis
When at least 1 cm of healthy posterior duodenal wall is

available, a routine gastroduodenal anastomosis is con-
Fig. 29.10
a b
Fig. 29.11
structed. The Allen clamp previously applied to the unsu- interrupted 4–0 silk seromuscular Lembert sutures
tured portion of the gastric pouch should contain a width of (Fig. 29.16). To prevent postoperative obstruction, take care
stomach approximately equal to the diameter of the duode- not to invert an excessive amount of tissue.
nal stump. Insert the corner sutures by the Cushing tech- Remove the Allen clamp and anastomose the inner back
nique. Complete the remainder of the posterior layer with wall using a double-armed 4–0 PG suture, initiating it at the
midpoint of the posterior layer, and continuing with a run-
ning suture (Figs. 29.17 and 29.18). Approximate the ante-
rior mucosal layer with a continuous Connell or Cushing
suture, which should be terminated at the midpoint of the
Fig. 29.12 Fig. 29.14
a b
Fig. 29.13
Fig. 29.15 Fig. 29.16
Fig. 29.17
Fig. 29.18
Fig. 29.19 Fig. 29.20
anterior layer (Fig. 29.19). Reinforce this suture line by a stump. Continue this also to the middle of the stump, and
seromuscular layer of interrupted 4–0 silk Lembert sutures terminate it by tying it to the first strand (Fig. 29.22).
(Fig. 29.20). At the “angle of sorrow,” where the Hofmeister Supplement this with a layer of interrupted 4–0 silk Lembert
shelf of the gastric pouch meets the duodenal suture line at sutures (Fig. 29.23).
its lateral margin, insert a crown stitch by taking seromuscu-
lar bites of the anterior wall of the gastric pouch and then of
the posterior wall of the gastric pouch, returning to catch the Duodenal Closure with Surgical Staples
wall on the duodenal side (Fig. 29.21). If the sutures have
been properly inserted, the lumen should admit the tip of the If the duodenal wall is not thickened markedly with fibro-
surgeon’s thumb. Loosely suture omentum over the sis or edema, the stump may be closed safely using a lin-
anastomosis. ear stapling device with a 3.5 (blue) load. Apply the
stapler to the duodenal stump before dividing the speci-
men. After the stapler has been fired, apply an Allen clamp
Billroth II: Closure of Duodenal Stump on the specimen side, and, with a scalpel, transect the
stump flush with the stapling device (Fig. 29.24). Lightly
If a stapler was not used to transect the duodenum, suture the electrocauterize the everted mucosa of the duodenal stump
healthy duodenal stump closed with an inverting Connell before removing the stapling device. There is no need to
suture of 4–0 PG. Initiate the Connell suture by placing a invert this closure with a layer of sutures. Generally, we
half purse string stitch at the right lateral margin of the duo- cover the stapled stump with omentum or the pancreatic
denum. Continue this strand to the middle and initiate a sec- capsule with a few sutures, but we do not invert the
ond strand of 4–0 PG at the left margin of the duodenal mucosa.
Fig. 29.21
Fig. 29.24
Fig. 29.22
Fig. 29.25
illroth II Gastrojejunal Anastomosis,

B
Handsewn
Although there are variations in the technique for constructing

Billroth II anastomoses, we prefer an antecolic, isoperistaltic
anastomosis with a Hofmeister shelf. The distance from the
ligament of Treitz to the gastric pouch should be no more
than 12–15 cm.
Place a stay suture between the jejunum and the stomach
at either end of the planned anastomosis. Start by performing
the outer back layer of the anastomosis: attach the jejunum to
the gastric pouch with interrupted 4–0 silk seromuscular
Lembert sutures placed about 5 mm apart (Fig. 29.25). Cut
Fig. 29.23 all the remaining silk tails.
Then, use electrocautery to make an incision along the full thickness of the gastric and jejunal walls and tied
antimesenteric line in the jejunum. Open the mucosa of the (Fig. 29.27a–c). Start a continuous suture from the midpoint,
jejunum (Fig. 29.26). Control bleeding points with electro- and run it in both directions. Continue along the anterior
cautery. The incision in the jejunum should be a few millime- wall; some surgeons switch to a Connell suture here. Initiate
ters shorter than the diameter of the opening in the gastric the suture line first at the right-hand margin of the anastomo-
pouch, since the opening in the small bowel has a tendency sis (Fig. 29.28a) and then on the left (Fig. 29.28b), working
to stretch. both needles toward the midpoint, where the two strands
Remove the Allen clamp and open the gastric pouch. should be tied to each other (Fig. 29.28c). Complete the ante-
Next, perform the inner layer of the anastomosis. Initiate this rior layer with a row of interrupted 4–0 silk seromuscular
suture at the midpoint of the posterior wall with a double- Lembert sutures (Figs. 29.28d and 29.29). Alternatively, the
armed 3–0 PG suture, which should be inserted through the outer layer may be performed in an over-and-over continu-
ous Lembert fashion using 3–0 PG instead of interrupted silk
sutures. At the medial margin of the anastomosis (the “angle
of sorrow”), insert a crown stitch (Fig. 29.30).
Billroth II Gastrojejunal Anastomosis, Stapled
Ligate the vessels along the gastric wall at the site of intended
transection as described above. It is imperative to ensure that
the nasogastric tube is pulled back so that it cannot become
trapped in the gastric staple line. Next, apply a linear stapler
across the entire stomach, and fire (Fig. 29.31). Multiple fir-
ings of an Endo-GIA may also be used. Apply a large clamp
to the specimen side of the stomach, and divide the stomach
flush with the stapling device by a scalpel. Lightly electro-
cauterize the everted mucosa and remove the stapler. Close
the duodenal stump with the linear stapler as previously
described and remove the specimen (Fig. 29.32).
Next, identify the ligament of Treitz and bring a segment
of proximal jejunum in an antecolic, isoperistaltic fashion to
the greater curvature side of the gastric pouch. Approximate
the antimesenteric border of the jejunum with a 4–0 silk
suture to a point on the greater curvature of the stomach
about 2 cm proximal to the staple line. Make small stab
Fig. 29.26 wounds in the gastric pouch and jejunum adjacent to this
a b c
Fig. 29.27
a b
c d
Fig. 29.28
Fig. 29.31
Fig. 29.29
Fig. 29.32
suture and just deep into it. Then, insert the cutting linear
stapling device so one fork enters the gastric pouch parallel
to the staple line and the other fork enters the jejunum and is
placed exactly along the antimesenteric border (Fig. 29.33).
Take care not to allow any other organ or tissue to intrude
between the stomach and jejunum being grasped by the sta-
pling device. When this stapler has been positioned well,
close and lock it (Fig. 29.34). Then reinspect the area. There
should be a 2 cm width of posterior gastric wall between the
staple line and the proposed anastomotic staple line. At this
point, fire and remove the stapler.
Apply Allis clamps to the anterior and posterior termina-
tions of the staple line, and carefully inspect the mucosal sur-
face of the stapled anastomosis for bleeding. After hemostasis
is ensured, approximate the gastric and jejunal layers of the
open stab wounds in an everting fashion with several Allis
clamps. Close the defect with one application of a linear sta-
pler (Fig. 29.34). This staple line must include the anterior
and posterior terminations of the anastomotic staple line,
guaranteeing that there is no defect between the two lines of
staples. Excise the redundant tissue, lightly electrocoagulate
Fig. 29.30 the everted mucosa, and remove the stapler. Alternatively,
Fig. 29.35
Fig. 29.33
Fig. 29.34
close the stab wound defect in an inverting fashion by vari-

ous suturing techniques. Then, place a single 4–0 silk sero-
muscular suture at the right termination of the stapled
anastomosis (Fig. 29.35). The gastrojejunal stoma should
admit two fingers. A three-dimensional representation of the
anastomosis is shown in Fig. 29.36. Fig. 29.36
Drainage and Closure treatment, reoperation too is probably necessary. Be aware

that the Billroth II gastrojejunal anastomosis occasionally
Whenever the surgeon thinks the duodenal closure is less develops an outlet obstruction that appears due to malfunc-
than perfect after a Billroth II operation, a closed suction tion of the efferent loop of the jejunum. This diagnosis can
drain should be brought out from the vicinity of the duodenal be confirmed by inserting a gastroscope well into the efferent
stump through a stab wound in the right upper quadrant. The and afferent limbs of the jejunum, which demonstrates the
drain should be separated from the duodenal suture line by a absence of any mechanical stomal obstruction. Relaparotomy
layer of omentum. Accomplished this way, drainage does no in these cases is of no value. Generally, several weeks of con-
harm to the patient. Close the abdominal wall in the usual servative treatment with nutritional support and a prokinetic
fashion after taking pains to ensure that the efferent limb of agent is successful. Passage of a small feeding tube into the
the jejunum descends freely and without kinks. efferent limb allows direct enteral support until function
recovers.
Postoperative Care
fferent Loop Obstruction and Afferent Loop
A
Nasogastric suction is generally not needed after gastric Syndrome
wedge resection or distal gastrectomy. Oral intake can be ini-
tiated on postoperative day #1 and advanced when there is Acute mechanical blockage of the afferent stoma, often
evidence of bowel function. accompanied by jejunogastric intussusception or internal
hernia, causes an acute closed-loop obstruction that mani-
fests as excruciating upper abdominal pain and retching.
Complications Gastrointestinal radiography reveals complete block at the
afferent stoma, which can be confirmed by endoscopy. This
Duodenal Fistula situation is a surgical emergency because if the distended
afferent loop bursts, lethal peritonitis results. Obviously,
In the presence of an adequate drain, the appearance of duode- emergency surgery for correction of the obstruction is
nal content in the drainage fluid with no other symptoms may essential.
not require vigorous therapy. On the other hand, if there are Intermittent afferent limb obstruction causes postprandial
signs of spreading peritoneal irritation, prompt relaparotomy pain that is relieved by bilious vomiting. Because the efferent
is indicated. If no drain was placed during the initial operation, limb is patent, the vomitus may not contain food. Exploration
immediate relaparotomy is undertaken whenever there is rea- and jejunojejunostomy allow drainage of the afferent limb
son to suspect duodenal leakage. On rare occasions, relapa- into the efferent limb.
rotomy can be performed before there is intense inflammatory Most afferent loop symptomatology can be prevented by
reaction of the duodenal tissues, and the defect may be closed ensuring that the distance between the ligament of Treitz and
by suture. This is seldom possible, however. In most cases the the gastric pouch is never more than 12–15 cm. These prob-
operation is done to provide excellent drainage. A small sump- lems do not occur after a Billroth I reconstruction.
suction drain should be inserted into the fistula and additional
latex and sumps placed in the area. If a controlled duodenocu-
taneous fistula can be achieved, it generally closes after a few Dumping Syndrome
weeks of total parenteral nutrition.
Leaks from Billroth I gastroduodenal anastomoses, The “dumping syndrome” may occur in any patient whose
though rare, are even more serious than from duodenal stump pylorus has been rendered nonfunctional. It is more common
(Billroth II) procedures. Generally, they are treated by the in patients of asthenic habitus who have never achieved nor-
Graham technique of closing a perforated duodenal ulcer mal body weight, even before surgery. Dietary alteration
with a segment of viable omentum (see Fig. 31.11a and b in generally controls dumping. Slow introduction of concen-
Chap. 31). Multiple sump drains should also be inserted. trated carbohydrate loads, particularly in liquid form (e.g.,
apple juice), may help avoid the problem.
Gastric Outlet Obstruction

Marginal Ulcer
Obstruction in the gastroduodenal anastomosis is generally
due to inversion of too much tissue, or acute angulation of One cause of recurrent ulcer is the surgeon having left behind
the anastomosis, which produces a mechanical block. If this gastrin-secreting antral mucosa on the duodenal stump fol-
condition does not respond after a period of conservative lowing a Billroth II gastrectomy.
Further Reading Goh P, Tekant Y, Isaac J, Kum CK, Ngoi SS. The technique of laparo-
scopic Billroth II gastrectomy. Surg Laparosc Endosc. 1992;2:258.
Nyhus LM, Wastell C. Surgery of the stomach and duodenum. Boston:
Bennett JJ, Rubino MS. Gastrointestinal stromal tumors of the stomach.
Little, Brown; 1977. p. 368.
Surg Oncol Clin N Am. 2012;21:21.
Sawyers JL. Management of postgastrectomy syndromes. Am J Surg.
Eagon JC, Miedema BW, Kelly KA. Postgastrectomy syndromes. Surg
1990;159:8.
Clin North Am. 1992;72:445.
Gholami S, Cassidy MR, Strong VE. Minimally invasive surgi-
cal approaches to gastric resection. Surg Clin North Am. 2017
Apr;97(2):249–64.
Perforated Duodenal Ulcer
30
Sharmila Dissanaike and Carol E. H. Scott-Conner
Indications • Preoperative antibiotics

• Monitoring of hourly urine output and acidosis as indicated
Perforated Duodenal Ulcer
Duodenal perforations are usually small, measuring less than Pitfalls and Danger Points
a centimeter in diameter. While it can be tempting to perform
primary suture repair alone, the tissues surrounding the ulcer • Inadequate fluid and electrolyte resuscitation prior to
are invariably stiff and inflamed; thus, repair with an omental induction of anesthesia
patch, also called a Graham’s patch, is preferred. • Closure of perforation under tension
Large duodenal ulcers can be much more challenging to
repair. Beware of the large duodenal ulcer that curves over
the edge of the duodenum to become confluent with a poste- Operative Strategy
rior ulcer, which can be associated with bleeding. There is no
easy way to completely close large perforations, which often The most important initial step of the operative strategy is to
require extensive duodenal mobilization and closure with a determine, on the basis of the principles discussed above,
pyloroplasty technique. If all else fails, tube duodenostomy whether the patient should be treated by patch repair or
can provide a temporizing measure and lead to formation of resection. On technical grounds alone, large defects may be
a controlled tract which then gradually seals once the tube is better handled by resection and reconstruction than by
removed after several weeks. attempted repair. If it appears that repair of a duodenal ulcer
Effective medical therapy has significantly diminished would cause narrowing and obstruction, resection is safer.
the role for vagotomy in this setting. Laparoscopic omental An alternative is excising the perforation as part of a pyloro-
patch repair is a good option in properly selected patients, plasty incision (see Chap. 27).
and may shorten the length of hospital stay. For most perforated duodenal ulcers, an attempt to close
the defect by sutures alone often results in the stitch tearing
through the edematous tissue. It is preferable to place a plug
Preoperative Preparation of viable omentum over the defect and use through-and-
through sutures to hold the omentum in contact with the wall
• Initiate fluid and electrolyte resuscitation of the duodenum. This practice avoids tension on the sutures.
• Nasogastric suction It is important to irrigate the abdominal cavity thoroughly
with large quantities of saline to remove the contamination
prior to placing sutures.
S. Dissanaike
Department of Surgery, Texas Tech University Health Sciences Documentation Basics
C. E. H. Scott-Conner (*) • Location and diameter of ulcer in centimeters
Department of Surgery, University of Iowa Carver College • Patch repair versus pyloroplasty versus resection

https://doi.org/10.1007/978-3-030-81415-1_30
248 S. Dissanaike and C. E. H. Scott-Conner
Operative Technique Patch Repair of Perforation
Incision Identify an area of omentum with sufficient laxity to raise a

tongue of tissue that will comfortably sit over the perfora-
A midline incision from the xiphoid to the umbilicus pro- tion. This should be at least 4 cm wide by 6 cm long, and lie
vides good exposure and can be made rapidly. comfortably in place without undue tension. Use ligatures
(2–0 or 3–0 silk) to divide this tongue from surrounding
omentum, taking care to preserve the vascular supply.
Identification of Perforation Place a 3–0 suture on an atraumatic needle beginning at a
point about 5 mm superior to the perforation. Bring the stitch
The perforation is almost always located on the anterior por- out about 5 mm distal to the perforation, staying superior to
tion of the first part of the duodenum just after the pylorus the perforation. Leave the ends untied and tag with a hemo-
(Fig. 30.1). It will often be partially sealed by omentum, stat for ease of identification. Next, place two similar sutures,
liver, or gallbladder. Palpating along the greater curve of the one directly across the perforation and one immediately infe-
stomach till the pylorus is felt and, then, carefully examining rior to it.
the surface of the duodenum immediately distal will usually Next, place the tongue of omentum over the perforation.
reveal the ulcer easily. If this area is not the site of the perfo- Tie the three sutures over the plug of omentum to fasten it in
ration, carefully examine the entire stomach up to the esoph- place (Figs. 30.2 and 30.3). Using braided filament allows
agus and include the entire posterior surface of the stomach for a snug grasp of the omentum without cutting into it. I
in the lesser sac. If this is negative, other sources of perfora- recommend using sutures of different colors (purple dyed
tion should be considered, and the incision extended if nec- vicryl, black silk, green polyester, and undyed white vicryl
essary to permit examination of the entire small intestine and all work well and are usually readily available) for each
colon. suture, to minimize the risk of accidentally tying the wrong
Manually move the nasogastric tube distal to the perfora- ends together. It is not necessary to approximate the margins
tion to ensure the repair is well drained, and ask the anesthe- of the hole in the duodenum but only to cap it with viable
siologist to tape it in this location. omental tissue.
Abdominal Closure
Close the midline incision without drainage using the modi-

fied Smead-Jones technique as described in Chap. 3. Unless
Fig. 30.1 Fig. 30.2

30 Perforated Duodenal Ulcer 249
Complications
• Subphrenic and subhepatic abscesses occur mainly in

patients whose operations have been delayed more than
8–12 h after the perforation.
• Duodenal obstruction, caused by the plication, should be
suspected if gastric emptying has not returned to normal
by the eighth or ninth postoperative day. It may be con-
firmed by a gastrointestinal contrast study.
• Delay in healing may occur, and be demonstrated by per-
sistent leak on contrast study. Continue NPO and reassess
in several days. In patients who were previously malnour-
ished, parenteral nutrition may be required until the per-
foration is sealed.
• Reperforation of the duodenal ulcer occurs in rare cases,
Fig. 30.3 and the surgeon must be alert to detect this complication.
When it does occur, gastric resection is mandatory if there
is to be any hope of stopping the duodenal leak.
the patient has advanced peritonitis, the skin may be closed
in routine fashion. Closed suction drains have not been
shown to reduce surgical site infection, and are not Further Reading
necessary.
Jordan GL Jr, Angel RT, DeBakey ME. Acute gastroduodenal perfo-
ration: comparative study of treatment with simple closure, subto-
tal gastrectomy and hemigastrectomy and vagotomy. Arch Surg.
Postoperative Care 1966;92:449.
Kutlu OC, Garcia S, Dissanaike S. The successful use of simple tube
• Nasogastric suction – the authors’ practice is to maintain duodenostomy in large duodenal perforations from varied etiolo-
gies. Int J Surg Case Rep. 2013;4(3):279–82.
NPO with NG suction for 4 days and obtain a contrast study
Ng EK, Lam YH, Sung JJ, et al. Eradication of helicobacter pylori
through the nasogastric tube at completion of this period. If prevents recurrence of ulcer after simple closure of duodenal ulcer
there is no evidence of leak, remove the tube and start clear perforation: randomized controlled trial. Ann Surg. 2000;231:153.
liquid diet. If this is tolerated, the patient may be discharged Stabile BE. Redefining the role of surgery for perforated duodenal ulcer
in the helicobacter pylori era. Ann Surg. 2000;231:159.
home. Slowly advance diet at home over the next week.
Svanes C, Lie RT, Svanes K, Lie SA, Soriede O. Adverse effects
• Test for Helicobacter pylori and treat if positive. of delayed treatment for perforated peptic ulcer. Ann Surg.
• Intravenous fluids while NPO. 1994;220:168.
Laparoscopic Plication of Perforated
Duodenal Ulcer 31
Edwin Onkendi
Indications Documentation Tips
• Hemodynamically stable, no significant medical cormo- • Intraoperative findings

bidities, and early (<24 hrs) presentation • Location of drains
• Primary suture closure: Small (<5 mm) anterior D1 duo- • Technique and integrity of perforation repair
denal ulcer perforation if healthy edges
• Pedicled omental patch/plug: Anterior D1 duodenal ulcer
perforation >5 mm, ulcer edges not optimal for primary Operative Strategy
closure
Laparoscopic repair is appropriate for a simple anterior per-
forated duodenal ulcer in a hemodynamically stable or resus-
Preoperative Preparation citated patient. A stepwise operative approach includes the
following steps:
• Fluid and electrolyte resuscitation
• Nasogastric decompression • Exploration and identification of perforation.
• Intravenous proton pump inhibitors • Peritoneal washout (5–10 L warm saline) and control of
• Broad-spectrum antibiotics contamination before attempt at repair.
• Assessment of the perforation and choice of appropriate
method of repair.
Potential Pitfalls and Dangers Points • Preparation of pedicled omental flap.
• Securing of the omental flap (absorbable suture through
• Delayed operative intervention after failed trial of non- seromuscular layer or full-thickness bites adjacent to the
operative management ulcer if health and viable, typically at four quadrants).
• Inadequate omental patch • Drainage of the hepato-renal recess.
• Inadequate securing of patch • Consider definitive acid reduction surgery with highly
• Large (>15–20 mm) or unusually positioned ulcer [intra- selective vagotomy (HSV), Taylor’s procedure (posterior
operative pre-repair esophagogastroduodenoscopy truncal vagotomy and anterior seromyotomy), or anterior
(EGD)] parietal cell vagotomy if patient has been on prior proton
• Preexisting duodenal obstruction (preoperative or intra- pump inhibitor (PPI) therapy, needs continued nonsteroi-
operative EGD) dal anti-inflammatory drugs (NSAID) therapy, potential
• Potential injury to the retro-duodenal bile duct due to the non-compliance with anti-Helicobacter Pylori, and anti-
distortion of peri-duodenal anatomy and obliteration of secretory therapy. Acid reduction surgery is appropriate
tissue planes only for hemodynamically stable patients, with limited
peritoneal contamination, early presentation <24 hrs, with
no significant comorbidities and a surgeon skilled in this
E. Onkendi (*) procedure.
Department of Surgery, Texas Tech University Health Sciences
e-mail: Edwin.Onkendi@ttuhsc.edu

https://doi.org/10.1007/978-3-030-81415-1_31
252 E. Onkendi
Laparoscopic plication is contraindicated for large

(>15 mm) or unusually positioned perforated ulcers. This
approach is also not recommended for gastric ulcers or
hemodynamically unstable patients or those with delayed
presentation or multiple comorbidities.
Operative Technique
Position the patient supine. Place four ports, including two

12 mm
12 mm and two 5 mm ports as shown in Fig. 31.1. It is impor-
tant to place the epigastric and right lateral trocars under
direct visualization after the abdomen is insufflated and
patient positioned in a Trendelenberg position to optimize 5 Hasson
mm 5
working space and triangulation. An angled 30 or 45 degree
mm
laparoscopic affords the necessary wide operative field of
view. Perform an initial laparoscopic exploration. Sometimes,
the site of perforation is walled off by the omentum, the
undersurface of the liver and falciform ligament. Before
breaking the seal and exposing the walled-off perforation,
suction and irrigation of the hepato-renal pouch of Douglas,
subphrenic recess, interloop spaces, pelvis, and all other
abdominal quadrants of any fluid and debris is done. Then
irrigate thoroughly with warm saline and aspirate until the Fig. 31.1
effluent returns clear.
Next give attention to the site of perforation. Insert a blunt
grasper through the right lateral subcostal trocar and a suc-
tion irrigator through the epigastric trocar and use these two
to bluntly and gently peel off the adherent liver, omentum,
falciform ligament, and gelatinous fibrinous material to
expose the site of perforation. Then retract the liver cephalad
using the blunt grasper. Alternatively, grasp the falciform
ligament close to the liver with a locking grasper and use this
to retract the liver cephalad. Thoroughly irrigate the subhe-
patic and perihepatic spaces, and gently debride any fibrin-
ous debri on the perforation in order to assess its full extent.
Assess the size of the duodenal perforation as well as the
quality of the edges to determine if primary closure and/or
omental patching/plugging is an option. A fresh small
(<5 mm) perforation with health viable edges is appropriate
for primary interrupted transverse suture closure. This can be
performed using a 3–0 absorbable suture taking interrupted
seromuscular bites on either side of the perforation and
approximating these in a transverse manner. If deemed nec-
essary, the closure can then be reinforced with a patch of
omentum secured with the already placed and tied 3–0
absorbable sutures now tied around the omental patch
(Fig. 31.2). If the quality of the duodenal edges around the
perforation is suboptimal for primary closure (edematous,
inflamed, friable), and the size of the perforation is >5 mm to
Fig. 31.2
<15 mm, omental patching/plugging is recommended.
31 Laparoscopic Plication of Perforated Duodenal Ulcer 253
Examine the right side of the omentum. Dissect and

mobilize a generous tongue of omentum with a perfusing
vascular pedicle (Fig. 31.2).
Securing the Omental Patch
A fully mobilized tongue of well-vascularized omentum is

used. The omental patch/plug may be secured in one of the
following three ways:
mental Onlay Patch after Primary Closure

O
Perform the primary repair by placing three or four sutures
across the ulcer to close it in a transverse manner. Then tie
each of these sutures first to close the ulcer with three to four
throws. Then separate the tails of each suture. Place the
tongue of omentum between the separated tails of the tied
sutures. Tie each suture over the omentum to secure the patch
(Fig. 31.3). Primary closure in this manner should only be
done for a fresh, small ulcer with fairly healthy ulcer edges
that can hold sutures and be approximated without tension or
tear when sutures are tied.
Omental Plug Technique

Place three or four interrupted absorbable sutures as
above. Before tying them, place the plug of omentum into
the perforation between the suture tails in a transverse
manner to cover the perforation completely. Once satis- Fig. 31.3
fied with the omental coverage of the duodenal hole, tie
each suture over the omental plug. The suture ties should esting the Integrity and Security
T
not be too tight to avoid choking off the blood supply to of the Perfortion Repair
the omental plug and subsequent necrosis and failure of
the plug. • Intraoperative testing: Perform a low-pressure nasogastric
tube air insuflation and check for air bubbles at the repair
mental Radial Patch Technique
O site submerged under saline.
If the ulcer edges are not optimal for safe approximation • Postoperative: Prior to initiating oral intake, perform an
(larger ulcer, poor quality edematous or friable ulcer hole upper gastrointestinal (UGI) Gastrografin contrast study
edges), appose the tongue of omentum onto the perforation on POD#3 if or when drain output nonbilious.
to fully cover it. Secure the omental patch by placing six to
eight sutures in a radial manner (Fig. 31.4a). For each site of
fixation, take seromuscular bites of the duodenal wall just off Postoperative Care
the perforation edge and another bite through the omentum
and leave each suture untied till all the necessary fixation • Continue PPI.
sutures have been placed. First tie the inferior margin/caudal • Nil per os with nasogastric tube decompression for the
suture before the other sutures are tied to prevent inadequate first 24–48 hours to allow for gastric ileus to resolve.
apposition and leakage at this site. Then tie all the other • Intravenous (IV) antibiotics continued until white blood
sutures beginning with the one furthest from the laparoscope cells (WBC) normalizes and patient afebrile.
(Fig. 31.4a and b). • Check for and treat Helicobacter pylori (Serology).
254 E. Onkendi
a b
Fig. 31.4
• Discontinue NSAIDs if these are the cause. Complications

• If no leak is visualized on postoperative UGI study, oral
intake can be initiated. Drain is kept in place till patient is • Inadequate ulcer closure resulting in postoperative leak
on full solid diet with no leak. and ongoing sepsis. This may be due to an inadequate size
• Discontinue drain if output is non-bilious and when of the omentum used, inadequate securing omental patch/
patient is on regular diet. plug and seal of perforation, and distal obstruction.
• Persistent postoperative bilious drain output-nonoperative • Postoperative intraabdominal abscess (typically sub-
management if no clinical effects. phrenic or subhepatic).
• Long-term PPI therapy if definitive ulcer surgery not
performed.
• Follow-up at 4–6 weeks with urea breath test to confirm
H. pylori eradication if present and treated. Further Reading
Lunevicius R, Morkevicius M. Systematic review comparing laparo-
scopic and open repair for perforated peptic ulcer. British J Surg.
Role of EGD 2005;92(10):1195–207.
Siow, SL; Mahendran HA, Wong CM et al.; Laparoscopic versus
EGD may be used as an adjunct for endoscopic snaring, pull- open repair of perforated peptic ulcer: Improving outcomes uti-
ing through, and plugging of the defect, therefore holding lizing a standardized technique; Asian J Surg, 2016 pii: S1015–
9584(16)30210-X. https://doi.org/10.1016/j.asjsur.2016.11.004.
omentum in place while suturing it during the omental plug [Epub ahead of print].
technique. Zhou C, Wang W, Wang J, et al. An updated meta-analysis of lapa-
Preoperative or intraoperative EGD may also be used to rule roscopic versus open repair for perforated peptic ulcer. Scientific
out distal obstruction which may cause failure of the repair of Reports. 2015;5:13976.
the perforation, or assess for multiple ulcers, check for malig-
nancy, and H. Pylori by obtaining appropriate biopsies.
Enteral Access
32
Mariela Rivera and Henry Schiller
Special gastrostomy tubes with a second jejunostomy limb

Indications can be used in selected cases when both gastric venting and
jejunostomy feedings are necessary.
Percutaneous Gastrostomy
• Enteral feeding Pitfalls and Danger Points

• Gastric decompression, such as may be required with
motility disorders or for palliation of malignant bowel PEG (or surgical gastrostomy) may not be feasible in patients
obstruction who have had extensive left upper quadrant surgery, such as
gastric bypass – consider jejunostomy in these cases
Surgical Gastrostomy • Injury to large bowel or small bowel

• Enteric leak into the peritoneal cavity
• Failed percutaneous approach • Tube dislodgment
• Inability to traverse esophagus endoscopically • Obstruction of bowel lumen by the tube (jejunostomy)
• Need for gastrostomy tube at the time of laparotomy for • Volvulus around the tube site (jejunostomy)
other indication
Operative Strategy
Jejunostomy
The PEG tube is widely available and has the benefit of allow-
• Enteral feeding in cases where gastrostomy is not feasi- ing enteral access while causing minimal discomfort to the
ble, for example, esophageal or gastric malignancy, patient. Placement depends on the stomach being able to be
gastro-colonic fistula, etc. distended enough with insufflation to come into direct contact
• Abdominal procedure with expected prolonged nothing with the anterior abdominal wall. In addition, the stomach
by mouth (NPO) status must be located below the costal margin, since most patients
• Intolerance to gastric feeds due to aspiration or gastric requiring a PEG tube have had a nasogastric tube in place at
paresis some point, an abdominal X-ray is adequate to ensure that the
patient does not have largely intrathoracic stomach. The pro-
Historically, gastrostomy tubes were used only for vent- cedure is most easily performed with two surgeons – one to
ing while jejunostomy tubes were used for feeding; however, operate the endoscope and the second to place the tube. The
with the data that jejunostomy tubes do not decrease the risk procedure can also be done with a surgeon (to place the tube)
of aspiration, this practice has been abandoned. Known com- and a trained assistant (to manipulate the endoscope).
plications of jejunostomy tubes, such as obstruction of the In cases where the endoscopic approach is not feasible, a
small bowel, dislodgement with enteric leak, and small surgical gastrostomy tube can be performed. The Stamm
bowel volvulus are other reasons that its use has declined. gastrostomy is a safe and technically easy procedure in
which the serosa around the gastrostomy site is inverted to
M. Rivera · H. Schiller (*) prevent leakage of gastric contents around the tube. The
Department of Surgery, Mayo Clinic, Rochester, MN, USA Stamm gastrostomy can also be performed laparoscopically.
e-mail: Schiller.Henry@mayo.edu

https://doi.org/10.1007/978-3-030-81415-1_32
256 M. Rivera and H. Schiller
When constructing a tube gastrostomy, the opening to the spot of light (focal light reflex) should shine through the
stomach is sutured to the anterior abdominal wall around the abdominal wall at the proposed tube site (Fig 32.1). Failure
stab wound made for the exit of the tube. This allows for the to see both focal indentation of the gastric wall with finger
formation of a scar tract that can be re-intubated in the future ballotment and a focal light reflex with transillumination
to replace a dislodged tube. It is important that the tube suggests that another structure, such as the colon, is inter-
remain in place for at least 6 weeks to allow formation of this posed between stomach and abdominal wall. This means that
scar tract, otherwise gastric contents may leak out of the gas- it is unsafe to proceed with PEG tube placement and surgical
trostomy opening into the abdominal cavity. Surgical G-tubes gastrostomy tube placement should be considered. Infiltrate
provide additional security afforded by suturing the anterior local anesthetic into the skin and abdominal wall at the pro-
gastric wall to the abdominal wall; however, earlier concerns posed tube site and make a 5 mm puncture wound with an 11
about an increased leak rate for PEG versus surgical gastros- blade scalpel. Insert an angiocatheter through the puncture
tomy have not been realized. site and observe it endoscopically entering the gastric lumen
Similar concepts apply for the construction of the Witzel (Fig. 32.2). Pass an endoscopy snare through the working
jejunostomy. The creation of the tunnel facilitates spontane- channel of the gastroscope and position the open loop around
ous closure after removal and also decreases the risk of tube the angiocatheter. Insert a long-looped string through the
dislodgement. Small bowel should be sutured to the abdomi- angiocatheter and grasp it by tightening the pre-positioned
nal wall for a distance of at least 10cm to prevent volvulus. endoscopy snare. Then withdraw both the gastroscope and
one end of the snared looped string through the patient’s
mouth. Tie or secure (with an interlocking loop) the looped
Operative Technique string to the tapered end of the PEG tube. By applying strong
steady traction to the part of the string passing out through
ercutaneous Endoscopic Gastrostomy (PEG)
P the abdominal wall, pull the looped end and gastrostomy
Tube Placement tube back through the patient’s mouth, through the stomach,
and back through the puncture wound in the abdominal wall.
This procedure is performed with a standard gastroscope and Since the gastroscope needs to be reintroduced into the stom-
any of a number of commercially available PEG tube kits. ach, we grasp the PEG tube bumper with the biopsy snare so
We prefer PEG tubes with a traction removable bumper. It is that the gastroscope is pulled back into the stomach along
important to position the tube site at least two fingerbreadths with the PEG tube. The tapered end of the PEG tube is pulled
below the costal margin to prevent discomfort from the tube through the anterior abdominal wall until the bumper is clear
when the patient is sitting. Prepare the abdomen and mark a in the stomach. Use care to watch the numbers on the shaft of
line in the left upper quadrant two fingerbreadths below the the PEG tube and not to pull too hard, as it is possible to
costal margin for a proposed tube puncture site. In order to inadvertently pull the bumper out of the stomach at this
prevent formation of a gastrocutaneous fistula, the tube stage.
should pass through a muscular portion of the abdominal Re-insufflate the stomach, disengage the biopsy snare
wall and not through a hernia sac or a broad diastasis recti. from the bumper by opening the loop of the snare, and fur-
Operating room lights are dimmed and the gastroscope is ther withdraw the PEG tube until the bumper gently indents
inserted through the oropharynx into the esophagus and the gastric mucosa. Test that the bumper is not too tight by
advanced into the stomach. We take this opportunity to eval-
uate the stomach and duodenum for abnormalities, such as
stress ulceration or peptic ulcer disease. Insufflate the stom-
ach until all rugal folds have flattened out. Maintain this dis-
tension throughout the procedure, as it helps to displace the
colon from the upper abdomen and brings the gastric wall in
apposition to the anterior abdominal wall.
Then press vigorously with the index finger over the tube
site as the anterior gastric wall is observed with the gastro-
scope. A clear focal indentation should be seen on the gastric
wall when the finger is pressing to indicate that the gastric
wall is directly adjacent to the anterior abdominal wall with-
out other structures (such as the colon) in the way. Next,
bring the gastroscope up against the gastric wall at the exact
location of the finger indentation and increase the gastro-
scope light source intensity to the transilluminate setting. A Fig. 32.1
32 Enteral Access 257
Fig. 32.2
Fig. 32.4
Fig. 32.3
twisting the tube and confirming that the bumper can spin
easily against the gastric mucosa. If the bumper is too tight
against the gastric wall, necrosis can result. Note the depth of
tube by looking at numbered gradations on the side of the
tube (Fig. 32.3) and place the skin-level retention disk over
the PEG tube to secure it in this position. Place the tube
clamp is placed, cut the tube to the desired length, and place
the feeding tube adaptor (Fig. 32.4). We keep the tube on
gravity drainage overnight before beginning tube feedings.
Stamm Gastrostomy
Fig. 32.5
When performed as part of another abdominal procedure,
any incision providing access to the upper abdomen can be
used. When gastrostomy is performed as the sole procedure, Choose a portion of the stomach that easily apposes to the
a very limited transverse incision in the left upper quadrant anterior abdominal wall in the left subcostal region.
can be used in thin patients. In overweight patients, an upper Generally, the gastrotomy should be closer to the greater cur-
midline incision is generally necessary. vature of the stomach to allow room for inversion of gastric
serosa around the tube (Fig. 32.5). Using 2-0 atraumatic
absorbable suture, insert a deep seromuscular or full- should now be brought up toward the anterior abdominal
thickness circular purse-string suture just larger than the wall and silk Lembert sutures should be placed circumferen-
diameter of the tube to be placed. tially around the tube to anchor the stomach securely to the
Generally, at least an 18F tube is used to prevent occlu- abdominal wall (Figs. 32.8 and 32.9). At the tube exit site,
sion with tube feeds, and larger diameter tubes can be used
for more efficient drainage. While Foley, Malecot, or mush-
room catheters have been used in the past, specifically
designed feeding tubes are now encouraged for use to pre-
vent medical tubing misconnection errors (i.e., EnFIT).
Grasp the abdominal wall fascia with a Kocher clamp and
place the fascia on traction. The tube should exit at least two
fingerbreadths below the left costal margin to prevent patient
discomfort when sitting. The tube should pass through the
rectus muscle to prevent formation of a gastrocutaneous fis-
tula, and to allow the tube site to contract and close down
once the tube is removed. Make a stab wound at the proposed
tube exit site and pass a hemostat full thickness through the
abdominal wall. Grasp the tip of the feeding tube and pull it
through the abdominal wall into the abdominal cavity. Incise
the stomach wall in the center of the purse string suture and
pass the feeding tube into the gastric lumen (Fig. 32.5). The
purse-string suture should now be tightened down snuggly
around the tube and tied (Fig. 32.6). As long as the purse-
string suture material is absorbable, the tails of suture mate-
rial may be tied around the tube itself to prevent the tube
from dislodging during the remainder of the procedure.
Inversion of the tube so that a generous layer of gastric serosa
is brought into apposition circumferentially around the tube
is critical to prevent leakage of gastric contents into the peri-
toneal cavity. This can be done either with a second concen-
tric purse-string suture (Fig. 32.7) or with a several generous
Lembert sutures on either side of the tube. The stomach
Fig. 32.7
Fig. 32.6 Fig. 32.8

32 Enteral Access 259
performed as the sole procedure, a very limited transverse

incision in the left upper quadrant can be used in thin patients,
with upper midline incision generally necessary for over-
weight patients. The jejunostomy tube should be placed in
the proximal jejunum in order to permit maximum absorp-
tion of nutrients. We generally select a segment of jejunum
approximately 20 cm distal to the ligament of Treitz that will
easily appose to a point on the anterior abdominal wall with-
Seromuscular
incision out tension. Grasp the abdominal wall fascia with a Kocher
clamp and place the fascia on traction. Jejunostomy tube
positioning is analogous to gastrostomy tube placement: the
tube should exit at least two fingerbreadths below the left
costal margin to prevent patient discomfort when sitting, and
the tube should also pass through the rectus muscle to pre-
vent formation of an enterocutaneous fistula, and to allow the
tube site to contract and close down once the tube is removed.
Make a stab wound at the proposed tube exit site and pass a
hemostat full thickness through the abdominal wall. Grasp
the tip of the jejunostomy tube and pull it through the abdom-
inal wall into the abdominal cavity.
Using 3-0 atraumatic absorbable suture, insert a deep
seromuscular or full-thickness purse-string suture just larger
Seromuscular than the diameter of the tube to be placed (Fig. 32.5). Great
incision
care must be taken to limit the size of the purse-string so that
it does not compromise the lumen of the jejunum, leading to
obstruction. A 5mm incision is made in the antimesenteric
border of the jejunum and the tube is inserted into the jeju-
num and directed distally for a distance of at least 15 cm. The
Fig. 32.9 purse-string suture is now tied down around the tube. As long
as the purse-string suture material is absorbable, the tails of
suture material may be tied around the tube itself to prevent
the G-tube is now fastened securely to the skin with a non- the tube from dislodging during the remainder of the proce-
absorbable suture. dure. If the tube used has an inflatable balloon, we place the
balloon in the jejunum at least 5 cm distal to the purse string
and inflate it with only 3 ccs of water. This is to prevent
Witzel Jejunostomy occluding the lumen of the jejunum. Starting at the jejunos-
tomy and proceeding distally approximately 5cm, the Witzel
Witzel Jejunostomy is a common procedure for jejunostomy tunnel is created by placing 3.0 silk seromuscular Lembert
creation. The creation of the seromuscular Witzel tube is sutures (Fig. 32.6). Again, great care must be taken to pre-
critical to prevent leakage of enteric contents from the jeju- vent the Witzel tunnel from occluding the lumen of the jeju-
nostomy into the abdominal cavity. Just as with the gastros- num. We also place a Lembert suture just proximal to the
tomy tubes, when the jejunostomy is no longer needed, jejunostomy to invert the purse string in order to prevent
removal of the tube usually results in prompt closure of the leakage of enteric contents into the abdominal cavity
tract. (Fig. 32.7). The needles should be left on the two sutures
Generally, at least a 12F tube is used to prevent occlusion adjacent to the tube, and the most distal suture of the Witzel
with tube feeds. While red rubber catheters are still being tunnel. The jejunum should now be brought up toward the
used, specifically designed feeding tubes with EnFIT fittings anterior abdominal wall and these sutures are used anchor
applied are now encouraged to prevent medical tubing mis- the jejunum securely to the abdominal wall (Fig. 32.8).
connection errors. When using a red rubber tube, we cut the Broad apposition of the jejunum to the anterior abdominal
end off the distal end of the tube so that it may later be wall resists the tendency for volvulus, and will allow for per-
replaced over a guidewire. When performed as part of cutaneous access to this loop of the jejunum by interven-
another abdominal procedure, any incision giving access to tional radiology, should the tube become dislodged and the
the upper abdomen can be used. When open jejunostomy is tract closed down. At the tube exit site, the jejunostomy tube
is now fastened securely to the skin with a non-absorbable Goncalves Pereira Bravo J, Ide E, Kondo A, Turiani Hourneaux
de Moura D, Turiani Hourneaux de Moura E, Sakai P, et al.
suture. Feeding can start same day of placement or after Percutaneous endoscopic versus surgical gastrostomy in patients
return of bowel function, in the case of ileus. with benign and malignant diseases: a systematic review and meta-
In instances when there is concern of possible obstruction analysis. CLINICS (Sao Paulo, Brazil) 2016;71(3):169–178
after the Witzel tunnel creation due to a small bowel caliber, Strong AT, Sharma G, Davis M, Mulcahy M, Punchai S, O’Rourke CP,
et al. Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube
we recommend doing a seromuscular incision 5cm in length Placement: A Single Institution Experience and Outcomes to 30
where the feeding tube will be placed and closure of the Days and Beyond. J Gastrointest Surg. 2017;21:446–52.
seromuscular layers on top (Fig. 32.9). This will elongate the Toh Yoon EW, Yoneda K, Nakamura S, Nishihara K. Percutaneous
area that will be used to create the Witzel tunnel, thereby endoscopic transgastric jejunostomy (PEG-J): a retrospective anal-
ysis on its utility in maintaining enteral nutrition after unsuccess-
preventing obstruction. ful gastric feeding. BMJ Open Gastro. 2016;3:e000098. https://doi.
org/10.1136/bmjgast-2016-000098.
Young MT, Troung H, Gebhart A, Shih A, Nguyen NT. Outcomes of
Further Reading laparoscopic feeding jejunostomy tube placement in 299 patients.
Surg Endosc. 2016;30:126–31.
Al-Bawardy B, Gorospe EC, Alexander JA, Bruining DH, Coelho-
Prabhu N, Rajan E, Wong Kee Song LM. Outcomes of double-
balloon enteroscopy-assisted direct percutaneous endoscopic
jejunostomy tube placement. Endoscopy. 2016;48:552–6.
Distal Gastrectomy with D2 Nodal
Dissection 33
Hisakazu Hoshi
• Adenocarcinoma of the distal stomach Extent of Resection
Distal gastrectomy with D2 nodal dissection is an en bloc

Preoperative Preparation resection designed to accomplish three things: (1) Remove
the distal stomach with adequate clean proximal and distal
• Endoscopic biopsy and ultrasonography margins, (2) remove regional lymph nodes in continuity for
• Computed tomography and other imaging studies as staging and tumor control, and (3) remove segments of adja-
appropriate to stage cent organs involved by direct extension in appropriate cases.
• Diagnositc laparoscopy with peritoneal washings, as Figure 33.1 shows the stomach lifted up to display the vascu-
appropriate to stage lar anatomy, and Fig. 33.2 shows the regional anatomy to
• perioperative systemic antibiotics demonstrate the close proximity of the stomach to the pan-
creas, liver, and transverse mesocolon.
Frozen sections are helpful for evaluating proximal and
Pitfalls and Danger Points distal margins. As with many gastrointestinal malignancies,
gastric cancer may extend submucosally for several centime-
• Inadequate resection ters beyond the obvious tumor mass. Generally, a well-
• Injury to pancreas or spleen differentiated adenocarcinoma requires at least 3 cm of gross
• Ischemia of gastric remnant pouch if splenectomy is per- margin, and a poorly differentiated carcinoma needs a 5 cm
formed (see Chap. 30) margin.
The nodal stations around the stomach are anatomically
defined and numerically classified by the Japanese
Documentation Basics Classification of Gastric Carcinoma published by Japanese
Gastric Cancer Association (JGCA) (Fig. 33.3, Table 33.1).
• Document extent of disease including presence of any Perigastric nodal stations are numbered 1 through 6 and
metastases. regional nodal stations are 7–12. Nodal stations numbered
• Document frozen sections taken, if any, and results. higher than 12 are generally considered “distant” nodal sta-
• Extent of lymphadenectomy. tions and are not included in the standard D2 nodal
• Type of reconstruction. dissection.
The level of the nodal dissection, known as the D number,
is defined by the guidelines from JGCA. While the classic
D1 nodal dissection is defined by complete dissection of the
first tier nodal stations which are determined by the location
of the primary lesion and is most compatible with current
H. Hoshi (*) concept of the “D1 nodes, perigastric nodes (station 1–6)” in
Department of Surgery, Surgical Oncology and Endocrine Surgery, western literature, current (2010) definition of D1 nodal dis-
University of Iowa, Iowa City, IA, USA section in Japan includes left gastric artery node station (sta-
e-mail: hisakazu-hoshi@uiowa.edu

https://doi.org/10.1007/978-3-030-81415-1_33
262 H. Hoshi
Fig. 33.1
Short gastric
artery
L. gastroepiploic
artery
L. gastric artery
Post. gastric
Inf. phrenic artery
artery
Hepatic artery Splenic artery
Gastroduodenal
artery
R. gastroepiploic
artery Sup. mesenteric artery
Ant. Inf. pancreaticoduodenal
pancreaticoduodenal artery
artery
Middle colic artery
Sup. mesenteric vein and vein
Fig. 33.2
Liver
Pancreas
Stomach
Kidney
Colon,
transverse
Omentum
Small
intestine
33 Distal Gastrectomy with D2 Nodal Dissection 263
a APIS b
8a
8p
2 AHC
2
Pan-
1 4sb AGB VP creas
7 13 VL
3 VGED
9
6
TGC VPDSA
8 4sb
AGES 14v VCDA
5
3
4sb VMS
AGB
6
VGED 4d 12a 11d
12p AGP 10
12b
4d 11p
8a
VCM 8p
VCDA
VCD
13 VL 4sb
18
VMS
17 VGED
TGC 14v 14a
VPDSA
AJ
13 VCDA
ACM
VCD AJ, VJ
ACD
VCM
Fig. 33.3 (a and b) (From Japanese Gastric Cancer Association. Japanese classifications of gastric carcinoma. 14th ed. Table 5. Tokyo: Kanehara
& Co., Ltd.; with permission)
tion 7) in addition to the perigastric nodal stations due to the 11d). Previous randomized trials examining D1–D2 nodal
observed high incidence of metastasis in this nodal station by dissection suffered from the complications of this historical
the early gastric cancer. approach. Currently, splenectomy and distal pancreatectomy
The technique described in this chapter removes all the are not recommended for nodal clearance in North America
D2 nodal stations (stations 1–12). The survival benefit of D2 and Europe. Due to the relatively high incidence of splenic
nodal dissection is still a topic of debate; however, superior hilar nodal involvement in advanced proximal gastric can-
locoregional cancer control has been demonstrated in large cers, a randomized trial of D2 nodal dissections with or with-
randomized trial. out a splenectomy preserving the pancreatic tail was
Gastric cancer can involve any contiguous organ by direct performed in Japan and the result showed no survival benefit
extension. Generally, such extension is obvious on the preop- of splenectomy.
erative imaging studies, but the surgeon must be prepared to
excise any involved adjacent organs in continuity. Posteriorly,
the tumor can invade the body or tail of the pancreas, the Blood Supply to Residual Gastric Pouch
middle colic artery, or the transverse colon; all of which can
be included in the specimen. Invasion of the aorta A major drawback of including the spleen in a resection that
contraindicates resection. Extension into the left lobe of the also involves ligation of the left gastric artery at its origin is
liver is amenable to resection, as is extension into the crus of that ischemia or necrosis of the residual gastric pouch may
the diaphragm. Generally, survival is poor when extensive develop. After ligation of both the left gastric artery and the
tumor dictates excision of adjacent organs. left gastroepiploic artery, the blood supply of the residual
gastric pouch is limited through short gastric arteries. About
40–97% of patients have a posterior gastric artery supplying
Pancreatico-Splenectomy, Splenectomy posterior portion of the gastric fundus that arises from the
middle portion of the splenic artery. It is possible to preserve
Historically, a splenectomy plus distal pancreatectomy have this artery if care is taken during the operation, but it is a
been an integral part of the classic D2 nodal dissection to small vessel and is easily traumatized. In addition, there are
ensure complete clearance of the splenic hilar nodal station collateral branches from the inferior phrenic vessels and
(station 10) and the distal splenic artery nodal station (station intramural circulation from the esophagus.
264 H. Hoshi
Table 33.1 Anatomical definitions of lymph node stations

No. Definition
1 Right paracardial LNs, including those along the first branch of the ascending limb of the left
gastric artery
2 Left paracardial LNs including those along the esophagocardiac branch of the left subphrenic
artery
3a Lesser curvature LNs along the branches of the left gastric artery
3b Lesser curvature LNs along the second branch and distal part of the right gastric artery
4sa Left greater curvature LNs along the short gastric arteries (perigastric area)
4sb Left greater curvature LNs along the left gastroepiploic artery (perigastric area)
4d Rt. greater curvature LNs along the second branch and distal part of the right gastroepiploic
artery
5 Suprapyloric LNs along the first branch and proximal part of the right gastric artery
6 Infrapyloric LNs along the first branch and proximal part of the right gastroepiploic artery down
to the confluence of the right gastroepiploic vein and the anterior superior pancreatoduodenal
vein
7 LNs along the trunk of left gastric artery between its root and the origin of its ascending branch
8a Anterosuperior LNs along the common hepatic artery
8p Posterior LNs along the common hepatic artery
9 Celiac artery LNs
10 Splenic hilar LNs including those adjacent to the splenic artery distal to the pancreatic tail and
those on the roots of the short gastric arteries and those along the left gastroepiploic artery
proximal to its first gastric branch
11p Proximal splenic artery LNs from its origin to halfway between its origin and the pancreatic tail
end
11d Distal splenic artery LNs from halfway between its origin and the pancreatic tail end to the end of
the pancreatic tail
12a Hepatoduodenal ligament LNs along the proper hepatic artery, in the caudal half between the
confluence of the right and left hepatic ducts and the upper border of the pancreas
12b Hepatoduodenal ligament LNs along the bile duct, in the caudal half between the confluence of
the right and left hepatic ducts, and the upper border of the pancreas
12p Hepatoduodenal ligament LNs along the portal vein in the caudal half between the confluence of
the right and left hepatic ducts and the upper border of the pancreas
13 LNs on the posterior surface of the pancreatic head cranial to the duodenal papilla
14v LNs along the superior mesenteric vein
15 LNs along the middle colic vessels
16a1 Para-aortic LNs in the diaphragmatic aortic hiatus
16a2 Para-aortic LNs between the upper margin of the origin of the celiac artery and the lower border
of the left renal vein
16b1 Para-aortic LNs between the lower border of the left renal vein and the upper border of the origin
of the inferior mesenteric artery
16b2 Para-aortic LNs between the upper border of the origin of the inferior mesenteric artery and the
aortic bifurcation
17 LNs on the anterior surface of the pancreatic head beneath the pancreatic sheath
18 LNs along the inferior border of the pancreatic body
19 Infradiaphragmatic LNs predominantly along the subphrenic artery
20 Paraesophageal LNs in the diaphragmatic esophageal hiatus
110 Paraesophageal LNs in the lower thorax
111 Supradiaphragmatic LNs separate from the esophagus
112 Posterior mediastinal LNs separate from the esophagus and the esophageal hiatus
Adapted from Japanese Gastric Cancer Association. Japanese classifications of gastric carcinoma. 14th ed. Table 5. Tokyo: Kanehara & Co., Ltd.;
with permission
As mentioned above, whenever the left gastric artery is adequate nourishment through the intramural channels
divided at its origin and splenectomy is performed, the from the esophagus if the posterior gastric and inferior
blood supply to the gastric remnant may be inadequate. phrenic collaterals prove inadequate. If there is any doubt
Thus one should avoid splenectomy in these cases unless about the adequacy of the blood supply, perform a total
so little gastric pouch is left behind that it may receive gastrectomy.
Duct of Santorini
When carcinoma approaches the pyloric region, microscopic

spread into the proximal 4–5 cm of the duodenum is possible
but rare event. When as much as 5 cm of the duodenum is
mobilized, the dissection has progressed beyond the gastro-
duodenal artery. In this area, there is a risk that the duct of
Santorini will be transected. Because the duodenal wall is free
of inflammation in cases of gastric cancer, this structure may
well be identifiable, in which case it should be divided and
ligated. If the duct of Santorini communicates with the duct of
Wirsung, the pancreatic juice then drains freely into the larger
duct, and there should be no postoperative consequence. In
some cases, the duct of Santorini does not communicate with
the main duct, in which event, despite the ligature, a pancreatic
fistula may well develop. This situation probably requires a Fig. 33.4
secondary operation to anastomose a Roux-en-Y segment of
the jejunum to the transected duct for internal drainage.
Fortunately, in most cases the two ducts do communicate. Fig. 33.2. Be alert to the difference in texture and color of the
fat in the epiploic appendices of the colon and that of the
omentum. Considerable bleeding and devascularization of
Operative Technique the transverse colon can be avoided by keeping the plane of
dissection between the appendices and the omentum
Incision and Exposure (Fig. 33.4). Once the lesser sac is entered through this plane,
identify the right border of the lesser sac, and by dividing the
An upper midline incision extending from the xiphoid to a layer of thin peritoneum the omentum can be separated from
few centimeters below the umbilicus gives good exposure the transverse mesocolon completely (Fig. 33.5a and b).
for this procedure. For patients with a high body mass index Take care to avoid damage to the mesocolon and middle
(BMI), a Chevron incision can be used as alternative. Place colic vessels. Follow the middle colic vessels and expose the
an Omni retractor or Thompson retractor to elevate the costal anterior surfaces of the neck of the pancreas (Fig. 33.6). The
margin. venous anatomy in this area is relatively complicated but
consistent. The right gastroepiploic vein joins with the right
colic (right accessory colic) vein forming the gastrocolic
Resection trunk which drains into right side of the superior mesenteric
vein (SMV) Dissect nodal tissue off of the gastrocolic trunk
Distal gastrectomy with D2 nodal dissection differs from toward the right gastroepiploic vein and ligate the vein at the
gastrectomy for peptic ulcer disease in terms of the dissec- junction. The gastroepiploic artery is located about 1/2 to
tion and the extent of resection. The reconstruction is essen- 1 cm cephalad to the vein and ligate this artery at the origin
tially the same and is not repeated here (see Chap. 30). from the head of the pancreas (Fig. 33.7a and b). Clear the
Begin with a thorough exploration of the abdomen. inferior edge of the bulbar portion of the duodenal wall and
Metastatic disease not detected on preoperative imaging connect this to previous dissection plane.
studies does not preclude resection for palliation in selected
patients. Evaluate the location and mobility of the tumor;
determine whether adjacent structures must be resected or if Dissection of Suprapyloric Nodes
a total gastrectomy (see Chap. 35) is more appropriate.
Start the dissection by dividing the lesser omentum 1 cm
from its attachment to the liver. Recognize any accessory/
mentectomy and Infrapyloric Nodal
O replaced left hepatic artery originating from left gastric
Dissection artery in this area. This can be preserved if no clinically posi-
tive nodes are seen around the left gastric artery by dissec-
Separate the entire gastrocolic omentum from the transverse tion of the nodes from the left gastric artery. Extend the
colon by dissection through the avascular embryonic fusion incision to the left border of hepatoduodenal ligament.
plane, as seen in the sagittal section of the abdomen in Remove soft tissue covering the proper hepatic artery toward
266 H. Hoshi
a b
Fig. 33.5
Hepatic Artery Node Dissection
Continue the nodal dissection along the common hepatic artery.

Divide the peritoneum along the superior border of the pancreas
toward left and dissect away the soft tissue covering the com-
mon hepatic artery. There is a distinctive plane between the
nodal tissue and the pancreas parenchyma, and this should be
recognized, and the dissection should be maintained in this
plane to avoid injury to the pancreas (Fig. 33.8). There are mul-
tiple small vessels present between these nodes and the upper
border of the pancreas, and these should be recognized and
coagulated before transection. The dissection plane also can be
maintained just outside of the perivascular nerve plexus unless
gross metastatic nodes are present along the artery. The left gas-
tric vein is typically present around the common hepatic artery
Fig. 33.6 but may be located in front of the common hepatic artery. Injury
to this vein, often referred to as the coronary vein, will create a
common hepatic artery. Identify the origin of right gastric bleeding situation that is difficult to control. Careful dissection
artery, ligate with 3–0 Silk ties, and divide it. Now, change and vessel control prior to division are recommended. The supe-
the dissection plane toward the upper border of bulbar por- rior border of the dissection is the right crus of the diaphragm.
tion of the duodenum and separate the soft tissues in the
suprapyloric area from the duodenal wall.
eliac Axis Dissection and Division of Left
C
Gastric Vessels
Division of the Duodenum
With the stomach elevated and retracted toward the patient’s
Dissect the posterior wall of the bulbar portion of the duode- left, it is a simple matter to palpate the left gastric artery as it
num from the anterior surface of the neck of the pancreas for travels from the region of the aorta, anteriorly, to meet the
a distance of 3–5 cm. If a stapled closure of the duodenum is lesser curvature of the stomach. Continuing the hepatic artery
elected, apply the blue load GIA stapler (author uses an endo dissection leads to the celiac axis and to the origin of the left
GIA to take advantage of the triple staple line) to the duode- gastric artery. By dissecting the areolar and lymphatic tissue
num and fire the stapler. away distally, the origin of the artery can be skeletonized.
a b
Fig. 33.7
Fig. 33.8 Fig. 33.9
After it has been double ligated, divide it. Continue the dissec-
tion along the splenic artery. Nodal tissue proximal to the ori-
gin of the posterior gastric artery should be dissected for all
gastric cancers except early gastric cancers.
In the retroperitoneum, the border of the right diaphrag-
matic crus is identified and peritoneum covering over the
crus is divided (Fig. 33.9). This will provide access to the
plane between the anterior surface of the aorta and the nodal
tissue along the lesser curvature of the stomach. Dissection
of this plane in right to left direction mobilizes node stations
1 (right cardiac), 3 (lesser curvature), 7 (left gastric artery),
and 9 (celiac) toward the stomach. In the end, left side of
esophageal hiatus will be completely exposed, and the
dissection plane should connect to the previous left gastric
artery and the splenic artery dissection plane.
At the conclusion of this step, the superior border of the
adjacent pancreas and the anterior surface of the celiac axis
and the aorta should be free of lymphatic tissue (Fig. 33.10). Fig. 33.10
268 H. Hoshi
a b
Fig. 33.11
At the greater curvature side, separation of the greater Reconstruction with a Roux-en-Y reconstruction is pre-
omentum from the transverse colon continues to the splenic ferred, as this prevents bile reflux. No drains are placed.
flexure. Take care not to pull the greater omentum to expose
this area until lower pole of the spleen is completely sepa-
rated from the specimen as excessive traction may tear the Postoperative Care
capsule of the spleen. At the lower pole of the spleen and the
tail of the pancreas, the origin of the left gastroepiploic artery Postoperative care is identical to that following gastrectomy
and vein from splenic vessels can be identified, and these for peptic ulcer (see Chap. 30). Enteral or total parenteral
should be ligated at this point to completely clear the left nutrition is added to the regimen when indicated.
greater curvature nodal tissue.
Both lesser curvature and greater curvature of the
stomach need to be cleared with nodal tissue for transec- Complications
tion. Along the greater curvature, all the terminal branches
from the left gastroepiploic artery should be ligated on the Complications are similar to those following gastrectomy for
wall of the stomach starting from the first branch of the peptic ulcer (see Chap. 30), but subphrenic and subhepatic
left gastroepiploic artery to planned transection point. abscess is more common because of the increased bacterial con-
Preserved short gastric arteries can prevent gastric rem- tamination associated with carcinoma. Also pancreatic fistula/
nant necrosis. pancreatitis can be seen as a complication of D2 nodal
On the lesser curvature, the previously dissected nodal dissection.
packet needs to be separated from the stomach wall. This can
be accomplished by ligating left gastric artery terminal
branches on the gastric wall from the esophagogastric junc- Further Reading
tion to the transection point or vice versa. The left gastric
artery has anterior and posterior branches which terminate Hoshi H. Standard D2 and modified nodal dissection for gastric adeno-
carcinoma. Surg Oncol Clin N Am. 2012;21:57–70.
corresponding surfaces of the stomach, thus both branches Hundahl SA, Macdonald JS, Benedetti J, et al. Surgical variation in a
need to be ligated (Fig. 33.11a and b). prospective, randomized trial of chemoradiotherapy in gastric can-
Once this portion of the dissection is complete, then cer: the effect of undertreatment. Ann Surg Oncol. 2002;9:278–86.
the stomach should be ready to be divided to remove all Japanese Gastric Cancer Association. Japanese classification of gastric
carcinoma: third English edition. Gastric Cancer. 2011;14:101–12.
the nodal tissue en bloc with the main specimen. For the Japanese Gastric Cancer Association. Japanese gastric cancer treatment
clean and complete dissection of the nodes in the correct guidelines 2010 (ver.3). Gastric Cancer. 2011;14:113–23.
plane, en bloc resection of the celiac nodes is recom- Sasako M. D2 nodal dissection. Oper Tech Gen Surg. 2003;5(1):36–49.
mended (with the exception of preservation of the left Songun I, Putter H, Kranenbarg EM, et al. Surgical treatment of gas-
tric cancer: 15-year follow-up results of the randomized nationwide
gastric artery in cases of a replaced left hepatic artery as Dutch D1D2 trial. Lancet Oncol. 2010;11(5):439–49.
previously noted).
Total Gastrectomy
34
Hisakazu Hoshi
Indications Documentation Basics
• Adenocarcinoma of the proximal stomach • Document extent of disease.

• Large proximal gastric gastrointestinal stromal tumors • Frozen sections taken and results.
(GIST) or other malignancy (lymphadenectomy is not • Extent of lymphadenectomy and resection of any adjacent
necessary except neuroendocrine carcinoma) organs.
• Life-threatening hemorrhage from extensive erosive gas- • Type of anastomosis performed.
tritis (rarely – and in this case, obviously, no lymphade- • Any drains placed.
nectomy is performed)
Operative Strategy
Exposure
• See Chap. 34.
If the primary lesion is a malignancy of the body of the stom-
ach that does not invade the lower esophagus, a midline inci-
Pitfalls and Danger Points sion from the xiphoid to a point 2–4 cm below the umbilicus
may prove adequate for total gastrectomy if the Omni or
• Improper reconstruction of the alimentary tract, which Thompson retractor is used to elevate the lower sternum. If
can lead to postoperative reflux alkaline esophagitis. the tumor is near the esophagogastric junction, it may be
• Erroneous diagnosis of malignancy. Patients have under- necessary to include 6–10 cm of the lower esophagus in the
gone total gastrectomy when surgeons have misdiagnosed specimen to circumvent submucosal infiltration by the tumor.
a large posterior penetrating ulcer as a malignant tumor. If In these selected cases, a left thoracoabdominal incision may
preoperative endoscopic biopsy has been negative, per- be indicated. Never attempt to construct an esophageal anas-
form a gastrotomy, and with an excision or a biopsy tomosis without excellent exposure. For patients with a high
punch, obtain a direct biopsy of the edge of ulcer in four body mass index (BMI), a Chevron incision can be used as
quadrants. alternative.
• Improper anastomotic technique resulting in leak or
stricture.
• Sepsis in wound or subhepatic and subphrenic spaces due Esophageal Anastomosis
to contamination by gastric contents or anastomotic leak.
• Failure to identify submucosal infiltration of carcinoma in We prefer an end-to-side esophagojejunal anastomosis
the esophagus or duodenum beyond the line of resection. because of the ease of performing a stapled anastomosis. In
addition, it permits invagination of the esophagus into the
jejunum if necessary, which in turn results in a lower inci-
H. Hoshi (*) dence of leakage. With an end-to-end esophagojejunostomy,
Department of Surgery, Surgical Oncology and Endocrine Surgery, invagination could result in constriction of the lumen.
e-mail: hisakazu-hoshi@uiowa.edu

https://doi.org/10.1007/978-3-030-81415-1_34
270 H. Hoshi
Prevention of Reflux Alkaline Esophagitis at its origin. The lymphatics along the common hepatic
artery and splenic artery also should be removed, along with
An anastomosis between the end of the esophagus and the those at the origin of the right gastroepiploic artery. Whether
side of the jejunum combined with a side-to-side jejuno- it is beneficial to skeletonize the proper hepatic artery and
jejunostomy (Fig. 34.1) results in a high incidence of dis- portal vein all the way to the hilus of the liver is not clear.
abling postoperative alkaline esophagitis. This must be Routine resection of the body and tail of the pancreas has
prevented by utilizing the Roux-en-Y principle in all cases. not been proven to improve a patient’s long-term survival.
The distance between the esophagojejunal anastomosis and However, if the tail of the pancreas shows evidence of tumor
the jejuno-jejunal anastomosis must be 45 cm or more to pre- invasion, this portion of the pancreas should certainly be
vent reflux of the duodenal contents into the esophagus. This included in resection. The anatomy of the structures involved
is a far more important consideration than is construction of in this operation can be seen in Fig. 33.1. Due to the high
a jejunal pouch for a reservoir, and we no longer create such incidence of splenic hilar nodal involvement in advanced
a pouch in these cases. proximal gastric cancers, a randomized trial of D2 nodal dis-
sections with or without a splenectomy preserving pancre-
atic tail was performed in Japan, and the result showed no
Extent of the Operation survival benefit of splenectomy.
This chapter describes a portion of the D2 dissection spe-
Microscopic submucosal infiltration may occur in the esoph- cific for total gastrectomy. See Chap. 33 for a detailed
agus as far as 10 cm proximal to a grossly visible tumor and description of the standard lymph node stations, the defini-
occasionally well down into the duodenum especially with tions of D level of dissection, and common portion of the D2
poorly differentiated adenocarcinoma. Frozen section micro- nodal dissection for both distal and total gastrectomy.
scopic examination of both the esophageal and duodenal
ends of the specimen should be obtained to avoid leaving
behind residual submucosal carcinoma (see Chap. 34). Operative Technique
The lymph nodes around the celiac axis should be
included in the specimen with the left gastric artery divided Incision and Exposure
In many cases, adequate exposure is obtained by a midline

incision from the xiphoid to a point 2–4 cm below the umbi-
licus, along with the use of an Omni or Thompson retractor.
When the carcinoma involves the lower esophagus, a left
thoracoabdominal approach may be necessary.
Exploration and Determination of Operability
Tumors are considered non-resectable when there is poste-

rior invasion of the aorta, vena cava, or celiac axis. Invasion
of the body or tail of the pancreas is not a contraindication to
operation, nor is invasion of the left lobe of the liver, as these
structures can be included in the specimen if necessary.
A palliative gastrectomy should rarely be performed since
it is associated with high morbidity and mortality. However,
well-selected cases with limited metastatic disease with a
surgically correctable symptom may benefit from
gastrectomy.
Invasion of the root of the mesocolon, including the mid-
dle colic artery, does not contraindicate resection if leaving
these structures attached to the specimen removes the tumor.
This often requires concomitant resection of a segment of the
transverse colon. It is surprising that in some patients, remov-
ing a short segment of the main middle colic artery does not
Fig. 34.1
34 Total Gastrectomy 271
impair the viability of the transverse colon so long as there is specimen. The fundus of the stomach is attached to the dia-
good collateral circulation. phragm. Now divide this peritoneal attachment toward the
gastroesophageal junction. Care should be exercised to avoid
injury to left inferior phrenic vessels.
mentectomy, Lymph Node Dissection,
O
and Division of Duodenum
Splenic Nodal Dissection without Splenectomy
The initial steps are performed as described in Chap. 33. The
dissection begins with a peritoneal wash cytology, complete After ligating the left gastroepiploic vessels at their origin,
omentectomy, ligation of the right gastroepiploic vessels at the short gastric vessels need to be ligated and divided close
their origin, and division of the duodenum. The lesser omen- to the splenic hilum. Once the short gastric vessels are ligated
tum is divided up to the esophagogastric junction and the left and divided, the gastric fundus can be mobilized completely
gastric artery is ligated and divided at its origin. Nodal tissue from the retroperitoneum and spleen. Finally, nodal tissues
is mobilized from retroperitoneum. If splenectomy is along the distal splenic artery (station 11d) and the hilum of
planned, it is frequently done as the next step. spleen (station 10) are dissected. To avoid injury to the
splenic vessels and tail of the pancreas, the dissection should
follow the previous dissection plane identified at the celiac
Splenectomy axis.
Splenectomy is performed only when tumor encroaches on the

spleen or splenic hilum. Incise the avascular lienophrenic liga- issection of the Esophagocardiac Junction:
D
ment that attaches the lateral aspect of the spleen to the under- Vagotomy
surface of the diaphragm (Fig. 34.2). As this incision reaches
the inferior pole of the spleen, divide the lienocolic ligament; Retract the left lobe of the liver to the patient’s right and
the posterior surface of the pancreatic tail can then be seen. incise the peritoneum overlying the abdominal esophagus.
The tail can be elevated gently from the retroperitoneal space. Dissect the esophagus away from the right and left diaphrag-
Previous dissection along the splenic artery at the superior matic crura. Then encircle the esophagus with the index fin-
border of pancreatic tail continues until the pancreatic tail is ger and perform a bilateral truncal vagotomy, as described in
completely dissected and splenic artery and vein clearly seen. Chap. 26. Pass the left hand behind the esophagocardiac
Ligate both artery and vein and separate the spleen from the junction, a maneuver that delineates the avascular gastro-
tail of the pancreas. For the retroperitoneal dissection, expose phrenic and any remaining esophagophrenic ligaments, all of
the fascia of Gerota and the left adrenal gland. If there is evi- which should be divided (Fig. 34.3), freeing the posterior
dence of direct tumor invasion, include these structures in the wall of the stomach.
Lienophrenic
lig
Splenic artery
Gastrophrenic
lig.
Fig. 34.2 Fig. 34.3

272 H. Hoshi
Preparation of the Roux-En-Y Jejunal Segment End-to-Side Sutured Esophagojejunostomy
After identifying the ligament of Treitz, elevate the proxi- The anticipated site of the esophageal transection should be
mal jejunum from the abdominal cavity and inspect the at least 3–5 cm above the proximal margin of the palpable
mesentery to confirm that it can reach the esophageal hia- tumor depending on tumor histology.
tus for the esophagojejunal anastomosis without tension. Apply a soft Satinsky vascular clamp to distal esophagus
In some patients who have lost considerable weight before about 2–3 cm above the transection line. Transect the esoph-
the operation, the jejunum reaches the esophagus without agus and remove the specimen and ask the pathologist to per-
the need to divide anything but the marginal artery. In form a frozen section examination of both the proximal and
patients whose jejunal mesentery is short, it may be nec- distal margins. If the frozen section examination is positive
essary to divide several arcade vessels. Transillumination for malignancy, further excision is indicated.
is a valuable aid for dissecting the mesentery without Place a 4–0 PDS suture beginning at the right lateral por-
undue trauma. tion of the esophagus with a full thickness bite. With the
Generally, the point of division of the jejunum is about same needle, take a bite at the right lateral margin of the
15 cm distal to the ligament of Treitz, between the second jejunal full thickness wall. Place a similar suture at the left
and third arcade vessels. Make an incision in the mesentery lateral margins of the esophagus and jejunum. Apply hemo-
across the marginal vessels and divide and ligate them with stats to each suture, as none is tied until the posterior suture
3–0 silk. Divide and ligate one to three additional arcade ves- line has been completed.
sels to provide an adequate length of the jejunum to reach the Place two additional 4–0 PDS suture at the midportion of
esophagus without tension (Fig. 34.4). the posterior wall and close posterior layer with running full
Apply a GIA stapler to the point on the jejunum previ- thickness bites. Once sutures reach the corner, first tie the
ously selected for division. Fire the stapler. previous corner sutures and then tie running sutures to the
Next make a 3- to 4-cm incision in the avascular portion corner sutures. Close the anterior wall with interrupted 4–0
of the transverse mesocolon to the left of the middle colic PDS full thickness sutures (Figs. 34.5 and 34.6). Inspect the
artery. Deliver the stapled end of the distal jejunum through anastomosis and if there is weak portion, place 4–0 PDS
the incision in the mesocolon to the region of the esophagus.
After the jejunal segment is properly positioned, suture the
defect in the mesocolon to the wall of the jejunum to prevent
herniation later.
Fig. 34.4 Fig. 34.5

Fig. 34.6 Fig. 34.7
muscular sutures on esophagus and seromuscular bite on post. Then transect the posterior wall with small cuff of tis-
jejunum and invert the anastomosis. sue left around the post and remove specimen. Typically, the
housing of the 25-mm EEA is small and cannot accommo-
date a large volume of tissue. Inspect the tissue around the
End-to-Side Stapled Esophagojejunostomy anvil post and if it is bulky then carefully trim it without
cutting purse-string suture.
An end-to-side esophagojejunostomy performed with a cir- An alternative approach is to transect the esophagus with
cular stapler requires easy access to 4–5 cm of relaxed a TA stapler and pass an Orvil 25 EEA anvil down the mouth
esophagus with good exposure to enable the surgeon to and through the staple line.
inspect the anastomosis carefully at its conclusion. We apply Bring the previously prepared Roux-en-Y segment of
the purse-string device before transecting esophagus. Once jejunum and pass it through an incision in the avascular part
this device is fired, then apply a large right angle clamp to the of the transverse mesocolon. The jejunum should easily
esophagus 2–3 cm distal to the device to prevent spillage. reach the esophagus with 6–7 cm to spare. Gently dilate the
Transect the anterior wall of the esophagus about 5 mm lumen of the jejunum and insert the lubricated cartridge of
below the edge of purse-string device. Grasp just the edge of the EEA circular stapler into the open end of the jejunum, as
proximal edge of the anterior wall of the esophagus and in Fig. 34.7. Deploy the rod of the stapler through the elbow
release the device. The posterior wall is still attached, pre- of the jejunum so the rod can penetrate the antimesenteric
venting esophageal stump retracting into mediastinum. border of the jejunum.
Carefully insert the EEA anvil into the proximal esophagus. Attach the anvil to the device and be certain the connection
We do not usually use a sizer. The 25-mm EEA is wide is tight (Fig. 34.8). Now turn the screw at the base of the sta-
enough, but use 28 mm if esophagus can accommodate it pler so the anvil is approximated to the cartridge. Watch distal
without causing mucosal tear. Tie the purse-string around the portion of jejunum and make sure not to incorporate the mes-
274 H. Hoshi
Fig. 34.9
Inspect the excised tissue rings in the stapler. If these are

satisfactory and the staple line looks intact, apply a blue GIA
to close the jejunal end. Apply the stapler at a point about
1–2 cm away from the anastomosis. Close the jaws of the
linear stapler and fire it. It is important to amputate the jeju-
num close to the anastomosis so no blind loop develops.
Roux-En-Y Jejunojejunostomy
Sutured Version
Attention should now be directed to restore the continuity of
Fig. 34.8 the small intestine by doing an end-to-side anastomosis
between the cut end of the proximal (biliopancreatic limb)
enteric side of the wall into the stapler (Figs. 34.9 and 34.10). jejunum and the side of the Roux-en-Y limb. This anastomo-
Also watch the angle and tension of stapler. Too much tension sis should be made at least 45 cm from the esophagojejunal
or angulation on the stapler will stretch the relatively immo- anastomosis to prevent bile reflux. After the proper site on
bile esophageal end and thus cause thin or incomplete forma- the antimesenteric border of jejunum has been selected, use
tion of esophageal tissue ring. Carefully inspect the staple interrupted 3–0 silk Lembert sutures for the posterior sero-
line before firing the device for any tissue protrusion or adja- muscular layer of the end-to-side anastomosis (Fig. 34.11).
cent tissue incorporation. When this has been completed, fire When all these sutures have been placed, make an incision
the device by pulling the trigger. Then turn the screw at the along the previously marked area of the jejunum and remove
base of the stapler the appropriate number of turns counter- the staple line from the proximal segment of the jejunum.
clockwise, rotate the device, and manipulate the anvil in such Approximate the full thickness layers using running 3–0
fashion as to withdraw the stapler from the anastomosis. Vicryl (Fig. 34.12). Take the first stitch in the middle of the
Fig. 34.12
Fig. 34.10
Fig. 34.13
posterior layer and tie it. Close the remainder of the posterior
layer with a continuous suture and transition to anterior
layer. Finally, approximate the seromuscular layer with 3–0
Fig. 34.11 silk Lembert sutures (Fig. 34.13).
276 H. Hoshi
Fig. 34.15
Fig. 34.14
Stapled Version
In most cases, we prefer to perform the Roux-en-Y jejunoje-
junostomy with a stapled technique. To accomplish this, the
biliopancreatic limb of the jejunum is approximated to the
Roux-en-Y limb with seromuscular stitches. With electro-
cautery, make a 1-cm longitudinal incision on the antimesen-
teric border. Insert a linear cutting stapling device: one fork
in the descending segment of the jejunum and the other fork
in the open end of the proximal segment of the jejunum
(Fig. 34.14). Be certain the open end of the proximal segment
of jejunum is placed so the opening faces in a caudal
direction to prevent intussusception. When the stapler is in
place, lock and fire it; it can be seen that the first layer of the
anastomosis has been completed in a side-to-side fashion
between the antimesenteric borders of the two segments of
Fig. 34.16
the jejunum. Inspect the intraluminal staple line for
bleeding.
To close the remaining defect in the anastomosis, apply Modifications of Operative Technique
Allis clamps to the right- and left-hand terminations of the for Patients with Benign Disease
staple line (Fig. 34.15). Then apply multiple Allis clamps in
between approximating full thickness of both sides of jejunal When total gastrectomy is being performed for benign dis-
wall. Apply the TA-45 blue stapling device deep to the Allis ease, several modifications are indicated. First, it is not nec-
clamps (Fig. 34.16). essary to excise considerable lengths of the esophagus or
Close the remaining potential defects between the mesen- duodenum. These structures are divided close to the margins
tery of the proximal and distal jejunum with interrupted of the stomach. Second, it is not necessary to remove the
sutures of 3–0 Vicryl to prevent internal herniation. spleen or omentum, and the greater curvature dissection can
be carried out by dividing each of the vasa brevia between caloric intake following total gastrectomy. Others seem to
the greater curvature of the stomach and the greater omen- do well with no dietary restrictions.
tum, leaving the omentum behind. Third, a lymphadenec- • Dietary supplements of vitamins, iron, and calcium as
tomy is not indicated. Except for the foregoing modifications, well as continued parenteral injections of vitamin B12 are
the technique is essentially the same as for cancer necessary for long-term management of patients follow-
operations. ing total gastrectomy.
Wound Closure Complications
Irrigate the abdominal cavity with saline. Consider placing • Sepsis of the abdominal wound or the subphrenic space is
a tube or needle-catheter jejunostomy in malnourished one complication that follows surgery for an ulcerated
patients. If hemostasis is excellent and the anastomoses gastric malignancy. Early diagnosis and management are
have been performed with accuracy, we do not insert drains necessary.
in the abdominal cavity. Otherwise, a 6-mm Silastic Blake • Leakage from the esophagojejunal anastomosis is the most
catheter may be brought out from the vicinity of the anasto- serious postoperative complication but occurs rarely if
mosis through a puncture wound in the abdominal wall and proper technique has been used. A minor degree of leak-
attached to closed suction drainage. A nasogastric tube is age may be managed by prompt institution of adequate
not necessary. drainage in the region. Nutritional support is essential, as
are systemic antibiotics. A covered esophageal stent placed
by an experienced gastroenterologist can resolve a leak in
Postoperative Care select patients. In the most serious cases, a diverting cervi-
cal esophagostomy may be required. Fortunately, a prop-
• Administer enteral feedings by way of the tube jejunos- erly performed Roux-en-Y anastomosis diverts duodenal
tomy (if placed). and pancreatic enzymes from the leak.
• As with other esophageal anastomoses, nothing should be
permitted by mouth until the fourth or fifth postoperative
day, at which time an esophagram should be obtained in Further Reading
the radiography department. If no leakage is identified, a
Hoshi H. Standard D2 and modified nodal dissection for gastric adeno-
liquid diet is initiated that may be increased rapidly carcinoma. Surg Oncol Clin N Am. 2012;21:57–70.
according to the patient’s tolerance. Japanese Gastric Cancer Association. Japanese classification of gastric
• Long-term postoperative management requires all carcinoma: third English edition. Gastric Cancer. 2011;14:101–12.
Japanese Gastric Cancer Association. Japanese gastric cancer treatment
patients to be on a dietary regimen that counteracts dump-
guidelines 2010 (ver.3). Gastric Cancer. 2011;14:113–23.
ing. The diet should be high in protein and fat but low in Majrtin RC II, Jaques DP, Brennan MF, Karpeh M. Extended local
carbohydrate and liquids. Frequent small feedings are resection for gastric cancer: increased survival versus increased
indicated. Liquids should not be consumed during or morbidity. Ann Surg. 2002;236(2):159–65.
Sano T, Sasako M, et al. Randomized controlled trial to evaluate sple-
1–2 h after meals to prevent hyperosmolarity in the lumen
nectomy in Total gastrectomy for proximal gastric carcinoma. Ann
of the proximal jejunum. Some patients require several Surg. 2017;265(2):277–83.
months of repeated encouragement to establish adequate Sasako M. D2 nodal dissection. Oper Tech Gen Surg. 2003;5(1):36–49.
Management of Gastrointestinal
Stromal Tumor of the Stomach 35
Eugene J. Won and Brian R. Smith
Introduction tion of smaller GISTs. Tissue diagnosis at the time of surgi-

cal resection has traditionally been the gold standard, but is
Gastrointestinal stromal tumors (GIST) are the most com- increasingly being replaced by EUS-FNA. Triple-phase
mon sarcomas of the gastrointestinal tract with a tendency to computed tomography (CT) with intravenous and oral con-
spread hematogenously to the liver (65%) or peritoneum trast, which includes native, portal venous, and arterial
(21%) (DeMatteo et al. 2000). The incidence of GIST is phases, can be useful to determine tumor size, location, and
approximately 1.5/100,000/year (Casali et al. 2009). Most extent of disease, specifically hepatic involvement. The
are located in the stomach (60%) or small bowel (jejuno- tumor typically has strong uptake on 18F fluorodeoxyglucose
ileum) (30%).(Miettinen and Lasota 2013) They can occur at positron emission tomography ((DeMatteo et al. 2013) FDG-
any age but tend to occur in the middle-aged or elderly, often PET), which may serve to show early metastases when
presenting with bleeding, pain, or early satiety. The tumor present.
arises from the interstitial cells of Cajal, the pacemaker neu-
ral cells of the gut. They are seen as a smooth subepithelial
mass on endoscopy. The discovery of the activating mutation Pitfalls and Danger Points
in the c-kit proto-oncogene and the development of specific
tyrosine kinase inhibitor (TKI) therapy has drastically • Rupturing the delicate pseudocapsule of the tumor lead-
enhanced the treatment of GISTs. (Gold and Dematteo 2006) ing to peritoneal dissemination
• Attempting to bluntly separate tumor from adherent adja-
cent structures with progressive thinning of the capsule
Preoperative Preparation until rupture occurs
• Underestimating adherence to adjacent structures and the
Many smaller GISTs are asymptomatic and noted inciden- need to resect them en bloc (e.g., colon, colonic mesen-
tally during workup of unrelated disease. It is important to tery, solid organs, and/or their blood supply)
obtain a tissue diagnosis because GISTs are one of several • Leaving a margin of tumor in the bowel wall
subepithelial lesions that can appear hypoechoic and irregu- • Creating an anatomically narrow or oddly shaped stom-
lar on endoscopic ultrasound, including leiomyoma, ectopic ach resulting in poor function/emptying
pancreas, schwannoma, carcinoid, lymphoma, and metasta-
ses.(Eckardt and Jenssen 2015) Endoscopic ultrasound-
guided fine needle aspiration (EUS-FNA) has been proposed Operative Strategy and Management
as a safe alternative for diagnosing GISTs (compared with
surgery), but inadequate tissue sampling remains a chal- The standard of care for primary localized GIST is surgery
lenge.(Philipper et al. 2010) Alternative endoscopic biopsy alone. The goal is complete resection with negative margins
strategies such as endoscopic core needle biopsy remain an while avoiding tumor rupture or injury to the pseudocapsule
ongoing area of investigation, especially in the early detec- to prevent dissemination (Nishida et al. 2016). Laparoscopic
wedge resection for smaller gastric GIST has been shown to
E. J. Won · B. R. Smith (*) be safe and effective (Xiong et al. 2017; Chen et al. 2015)
Department of Surgery, UC Irvine Medical Center, and equivalent to open resection in tumors as large as 8 cm
Orange, CA, USA (Karakousis et al. 2011). We recommend laparoscopic wedge
e-mail: smithbr@hs.uci.edu

https://doi.org/10.1007/978-3-030-81415-1_35
280 E. J. Won and B. R. Smith
Fig. 35.3
expanded criteria early gastric cancers and is an established

technique for smaller GISTs with a high en bloc resection
rate. “Submucosal tunneling,” originally described for per-
Fig. 35.1
oral endoscopic myotomy (POEM) in which a mucosal inci-
sion is made at least 5 cm proximal to the mass, is a novel
technique and modification to ESD.(Schmidt et al. 2014) It is
useful in treating esophageal GISTs arising from the muscu-
laris propria layer with the advantage of having a mucosal
layer overlying the resection site in the case of a perforation.
Endoscopic full-thickness resection (EFTR) with defect clo-
sure using clips and/or endoloop is an emerging technique
that requires further large prospective studies (Ye et al. 2014).
The management of positive microscopic margins after
resection is also currently under investigation. Patients who
undergo R1 resection could have a higher risk of recurrence
than their R0 counterparts but future trials need to elucidate
the impact on overall survival in these patients (Zhi et al.
2016; McCarter et al. 2012).
The management of incidentally noted GIST <2 cm
remains controversial. For small gastric GIST <2 cm that
lack high risk features on endoscopic ultrasound (e.g., irreg-
Fig. 35.2 ular borders, heterogeneity, and ulceration), surveillance
endoscopy has been proposed. The most reliable prognostic
resection for primary localized GISTs measuring less than factors are size and mitotic index, although even tumors less
5 cm located within the gastric body or fundus (Figure 35.1). than 2 cm with bland histologic features have potential for
The feasibility and safety of the laparoscopic approach for malignant transformation (Lamba et al. 2012). Our group
larger or non-gastric GIST is not well defined (Fig. 35.2). A obtains a definitive tissue diagnosis for all subepithelial
minimally invasive, oncologically sound approach may be tumors, though current NCCN guidelines do not recommend
more difficult for larger tumors in which the risk of rupture resection of sub-centimeter incidental GISTs.
is higher. Partial gastrectomy may be necessary depending Even after complete R0 resection of a primary GIST, the
on the size and location of the tumor as well as en bloc resec- recurrence rate remains high at approximately 40% (Joensuu
tion for locally advanced GISTs. Since lymph node metasta- et al. 2012a). The role of tyrosine kinase inhibitor (TKI)
sis is rare, lymphadenectomy is not routinely indicated or therapy following complete resection of a primary localized
performed. GIST is being addressed by randomized trials. Recent trials
Endoscopic enucleation has been shown to be a safe and suggest that adjuvant molecular therapy reduces recurrence
viable alternative to surgical resection in the treatment of after complete resection, (Dematteo et al. 2009) especially in
smaller GISTs, typically less than 5 cm, even if located in the patients who are deemed “high risk,” which was defined in a
esophagus or near the gastro-esophageal junction (Fig. 35.3). recent trial as tumor diameter > 10 cm, intraperitoneal tumor
Endoscopic submucosal dissection (ESD) is now preferred rupture or up to 4 peritoneal implants (DeMatteo et al. 2013).
over endoscopic mucosal resection (EMR) in the treatment of The optimal duration of adjuvant molecular therapy is not
35 Management of Gastrointestinal Stromal Tumor of the Stomach 281
known, though it has been recommended that all high-risk Operative Strategy and Technique
patients receive adjuvant imatinib for 3 years (Joensuu et al.
2012b; Joensuu et al. 2016). Laparoscopic Wedge Resection
TKI therapy is the standard of care for patients with meta-
static or unresectable GIST with first-line imatinib, second- Surgery should begin with diagnostic laparoscopy to confirm
line sunitinib, and third-line regorafenib (Nishida et al. resectability. Direct handling of the GIST should be limited
2014). Therapy should be continued indefinitely as interrup- as rupture of the pseudocapsule can cause peritoneal dis-
tion in treatment leads to disease progression (Blanke et al. semination. Divide the short gastric vessels between the
2008). Even in cases of advanced GIST refractory to greater curvature of the stomach and the greater omentum to
approved TKI therapy, there may still be a benefit to contin- maximize mobility of the stomach. For fundal GISTs, the
ued kinase suppression with respect to slowing disease pro- postero-superior gastric attachments need to be released in
gression (Kang et al. 2013). Whether surgery should be order to fully mobilize the fundus. Place a 36 French or
added to the molecular therapy in the management of larger bougie and perform a wedge resection of the tumor
advanced GIST is a subject of ongoing investigation, and using a series of 60 mm Endo GIA staples for those in the
treatment should be individualized for each patient. fundus. Endoscopic pneumatic leak testing can ensure an
Neoadjuvant TKI therapy for locally unresectable primary intact and air-tight staple line.
GIST is justified, although more data are needed to determine When partial or total gastrectomy is performed for GISTs
its impact. The most obvious reason is to increase the chances that anatomically mandate something beyond a wedge, it is
of complete resection of the tumor. Preoperative imatinib has acceptable to divide the esophagus and/or duodenum close to
been shown to decrease tumor size allowing complete tumor the stomach. Unlike adenocarcinoma, GIST tumor margins
removal. However, it is important to note the potential risks of can be very narrow and only need to be grossly negative.
neoadjuvant therapy in the setting of primary resistance to Moreover, a lymphadenectomy is not performed and the
imatinib, as a delay in surgery may permit a borderline resect- greater omentum is not dissected off of the transverse colon.
able tumor to convert to an advanced tumor. Recent studies When dividing the proximal duodenum, it is crucial to
have suggested that metastatic GIST in the absence of multifo- include the entire antrum to avoid a retained antral remnant.
cal progressive disease treated with cytoreductive surgery may Following a distal subtotal gastrectomy, either a Bilroth II or
be considered for select patients (Fairweather et al. 2017). Roux-en-Y gastrojejunostomy reconstruction is performed.
Nevertheless, in the absence of randomized data, it seems rea- GISTs located along the lesser curvature, pylorus, or
sonable to operate on patients with metastatic GIST that is antrum that are not amenable to enucleation may require
responsive to TKI therapy and amenable to R0 resection. partial gastrectomy with Bilroth II or Roux-en-Y recon-
However, further trials need to be considered. Meanwhile, the struction. An open approach begins with a vertical midline
role of surgery in progressive disease is also uncertain and incision from the xiphoid process to 2 cm below the umbi-
clinical trials should also be considered. licus, although we prefer a laparoscopic approach. Divide
GISTs arising from the stomach may be treated with the short gastric vessels between the greater curvature and
endoscopic enucleation, simple wedge resection or partial or greater omentum. Enter the lesser sac and create an open-
subtotal gastrectomy depending on the location. GISTs arising in the lesser omentum and encircle the stomach with a
ing from the esophagus require enucleation or esophagec- Penrose drain and retract the stomach laterally. March
tomy. GISTs arising from the small or large intestine are along the greater curvature toward the duodenum and
treated with segmental resection and primary anastomosis. suture ligate the right gastroepiploic vessels at their origin.
Smaller periampullary GISTs may be treated by local exci- Perform a Kocher maneuver to mobilize and divide the
sion whereas larger periampullary or pancreatic GISTs may duodenum. Early resection of the stomach with an Endo
require pancreaticoduodenectomy. GIA stapler can facilitate a difficult duodenal dissection.
The duodenal stump is closed with suture or stapler. Create
a gastrotomy along the inferior corner of the gastric rem-
Documentation nant to connect with the mobilized small intestine via
Bilroth II or Roux-en-Y. The gastrojejunal anastomosis can
• Findings be stapled or sutured. For the latter, we construct a two-
• Pseudocapsule intact or ruptured layered sutured anastomosis and use running absorbable
• Types of resection and repair sutures for the inner layer and an outer layer of interrupted
• Signs of metastasis or multifocal progressive disease Lembert sutures.
282 E. J. Won and B. R. Smith
Postoperative Care Eckardt AJ, Jenssen C. Current endoscopic ultrasound-guided approach

to incidental subepithelial lesions: optimal or optional? Ann
Gastroenterol. 2015;28(2):160–72.
• Use nasogastric decompression selectively in patients Fairweather M, Balachandran VP, Li GZ, et al. Cytoreductive surgery
with gastroduodenal or gastrojejunal anastomosis. for metastatic gastrointestinal stromal Tumors treated with tyrosine
• Early ambulation. kinase inhibitors: a 2-institutional analysis. Ann Surg. 2017.
Gold JS, Dematteo RP. Combined surgical and molecular therapy: the gas-
• Upper GI x-ray with water-soluble contrast early in the trointestinal stromal tumor model. Ann Surg. 2006;244(2):176–84.
postoperative period should precede resumption of dietary Joensuu H, Eriksson M, Sundby Hall K, et al. One vs three years of
intake. adjuvant imatinib for operable gastrointestinal stromal tumor: a ran-
domized trial. JAMA. 2012b;307(12):1265–72.
Joensuu H, Eriksson M, Sundby Hall K, et al. Adjuvant Imatinib for
high-risk GI stromal tumor: analysis of a randomized trial. J Clin
Complications Oncol. 2016;34(3):244–50.
Joensuu H, Vehtari A, Riihimäki J, et al. Risk of recurrence of gas-
• Staple line or anastomotic leak occurs in <1%. trointestinal stromal tumour after surgery: an analysis of pooled
population-based cohorts. Lancet Oncol. 2012a;13(3):265–74.
• Surgical site infection is rare. Kang YK, Ryu MH, Yoo C, et al. Resumption of imatinib to control
• Odd shapes of stomach after large wedge resections of metastatic or unresectable gastrointestinal stromal tumours after
greater curve may results in poor gastric function. failure of imatinib and sunitinib (RIGHT): a randomised, placebo-
• The management of positive microscopic margins is the controlled, phase 3 trial. Lancet Oncol. 2013;14(12):1175–82.
Karakousis GC, Singer S, Zheng J, et al. Laparoscopic versus open gas-
subject of ongoing investigation, but should ideally be tric resections for primary gastrointestinal stromal tumors (GISTs):
discovered at the time of surgery with inspection of the a size-matched comparison. Ann Surg Oncol. 2011;18(6):1599–605.
specimen. Lamba G, Gupta R, Lee B, Ambrale S, Liu D. Current management and
prognostic features for gastrointestinal stromal tumor (GIST). Exp
Hematol Oncol. 2012;1(1):14.
McCarter MD, Antonescu CR, Ballman KV, et al. Microscopically posi-
tive margins for primary gastrointestinal stromal tumors: analysis of
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9. discussion 59-60
Blanke CD, Demetri GD, von Mehren M, et al. Long-term results from Miettinen M, Lasota J. Gastrointestinal stromal tumors. Gastroenterol
a randomized phase II trial of standard- versus higher-dose imatinib Clin N Am. 2013;42(2):399–415.
mesylate for patients with unresectable or metastatic gastrointestinal Nishida T, Blay JY, Hirota S, Kitagawa Y, Kang YK. The standard diag-
stromal tumors expressing KIT. J Clin Oncol. 2008;26(4):620–5. nosis, treatment, and follow-up of gastrointestinal stromal tumors
Casali PG, Jost L, Reichardt P, Schlemmer M, Blay JY, Group based on guidelines. Gastric Cancer. 2016;19:3–14.
EGW. Gastrointestinal stromal tumours: ESMO clinical recom- Nishida T, Doi T, Naito Y. Tyrosine kinase inhibitors in the treatment of
mendations for diagnosis, treatment and follow-up. Ann Oncol. unresectable or metastatic gastrointestinal stromal tumors. Expert
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Chen K, Zhou YC, Mou YP, Xu XW, Jin WW, Ajoodhea H. Systematic Philipper M, Hollerbach S, Gabbert HE, et al. Prospective comparison
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Dematteo RP, Ballman KV, Antonescu CR, et al. Adjuvant imatinib Schmidt A, Bauder M, Riecken B, Caca K. Endoscopic resection of sub-
mesylate after resection of localised, primary gastrointestinal stro- epithelial tumors. World J Gastrointest Endosc. 2014;6(12):592–9.
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Lancet. 2009;373(9669):1097–104. tion in patients with gastrointestinal stromal tumors: an updated sys-
DeMatteo RP, Ballman KV, Antonescu CR, et al. Long-term results of tematic review and meta-analysis. Am J Surg. 2017.
adjuvant imatinib mesylate in localized, high-risk, primary gastro- Ye LP, Yu Z, Mao XL, Zhu LH, Zhou XB. Endoscopic full-thickness
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DeMatteo RP, Lewis JJ, Leung D, Mundan SS, Woodruff JM, Endosc. 2014;28(6):1978–83.
Brennan MF. Two hundred gastrointestinal stromal tumors: recur- Zhi X, Jiang B, Yu J, et al. Prognostic role of microscopically positive
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2000;231(1):51–8. review and meta-analysis. Sci Rep. 2016;6:21541.
Exposure of the Third and Fourth
Portions of the Duodenum 36
Natasha Leigh and Benjamin Golas
Indications After liberating the right colon by incising the peritoneum

of the right paracolic gutter, the renocolic attachments are
• Tumors limited to the duodenum (i.e., GIST, carcinoid) divided. Continuing in this plane, the surgeon can then free
• Stricture not amenable to endoscopic dilation the entire mesentery of the small intestine in an entirely avas-
• Trauma cular dissection. It is important to devote special attention to
the superior mesenteric vein as it emerges from behind the
neck of the pancreas; rough traction in this area may avulse
Preoperative Preparation one of its branches, producing troublesome bleeding.
When planning a resection of the distal duodenum, it is
• Optional nasogastric tube endoscopy important to take note of its vascular supply. The third por-
• Computed tomography (CT) of the abdomen tion is supplied by small branches of the inferior pancreatico-
duodenal arcade, which arise to the right of the superior
mesenteric vessels. These branches must be individually dis-
Pitfalls and Danger Points sected, divided, and ligated delicately, to avoid pancreatic
trauma and postoperative acute pancreatitis. The fourth por-
• Trauma to superior mesenteric artery or vein tion of the duodenum is free of the pancreatic body to the left
• Trauma to pancreas of the superior mesenteric vessels. Its blood supply arises
from branches of the superior mesenteric artery, as does that
of the proximal jejunum. These branches are easily identified
Operative Strategy and controlled.
When performed for duodenal tumors, provided there is
Because the third portion of the duodenum is located behind neither pancreatic nor ampullary involvement, it is possible
the superior mesenteric vessels and transverse mesocolon, to resect the third and fourth portions of the duodenum and
approaching it directly would be hazardous. Liberating the construct an anastomosis between the descending duodenum
right colon and small bowel mesentery from their attach- and the jejunum. When working in this area, it is essential
ments to the posterior abdominal wall permits the surgeon to that the ampulla of Vater be identified early during the
elevate them to a position over the patient’s thorax. This dissection.
alters the course of the superior mesenteric and middle colic
vessels so they travel directly to cephalad, leaving the trans-
verse portion of the duodenum completely exposed. This Documentation Basics
exposure is sometimes termed the Cattell-Braasch
maneuver. • Findings
• Extent of procedure performed
N. Leigh (*) · B. Golas

Department of Surgery, Mount Sinai West Hospital, New York,
NY, USA
e-mail: leigh@wustl.edu

https://doi.org/10.1007/978-3-030-81415-1_36
284 N. Leigh and B. Golas
Operative Technique Liberation of Small Bowel Mesentery
Incision Insert the left index finger underneath the remaining avascu-
lar attachments between the mesentery of the small bowel
A mid-line incision from the midepigastrium to the pubis and the posterior abdominal wall. Incise these attachments
gives excellent exposure for this operation. until the entire small intestine up to the ligament of Treitz is
free and can be eviscerated over the patient’s thorax. This
configuration resembles the anatomy of patients who have a
Liberation of Right Colon congenital failure of rotation or malrotation of the bowel
(Fig. 36.2).
Open the peritoneum of the right paracolic gutter with
Metzenbaum scissors or electrocautery. Insert an index fin-
ger to separate the peritoneum from underlying fat and areo- Intraoperative Endoscopy
lar tissue, along the avascular plane. When the hepatic flexure
is encountered, electrocautery can help control bleeding as In cases of tumor or stricture, intraoperative upper endos-
the peritoneum is cut. It is not necessary to dissect the greater copy may be useful to ensure accurate localization of the dis-
omentum off the transverse colon during this operation. It is ease pathology.
important, however, to continue the division of the paracolic
peritoneum around the inferior portion of the cecum and
continue medially to liberate the terminal ileum, all in the Resection of Duodenum
same plane (Fig. 36.1). Identify the renocolic ligament at the
medial margin of Gerota’s fascia. Division of this thin struc- There is no structure overlying the third and fourth portions
ture completely frees the right mesocolon and ensures that of the duodenum or proximal jejunum at this time. If a tumor
the right kidney and associated structures remain protected of the duodenum is to be resected, it is important to deter-
in the retroperitoneum. mine now if it is safe to do so. If some portion of the pancreas
has been invaded, a pancreatico-duodenectomy may be indi-
cated depending upon the patient’s pathology. If the duode-
Sup. mesenteric
a. and v.
Pancreas
Duodenum
Incision in Dotted lines enclose area

parocolic of mesentery to be elevated
peritoneum from posterior attachments
Fig. 36.1 Dissection planes for liberation of the right colon Fig. 36.2 Reflection of the right colon and small bowel cephalad after
mobilization to expose the third and fourth portions of the duodenum
36 Exposure of the Third and Fourth Portions of the Duodenum 285
num is free, use an energy device such as Ligasure to divide

the mesentery. As the pancreatic head is approached, per-
form this dissection with delicacy. It is possible to identify
and divide each of the small vessels arising from the pan-
creas. The location and type of pathology will determine the
amount of duodenum to be resected. If necessary, divide the
Ligament of Treitz and deliver the duodenum out from under
the root of the mesentery. Once mobilization is complete,
resect the segment of duodenum and pass off the specimen.
About 1 cm of the duodenum should be freed from the
pancreas proximal to the point of transection. This permits
an end-to-end anastomosis between the proximal duodenum
and a segment of jejunum that is brought over for this pur-
pose. If the end of the duodenum is suitable for closure but
not anastomosis, a side-to-side anastomosis between the sec-
ond portion of the duodenum and proximal jejunum is a
good alternative. Our preference is to perform this as a hand-
sewn anastomosis; however, use of a stapler is also an option.
Of note, closure of the distal duodenum plus a gastrojejunos-
tomy is not the ideal reconstruction, because the proximal
duodenum will eventually dilate and form a blind loop.
Closure
Fig. 36.3 Laparoscopic port placement for minimally invasive expo-
After the anastomosis has been performed, return the right sure of the third and fourth portions of the duodenum
colon and small bowel to the abdomen. Make no attempt to
reestablish the posterior attachments of the mesentery. A
Jackson Pratt drain may be placed behind the duodeno- used to open the gastrocolic ligament along the greater cur-
jejunostomy to monitor for anastomotic leak, as per the sur- vature of the stomach while preserving the gastroepiploic
geon’s preference. Close the abdomen in routine fashion. arcade. This is continued up to the level of the short gastric
vessels, which usually are spared. This maneuver will fully
expose the third and fourth portions of the duodenum, the
Minimally Invasive Approach superior mesenteric vein, and the neck and body of the pan-
creas. A laparoscopic Kocher maneuver is then performed
For elective (non-trauma) cases, a laparoscopic or robotic by using blunt dissection and electrocautery to release the
approach is reasonable in experienced hands. Optimal port lateral attachments of the second portion of the duodenum.
placement for the laparoscopic approach is shown below Care is taken to protect the hilar structures during this
(Fig. 36.3). The periumbilical port is best used for the cam- maneuver. Next, identify and release the ligament of Treitz
era. A split-leg operating table with a footboard is preferred with care to avoid injury to the inferior mesenteric vein.
as it allows the operating surgeon to stand between the With the duodenum completely mobilized, the mesentery
patient’s legs with steep reverse Trendelenburg. Principles to the distal duodenum is isolated and divided with an
of exposure are similar to an open approach. Placement of energy device. Divide the proximal duodenum distal to the
a liver retractor through an epigastric incision may facili- ampulla and the proximal jejunum with an endoGIA sta-
tate exposure. Start by mobilizing the right colon using an pler. The mesentery to the jejunum is then serially divided
energy device to divide the White line of Toldt. The hepatic with an energy device with care to protect the superior mes-
flexure should be completely mobilized off the duodenum. enteric vein (SMV), superior mesenteric artery (SMA), and
Care is taken to isolate and ligate the right gastroepiploic inferior mesenteric vein (IMV). In cases of malignancy,
vessels with electrocautery. The dissection should continue mesenteric resection should be as wide as possible to
to the patient’s left side by dividing the gastrocolic liga- account for lymph node harvest without risking injury to
ment and opening the lesser sac. This is done by retracting the mesenteric vessels. The specimen is then gently deliv-
the transverse mesocolon inferiorly while the stomach is ered out from under the root of the mesentery and placed
retracted in a cephalad position. An energy device is then into the left upper quadrant for later retrieval. A window is
286 N. Leigh and B. Golas
then made with electrocautery in the transverse mesocolon complication of any dissection in the region of the pancreas
to the right of the middle colic vessels. The cut end of the and requires supportive care.
jejunum is then brought up through the window in proxim-
ity to the second portion of the duodenum. A stapled side-
to-side anastomosis is then created between the lateral wall Complications
of the second portion of the duodenum and the jejunum
with a linear endoscopic stapler. The common enterotomy • Anastomotic leak
can be closed with a stapler or hand-sewn. A laparoscopic • Pancreatitis
leak test can be performed by instilling the upper abdomen • Vascular injury
with sterile water, clamping the bowel distal to the anasto-
mosis, and instilling air via a nasogastric tube. Lastly, the
specimen is placed into an endoscopic retrieval bag and Further Reading
brought out through the umbilical port. If needed, the
umbilical port can be extended vertically to facilitate Androulakis J, Colborn GL, Skandalakis PN, Skandalakis LJ,
Skandalakis JE. Embryologic and anatomic basis of duodenal sur-
extraction. gery. Surg Clin North Am. 2000;80:171.
Asensio JA, Demetriades D, Berne JD, et al. A unified approach to the
surgical exposure of pancreatic and duodenal injuries. Am J Surg.
Cattell RB, Braasch JW. A technique for the exposure of the third
and fourth portions of the duodenum. Surg Gynecol Obstet.
A nasogastric tube may be left at the discretion of the sur- 1960;111:379.
geon. An oral diet may be begun after the passage of flatus, Nauta RJ. Duodenojejunostomy as an alternative to anastomosis of
denoting resumption of bowel function. Alternatively, an the small intestine at the ligament of Treitz. Surg Gynecol Obstet.
1990;170:172.
upper gastrointestinal (GI) series with Gastrografin in the Tanaka E, Kim M, Lim JS, Choi YY, Saklani A, Noh SH, Hyung
postoperative period may be obtained to ensure no anasto- WJ. Usefulness of laparoscopic side-to-side duodenojejunostomy
motic leak prior to the initiation of oral intake. Postoperative for gastrointestinal stromal tumors located at the duodenojejunal
care is otherwise routine. Acute pancreatitis is a possible junction. J Gastrointest Surg. 2015;19:2.
Laparoscopic Sleeve Gastrectomy
37
John M. Morton and Jamie Dutton
Indications workup as well as selective testing depending on the

patient’s comorbidities.
• Body mass index (BMI) ≥40 BMI between 35 and 40 • Routine lab work includes a CBC, BMP, liver function
with high-risk comorbid conditions or lifestyle-limiting tests, HgbA1c, thyroid stimulation hormone, vitamin D,
obesity-induced physical conditions micronutrients including iron and calcium, UA, and urine
pregnancy (females).
• Selective lab work includes vitamin B1, vitamin B12,
Contraindications albumin, Helicobacter pylori, urine toxicology, and urine
nicotine.
• Patients unable to undergo general anesthesia, uncorrect- • Routine consultations include nutritional and psychologi-
able coagulopathy, limited life expectancy secondary to cal evaluation.
inoperable malignancy, or irreversible cardiopulmonary • Selective consultations depend upon the patient’s specific
disease/end-organ failure comorbidities or any concerns that arise during preopera-
• Patients who are pregnant or expect to be pregnant within tive workup. The most common are cardiology and/or
12 months should be deferred pulmonary consultations.
• Routine testing: chest X-ray, ECG, endoscopy. Selective
testing: UGI series, pH/esophageal manometry, dexa
Relative Contraindications scan, sleep study, colonoscopy, mammography, ultra-
sound, gastric-emptying study, echocardiogram. Routine
• Lack of mental capacity to understand the surgery and screening: sleep apnea (STOP-BANG Questionnaire),
lifestyle changes involved active substance abuse issues, functional status, smoking, substance abuse. Selective
severe and untreated psychiatric illness, active peptic screening: malignancy.
ulcer disease.
reoperative Optimization to Enhance

P
Preoperative Preparation Effectiveness and Decrease Complications
• Preoperative preparation should be tailored to the indi- • Routine diet: liquid diet 2–4 weeks for preoperative
vidual patient. However, guidelines exist for routine weight loss (consider antiobesity medications on selected
basis)
• Blood pressure/glycemic control
J. M. Morton (*) • Smoking cessation
Bariatric and Minimally Invasive Surgery, Department of Surgery,
Yale School of Medicine, New Haven, CT, USA
e-mail: John.morton@yale.edu Day of surgery: preoperative antibiotics, subcutaneous
heparin for deep venous thrombosis prophylaxis, sequential
J. Dutton
Department of Surgery, Northwest Medical Center, compression devices
Bentonville, AR, USA

https://doi.org/10.1007/978-3-030-81415-1_37
288 J. M. Morton and J. Dutton
Pitfalls and Danger Points Documentation Basics
• Bleeding The operative report should be completed in a timely fashion

• Staple line leak within 24 hours and should include:
• Stricture
• Resection amount
• Demonstration of hemostasis
Operative Strategy • Findings, including presence or absence of hiatal hernia
• Size of the sleeve, including the size of the bougie or
This operation requires the creation of a smooth linear tube endoscope used
to fully remove fundus, preserve pylorus, and reduce gastric • Size and type of stapler, if any buttressing material is used
volume by 80% while avoiding complications. It may be or if the staple line is oversewn
conceptualized in four phases: • Negative leak test if performed
1. Port placement and liver retraction

2. Mobilization of the stomach Operative Technique
3. Creation of the sleeve
4. Leak test Positioning and Port Placement
Beyond the actual operation, there is mounting evidence Position the patient supine on a bariatric bed in a split-leg
that standardizing perioperative care helps decrease compli- position (or stirrups in low lithotomy if no split-leg bed is
cation rates. This includes a thorough multidisciplinary pre- available). Take care to secure the patient in anticipation of
operative patient selection program, continues with a steep Trendelenburg position, with a footboard and straps on
standard approach to the operation itself, and finishes with a each limb with sufficient padding to avoid nerve injury. Put
postoperative pathway. Enhanced recovery after surgery both arms out on padded armboards. After intubation, have
(ERAS) pathways are available for sleeve gastrectomy, and the anesthesia team pass an orogastric tube to decompress
can improve length of stay and decrease postoperative com- the stomach.
plication rates. Port placement can vary, as can techniques or preferences
for accessing the abdomen. Our preferred port placement is
pictured in Fig. 37.1. Access is gained via a Veress needle at
Avoiding Operative Bleeding Palmer’s point, two finger’s breadth below the right midcos-
tal margin. A 5-mm port for the liver retractor is placed in the
Care should be taken while taking down the blood supply to right upper quadrant. A camera port is placed 12–15 cm
the greater curvature of the stomach. An advanced bipolar below the xiphoid in the midline, and three working ports are
cutting device or ultrasonic scalpel is used to seal the blood placed laterally and medially.
vessels. At the most proximal portion of the stomach the
short gastric vessels can be in close proximity to the spleen.
The surgeon must avoid excessive retraction in this area to
avoid a traction injury.
Avoiding Postoperative Stenosis and Leak
Use a bougie (32–40F) to guide the staple line along the

sleeve. A tight sleeve especially at the incisura can lead to
outflow obstruction and predispose to a more proximal leak.
Many surgeons perform an intraoperative leak test with
either air or methylene blue to evaluate the staple line. If the
leak test is positive, then the staple line can be reinforced or
oversewn in the areas of concern. Fig. 37.1
37 Laparoscopic Sleeve Gastrectomy 289
Fig. 37.4
Fig. 37.2
ach and made to lie along the lesser curvature. The

International Sleeve Consensus Statement recommends
using a 32–36F bougie as a sizer (Fig. 37.4). At this point, it
is essential to ensure that there are no other tubes, tempera-
ture probes, or foreign bodies in the stomach. Then divide
the stomach, starting approximately 5–7 cm from the pylorus
where the gastrocolic ligament was divided. Tailor the height
of the staple load to the thickness of the stomach. Avoid
dividing the stomach too close to the incisura to avoid stric-
ture at this area. In addition, ensure that the anterior and pos-
terior edges of the gastric resection line are the same distance
from the lesser curvature to avoid kinking, twisting, or “spi-
Fig. 37.3 raling” of the sleeve gastrectomy. Retracting the greater
curve gently and laterally through the assistant port can help
maintain even tension.
Mobilization of the Stomach Some surgeons elect to use buttressing material within
their staples. Data demonstrate that buttress use does
To expose the stomach, place the patient in steep Trendelenburg decrease bleeding, but not necessarily leaks. Surgeons
and use a liver retractor to elevate the left lobe. Identify the may also oversew the staple line for hemostasis and leak
distal margin of the sleeve approximately 5–7 cm proximal to prevention or reapproximate the omentum to the new
the pylorus (Figs. 37.2 and 37.3). Completely mobilize the greater curve with interrupted sutures to maintain a flat,
greater curve of the stomach by transecting the gastrocolic straight sleeve to potentially decrease postoperative nau-
ligament and short gastric vessels close to the wall of the stom- sea or leaks.
ach with an advanced bipolar cutting device or the ultrasonic
scalpel device. Continue this dissection to the highest short
gastric arteries near the spleen. Take care to avoid injuring the Leak Test
splenic vein and artery during the dissection. Mobilize any
posterior attachments of the stomach off the lesser sac and If the flexible endoscope is used as a sizer for the sleeve, the
take down any attachments of the gastric fundus to the left crus leak test can easily be accomplished by submerging the
of the diaphragm. The resulting exposure of left crus to fully sleeve in saline irrigation, clamping the distal stomach, and
mobilize fundus without inducing a hiatal hernia is considered insufflating with the endoscope. If no bubbles are seen, the
a critical view. At this point, if a hiatal hernia is apparent, it air is released and the saline suctioned out of the abdominal
should be fixed in a traditional posterior approach. cavity. It is also possible to use methylene blue through a
nasogastric tube for a leak test, although this requires more
placement and replacement of tubes. The stomach is then
Creation of the Sleeve removed, usually by extending the right lateral 12-mm port
site. The extraction site fascia is closed either under direct
Sizing of the sleeve is important and relies on either a bougie vision or using a fascial closure device, and the liver retractor
or a flexible endoscope that should be passed into the stom- and remaining ports are removed.
290 J. M. Morton and J. Dutton
Postoperative Care • Leak is one of the most serious complications of the

sleeve gastrectomy, and occurs rarely. Management can
• Prophylaxis: Early ambulation and aggressive pulmonary include drainage, antibiotics, surgical repair, and stenting,
toilet with incentive spirometer are important preventa- depending on when the leak is diagnosed and the patient’s
tive care. Patients who are on home CPAP should con- clinical presentation.
tinue to get CPAP at night with their usual settings. • Urinary tract infection can occur in any postoperative
Sequential compression devices and prophylactic heparin patient, but obesity and diabetes increase the risk. Minimizing
should begin prior to incision and continue while patient catheter use and avoiding routine intraoperative foley place-
is hospitalized. ment, if possible, can help decrease this complication.
• Upper GI contrast study: A contrast study may be • Surgical site infection (SSI) occurs rarely. SSI can be
obtained, but it is not a routine postoperative maneuver. avoided by weight-based, preincision antibiotic dosing,
The benefits of the UGI may include diagnosis of a leak glycemic control, possibly shielding wound when extract-
or obstruction as well as having a baseline anatomy study ing specimen, and irrigation and loose closure of wound.
for any future symptoms. • Stricture or obstruction of the sleeve can occur in rare
• Diet: Patients should not begin eating solid food until instances and is usually a late complication; treatment
more than 2 weeks postoperatively. Patients are kept includes both surgical and endoscopic approaches.
NPO (nothing by mouth) until postoperative day 1, or • Gastroesophageal reflux (GERD): Some studies show an
after the contrast study, at which point they begin a increase in GERD after sleeve gastrectomy, although the
restricted diet of 30 cc/hour. They are discharged usually causative relationship is controversial. In severe cases,
on postoperative day 1 or 2 on a liquid diet. Some refractory GERD can necessitate conversion to a gastric
enhanced recovery programs advocate liquid diet within bypass. A standard operative technique may decrease
4 hours of surgery. postoperative GERD.
• Discharge medications: Patients are discharged on acid • Deep vein thrombosis (DVT) or pulmonary embolism
suppression and a multivitamin. (PE): Obesity is a risk factor for thrombosis, and all
• Drain may or may not be placed at the time of surgery patients should receive preoperative heparin. Heparin,
depending on surgeon preference. sequential compression devices, and early ambulation are
• Glycemic control is essential to reduce infections or all critical elements in preventing DVT.
hyperglycemia.
• Follow-up: Patient should have regular follow-up with
both the surgeon and a nutritionist typically at 2 weeks,
3 months, 6 months, 1 year, and then annually. Further Reading
Deitel M, Gagner M, Erickson A, Crosby R. Third International
Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis.
Complications 2011;7:749–59.
Nguyen N, Blackstone R, Morton J, Ponce J, Rosenthal R, editors. The
• Bleeding, most commonly from the staple line, is usually ASMBS textbook of bariatric surgery. New York: Springer; 2015.
self-limited and managed with transfusions. There is Rosenthal R. International Sleeve Gastrectomy Expert Panel Consensus
Statement: best practice guidelines based on experience of >12,000
some evidence that reinforcing the staple line, either by cases. Surg Obes Relat Dis. 2012;8:8–19.
using a reinforced stapler or by oversewing, decreases the Telem D, Gould J, Pesta C, et al. American Society for Metabolic and
risk of staple line bleed, and we do use a buttressed stapler Bariatric Surgery: care pathway for laparoscopic sleeve gastrec-
for the sleeve. tomy. Surg Obes Relat Dis. 2017;13:742–9.
Laparoscopic Roux-en-Y Gastric Bypass
38
Katherine M. Meister and Stacy A. Brethauer
pressure settings prior to surgery. Routine upper endoscopy

Preoperative Preparation is performed at the discretion of the operating surgeon, but
should be considered in patients with prior gastric surgery or
Indications those with symptoms of esophageal reflux.
Patients are advised to begin a high protein, liquid diet
According to the 1991 NIH Consensus Guidelines, bariatric prior to surgery, as this aids in decreasing the size of the liver
surgery, including Roux-en-Y gastric bypass, is indicated for at the time of surgery.
patients with morbid obesity, including body mass index
(BMI) of greater than 40 m/kg2, or those with BMI greater
than 35 m/kg2 with associated comorbid conditions such as Pitfalls and Danger Points
diabetes mellitus, obstructive sleep apnea, obesity-related
cardiomyopathy, and severe joint problems. Additionally, the • Laparoscopic access in a morbidly obese patient should
2017 American Diabetes Association guidelines recommend be obtained in the left upper quadrant.
that bariatric surgery should be considered in patients with • Handle the bowel gently, with atraumatic graspers to
BMI 30–34.9 with hyperglycemia that is inadequately con- decrease the risk of enterotomy.
trolled with medical therapy. • The jejunal mesentery should be divided directly between
The perioperative care of a bariatric surgery patient the two limbs of bowel to ensure adequate blood supply to
requires a multidisciplinary approach. Prior to undergoing the jejunojejunostomy and the gastrojejunostomy.
bariatric surgery, patients are required to undergo counseling • Early identification and preservation of the left gastric
and obtain clearance from a qualified psychologist, nutri- artery will maintain adequate blood supply to the
tional team, and medical physician. gastrojejunostomy.
• Be cognizant of the location of the splenic artery when
performing the posterior dissection of the gastric pouch.
Preoperative Examination • Examine the mesentery of the Roux limb prior to creation
of the gastrojejunostomy to ensure there are no twists.
Comorbid conditions should be investigated and optimized
prior to surgery. Routine laboratory tests should be per-
formed including complete blood count, metabolic panel, Documentation
lipid panel, coagulation profile, thyroid function, iron panel,
and vitamin D level. Cardiac evaluation includes electrocar- The operative note should include the BMI and associated
diogram; stress testing should be considered in patients with comorbidities at the time of the initial operation. The appear-
risk factors for coronary artery disease. Patients should be ance of the liver should be mentioned, as hepatomegaly and
screened for obstructive sleep apnea using an in-office ques- fatty liver disease are prevalent in this patient population. It
tionnaire and undergo polysomnography if necessary. If is important to document the approximate size of the gastric
polysomnography is positive, patients should obtain a prop- pouch, as well as length of the biliary-pancreatic and Roux
erly fitted mask and appropriate continuous positive airway limbs, as there may be variation from surgeon to surgeon.
K. M. Meister (*) · S. A. Brethauer

Section of Laparoscopic and Bariatric Surgery, Department of
Surgery, Cleveland Clinic, Cleveland, OH, USA

https://doi.org/10.1007/978-3-030-81415-1_38
292 K. M. Meister and S. A. Brethauer
scopic guided transversus abdominis plane block is per-

Operative Strategy formed. A 12-mm trocar is then placed approximately one
hand’s breadth to the right of the camera port, which will be
The basic steps to the operation include division of the jeju- approximately one hand’s breadth inferior to the costal mar-
num and mesentery, creation of the jejunojejunostomy, iden- gin. A 5-mm trocar is placed approximately one hand’s
tification of the left gastric vascular pedicle and formation of breadth superior to the 12-mm trocar, just off the costal mar-
the gastric pouch, creation of the antecolic gastrojejunos- gin. An additional 5-mm right-sided trocar is placed laterally
tomy, and closure of mesenteric defects. for the liver retractor. This trocar is placed just inferior to the
edge of the liver; additional retraction may be necessary to
protect the colon during placement. The final 5-mm trocar is
Operative Technique placed on the left side of the abdomen, approximately one
hand’s breadth inferior and lateral to the initial 5-mm trocar
Patients should receive appropriate prophylaxis prior to (Fig. 38.2).
induction of anesthesia. Patients should receive antibiotics,
typically a first-generation cephalosporin, for superficial sur-
gical site infection prophylaxis. Additionally, patients should ivision of the Jejunum and Creation
D
receive venous thromboembolism prophylaxis, including of Jejunojejunostomy
chemoprophylaxis and placement of intermittent pneumatic
compression devices, as patients undergoing bariatric sur- With the patient flat, the omentum and transverse colon are
gery are considered moderate to high risk for venous retracted cephalad to expose the ligament of Treitz. The jeju-
thromboembolism. num is then run 50 cm distal to the ligament of Treitz. When
The patient is placed on the table in the supine position, running the bowel, the proximal bowel is kept cephalad to
taking care to adequately pad pressure points. The arms are the top of the screen. Prior to dividing the bowel, the mesen-
secured on the armboards and remain extended, untucked. A tery should be flat to create a large “C” loop, with the proxi-
footboard is placed to prevent sliding when the patient is mal bowel, or biliopancreatic (BP) limb, at the top of the
placed in steep reverse Trendelenburg position. In addition to screen and the distal bowel, or Roux limb, at the bottom of
the safety belt placed at the thighs, tape is placed circumfer- the screen. The bowel is then divided using a 2.5-mm endo-
entially around the patient and table, above and below the scopic staple load though the 12-mm trocar. The mesentery
knees, to secure the patient when placed in steep reverse is divided using ultrasonic shears, taking care not to devascu-
Trendelenburg. After successful induction and intubation, larize either limb of bowel. The Roux limb is then marked
the skin is prepped and draped in the usual sterile fashion with a stitch. The bowel is then run 150 cm distal, with the
using a standard laparoscopic drape. The primary surgeon is first 20 cm of bowel placed cephalad to the BP limb. A stitch
working from the patient’s right side throughout the proce- is placed to approximate the BP limb and the Roux limb,
dure, with the assistant working from the left side (Fig. 38.1). placed 1–2 cm from the BP staple line, along the antimesen-
teric borders of the bowel. The assistant grasps this stitch to
create tension on the bowel.
Trocar Placement The ultrasonic shears are then used to create enteroto-
mies. The enterotomy in the BP limb is created by removing
The first incision is made in the left upper quadrant, approxi- a small portion of the antimesenteric portion of the staple
mately one hand’s breadth from the xiphoid just below the line. The shears are then placed within the enterotomy to
costal margin. A Veress needle is inserted and the abdomen ensure patency and the enterotomy is enlarged to allow for
is insufflated to a pressure of 15 mmHg. Following adequate the entry of a stapler cartridge. The enterotomy on the Roux
insufflation, the Veress is removed and the abdomen is limb is created by placing counter tension on the bowel. This
entered using a 5-mm, 0 degree laparoscope with an optical will create a ridge along the antimesenteric border. The ultra-
trocar. The laparoscope is then inserted and the abdomen is sonic shears are then used to create an enterotomy approxi-
inspected for injuries from initial trocar placement. The lapa- mately 2–3 cm from the stay suture. Again, the bowel is
roscope is then transitioned to a 5-mm, 45 degree scope, entered and the enterotomy is enlarged to allow for entry of
which is used for the remainder of the procedure. A 5-mm the stapler. Using a 2.5-mm staple load, the stapler is then
trocar is placed approximately one hand’s breadth inferior to placed through each of the enterotomies, with the antimesen-
the xiphoid, through the rectus, just to the left of midline. teric borders aligned in a side-to-side manner (Fig. 38.3).
This trocar will be used for the laparoscope throughout the The stapler is removed, taking care not to enlarge the com-
case and larger trocar can be used at this site if needed for a mon enterotomy.
10-mm camera. After the camera port is in place, a laparo-
38 Laparoscopic Roux-en-Y Gastric Bypass 293
Fig. 38.1 (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2006–2017. All Rights Reserved)
A suture is placed through the bowel, on either side of the amount of bowel removed as to not narrow the anastomosis.
common enterotomy, to approximate the staple line together. A stitch is placed at the edge of the staple line, between the
A minimal amount of bowel should be included in this BP limb and common channel. Clips are placed to mark the
suture, to avoid narrowing the bowel at the anastomosis. An jejunojejunostomy and ensure hemostasis of the staple line.
additional 2.5-mm staple load is then used to close the com- An antiobstruction stitch is placed between the Roux limb
mon enterotomy, placed across the bowel transversely in and the blind end of the BP limb.
relation to the previous staple line, with only a very small The mesenteric defect of the jejunojejunostomy is then
closed using 2–0 nonabsorbable braided suture. The antiob-
struction stitch is held by the assistant and the proximal Roux
limb is placed cephalad. This will create tension along the
mesenteric defect with the cut edge of the BP mesentery on
the left and the Roux mesentery on the right. A purse string
suture is placed at the base of the mesentery and this defect
is closed in a running fashion, toward the jejunojejunostomy.
The size of the bite should be large enough that the suture
does not tear through the mesentery, though bleeding can
occur if the bite is too large. The suture is then tied to the
antiobstruction stitch previously placed. The omentum is
then divided along the proposed route of the Roux limb.
Creation of the Gastric Pouch
The patient is then placed in steep reverse Trendelenburg posi-

tion. The liver retractor is placed through the right lateral 5-mm
trocar and the left lateral segment of the liver is retracted anteri-
orly to expose the hiatus. The liver retractor is then secured to
the table. The pars flaccida is entered. The left gastric pedicle is
then identified. A closed grasper is then placed just distal to the
left gastric pedicle and retracted anteriorly to expose the lesser
sac (Fig. 38.4). Any adhesions from the posterior stomach to the
pancreas are taken down at this time. The descending branch of
the left gastric is then identified and ligated using proximal and
distal sutures and divided using the ultrasonic shears. Proximally,
the epiphrenic fat pad is removed if required to expose the left
crus of the diaphragm at the angle of His and remove the perito-
neal attachments between the stomach and diaphragm. Prior to
Fig. 38.2 (Reprinted with permission, Cleveland Clinic Center for firing a staple load on the stomach, confirm that there are no
Medical Art & Photography © 2006–2017. All Rights Reserved) tubes or probes placed into the esophagus by verifying with
Fig. 38.3 Fig. 38.4

anesthesia that the endotracheal tube is the only tube in the braided absorbable suture, from either side of the defect, in run-
mouth. The pouch is then created using 3.5-mm staple loads. ning fashion. A 32-French endoscope is placed with laparo-
The initial load is oriented transversely, just distal to the left scopic guidance through the anastomosis and the final sutures
gastric artery. The subsequent loads are then oriented vertically, are placed with the endoscope in place. With the endoscope still
toward the angle of His. The final load should be approximately in place, a second layer is then placed anteriorly across the anas-
1–2 cm from the gastroesophageal junction (Fig. 38.5). The tomosis, using 2–0 absorbable suture, imbricating the Roux
pouch is then dissected free from the left crus. The proximal one limb and gastric pouch (Fig. 38.7). Upon completion of the
third of the staple line is imbricated using 2–0 nonabsorbable anastomosis, a bowel clamp is placed across the Roux limb and
braided suture. a leak test is performed with the patient in slight Trendelenburg
position. Using the endoscopic view and insufflation, the anas-
tomosis and gastric pouch are assessed for size and bleeding,
Creation of the Gastrojejunostomy while laparoscopically the anastomosis is submerged in water.
After a negative leak test, omentopexy is performed. A piece of
The gastrojejunostomy will be created in a two layer, end to side omentum from the left side of the abdomen placed over the
fashion. The Roux limb is brought up in an antecolic-antegastric anastomosis and secured in place. With the patient in the flat
fashion. Prior to approximating the Roux limb to the pouch, the position, the transverse mesentery is exposed by reflecting the
Roux limb is run distal to the jejunojejunostomy to ensure there omentum and transverse colon cephalad, on the right side of the
are no twists in the mesentery of the Roux limb. The Roux limb Roux limb. This will expose the Petersen’s space. The defect is
is then approximated to the posterior aspect of the pouch with a closed by placing a purse string from the mesentery of the Roux
running 2–0 nonabsorbable braided suture, with the blind end of limb across the base of the transverse colon mesentery with 2–0
the Roux limb oriented to the patient’s left side. A gastrostomy nonabsorbable braided suture and run anteriorly closing the
is created directly through the staple line, using the ultrasonic defect in entirety.
shears. An adjacent enterotomy is created in a similar fashion. A After final inspection of the abdomen, the fascia of the
linear stapler, with 3.5-mm load, is then placed through either 12-mm trocar is closed using 0 Vicryl suture on a suture
opening to create a 1.5- to 2-cm inner layer of the gastrojejunos- passer. The abdomen is desufflated and the remaining 5 mm
tomy (Fig. 38.6). The common defect is then closed using 2–0 trocars are removed. The skin incisions are closed with 4–0
absorbable subcuticular suture and glue.
Postoperative Care
Enhanced recovery principles and pathways are now being

utilized in bariatric surgery. Typical length of stay after routine
laparoscopic Roux-en-Y gastric bypass is 1–2 days. Patients
are started on a Phase 1, clear liquid diet, immediately after
surgery and advanced to a Phase 2, full liquid diet, on the
morning of postoperative day one. Patient are encouraged and
expected to ambulate within hours of surgery and at least 5–6
times a day. A multimodal pain management approach includ-
Fig. 38.5
Fig. 38.7
Fig. 38.6
ing the intraoperative regional block and postoperative sched- technical error. Late obstruction can be secondary to internal
uled acetaminophen and ketorolac aids in limiting narcotic hernias or secondary to adhesive disease. Routine closure of
administration. Multiple antiemetic medications should be the mesenteric defects has been shown to decrease the rates
available on an as needed basis. Patients should have intermit- of internal hernias.
tent pneumatic compression boots in place while in bed and
remain on scheduled low-molecular-weight heparin while in
the hospital. Additionally, extended outpatient prophylaxis Late Complications
should be considered in high-risk patients. Patients are placed
on 6 months of ulcer prophylaxis. The most common late complications include bowel obstruc-
tion secondary to internal hernia, anastomotic stricture, and
ulcer formation.
Avoiding Complications An internal hernia can present as a surgical emergency
with acute onset of abdominal pain, nausea, and emesis as a
The most frequent early complications after bariatric surgery result of incarcerated bowel. It can also present as nonspe-
include venous thromboembolism, anastomotic leak, post- cific postprandial abdominal pain if the bowel is intermit-
operative bleeding, obstruction, and surgical site infections. tently herniated. If an internal hernia is suspected, surgical
Venous thromboembolism is the leading cause of mortal- exploration is warranted. There are three possible locations
ity after bariatric surgery. As such, it is imperative that for an internal hernia: the mesenteric defect of the jejunoje-
patients receive prophylaxis as discussed earlier. High-risk junostomy, Petersen’s space between the Roux limb and the
patients should receive extended outpatient prophylaxis, as mesentery of the transverse colon, and through the transverse
most of these events occur after discharge from the hospital. mesentery defect if a retrocolic reconstruction was
Anastomotic or staple line leak occurs most frequently at performed.
the gastrojejunostomy, but can occur at the jejunojejunos- Strictures can develop at either the gastrojejunostomy or
tomy and the staple line of the gastric remnant. This can the jejunojejunostomy. Patients typically present with pro-
occur secondary to ischemia, tension, or hematoma forma- gressive inability to tolerate solid foods or with obstructive
tion at the anastomosis or staple line. Division of the jejunal symptoms including abdominal pain, nausea, and emesis.
mesentery and division of the greater omentum are steps Strictures at the gastrojejunostomy can undergo endoscopic
taken to decrease the tension on the gastrojejunostomy. dilation, though they may require surgical revision of the
Prompt recognition and management is crucial for optimal anastomosis. Strictures at the jejunojejunostomy typically
outcomes. Persistent tachycardia, fever, and increased require surgical revision.
abdominal pain should raise suspicion of a postoperative A marginal ulcer, present on the jejunal side of the gastro-
leak, though fever and abdominal pain are often absent. jejunostomy, or gastric ulcers typically present with post-
Large leaks can lead to hemodynamic instability and these prandial epigastric abdominal pain. They can be associated
patients should return to the operating room for drain place- with bleeding and strictures. Known risk factors for ulcer
ment and washout. In the stable patient, management formation include the use of nonsteroidal anti-inflammatory
includes diagnostic imaging, source control with percutane- drugs, as well as tobacco use; as such, patients should be
ous drains, and alternate forms of nutrition. counseled preoperatively on the risks of use and recidivism.
Bleeding can occur from a variety of locations after Roux- Endoscopy is diagnostic. Treatment includes avoidance of
en-y gastric bypass. This includes the staple lines at the jeju- precipitating factors, proton pump inhibitors, and sucralfate.
nojejunostomy, gastrojejunostomy, and gastric remnant, as Surgical management is indicated for bleeding, perforation,
well as areas without staple lines including the descending and failure of medical therapy.
branch of the left gastric, the split mesentery or omentum, or
bleeding from the abdominal wall trocar sites. Patients may
present with tachycardia, hypotension, hematemesis, melena, Further Reading
ecchymosis, or hematoma at an incision site. While most
bleeding will resolve with resuscitation, persistent bleeding Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gas-
tric bypass surgery. N Engl J Med. 2007;357:753–76.
or unstable patients may require surgical or endoscopic Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a system-
intervention. atic review and meta-analysis. JAMA. 2004;292:1724–37.
Bowel obstruction can occur at any time during the post- Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines
operative period. Patients typically present with nausea, for the perioperative nutritional, metabolic, and nonsurgical sup-
port of the bariatric surgery patient – 2013 update: cosponsored by
vomiting, and inability to tolerate oral intake. In the immedi- American Association of Clinical Endocrinologists, The Obesity
ate postoperative period, obstruction can be secondary to Society, and American Society for Metabolic & Bariatric Surgery.
hematoma at the jejunojejunostomy, trocar site hernia, or Surg Obes Rel Dis. 2013;9(2):159–91.
National Institute of Health Consensus Conference. Gastrointestinal Schaer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus inten-
surgery for severe obesity. Consensus development conference sive medical therapy for diabetes – 5-year outcomes. N Engl J Med.
panel. Ann Intern Med. 1991;115:956. 2017;376:641–51.
Podnos YD, Jimenez JC, Wilson SE, et al. Complications after lapa- Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after lapa-
roscopic gastric bypass: a review of 3464 cases. Arch Surg. roscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg.
2003;138:957–61. 2000;232:515–29.
Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery in the treat- Stenberg E, Szabo E, Agren G, et al. Closure of mesenteric defects in
ment algorithm for type 2 diabetes: a joint statement by interna- laparoscopic gastric bypass: a multicentre, randomised, parallel,
tional diabetes organizations. Diabetes Care. 2016;39(6):861–77. open-label trial. Lancet. 2016;387:1397–404.
Laparoscopic Reoperative Bariatric
Surgery 39
Giulio Giambartolomei, Emanuele Lo Menzo,
Samuel Szomstein, and Raul J. Rosenthal
Introduction mary operation should also be known, as they can influence

the reoperation choice and strategy. The clinical assessment
According to ASMBS, 196,000 bariatric procedures were should include a comprehensive physical examination with
performed in 2015, 13.6% of which were reoperations. The particular attention paid to specific potential signs of previ-
2016 statistics have been released and the number has ous complications, such as abdominal tenderness (ulcers,
slightly decreased to 9.9%. The rates among the different abscess, or internal hernia), abdominal distention, discharge
types of reoperations vary significantly based on the primary from previous wounds or a newly formed cutaneous fistula,
operations. The indications for reoperation vary as well, signs of bleeding, or sepsis. The assessment should be com-
whether it originates from complications or nonresponders pleted with vital signs and full blood work.
of the primary intervention (Table 39.1). The type of reop- A multidisciplinary team should evaluate patients in order
eration can be classified as revision, conversion, or reversal to obtain medical clearance tailored to the previous existing
based on the anatomic result of the reoperation (Table 39.2). comorbidities. As such, consultations with internal medi-
Nonetheless, a common strategy to approach these condi- cine, endocrinology, pulmonology, and cardiology services
tions can be identified. This chapter aims to discuss the peri- might be necessary. Also, a dietary and nutritional assess-
operative and operative steps of laparoscopic reoperative ment is advised, since these patients could have been on total
bariatric surgery. parenteral or enteral nutrition for long periods of time, and
therefore, are expected to be malnourished in varying
degrees. This is especially important to properly select
Preoperative Preparation patients for failure of weight loss or weight regain, as many
of these failures are not attributable to anatomical derange-
A meticulous and comprehensive clinical evaluation is ments of the primary operation. Finally, a psychological/psy-
essential, regardless of the primary operation. A thorough chiatric evaluation is advised in order to rule out a potential
past medical and surgical history, with particular attention reason of noncompliance.
paid to the previous primary operation, is a paramount start- Finally, it is essential to perform an extensive evaluation
ing point. Mandatory, in this regard, is to obtain, when pos- of the anatomy and function of the gastrointestinal tract.
sible, all previous operative reports, preoperative assessments, Investigations such as upper endoscopy, fluoroscopic gastro-
and postoperative charts in order to acquire a rounded intestinal series, and CT scan will help understand the post-
impression of the clinical and surgical history of the patient. surgical anatomy, the presence of ulcers, fistulae or other
Also, it is important to review the technical details such as complications, and the potential presence of prosthetic mate-
previous surgical approach, dissection, resection and recon- rial in order to plan a feasible approach and choose the most
struction techniques, materials used for stapling, and sutur- reasonable type of reoperation.
ing and reinforcement of anastomosis and staple lines. The
postoperative course and potential complications of the pri-
G. Giambartolomei · E. Lo Menzo · S. Szomstein
R. J. Rosenthal (*) • Disrupted anatomy
The Bariatric and Metabolic Institute, Cleveland Clinic Florida, • Presence of active foci of infection
Weston, FL, USA
e-mail: rosentr@ccf.org

https://doi.org/10.1007/978-3-030-81415-1_39
300 G. Giambartolomei et al.
Table 39.1 Indications for reoperative surgery Operative Strategy

Indications Failures Weight regain Technical
Nonresponders Medical Preoperative Preparation
compliance
Recurrence of Metabolic
comorbidities
Bowel preparation is done the day before surgery with mild
Complications Time of onset Acute (<7 days) laxatives and a clear liquid diet. Standard antibiotic and deep
Early venous thrombosis prophylaxis should be implemented.
(7 days–6 weeks) The patient is positioned supine on the OR table with
Late arms out. Properly pad all pressure points and securely strap
(6–12 weeks) the patient to the table. Take care with these steps to avoid
Chronic
neurological pressure injuries and upper extremity
(>12 weeks)
Type Surgical or overextension.
anatomical
Nutritional or
metabolic Abdominal Entry and Initial Exposure
Table 39.2 Types of reoperations The laparoscopic approach is usually preferred; however, a
Type of conversion to a midline laparotomy should be performed
procedures whenever safe maneuvers cannot be achieved
Revision Maintains the basic anatomy of the primary laparoscopically.
procedure According to the type of intervention, the operative strat-
Conversion Change of the anatomy to a different operation
egy may vary, but we can identify three main steps that
Reversal Restore original anatomy
should be performed in every reoperative bariatric surgery.
In general, gasless supraumbilical optical trocar entry can be
• Scarred tissue (consider higher staple height, and over safely used. Obviously the presence of previous laparotomy
sawing suture lines) incision, meshes, or previous extensive surgery might require
• Areas of local ischemia an alternative technique of entry, such us open (Hasson)
• Dense adhesions approach, or a subcostal optical entry. After having safely
• Intraoperative and postoperative bleeding positioned the first trocar, exploration of the abdomen is car-
• Poor tissue quality for new anastomosis ried out in order to choose a safe position for the remaining
additional trocars and their insertion under direct
visualization.
Documentation
Given the reoperative nature of the procedure, a brief sum- Adhesiolysis

mary of the primary intervention should be mentioned in the
operative note, along with the indication for surgery, preop- Due to the reoperative nature of the procedure, adhesions are
erative assessment, and imaging. expected and vary significantly in amount, tenacity, and vas-
Every step should be thoroughly described, especially the cularity. This is often a limiting step in the ability to com-
findings related to the reoperative nature of the procedure. It plete the procedure laparoscopically. The first step is a
is important to document the length of intestine bypassed thorough, sharp adhesiolysis, followed by hemostasis.
and remaining, in case of gastric bypass. The presence and Energy devices can be safely used in the absence of viscera
complete removal of foreign bodies should be also within the adhesions. Omentoparietal and enteroparietal
documented. adhesions should be taken down at least in the suprameso-
In case an anastomosis is created, it is important to colic area of the abdomen, although an extension to the
describe the type and the materials used, such as staple height inframesocolic area may be needed along with a viscerolysis
and/or sutures. Any drain placed should be mentioned. when a Roux-en-Y bypass is sought.
39 Laparoscopic Reoperative Bariatric Surgery 301
Left Liver Lobe Mobilization Another aspect that has to be taken into consideration is
surgeon’s experience, which has been correlated with better
In order to reach a satisfactory exposure of the gastroesopha- outcomes in all surgical fields. It is therefore advisable to
geal junction, the left liver lobe has to be cranially retracted; refer this type of patients to expert surgeons.
however, this maneuver is often not possible due to dense
adhesions and fibrotic tissue secondary to inflammatory pro-
cesses involving the area. The adhesions can be dense enough Operative Technique (Step by Step)
that, in order to avoid gastric or bowel injury, sometimes the
dissection has to be carried out within the liver subcapsular Patient Positioning and Trocar Placement
space.
As previously mentioned, place the patient supine with the
arms abducted and padded on an armboard. Achieve initial
Diaphragmatic Hiatus Exposure entry by placing a 12-mm trocar through an open Hasson
technique at the level of the umbilicus. If the previous scar is
Regardless of the type of reoperation planned, the gastro- well healed, an optical trocar may be used. Alternatively a
esophageal junction has to be exposed and mobilized cir- left upper quadrant gasless optical trocar entry is advised.
cumferentially. It is imperative that the dissection starts on Insert six additional operative trocars under direct vision:
the lesser curve of the stomach dividing the pars flaccida and 12 mm in epigastrium, 5 mm subxiphoid, 12 mm right upper
pars densa if intact and clearly identifying and dissecting the quadrant, 12 mm right paramedian middle quadrant, 12 mm
right crus of the diaphragm. That gives the surgeon situa- left upper quadrant, and 5 mm left flank (Fig. 39.1). This
tional awareness of major vascular structures, such as IVC configuration allows excellent visualization and dexterity
and aorta as well as the esophagus. Dissecting the right crus during all the steps of the surgery, from dissecting the liver
and identifying the left gastric artery may be considered the attachments to manipulating the gastroesophageal junction.
“Achilles heel” of a reoperation. The surgeon stands on the patient’s right side, the second
The dissection may be extended voluntarily (in case an camera assistant to the surgeon’s right, and the first assistant
esophagojejunostomy is planned) or accidentally through the to the patient’s left side. Two monitors should be placed at
mediastinum; therefore, the surrounding structures have to each side of the patient at the head level.
be respected, such as the aorta posteriorly, the pleura later-
ally, and the pericardium anteriorly. In the presence of a
known or intraoperatively discovered hiatal hernia, posterior Exploration
approximation of the crura is advised in order to avoid post-
operative herniations and to decrease the potential for gastro- Begin the procedure with a meticulous exploration of the
esophageal reflux. entire abdomen in order to evaluate the amount and quality
of adhesions and the presence of undiagnosed fluid collec-
tions. At this point, decide whether to proceed laparoscopi-
Avoiding Postoperative Complications cally or convert to open, to ensure patient safety.
Tactics to reduce postoperative complications include the

following:
• Thorough hemostasis, since inflammatory tissue is more

prone to bleed
• Resection of any potentially ischemic tissue that can
evolve to necrotic and infected areas
• Staple line reinforcement, either by oversewing or but-
tressing the stapler line, in order to reduce the risk of
bleedings and leaks
• Air leak test, either endoscopically or with a gastric tube
• Positioning closed suction drainage to allow any dis-
charge to drain out of healing tissues
• Primary hiatal hernia closure/crura approximation to
avoid postoperative herniation Fig. 39.1
Critical Anatomy Exposure When the supramesocolic space is free of adhesions,

mobilize the left liver lobe.
Using traction and counter traction, expose adhesions and Often the dissection has to be performed along both the
take the omentum or small bowel off the anterior abdominal superior and inferior surface of the liver. When dissecting
wall. Identify the dissection plane, not entering the preperi- along the superior aspect, take care not to injure the dia-
toneal space (Fig. 39.2). phragm (Fig. 39.3a). Sometimes the superior adhesions aid
The presence of multiple trocars allows one to visualize in maintaining cephalad retraction of the left lobe of the
the adhesions from different angles to ensure the best and liver, and thus, it may be advantageous to leave these intact.
safest approach. Along the inferior aspect, avoid gastric and vascular injuries.
We recommend performing adhesiolysis using a sharp Next, attain thorough liver hemostasis.
technique in order to avoid any possible delayed burn inju- Once the left liver lobe is mobilized, retract it cranially
ries to the bowel; energy devices should be used only when with a liver retractor inserted through the subxiphoid port
nearby bowel is not present. Take down the omental-parietal and secured to the table (Figs. 39.3 and 39.4).
and enteroparietal attachments at least in the supramesocolic
space, to reach an adequate exposure of the liver and the gas-
troesophageal junction. If a bypass is planned, perform small G astroesophageal Junction Mobilization
bowel adhesiolysis to ensure adequate length for a tension-
free anastomosis. At this point, the dissection should proceed to the gastro-
esophageal junction in order to clarify the anatomy and iden-
tify structures like the intra-abdominal esophagus, the aorta,
and vena cava.
However, a direct approach to the esophagus may end in
a perforation; therefore, it is safer to expose the right crus of
the diaphragm as this will allow entrance into the retroesoph-
ageal space. The dissection can then be continued between
the aorta and the esophagus. The muscular fibers of the right
crura should be clearly exposed and the dissection should
move slightly toward the arch.
In order to safely create a retroesophageal tunnel, bluntly
advance an atraumatic grasper just across the right crus
(Fig. 39.5).
During these steps, take care not to grasp the esophagus
as it may result in perforation or damage to the vagus nerves.
Instead, gently manipulate it with a closed grasper.
Fig. 39.2
a b
Fig. 39.3
Fig. 39.6
Fig. 39.4
Fig. 39.5 Fig. 39.7
Intraoperative endoscopies or calibrating tubes can also After a complete mobilization of the gastroesophageal
aid in the recognition and preservation of the gastroesopha- junction, evaluate the hiatus for any potential hiatal hernia, and
geal junction, which may be difficult to recognize perform a primary repair. This can be achieved with inter-
laparoscopically. rupted stitches or with a continuous barbed suture posteriorly.
Then continue blunt dissection of the gastroesophageal The following steps depend on what the primary interven-
junction, moving laterally and behind the esophagus. For this tion was and the strategy that the surgeon decided to adopt
purpose, gently retract the esophagus anteriorly with an (Fig. 39.7).
umbilical tape or a Penrose drain placed around the distal
esophagus. This will allow a better visualization of a safe
dissection plane between the esophagus and the preaortic Types of Reoperations
fascia.
When a retroesophageal window has been created, the left As already mentioned, the specific type of reoperation varies
crus is dissected and exposed (Fig. 39.6). depending on several factors.
When dissecting and manipulating the gastroesophageal Regarding purely a revision procedure, where the anat-
junction, identification and preservation of the anterior and omy of the primary intervention is maintained, most com-
posterior branches of the vagus nerve may be difficult, and mon examples are pouch trimming, redo of the gastrojejunal
sometimes these must be sacrificed in order to mobilize the anastomosis due to stricture and resection of gastrogastric
esophagus for further maneuvers. fistula after gastric bypass, and “re-sleeve.”
Take care in removing all the components of the band,

including the connecting tube and the subcutaneous port.
Another described reversal procedure is from gastric
bypass, named “SARR procedure” (single-anastomosis
reversal of gastric bypass), usually performed because of
postgastric bypass dumping syndrome and hypoglycemia.
This procedure maintains the restrictive action of the gastric
pouch, though restoring the function of the remnant stomach
and duodenum, reducing the malabsorptive aspect of the gas-
tric bypass.
Postoperative Care
Standard adequate fluid resuscitation and pain control are

Fig. 39.8 advised in the postoperative period. Antibiotic and deep
venous thrombosis prophylaxis should be continued as
needed, especially if an intra-abdominal infection was found
The most common conversion procedures are instead the during the intervention.
following: Since the most frequent and feared acute complications of
reoperative surgery are bleeding and leaks, particular empha-
• Adjustable gastric band to sleeve gastrectomy or gastric sis should be put on monitoring the patient’s specific symp-
bypass: this kind of conversion can be achieved in one or toms and signs. Heart monitoring is paramount because
two steps, according to the surgeon’s confidence and gas- either complication usually presents with an alteration of the
troesophageal tissue scarring. If performed in one stage, basal heart rate. More specifically, since abdominal symp-
the main steps of this reoperation are: dissection of the toms may be underexpressed due to pain control and obesity,
anterior capsule to both diaphragmatic cruces, takedown an early sign of a leak is often a rapid increase in heart rate,
of the wrap, band removal and posterior capsule dissec- resistant to beta-blockers, and stable, without oscillations.
tion, and stapling according to the procedure previously An acute bleed is conversely characterized by an oscillatory
established. increase in heart rate, responsive to fluid resuscitation and
• Sleeve gastrectomy to gastric bypass: the most common beta-blockers.
reason for this type of conversion is a new onset of drug- On postoperative Day 1, an upper GI evaluation can be
refractory gastroesophageal reflux disease. It is impera- performed to rule out any leak and consequently allow the
tive to identify the left gastric artery during the dissection patient to start a liquid diet. Depending on the extent of the
and staple below its entrance into the lesser curvature surgery, the approach used (laparoscopic or open), and
when creating the pouch. patient compliance, the discharge timing may vary according
• Vertical banded gastroplasty to gastric bypass: it can be to surgeon’s judgment. An enhanced recovery after surgery
performed either with or without remnant gastrectomy. (ERAS) protocol is not usually adopted due to the nonelec-
Our advice is to perform a simultaneous remnant gastrec- tive nature of the intervention.
tomy in order to avoid possible leaks. It is also advisable
to maintain the left gastric artery when creating the pouch.
Complications
Reversals usually consist of restoring the normal anat-
omy, due to nutritional or metabolic complications, unless a The complications arising from reoperative bariatric surgery
permanent removal of an organ was performed, such as in can substantially resemble the complications expected after
sleeve gastrectomy. a primary procedure. However, it should be emphasized that
A frequent reversal procedure is the removal of an adjust- reoperative surgery “pays a price” and the morbidity of these
able gastric band. In this particular case, basic steps are: procedures is higher, with series reporting an incidence up to
identify the capsule of scarred tissue surrounding the band 33%.
and the buckle; then carefully proceed to perform a capsulec- Based on the onset time, complications can be described
tomy, avoiding injury to the plicated stomach; once the band as acute, early, late, and chronic, as listed under
is exposed, cut it at the level of the buckle and carefully “Complications” in Table 39.1.
remove it (Fig. 39.8). We can include in the acute/early complications:
• Leaks, either from an anastomosis or from a staple line. the stomach. Worsening acid reflux (GERD) can be seen
• Bleeding: further divided into intraluminal or intra- in patients after sleeve gastrectomy or bypass with short
abdominal, depending on the source and presenting with alimentary limbs.
different and misleading symptoms. The first (intralumi-
nal) usually manifested with hematemesis or melena, the
latter (intra-abdominal) with increased drainage output
and hemorrhagic symptoms such as abdominal distension Further Reading
and peritoneal signs.
• Bile leaks can occur after extensive dissection of the liver Abdemur A, Han SM, Lo Menzo E, Szomstein S, Rosenthal R. Reasons
and outcomes of conversion of laparoscopic sleeve gastrectomy to
off the stomach. Often they are not recognized intraopera- Roux-en-Y gastric bypass for nonresponders. Surg Obes Relat Dis.
tively and become evident in the first few days 2016;12(1):113–8.
postoperatively. Marin-Perez P, Betancourt A, Lamota M, Lo Menzo E, Szomstein S,
• Medical complications such as pulmonary embolism and/ Rosenthal R. Outcomes after laparoscopic conversion of failed
adjustable gastric banding to sleeve gastrectomy or Roux-en-Y gas-
or deep vein thrombosis are also to be kept in mind in dif- tric bypass. Br J Surg. 2014;101(3):254–60.
ferentiating the origin of tachycardia. Nguyen N, Still CD, American Society for Metabolic and Bariatric
Surgery. The ASMBS textbook of bariatric surgery. New York:
Late/chronic complications include the following: Springer; 2014.
Nguyen D, Dip F, Huaco JA, Moon R, Ahmad H, LoMenzo E, Szomstein
S, Rosenthal R. Outcomes of revisional treatment modalities in non-
• Fistulas: depending on the type of reoperation, they can complicated Roux-en-Y gastric bypass patients with weight regain.
develop after an acute leak or are discovered during rou- Obes Surg. 2015;25(5):928–34.
tine exams; they usually present with weight regain or Patel S, Eckstein J, Acholonu E, Abu-Jaish W, Szomstein S, Rosenthal
RJ. Reasons and outcomes of laparoscopic revisional surgery after
nonspecific epigastric symptoms. laparoscopic adjustable gastric banding for morbid obesity. Surg
• Strictures: can occur at the level of the gastrojejunal anas- Obes Relat Dis. 2010;6(4):391–8.
tomosis in the gastric bypass, or at the level of the incisura Patel S, Szomstein S, Rosenthal RJ. Reasons and outcomes of reopera-
angularis in the sleeve gastrectomy, usually when the sta- tive bariatric surgery for failed and complicated procedures (exclud-
ing adjustable gastric banding). Obes Surg. 2011;21(8):1209–19.
pler has been applied too close to the lesser curvature of
Endoscopic Intragastric Balloon
40
Camila B. Ortega, Alfredo D. Guerron, and Dana Portenier
Indications pharynx and esophagus, esophageal varices, previous gastric

or bariatric surgery, active bleeding lesion of the upper gas-
Endoscopic IGB is indicated as follows: trointestinal tract, severe liver disease, coagulation disorder,
pregnancy, breastfeeding, inability to take proton pump
• As “primary metabolic therapy” for individuals with inhibitors (PPI), or any contraindication to endoscopy.
obesity-related comorbidities whose BMI falls below the Relative contraindications include esophagitis, previous
established eligibility criteria to qualify for bariatric abdominal surgery, nonsteroidal anti-inflammatory drug
surgery therapy, Crohn’s disease, or untreated psychiatry disorders.
• As a “bridging therapy” for individuals considered to be An esophagogastroduodenoscopy should be performed at
at high surgical risk due to excessively high BMI or poor baseline to evaluate the anatomy and to identify any potential
general health status contraindications.
• As “early intervention/preemptive obesity therapy” for Once the procedure is scheduled, patients are instructed
individuals with obesity classes I and II who have a high to use a daily PPI 5–7 days prior to the IGB placement, to
cardiovascular risk profile ingest a semiliquid diet 3–4 days prior to the procedure, fol-
• To individuals required to lose weight as a bridge to non- lowed by 24 hours of clear liquids and 12 hours of fasting
obesity therapies (organ transplant, knee or hip replace- immediately before the procedure.
ment) seeking nonsurgical/pharmacological options

• Patient intolerance to the endoscopic procedure
All candidates for intragastric balloon therapy should • Patient not NPO
undergo a multidisciplinary assessment including clinical, • Large hiatal hernia
nutritional, and psychological evaluations. Patient education • Intra or post-procedure bleeding
sessions should emphasize eating patterns, lifestyle changes, • Gastric or esophagic injury
postprocedure diet, and follow-up appointments. Patients • Balloon malfunctioning (unable to fill, punctured, leak-
must commit to attend the scheduled follow-up dates to min- ing, etc.)
imize complications and have the balloon removed after
6 months of insertion. Careful patient selection is mandatory
to enhance the safety profile of the device. Absolute contra- Operative Strategy
indications for the use of intragastric balloon therapy include
large hiatal hernia ≥5 cm or ≤5 cm with associated gastro- The facility should ensure the appropriate equipment for
esophageal reflux symptoms, structural abnormalities of the patient size and weight, as well as oxygen and personnel
trained in life support and airway management.
The procedure comprises two phases: endoscopic place-
C. B. Ortega · A. D. Guerron · D. Portenier (*) ment of the intragastric balloon and endoscopic removal
Department of Surgery, Division of Metabolic and Weight Loss after 6 months of insertion. Monitored anesthesia care
Surgery, Duke University Health System, Durham, NC, USA (MAC) is generally recommended for both phases. General
e-mail: Daniel.guerron@duke.edu; dana.portenier@duke.edu

https://doi.org/10.1007/978-3-030-81415-1_40
308 C. B. Ortega et al.
anesthesia may be considered in selected cases. Placement is

divided into five steps: diagnostic endoscopy, insertion of the
uninflated balloon, confirmatory endoscopy, balloon filling,
and endoscopic reevaluation. Removal is divided into three
steps: diagnostic endoscopy, balloon deflation, and removal
of the balloon system.
Operative Technique
Placement
In the operative room, have the appropriate endoscopic

and intragastric balloon placement equipment ready in
addition to water soluble lubricant, a 50-cc syringe, and
sodium chloride 0.9% intravenous solution. Administer a
PPI and an antiemetic intravenously. Place the patient in
the left lateral decubitus position and administer proper
Fig. 40.1
sedation.
Diagnostic Endoscopy
The initial endoscopic evaluation has two objectives:
• Confirmation of fasting: if any food or residue is found in

the stomach, postpone the procedure until the next avail-
able time that the patient can comply with 12 hours of
fasting.
• Search for any anatomic contraindication to balloon
placement, such as large hiatal hernia, erosion, etc.
Insertion of the Uninflated Balloon
After removing the endoscope, lubricate the uninflated bal-

loon catheter assembly and insert it through the mouth into
the stomach (Fig. 40.1). If the patient is under conscious
Fig. 40.2
sedation, ask the patient to swallow to assisting the catheter’s
movement. If general anesthesia is used, ask the team to tem-
porarily deflate the tracheal balloon. Do not remove the guide ing. Once the correct placement of the catheter is confirmed,
wire before endoscopic confirmation of the catheter’s the guide wire can be safely removed.
position.
Balloon Filling
Confirmatory Endoscopy Connect the provided filling tube assembly to the catheter.
With the endoscope, determine that at least 1–3 cm of the Use the syringe to fill the balloon with sterile saline mixed
lower end of the placement catheter is present in the stom- with 10 ml of methylene blue (Fig. 40.2). Under direct endo-
ach. This correct positioning of the catheter must be con- scopic visualization, inflate the balloon slowly and steadily
firmed before removing the guide wire. If the catheter is to prevent damaging of the valve and premature balloon
incorrectly placed, the balloon cannot be inflated as it may detachment. The minimum filling volume to ensure appro-
get lodge in the gastroesophageal junction and cause injury priate balloon deployment is 400 cc. The maximum filling
to the esophagus or balloon rupture. Retroflexing the scope volume is 700 cc. Once the desired volume has been injected,
may assist in obtaining a clear view of the esophageal open- remove the catheter under direct visualization.
40 Endoscopic Intragastric Balloon 309
Fig. 40.3
Endoscopic Reevaluation
Reinsert the endoscope to evaluate the status of the filling
valve and the balloon (Fig. 40.3). Special attention must be
Fig. 40.4
taken at inspecting the valve to ensure that there is no visible
fluid leakage.
Postoperative Care
Removal
After the placement and the removal process, patients should
The intragastric balloon is intended to be used for a maxi- remain in the recovery room until complete sedation recov-
mum of 6 months. At this point, removal of the device is ery. Postplacement medication to be administered: an anti-
required to prevent complications. Similarly to the balloon emetic every 4 hours for the first 24 hours (even if
placement procedure, patients should consume a semiliquid asymptomatic) and maintained for 3–4 days, an antispas-
diet 3–4 days prior to the procedure, a clear liquid diet within modic, if needed, and an oral PPI daily through balloon
24 hours of the removal procedure and 12 hours of fasting removal. Postremoval medication to be administered: an oral
immediately prior to the removal procedure. In the operating PPI for 7 days and an antispasmodic if needed.
room, have the appropriate endoscopic and intragastric bal- Nausea and vomiting are expected symptoms during the
loon removal equipment ready. After proper sedation, place first week after intragastric balloon placement. Dehydration
the patient in the left lateral decubitus position. is the main concern. Recommendations for the management
of these symptoms:
Diagnostic Endoscopy
Insert the endoscope to confirm that the stomach is empty. If • Medications: antiemetic for 3–5 days. Continue with PPI
food is present in the stomach, immediately secure the airway. through removal of the device. Antispasmodic PRN.
• Diet: liquid diet during first week. Slowly progress diet.
Balloon Deflation Step back, if needed.
Insert an aspiration needle-catheter assembly into the stom- • Position: left lateral decubitus. Return to normal activity
ach through the working channel of the endoscope. Puncture as tolerated.
the balloon and then push the catheter into the balloon for • Monitoring: contact patient every 24 hours until symp-
5–6 cm before removing the aspiration needle. Aspirate the toms resolution.
saline via the catheter (Fig. 40.4). Once the balloon is com-
pletely deflated, remove the aspiration catheter from the During weeks 2–6 after intragastric balloon placement, a
working channel of endoscope. small percentage of patients may experience pseudogastro-
paresis presenting nausea and vomiting, foul smell, and
emoval of the Balloon System
R delayed vomiting of food eaten 12–24 hours earlier. Manage
Insert an endoscopic grasper through the working channel of this condition by stopping any antispasmodic, returning to
the endoscope and grasp one border of the deflated device. liquid diet, starting antiemetic therapy, adding a prokinetic
Remove the device under direct visualization. Protect the air- agent, and recommending left lateral position.
way during the process. Standard follow-up is shown in Fig. 40.5.
310 C. B. Ortega et al.
1st Week 3 months 6 months
Active monitoring Next Next

e/24h appointment appointment Removal
Placement
Fig. 40.5
Situations requiring early removal of the intragastric as minor (accommodative in nature) complications and
balloon: major complications.
• Confirmed pregnancy
• Patient undergoing any surgery Minor Complications
• Any symptoms suggesting balloon malfunction and/or
patient injury Minor complications generally show a pattern of decreased
• Balloon deflation. Suspect it when a patient reports weight intensity and frequency over time and are highly responsive
gain, increased hunger, loss of satiety to supportive therapy.
• Abdominal pain
Avoiding Postoperative Complications • Nausea
• Vomiting
The most important factor for preventing complications of • Dyspepsia
intragastric balloon is to carefully select a patient committed
to adhere with the proposed follow-up appointments and
device removal within 6 months. Intragastric balloons pres- Major Complications
ent for longer than 6 months put the patient at increased risk
for balloon deflation, migration, and intestinal obstruction. • Gastric ulceration
The second most important factor is the thorough inspec- • Deflation and migration of the balloon
tion of the intragastric balloon valve during the placement • Small bowel obstruction
procedure, after initial inflation. Identifying fluid leakage • Mallory-Weiss syndrome
from defective valves in a timely manner helps preventing • Esophageal or gastric laceration
deflation and related complications. • Esophageal or gastric perforation
Another preventive measure of complication is filling the • Early removal
balloon with the appropriate volume. Underfilled balloons
present higher risk for balloon migration and intestinal
obstruction. Overfilled balloons may perforate and cause
injury. Concomitantly injecting methylene blue along with Further Reading
saline during the filling process is another measure for
detecting balloon leakage or perforation, as the substance Ali MR, Moustarah F, Kim J. Position statement on intragastric balloon
therapy endorsed by SAGES. 2015.
will be absorbed upon leakage and excreted into the urine. ASGE Bariatric Endoscopy Task Force. ASGE position statement on
Warn the patient to report this promptly if observed. endoscopic bariatric therapies in clinical practice. 2015.
Ultrasonography at regular intervals can be useful in detect- ASGE/ASMBS Task Force on Endoscopic Bariatric Therapy. A
ing deflation and minimizing complications. pathway to endoscopic bariatric therapies. Surg Obes Relat Dis.
2011;7(6):672–82.
Dumonceau JM. Evidence-based review of the bioenterics intragastric
balloon for weight loss. Obes Surg. 2088;18:1611–7.
Complications Fernandez MAP, Atallah AN, Soares B, Saconato H, Guimaraes SM,
Matos D, Carneiro LR, Richter B. Intragastric balloon for obesity
(review). Cochrane Database Syst Rev. 2007;(1):CD004931. https://
Intragastric balloon complications are associated with the doi.org/10.1002/14651858.CD004931.pub2.
endoscopic method, such as sedation issues or organ perfora- Laing P, Pham T, Taylor LJ, Fang J. Filling the void: a review of intra-
tion, and with the balloon itself. These are further classified gastric balloons for obesity. Dig Dis Sci. 2017;62:1399–408.
Part IV
Small Intestine and Appendix
Andreas M. Kaiser
Concepts in Surgery of the Small
Intestine and Appendix 41
Introduction during complex reconstructive abdominal surgeries to form

an ileal pouch (ileal pouch-anal anastomosis, IPAA; conti-
The small intestine (small bowel) extends from the pylorus nent ileostomy), Roux-en-Y gastric reconstruction or bypass,
to the ileocecal valve. Strictly speaking, the appendix is not or for urinary tract reconstruction/diversion is not covered in
part of the small bowel but for convenience reasons has been this section. These more specific restorative procedures are –
included in this section of the book. The arterial blood to the if appropriate – discussed in those specific chapters.
small bowel supply largely derives from the superior mesen-
teric artery; collateral circulation exists on either end to the
celiac artery and via the marginal artery to the inferior mes- Diagnostics
enteric artery, respectively. The venous blood from the small
bowel collects in the superior mesenteric vein which merges Modern evaluation for abdominal symptoms and diseases
with the splenic vein to the portal vein system. has become a lot more sophisticated in the last few decades.
Appendiceal pathology is frequent, whereas specific dis- In particular, radiographic and endoscopic tools have allowed
eases affecting the small intestine are comparably rare. for a more precise level of information and potentially even
Nonetheless, by virtue of its involvement in other disease a respective targeted nonsurgical intervention. A surgical
origins, operations on the small bowel are disproportionately exploration (diagnostic laparoscopy or laparotomy) solely
common. Complications involving the small bowel can be for diagnostic purposes has become exceedingly rare these
horrendous and quickly turn into a long-term nightmare. A days but may continue to play a role to define the extent of a
solid knowledge about different surgical techniques is there- particular disease (e.g., carcinomatosis) before definitive
fore key to successful outcomes of such operations. This decision-making.
chapter introduces the concepts necessary to safely operate Historically, conventional endoscopy was limited to
on the small bowel and the appendix by discussing the opera- stomach/duodenum on the proximal end, and to the colon/
tions in the context of common pathologic entities. terminal ileum on the distal end, whereas the small bowel in
Procedures commonly performed on the small bowel between was not accessible for a more detailed evaluation.
include lysis of adhesions, small bowel resection and anasto- Advanced endoscopic techniques to visualize the small
mosis, stricturoplasty for treatment of strictures secondary to bowel include double-balloon enteroscopy and capsule
inflammatory bowel disease or radiation, and Meckel diver- endoscopy. Advanced cross-sectional imaging beyond ultra-
ticulectomy. Other operations include creation or takedown sound includes Duplex and three-dimensional
of an ileostomy or a jejunostomy. The use of small bowel (3D)-technology; beyond standard computed tomography
(CT) and magnetic resonance imaging (MRI) scans, CT or
MRI angiography or enterography has evolved, the latter of
which has largely replaced conventional small bowel follow-
N. Saldana Ruiz
through radiographies. Positron emission tomography (PET)
Department of Surgery, Keck School of Medicine of the University
of Southern California, Los Angeles, CA, USA scans have become routine to evaluate for disseminated can-
cer manifestations. And interventional radiology has reached
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of incredible levels of precision and selectivity that it plays an
Hope National Medical Center/Comprehensive Cancer Center, important diagnostic and therapeutic tool in patients with
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_41
314 N. Saldana Ruiz and A. M. Kaiser
gastrointestinal (GI) bleeding, pathology of uncertain nature, • Laparoscopic surgery (LS): straight multiport LS, hand-
or septic complications of illness or intervention. assisted LS (HALS), single incision LS (SILS).
• Robotic surgery.
Nonsurgical Treatments This growth of minimally invasive surgery unquestion-

ably has expanded the surgical options and introduced less
The treatment approach to various specific diseases and con- aggressive options for standard surgeries. However, the
ditions has dramatically changed. So has our surgical atti- simultaneous presence of competing but incompatible sys-
tude to postoperatively managing the small bowel after an tem components has added cost. The best choice of surgical
abdominal exploration. Examples include targeted biological platform depends on a variety of factors that not at last
medications that allow for more specific interference and include the surgeon’s experience, the patient condition, and
hence better suppression of disease activity in inflammatory the expected intra-abdominal findings and anticipated surgi-
bowel disease or disseminated cancer. Proactive protocols of cal steps.
enhanced recovery after surgery (ERAS) have been widely The majority of surgical concepts and techniques on how
adopted, as they have been shown to accelerate the return of to manage the small intestines have not changed (see respec-
bowel function and reduce complications. tive chapters). The interventions typically fall into the fol-
Even for classical surgical diseases such as appendicitis, lowing categories:
nonsurgical management has challenged old dogmas and has
been recognized under select circumstances as a valid option • Lysis of adhesions
that even stands justification to be subjected to respective • Small bowel resection, appendectomy
comparative trials. Complex abdominal infections including • Repair of bowel defects and weaknesses (e.g., enterotomy
postsurgical or disease complications may frequently benefit repair)
from a prudent self-restraint of the surgeon, until the hostile • Reduction of hernias (internal, abdominal wall,
activity and dense adhesions have cooled off to allow for a diaphragmatic)
safer entry to the abdomen. • Avoidance of internal and abdominal wall hernias
Adhesive disease remains a major cause for prolonged • Creation/revision of a stoma, internal bypass
recovery and recurrent hospitalizations. It remains speculative • Restore intestinal continuity including takedown of sto-
but not impossible that the increased use of minimally invasive mas or fistulas
surgical techniques in the long run contributes to a reduced • Improve the passage (e.g., stricturoplasty)
incidence of such episodes. But to the current day, adhesion- • Pouch creation
related small bowel obstructions or prolonged postoperative • Exclusion of small bowel segments for other purposes
ileus remain a daily problem and weighing medical manage- (e.g., for urinary conduit)
ment versus a surgical exploration a routine challenge. • Cytoreductive surgery and hyperthermic intraperitoneal
chemotherapy (HIPEC)
Surgical Tools
Perioperative Management
Abdominal surgeries have witnessed a major revolution over
the last 30 years that has been exciting and challenging alike. As noted for specific colorectal operations, the perioperative
Surgeons constantly need to be able to get out of their com- management has dramatically changed, is more proactive,
fort zone and stay open-minded to change while resisting the and is subject to reaching quality benchmarks. Specific areas
temptation to ride every single new wave. Unquestionably, of attention are surgical site infections, postoperative ileus,
there have been plenty of very useful developments particu- pain management, secondary morbidity (deep vein thrombo-
larly in the context of stapling, energy delivery, perfusion sis (DVT), atelectasis/pneumonia, urinary tract infections),
assessment, imaging and visualization, tissue enforcement fluid management, overall length of stay, and unnecessary
(e.g., hernia treatment/prevention), and most importantly readmissions.
access through a minimally invasive surgery (laparoscopic, Enhanced recovery after surgery (ERAS) protocols include
robotic, or endoluminal). The major surgical platforms to shortened preoperative fasting periods with carbohydrate
play a role for the abdomen are: boost drink, early postoperative mobilization and feeding,
opioid-sparing pain management, peripheral opioid antago-
• Open surgery: single site/single organ, combination of nists, avoidance or shorter periods of drains and catheters.
multiple sites, multivisceral (same location), major en An unfortunate trend with a high risk of worse outcomes
bloc resections. lies in the nationwide obesity epidemic. Even the most
41 Concepts in Surgery of the Small Intestine and Appendix 315
sophisticated techniques may hit physical limits which result level obstructions from advanced tumor manifestations, and
in less perfect dissections, as well as increased surgical and importantly a time frame of 7–42 days after a recent explora-
general morbidity and mortality. tion (hostile abdomen). It is expected that surgery can be
Last but not least, surgery may be necessary in an increas- avoided in up to 85% of patients. A surgical exploration is
ing number of patients with immunosuppression, active can- indicated if there are the above-mentioned signs of severe
cer, or hematological proliferative diseases, biological acuity or if a reasonable period (e.g., 48–96 hours) of non-
treatments, current/recent/past chemotherapy and/or radia- surgical management does not achieve an improvement of all
tion therapy, or possibly m alnutrition/malabsorption/dehy- parameters and/or fails to restore bowel function. The surgi-
dration. Careful consideration of these risk factors, optimized cal strategy and technique are described in Chap. 42. Whether
timing, where possible a preoperative tune-up, and poten- or not to pursue a minimally invasive or an open access
tially an alternative surgical strategy are crucial for opti- depends on the case specifics and the surgeon’s experience.
mized outcomes. Unquestionably, cases that are amenable to a laparoscopic
approach are genuinely less challenging, and a comparison
of laparoscopic versus open approach is likely to fall victim
Diseases to a selection bias.
There are a number of strategies to reduce the formation
Small Bowel Obstruction of adhesions. Where appropriate, that is, not in immediate
proximity to an anastomosis, it may be very reasonable to
Small bowel obstruction is a common clinical entity with a utilize such products. Studies have shown that they generally
broad spectrum of presentations that result from a wide vari- reduce the extent of adhesions; however, that finding may not
ety of causes. The decision whether to medically manage or translate into a lower incidence of subsequent small bowel
to operate can be difficult. The differential diagnosis most obstructions. Experience shows that very often cases of non-
commonly includes intestinal adhesions from previous inter- resolving bowel obstruction have a limited number of very
ventions, malignant or benign tumors (e.g., carcinomatosis), tight adhesive bands that strangulate the bowel, whereas
herniation, or strictures from Crohn disease or radiation. broad adhesions keep the bowels in a constant position and
Situation- and age-dependent, more rare conditions may less frequently result in such severe obstructions.
have to be considered such as small bowel twisting around a More difficult than defining an action plan in the acute
stoma-bearing segment, gallstone ileus, intussusception, setting is to counsel patients with resolving episodes or who
atresia (newborn), and others. experience a series of recurrent episodes of small bowel
The diagnosis is to be suspected based on the patient’s obstruction. Most important is to determine by means of
symptoms and typically corroborated by imaging and blood imaging whether there is an identifiable “transition point.” A
work. Symptoms include abdominal pain that is often col- blind surgical exploration without a target in mind is only
icky in character, abdominal distention, nausea, vomiting, rarely successful. Further aspects to be considered in the
and an alteration or a lack of bowel movements. The physical decision-making process are the nature and prognosis of the
examination has to focus on tympany, presence of peritoneal underlying disease, the details of previous surgeries or other
signs, evidence of scars and hernias, and presence or absence treatments (e.g., radiation), and the role and timing of other
of bowel sounds. Abdominal radiographs provide a broad necessary treatments (e.g., chemotherapy).
impression, but cross-sectional imaging such as a contrast
CT scan is unquestionably more valuable, as it often allows
for identification of the site and cause of the obstruction and Small Bowel Tumors
provides information about the state and viability of the
obstructed bowel. Small bowel tumors are rare and account for less than 3% of
The initial management of fluid resuscitation and decom- all gastrointestinal malignancies. Symptoms are limited and
pressive efforts needs to be paralleled immediately with an unspecific. Such tumors are difficult to diagnose but should
overall assessment with definition of the broader manage- always be in the differential diagnosis in a patient with
ment strategy and benchmarks that define a necessary change unknown cause for a bowel obstruction. Benign tumors
in course. A course of medical management is generally jus- include adenomas, leiomyomas, lipomas, and hemangiomas.
tified, unless there is evidence for an incarcerated hernia, Primary malignant tumors include adenocarcinoma, carci-
peritoneal signs, perforation, closed loop obstruction, or noid, lymphoma, desmoid, and gastrointestinal stromal
compromised bowel viability (e.g., pneumatosis, portal tumors (GISTs). More frequent than primary malignancies
venous gas). Parameters to favor nonsurgical management are peritoneal manifestations of other primary tumor sites
are absence of alarming clinical or imaging signs, a response (carcinomatosis). Intestinal lymphoma can occur in the set-
to decompressive efforts, an overall poor prognosis or multi- ting of celiac disease, chronic immunosuppression, or human
immunodeficiency virus (HIV). Melanoma is the most com- a specimen, as other differential diagnoses including can-
mon tumor to metastasize to the mucosa of the gastrointesti- cer may look very similar.
nal tract. Other common tumors to metastasize to the small • Is more than one bowel segment involved?
bowel include cancer from primary cancers of the lung and –– If no, a resection may be advisable, whereby there is
breast (particularly lobular carcinoma). no benefit for excessive margins.
The poor prognosis associated with malignant small –– If yes, numerous individual or a long-segment resec-
bowel tumors is a result of the delayed diagnosis. Surgical tion should be avoided.
treatments include a segmental resection with or without • Is more than one organ involved? If yes, how are these
lymphadenectomy, rarely an endoscopic resection of a other organs dealt with?
lesion. Symptomatic metastatic cancers affecting the small • What is the patient’s overall condition, nutritional status,
bowel may be treated with a palliative resection, cytoreduc- and immunosuppression status?
tive surgery, an internal bypass, or a proximal diversion; –– Is there space for optimization prior to surgery, for
placement of a percutaneous gastrostomy may be the only example, nutritional support with parenteral
option in advanced terminal disease. nutrition?
–– Should the surgery be coordinated with the administra-
tion schedule of biological medications?
Crohn’s Disease –– Should steroids be tapered before surgery?
• Is the main problem an active infection with uncontrolled
Crohn’s disease is one of the few specific diseases that affect abscess formation and sepsis? If yes, have nonsurgical
the small bowel (as well as any other part of the gastrointes- measures been fully exhausted (antibiotics, percutaneous
tinal tract). The primary management is always medical. drains, etc.). If surgery is inevitable, it may be desirable to
Introduction of biologicals has clearly added value to the avoid a resection but rather create an ostomy proximal to
armamentarium. Factors that determine a need for surgery the affected bowel segments to allow for cooling off; the
include the acuity of the presentation, short-term or long- chance to avoid excessive resection and preserve small
term complications, as well as the response to medical bowel length increase.
management. • Is the main problem fibrostenotic disease?
In contrast to ulcerative colitis, the disease is not curable –– Has the rest of the small bowel and GI tract been
by means of surgery. Yet, at least 70–80% of patients need at evaluated?
least one surgery in their lifetime, mostly for disease compli- –– If there is more than one segment, the probability of
cations. Reoperations are frequent, with at least 70% requir- future recurrent areas increases. Hence, the preference
ing a second and up to 30% requiring multiple procedures. should be to avoid a resection and rather do multiple
Disease complications are fibrostenotic disease with stric- individual stricturoplasties or a long-segment isoperi-
ture formation, suppurative disease with intestinal or peristaltic side-to-side anastomosis.
anal abscess and fistula formation, bleeding, or formation of • Is there healthy distal bowel and anorectum to preserve an
a cancer. Patients may present with high-grade obstruction or option of immediate or future restoration of intestinal
sepsis, but more often the indication for surgery comes under continuity?
(semi-)elective circumstances for failure of medical therapy • Should an anastomosis be performed or a stoma be
to improve these complications. created?
The type and extent of surgery depend on the specifics of • Is there a chance for a minimally invasive approach (lapa-
the individual disease manifestations and locations and on roscopic, robotic)? If yes, that modality would be pre-
whether the patient had prior surgeries, in particular previous ferred to minimize formation of adhesions in these
small bowel resections. A cardinal goal of surgery is to pre- patients who have a high probability of reoperation.
serve small bowel length and absorptive capacity. The surgi- • After surgical induction of remission, what regimen
cal tools include resection, diversion, or stricturoplasties; should be recommended for maintenance of remission?
creation of an internal bypass is not recommended, unless • What diagnostic tools should be employed and at what
there are no other alternatives. frequency to define whether and what type of recurrence
Surgical management for Crohn’s disease should always a patient may develop?
be planned in an interdisciplinary discussion, whereby a
number of questions must be addressed before deciding on a It is important to define the goals of care with the patient.
specific strategy: Primary goal should always be to preserve or restore the
patients’ quality of life and keep them functional and out of
• Has the diagnosis of Crohn’s disease been histologically the hospital. Secondary goals may be related to the develop-
confirmed before? If not, a resection is advised to obtain ment of recurrent disease, whereby the meaning of recur-
rence should be clarified. Clinical recurrence indicates the atic), which may trigger bleeding from the adjacent normal
renewed presence of inflammatory symptoms or changes on small bowel as a result of the ulcerogenic acid-secreting
imaging; endoscopic recurrence relates to mucosal changes mucosa.1
only without clinical signs, and surgical recurrence indicates The diagnosis of a symptomatic Meckel diverticulum
a need for a repeat operation. should be considered in patients with unexplained intestinal
bleeding or with abdominal mostly right lower quadrant
pain, nausea, and vomiting that can mimic acute appendici-
Appendicitis tis, intestinal obstruction, Crohn’s disease, and peptic ulcer
disease. A technetium-99 m pertechnetate scan detects iso-
Appendicitis remains one of the most common clinical enti- tope uptake in heterotopic gastric tissue and is fairly specific
ties in acute care surgery. Appendicitis and Crohn’s disease to confirm the suspected diagnosis. A symptomatic Meckel
are in each other’s differential diagnosis. The workup and diverticulum is best treated by a segmental resection and
diagnosis rely on clinical examination, imaging, and blood anastomosis. More often, though, a Meckel diverticulum is
work. Appendectomy remains the cornerstone of therapy, an incidental finding during abdominal surgery. As the life-
even though medical management for select patients has time risk of complications is very low (2%), it is recom-
moved into the center of research interest. It is important to mended to leave an incidentally found Meckel diverticulum
define circumstances where an immediate operation may not untouched.
be prudent: examples include presence of an abscess or fea- Acquired small bowel diverticula are likely underreported
tures that suggest presence of a tumor (chronic anemia, mass, incidental findings during surgery or on imaging. They are
weight loss, and possibly age). And vice versa, indicators to located along the mesenteric border and are more common in
suggest a need for surgery are diffuse perforation, diffuse the duodenum and proximal small bowel. These diverticula
peritonitis, or presence of an appendicolith. are generally asymptomatic, have a low probability to cause
Appendectomy outside the acute presentation remains a any complications, and hence are best left alone. Reported
matter of debate. Incidental appendectomy is typically not rare complications include inflammation, perforation,
indicated. Interval appendectomy may be beneficial in select obstruction, intussusception, hemorrhage, and bacterial
cases once the acute inflammation has resolved, for example, overgrowth. While small intestinal bacterial overgrowth
after treatment of an abscess or when an appendicolith has (SIBO) has otherwise even outside the context of diverticula
been identified. become a more prominent area of public and scientific inter-
Very important is to recognize that there is a known inci- est, it may at most require treatment with antibiotics but not
dence of unexpected findings during appendectomy or within typically any surgical intervention.
the appendectomy specimen. Incidental tumors (carcinoid,
adenocarcinoma, and others) may or may not be directly
related to the development of the acute presentation. Mesenteric Ischemia
Regardless, the surgeon must take the type and behavior of
specific tumor entities into consideration for appropriate Acute mesenteric ischemia is primarily caused by flow dis-
management. Specifically, it must be determined whether a ruptions in the superior mesenteric artery distribution but can
simple appendectomy is sufficient or whether a formal right on occasion also result from a venous occlusion (portal or
hemicolectomy with respective lymphadenectomy is needed mesenteric vein thrombosis). Common scenarios are emboli,
even if it means to perform a second operation. for example, from a cardiac source (which may affect other
organs), thrombotic occlusions that aggravate existing ath-
erosclerosis, aortic dissection, or a hypoperfusion (low flow
Small Bowel Diverticula state, also referred to as nonocclusive mesenteric ischemia).
The latter may result from low output cardiac failure, from
Small bowel diverticula may be divided into two kinds: excessive pressor requirements, or from abdominal compart-
acquired diverticula (usually duodenal and jejunal) and ment syndrome.
Meckel’s diverticulum. These will be considered separately. Symptoms of ischemia may unfortunately be unspecific,
Meckel diverticulum, a remnant of the embryologic yolk misleading, or be masked by other comorbidities or a state of
sac, is the most common developmental anomaly of the unconsciousness. The prognosis of intestinal ischemia
small bowel, occurring in approximate 2–4% of the popula- depends on the underlying cause and relevant comorbidities,
tion. This diverticulum is a true diverticulum (containing all the extent of ischemic and of remaining perfused bowel, and
bowel wall layers) and arises from on the antimesenteric
bowel edge within the distal 100 cm from the ileocecal valve. 1
Rule of 2 s: Meckel occurs in 2% of the population, 2 feet from ileoce-
There is a high incidence of ectopic mucosa (gastric, pancre- cal valve, 2 inches long, and 2% become symptomatic.
the interval between onset and treatment. Signs of sepsis and egy, which include interventional radiology or capsule
hemodynamic instability from both, other organ failures or endoscopy. “Blind surgery” (i.e., without a defined target)
the ischemia itself, have a particularly poor prognosis. has its role for massive lower GI bleeding with a suspected
Surgical management for acute intestinal ischemia needs large intestinal origin but is not typically advocated if an
to recognize numerous decision points along the way: upper or lower bleeding source have been ruled out.
Occasionally, however, an exploration is combined with a
• Is surgery indicated and does it (in the global perspective guided endoscopy in hope to identify the bleeding source.
for the patient) have a chance to change the outcome?
• If yes, what is the fastest time to get to surgery while
allowing for optimizing the general condition? Trauma
• What is the degree of ischemia upon exploration and is
the length of remaining bowel compatible with survival? Blunt or penetrating trauma can result in a variety of inju-
If not, it might be best to abort the surgery and initiate the ries, including perforation, contusion, mural hematoma,
best palliative care. and mesenteric avulsion. The impact may range from
• What is the perfusion of the remaining bowel? A number inconsequential to life-threatening. Accuracy and limita-
of tools (Doppler, indocyanine green (ICG) fluorescence tions of currently available diagnostic modalities must be
imaging) may support conventional surgical assessment. considered in the decision-making process, which must
• Are there borderline segments? If yes, a second-look also include the trauma mechanism and the extent of asso-
operation should be planned. ciated injuries. Damage control laparotomy (see Chap. 8)
• Should the bowels be anastomosed, left in discontinuity, is an important strategy in the management of such
or be brought out as ostomies or mucus fistulas? patients.
• Should the abdomen be closed or left open?
Chronic mesenteric ischemia results from atherosclerotic Further Reading

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Small Bowel Resection and Anastomosis
42
Indications • Review all available images to define the anatomy; cross-

sectional imaging (computed tomography (CT), CT/MRI
• Ileostomy takedown (magnetic resonance imaging) enterography, capsule
• Trauma (including nonreparable enterotomies during endoscopy, and small bowel follow-through).
lysis of adhesions) • Acute setting: Nasogastric tube placement in selected
• Strangulation (adhesions, hernia) cases (obstruction, perforation).
• Perforation • Antibiotic prophylaxis versus treatment, depending upon
• Ischemic enteritis the clinical scenario.
• Radiation enteropathy (e.g., stricture formation)
• Crohn’s enteritis with complications
• Tumor Pitfalls and Danger Points
• Reconstruction/rerouting after previous or unrelated sur-
gery (ileum conduit, Roux-en-Y, etc.). • Surgery too early after previous surgery (if possible, oper-
ate within the first week or after 4–6 weeks after previous
surgery, avoiding the time in between when inflammation
Contraindications is likely to be at its maximum)
• Anastomotic bleeding
• Incidental pathology without symptoms or risks • Stricturing
• Poor performance status with limited life expectancy • Anastomotic leakage
• Metastatic tumor, specifically known extensive carcino- • Intra-abdominal abscess
matosis, not amenable to cure • Anastomotic leak with the formation of enterocutaneous
• Extensive ischemia with insufficient viable bowel fistula
Small bowel anastomosis in healthy tissue is generally

Preoperative Preparation safe. Risk factors for failure include impaired blood sup-
ply, tension, advanced peritoneal sepsis, poor nutritional
• Review the patient’s history, diagnosis, functional/nutri- status, radiated bowel, immunosuppression, and chemo-
tional aspects, and appropriate indication for surgery therapy. Unfavorable timing of a reintervention after a pre-
(based on clinical and radiographic means). vious surgery dramatically increases the risk of
enterotomies. When a small bowel anastomosis fails
because of technical errors, the leak often occurs at the
N. Saldana Ruiz mesenteric border, where the serosa was not adequately
Department of Surgery, Keck School of Medicine of the University cleared of blood vessels and fat.
A. M. Kaiser (*)
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_42
Operative Strategy 4. Avoid excessive force when tying sutures. Bowels are
delicate structures. Excessive force (visible as tissue
Open Versus Laparoscopic Technique blanching) must be avoided when tying the anastomotic
sutures, as it would result in compromised perfusion. If
Intervention for the sole purpose of a limited small bowel the suture should inadvertently have been placed through
resection is very rare. More often, a small bowel resection is the full thickness of the bowel and into the lumen, the
a necessary step in a bigger project. The appropriate choice strangulated tissue will be cut through and result in a
of approach would typically depend on the needs of the main leak. Tie sutures with no more tension than is needed to
indication and procedure. approximate both intestinal walls.
As with other abdominal procedures, laparoscopic or 5. Avoid applying excessive force to the forceps. When
robotic techniques have been successfully applied to small manipulating the ends of the bowel to be anastomosed,
bowel resection and anastomosis. This chapter details basic there must be no excessive force. If the imprint of forceps
principles essential for success independent of the approach teeth is visible on the serosa after the forceps have been
and stresses safe performance of small bowel anastomoses removed, the surgeon obviously compressed the tissue
(sutured or stapled). with too much force. Pass the curved needle through the
tissue with a rotatory motion to minimize trauma. As dis-
cussed in an earlier chapter, it does not matter whether an
Successful Bowel Anastomosis Requirements intestinal anastomosis is sutured or stapled so long as a
proper technique is employed.
1. Good blood supply. Primarily determine this aspect by 6. Learn the pitfalls. One must learn the pitfalls (technical
visual assessment of the bowel (pink appearance, imme- and conceptual) before constructing stapled intestinal
diate capillary mucosal bleeding) and mesentery. If in anastomoses. Study the strategy of avoiding the compli-
doubt, verify the patient’s blood pressure and check for cations of surgical stapling. Consider the alternatives,
pulsatile flow, after dividing a terminal arterial branch in such as creating an ostomy.
the region where the bowel is to be transected. There 7. Avoid common errors. In learning and mastering the art
should be no hematoma near the anastomosis, as it could of anastomotic suturing, avoid these common errors:
impair circulation. Alternatively, a Doppler probe may be • Catching the backwall: Do not insert the outer layer of
used to investigate flow to the bowel. seromuscular sutures with the collapsed bowel resting
Arterial perfusion can be further verified with the use on a flat surface. An even worse error consists in put-
of visual fluorescence technology by intravenous admin- ting the left index finger underneath the back of the
istration of indocyanine green (ICG) fluorescein dye and anastomosis while inserting the anterior seromuscular
monitoring the bowel wall under ultraviolet sutures. Both errors make it possible to pass the sero-
illumination. muscular suture through the bowel lumen and catch a
2. Accurate apposition of the seromuscular coats. There portion of the posterior wall. When the sutures are
should be no fat or other tissue between the two bowel tied, an obstruction is created. Although some of these
walls being sutured. The seromuscular suture must catch sutures may later tear out of the backwall in response
the submucosa, where most of the tensile strength of the to peristalsis, others remain permanently in place and
intestine is situated. Optimal healing of an anastomosis produce a stenosis. To prevent this complication, sim-
requires serosa-to-serosa approximation. Devote special ply have the assistant grasp the tails of the anastomotic
attention to the mesenteric border of any anastomosis. sutures that have already been tied. Skyward traction
This is the point at which several terminal blood vessels on these sutures keeps the lumen of the anastomosis
and accompanying fat are dissected from the bowel wall open while the surgeon inserts additional sutures.
to provide visibility for an accurate seromuscular suture • Suturing under tension: Another error consists in insert-
placement. Clear fat and blood vessels from a 1-cm-wide ing anastomotic sutures while the bowel is under linear
area of serosa around the circumference of an anastomo- tension. This practice stretches the bowel wall, so it
sis. This allows increased accuracy for suture placement becomes relatively thin, making it difficult to enclose a
without causing ischemia. substantial bite of tissue in the suture. A sufficient
3. Sufficient mobility of the two ends of bowel. A sufficient length of intestine, proximal and distal, should be
length of bowel must be freed proximal and distal to each loosely placed in the operative field. After the first sero-
anastomosis to ensure there is no tension on the healing muscular bite has been taken, the needle is ready to be
suture line. Remember to allow for some degree of fore- reinserted into the wall of the opposite segment of
shortening if postoperative edema and bowel distension intestine. At this time, it is often helpful to use forceps
occur. to elevate the distal bowel at a point 3–4 cm distal to the
42 Small Bowel Resection and Anastomosis 323
anastomosis. Elevation relaxes this segment of the form a systematic four quadrant exploration to confirm the
bowel and permits the suture to catch a substantial bite preoperative assessment and rule out unexpected pathology.
of tissue, including the submucosa. Each bite should Establish exposure to the target pathology.
encompass about 4–5 mm of tissue. These stitches
should be placed about 4–5 mm from each other. ivision of Mesentery and Bowel Resection
D
Expose the segment of intestine to be resected by laying it flat
on a moist gauze pad on the abdominal wall. Score the serosa
Contraindications to Anastomosis of the mesentery in a V-type fashion using scalpel or electro-
cautery, carrying it through the superficial peritoneal layer
Because of the excellent blood supply and substantial sub- only, to expose the underlying blood vessels (Fig. 42.1).
mucosal strength of the small bowel, anastomoses are often Divide the deeper layers in appropriate-size steps, using an
successful even in the presence of such adverse circum- advanced energy device or by applying medium-size hemo-
stances as intestinal obstruction or gross contamination of stats in pairs to the intervening tissue. In the latter case, divide
the abdominal cavity. Consequently, the only major contrain- the tissue between hemostats and ligate each with 2-0 PG.
dications to a primary small bowel anastomosis are perito- After the wedge of mesentery has been completely freed,
neal sepsis, a questionable blood supply, or a patient whose you may either first resect the bowel and then focus on per-
condition on the operating table is precarious. In these chal- forming the anastomosis, or you combine the resection with
lenging cases, options include to bring both ends of the a stapled anastomosis in a shortened version. One option to
divided small bowel to the skin as temporary enterostomies, minimize the spillage of intestinal contents is to divide the
or to simply staple them closed to be left in discontinuity bowel proximally and distally with a linear stapler.
until a planned second look within 24–48 hours. Alternatively, place Allen clamps to the bowel on the speci-
men sides and apply noncrushing intestinal clamps with a
single click proximally and distally, before removing the dis-
Documentation Basics eased segment of intestine by scalpel division or
electrocautery.
Coding for surgical procedures is complex. Consult the most
recent edition of the AMA’s Current Procedural Terminology
book for details (see references at the end). In general, it is Open Two-Layer Anastomosis
important to document the following:
Considerable manipulative trauma to the bowel wall can be
• Findings avoided, if the posterior layer of seromuscular sutures is the
• Extent of resection first layer to be inserted by successive bisection (see Chap. 4).
• Location of resection (proximal versus distal, ileum ver-
sus jejunum)
• Length of remaining bowel
• Quality of the bowel
Operative Technique
Small Bowel Anastomosis by Suturing
Access and Incision

The choice and extent of access and exposure incision is
defined by the main purpose and needs of the operative pro-
cedure. The extent, complexity, and nature of the visible
pathology as well as the patient’s past history are key ele-
ments to decide whether you can carry out the surgery through
a minimally invasive approach (robotic, laparoscopic) or
whether a formal laparotomy would be more appropriate.
Create access to the peritoneal cavity according to stan-
dard procedures of your chosen platform (laparotomy versus
first trocar placement). Develop the working space and per- Fig. 42.1
This can be done by placing two holding stitches on either end third Lembert suture at this point. Follow this sequence, until
or by temporarily flipping the backside up. First, use 3-0 Vicryl the anterior seromuscular layer has been completed
on an atraumatic needle and insert a seromuscular suture on (Fig. 42.3a). Retain the two end sutures as holding stitches, but
the antimesenteric border followed by a second suture on the cut the tails of all the remaining sutures. Pass holding suture A
mesenteric border (Fig. 42.2). Tie both sutures. Next, bisect behind the anastomosis and flip the bowel (Fig. 42.3b), such
the distance between these two sutures, and insert and tie the that the inner layer of the posterior wall is in view (Fig. 42.3c).
Close the mucosal layer of the posterior wall with a run-
ning 3-0 double-armed polydioxanone (PDS) suture. Insert
the two needles at the midpoint of the deep layer (Fig. 42.4a).
Tie the suture and close the posterior layer, which should
include the mucosa and a bit of seromuscular tissue, with a
continuous locked suture (Fig. 42.4b–d).
Once the running sutures have reached the edges on both
sides, you have to transition them to the frontwall of the
bowel. Turning in the corners with this technique is simple.
Bring the needle from inside out through the outer wall of the
Fig. 42.2 intestine (Fig. 42.5a). Then, complete the final mucosal layer
a b
Fig. 42.3
a b
c d
Fig. 42.4
a b
Fig. 42.5
ning PDS suture that is tied on the outside of the bowel. Once
the ends near the holding stitches are reached, flip the bowel
to expose the opposite, unsutured bowel (Fig. 42.3b–c).
Approximate this too by using the same technique as for the
backwall. Pay special attention to the mesenteric border,
where fat and blood vessels may hide the seromuscular tis-
sue from view if the dissection has not been thorough.
After the anastomosis is completed, check it closely for
defects. Test the size of the lumen by invaginating the wall
with a fingertip.
Alternatively, instead of Lembert sutures, “seromucosal”
stitches may be inserted. This suture enters the seromuscular
Fig. 42.6 layer and, like the Lembert sutures, penetrates the submu-
cosa; but instead of emerging from the serosa, the needle
emerges just beyond the junction of the cut edge of the serosa
and underlying mucosa. This stitch has the advantage of
inverting a smaller cuff of tissue than does the Lembert or
Cushing technique and may therefore be useful when the
small bowel lumen is exceedingly small. When inserted
properly, the seromucosal suture inverts the mucosa but not
to the extent seen with the Lembert stitch.
Closure of Mesentery
Close the defect in the mesentery by a continuous suture of

3-0 PG on an atraumatic needle. Take care not to pierce the
blood vessels. The mesentery should be completely approxi-
Fig. 42.7 mated to avoid any future concern of internal herniation.
using the Connell technique or a continuous Cushing suture mall Bowel Anastomosis Using Stapling
S
(Fig. 42.5b). After this mucosal layer has been completed, Technique
insert the final seromuscular layer of interrupted 3-0 Vicryl
Lembert sutures (Fig. 42.6). The technique of successive In our experience, the most efficient method for stapling the
bisection is not necessary in the final layer because the two small bowel is a two-step functional end-to-end technique. It
segments of bowel are already in accurate apposition. requires the two segments of the small bowel to be posi-
After all the suture tails have been cut, carefully inspect tioned, so that their antimesenteric borders are in apposition.
for imperfections in the suture line, especially at the mesen- Unless the bowel ends are open, create a small enterotomy at
teric margin. Test the patency of the lumen by invaginating the antimesenteric edge and insert a cutting linear stapling
one wall of the intestine through the anastomosis with the tip device, one jaw in the proximal and the other jaw in the distal
of the index finger. segment of the intestine (Fig. 42.8). Fire the stapling instru-
ment, which forms one layer of the anastomosis in an invert-
ing fashion (Fig. 42.9). Remove the stapler and apply Allis
Open One-Layer Anastomosis clamps to two lips of the enterotomy. Close the remaining
defect in the anastomosis by firing a new stapler cartridge in
The first step in constructing an end-to-end anastomosis in transverse direction (Fig. 42.10).
one layer is identical to the steps in Figs. 42.2 and 42.3a. Carefully inspect the staple line to be sure that there are
Insert two interrupted seromuscular holding stitches using no gaps. Bleeding may be controlled by conservative electro-
3-0 Vicryl on either end of the backwall. Close the entire cautery or by using interrupted 3-0 atraumatic PG sutures.
backwall in one layer with a larger bite in the serosa and Consider oversewing the staple lines with 3-0 Vicryl sutures.
capture a small ledge of the mucosa (Fig. 42.7). This can be Close the defect in the mesentery with a continuous 3-0
carried out using either interrupted Vicryl sutures or a run- atraumatic PG suture. If feasible, cover the anastomosis with
Fig. 42.10
• Intravenous fluids: Maintain adequate fluid until return of

bowel function.
• Nasogastric tube: No routine use in elective cases; keep it
Fig. 42.8
in nonelective cases until evidence of return of bowel
function.
• Enhanced recovery after surgery (ERAS) protocol: in
elective cases, initiate oral intake on the day of surgery
and advance to solid food as patient demonstrates return
of bowel function.
• Nutritional support: If a substantial portion of ileum has
been removed or shortcut, plan for monthly intramuscular
injections of Vitamin B12. If return of bowel function is
delayed by more than 5 days, initiate parenteral
nutrition.
Complications
Fig. 42.9 • Anastomotic leak/dehiscence
• Intra-abdominal abscess
a layer of omentum, whenever possible, to prevent • Enterocutaneous fistula formation
adhesions. • Wound infection
• Ileus/bowel obstruction
• Anastomotic bleeding
Postoperative Care • Short bowel syndrome
• Malnutrition/malabsorption (including vitamin B12 if ter-
• Antibiotics: Routine coverage for the perioperative minal ileum is resected)
24-hour period. In case of an underlying infection/sepsis,
continue respective therapeutic antibiotics for that
indication.
Further Reading Qureshi U, Hanif M, et al. Role of nasogastric intubation after small
bowel anastomosis. J Coll Physicians Surg Pak. 2009;19(6):354–8.
Sudan D, Thompson JS, Botha J, et al. Comparison of intestinal length-
American Medical Association. Current procedural terminology:
ening procedures for patients with short bowel syndrome. Ann Surg.
CPT ®. Professional ed. Chicago: American Medical Association;
2007;246:593–601.
2022.https://www.ama-assn.org/practice-management/cpt.
Thompson JS, Rochling FA, Weseman RA, et al. Current management
Cai J. Intestine and multivisceral tranplantation in the United States: a
of short bowel syndrome. Curr Probl Surg. 2012;49:52–115.
report of 20-year national registry data (1990-2009). Clin Transpl.
2009:83.
Marks VA, Farra J, et al. A bidirectional stapling technique for
laparoscopic small bowel anastomosis. Surg Obes Relat Dis.
2013;9(5):736–42.
Enterolysis for Intestinal Obstruction
43
Indications • Review all available images to define the anatomy and the
suspected transition point; cross-sectional imaging (com-
Enterolysis is indicated for acute cases of complete small puted tomography (CT), CT/MRI (magnetic resonance
bowel obstruction as well as for chronic, recurrent, or inter- imaging) enterography, capsule endoscopy, and small
mittent small bowel obstructions with an identified transition bowel follow-through).
point (adhesive band, kinking, internal hernia). Beyond these • Acute setting: Nasogastric tube placement before induc-
targeted interventions, it is frequently performed as an inci- tion of anesthesia (reduce the risk of aspiration).
dental procedure to develop the working space and clarify • Antibiotic prophylaxis versus treatment.
the anatomy when the previously operated abdomen must be
reentered for the purpose of another surgical procedure.
Contraindications • Surgery to early after previous surgery (if possible avoid

between 1 week and 4–6 weeks after previous surgery)
• Spontaneously resolving bowel obstruction without iden- • Small bowel laceration (serosal tear, enterotomy, or bowel
tifiable persistent transition point disintegration) with immediate or delayed spillage of
• Dysmotility rather than morphological obstruction (ileus, intestinal contents
Ogilvie, etc.) • Thermal or electrocautery injury to small bowel with
• Obstruction related to known extensive carcinomatosis, delayed leak
not amenable to cure • Failure to identify and relieve sequential points of obstruc-
• Reexploration between 1 week and 4–6 weeks after previ- tion, particularly when they are located distal to a transi-
ous surgery unless for life-saving necessity tion point and have hence not become symptomatic
• Review the patient’s surgical history, diagnosis, func- Open Versus Laparoscopic Technique
tional/nutritional aspects, and appropriate indication for
surgery (based on clinical and radiographic means). The appropriate choice of the approach (open or laparo-
scopic) depends on the circumstances, the level of abdominal
distention, and the known or suspected degree of intraab-
N. Saldana Ruiz
dominal adhesions. Under semi-elective or elective circum-
Department of Surgery, Keck School of Medicine of the University stances for recurrent obstructions with currently
of Southern California, Los Angeles, CA, USA asymptomatic transition point, the abdomen may very well
A. M. Kaiser (*) be amenable to a laparoscopic approach. If the lysis of adhe-
Department of Surgery, Division of Colorectal Surgery, City of sions is not the goal but a necessary part of a major proce-
Hope National Medical Center/Comprehensive Cancer Center, dure, the decision about the approach depends on the needs
Duarte, CA, USA
of the main operation.

https://doi.org/10.1007/978-3-030-81415-1_43
Timing of Intervention is often cumbersome and less effective but avoids an inten-
tional enterotomy.
Defining the best time for an intervention is an art that needs
to avoid excessive aggressiveness and untimeliness on one
hand and fearful hesitance on the other hand. Unnecessary Adhesion Prevention
surgeries, complications from surgeries, or complications
from delayed interventions are equally undesirable out- The perfect solution to preventing adhesion is far from being
comes. Adhesions start forming immediately after surgery, known. In general, you should make every effort to minimize
but for the first week are generally filmy and can be easily the surgical trauma (including laparoscopic rather than open
separated. In the “no-man’s” period starting about 1 week where feasible) and to avoid bowel having any contact with
and lasting to 4–6 weeks after a previous intervention, adhe- a synthetic implant such as mesh. It is sometimes even desir-
sions become denser, more fibrous, and more vascular. able to cover staple lines with some natural tissue (omentum,
Re-laparotomy should be strongly discouraged during this fat pads). Last but not least, there are commercially available
period unless there is a life-threatening necessity such as a anti-adhesion products which may be used to cover raw sur-
massive hemorrhage, ischemia, or feculent peritonitis from faces and have been shown to reduce adhesions; however, it
an anastomotic leak or a free perforation. may not be safe to place them directly onto an anastomosis.
Dissection Documentation Basics
The dissection needs to be careful, patient, and systematic to Coding for surgical procedures is complex. Consult the most
avoid collateral damage, spillage of intestinal contents, and recent edition of the AMA’s Current Procedural Terminology
contamination of the surgical field. Bacterial overgrowth book for details (see references at the end). In general, it is
occurs rapidly when the bowel contents stagnate. Massive important to document:
distension with thinning of the bowel wall makes a rupture
much more likely to occur and more serious if it happens. • Findings
Enter the abdomen through a scar-free area and carefully • Extent of adhesions
dissect the bowel from the underside of the abdominal wall. • Blunt or sharp lysis of adhesions
Adhesions are often increasingly dense in the regions of old • Presence and location of obstruction
scars, in areas of implants such as synthetic meshes, or in • Small bowel decompression
areas involved in infection or cancer. • Quality of the bowel
Separate loops of bowel and steadily work from regions
of easy dissection toward those where it is difficult. The
additional exposure gained by doing the easy dissection first Operative Technique
facilitates work in the more difficult parts. Increase the size
of the incision as needed to optimize exposure. Work on the Access, Incision, and Bowel Mobilization
collapsed region (distal to the obstruction) first, if possible,
and keep the dilated proximal bowel in the abdomen as long Establish safe access preferably in an area at a distance of
as possible. 3–5 cm from previous incisions to enter the abdomen through
virgin territory. In the case of laparoscopy, it is in these situ-
ations without exception advisable to use a cut-down Hasson
Bowel Decompression technique to place the first trocar. For an open approach, a
midline incision is prudent, as it can be easily extended to
Severely distended bowels increase the risk of complications full length if necessary. If the old scar extends from xiphoid
and challenged closure of the incision. There is a risk of to pubis, enter through the cephalad part of the incision,
compartment syndrome and of a negative impact on respira- where it is likely that only the stomach or the left lobe of the
tory function. Depending on the situation and particularly if liver (rather than distended loops of bowel) will be
a bowel resection is needed anyway, it is sometimes easiest encountered.
to decompress the stretched-out bowels by creating an enter- If you used laparoscopy to start the case, you first need
otomy through the area to be resected and passing a chest to develop space to place additional working ports under
tube or a Poole-tip sucker proximally and distally before visual control. If the adhesions are filmy, you may use some
manipulating them. Decompression via the nasogastric tube wiping movement with the camera to increase the working
43 Enterolysis for Intestinal Obstruction 331
space and allow for the next trocar placement. The exact Approach to Dense Adhesions
number and location of additional ports is of much less rel-
evance than doing the dissection under direct view, con- If a substantial part or the entire abdomen shows dense adhe-
trolled and with adequate progress. Convert to a laparotomy sions during laparoscopic exploration, always proceed to an
if (1) the adhesions are too dense and broad, (2) the dis- open dissection. Minimize enterotomies as much as possible.
tended bowel loops prevent a safe handling, or (3) if you do Whereas the content of the normal small intestine is sterile,
not make adequate progress or even have a setback like an intestinal obstruction with stagnation of bowel content
enterotomy. results in overgrowth of virulent bacteria with production of
For a primary or conversion laparotomy, carry the skin toxins. When these substances spill into the peritoneal cav-
incision through the old scar and down to the linea ity, the likelihood of postoperative morbidity and mortality
alba. Use the scalpel and not the electrocautery to cut increases significantly. To avoid this mishap, dissection
through the fascia level. Small bowel loops may adhere should be done carefully and patiently. A guiding principle is
directly to the fascia and could suffer cautery injury. After to perform the easy dissection first. Avoid tackling a dense
opening the first portion of the incision, identify the peri- adherent mass directly; the more the loops of intestines going
toneal cavity and then carefully incise the remainder of to and coming from the adherent mass have been dissected
the scar. If entry into the peritoneum is difficult, lift up on out, the easier it becomes to untangle a sometimes confusing
the skin and subcutaneous tissues on both sides of the conglomerate of “caked” intestines.
incision to create locally negative intra-abdominal pres- The basic dissection strategy remains the same as before.
sure, and gently continue to incise with a scalpel. As soon If possible, enter the abdominal cavity through a scar-free
as the peritoneum is entered, air flows into the peritoneal area. Even though an old midline scar is frequently used to
cavity and creates a safe zone for continued dissection. At reenter an abdomen to relieve an obstruction, it is advanta-
the same time, dissect away any adherent segments of geous to make some part of the incision through an area of
underlying intestines (Fig. 43.1). the abdomen above or below the old scar. Access to the peri-
toneal cavity through an unscarred area often gives the sur-
geon an opportunity to assess the location of adhesions in the
vicinity of the anticipated incision. If an area of free abdomi-
nal cavity can be found, use that as a starting point to extend
the incision and expand the working space. Free any adher-
ent segments of intestines, until the remainder of the incision
can be carefully completed.
Attach Kocher clamps to the fascia on one side of the inci-
sion and have the assistant lift up on the clamps. In contrast
to filmy adhesions, blunt wiping with the finger or a sponge
on a stick is often risky for dense adhesions and may result in
enterotomies. Sharp dissection is preferable because it is bet-
ter controlled. Metzenbaum scissors or the scalpel are the
preferred tools to incise the adhesions under direct vision,
always making sure not to injure bowels on either side of the
adhesion (Fig. 43.1). If the left index finger can be passed
underneath or behind a loop of bowel adherent to the abdom-
inal wall, gentle traction helps guide the dissection. The aim
is to free all the intestine from the anterior and lateral parietal
peritoneum of the abdominal wall, first on one side of the
incision and then on the other (Fig. 43.2).
Once the intestines have been separated from the abdomi-
nal wall, free the individual bowel loops. Trace a normal-
looking segment to the nearest adhesion. If possible, insert
an index finger into the leaves of the mesentery, separating
the two adherent limbs of the intestine. In general, the strat-
egy is to insinuate either the left index finger or closed blunt-
tipped curved Metzenbaum scissors underneath an adhesion
to delineate the plane and then withdraw the closed scissors
Fig. 43.1 and cut the fibrous layer. By gently bringing the index finger
In the case of an acute small bowel obstruction, fre-

quently there are only one or two adhesions and a markedly
distended proximal bowel. When this occurs, be careful not
to permit the distended bowel to leap out of a small portion
of the incision, as it may be torn in the process. If possible,
first deliver the collapsed bowel (distal to the point of
obstruction) and trace it retrograde up to the point of
obstruction. The adhesion can then be divided under direct
vision and the entire bowel freed. Free the remainder of the
bowel of adhesions, from the ligament of Treitz to the ileo-
cecal valve. In some cases, there are adhesions of a cartilagi-
nous nature, especially in patients whose obstruction is due
to multiple malignant implants. Bold scalpel incisions
should be made to divide adhesions of this type. Again, by
doing the easy dissection first, the difficult parts become
easier.
Early Re-laparotomy
In early re-laparotomies, the adhesions have not yet formed

any strength. The loops of bowel can be separated by blunt
gentle force, for example, by inserting the index finger
between the leaves of adjoining mesentery and stretching the
adhesions between the bowel segments, or by pinching them
gently between thumb and index finger.
Fig. 43.2
Re-laparotomy operations done after the first postopera-
tive week tend to be enormously challenging and risky, as the
bowels may appear glued together and are increasingly rigid
and rubbery. The dissection often requires sharp dissection
to enter the abdomen and divide adhesions. The extent of
dissection needs to be limited onto the immediate necessity.
Operative Intestinal Decompression
Severely distended and thinned out bowels are a constant

risk to rupture during manipulation and they may prevent a
safe closure of the laparotomy. For many reasons, it is often
advantageous to perform a controlled decompression and
improve the patient’s postoperative course. Decompression
through a nasogastric or a Baker intestinal tube is usually
slow and not very effective, but avoids an enterotomy.
Oftentimes, it is faster and more effective to use a large
diameter chest tube that is inserted into the most distal bowel
through an enterotomy. If possible, choose the site even dis-
tal to the obstruction where the bowel wall is normal. If a
resection is needed, select the site such that the enterotomy
Fig. 43.3
will eventually be resected.
Place a monofilament pursestring suture around the des-
up between the leaves of the mesentery, the adherent layer ignated enterotomy site. Place a noncrushing bowel clamp
can often be stretched into a fine, filmy membrane, which is proximally and distally. A chest tube of at least 30F diameter,
then easily divided with scissors (Fig. 43.3). connected to the suction, works very well. Insert it into the
43 Enterolysis for Intestinal Obstruction 333
enterotomy and always leave part of the last whole uncov- or substantial field contamination, continue respective
ered to avoid suctioning in the bowel wall. Gently massage antibiotics in therapeutic indication.
the stool toward the tube. Once decompressed, remove the • Intravenous fluids: Maintain adequate fluid until return of
dirty tube without contaminating the field and tie the purse- bowel function.
string suture. Depending on the circumstances, either for- • Nutritional support: If there is evidence for malnutrition
mally repair the enterotomy, perform a resection with or delayed return of bowel function (more than 5 days),
anastomosis, or create an ostomy. initiate parenteral nutrition.
Repair of Damage to Bowel Wall Complications
Small areas of intestine from which the serosa has been • Anastomotic leak/dehiscence
avulsed by the dissection require no sutures for repair if the • Intra-abdominal abscess
submucosa has remained intact. This is evident in areas • Enterocutaneous fistula formation
where some muscle fiber remnants remain. Otherwise, when • Wound infection
only thin mucosa bulges out and the mucosa is so transparent • Ileus/bowel obstruction
that bubbles of fluid can be seen through it, the damage is • Anastomotic bleeding
extensive enough to require inversion of the area with either • Short bowel syndrome
interrupted or continuous seromuscular 4-0 PG Lembert • Malnutrition/malabsorption (including vitamin B12 if ter-
sutures. Make it a habit to address such areas immediately or minal ileum is resected)
mark them, as they may otherwise escape later recognition.
Large areas of damage should be repaired transversely by
one or two layers of Lembert sutures in a transverse manner.
Extensive damage requires bowel resection with anastomo- Further Reading
sis by sutures or stapling.
If a segment of bowel is of questionable viability, return it Aloia TA, Cooper A, et al. Reoperative surgery: a critical risk factor
for complications inadequately captured by operative reporting and
to the abdomen and cover the incision with warm, moist coding of lysis of adhesions. J Am Coll Surg. 2014;219(1):143–50.
packs. Communicate with the anesthesiologist about current American Medical Association. Current procedural terminology: CPT
blood pressure and oxygenation. Reevaluate the bowels ®. Professional ed. Chicago: American Medical Association; 2022.
10–15 min later: often, the bowel regains some color, tone, https://www.ama-assn.org/practice-management/cpt.
Behman R, Nathens AB, et al. Laparoscopic surgery for adhesive
and peristalsis, indicative of recovering perfusion. small bowel obstruction is associated with a higher risk of bowel
injury: a population-based analysis of 8584 patients. Ann Surg.
2017;266(3):489–98.
Closure Cosse C, Regimbeau JM. The use of water-soluble contrast medium
(Gastrografin) in uncomplicated acute adhesive small bowel
obstruction remains a hot topic. Surgery. 2017;162(1):200–1.
After decompressing the bowel, return it to the abdominal Hackenberg T, Mentula P, et al. Laparoscopic versus open surgery for
cavity. If there has been any spillage, thoroughly irrigate the acute adhesive small-bowel obstruction: a propensity score-matched
abdominal cavity with large volumes of warm saline solu- analysis. Scand J Surg. 2017;106(1):28–33.
Pei KY, Asuzu D, et al. Will laparoscopic lysis of adhesions become
tion. Close the abdominal wall in the usual fashion (see the standard of care? Evaluating trends and outcomes in laparo-
Chap. 3). At times when closure of the abdomen cannot be scopic management of small-bowel obstruction using the American
safely completed, you may employ temporary closure College of Surgeons National Surgical Quality Improvement Project
devices and techniques, with the aim of returning to the oper- Database. Surg Endosc. 2017;31(5):2180–6.
Stuparich MA, Ecker AM, et al. Lysis of anterior abdominal wall
ating room for a subsequent second look and future attempts adhesions: a systematic approach. J Minim Invasive Gynecol.
at abdominal closure. 2015;22(6S):S3.
Suwa K, Ushigome T, et al. Risk factors for early postoperative small
bowel obstruction after anterior resection for rectal cancer. World J
Surg 2018;42:233–38.
Postoperative Care Wancata LM, Abdelsattar ZM, et al. Outcomes after surgery for
benign and malignant small bowel obstruction. J Gastrointest Surg.
• Nasogastric tube: Maintain until the evidence of return of 2017;21(2):363–71.
bowel function. Yang PF, Rabinowitz DP, et al. Comparative validation of abdominal
CT models that predict need for surgery in adhesion-related small-
• Antibiotics: Routine coverage for the perioperative bowel obstruction. World J Surg. 2017;41(4):940–7.
24-hour period. In case of an underlying infection/sepsis
Baker Tube Stitchless Plication: Surgical
Legacy Technique 44
Indications the tube via the nasogastric route, as the tube must remain in
place for at least 10 days. A nasogastric tube may be required
• Operations for intestinal obstruction due to extensive to decompress the stomach postoperatively.
adhesions, when the patient has already undergone
numerous similar operations
• Extensive serosal damage following division of many Operative Technique
adhesions
Enterolysis of the entire small bowel should be performed as
the first step of this operation. Create a Stamm gastrostomy
Preoperative Preparation (see Chap. 36). The Baker tube is an 18F 270-cm-long intes-
tinal tube with a balloon at the end and a dual lumen. The
• See Chaps. 42 and 43. primary lumen may be placed for suctioning the bowel to
• Nasogastric suction should be initiated before the decompress it during tube passage and during the early post-
operation. operative period. The second lumen controls inflation and
deflation of the balloon.
Pass the sterile Baker tube into the gastrostomy and then
Pitfalls and Danger Points through the pylorus; partially inflate the balloon. By milking
the balloon along the intestinal tract, the tube may be drawn
• Trauma to the bowel while passing the Baker tube through the entire length of the intestine. Supply intermittent
• Reverse intussusception when the tube is removed suction to the tube to evacuate gas and intestinal contents.
Pass the balloon through the ileocecal valve and inflate it to
5 ml.
Operative Strategy Distribute the length of the intestine evenly over the
length of the tube. Then, arrange the intestine in the shape of
Adhesions tend to form again after enterolysis. Plication multiple gentle S-curves as shown in Fig. 44.1. Irrigate the
attempts to prevent multiple recurrent adhesions by holding peritoneal cavity and close the abdomen in the usual fashion.
the bowel in a prearranged orderly fashion (Fig. 44.1) during If there has been any spillage of bowel contents during the
the period of adhesion formation. In this manner, any adhe- dissection, if gangrenous bowel has been resected, or if an
sions that develop presumably form between loops of intes- enterotomy has been performed for intestinal decompres-
tine that are held in gentle curves, minimizing the chances of sion, do not close the skin incision, as the incidence of wound
recurrent adhesive obstruction. infection is extremely high.
The Baker tube may be passed through a Stamm gastros- When local factors contraindicate a gastrostomy, a poten-
tomy (preferred), a jejunostomy, or under rare circumstances tial “bailout” maneuver is to pass the Baker tube through a
retrograde through a cecostomy. It is not advisable to pass stab wound near McBurney’s point and construct a cecos-
tomy by the Stamm technique. Insert a purse-string suture
C. E. H. Scott-Conner (*) using 3-0 PG in a portion of the cecum near the stab wound.
Department of Surgery, University of Iowa Carver College Make a puncture wound in the center of the purse-string
of Medicine, Iowa City, IA, USA suture, insert the Baker tube, and hold the purse-string suture

https://doi.org/10.1007/978-3-030-81415-1_44
abdominal wall with one 3-0 PG suture in each quadrant sur-

rounding the abdominal stab wound.
Postoperative Care
Connect the Baker tube to low wall suction. Deflate the bal-
loon at the end of the Baker tube on the second postoperative
day. We cut off the port after balloon deflation to ensure that
the balloon is not inadvertently reinflated. The tube itself
must stay in place for 14–21 days if a stitchless plication is
to be achieved. An additional nasogastric tube may be
required for several days. Prolonged ileus due to preopera-
tive obstruction or the manipulation of bowel required to
pass the tube is common.
When bowel function returns, remove the Baker tube
from the suction and allow the patient to eat. Simply clamp
the tube and leave it in place as a stent. When it is time to
remove the Baker tube, do so gradually, with the balloon
deflated to avoid creating (reverse) intussusception.
Antibiotics are given postoperatively to patients who have
had an intraoperative spill of intestinal contents.
Postoperative Complications
Fig. 44.1
• Wound infection
taut. To pass the Baker tube through the ileocecal valve,
make a 3- to 4-mm puncture wound in the distal ileum. Then,
insert a Kelly hemostat into the wound and pass the hemostat
into the cecum. Grasp the Baker tube with the hemostat and Further Reading
draw the tube into the ileum. Close the puncture wound with
sutures. Baker JW. Stitchless plication for recurring obstruction of the small
bowel. Am J Surg. 1968;116:316.
Inflate the balloon of the Baker tube and milk the balloon Childs WA, Phillips RB. Experience with intestinal plication and a pro-
in a cephalad direction until the tip of the Baker tube has posed modification. Ann Surg. 1960;152:258.
reached a location proximal to the point of obstruction and to Kuehn F, Weinrich M, Ehrmann S, Kloker K, Pergolini I, Klar
any area of bowel that has suffered serosal damage. Suction E. Defining the need for surgery in small-bowel obstruction. J
Gastrointest Surg. 2017;21:1136–41.
all the bowel contents through the Baker tube and deflate the Noble TB. Plication of small intestine as prophylaxis against adhesions.
balloon. Am J Surg. 1937;35:41.
Insert a second 3-0 PG purse-string suture, inverting the
first purse-string suture. Then, suture the cecostomy to the
Appendectomy (Open, Laparoscopic)
45
Indications quadrant symptoms are atypical, develop in middle-aged or

older patient, or if they are associated with anemia or a mass
• Acute appendicitis on imaging.
• Incidental appendectomy: if appearance or location is
found to be abnormal during a surgery for another indica-
tion (if that does not include the placement of a foreign Preoperative Preparation
body, for example, mesh)
• Diagnostic studies:
–– Acute presentation: clinical exam, ultrasonography, or
Possible Indications computed tomography (CT), blood work
–– Chronic/elective: imaging, possible colonoscopy
• Acute right lower quadrant pain necessitating a laparo- (depending on age and circumstances), blood work
scopic or open exploration and absence of another patho- • Intravenous fluids
logical finding • Perioperative antibiotics (prophylactic versus therapeutic,
• Interval appendectomy following conservative treatment depending on indication and level of infection)
of appendiceal abscess or phlegmonous appendicitis, or if • Indwelling bladder catheter (to be removed within
an appendicolith is identified 24 hours)
• Appendiceal neoplasm (mucocele of appendix, carcinoid, • Nasogastric tube only if ileus is present
or adenocarcinoma not involving the base) as preliminary
diagnostic versus potentially definitive treatment
• Right lower quadrant pain of unknown etiology (rare in Pitfalls and Danger Points
the era of modern imaging)
• Inadvertent laceration or avulsion of inflamed cecum dur-
ing blunt dissection
Contraindications • Inadequate control of blood vessels in edematous
meso-appendix
An appendectomy alone should not be performed in a known • Injury to other structures from trocars or instruments
or suspected cancer of the appendix or cecum, as appropriate • Incomplete appendectomy, resulting in a retained stump
surgical management of these consists of a right hemicolec- • Failure to recognize appendiceal or cecal neoplasm
tomy including respective lymphadenectomy (see Chap. 56).
Have a high index of suspicion for malignancy if right lower
Operative Strategy
M. Zelhart
Department of Surgery, Tulane University, New Orleans, LA, USA Laparoscopic appendectomy has gained wide popularity
over the past three decades. Apart from the smaller incisions,
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of the approach is not dependent on knowing the exact location
Hope National Medical Center/Comprehensive Cancer Center, of the appendix; furthermore, it allows for a thorough visual
Duarte, CA, USA inspection of the abdominal cavity and hence is especially

https://doi.org/10.1007/978-3-030-81415-1_45
338 M. Zelhart and A. M. Kaiser
useful in cases in which the diagnosis is questionable. Other During open appendectomy, it is best to divide the mesen-
causes of lower abdominal pain, such as an inflamed tery before amputating the appendix. For laparoscopic
Meckel’s diverticulum or torsion of an ovarian cyst, may also appendectomy, conversely, it may often be easier if the base
be treated laparoscopically. However, be cautious and con- of the appendix is developed and divided, followed by the
sider an open approach if encountering a mucocele, as a rup- mesentery.
ture would result in spillage and seeding into the peritoneal It is always possible to encounter unexpected findings:
cavity. normal appendix, Crohn disease, ovarian pathology, Meckel
While open appendectomy is considered by some to be a diverticulum, mesenteric lymphadenitis, diverticulitis, and
“legacy surgery,” it remains a solid and noninferior approach neoplasms. It depends on the details of the circumstances
that can be very useful in patients with abdominal hernias, regarding what to do in these situations. However, if the indi-
dense adhesions, or other contraindications to laparoscopic cation for the surgery was based on clinical symptoms, a
surgery. general guideline is to remove the appendix if it is abnormal
In a traditional open appendectomy, an incision is made at or if no other pathology is found, but to leave it if there is
McBurney’s point over the presumed location of the a ppendix another new explanation for the presentation. If a more
base, whereby the individual layers of the abdominal wall extensive surgery is needed (e.g., right hemicolectomy), it is
are opened in the respective direction of their fibers a matter of the findings, surgical judgment, and the preopera-
(Fig. 45.1). The location of the cecum and the appendix can tive discussion and consenting whether immediate proceed-
vary considerably, so imaging modalities should be reviewed ing or backing out are in the patient’s (and the surgeon’s)
to plan and best-guess an open incision. In less than clear best interest.
presentations with diffuse peritonitis, a midline laparotomy Make sure that the patient and family know for certain if
may be more appropriate and provide more flexibility to the appendix was removed or not. A surprising number will
enlarge the incision if needed. simply recall, years later, that they had “appendicitis” (when
For laparoscopic surgery, three ports are most commonly in fact there may have been other pathology).
used but some surgeons prefer a single port access to limit
the number of incisions. The first port is around the umbili-
cus, with the working ports in the lower abdomen. Depending Documentation Basics
on the technique of transection, one of the ports needs to
accommodate an endoscopic linear stapler. Coding for surgical procedures is complex. Consult the most
book for details (see references at the end). In general, it is
important to document:
• Findings
• Perforated?
• Peritonitis
• Tumor?
• Drains
Operative Technique
1/3 Laparoscopic Appendectomy
2/3 Positioning
Position and secure the patient supine on the operating
table and assure that there will be no shifting with assum-
ing other table positions (Fig. 45.2). Tuck at least the left
arm to allow for sufficient space for the surgeon and the
assistant to move cephalad as needed. Position the monitors
on the patient’s right, such that surgeon – pathology – mon-
itor are in one line. Insert a Foley catheter to have the blad-
Fig. 45.1 der decompressed.
45 Appendectomy (Open, Laparoscopic) 339
Anesthesiologist
and
Machine
1st 2nd
Assistant Assistant
Surgeon
Monitor
Nurse
Monitor
Mayo Table
Fig. 45.2
Incision and Exposure era and inspect the peritoneal cavity. Place the other ports
Keep safety in mind when placing the first trocar for the under direct visual control, that is, usually a 5-mm trocar and
camera. An open cut-down approach (Hasson technique) is a 12-mm trocar. The use of a stapler is facilitated if the
always the safest, but you may use the faster Veress needle 12-mm port is not right over the appendix. Different sur-
technique in select favorable patients without prohibitive geons may vary the locations a little bit, but you may choose
previous surgery, abdominal distention, or peritonitis. Once any two of the three locations: left or right suprainguinal, or
the pneumoperitoneum has been established, insert the cam- the suprapubic area. The goal should be to achieve instru-
Fig. 45.3
ment triangulation to the appendix. If necessary for retraction,

you may insert a fourth trocar in the right upper quadrant in
the midclavicular line.
Enhance the exposure by placing the patient in
Trendelenburg position with the right side up. Gently sweep
the omentum up and over the transverse colon. Oftentimes in Fig. 45.4
early appendicitis, this will deliver the inflamed tip into the
field of view. Next, push the small intestine medially to
expose the cecum, which may be recognized by its size and
white color and the presence of taeniae (Fig. 45.3). In the
most common situation, the appendix lies underneath the ter-
minal ileum and is tethered posteriorly by its mesentery. If
the base of the appendix is not clearly seen, often secondary
to inflammation and adhesions, the taeniae of the colon can
be followed down until they converge on the base.
Pass a laparoscopic bowel grasper through the suprapubic
trocar and gently pull the cecum toward the patient’s left
shoulder, such that the lateral aspect of the cecum and the
base of the appendix come into view. Using an atraumatic
clamp (e.g., Babcock clamp), lift the appendix straight up
toward the anterior abdominal wall. It may be better to
broadly grasp the meso-appendix than the often friable
appendix itself. Identify the base and once again confirm its
location by the convergence of taeniae on the cecum.
Creating a Window
Your next step is to safely create a window between the base
of the appendix and the fatty meso-appendix (mesentery of
the appendix). Often the appendiceal mesentery is a bit thin-
ner or even transparent at this point. It is important to neither
damage the cecum nor to leave too long of an appendix base.
You can use a number of instruments for the dissection, such Fig. 45.5
as a Maryland dissector, right-angle clamp, or the branches
of an energy device. Gently open and spread, withdraw, the base of the appendix. You may either use a vascular car-
close, and reinsert the instrument until the tip passes com- tridge of a linear stapler, an energy device, or bipolar clamps.
pletely through the mesentery at this point. Enlarge this win- If you choose one of the latter two, make sure for safety pur-
dow until it is at least 1 cm in diameter. Reconfirm that the poses to do it slowly in small bites, as the artery may other-
window is exactly at the base of the appendix (Fig. 45.4). wise retract into the tissue but continue to bleed. If that
occurs, grab the area of the bleeding, and reapply energy, or
Division of the Meso-appendix place an endo-loop or a clip (Fig. 45.5).
It is not relevant whether the meso-appendix or the appendix Take care throughout not to touch any of the bowels with
base is divided first, although it is often easier to start with the hot instruments. If necessary, begin creating the window
Fig. 45.7
proposed site of transection and assure that neither cecum

Fig. 45.6 nor other structures are caught in the stapler. Fire the
stapler.
If the meso-appendix has already been divided, secure the
just above the termination of the appendix to ensure that the appendix with a grasper. Open the stapler and release the tis-
tips of the clamp do not inadvertently injure the cecum sue. Move the stapler to a safe location, close and remove it.
behind the mesentery. If you use the stapler, avoid dropping Carefully inspect the staple lines for completeness and
unused staples into the field as the device is opened after fir- hemostasis. Control any bleeding by endoscopic clips or
ing to release the tissue. suture. It may sometimes be necessary to divide a small
amount of tissue with scissors. If this must be done, visually
ivision of Appendix Base
D confirm that the staple line extends to the full length of the
As stated above, you may choose to divide the appendix base appendiceal base (Fig. 45.7).
before or after the mesentery. A clean and quick way is to use Alternatively, you may divide the appendix base with
an endoscopic stapler through the 12-mm port. The hinge of scissors between two endo-loops (Figs. 45.8 and 45.9). If
the stapler must be completely outside the trocar for the sta- you choose that route, the meso-appendix has to be divided
pler to open properly. It may be necessary to pass the stapler first. Once divided, cauterize the exposed mucosa at the
behind and beyond the appendix to have sufficient distance. appendiceal stump. Consider oversewing the cecum to dunk
Open the stapler and place it around the appendix base. If the stump and have it covered with tissue.
you have not yet divided the mesentery, maneuver the
narrower jaw through the previously created window.
Specimen Removal
Visualize the tip emerging on the far side of the appendix. Secure the appendix and make sure not to lose it while bring-
Rotate the stapler as needed to optimize visualization of all ing in a specimen bag. Place it in the bag and remove it
structures (appendix, mesentery, stapler, and cecum). Pull up through the 12-mm port using a specimen bag. As it occa-
on the appendix and push down on the stapler as you close sionally may be necessary to remove the trocar and possibly
the jaws of the stapler (Fig. 45.6); this move maximizes the enlarge the trocar site, finish up everything else inside. Verify
chances of positioning the stapler properly (across the base hemostasis. Irrigate with moderation, unless there was dif-
so no appendiceal remnant is left). Close, but do not fire, the fuse peritonitis. Once the specimen is out, assess it on the
stapler. Rotate the stapler back and forth to fully visualize the back table for presence of a tumor.
Fig. 45.10
Fig. 45.8
Fig. 45.11
b anagement of the Retrocecal Appendix

M
The appendix is occasionally completely retrocecal and can-
not be visualized without mobilizing the cecum and right
colon. Incise the line of Toldt from the cecum up to the vicin-
ity of the hepatic flexure (Fig. 45.10). Grasp the cut edge of
peritoneum adherent to the right colon and pull the right
colon medially while lysing any residual adhesions by sharp
and blunt dissection (Fig. 45.11).
The appendix is then found on the back wall of the cecum,
generally adherent to the cecum with fibrous bands. It may
be so encased in fibrous tissue; it is difficult to identify at
a first. Tactile perception from the laparoscopic bowel grasper
may help identify the appendix, which feels like a small, firm
Fig. 45.9 cylinder compared with the softer cecum.
Fig. 45.12
Fig. 45.13
Grasp the appendix near its base and sequentially lyse the
fibrous adhesions that tether the appendix to the cecum
(Fig. 45.12). Sharp dissection with scissors or ultrasonic
shears is best. Remove the appendix either in the usual fash-
ion visualizing tip to base, or alternatively free up and tran-
sect the base and meso-appendix and subsequently perform a
retrograde mobilization of the entire structure.
Closure
Even if purulent material is encountered, it is usually safe to
close the laparoscopic incisions fascia as usual. If the
specimen bag ruptured and the extraction site is contami-
nated, close the fascia but leave the skin open.
Open Appendectomy
Incision
Make a transverse incision over McBurney’s point over the
approximated area of the appendix (Fig. 45.1). Depending Fig. 45.14
on the size of the patient, start with an incision of roughly
4–6 cm. If in doubt, place the incision rather a bit higher than thin fascia of the internal oblique muscle. Then, insert a
too low. Gently palpate the abdomen after induction of anes- Kelly hemostat to separate the muscle fibers of the internal
thesia; if you feel a mass in the right lower quadrant, use this oblique and underlying transversus muscle (Fig. 45.14).
information to guide incision placement. Using either two Kelly hemostats or both index fingers,
Deepen this incision through the external oblique aponeu- enlarge this incision sufficiently to insert small Richardson
rosis, along the line of its fibers (Fig. 45.13). Start the inci- retractors (Fig. 45.15).
sion with a scalpel and extend it with Metzenbaum scissors. Elevate the peritoneum between two hemostats and make
Then, elevate the medial and lateral leaves of the external an incision into the peritoneal cavity (Fig. 45.16). Enlarge
oblique aponeurosis from the underlying muscle and sepa- the incision sufficiently to insert Richardson retractors and
rate them between retractors (Fig. 45.14). explore the region. Alternatively, you may use a small wound
Note that the internal oblique muscle, which is fairly protector to provide exposure and limit contamination of the
thick, and the transversus muscle, which is deep to the inter- abdominal wall. Generally, the cecum will be seen filling the
nal oblique, run in a transverse direction. Make an incision incision. Take cultures if pus is present.
just below the level of the anterosuperior iliac spine into the
Fig. 45.15
Fig. 45.17
caudal direction. This leads to the base of the appendix,

which can then be grasped in a Babcock clamp. Apply a
second Babcock clamp to the tip of the appendix and deliver
it into the incision. As for the laparoscopic approach, it may
occasionally be necessary that you start the dissection at the
base before following and freeing up the appendix to the tip.
Always verify that the entirety of the appendix is removed.
Division of Meso-Appendix
Develop a window between the appendix base and the meso-
appendix and apply a single pair of clamps. Alternatively,
divide the meso-appendix between serially applied hemo-
stats and ligate each with 2-0 or 3-0 PG, until the base of the
appendix has been dissected free (Fig. 45.18). Generally, you
gain greater mobility if you divide the meso-appendix before
removing the appendix.
Fig. 45.16
ivision of Appendix and Ligation/Inversion

D
Delivery of Appendix of Appendiceal Stump
Grasp the anterior wall of the cecum gently with a moist Hold the tip of the appendix in a Babcock clamp. Pre-lay a
gauze pad (Fig. 45.17). With the cecum partially exterior- purse-string suture around the base of the appendix using 3-0
ized, identify the appendix. If the appendix cannot be seen, PG on an atraumatic needle. The radius of this suture should
explore the area with the index finger which may reveal an exceed the anticipated length of the appendiceal stump to
inflammatory mass consisting of inflamed appendix and allow sufficient space for the stump (Fig. 45.19).
meso-appendix. Perform a gentle sweep from lateral to Take a straight hemostat clamp, shortly squeeze the
medial to attempt delivering the appendix into the incision. appendix base 4–6 mm from the cecum, and subsequently
If this maneuver is not successful in locating the appen- place it 3 mm distal to that. Double-ligate the appendix base
dix, follow the taenia on the anterior wall of the cecum in a with 2-0 PG. Using a scalpel, transect the appendix just dis-
Fig. 45.20
Fig. 45.18
Fig. 45.21
tal to the hemostat (Fig. 45.20), retrieve the specimen, and

discard both the clamp and the scalpel. Gently cauterize the
exposed mucosa at the stump (Fig. 45.21). Using forceps,
invert the stump into the previously placed purse-string
suture (Fig. 45.22) and tie that while gradually withdrawing
the hemostat. The purse-string suture should be sufficient; if
there is some doubt of its adequacy, it may be reinforced with
a figure-of-eight suture of the same material.
Once the specimen is out, assess it on the back table for
Fig. 45.19 presence of a tumor prior to finishing the surgery.
Fig. 45.24
Fig. 45.22
Fig. 45.23
Closure of Incision
Fig. 45.25
Irrigate the right lower quadrant and pelvis with saline or a
dilute antibiotic solution; then, apply four hemostats to the transversus muscles as a single layer with interrupted sutures
cut ends of the peritoneum to elevate it into the incision, of 2-0 sutures (Fig. 45.24). Close the external oblique apo-
facilitating closure. You do not have to routinely place a neurosis with continuous or interrupted sutures of 2-0
drain, but in select cases, it may be prudent to insert a drain prolene, polydioxanone (PDS), or Vicryl (Fig. 45.25).
through a separate stab incision and place it in the right lower Close the skin loosely for the majority of cases. But if
quadrant. intraperitoneal pus or a gangrenous appendix were present,
Close the peritoneum with continuous 3-0 atraumatic either leave the skin incision open or consider placing a
Vicryl sutures (Fig. 45.23). Close the internal oblique and small penrose drain.
Postoperative Care versus reintervention (interventional radiology, rarely

surgical).
• Antibiotics: Routine coverage for the perioperative • Wound infection following an appendectomy for a per-
24-hour period. In case of gangrene, perforation, diffuse forated appendicitis is another cause of fever. It can be
peritonitis, or persistent signs of infection/sepsis, con- prevented by delaying closure of the skin. When a
tinue therapeutic antibiotics. wound abscess is detected, open the overlying skin for
• Intravenous fluids: Most patients recover rapidly follow- drainage.
ing an appendectomy and rarely require intravenous fluid • Prolonged postoperative ileus (versus bowel obstruction):
for more than 1 day. While frustrating, reintervention should be the exception
• Diet: Start diet if the patient is not nauseated or distended, for when you identify a very specific target problem.
and advance as tolerated. Otherwise, the more common management is to bridge
• Wound care: If the skin wound has been left open, change the period until return of bowel function with nasogastric
the wet-to-dry dressings daily. decompression and parenteral nutrition if it lasts longer
• Drain: An intra-abdominal drain can be removed when than 5 days.
the output clears up or subsides; a wound drain (e.g., pen-
rose drain) can be removed after a few days when the
wound looks quiescent. Further Reading
• Activity: All activities that the patient tolerates using
American Medical Association. Current procedural terminology: CPT
commonsense are permitted.
®. Professional ed. Chicago: American Medical Association; 2022.
• Pathology: Follow-up on the pathology: If an incidental https://www.ama-assn.org/practice-management/cpt.
tumor is found, take appropriate steps for further Brügger L, Rosella L, Candinas D, Güller U. Improving outcomes after
management. laparoscopic appendectomy: a population-based, 12-year trend
analysis of 7446 patients. Ann Surg. 2011;253:309–13.
Kim JH, Kim HY, Park SK, Lee JS, Heo DS, Park SW, Lee YS. Single-
incision laparoscopic appendectomy versus conventional
Complications laparoscopic appendectomy: experiences from 1208 cases of single-
incision laparoscopic appendectomy. Ann Surg. 2015;262:1054–8.
Masoomi H, Nguyen NT, Dolich MO, Wikholm L, Naderi N, Mills
• Postoperative sepsis: peritonitis, pelvic, or interloop S, Stamos MJ. Comparison of laparoscopic versus open appendec-
abscess. If the patient remains or becomes febrile after tomy for acute nonperforated and perforated appendicitis in the
the fourth or fifth postoperative day, perform a com- obese population. Am J Surg. 2011a;202:733–9.
Masoomi H, Mills S, Dolich MO, Ketana N, Carmichael JC, Nguyen
puted tomography (CT) scan and assess for the pres-
NT, Stamos MJ. Comparison of outcomes of laparoscopic versus
ence and location of an abscess as well as the most open appendectomy in adults: data from the nationwide inpatient
appropriate form of drainage (reopening of the wound, sample (NIS), 2006–2008. J Gastrointest Surg. 2011b;15:2226.
CT-guided drain placement). Soper N, Scott-Conner CEH. The SAGES manual volume I – laparo-
scopic appendectomy. New York: Springer; 2012.
• Cecal stump leak and fecal fistula: If there is clinical or
Spanos CP, Kaiser AM. Chapter 37: appendiceal neoplasms. In: Steele
imaging evidence for a stump leak, you need to carefully SR, Hull TL, Read TE, et al., editors. The ASCRS textbook of colon
weigh the further steps: watch and wait with antibiotics and rectal surgery. New York: Springer; 2016. p. 617–30.
Management of Appendicostomy
for Malone Antegrade Continence 46
Enema (MACE)
Abigail K. Zamora and Andreas M. Kaiser
Introduction Indications
Malone first described the appendicostomy for antegrade Primary Indication for MACE Procedure
continence enemas (ACE) in 1990 and hence it was quickly
coined as the Malone Antegrade Continence Enema (MACE).
It was derived from the Mitrofanoff conduit and indicated for Incontinence/encopresis:
the treatment of fecal incontinence or constipation. Patient • Structural: Anorectal malformations, history of anorectal
selection is critical to benefit from this procedure. Candidates surgeries, history of rectal prolapse surgery, history of
for the MACE procedure are older children or adults with low anterior resection and multimodality treatment
neurogenic bowel dysfunction (e.g., multiple sclerosis, spina (LARS, low anterior resection syndrome), secondary per-
bifida, paraplegia) or anorectal malformations who have ineal colostomy after previous abdomino-perineal resec-
failed aggressive medical management and have families tion (APR)
committed to the education and practice required to success- • Neurogenic bowel: Spina bifida, spinal cord injury, cere-
fully perform ACEs. bral palsy, multiple sclerosis
Although the MACE procedure is not common, there are • Patients who are not candidates or have failed more con-
increasing indications even in adult patients. Furthermore, ventional treatments
because appendicostomies frequently require surgical revi-
sions, even a general surgeon may come across a patient with
such a surgical history. Knowledge of the procedure and its Constipation:
complications will impart confidence and facilitate a smooth • Structural: Hirschsprung’s disease, stricture, colonic
transition of care, for example, as children outgrow pediatric J-pouch
specialty care. The leading causes for revision include infec- • Neurogenic bowel: Spina bifida, spinal cord injury, cere-
tion, stricture, or leakage. This chapter will address the cre- bral palsy, multiple sclerosis
ation of the Malone appendicostomy as well as strategies for • Functional fecal outlet obstruction, pelvic floor dysfunc-
revision. tion (rare)
Indications for Secondary MACE Management
Chronic:
A. K. Zamora • Difficult access (stricture, retraction, epithelialization)
Department of Surgery, Keck School of Medicine of the University • Leakage
of Southern California, Los Angeles, CA, USA • Stoma prolapse or peristomal herniation
A. M. Kaiser (*)
Hope National Medical Center/Comprehensive Cancer Center, Acute:
Duarte, CA, USA
e-mail: akaiser@COH.org • Ischemia or torsion of the appendicostomy

https://doi.org/10.1007/978-3-030-81415-1_46
350 A. K. Zamora and A. M. Kaiser
• Perforation with abdominal wall infection (epifascial) or the situation should be analyzed regarding morphological
peritonitis subfascial/intraperitoneal) aspects and suitability for such a procedure. For example,
massive obesity poses substantial challenges and may repre-
sent a contraindication. Or a patient may have had extensive
Evaluation and Preparation abdominal surgeries (including but not limited to an appen-
dectomy) or radiation which may be less ideal and add
Review the patient’s history, diagnosis, and functional complexity.
aspects. That information and respective records are fre- Most importantly however it should be analyzed whether
quently not available when MACE was created decades an ACE has a reasonable chance of providing the patient
earlier. with the desired quality of life. Sometimes patients present
with pre-made opinions and desires without having obtained
Creation: adequate information about physical and functional out-
• Patient Selection: This is the most important aspect comes or alternatives (Table 46.1). Even a patient with an
MACE success depends on objective parameters and existing ACE may achieve a better quality of life with alter-
patient/family education and motivation alike. native options. The basic decision in any such patients are
therefore:
Revision:
• Recognize acute problems that necessitate immediate • Pursue ACE (create or revise).
action. • Close an existing ACE.
• Characterize chronic problems to plan appropriate • Leave ACE but pursue alternative management
workup. strategies.
Define appropriate work-up depending on individual and

age-dependent factors to assure that there are no other condi- Definition of Access
tions that require priority attention or that the patient’s com-
plaints can be addressed with a simpler approach. If antegrade colonic enema management remains the treat-
Discuss and document with the patient and the family ment goal, the next step is to define whether appendix is
possible intraoperative situations that may require to pursue present and usable, whether alternative technical method
alternative routes including the creation of a stoma. should be used to create a neo-appendix, or whether an endo-
scopic/percutaneous catheter cecostomy (trap door button)
should be contemplated.
Pitfalls and Danger Points While the takedown of an existing appendicostomy may
be suitable for a minimally invasive approach even by a
• Inadequate imbrication of the appendix resulting in leak- general surgeon with respective training, the (re-)creation
age when not in use. or revision of an ACE should be limited to experienced
• Excessive tension on the appendicostomy leading to surgeons who based on their background may decide
retraction (higher risk in obese patient). whether a minimally invasive or an open approach should
• Excessive division or twisting of mesoappendix causing be used.
devascularization of the appendix.
• Malpositioned feeding tube leading to creation of false
passage, possible peritonitis secondary to perforation, or
inability to properly perform ACEs. Table 46.1 Surgical alternatives to ACE/MACE
• Removing feeding tube too early leading to stricture of Fecal incontinence Constipation
appendicostomy. Sacral nerve stimulation Correction of pelvic organ
Sphincteroplasty prolapse
Creation of stoma: (Sub-)Total colectomy
Colostomy Creation of stoma:
Operative Strategy Ileostomy Colostomy
Radiofrequency administration Ileostomy
Decision-Making Artificial implants: Sacral nerve stimulation
Neosphincter
Magnetic ring
The first distinction to be made is whether the patient desires Perianal expandable implants
to have a new ACE created or whether the patient has an (GateKeeper)
existing one that requires a surgical intervention. In any case, Dynamic graciloplasty
46 Management of Appendicostomy for Malone Antegrade Continence Enema (MACE) 351
Closure of Appendicostomy Have a selection of feeding tubes (recommended) or red rub-

ber catheters in the operating room. 8Fr and 10Fr are the
The MACE is typically considered to be a permanent stoma, most commonly used sizes. Occasionally, a stylet may prove
but on rare occasions, it is chosen as a temporary measure. If useful to prevent the tubing from bending.
the appendicostomy does not meet the functional goals or suf- Either alcohol-based (chlorhexidine) or iodine-based prep
fers a non-fixable complication, it may have to be closed. The solutions can be used and should be applied from nipple line
decision to reverse the stoma should be a carefully weighed in to mid-thigh. Be sure that the site mark remains visible after
multilevel discussions. Prior to reversing the appendicostomy, prepping. Drape to include a wide surgical field.
it should be discussed whether to consider an immediate alter-
native, for example, creation of a colostomy.
MACE Creation: Open Approach
Preoperative Marking Make a lower midline laparotomy. Stay either at a distance of

the umbilicus or—if necessary—go around it at a distance of
There are different options for the stoma site, commonly the 2–3 cm. Upon entrance into the abdomen, evaluate all four
umbilicus versus a site in the right lower quadrant which is quadrants. Locate the cecum and verify the presence of the
typically substantially lower than for a conventional stoma. appendix, which may not always be in the right lower quad-
The patient should be marked preoperatively for possible rant if the patient has an undiagnosed malrotation. Evaluate
sites of a MACE as well as possibly a conventional stoma, if the appendix will reach the proposed stoma site. Mobilize
should the need arise intraoperatively. If one selects an open the ascending colon if additional length is needed to allow
approach, take care to ensure the site is adequate distance for a tension-free appendicostomy. The degree of colonic
from the midline to minimize surgical site infections and to mobilization required will depend on the in situ position of
facilitate ease of wound and ostomy care. the appendix as well as the desired stoma site. For example,
an umbilical stoma site requires more mobilization.
Next, use interrupted stitches to imbricate the base of the
Anesthesia and Positioning appendix into the cecal pole in a Witzel channel-type fash-
ion. When carried out over a distance of approximately
All procedures should be performed in a regular operating room 1.5–2 cm, this creates an anti-reflux valve mechanism to pre-
under general anesthesia. A supine position is adequate as there vent leakage from the appendicostomy site. Create a small
is typically no need for access to the anus. The exception, which window in the mesoappendix if necessary to adequately
would require a modified lithotomy position, would be if the imbricate the base of the appendix, but carefully avoid dam-
discussion with the patient included potential escalation strate- age to the mesoappendix which could cause devasculariza-
gies with colostomy creation or abdomino-perineal resection. tion of the appendix.
Next, excise a small disc of skin at the proposed stoma
site. The disc should be the approximate width of the appen-
Documentation Basics dix. If you choose the umbilicus, try to evert it completely
and excise a skin circle in its center. Dissect down to the
Coding for surgical procedures is complex. Consult the most fascia. Incise the fascia using either an elliptical or cruciate
recent edition of the AMA’s Current Procedural Terminology incision. Ensure the incision does not narrow the lumen of
book for details (see references at the end). In general, it is the appendix nor predispose the patient to parastomal hernia-
important to document: tion. Gently grasp the tip of the appendix and pull it through
the anterior abdominal wall. Assess the vascularity of the
• Rational and indications appendix and ensure there is no tension or twisting of the
• Specific findings, particularly if revision or takedown appendix.
required As next step secure the appendix to the abdominal wall and
skin and mature the appendicostomy such that it is well
secured and does not retract. It may be advisable that you first
Operative Technique amputate the tip of the appendix. If the diameter is very small,
cut in a slightly oblique direction. Carefully insert a feeding
General Considerations tube into the stoma. Most feeding tubes will have measure-
ments on the side. Confirm the tube is in the cecum by inject-
Set the room up as for an appendectomy (Chap. 45), and ing 30 cc air into the feeding tube. The cecum should gently
modify it depending on the approach (laparoscopic or open). inflate. Sequentially secure the appendix to the dermis as you
352 A. K. Zamora and A. M. Kaiser
go. The stitches will be seromuscular to mucosa on the appen- Revision for Appendicostomy Stricture
dix then superficial to deep on the dermis. This will usually be
adequate, but place extra stitches as needed to secure the Most of the times, you can perform a small revision for a
stoma. Do not Brooke the appendix as there is no ostomy strictured access with a local approach. Confirm that appro-
appliance placed when not in use, just dry gauze and tape. priate consent for various alternate scenarios is available.
Finally, close the midline incision in layers, and apply dress- Assure that a variety of small tubes have been supplied to the
ings. Secure the feeding tube well as it will remain in place for operating room. Unless the entire appendix has strictured
3 weeks to prevent stricture or false passage. Note the position down (e.g., from ischemia), you may be able to excise it with
of the tube at the entrance to the stoma. Apply dressings to the a little wider skin edge, mobilize and re-mature it (as describe
surgical wounds. Place non-adhering petroleum gauze fol- above). Again, make sure to leave a tube in place for at least
lowed by regular gauze to the appendicostomy. 3 weeks. Be aware of the risk that as you try to insert the
tube, you risk causing a perforation prior to entering the
cecum. Hence, avoid any force when inserting the tube. If
MACE Creation: Laparoscopic Approach you feel resistance and depending on your preoperative dis-
cussion with the patient, either stop the procedure or plan for
For the laparoscopic approach, either enter the abdomen an abdominal verification (through a laparoscopy or
through the center of the umbilicus (using a 5 mm camera) or laparotomy).
at a distance from the umbilicus. Place additional trocars as If you realize that the appendicostomy is not salvageable,
desired depending on the proposed stoma site. For example, proceed with a removal (see below).
for a right lower quadrant appendicostomy, two additional
ports on the left side and one 5 mm port at the designated
stoma site easily facilitate the appendicostomy creation. Appendicostomy Takedown
Proceed laparoscopically with the appendicostomy cre-
ation as described above. If you have to remove the appendicostomy (either planned or
At the end of the case, insert the laparoscope and reinsuf- due to the intraoperative findings), you must address two
flate to confirm position of the feeding tube in the cecum. issues: (1) to excise the actual access segment from the skin
Insert 30 cc air into the feeding tube, and watch the cecum and the abdominal wall, and (2) removal of the appendix and
gently inflate. At this point, remove the trocars under direct possibly the cecal pole. Make sure that you do not leave
visualization, and desufflate the abdomen. Close the port mucosal fragments behind in the abdominal wall, as they
sites and apply dressings. could result in recurrent infections and mucus collections.
Excise the stoma site with an elliptic incision of the skin and
dissect the appendix all the way to the peritoneal cavity.
ACE Creation in Absence of Appendix Place a tie to the visible part of the appendix and resect the
tip with the skin. Most of the times, the intra-abdominal part
If the patient previously had an appendectomy, you must can be done via a minimally invasive approach. You may use
either abandon the plan or consider one of the alternative the excision site to place a camera port, insufflate, and place
options: other trocars as needed. The most definitive approach is that
you completely remove the appendix to its base (which has
• Tube cecostomy (created surgically, open or previously been imbricated for the valve). Unless the wrap is
laparoscopically) easily undone, you therefore may have to perform a cecec-
• Percutaneous, colonoscopically or radiologically guided tomy. Visualize the ileocecal junction to assure that you do
placement of cecostomy (analogous to percutaneous not narrow the terminal ileum. An endoscopic linear stapling
endoscopic gastrostomy, PEG) device can be used to resect the cecal pole and place it into a
• Creation of a different type of access segment (from the specimen bag. Proceed further as for a standard
ascending colon wall or the terminal ileum) appendectomy.
Leaving the appendix base with the wrap in place is not
The details of these procedures are beyond the scope of recommended as there is a not quantifiable risk of future
this book, and these patients should be referred to centers problems (stump appendicitis, mucocele, misinterpretation
with respective experience. on imaging, or endoscopy).
46 Management of Appendicostomy for Malone Antegrade Continence Enema (MACE) 353
Postoperative Care • Hyperphosphatemia (depending on irritation solution)

• Social/behavioral opposition
• General: Follow ERAS protocol and restart diet immedi-
ately and advance as tolerated.
• Antibiotics: Only for specific therapeutic indication.
• Catheter management: Monitor and record output every Further Reading
6 hours. Irrigate the catheter twice daily with 30 cc of tap
Abbes Orabi N, Vanwymersch T, Paterson HM, et al. Total perineal
water: Instillation and withdrawal should have not
reconstruction after abdominoperineal excision for rectal cancer:
resistance. long-term results of dynamic graciloplasty with Malone appendi-
• Feeding tube care: Leave the appendicostomy tube for at costomy. Color Dis. 2011;13(4):406–13.
least 3 weeks. Change the dressing around the tube daily. American Medical Association. Current procedural terminology: CPT
In the long term, patients may not require any protective
https://www.ama-assn.org/practice-management/cpt.
dressing over the stoma. Irrigate the tube with 10–30 cc of Chan DS, Delicata RJ. Meta-analysis of antegrade continence enema
saline daily: make sure not to use force, the instillation in adults with faecal incontinence and constipation. Br J Surg.
should go easily, otherwise verify the correct tube loca- 2016;103(4):322–7.
Chatoorgoon K, Pena A, Lawal T, et al. Neoappendicostomy in the
tion with a contrast x-ray.
management of pediatric fecal incontinence. J Pediatr Surg.
• Bowel care and teaching: Begin the teaching the patient 2011;46(6):1243–9.
and the family about the antegrade enemas during the Chereau N, Lefevre JH, Shields C, et al. Antegrade colonic enema for
hospitalization but wait with formal initiation for a few faecal incontinence in adults: long-term results of 75 patients. Color
Dis. 2011;13(8):e238–42.
weeks. The goal is to perform a single daily intubation of
Didailler R, Denost Q, Loughlin P, et al. Antegrade enema after total
the appendicostomy with ACE. The process will take mesorectal excision for rectal cancer: the last chance to avoid defini-
30–60 minutes and should provide a full cleansing of the tive colostomy for refractory low anterior resection syndrome and
entire colon. Insufficient duration and completeness of fecal incontinence. Dis Colon Rectum. 2018;61(6):667–72.
Lawal TA, Rangel SJ, Bischoff A, et al. Laparoscopic-assisted Malone
the ACE may cause unsatisfactory results. If the stoma is
appendicostomy in the management of fecal incontinence in chil-
not used, advise the patient to nonetheless perform daily dren. J Laparoendosc Adv Surg Tech A. 2011;21(5):455–9.
intubations to preserve stoma patency. Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade
• Irrigation solutions: tap water, normal saline, polyethyl- continence enema. Lancet. 1990;336(8725):1217–8.
Patel AS, Saratzis A, Arasaradnam R, et al. Use of Antegrade conti-
ene glycol. Do not hesitate to change irrigation solution if
nence enema for the treatment of fecal incontinence and functional
the patient has persistent incontinence or constipation. constipation in adults: a systematic review. Dis Colon Rectum.
Sometimes a simple change in irrigant may improve the 2015;58(10):999–1013.
results. Rangel SJ, Lawal TA, Bischoff A, et al. The appendix as a conduit for
antegrade continence enemas in patients with anorectal malforma-
tions: lessons learned from 163 cases treated over 18 years. J Pediatr
Surg. 2011;46(6):1236–42.
Complications Siminas S, Losty PD. Current surgical management of pediatric idio-
pathic constipation: a systematic review of published studies. Ann
Surg. 2015;262(6):925–33.
• Insufficient gain in quality of life: persistent incontinence
Sturkenboom R, Van Der Wilt AA, Van Kuijk SMJ, et al. Long-term
and/or constipation outcomes of a Malone antegrade continence enema (MACE) for
• Leakage when not in use the treatment of fecal incontinence or constipation in adults. Int
• Stricturing of the access segment J Color Dis. 2018; Epub ahead of print; https://doi.org/10.1007/
s00384-018-3088-5.
• Perforation of the access segment
Management of Enterocutaneous
and Enteroatmospheric Fistulas 47
Kazuhide Matsushima and Demetrios Demetriades
Definitions and Classifications las and involved bowel loops, restoration of the gastrointestinal
continuity, and abdominal wall reconstruction to provide soft
Enterocutaneous fistula (ECF) is a direct communication tissue coverage.
between the intestine and the skin. EAF is an intestinal leak
exposed to the atmosphere and is a complication of an open
abdomen following damage control operations, severe Preoperative Preparation
abdominal sepsis or decompressive laparotomy for abdomi-
nal compartment syndrome. In the enteroatmospheric fistula elineate Fistula Anatomy and Manage Any
D
(EAF), the external orifice is at the surface of a granulating, Intra-abdominal Infections
usually frozen open abdomen (Figs. 47.1 and 47.2).
Enteric fistulas are also classified by their location and The perioperative and definitive management of enteric fistu-
output. A useful anatomical classification is proximal/distal las depend on the underlying etiology, the presence of any
small bowel or colon fistulas. On the basis of output, fistulas associated intra-abdominal infection, the anatomical site of
are classified as low-output (less than 200–300 mL/day), the fistula and the presence of distal obstruction. Computed
moderate output fistula (300–500 mL/day), and high output tomography (CT) with oral and intravenous contrast can help
(more than 500 mL/day). in determining the anatomical site of fistulas, identify associ-
ated intra-abdominal pathologies, and distal bowel
obstruction.
Indications For septic patients with suspected enteric fistulas, ade-
quate control of intra-abdominal infection is the mainstay of
The management of any enteric fistula is a major surgical initial management. Any associated intra-abdominal infec-
challenge and requires meticulous evaluation of fistulas, pre- tion should be controlled by surgery or image-guided percu-
operative preparation, and complex operative techniques. taneous drainage. In addition, broad-spectrum antibiotics
The operative management includes definitive source control with/without antifungal regimens are strongly recommended
of any associated intra-abdominal infection, reduction and in patients with clinical signs of sepsis.
diversion of fistula output, and optimization of the nutritional
status.
Many ECF may close spontaneously, provided there is no Reduce and Divert Fistula Output
distal obstruction, or residual malignancy or inflammatory
bowel disease. In some cases, adjunct endoscopic or image- Patients with high-output fistulas, defined as >500 mL per
guided percutaneous procedures may help spontaneous ECF day, can easily develop acute kidney injury secondary to
closure. On the other hand, EAF almost always need com- severe dehydration with electrolyte derangements. In addi-
plex operations, which usually involve resection of the fistu- tion to appropriate fluid replacement therapy, the trial of a
somatostatin analogue and antidiarrheal medications can be
considered to reduce the fistula output.
K. Matsushima (*) · D. Demetriades
Department of Surgery, Division of Trauma and Acute Care Many ECF, especially the low or medium output ones,
Surgery and Surgical Critical Care, Los Angeles County – USC may close spontaneously with adequate supportive treat-
Medical Center, Los Angeles, CA, USA ment, such as control of any intra-abdominal sepsis and
e-mail: Kazuhide.Matsushima@med.usc.edu

https://doi.org/10.1007/978-3-030-81415-1_47
356 K. Matsushima and D. Demetriades
Fig. 47.1
Fig. 47.3
leak of intestinal contents on the surrounding exposed bowel

and granulation tissue, the chemical irritation of the skin, and
the soiling and malodor create a challenging task for the phy-
Fig. 47.2 sicians and nurses and a distressing situation for the patient.
Efforts to create a controlled fistula by inserting a Foley cath-
nutritional support. Factors that are favorable for spontane- eter almost never succeed and they usually make the fistula
ous closure include low-output small bowel or colonic ECF, larger (Fig. 47.3). Attempts to suture the fistula rarely suc-
small anastomotic leaks or small bowel-wall disruption, and ceed, unless the repair is done without tension and is imme-
long-tract ECF. diately covered by normal skin or skin graft. In many cases,
Factors that make spontaneous closure almost impossible a negative pressure therapy combined with commercially
include distal complete bowel disruption, malignancy, distal available fistula devices can be effective in achieving con-
bowel obstruction, irradiation, residual local malignancy or trolled diversion of the fistula contents (Fig. 47.4a–e). The
active inflammatory process such as Crohn’s or ulcerative fistula devices come in different sizes and shapes. The selec-
colitis, tuberculosis, actinomycosis, foreign bodies, and und- tion of the fistula isolation device depends on the size, loca-
rained abscesses. tion, and number of EAF.
The management strategy in EAF should include tempo- Along with recent advances in endoscopic techniques and
rary local control of effluent to prevent spillage of enteric devices, there has been an increase in case reports of suc-
contents on the surrounding tissues, good nutritional sup- cessful endoscopic closure of the enteric fistulas. Currently
port, and optimization of the patient for a major and complex available options include stent placement (Fig. 47.5), endo-
surgery. Spontaneous closure of EAF is highly unlikely, clips, endoscopic suturing, and tissue sealants. Similarly,
except in very small leaks. Local control of the EAF is a injection of fibrin glue or medical epoxy glues into the fistula
major challenge because it is very difficult to apply an effec- tract can be considered as another nonoperative option
tive collective system, such as an ostomy bag. The constant (Fig. 47.6).
47 Management of Enterocutaneous and Enteroatmospheric Fistulas 357
a b c
d e
Fig. 47.4
Fig. 47.6
nal mucosal barrier and immunologic and hormonal gut func-

Fig. 47.5 tion. In contrast, parenteral nutrition often remains the only
option in proximal high-output fistulas. Nutritional status
Optimize Metabolic and Nutritional Status should be evaluated and monitored regularly by clinical
examinations and laboratory parameters. Preoperative malnu-
Nutritional support is another important component of peri- trition is significantly associated with poor postoperative out-
operative patient care and increases the possibility of sponta- comes in patients undergoing surgical closure of the fistulas.
neous ECF closure or successful operative management.
Nutritional support can be provided by means of parenteral or
enteral feeding or a combination of the two routes. In low- P itfalls and Danger Points
output fistulas, low-residue enteral diet is usually well-
tolerated and provides adequate nutritional needs. Enteral • Failure to control associated intra-abdominal sepsis will
feeding is encouraged, if tolerated, as it preserves the intesti- not allow successful definitive management of the fistula.
• Distal bowel obstruction or residual malignancy or Operative Technique

inflammatory bowel disease prevent spontaneous healing
of ECF. Anesthesia, Positioning, and Instruments
• Ineffective isolation of EAF increases the risk of develop-
ment of additional EAFs and causes severe chemical irri- Under general anesthesia, place the patient in the supine posi-
tation of the skin and major patient discomfort. tion. Consider additional regional anesthesia options (e.g., epi-
• Early operation for fistula closure makes the procedure dural anesthesia) for postoperative pain management. To obtain
difficult because of immature and dense adhesions. a better exposure of the abdominal cavity, request a surgical
Ideally, wait 4–6 months after the last laparotomy. retractor (e.g., Bookwalter retractor) in the room. In addition to
• Failure to optimize patient’s metabolic and nutritional sta- a standard laparotomy set of the surgical instruments, surgical
tus before fistula closure operation results in a high risk energy devices may minimize intraoperative blood loss. In
for breakdown of the repair. cases that require abdominal wall reconstruction, appropriate
• Failure to identify all fistula sites during operation. sizes of surgical meshes should be available in the room.
• Inadequate preoperative planning of abdominal wall
reconstruction.
• The operative management of an EAF is a major surgical Incision and Entering the Abdominal Cavity
challenge and ideally these cases should be referred to
centers with significant experience in the management of Preoperative evaluation of intra-abdominal anatomy is a key in
this problem. making an operative plan. Patients with enteric fistula com-
monly have had multiple previous abdominal operations.
Further, it is not uncommon for patients with EAF to have a
Operative Strategy large abdominal wall defect. Thus, surgeons have to be careful
not to make any additional enterotomies. Make a midline inci-
The key points to a successful strategy for fistula include the sion in patients without enteric fistula in the middle part of the
following: abdomen. Although it would be ideal to enter the abdominal
cavity away from a previous incision (by going above or below
1. Entering the abdominal cavity safely a previous limited midline incision), the patient often has a large
2. Lysis of adhesions and identifying the involved segment midline surgical scar from the xiphoid process to the pubic sym-
of bowel physis. Avoid using an electrocautery to dissect the subcutane-
3. Resection of the segment of bowel including the fistula ous and fascial layers of the abdominal wall. In the patient with
site open abdomen that had been managed with negative pressure
4. Bowel anastomosis using either staple device or hand- wound therapy and skin graft previously, excise the redundant
sewn technique skin over the abdominal wall defect, then continue dissection to
5. Abdominal wall closure enter the abdomen. In the case with dense adhesions underneath
previous incision where the abdomen cannot be safely entered,
consider making a separate vertical incision 8–10 cm lateral to
Documentation Basics the open abdominal wound (Fig. 47.7).
Coding for surgical procedures is complex. Consult the

most recent edition of the AMA’s Current Procedural
Terminology book for details (see references at the end). In
general, document the following information in the opera-
tive report:
• Etiology of enteral fistulas (spontaneous, postsurgical,

open abdomen)
• Type of enteric fistulas (ECF, EAF)
• Intraoperative findings including the origin of enteric fis-
tulas (small bowel, large bowel) and any associated intra-
abdominal abscess
• Performed procedures (small/large bowel resections, total
length of resected segments)
• Abdominal wall reconstruction technique Fig. 47.7
47 Management of Enterocutaneous and Enteroatmospheric Fistulas 359
• Keep the drains until they are almost completely dry.

• Similar to other major abdominal operations, it is crucial
to implement enhanced recovery after surgery (ERAS)
protocols including multimodal pain management, early
mobilization and adequate venous thromboembolism pro-
phylaxis regimen, and removal of unnecessary tubes,
catheters, and drains.
• In patients with parenteral nutritional support preopera-
tively, it can be continued after the operation. However,
start enteral nutrition also in the early postoperative period
unless it is contraindicated.
• Upon discharge, instruct the patient to monitor for any
signs of wound infection, recurrence of enteric fistula
such as fever, abdominal pain, or drainage from the inci-
Fig. 47.8
sion site.
bdominal Exploration, Adhesiolysis,

A
and Resection of Enteric Fistulas Complications
Once the abdomen is entered, start with lysis of adhesions as • Uncontrolled enteric fistula and intra-abdominal sepsis
well as mobilization of the loops of bowel involved in the can be life-threatening. The aggressive use of diagnostic
enteric fistula, which can be challenging due to dense and studies (e.g., CT, ultrasound) to identify the source of sep-
extensive fibrotic tissues as the result of previous intra- sis is often indicated. Consider to perform image-guided
abdominal infections. Again, meticulous techniques are percutaneous drainage for localized abscess or fluid
required to avoid creating new enterotomies and other organ collection.
injuries. Mobilize the loops of bowel underneath the fistulas • Dehydration, electrolytes derangement, acid-base distur-
and granulation tissue bed. Then, remove them en bloc bance, and malnutrition should be avoided. Adequate
(Fig. 47.8). control and replacement of fistula output is important. In
patients with high-output fistulas, the use of somatostatin
analogues can be considered for reducing the output.
Abdominal Wall Closure Although enteral route of nutritional support is preferred,
supplemental nutrition by parenteral route may be
Once continuity of the gastrointestinal tract has been required if the patient cannot tolerate the enteral
restored, carefully inspect the abdominal cavity to look for nutrition.
any missed enterotomies or undiscovered fistulas/abscesses. • Skin irritation, breakdown, and related wound problems
Placement of intra-abdominal drains is not necessary. Close are caused by ineffective control of enteric fistulas. The
the abdominal wall in the usual fashion in the case without management of EAF is usually more difficult than ECF as
abdominal wall defect. A variety of options are available for it is technically more challenging to isolate enteric fistulas
abdominal wall closure for the patients with a large abdomi- in the middle of an open abdomen. A variety of options
nal wall defect. The fascia defect is closed with a biological are available for fistula effluent diversion.
mesh because of the high risk of infection. The skin and sub- • The risk of failure of the operative management of EAF is
cutaneous tissues are then mobilized at the fascia level, up to high. Meticulous planning and operative techniques are
the anterior axillary lines, and the skin is closed over closed essential.
drains.
Postoperative Care Further Reading
• Discontinue perioperative prophylactic antibiotics within American Medical Association. Current procedural terminology: CPT
24 hours after the operation, unless there is concern for http://www.ama-assn.org/ama/pub/physician-resources/solutions-
ongoing intra-abdominal infection. managing-your-practice/coding-billinginsurance/cpt.page.
• Apply an abdominal binder in the operating room in Demetriades D. A technique of surgical closure of complex intestinal
patients with abdominal wall reconstruction and keep it fistulae in the open abdomen. J Trauma. 2003;55:999–1001.
Demetriades D, Salim A. Management of the open abdomen. Surg Clin
postoperatively. North Am. 2014;94:131–53.
Di Saverio S, Tarasconi A, Inaba K, Navsaria P, Coccolini F, Schecter WP, Ivatury RR, Rotondo MF, Hirshberg A. Open abdomen
Costa Navarro D, Mandrioli M, Vassiliu P, Jovine E, Catena F, after trauma and abdominal sepsis: a strategy for management. J Am
Tugnoli G. Open abdomen with concomitant enteroatmospheric Coll Surg. 2006;203:390–6.
fistula: attempt to rationalize the approach to a surgical night- Teixeira PG, Inaba K, Dubose J, Salim A, Brown C, Rhee P, Browder T,
mare and proposal of a clinical algorithm. J Am Coll Surg. Demetriades D. Enterocutaneous fistula complicating trauma lapa-
2015;220:e23–33. rotomy: a major resource burden. Am Surg. 2009;75:30–2.
Polk TM, Schwab CW. Metabolic and nutritional support of the entero- Willingham FF, Buscaglia JM. Endoscopic Management of
cutaneous fistula patient: a three-phase approach. World J Surg. Gastrointestinal Leaks and Fistulae. Clin Gastroenterol Hepatol.
2012;36:524–33. 2015;13:1714–21.
Stricturoplasty in Crohn’s Disease
48
Indications • Cancerous obstructions

• Lack of symptoms
Crohn’s disease (CD) is a chronic inflammatory bowel disease • Poor performance and nutritional status
that—unlike ulcerative colitis (UC)—can involve any part of
the gastrointestinal tract. CD should primarily be managed
medically because it is not curable by surgical techniques. Yet, Preoperative Preparation
patients with CD have a high probability of requiring surgery
for disease complications. Indications for surgical manage- • Review the patient’s history, diagnosis, functional aspects,
ment of CD include obstruction, fistula, malignancy, hemor- and appropriate indication for surgery (based on clinical,
rhage, and perforation. Patients who undergo multiple radiographic, or endoscopic means).
operations on the small intestine are at risk of developing short • Colonoscopy to confirm the diagnosis and exclude other
gut syndrome, which has an enormous impact on quality of pathology.
life and serious morbidity and mortality. • Review all preoperative images to define anatomy and
Fibrostenotic strictures are a common presentation of confirm or rule out local tumor. CT enterography or MRI
Crohn’s disease resulting in obstructive symptoms that often enterography to characterize the extent and multicentric-
require surgical intervention. Given the immediate or long- ity of the disease.
term concern for short bowel syndrome as a result of multi- • If applicable, encourage smoking cessation.
ple bowel resections, it is preferable to preserve bowel • Consider nutritional tune-up in case of malnutrition.
whenever possible. Stricturoplasty in lieu of multiple small • Mechanical bowel preparation if clinically tolerated.
bowel resections should be considered in patients with • Wean corticosteroids if possible in the setting of elective
known Crohn’s disease, particularly in those with long seg- procedures, plan for steroid stress dose.
ment disease, or those with multiple strictures separated by • Continue immunosuppressants and biologicals (e.g., inf-
normal bowel. liximab) if part of the established medical management; if
possible schedule surgery to nadir (i.e., just before redos-
ing and skip that treatment).
Contraindications • Antibiotic prophylaxis versus treatment.
• Incomplete obstructive symptoms related to acute inflam-

mation amenable to medical management Pitfalls and Danger Points
• Chronic strictures not proven to be caused by Crohn’s
disease • Extensive adhesive disease from previous inflammation
and surgeries
G. K. Low • Chronic and acute inflammation with tissue friability and
Department of Surgery, University of Tennessee, Knoxville, TN, USA mesenteric thickening
A. M. Kaiser (*) • Multicentricity of stricture formation and risk of missing
Department of Surgery, Division of Colorectal Surgery, City of concurrent silent strictures
Hope National Medical Center/Comprehensive Cancer Center, • Restricturing
Duarte, CA, USA
• Distal obstruction with anastomotic blow-out

https://doi.org/10.1007/978-3-030-81415-1_48
362 G. K. Low and A. M. Kaiser
• Need for resection, risk for short bowel syndrome car placement). Develop the working space and establish
• Malignancy mimicking benign stricture exposure to the target pathology. If extensive adhesive dis-
ease and/or inflammation is encountered, do not hesitate to
extend the incision. Perform a systematic four quadrant
Operative Strategy exploration to confirm the preoperative assessment and rule
out unexpected pathology. Thoroughly explore the abdomen
While the procedures described below relate to open opera- to identify the extent of involved bowel. As the bowel lumen
tions, laparoscopic and robotic techniques are feasible will be exposed for a substantial period of the surgery, it is
options in select patients. It depends on the specific circum- advisable to use a wound protector for the laparotomy or the
stances whether the minimally invasive approach primarily extraction site.
serves at mobilizing the bowels to eventually perform an It is not only important that you evaluate the target stric-
extracorporeal stricturoplasty, or whether the entire proce- ture for length and tissue quality, but you also need to assess
dure is done intracorporeally. Always keep in mind that the the rest of the small bowel for synchronous stricture sites and
critical part defining a successful outcome is the effective- the total length. One way is to insert the balloon of a Fogarty
ness of the stricturoplasty and to a much lesser degree the catheter or even better of an endoscopic dilator through the
access. enterotomy for the stricturoplasty and manually advance it
After establishing access, the exploration needs to first through the small bowel; you can then insufflate it and pull it
define if the patient is a good candidate for stricturoplasty or back to see whether it gets caught in other areas. The advan-
whether an alternative plan needs to be executed (resection, tage of this tool is that it is long enough and fulfills the pur-
ostomy). Traditional contraindications to performing a stric- pose; the downside is its expense. Cheaper alternatives
turoplasty are listed above and include active disease with include the metal bullets of an esophageal dilator set
severe inflammation, abscess, fistula, or perforation. (Eder-Puestow).
Numerous stricturoplasty techniques have been described
for use in Crohn’s disease. The most important consideration
when choosing a particular technique is the length and loca- Heineke-Mikulicz Stricturoplasty
tion of the stricture. If there are more than one stricture, it
may be necessary to perform several independent stricturo- Heineke-Mikulicz stricturoplasty is one of the most com-
plasties or potentially combine the areas into a long-segment monly utilized techniques for short segment strictures (i.e.,
isoperistaltic side-to-side stricturoplasty. not longer than 1–1.5 times the diameter of the bowel).
Make a longitudinal incision on the antimesenteric boarder
of the stenotic bowel segment. Extend this incision 1–2 cm
Documentation Basics beyond the stricture in both directions. Identify the mid-
way point of the enterotomy and then place a 3-0 Vicryl
Coding for surgical procedures is complex. Consult the most stay suture on either side of the enterotomy and apply gen-
recent edition of the AMA’s Current Procedural Terminology tle tension. Close the enterotomy transversely in single or
book for details (see references at the end). In general, it is dual layer technique using a running 3-0 polydioxanone
important to document: suture (PDS) and interrupted seromuscular Vicryl sutures
(Fig. 48.1).
• Indication and reasoning for choice of intervention
• Findings and intraoperative decision-making
• Approach and type of repair(s) or resection Finney Stricturoplasty
• Accurate description of locations, length and character of
stricture, and/or any active disease The Finney stricturoplasty technique is utilized for longer
• Pre- and postoperative small bowel length strictures that are not amenable to the simple longitudinal
incision to transverse closure approach described above.
This technique more resembles a functional end-to-end small
Operative Technique bowel anastomosis (Fig. 48.2a–c). It can also be utilized in
patients with strictures involving the terminal ileum by car-
Access and Exploration rying the distal extent of the enterotomy over the ileocecal
valve and onto the ascending colon.
Depending on the location of the stricture, plan and create
access to the peritoneal cavity according to standard proce- Handsewn Bring the proximal and distal margins of the
dures of your chosen platform (laparotomy versus first tro- stricture together to form a U-shape of bowel. Create a back-
48 Stricturoplasty in Crohn’s Disease 363
a b
Fig. 48.1
wall row of seromuscular sutures in interrupted fashion with Isoperistaltic Side-to-Side Stricturoplasty
3-0 Vicryl. Make a full thickness, longitudinal incision on
the antimesenteric surface of the strictured segment. Extend The isoperistaltic side-to-side stricturoplasty is ideal for long
this incision 1–2 cm beyond the stricture in either direction. segment strictures or those with multiple short segment stric-
Close the posterior wall in a running full-thickness 3-0 PDS tures in close sequence. It essentially duplicates the lumen
suture (see Chap. 42). Add an additional row of interrupted and alleviates the obstruction while preserving the small
Vicryl sutures to complete the anterior wall. bowel surface.
Identify the length of the strictured segment. You typi-
Stapled Unless the tissue of the bowel wall is too thickened, cally divide the bowel at the midpoint of the stenotic seg-
you may achieve the same by doing a stapled functional ment and line up in parallel the two halves which are the
end-to-end anastomosis (also similar to a J-pouch creation). anastomosed (Fig. 48.3e). Alternatively, if both sides would
Form the bowel-U and make an enterotomy at the apex. seem very difficult to anastomose, you may divide the bowel
Insert the two branches of the linear stapler. Make sure that at one of the ends of the stricture and augment a healthy
the mesentery is not included and fire the stapler. Close the bowel onto the strictured segment.
enterotomy in two layers or fire another stapler cartridge Divide the mesentery at your division point as much as
across. necessary to allow for sufficient mobility and adequate
Fig. 48.2
a
b c
lineup. Place interrupted seromuscular stay sutures with a complete the anastomosis with addition of interrupted
3-0 Vicryl starting at either end and eventually approximat- seromuscular Vicryl sutures as outer layer of the front
ing the length of the two bowel segments. wall.
Handsewn If you hand-sew the entire anastomosis, make Stapled Alternatively, you may connect the two bowel
an enterotomy in either bowel over the length of the bowel sides by means of a series of sequential linear stapler fir-
overlap. Using a running 3-0 PDS, perform a full-thick- ings. However, you will need the endoscopic stapler device
ness anastomosis starting on the back wall and extending it as only that one can be inserted into the depth of the two
to the front (see Chap. 42). Once the inner layer is finished, bowels over a distance. For this approach, you only per-
48 Stricturoplasty in Crohn’s Disease 365
a b c
d e
Fig. 48.3
form a small enterotomy on either side and proceed from tion to start medical therapy unless there is evidence of
one to the other end. Close the enterotomy in two layers disease recurrence during follow up.
and oversew the staple line with interrupted seromuscular • For high-risk patients (smokers, young patients, multi-
Vicryl sutures. ple previous operations, or those with perforations/fistu-
las at operation), the decision is more complicated. In
general, medical therapy should be reinitiated 4–8 weeks
Wound Closure and Reconstruction postoperatively to decrease the risk of recurrence.
• Perform screening endoscopy to evaluate for disease
Remove the wound protector and any trocars. Irrigate the recurrence 1 year or sooner as needed postoperatively.
wounds. Close the laparotomy incision or the trocar and
extraction sites, respectively, in standard fashion. Close the
skin and subcutaneous tissue in layers using absorbable Complications
suture.
• General complications in the immediate postoperative
period: ileus, small bowel obstruction, leak, fistula for-
Postoperative Care mation, wound infections, and urinary tract infections.
• Long-term complications: recurrence following stricturo-
• Antibiotics: Continue beyond the perioperative 24-hour plasty, need for escalation of medical therapy and poten-
prophylaxis period. tially reoperation. Short gut syndrome, dependence on
• Nasogastric tube: If preoperatively obstructed, leave a parenteral nutrition with respective morbidity.
nasogastric tube in place until return of bowel function.
• Diet: in elective non-obstructed cases: follow ERAS pro-
tocol; consider parental nutrition if prolonged postopera-
tive ileus or preexisting malnutrition.
Further Reading
• Multidisciplinary care is essential in the postoperative Ambe R, Campbell L, et al. A comprehensive review of strictureplasty
period especially regarding the management of medical techniques in Crohn’s disease: types, indications, comparisons, and
therapy. In low risk patients there is generally no indica- safety. J Gastrointest Surg. 2012;16(1):209–17.
American Medical Association. Current procedural terminology: CPT Regueiro M, Strong SA, et al. Postoperative medical management
®. Professional ed. Chicago: American Medical Association; 2022. of Crohn’s disease: prevention and surveillance strategies. J
https://www.ama-assn.org/practice-management/cpt. Gastrointest Surg. 2016;20(8):1415–20.
Maguire LH, Alavi K, et al. Surgical considerations in the treat- Schlussel AT, Steele SR, et al. Current challenges in the surgical
ment of small bowel Crohn’s disease. J Gastrointest Surg. management of Crohn’s disease: a systematic review. Am J Surg.
2017;21(2):398–411. 2016;212(2):345–51.
Michelassi F, Sultan S. Surgical treatment of complex small bowel Strong S, Steele SR, et al. Clinical practice guideline for the sur-
Crohn disease. Ann Surg. 2014;260(2):230–5. gical management of Crohn’s disease. Dis Colon Rectum.
2015;58(11):1021–36.
Placement of Feeding Tube
Jejunostomy 49
Kulmeet K. Sandhu
Indications • Inadequate securement of the small bowel to the abdomi-

nal wall leading to separation of the small bowel and leak-
• Long-term nutritional support when enteral feeding is age of abdominal contents or tube displacement.
viable. • Malpositioning/kinking of the tube leading to feeding
• History of gastroesophageal reflux or aspiration. tube obstruction or small bowel obstruction.
• Using too much small bowel lumen for the purse-string or
during the Witzel technique may lead to small bowel
Contraindications obstruction proximally.
• Non-resolved distal pathology

• Unfavorable operability criteria Operative Strategy
Anesthesia and Positioning

Using general anesthesia, the patient is placed in the supine
• Diagnostic studies (if indicated) may include small bowel position. If a laparoscopic approach is planned for placing
follow through to evaluate for obstruction or a CT scan of the feeding jejunostomy, the arms should be tucked. Port
the abdomen to rule out metastatic disease. placement for laparoscopic jejunostomy tube insertion is
• Review any previous abdominal surgeries, especially any geared toward triangulation towards the left upper quadrant.
that involved small bowel resection or reconstruction.
• NPO, intravenous fluids.
• Perioperative systemic antibiotics. obilization of the Small Bowel and Purse-
M
String Placement
Pitfalls and Danger Points Choose a feeding tube site approximately 30 cm from the liga-
ment of Treitz. Select an entry site for the tube in the left upper
• Peritoneal carcinomatosis with frozen abdomen and quadrant where it does not interfere with the rib cage. Mobilize
inability to place a feeding tube. the bowel sufficiently so that it reaches the anterior abdominal
• Bowel injury away from the area of the jejunostomy tube. wall without any tension or torsion. Place the purse-string suture
• Through and through injury to the small bowel while on the anti-mesenteric side of the jejunum. Avoid making too
making the small bowel enterotomy for the feeding tube. large a purse-string, as this can cause a luminal obstruction.
• Inadequate tightening of the purse-string leading to leak-
age of enteric contents into the abdomen.
eeding Tube Placement and Securing
F
the Jejunum to the Abdominal Wall
K. K. Sandhu (*)
Department of Surgery, Division of Upper Gastrointestinal and
General Surgery, Keck School of Medicine of the University of Note the orientation of the bowel loop and place the feeding
Southern California, Los Angeles, CA, USA tube distally. If the tube migrates proximally, resultant gas-
e-mail: kulmeet.sandhu@med.usc.edu

https://doi.org/10.1007/978-3-030-81415-1_49
368 K. K. Sandhu
tric feeding can cause an increased risk of gastroesophageal

reflux and aspiration. Do not tie the purse-string too tightly
as this may cause obstruction of the tube nor too loosely as
this can result in leakage of enteric contents. During creation
of the Witzel tunnel, overly large bites of the small bowel
may result in jejunal obstruction.
Securing the jejunum to the abdominal wall helps prevent
separation of the bowel from the abdominal wall if the tube
is accidentally dislodged in the immediate postoperative
period. It also helps to form a durable tract so that the feeding
tubes can be exchanged without the need for a repeat inva-
sive procedure.
Documentation Basics Fig. 49.1

Abdominal wall
book for details (see references at the end). In general, it is Small Enterotomy
important to document: bowel
• Indication for feeding tube

• Technique chosen (laparoscopic, open) and whether the
Witzel technique was used
• Distance from the Ligament of Treitz (LOT) that the feed-
ing tube was placed Purse-string
• Size and type of feeding tube placed suture
Fig. 49.2 (Courtesy of Anantdeep Gill)

Operative Technique
Open Placement of Feeding Jejunostomy Tube Make a 5 mm skin incision at the proposed tube site and pass
a clamp from inside the abdomen to the skin incision. Grasp
If the feeding jejunostomy is placed with an open approach, the feeding tube and pull it into the abdominal cavity. The
utilize a supraumbilical midline incision. The incision needs feeding tube can be a red rubber catheter or a silicone jeju-
to be large enough to locate the ligament of Treitz (LOT), nostomy tube. If a 12-French red rubber catheter is used,
mobilize the jejunum, and secure the jejunum to the abdomi- additional side holes can be created prior to insertion. Avoid
nal wall around the feeding tube site. Lengthen the incision larger balloon catheters as an overfilled balloon can lead to
as needed to provide adequate visualization for these crucial luminal obstruction or bowel wall pressure necrosis.
steps. Create an enterotomy at the center of the purse-string
After entering the peritoneal cavity, locate the ligament of suture using cautery. Take care to avoid a through and
Treitz by reflecting the transverse colon and omentum supe- through injury to the jejunum during this step. Then, pass a
riorly. Then, inspect the small bowel from the LOT to the clamp into the small bowel to ensure entrance into the small
ileocecal valve to rule out any occult distal disease. Select a bowel lumen. Pass the feeding tube through this enterotomy
site on the jejunum for tube placement at a distance of and direct it distally. Check the bowel to confirm that the
20–30 cm distance from the LOT to ease its delivery to the tube is going in the right direction and is not curling or kink-
abdominal wall in the left upper quadrant. ing. Gently tie down the purse-string and flush the tube to
Place a purse-string suture in a diamond configuration on confirm that the tube is patent and there is no leaking around
the anti-mesenteric side of the selected jejunum using 3-0 the tube (Fig. 49.3).
suture. This should be just slightly larger than the feeding A Witzel tunnel can then be created to further secure the
tube to be inserted (Figs. 49.1 and 49.2). tube to the small bowel. Use seromuscular bites of jejunum
At this time, turn your attention to the abdominal wall. on either side of the tube using 3-0 suture to close the small
Retract the fascia of the left abdomen medially and elevate it. bowel over the feeding tube. Perform this imbrication for
49 Placement of Feeding Tube Jejunostomy 369
Jejunostomy
tube
Fig. 49.5
Witzel Tunnel
x
x x
x
x
x = Abdominal wall tacking sites
Fig. 49.4 Fig. 49.6 (Courtesy of Anantdeep Gill)
several centimeters and place the stitches so that the tube is

concealed (Fig. 49.4).
Once the tube is secure, suture the jejunum to the abdomi-
nal wall around the tube exit site. Bring the bowel up to the
abdominal wall in a relaxed fashion and confirm that the
mesentery is not kinked or twisted prior to placement of the
tacking sutures. Place four separate 3-0 sutures from the
abdominal wall to the jejunum in a seromuscular fashion.
Position the sutures superior, inferior, lateral, and medial to
Assistant 5mm
the feeding tube site. Get all of the sutures situated prior to port & eventual
tying them down (Fig. 49.5). Place an anti-swivel stitch more Surgeon feeding tube site
distally on the small bowel to help further secure the bowel working ports
Camera port
to the abdominal wall and help prevent torsion around the
feeding tube site (Fig. 49.6). Flush the tube again to confirm
integrity. Secure the tube to the skin and cap it. Close the Fig. 49.7 (Courtesy of Anantdeep Gill)
midline incision in the usual fashion.
complications. Place a 5 mm port at the umbilicus in the pre-
ferred manner. Then, place a 5 mm trocar in the right upper
aparoscopic Placement of Feeding
L quadrant and an 11 mm trocar in the right lower quadrant to
Jejunostomy Tube allow for laparoscopic suturing in the left upper quadrant.
Put an additional 5 mm trocar as an assistant port in the left
If feasible, the laparoscopic approach is preferred due to upper quadrant (Fig. 49.7). This will eventually become the
decreased pain, less risk of postoperative ileus and of wound jejunostomy tube exit site.
370 K. K. Sandhu
Position the patient in a slight Trendelenburg position and

locate the ligament of Treitz by reflecting the transverse
colon and omentum superiorly. Select a site on the jejunum
for tube placement at a distance of 20–30 centimeters dis-
tance from the LOT to ease its delivery to the 5 mm assistant
port in the left upper quadrant. Check the remainder of the
small bowel to ensure no other pathology is present. Suture
As in the open technique, place a purse-string suture in a passer
diamond configuration on the anti-mesenteric side of the
selected jejunum using 3-0 suture (Fig. 49.8). This can be
done using a laparoscopic needle driver and atraumatic
grasper or with an endoscopic suturing device.
At this time, turn your attention to placing four separate Transabdominal
3-0 tacking sutures around the purse-string. Position these suture
superior, inferior, lateral and medial to the purse-string
suture, as described previously for the open technique. Place
these sutures laparoscopically through the seromuscular
layer of the jejunum and leave the tails long so that they can
eventually be grasped with a fascial closure device
(Fig. 49.9). Once these have been placed, make small stab
incisions superior, inferior, medial, and lateral to the 5 mm
assistant port site in the left upper quadrant. Use a fascial
closure device to grab the tacking sutures through the stab Fig. 49.9 (Courtesy of Anantdeep Gill)
incisions. This will result in four transfascial tacking sutures
(Figs. 49.10 and 49.11). Do not tie these down until the feed-
ing tube has been placed.
Apply slight tension to the transfascial sutures, thereby
allowing for easier feeding tube placement. Make an enter-
otomy using cautery at the center of the purse-string. Insert
an atraumatic laparoscopic grasper through a working port
and bring its tip back out in reverse direction through the
5 mm trocar in the left upper quadrant. Remove the port, then
grasp and insert the feeding tube by pulling the grasper back
inside. Direct the tube into the enterotomy and guide it dis-
tally. This step can be difficult so periodically flush the tube
with saline to help expand the jejunal lumen, making it easier
to advance the tube distally. Tie down the purse-string using
Fig. 49.10
laparoscopic instruments (Fig. 49.12). Subsequently tie the

transfascial sutures so that the tube is no longer visible lapa-
roscopically (Fig. 49.13). As in the open surgery, place an
additional anti-swivel stitch slightly distally to prevent tor-
sion or kinking of the small bowel (Fig. 49.14). Suture the
feeding tube to the skin and flush it to confirm that it is pat-
ent. Cap the tube, remove the remaining trocars, and close
Fig. 49.8 the port sites in the usual fashion.
49 Placement of Feeding Tube Jejunostomy 371
Fig. 49.14
is also possible, if preferred, to place intracorporeal

stitches or T fasteners around the tube site in order to
secure the jejunum to the abdominal wall, rather than
transfascial sutures.
Another option for jejunal feeding tube placement is
laparoscopic needle catheter jejunostomy using the
Seldinger technique. In this method, place the transfascial
or intracorporeal tacking sutures without a purse-string
suture. Enter the bowel with a percutaneous needle and
insufflate it with air. This helps prevent through and
through injury when placing the dilator and feeding tube.
After insufflation, advance a guide wire into the distal jeju-
Fig. 49.12
num. Remove the introducer needle and place a dilator
over the wire. Take out the dilator and introduce the feed-
ing tube. Confirm distal placement of the feeding tube with
saline or air insufflation prior to tightening the tacking
sutures.
Postoperative Care
• Provide postoperative routine antibiotics for 24 hours.

• Place an abdominal binder to help prevent early postop-
erative feeding tube dislodgement.
Fig. 49.13 (Courtesy of Anantdeep Gill) • Start the patient on trickle tube feeds on postoperative day
one.
It is not this author’s practice to use the Witzel tech- • All medications should be crushed or in liquid form to
nique when performing placement of a laparoscopic jeju- avoid clogging of the tube.
nostomy tube but if desired, this may be done by inserting • If this is tolerated, slowly advance the tube feeds starting
the feeding tube prior to placing the transfascial sutures. It on postoperative day two.
372 K. K. Sandhu
Complications taken with this technique, as perforation of the jejunum is

possible. If these fail and the tract is mature, the tube can
• Postoperative sepsis: This can be due to an enterotomy, be removed and replaced with a new feeding tube.
separation of the small bowel from the abdominal wall, or
feeding tube dislodgement. Symptoms may include
increasing abdominal pain, fever, and possible nausea and
vomiting. Imaging helps with confirmation and treatment Further Reading
includes NPO, intravenous fluids and intravenous antibi-
otics. Surgical reintervention may be required depending American Medical Association. Current procedural terminology:
CPT ®. Professional ed. Chicago: American Medical Association;
on the cause of the sepsis. 2013. http://www.ama-assn.org/ama/pub/physician-resources/
• Tube site infections: Overall comparably rare and less solutions-m anaging-y our-p ractice/coding-b illinginsurance/cpt.
dramatic, this may present as cellulitis, requiring local page.
wound care and antibiotics. Siow SL, Mahendran HA, Wong CM, et al. Laparoscopic T-tube feed-
ing jejunostomy as an adjunct to staging laparoscopy for upper
• Small bowel obstruction: This is more often related to gastrointestinal malignancies: the technique and review of out-

underlying disease than the tube itself. It may present as comes. BMC Surg. 2017;17(1):25.
nausea, abdominal pain, and distention; vomiting may not Speer EA, Chow SC, Dunst CM, et al. Clinical burden of laparoscopic
be possible if there is an obstructing tumor more proxi- feeding jejunostomy tubes. J Gastrointest Surg. 2016;20(5):970–5.
Strong AT, Sharma G, Davis M, et al. Direct percutaneous endoscopic
mally. Imaging may help elucidate the cause of the jejunostomy (DPEJ) tube placement: a single institution experi-
obstruction. A coiled or twisted tube may be repositioned ence and outcomes to 30 days and beyond. J Gastrointest Surg.
by interventional radiology. If the issue is torsion around 2017;21(3):446–52.
the jejunostomy tube site or a too-wide Witzel tunnel, a Yang SM, Hsiao WL, Lin JH, et al. Laparoscopic percutaneous jejunos-
tomy with intracorporeal V-Loc jejunopexy in esophageal cancer.
surgical reintervention is often warranted. Surg Endosc. 2017;31(6):2678–86.
• Clogging of the tube: Feeding jejunostomy tubes tend to Ye P, Zeng L, Sun F, et al. A new modified technique of laparoscopic
be smaller than gastrostomy tubes and their smaller needle catheter jejunostomy: a 2-year follow-up study. Ther Clin
lumens and side holes increase the risk of occlusion. This Risk Manag. 2016;12:103–8.
Young MT, Troung H, Gebhart A, et al. Outcomes of laparoscopic
may be treated with forceful irrigation or instilling soda in feeding jejunostomy tube placement in 299 patients. Surg Endosc.
the catheter. Occasionally, a soft-tipped guidewire may be 2016;30(1):126–31.
used to break up the occluding agent. Care should be
Creation of Ileostomy (Loop, End)
50
Indications Contraindications
The choice of loop versus end ileostomy is determined by the • Short bowel syndrome, stoma site too proximal within
clinical scenario and patient factors. A loop is created as a small bowel
temporary solution to divert the fecal stream from a distal • As sole intervention for large bowel obstruction
area of concern. Examples include a distal anastomosis, • As sole intervention for Ogilvie syndrome
manifestations of inflammatory bowel disease (fistulas,
abscess), rectovaginal fistula. A loop ileostomy is the diver-
sion of choice for elective scenarios, particularly if there is a Preoperative Preparation
probability that later reconstructive colorectal efforts might
be needed. In contrast, loop transverse colostomy (occasion- • Study the patient’s history and verify the diagnosis and
ally sigmoid loop colostomy) are more often created when a appropriate indication by available clinical, radiographic,
colonic complication has already occurred (leak of a previ- or endoscopic means.
ously undiverted anastomosis, large bowel obstruction). • Review available images (CT scans, plain x-ray films,
An end ileostomy is created (1) if there is no receiving contrast enemas).
distal segment for a reconnection (e.g., total abdomino- • Stoma marking: Mandatory for elective stoma creations.
perineal proctocolectomy) or (2) if a connection appears not • Patient education about stoma function and lifestyle
to be prudent at the time of surgery. Examples for the latter modifications.
include fulminant colitis that require an urgent/emergency • Routine antibiotic prophylaxis (unless therapeutic indica-
total colectomy in a deconditioned patient. tion for active infection).
It should be noted that an elective total colectomy (e.g., in
the context of Lynch syndrome or attenuated FAP) does not
require an ileostomy, but an ileo-rectal or ileo-sigmoid anas- Pitfalls and Danger Points
tomosis is carried out.
Since both types of ileostomy are most commonly done • Poorly selected stoma location (near skin folds/divots, or
as part of a major procedure (LAR, TPC), the choice of open bony prominences), preventing proper seating of the
versus laparoscopic versus robotic is defined by the approach appliance and result in peristomal skin complications.
used for the main procedure. • Inadequate protrusion (“nipple”) or recession of the ileos-
tomy, resulting in poor fitting, stool undermining, and
loosening the ileostomy faceplate.
• Obesity: thick mesentery limits the reach, prone to retrac-
M. P. Duldulao tion, renders nipple formation difficult.
• Devascularization (from excessive denudation of ileum,
Los Angeles, CA, USA too narrow fascial gap, “brooking” of very obese mesen-
tery), leading to stoma necrosis and stricture formation (if
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of above the fascia), or to abdominal sepsis (if below the
Hope National Medical Center/Comprehensive Cancer Center, fascia).
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_50
374 M. P. Duldulao and A. M. Kaiser
• Wide fascial or skin opening, resulting in tenting of the should be prepared prior to losing the pneumoperitoneum.
nipple base or peristomal herniation. That entails identification, mobilization, and correct orienta-
• Maturing the “wrong end” (i.e., efferent instead of affer- tion of the most distal ileum segment that is able to reach; a
ent limb). mesenteric window should be created and a soft drain (e.g.,
• Stitch granulomata or ileocutaneous fistula formation. penrose) inserted as a handle by which the loop can later be
pulled to the surface; last but not least, afferent versus effer-
ent limb need to be marked in an absolute fashion. Last but
Operative Strategy not least, in a laparoscopic procedure, you should plan ahead
where to extract a specimen. The planned ileostomy site may
Choice of Procedure and Site be a great choice for this purpose, except that the abdominal
gap might need to be bigger than if just an ileostomy were
A loop ileostomy is the preferred diverting stoma and better created.
than a transverse colostomy for the majority of elective situ-
ations. In general, one of the main advantages of an ileos-
tomy apart from the more straightforward takedown is the Proper Ileostomy Configuration
fact that the entire residual colon remains uncompromised
and—if needed in a subsequent surgery—can be mobilized Most peristomal skin complications result from poor posi-
and rotated without limitations. Downsides of an ileostomy tioning or unfavorable appearance of the ileostomy. If avail-
include the fluid and electrolyte imbalances and that it does able, a consultation with an enterostomal therapist to select
not properly decompress an unprepped colon. potential ostomy sites prior to the operation is beneficial. In
A transverse colostomy may be more advantageous in a emergency situations, rely on an “educated guess” and avoid
very obese patient, or when a stoma is required because com- placing the ostomy near bony prominences, within skin
plications have developed after a previously non-diverted folds, or below the presumed belt line as this will prevent the
pelvic surgery. In the latter situation, a transverse colostomy faceplate of the ileostomy appliance from seating properly.
may be more easily constructed and provides continued The ileostomy (i.e., afferent limb of loop ileostomy, and
access to the colon even if the area of the complication results the end of end ileostomy) should ideally have a smooth and
in an unpassable stricture. In contrast to an ileostomy, this symmetric appearance, protrude 2 cm above the skin level,
direct colonic access is important to allow for decompres- and the base should have the same diameter as the top,
sion, washout, diversion, and colonoscopic evaluation. whereas the efferent limb should not be visible at the base of
Under urgent/emergency circumstances, when a the nipple.
Hartmann-type resection (total abdominal colectomy, right In rare situations, the afferent and efferent limb are
hemicolectomy) is performed under adverse circumstances matured as Prasad-type ileostomy (with completely closed
and in a deconditioned patient, the creation of the end ileos- efferent limb), as double-barrel stoma (equal weight of affer-
tomy may follow similar principles except that it is preceded ent and efferent limb), or as loop over a bridge without nip-
by a bowel resection and damage control. ple formation.
Identification of an optimal stoma site will reduce local
complications such as skin irritation, stoma trauma, and
retraction. In elective situations, use all positions (standing, Documentation Basics
supine, and sitting) to mark the stoma site which on a vertical
line ideally comes to lie in the rectus muscle. Remember to Coding for surgical procedures is complex. Consult the most
select a comparably much higher (cephalad) stoma site in recent edition of the AMA’s Current Procedural Terminology
obese patients as the pannus may shift downwards and bury book for details (see references at the end). In general, it is
a classical “right lower quadrant” location. important to document:
• Findings and indication for diversion.

Access • Reasoning for choice of type and site.
• Construction details: loop, Prasad-type, end, double
The creation of the ileostomy can be carried out as part of an barrel.
open, a laparoscopic, or a robotic surgery. The choice is • Use of stoma bridge.
defined by the main procedure. In an open procedure, the • Use of abdominal wall reinforcement.
ileostomy creation is typically the last step. In a minimally • Technical details when fashioning any type of stoma. This
invasive main procedure, the bowel loop for the ileostomy will facilitate the reversal of a temporary stoma.
50 Creation of Ileostomy (Loop, End) 375
Operative Technique anterior abdominal wall and free any adhesions that restrict
its mobility. If necessary, adjust the final position of the
The construction of an ileostomy can be done in any position stoma to facilitate stoma creation without tension.
suited for an abdominal procedure and is usually determined
by the main surgery component. I ncision and Creation of a Passage
Make a circular skin incision in the right lower quadrant. The
diameter should reflect the diameter of the respective small
End Ileostomy Creation bowel and measure about 1.5–2 cm. Excise the overlying
skin. Do not excise a column of subcutaneous fat as it would
reoperative Selection of Ileostomy Site
P result in a concave surface. In obese patients, choose a more
Position the ileostomy within the right lower quadrant within cephalad ostomy site where the abdominal wall is suffi-
the confines of the rectus sheath. Adjust the location depend- ciently thinner (Fig. 50.2). Incise vertically within the circu-
ing on underlying skin folds, proximity to bony prominences lar incision, insert retractors to spread the subcutaneous
(antero-superior iliac spine, costal margin), and body habi- tissue and expose the underlying anterior rectus sheath fascia
tus. Occasionally, other locations (e.g., contralateral side) are (Fig. 50.3). Make a 2 cm cruciate incision within the fascia
better in an individual patient. If circumstances allow, mark to expose the rectus muscle (Fig. 50.4). Bluntly spread the
several locations prior to proceeding to the operation and muscle fibers utilizing a large pean or Kelly clamp supported
confirm proper placement while patient is positioned standby retractors (Fig. 50.5). Ensure that bowel is not immedi-
ing, sitting, and while lying on their back and sides. This can ately underlying the abdominal wall and peritoneum by plac-
be done with the assistance of an enterostomal therapist. ing a lap sponge or your nondominant hand below the
During emergency operations, position the stoma within the peritoneum in open operations, or maintaining adequate
“stoma triangle” bounded by the pubic tubercle, anterior insufflation during laparoscopic cases. Once the underlying
superior iliac spine, and umbilicus (Fig. 50.1). bowel is cleared, make an incision in the peritoneum. The
Prior to making an incision within the abdominal wall, opening should accommodate at least two fingers breadth
choose a segment of small bowel with adequate reach to the (Fig. 50.6).
Fig. 50.1 Fig. 50.2

Fig. 50.5
Fig. 50.3
Fig. 50.6
Fig. 50.4
ashioning the Ileal Mesentery

F “ Brooking” the Ileostomy (Eversion
Preserve a sufficient width of mesentery to ensure vascular- and Mucocutaneous Fixation)
ity to the limb of small bowel. The vascular arcade is well Maturation of the ostomy occurs at the end of the operation.
visualized within the ileal mesentery and vasa recta pre- Close all abdominal incisions and cover them with a sterile
served up to 2 cm from the distal tip of the bowel. For end dressing to prevent contamination from opening the distal
ileostomies, mobilize at least 6–7 cm of ileum to create a small bowel. Remove the stapled end of the terminal ileum to
properly protruding ileostomy. For obese patients, more open up the distal small bowel. Inspect the mucosal edge for
length is required but also more difficult to obtain. bleeding and examine for evidence of ischemia. Mature the
ostomy by placing but not tying four interrupted sutures cir-
Exteriorization and Closure of Mesenteric Gap cumferentially, always going through dermis before going
Insert a Babcock clamp into the abdominal cavity through through the bowel. First, take a perpendicular bite through
the opening made for the ileostomy (Fig. 50.7a). Grasp the the dermis. With the same suture take an additional seromus-
tip of the ileum gently and bring it through the opening cular bite at the base of the ileum. Lastly, take a full-thickness
(Fig. 50.7b). Do not pull up forcefully with the clamp. bite including a small edge of the mucosa at the distal aspect
Instead push the bowel up from the peritoneal side to avoid of the ileum. Do not place a stitch within the same line as the
tearing with the clamp. Orient the mesentery in a caudo- small bowel mesentery. Instead straddle the mesentery and
lateral direction and maintain a straight line along the edge place a stitch just to the side the mesentery. Temporarily hold
of the mesentery all the way to the mesenteric root. The ile- each stitch in a hemostat until a stitch is placed in each quad-
ostomy should sit with adequate protrusion from the skin rant. Once four sutures are placed surround the ileostomy
level without tension on the mesentery. (Fig. 50.9), evert the ileum by gentle traction on all and tying
If a permanent end ileostomy is anticipated, suture the cut the sutures (Fig. 50.10). Place additional sutures between
edge of the ileal mesentery to the paracolic gutter (Fig. 50.8). each four quadrant stitch to completely approximate the
This obliterates the lateral passage and prevents internal her- mucosal and cutaneous edges circumferentially.
niation with twisting of small bowel around the ileostomy-
bearing segment and a bowel obstruction.
Loop Ileostomy Creation
a I ncision and Creation of a Passage
Selecting the site and creating the opening in the abdominal
wall are identical to the end ileostomy (see above).
xteriorization and Proper Orientation

E
Choose a loop of small bowel that is at least 15 cm proximal
to the ileocecal valve and has enough mobility to reach the
Fig. 50.7 Fig. 50.8

Fig. 50.11
Fig. 50.9
Fig. 50.12
through the ileostomy site. Insert a Babcock clamp through

the aperture for the ileostomy and grasp the previously place
penrose drain. Wrapping the bowel loop with an adhesion-
reducing sheath of Seprafilm is optional. Gently pull the loop
of ileum up until it protrudes above the skin. Confirm the
proper orientation and ensure that there are no twists in the
small bowel. Orient the previously placed sutures so that the
dyed Vicryl stitch is aligned caudad at the inferior aspect.
Close all abdominal incisions to prevent contamination with
bowel contents prior to maturing the ostomy.
“ Brooking” of the Afferent Limb

Approximately, a 4 cm loop of bowel should be protruding
through the aperture of the ileostomy (Fig. 50.12). To
Fig. 50.10
mature the ostomy, make a transverse incision on the effer-
ent limb of ileum just above the skin level (Fig. 50.13). Do
designated ileostomy site. Create a very small window in the not evert the efferent limb. Secure that efferent opening
small bowel mesentery and pass a penrose drain through it with three stitches to the dermis at the inferior apex of the
(Fig. 50.11). Mark the distal limb with a dyed Vicryl suture skin opening: space the stitches on the dermis narrowly, but
and maintain the orientation of the loop as it is brought keep them wide on the efferent bowel lumen. This ensures
Distal
ileum
Proximal
ileum
Fig. 50.13
Fig. 50.15
Postoperative Care
• In the operating room, apply an adhesive-type transparent

colostomy bag.
• Antibiotics: Largely depending on the main procedure.
Routine coverage for the perioperative 24-hour period. In
case of an underlying infection/sepsis, continue respec-
tive therapeutic antibiotics for that indication.
bowel function.
• Diet: Start diet as tolerated.
• Stoma: Start early stoma teaching to avoid delaying
Fig. 50.14 discharge.
• High ileostomy output: Watery high output of more than
1000 cc per day is suggestive of a partial small bowel
that the proximal limb dominates and occupies a majority obstruction. Maintenance of adequate hydration is cru-
of the ileostomy aperture and completely diverts the fecal cial, if necessary by means of home hydration via a
stream. peripherally inserted central access line.
Subsequently, focus on creating a nipple with the afferent
limb. Place four stitches similar to the endoileostomy but
only focusing on the afferent limb. Start with the dermis, take Complications
a seromuscular bite at the base and last go full-thickness
through the bowel edge where it had been transversely • Peristomal abscess and sepsis is rare. Treatment requires
opened. Make sure the four sutures are equally distributed on incision and drainage either into the stoma bag, or far
the circumference of (1) the skin opening and (2) the base of enough to be outside the waver of the appliance. Massive
the afferent bowel. In order to get a symmetrical appearance sepsis may require stoma relocation.
of the nipple, it is important that the second step bite (sero- • Stoma necrosis or retraction, particularly in very obese
muscular) hits the bowel at the same level in all four quad- patients: If the stoma appears dusky or dark, evaluate it by
rants. Upon gentle traction on all four stitches, the afferent inspecting the mucosa above and below the fascia. If the
limb will evert and form a dominant nipple (Figs. 50.14 and viability is compromised below the fascia, the stoma
50.15). Tie the sutures and place one or two additional needs to be revised immediately. If it only affects the
stitches in-between from dermis to the cutting edge. bowel part above the fascia, it will likely stricture; timing
of a stoma revision versus takedown can be Corman ML. Intestinal stomas. In: Corman ML, editor. Bergamaschi
RCM, Nicholls RJ, Fazio VW, (Assoc Eds) Corman’s colon and
individualized. rectal surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins;
• Obstruction of ileostomy due to edema: Insertion of a 2013. p. 1396–450.
catheter may allow for stool to pass. Erwin-Toth P. Chapter 32: wound, ostomy, and continence nursing.
• Parastomal hernias: the rule rather than the exception. In: Corman ML, Bergamaschi RCM, Nicholls RJ, Fazio VW, edi-
tors. Corman’s colon and rectal surgery. Philadelphia: Lippincott
• Skin dermatitis from intestinal content leakage: best man- Williams & Wilkins; 2013. p. 1451–72.
aged by good education, cutting the opening in the adhe- Guenaga KF, Lustosa SA, et al. Ileostomy or colostomy for temporary
sive faceplate to just accommodate the nipple but covering decompression of colorectal anastomosis. Cochrane Database Syst
all skin. Rev. 2007;(1):CD004647.
Kaiser AM. McGraw-Hill Manual Colorectal Surgery. Access Surgery;
2009. Retrieved November 14, 2022, from https://accesssurgery.
mhmedical.com/book.aspx?bookID=425.
McGee MF, Cataldo PA. Chapter 55: intestinal stomas. In: Steele SR,
Further Reading Hull TL, Read TR, Saclarides TJ, Senagore AJ, Whitlow CB, edi-
tors. The ASCRS textbook of colon and rectal surgery. 3rd ed.
New York: Springer; 2016. p. 971–1013.
Parmar KL, Zammit M, et al. A prospective audit of early stoma com-
plications in colorectal cancer treatment throughout the Greater
Manchester and Cheshire colorectal cancer network. Colorectal
Cataldo PA. Technical tips for stoma creation in the challenging patient.
Dis. 2011;13(8):935–8.
Clin Colon Rectal Surg. 2008;21:17–22.
Stocchi L. Ileostomy. In: Fazio VW, Church JM, Wu JS, editors. Atlas
of intestinal stomas. New York: Springer; 2012.
Closure of Loop Ileostomy
51
Indications Preoperative Preparation
Closures of a temporary diverting ileostomy can be per- • Digital rectal exam.

formed under two circumstances: • Gastrograffin enema or CT with rectal contrast to exam-
ine the distal colon and the anastomosis for leaks or
• The original area of concern has completely healed and strictures.
there is a functional anatomy distal to the ileostomy site. • Flexible endoscopy to visually examine the distal anasto-
• The distal problem is unsalvageable (persistent leak, fis- mosis and integrity of colonic conduit.
tula, stricture, tumor, etc.), and in order to minimize fluid • Verify normalized nutritional status and that steroids have
imbalances or restore full access to the residual colon, the been completely tapered off.
ileostomy is taken down and instead a permanent colos- • Perioperative antibiotics.
tomy created (e.g., abdomino-perineal resection). • Perioperative steroid stress dose, if the patient was on ste-
roid treatment within 6 months.
This chapter describes to close a temporary loop ileos-
tomy. Most commonly, that procedure can be carried out
locally through the abdominal wall aperture that was created Pitfalls and Danger Points
for the ileostomy.
• Anastomotic leak at the takedown site, intraabdominal
abscess, enterocutaneous fistula
Contraindications • Reactivation of former (distal) area of concern (leak, fis-
tula) with need to redivert
• Less than 6–12 weeks has elapsed since index surgery and • Surgical site infections (intra-abdominal abscess, wound
ileostomy creation infection)
• Distal obstruction • Anastomotic stricture and adhesions, causing small bowel
• Uncorrected distal problem, unless definitively addressed obstruction
• Persistent poor performance status, nutritional status • Incisional hernia
• Ongoing chemotherapy or immunosuppression
• Uncorrected coagulopathy (including liver failure)
Operative Strategy
Most ileostomy closures can be performed via the same

M. P. Duldulao aperture where the ileostomy was placed. However, do not
hesitate to extend the fascial incision laterally or perform a
Los Angeles, CA, USA midline laparotomy to safely lyse dense adhesions and obtain
adequate exposure and mobility if necessary.
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of If the reason for the difficulty comes from dense adhe-
Hope National Medical Center/Comprehensive Cancer Center, sions, escalating to a laparoscopic approach is generally not
Duarte, CA, USA advisable.

https://doi.org/10.1007/978-3-030-81415-1_51
Use only healthy well-vascularized bowel for the small • Type of anastomosis (end-to-end, side-to-side)
bowel anastomosis. Resect any devascularized or roughed up • Stapled or hand-sewn
segment and perform an anastomosis with healthy limbs of • Hernia repair (with or without collagen implant)
bowel. • Wound closure or not
Superficial wound infections are common (20–25%) fol-
lowing ostomy closure. Weigh the option of avoiding this
problem by leaving the skin open against the substantially Operative Technique
longer wound healing time.
When a longstanding ileostomy is reversed, there is often Incision
a substantial hernia. Usually it is advisable to remove the
hernia sac and to simply readapt the abdominal wall only. A Using a scalpel, make a transverse elliptic skin incision
formal hernia repair with mesh implantation should be around the stoma that tangentially cruises along the upper
planned for a separate time without open bowel. and lower mucocutaneous junction at 1–2 mm distance
and extends 1 cm on the sides (Fig. 51.1a). Use electro-
cautery to stop any skin bleeders. Place Kocher or Allis
Documentation Basics clamps to each of the lateral skin tongues (potentially also
a Babcock clamp to the ileostomy nipple), and gently lift
Coding for surgical procedures is complex. Consult the most them up.
recent edition of the AMA’s Current Procedural Terminology Deepen the incision with the cautery and switch to fine
book for details (see references at the end). In general, it is Metzenbaum scissors when the seromuscular layer of the
important to document: bowel becomes visible. Follow the bowel wall and separate
it from the subcutaneous fat with meticulous sharp dissection
• Findings justifying stoma takedown (Fig. 51.1b). Take care not to injure the bowel wall. Continue
• Extent of adhesions down to the point where the bowel meets the anterior rectus
• Resection of bowel fascia.
Fig. 51.1
a b
51 Closure of Loop Ileostomy 383
Fascial Dissection while freeing the bowel from the peritoneum, extend the
incision laterally to provide better exposure.
Continue the dissection carefully and with patience.
Anticipate that the anatomical layers will be distorted;
often there is a hernia sac and the fascia not immediately tapled Resection and Anastomosis
S
visible. The more difficult the dissection seems, the more of Ileostomy
you should preserve control and avoid any undue traction
or blunt finger dissection, as it may trigger a bowel injury This is the most commonly used technique and is well suited
in the depth of the wound that (1) you may not only not if the bowel loop can be easily exteriorized. It has the advan-
notice, but that (2) you also would have tremendous diffi- tage to remove any segment with questionable bowel
culty to repair. Follow the bowel wall circumferentially and quality.
dissect it off the fascial ring and muscle layer until the peri- Identify where to resect the bowel on the proximal and
toneal cavity is entered (Fig. 51.1b). If the bowel was previ- distal side. Divide the mesentery between these two spots
ously sutured to the fascia, do not hesitate to cut the fascia using the clamping/ligating method or an advanced energy
(err on the side of fascia) to release the bowel. Once the device. Typically, resection of the ileostomy-bearing seg-
peritoneal cavity is identified, insert an index finger to iden- ment and the reanastomosis can be accomplished with two
tify areas of adhesions, but resist to bluntly tearing them loads of the linear stapler. Create a small enterotomy in anti-
down with the wipe of the finger. mesenteric position on either side (Fig. 51.2a). Insert the sta-
pler jaws such that the two bowel loops line up on their
antimesenteric side (Fig. 51.2b, c). Check that the mesentery
Peritoneal Dissection is not trapped in the stapler (Fig. 51.3). Fire the stapler and
get a reload. Grasp the ends of the enterotomy and fire the
Continue to use the finger to separate the remaining adhe- second stapler cartridge in transverse direction (Fig. 51.4a).
sions from the peritoneum. If any difficulty is encountered This closes off the end while resecting the bowel at the same
a b c
Fig. 51.2
time (Fig. 51.4b). You may choose to oversew the staple lines Hand-Sewn Closure of Enterotomy
with absorbable sutures and to close the mesenteric gap.
Alternatively, you may on occasion choose to perform a Particularly if the bowel mobility is limited, you may be bet-
stapled isoperistaltic side-to-side anastomosis and manually ter served by doing a hand-sewn anastomosis. You can either
close off the enterotomy site in two layers with absorbable do this by means of a limited resection of the bowel and an
sutures. end-to-end handsewn anastomosis in two layers, using a run-
ning absorbable suture such as a 3-0 PDS and interrupted
Vicryl sutures.
If difficult circumstances do not even permit such a lim-
ited resection, you may elect to undo the nipple by carefully
freeing the adhesions between the everted part and the inside
layer. Once you have achieved that, the remaining opening
reflects the original transverse incision into the bowel when
the ileostomy was created. Place two holding stitches on
either end. Close the defect transversely in two layers. In
contrast to a wide-lumen colostomy takedown, there is not
usually sufficient space to close that transverse ileostomy
opening with staplers.
Closure of Abdominal Wall
Reduce the small bowel into the abdominal cavity. Irrigate

out the wound copiously with saline. Remove residual hernia
sac and dissect the subcutaneous fat off the anterior wall of
the fascia. Reapproximate the muscle layer with a few inter-
rupted Vicryl stitches. Close the fascia with a running absorb-
able monofilament suture (e.g., PDS #1). Once the fascia is
closed, irrigate out the wound with additional saline
Fig. 51.3 solution.
a b
Fig. 51.4
51 Closure of Loop Ileostomy 385
Management of Skin Wound • Enterocutaneous fistula

• Abdominal abscess
Most commonly, the ileostomy wound can be closed without • Anastomotic leakage
enlarging the skin incision. Closing of the wound is associ- • Internal hernia
ated with a 20–25% incidence of wound infection. Many sur-
geons therefore leave the skin open for healing by secondary
intention. Since 75–80% do not get infected, you might con-
sider closing it and only open it if signs of infection develop. Further Reading
Additional methods include placing a dermal purse string
suture with 3-0 monocryl throughout the circumference of American Medical Association. Current procedural terminology: CPT
the wound. Clinch the purse string down to contract the skin https://www.ama-assn.org/practice-management/cpt.
edges and loosely pack gauze within the opening of the Corman ML. Chapter 31: intestinal stomas. In: Corman ML,
wound. Bergamaschi RCM, Nicholls RJ, Fazio VW, editors. Corman’s
In any open wound scenario, you would manage the colon and rectal surgery. Philadelphia: Lippincott Williams &
Wilkins; 2013. p. 1396–450.
wound by placing loosely packed moist gauze into the sub- Erwin-Toth P. Chapter 32: wound, ostomy, and continence nursing.
cutaneous space to keep the tissue separated. In: Corman ML, Bergamaschi RCM, Nicholls RJ, Fazio VW, edi-
tors. Corman’s colon and rectal surgery. Philadelphia: Lippincott
Williams & Wilkins; 2013. p. 1451–72.
Gong J, et al. Stapled vs hand suture closure of loop ileostomy: a meta-
Postoperative Care analysis. Colorectal Dis. 2013;15:e561–8.
Krand O, Yalti T, Berber I, Tellioglu G. Early vs delayed clo-
• Placement of nasogastric tube is not routine, but may be sure of temporary covering ileostomy: a prospective study.
necessary in patient who develop a profound ileus with Hepatogastroenterology. 2008;55:142–5.
nausea and vomiting. Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, edi-
• Daily wound care to wound bed. Educate the patient on tors. The ASCRS textbook of colon and rectal surgery. Springer;
proper wound care and packing techniques. 2016. https://doi.org/10.1007/978-3-319-25970-3_55.
Salvadalena G. Incidence of complications of the stoma and peristo-
mal skin among individuals with colostomy, ileostomy, and uros-
tomy: a systematic review. J Wound Ostomy Continence Nurs.
Whitehead A, Sea A, Cataldo P. Technical tips for difficult stomas. In:
• Wound infection Steel S, et al., editors. Complexities in colorectal surgery: decision-
making and management. New York: Springer; 2014.
• Prolonged ileus
Management of Problems Related
to an Existing Continent Ileostomy 52
Indications • Recognize acute problems that necessitate immediate

action (Table 52.1).
There are three well-established configurations for construc- • Characterize chronic problems to plan appropriate
tion of a continent ileostomy: Kock pouch (1969), Barnett workup (Table 52.2).
continent intestinal reservoir (BCIR, 1984), and T-pouch • Attempt a gentle intubation to allow drainage of at least
(2002). Each features an ileal pouch reservoir with a valve some gas/stool using any available catheter of any size.
mechanism created to prevent leakage of accumulating stool. • Provide fluid resuscitation and electrolyte replacement if
It is offered to select patients after proctocolectomy for unable to tolerate oral intake.
ulcerative colitis or FAP as a salvage alternative to an ileal • Identify signs of sepsis and administer antibiotics.
J-pouch anal anastomosis or end ileostomy. Despite a notori-
ous revision rate, these constructs offer the potential for
improved quality of life, “continence,” and avoidance of a Pitfalls and Danger Points
cumbersome external appliance.
Continent ileostomies are increasingly rare, and due to • Inability to intubate/drain a continent ileostomy:
the required expertise, performed by only a few specialized Recognize that this is functionally a complete bowel
centers. Nonetheless, patients with existing continent ileos- obstruction. Emergency intervention is required to
tomies may present to general surgeons. It is important to decompress before bowel ischemia and perforation occur.
have a baseline understanding of the function, possible com- • Placement of a nasogastric tube as a sole intervention is
plications, and solutions to avert a catastrophe. This chapter insufficient but may supplement decompression of the
describes these strategies for management of complications pouch and bowel.
related to existing continent ileostomies. • Valve slippage may result in a tortuous access segment:
Forceful blind intubation may traumatize or even perfo-
rate the valve segment or the pouch.
Evaluation and Preparation • Abdominal exploration: Patients with continent ileos-
tomy frequently have extensive adhesions. They also have
• Review the patient’s history, diagnosis, and functional a severely altered anatomy and counterintuitive blood
aspects. Oftentimes, however, that information and supply to bowel segments that together, increase the risk
respective records are not available when the continent for enterotomies, bowel loss, and short bowel syndrome.
ileostomy had been created decades earlier. • Cancer risk: Patients with inflammatory bowel disease or
hereditary cancer syndromes such as FAP are at increased
risk to develop cancer in the small bowel including the
E. R. Noren pouch. This must be considered in the differential diagno-
Department of Surgery, Division of Colorectal Surgery, Keck sis of a bowel obstruction.
A. M. Kaiser (*)
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_52
Table 52.1 Acute complications: Assessment and immediate management

Acute problem Assessment Risk Next steps
Inability to intubate with small bowel SBO cause at pouch/valve Pouch perforation 1. Establish quick and safe pouch intubation
obstruction Bowel perforation 2. Possible NGT, IV hydration, possible
Aspiration antibiotics
Small bowel obstruction despite SBO cause proximal to Bowel perforation NGT, IV hydration, possible antibiotics.
ability to intubate pouch Aspiration Possible exploration.
Inability to intubate due to: Need to bridge this time Pouch perforation Intubate pouch for continued drainage
loss of consciousness, coordination, period Bowel perforation
mental capacity Aspiration
anesthesia for unrelated problem
Perforation (due to intubation or due Peritonitis/abscess Peritonitis: Surgical exploration, antibiotics
to inability to intubate) formation Contained/valve segment: Intubate pouch for
Enterocutaneous continued drainage, antibiotics
fistula
Incompetent valve
Internal loss of intubation tube Retained foreign body No immediate risks Endoscopic retrieval
Aggravated incontinence/urgency Pouchitis Accidents/ Antibiotics
Decompensated or embarrassment Skin protection
traumatized valve Skin damage Pouch intubation + ostomy appliance
Valve fistula
SBO small bowel obstruction, NGT nasogastric tube, IV intravenous
Table 52.2 Chronic problems: Workup and management planning

Acute problem Assessment Risk Next steps
Chronic problems Assessment
Difficult intubation (stricture, Skin level stricture Progression to bowel Once pouch intubated, leave/secure drain
desintussusception, kinking) Valve stricture obstruction (with/without continued drainage) for
Valve kinking 4 weeks
Incremental trauma/edema
Incontinence and peristomal skin Pouchitis Accidents/ Antibiotics
irritation Decompensated or traumatized embarrassment Skin protection
valve Skin damage Pouch intubation + ostomy appliance
Valve fistula
Pouchitis with urgency/frequency Accidents/ Antibiotics, probiotics
embarrassment Endoscopy, possible pouchogram
Skin damage
Formation of fistula from valve to Valve mechanism annihilated Accidents/ Pouchogram or/and CT scan
reservoir embarrassment Pouchoscopy
Skin damage Elective surgery
Prolapse Partial valve desintussusception Progression to Pouchogram or/and CT scan
incompetent valve Pouchoscopy
Progression to Possible elective surgery
difficult intubation
Peristomal herniation Abdominal wall weakness Discomfort Observation vs. hernia surgery
Appearance
SBO (rare)
Bleeding DDx: Anemia Pouchoscopy
Intubation trauma
Pouchitis
Crohn disease
Neoplasia
Anemia Malabsorption Secondary Pouchoscopy
Mucosal pathology (IBD, Vitamin B12 evaluation/replacement
neoplasia) Search for other causes
Stone formation Common incidental finding Pouchitis Removal only if revisional surgery for
other reason
Disease transformation to Crohn Inflammatory changes in afferent Pouch failure Pouch removal, biological treatment
small bowel, fistula formations
Neoplasia Change of priorities Cancer progression Cancer management, including possible
resection and pouch removal, ileostomy
52 Management of Problems Related to an Existing Continent Ileostomy 389
Operative Strategy pouch (e.g., cholecystectomy, gynecological, and urologi-

cal). In such cases, anticipation is the best protection.
Quickly determine whether the patient’s situation reflects an Imaging should be reviewed to determine the position and
acute emergency that necessitates an urgent intervention, or strategize about safest access routes. Extensive adhesions
whether a chronic management problem exists. As long as are common and may preclude minimally invasive
stool can be drained from the pouch, there is usually no acute procedures.
emergency. It may be the case that intermittent intubation For minor/short procedures, it is sufficient to instruct the
must be interrupted. An indwelling tube can be left in place patient to intubate and empty the pouch immediately before
to enable continuous drainage, or can be intermittently and after surgery. For longer or complex surgeries, it is advis-
clamped and drained. Do not hesitate to contact a center with able to place an indwelling soft ileostomy tube that is con-
experience in managing continent ileostomies and their nected to a draining bag and excluded from the surgical field
complications. underneath the sterile draping. In addition to providing con-
tinuous drainage, the tube facilitates palpation and identifica-
tion of the pouch during the operation. If necessary, the
Difficult Stoma Intubation pouch can be filled with water to further clarify the anatomy.
Postoperatively the tube is left in place and monitored for
The most common causes for difficult intubation are a desintus- regular output until the patient is again capable to resume
sucepted valve with a tortuous course of the access segment, self-intubations.
chronic stricturing (at the skin level stoma or the valve itself), or
acute traumatization from failed intubations with worsening
edematous swelling. An excessively full pouch can also result in Acute Pouch Surgery
kinking of the valve segment or the afferent bowel, which may
induce a vicious circle of overload and dysfunction. Pouch revision is a complex procedure and should not be
The absolute priority is to establish access and successful considered without respective experience. Approach acute
decompression of the pouch, which should be achieved before problems with a pouch that necessitate a nonelective abdom-
other any other steps or imaging. If a tube with a soft tip can- inal intervention, by the following strategies (individually or
not be easily inserted, pouch intubation under direct visualiza- in combination):
tion is required. Depending on the circumstances, that may be
possible on the spot (bedside, clinic) or require an interven- 1. Repair acute injury and establish proper pouch drain
tional suite (operating room, GI, or fluoroscopy suite). position and function.
2. Proximal diversion with loop ileostomy.
3. Pouch excision and creation of end ileostomy.
anagement During Non-related Surgeries or
M
Incapacitation Unless specifically consented for, the decision to per-
form a definitive pouch removal should be approached
To manage patients who are temporarily incapacitated and with caution. A true pouch revision during an emergency
unable to perform intubations for more than 4–6 hours (e.g., is discouraged, and whenever possible revision surgery
during anesthesia for a non-related surgery, or due to mental should be deferred until the patient and the tissues are in
or physical factors), an indwelling tube should be placed and optimal condition to minimize the postsurgical
secured to a gravity draining bag, until the ability to intermit- morbidity.
tently intubate is restored. During that period the output
needs to be carefully monitored and the tube may need to be
flushed to maintain patency. Chronic Pouch Dysfunction
Non-emergent problems with a continent ileostomy warrant

onsiderations for Unrelated Abdominal
C a proper workup leading to a thorough decision-making pro-
Surgery cess about the options and expectations. When confronted
with chronic pouch issues, establish temporary measures to
Patients with a functional continent ileostomy may need mitigate the symptoms and refer the patient to a center with
an abdominal surgery that is entirely unrelated to their experience in continent ileostomy surgery.
Documentation Basics ileostomy and advance it under direct visualization and

with the minimum necessary insufflation. Once you
Coding for surgical procedures is complex. Consult the most reach the pouch, gently advance the tube into the reser-
recent edition of the AMA’s Current Procedural Terminology voir and remove the scope. Stool should immediately
book for details (see references at the end). In general, it is start to drain. Repeated water irrigations may be neces-
important to document: sary to flush the openings. Secure the drain in place and
connect it to a catheter bag to gravity drainage.
• Findings and indications
• Bowel viability
• Absence of twisted efferent segment or small bowel Pouchoscopy
mesentery
• Pouchoscopy—adequacy of views/preparation, ease of When performing a flexible pouchoscopy for diagnostic rea-
scope insertion, length and configuration of valve seg- sons rather than therapeutic pouch decompression (see
ment, mucosal appearance, abnormal findings, and any above), use the largest flexible instrument that fits through
biopsies performed the skin level stoma. Oftentimes, that is the pediatric endo-
scope. Sedation and analgesia are not routinely administered,
but may be optional per patient request.
Operative Technique Insert the endoscope into the skin-level stoma and slowly
advance under direct visualization, utilizing fluid irrigation
Endoscopic Pouch Decompression or insufflation as necessary, until the pouch reservoir is visu-
alized. Use irrigation as needed to remove residual stool and
First examine the abdomen and visualize the skin-level inspect for any mucosal abnormalities. Identify the afferent
ostomy. A digital exam is almost always inappropriate. limb and attempt to follow it for 20 cm. Retroflex in the
Instead, use a small catheter or a Q-tip to gently “palpate” pouch reservoir to visualize the valve segment. Be sure to
the valve segment and get an idea about the direction for the describe the intestinal mucosa, any abnormal findings, as
intubation. Assess the diameter of the opening and decide well as the length and structure of the valve segment.
which instrument to use. Sedation in most circumstances is Routinely take biopsies from the afferent limb and the pouch
not necessary. reservoir, or from any suspected pathology. Avoid biopsying
the valve segment. Suck out as much air as possible as the
A. Narrow rigid sigmoidoscopy: This instrument can often scope is withdrawn.
be advanced to the pouch reservoir and facilitate prelimi-
nary decompression. However, the narrow sigmoido-
scope is too small to accommodate passage of an Pouch Revision
adequate size indwelling tube (24-30F), and a standard
thin guide wire is too soft to serve as a reliable help. A more detailed explanation of the technical aspects of
Therefore, you must first slide in a smaller tube that fits pouch revision surgery is beyond the scope of this chapter.
through the lumen of the rigid scope and then advance
the desired tube over the first one. Take precaution not to
inadvertently push the smaller tube further into the pouch Postoperative Care
where it may become a lost foreign body. A conventional
guide wire may be pushed through the plastic at the end • Diet: Restart immediately if no obstruction, otherwise as
of the small catheter and looped to create a handle for soon as return of bowel function
added security. The larger tube can now be slid over the • Catheter management: Monitor and record output every
small tube+guidewire loop until the reservoir is reached. 6 hours. Irrigate the catheter twice daily with 30 cc of tap
Withdraw the small tube and verify appropriate pouch water: Instillation and withdrawal should have not
drainage from the larger tube. Secure it in place and con- resistance.
nect it to a catheter bag to gravity drainage. • Antibiotics: Only for specific therapeutic indication.
B. Flexible endoscope: Select the appropriate size of instru-
ment. A very slim 5–6 mm scope can usually be inserted
but does not allow for appropriate drainage. Hence, using Complications
lots of lubricant, slide a larger drainage tube with an open
end tip as a sheath over the flexible part before accessing • Bowel/pouch perforation
the pouch. Then insert the sheathed instrument into the • Enterotomies
52 Management of Problems Related to an Existing Continent Ileostomy 391
• Trauma to valve segment or pouch Kaiser AM. Kock pouch dysfunction. In: McGraw-Hill Manual
Colorectal Surgery. Access Surgery; 2009. Retrieved November
• Abscess formation 14, 2022, from https://accesssurgery.mhmedical.com/book.
• Enterocutaneous fistula formation aspx?bookID=425.
Kaiser AM. T-Pouch: results of the first 10 years with a nonintussus-
cepting continent ileostomy. Dis Colon Rectum. 2012;55:155–62.
Kaiser AM, Stein JP, Beart RW Jr. T-pouch: a new valve design for
Further Reading continent ileostomy. Dis Colon Rectum. 2002;45:411–5.
Kock NG. Intra-abdominal “reservoir” in patients with permanent ile-
American Medical Association. Current procedural terminology: CPT ostomy. Preliminary observations on a procedure resulting in fecal
®. Professional ed. Chicago: American Medical Association; 2022. “continence” in five ileostomy patients. Arch Surg. 1969;99:223–31.
https://www.ama-assn.org/practice-management/cpt. Murrell Z, Fleshner P. Ulcerative colitis: surgical management. In:
Aytac E, Ashburn J, Dietz DW. Is there still a role for continent ile- Beck DE, The ASCRS, editors. Textbook of colon and rectal sur-
ostomy in the surgical treatment of inflammatory bowel disease? gery. 2nd ed. New York: Springer; 2011. p. 479–97.
Inflamm Bowel Dis. 2014;20:2519–25. Nessar G, Fazio VW, Tekkis P, et al. Long-term outcomes and quality of
Barnett WO. Modified techniques for improving the continent ileos- life after continent ileostomy. Dis Colon Rectum. 2006;49:336–44.
tomy. Am Surg. 1984;50:66–9. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcer-
Beck DE. Continent ileostomy: current status. Clin Colon Rectal Surg. ative colitis. BMJ. 1978;2:85–8.
2008;21:62–70.
Part V
Large Intestine
Andreas M. Kaiser
Concepts in Surgery of the Large
Intestine 53
Andreas M. Kaiser
Introduction Diagnostics
Surgery with its subspecialties remains the queen of all med- Modern evaluation for colorectal symptoms and diseases has
ical disciplines. Second to none, it combines a proactive atti- become a lot more sophisticated in the last 20–30 years.
tude and risk taking with knowledge and skills when facing Radiographic, endoscopic, pathological, as well as biochem-
the sometimes enormous intellectual and technical chal- ical and molecular analytical tools and combinations thereof
lenges in the management of a wide spectrum of different have found their way into daily routine. Goal is to better
diseases, all of which keep changing and evolving at an characterize nonmalignant and malignant conditions in order
unparalleled speed. to define subgroups and develop tailored treatment plans.
As the field constantly evolves with high-tech tools and Prime examples include colorectal cancer at all stages. At
diagnostics, there is unquestionably a high pressure from the prevention level, increasingly consistent guidelines have
patients and the public alike to obtain and demonstrate high defined risk groups and established the start, appropriate
quality education and training, remain up-to-date and knowl- tools, and interval/frequency of screening (Verma et al. 2015;
edgeable, while being patient-friendly, modern, safe, and Ransohoff and Sox 2016). Screening aims at identifying and
cost-conscious all at the same time. The large variety of old eliminating precancerous lesions or detecting less advanced
and new tools and techniques for more detailed diseases tumors such that the eventual cancer incidence and mortality
result in increasingly complex management algorithms that can be reduced by 75–90% and 50–60%, respectively
offer a great opportunity for success, but also carry risks, (Loberg et al. 2014; Winawer 2014). Colonoscopy remains
traps, and pitfalls. the gold standard for screening and is recommended to start
This chapter provides from a surgical perspective an over- no later than 50 years of age in average risk individuals
view over the intellectual, technical, and decision-making (Bibbins-Domingo et al. 2016). However, it is important to
challenges within the colorectal specialty. It defers compre- identify increased risk constellations (positive family his-
hensive disease presentations and review of pathophysiolog- tory, African-American ethnicity, Ashkenazi Jews, known
ical and epidemiological details to respective texts. The genetic treats, inflammatory bowel disease), for which
focus here is to emphasize specific aspects that are relevant screening has to start at an earlier time point. Alternative
for establishing safe practice patterns and allowing for a screening modalities include CT colonography, or fecal
structured development of surgical strategies—in general DNA or FIT (Quintero et al. 2012).
and with a focus on the most recent trends. While the surgi- Once a colonic lesion has evolved, advanced endoscopic
cal dissection of a particular anatomy should largely be the techniques allow for removal, marking/tattooing, or place-
same regardless of the target pathology or the technical ment of colonic stents. Cross-sectional imaging such as
modality, it is often more a matter of the when, how much, ultrasound, CT scan, MRI, PET scan, or interventional radi-
and what type of reconstruction that optimize the surgical ology have become a lot more sensitive and precise and
outcomes. hence play an important role in defining the exact nature and
pretreatment staging. More importantly, however, they delin-
eate the normal and pathological anatomy in a way that
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of should allow a surgeon and associated specialties to define
Hope National Medical Center/Comprehensive Cancer Center, operability and resectability, as well as the appropriateness,
Duarte, CA, USA role, and sequence of various treatment modalities.

https://doi.org/10.1007/978-3-030-81415-1_53
396 A. M. Kaiser
Immunohistochemical, molecular, and genetic profiling pro- 2011). On the other hand, it remains to be seen whether those
vide information about current and future risks for the indi- new drugs truly reduce the overall need for surgical interven-
vidual as well as for the family members (Chubb et al. 2015). tion or only delay it with a shift of the curve to the right.
Furthermore, it may help shaping the decision-making pro- Additional concerns include that presence of such complex
cess about the value and extent of additional prophylactic pharmacological and biological interventions alter the surgi-
surgeries (e.g., more extensive colorectal resection, hysterec- cal field, suppress healing capacity, and potentially dispro-
tomy), surveillance, and adjuvant treatment modalities. To portionately increase peri- and postoperative risks, such that
name a few examples, MSI-high tumors are characterized by the traditional two-stage operations for ulcerative colitis
a less well-differentiated tumor histopathology, decreased more frequently give way to a three-stage approach (Devaraj
response rates to 5-FU-based chemotherapy, and yet para- and Kaiser 2015a).
doxically an overall better survival (Saridaki et al. 2014; Multimodality treatment for rectal cancer has shifted
Erstad et al. 2015). Or, chemotherapy with cetuximab is con- from postoperative adjuvant treatment to preoperative neo-
traindicated because largely ineffective in patients with adjuvant chemoradiation for locally advanced disease. While
KRAS-mutated tumors (Van Cutsem et al. 2009). this approach has been shown to reduce the incidence of
Similar to the abovementioned example of colorectal can- local tumor recurrence, it has typically not resulted in pro-
cer, and without going into every single detail, other benign longed survival but increased the risks of postsurgical com-
and malignant colorectal conditions rely on their own set of plications such as anastomotic leaks, hence necessitating a
disease-specific characterization to guide their evaluation higher probability of a diverting ileostomy. On the other
and treatment. The value of such parameters should not be hand, this approach has resulted in a new management entity
underestimated. It is very well imaginable, not to say likely, of patients who show a complete clinical response after neo-
that future research will bring to light even more detailed adjuvant chemoradiation and may choose/be offered to forgo
molecular and genetic features. Those will broaden our the standard of care oncological resection and pursue a watch
understanding of normal and disease processes. They may and wait approach (“Habr-Gama”).
replace conventional staging and predictive/prognostic Management of metastatic colorectal cancer has become
parameters and help prevent, understand, diagnose, and exceedingly complex with some patients being candidates
manage diseases more precisely. for treatment in curative intent, others being potentially cur-
able, while the remaining majority still asks for optimized
palliative treatment (Tol et al. 2009). The benefit should not
Nonsurgical Treatments be underestimated as the overall survival for metastatic
colorectal cancer has increased from just a few months to
Management of numerous diseases and pathologies that tradi- over 2 years with some living with metastatic diseases even
tionally were without exception in the surgery bucket has more than 5–10 years. All such patients will have to be ana-
evolved over the past 2–3 decades. Better knowledge has lyzed individually, best through interdisciplinary tumor
resulted in improved strategies and optimized outcomes. For board discussions, as to whether they are benefiting from
example, routine postoperative management has changed systemic treatment first, or whether a diverting stoma or
from a passive waiting to a proactive enhanced recovery after removal of the primary tumor prior or in between treatment
surgery (ERAS) protocol to accelerate return of bowel func- cycles is prudent to prevent or treat tumor complications.
tion and reduce complications (Mortensen et al. 2014; Last but not least, modern radiation techniques including
Carmichael et al. 2017). Powerful new nonsurgical tools have gamma knife, radiofrequency ablation, and others allow for
been developed in many fields including management of can- nonsurgical “resection” for areas with recurrent or metastatic
cer, inflammatory bowel disease, or complex abdominal infec- disease.
tions including postsurgical or disease complications. While The evolution of interventional radiology has greatly
many of those new treatments have added value and improved improved management of complex patients whose only sur-
outcomes, the expanded number of options frequently also gical alternatives would be massive surgery (for example,
add to the complexity of surgical decision-making. total abdominal colectomy) or exploration/reoperation at a
For example, introduction of biological treatments for suboptimal time point. Examples include severe lower GI
inflammatory bowel disease has on the one hand been able to bleeding, abdominal infections with abscess formations
control more severe disease presentations that previously (such as diverticulitis, postsurgical, Crohn disease, appendi-
only had steroids and a few immunosuppressive drugs avail- citis, and others), or tumors/masses not yet specified/
able before curative surgery had to come in (Ford et al. characterized.
53 Concepts in Surgery of the Large Intestine 397
Surgical Tools Table 53.1 Components of modern perioperative management

Time period Detail/discussion points/variations
The armamentarium of surgical tools has rapidly expanded. Preoperative
The introduction and fast pace evolution of minimally inva- Bowel preparation Various protocols, +/− oral antibiotics
sive surgery has turned a necessity into a booming industry Preoperative fasting 6–8 hours per ASA guidelines, except:
Essential medications with water
that has contributed on a number of different fronts including Carbohydrate-rich drink 2 hours before
energy delivery, laparoscopic, robotic and endoscopic or surgery
transanal tools for access, visualization, instrumentation, and Skin Prewash with chlorohexidine
retrieval. The major surgical platforms to play a role for the decontamination
abdomen and large intestines are: Intraoperative
Antibiotic Appropriate selection dependent on case,
prophylaxis 24 hours maximum
• Open surgery: single site/single organ, combo multiple Maintenance of Avoidance of fluid overload and/or
sites, multivisceral (same location), major en-bloc euvolemia underresuscitation
resections Maintenance of
• Laparoscopic surgery (LS): straight multiport LS, hand- normal body
assisted LS (HALS), single incision LS (SILS) temperature
Maintenance of
• Robotic surgery
normal blood
• Transanal surgery: conventional, transanal endoscopic glucose
microsurgery (TEMS), transanal minimally invasive sur- DVT/PE Initiation preoperatively (in absence of
gery (TAMIS), transanal total mesorectal excision prophylaxis contraindications)
(taTME) Type of surgery Minimally invasive vs most efficient
• Endoscopic interventions: polypectomy, endoscopic Postoperative
Optimized fluid Administration of adequate fluid until
mucosal resection (EMR), endoscopic submucosal dis-
maintenance return of bowel function
section (ESD), stent placement, tattooing Catheters/drains Avoidance/discontinuation of NGT, Foley
• Combined endoscopic-laparoscopic surgery (CELS) catheter, drains at earliest possible moment
Antibiotics Routine coverage for the perioperative
This growth unquestionably has expanded horizons and, on 24-hour period
the one hand, offers less aggressive options for standard surger- In case of contamination or underlying
infection/sepsis, continuation of
ies and, on the other hand, allows for tackling more advanced therapeutic antibiotics
and complex diseases. However, there is also competing overlap Diet Unless specific contraindications, early
between the various techniques, which has added cost, and an postoperative e feeding starting POD#0-1,
incredible incidence of noncompatible systems and subjective advance as tolerated to regular diet as
tolerated
preferences. Oversight and careful consideration of objective
Ambulation/ Emphasize early mobilization and
benefits and cost with a comprehensive institution-wide infra- Activity encourage ambulation starting on POD0
structure and equipment plan with space for both growth and DVT/PE Continued from preoperative or initiated
restrictions alike are among the most challenging tasks modern prophylaxis within 24 hours (in absence of
leadership is faced with (Zelhart and Kaiser 2017). contraindications)
Respiration Encourage deep inspiration with incentive
spirometer
Chest physical therapy and inhaler
Perioperative Management treatment individualized
Adequate pain control
Over the past 20–30 years, the perioperative management of Pain Multimodality approach (preferably
opiate-sparing):
patients with colorectal operations has dramatically changed.
Gabapentin
A more proactive and standardized approach aims at reach- Acetaminophen
ing quality benchmarks. Specific efforts are in reducing sur- Opiates as needed
gical site infections, shortening the postoperative ileus, Local or systemic anesthetics (e.g.,
lidocaine)
optimizing pain management, reducing secondary morbidity
NSAIDS: concern about increased
(DVT, atelectasis/pneumonia), optimizing fluid manage- anastomotic leak rates, renal failure,
ment, overall shortening of the length of stay, and avoiding peptic ulcer
unnecessary readmissions (Table 53.1).
398 A. M. Kaiser
A number of those factors are included and summa- Diseases

rized in enhanced recovery after surgery (ERAS) proto-
cols with early mobilization and early feeding (Carmichael Colorectal Polyps
et al. 2017). In addition, there is an impetus to use mini-
mally invasive surgically surgery techniques wherever The majority of colorectal lesions are of epithelial origin and
possible, and to minimize the use of drains and catheters. develop on the mucosal surface as a polyp. Descriptively,
Preoperative fasting for 6–8 hours as required by tradi- polyps can be classified by size and appearance, for example
tional anesthesia protocols has also been challenged inso- as diminutive, flat/sessile, or pedunculated. More sub- or
far as the prolonged absence of enteric stimulation was extramucosal pathologies (e.g., lipoma, carcinoid, GIST,
shown to rather diminish the bowel recovery than improve lymphoma, Kaposi, and others) should be kept in mind when
it. ERAS protocols therefore include a carbohydrate boost assessing a specific irregularity. Benign epithelial polyps
drink even within less than 6 hours without increased risk without malignant potential include the non-adenomatous
of aspiration. polyps (e.g., hamartomatous, inflammatory, or small hyper-
Preoperative bowel cleansing remains a matter of debate plastic polyps). More relevant are the polyps that carry a
as to whether it is necessary in the first place, and whether it potential risk of malignant transformation and consist of
should include antibiotics. Unquestionably for left-sided adenomatous polyps, very large hyperplastic, or serrated pol-
anastomosis, a stool load represents a clear disadvantage, yps. The risk of high-grade dysplasia or cancer in an adeno-
whereas for right-sided anastomoses, that may not be rele- matous polyp increases with size and depends on its
vant. But a proper bowel cleansing offers a number of advan- predominant feature (villous > tubulovillous > tubular).
tages including the ability to perform intraoperative The transition from a polyp with malignant potential
colonoscopy if necessary, advance staplers, or to carry out through dysplasia to an invasive cancer is a fairly slow pro-
intracorporeal anastomoses without spillage of enteric cess that may take years, except if genetic mutations cause a
contents. dramatic acceleration (Hadac et al. 2015). This generally
Much debate continues about the safest way to perform a allows for adequate screening and intervention with removal
bowel anastomosis and remains a matter of surgeon’s prefer- of precursor lesions as a means for risk reduction (Meester
ence and diligence. Staplers have largely facilitated the pro- et al. 2015). As long as dysplastic cells in a polyp do not
cess but maintaining solid skills for hand-sewn techniques is cross the boundaries of the mucosa (basement membrane
crucial. In general, it is recommended to achieve a tension- and muscularis mucosae), there is no access to lymphovascu-
free reach, preserve an excellent blood supply on both sides lar and vascular structures and therefore no risk for
of the anastomosis, achieve a negative air leak test, and metastases.
potentially cover the anastomosis with other tissues such as Detection and removal of premalignant lesions is the pri-
an omental flap. mary task of advanced endoscopic techniques which are in
While many trends appear to result in improved care and the realm of colorectal and some general surgeons (Lieberman
outcomes, there is one serious trend that works in the oppo- et al. 2012). Depending on the size and shape, cold forceps
site direction. In a nationwide epidemic, obesity, morbid polypectomy, snare polypectomy, endoscopic mucosal resec-
obesity, and superobesity have become so prevalent that we tion (EMR), or endoscopic submucosal dissection (ESD)
have dramatically shifted our perception of “normal weight may be utilized. A number of additional tools allow for con-
patients.” A normal body mass index (BMI) in the past is trol of bleeding, approximation of the defect, and specimen
used to be defined as being between 20 and 25. Nowadays, a retrieval. And last but not least, a difficult endoscopic polyp-
BMI of 30–35 is the new norm and does not really change ectomy may be monitored and supported by a simultaneous
any of the surgical strategies and techniques. However, laparoscopy and bowel manipulation (combined endoscopic
beyond that, there are truly superobese patients with BMIs laparoscopic surgery, CELS). If a lesion is located in the rec-
above 40, 50, up to 80! It is not difficult to recognize that tum, transanal endoscopic microsurgery (TEMS) or trans-
even the most sophisticated techniques may hit substantial anal minimally invasive surgery (TAMIS) may allow for a
obstacles that result in less perfect dissections, as well as removal without a segmental resection (Devaraj and Kaiser
increased surgical and general morbidity and mortality. It is 2015b).
very likely that over time, this may cause a “worsening” of With availability of these sophisticated tools that aim at
the overall outcomes—unless the data are normalized to the avoiding a bowel resection, the true art comes to the decision-
respective BMIs. making about the appropriateness of a specific approach as
Table 53.2 Appropriateness of various approaches to colorectal lesions

Endoscopic/TEMS/TAMIS CELS Resection
Appropriate Noncancerous polyp: Noncancerous polyp: Noncancerous polyp:
Single Difficult access Multiple locations
Manageable number of In peritonealized portions Too large
polyps Cancerous polyp: Extending over several folds
Small, stalk, easy lift Complete excision with 2 mm Not amenable to EMR/CELS
Cancerous polyp: negative margin Poor lift
Complete excision with Recurrent polyps
2 mm negative margin Genetic cancer syndromes
Cancerous polyp:
incomplete excision, less than 2 mm margin,
lympho-vascular invasion
Invasive cancer T1-4 Nx
Debatable Lesions with high chance of Lesions with high chance of Any of the above in high risk patients (operability)
incomplete excision incomplete excision
Lesions with high risk of Lesions with high risk of
perforation/bleeding perforation/bleeding
T1 cancer T1 cancer
Polyps in Lynch syndrome
Contraindicated FAP, aFAP, MAP (except for FAP, aFAP, MAP Non-adenomatous polyps
biopsy confirmation) Endoscopically manageable polyps
opposed to a resective surgery (Table 53.2). Without any gene mutations, and others (Chang et al. 2012; Langman
doubt, true polyposis syndromes are not appropriate for non- et al. 2017).
surgical including endoscopic management except for diag- The surgical management has overall been relatively
nostic purposes. Good indications are single or a limited well-defined in regard to the goals that should be achieved
number of benign lesions that are either small, on a narrow (Chang et al. 2012; Langman et al. 2017). However, the tools
stalk, or easily lift with submucosal injection. In skilled and pathways as well as timing to pursue those goals still
hands, the absolute size may need to be taken into consider- lack uniform consensus and frequently need to be deter-
ation but is not necessarily a limiting factor. If the number or mined on an individual basis through interdisciplinary tumor
size of such lesions render them unamenable to endoscopic board discussions.
management, deep rather than mucosal three-quadrant tat- Outcomes parameters include overall survival, cancer-
tooing and good documentation is crucial to identify the cor- specific survival, disease-free survival, local recurrence
rect target segment at the time of the surgical resection. rates, stoma-free survival rates, other quality of life parame-
ters, as well as rate of treatment-related dose-limiting short-
term as well as long-term toxicity (Rivoirard et al. 2016).
Treatment parameters for unresected disease include rate of
Colorectal Cancer
tumor progression, tumor response and regression rates,
complete remission, and progression-free interval. Additional
The complexity of colorectal cancer management to a large
surgical quality parameters include the completeness and
degree lies in the limited individual predictability and the
integrity of the specimen (mesocolon, mesorectum), resec-
resulting threat of the disease to the overall survival (Kaiser
tion margins (proximal, distal, circumferential), lymph node
et al. 2013). Surgical resection remains with few exceptions
harvest, conversion rates for minimally invasive approaches,
the only potentially curative treatment for colorectal cancer.
perioperative morbidity and mortality, anastomotic leak rate,
However, from historically being an easily defined treatment
return of bowel function, length of hospital stay, or time to
target, the modern approach has become a very challenging
initiate chemotherapy.
intellectual exercise. Not only are there multiple presenta-
The role and timing of other treatment modalities (sys-
tions and symptoms, stages and even within respective stages
temic chemotherapy or radiation treatment) depends on the
a large variability, but there are also on a pathophysiological
tumor stage at the time of presentation and further has to
level a number of different genes and risk constellations to
distinguish between colon cancer and rectal cancer. In
be taken into account (Punt et al. 2017). The treatment strat-
absence of distant metastases (stage IV disease) or tumor
egy depends on elective versus emergency presentation,
invasion into surrounding structures (T4), the primary tumor
stage of the disease at the time of the presentation, resect-
should be addressed in curative intent. Tumor adjacency or
ability of the tumor, overall patient performance status and
invasion of surrounding structures may require multivisceral
operability, predisposing underlying pan-colonic diseases or
400 A. M. Kaiser
resections, but if critical structures or locations (e.g., iliac Colon Cancer

blood vessels, lateral pelvic sidewall) are involved, the tumor Depending on the location of a primary tumor, standard
may be unresectable. In the majority of cases, surgical resec- extents of resection have been defined, largely based on the
tion represents the first step for localized or locoregional respective blood supply and lymph node drainage. A high
colon cancers, followed by adjuvant chemotherapy for stage ligation of the vascular pedicles and dissection along the
III and selected high risk stage II patients. In contrast, stage natural, embryologically defined planes aims at achieving an
II/III rectal cancer (as defined by being within 15 cm of the intact mesocolic resection with an adequate lymph node har-
anal verge or distal to the coalescence of tenia) are typically vest to assure a representative lymph node analysis and
offered neoadjuvant chemoradiation prior to a surgical resec- tumor staging (Bokey et al. 2016). Harvesting or reporting
tion unless stage uncertainty (stage I versus stage II), less than 15 lymph nodes may result in understaging of the
radiation-sparing protocols, or other favorable situations tumor. The defined segmental oncological resections repre-
allow for a surgical resection and subsequent tailored adju- sent the minimally necessary extent for a specific cancer
vant chemoradiation based on the definitive pathological location. In case of multiple primary tumors, underlying
tumor stage. Current research efforts including development genetic diseases (such as Lynch syndrome, FAP and attenu-
of MRI criteria aim at more specifically identifying patients ated FAP, or MYH-associated polyposis), or inflammatory
who benefit from the neoadjuvant and/or adjuvant treatment bowel disease, more extensive risk-reducing prophylactic
in general and specifically from radiation to justify the long- resections may be appropriate even before an invasive cancer
term side effects (Chand et al. 2015). develops (Church and Simmang 2003; Herzig et al. 2017).
If stage IV is identified at the time of diagnosis, systemic With relatively rare exceptions, resections that do not extend
treatment is the primary strategy but management of the pri- into the rectum will not require creation of a stoma under
mary tumor needs to be individualized based on its symp- elective circumstances. It may be necessary under emer-
tomatology (obstruction, perforation, bleeding) and the gency conditions, certain high risk constellations, or in case
overall tumor burden. The metastatic tumor manifestations of a complication (anastomotic leak), which should not
should be classified as resectable, potentially resectable, or exceed 2–5% overall.
unresectable. Based on that, the multidisciplinary team In contrast to other disease managements (e.g., breast
should define whether the goal remains possible cure, best cancer or melanoma), the technique of sentinel lymph node
palliation, or is indeterminate until the response to systemic dissection has not gained traction in colorectal surgery as
treatment can be assessed. In the comparably small subgroup studies had failed to show reproducibility and predictability.
of stage IV patients that aim for a surgical resection of the While historically the open resection technique was
primary and metastatic sites in curative intent, one of the defined as the standard, minimally invasive approaches (such
unsolved discussions is whether they should be resected at as laparoscopic) have established themselves through well-
the same time, or in a staged approach. In the latter case, it designed prospective randomized trials as being either equiv-
remains a matter of debate whether the systemic disease or alent or even superior if done by appropriately trained
the primary tumor should be addressed first. surgeons. Yet, and likely due to the complexity of such tech-
Preoperative evaluation and staging of colorectal tumors niques, the market penetration has only slowly increased
includes histopathological evaluation, local and systemic over the last 15 years. Benefits of the laparoscopic as opposed
staging, and clearance of the rest of the colon (Table 53.3). to open approach include not only the smaller and often
more cosmetic incisions but also a decreased negative impact
on the physiology of the intestines, overall reduced postop-
Table 53.3 Workup for colorectal cancer erative ileus, as well as decreased long-term complications
FIRST choice Alternatives of hernias and adhesions (Chang et al. 2012; Langman et al.
Pathology Conventional histopathology + Specific tumor 2017). Parallel to increased use of minimally invasive tech-
immunohistochemistry and profiling in niques, introduction of the previously mentioned enhanced
MSI testing selected cases
PCR recovery after surgery (ERAS) protocols have contributed to
Colon Full colonoscopy CT colonography, faster return of bowel function and decreased length of hos-
contrast enema pital stay (Carmichael et al. 2017; Devaraj and Kaiser 2015a).
Local tumor Colon cancer: CT abdomen/ PET/CT scan
staging pelvis with oral/IV and Rectal Cancer
possible rectal contrast
Rectum: MRI or ultrasound Even though colon and rectal cancer in many aspects are
Systemic CT chest/abdomen/pelvis PET/CT scan comparable, there are significant differences about the tumor
tumor staging characteristics and behavior, the tumor geography with prox-
Assessment Individualized imity to other relevant structures, as well as functional
of operability aspects. The latter are related to the bowel control, sexual
function and fertility, as well as urinary function. The closer intersphincteric groove with a colo-anal pull-through and
a lesion is to the pelvic floor and sphincter complex and the hand-sewn anastomosis. That preservation of seemingly nor-
larger it is, the higher is the likelihood to require at least a mal anatomy however comes at the price of decreased func-
temporary if not a permanent stoma. Even if ultimately, the tionality with passive incontinence particularly at nighttime.
intestinal continuity can be preserved, the price tag may be a For the very low anastomosis (colo-anal anastomosis), cre-
substantial impact on the function with a non-negligible inci- ation of a 5–6 cm long colonic J-pouch may obviate some of
dence of potentially incapacitating low anterior resection those functional issues particularly in the first 1–2 years. The
syndrome (LARS). Locally advanced tumors (stages II/III) low pressure reservoir with reversed peristalsis may have the
are typically treated with neoadjuvant chemoradiation unless benefit of reduced urgency; in the long run, however, the
an obstruction requires a temporary diversion or definitive advantage disappears and there may in fact be a risk of stool
resection (see section on large bowel obstruction) (Sauer clustering with fecal outlet obstruction. Such a pouch should
et al. 2004). The chemoradiation is offered in two different not be done for mid to upper level rectal anastomoses.
setups which have not been compared in a systematic fash- In case of tumors reaching the mesorectal envelope or
ion. The short course is more common in Europe and involves invading surrounding structures, more extensive resections
5 days of radiation with a total of 2500 cGy, followed by including the anterior pelvic compartments (“pelvic exen-
surgery after roughly 1 week (Lutz et al. 2016). The advan- teration”) or the sacrum (sacrectomy) may be appropriate
tage of this approach is its fairly short sequence and likely choices if a negative margin can be achieved. As the size of
lower cost, but obviously tumor regression by the time of the resulting defect may not allow for direct tissue approxi-
surgery cannot be expected. The long course is the most mation and closure, advanced planning for possible transpo-
common setting in the USA and involves typically 5040 cGy sition of a myo-cutaneous flap is necessary. Under special
radiation and 5-FU-based chemotherapy over the course of circumstances, such aggressive resections may even be justi-
5–6 weeks; surgery is performed after an interval of fied for best palliation of highly symptomatic tumors even
6–8 weeks from the last radiation to allow for regeneration of without being able to achieve cure. Again, depending on the
damaged noncancerous tissues and continued tumor regres- specific circumstances and whether the pelvic floor is pre-
sion. In fact, there is a 15–25% chance of a complete clinical served or involved, there may still be an opportunity to
and pathological response of the tumor such that some cen- restore continuity. Alternatively, one or even two ostomies
ters offer a Habr-Gama watch and wait approach (Kosinski will have to be created.
et al. 2012). A lot of discussion and ongoing controversy in the man-
The standard, however, remains an oncological surgical agement of rectal cancer is related to the following areas:
resection. It has become very clear that in no other disease is
surgical technique of such importance when it comes to 1. Role of local excision: The transanal local excision under
reducing the risk of local recurrence (Peeters et al. 2007; van either direct view or by means of TEMS or TAMIS
Gijn et al. 2011; Nelson et al. 2017). A mesorectal excision excises the lesion in either superficial or full thickness
follows the natural planes with the goal to preserve the hypo- fashion, but leaves the lymph nodes behind. Even for a T1
gastric nerve plexus, avoid the dangerous presacral veins, lesion, the chance of having positive lymph nodes is in
and most importantly to obtain a specimen with a complete the range of 6–13%. Even in the most selected favorable
mesorectum and an intact fascial envelope. Such a conscious subgroup of rectal cancer patients (T1, well differenti-
and specimen-oriented dissection has the best chance to ated, no negative features, less than 25% of the circumfer-
achieve a negative circumferential radial margin (CRM) and ence), the local recurrence rates after local excision are
has been associated with lower incidence of local recur- shockingly high (up to 20% in some series). This unfa-
rences. While the proximal margin is defined by the vascular vorable outcome cannot be explained just by unexcised
pedicle, the necessary minimal distal margin has been a mat- lymph nodes alone, but probably results from a direct
ter of debate. Ideally, a 5 cm margin should be attempted implantation of exfoliated cancer cells into the wound.
unless that would involve resection of the sphincter complex. Hence, unless a patient displays a relevant surgical or
In the cases of the lower one third of the rectum, a 2 cm is operative risk, a proper oncological resection should be
desirable, a 1 cm margin acceptable, and a negative margin recommended—even if that would entail an abdomino-
potentially sufficient. However, if a tumor reaches the perineal resection with a permanent colostomy (Devaraj
sphincter complex, an abdomino-perineal resection with per- et al. 2016).
manent colostomy is typically the surgical treatment of 2. Noninferiority trials of transabdominal minimally inva-
choice. In some cases of distal rectal cancer, a partial sphinc- sive approaches (laparoscopic, robotic): It should be
ter preservation can be obtained by performing an inter- noted that rectal cancers were originally excluded from
sphincteric dissection. The external sphincter muscle is left the early laparoscopy trials in the early 2000s, and lapa-
intact, but the internal sphincter is sacrificed at the roscopy was only later introduced as experience overall
402 A. M. Kaiser
expanded. More recently, however, two large trials raised risk, and family planning (Espenschied et al. 2017). The
some concerns that the laparoscopic arms were not able hereditary cancers often affect younger patients and hence
to achieve an equal specimen quality as conventional have to be suspected in any young patient. It is increasingly
open surgery (Fleshman et al. 2015). Robotic surgery par- recommended practice that pathologists routinely perform a
ticularly in the narrow deep pelvis has gained a lot of trac- base array of tissue testing in any colorectal cancer (Kastrinos
tion, but there is no objective proof of superiority yet and Syngal 2012). It should be noted that there are families
(Zelhart and Kaiser 2017; Collinson et al. 2012). with a significant colorectal cancer incidence in whom no
3. Abdominal versus transanal oncological resection: The known genetic defect can be identified as off now. If a genetic
gold standard that finally has been established over many syndrome is known or newly established, there is not only a
years of surgeon’s education is the abovementioned need to address a single cancer, but also the entire cancer
abdominal total mesorectal excision. A still relatively predisposition with the respective lifetime risk of subsequent
limited number of proponents increasingly push for an colorectal and extraintestinal malignancies. Ideally, a surgi-
oncological resection through a transanal minimally inva- cal intervention is to be carried out before the cancer devel-
sive approach. The transanal total mesorectal excision ops, that is, as early as the age of 18–30. In the case of the
(taTME) is challenging and associated with a not negli- pan-colonic polyposis syndromes, that translates into a proc-
gible incidence of unusual complications (e.g., urogeni- tocolectomy, or occasionally a total colectomy if the rectum
tal). At the present time, that technique should therefore is relatively spared. In Lynch syndrome, the decision relates
be monitored and reserved to specialized centers only to the question whether in addition to the minimum standard
(Denost et al. 2014). oncological resection a prophylactic resection should be
4. Role and timing of multimodality treatment, that is, included (Lynch and Lynch 2013). Examples are a subtotal
patient selection, duration of radiation (short course ver- colectomy rather than a right hemicolectomy, or in women
sus long course), timing and interval in relations to sur- with completed family planning inclusion of a hysterectomy
gery, radiation-sparing protocols. The goal of future in addition to the colon resection (Herzig et al. 2017).
research efforts is to optimize outcomes and avoid under- Additional management decisions which go beyond the
treatment, while minimizing side effects and limiting scope of this chapter are the relative resistance of Lynch syn-
overtreatments. drome to 5-FU-based chemotherapy, the type and timing of
5. Complete response after neoadjuvant chemoradiation: In genetic counseling and testing for family members, as well
locally advanced rectal cancer, neoadjuvant chemoradia- as appropriate surveillance versus intervention strategies in
tion is initiated with the intent to later perform the surgi- known gene carriers (Lynch and Lynch 2013).
cal resection. As stated above, however, a subset of
patients achieves a complete clinical and even pathologi- Carcinomatosis
cal response. The value of the standard-of-care resection Presence of peritoneal seeding is usually a poor prognostic
with its morbidity as opposed to a monitoring remains a parameter. It may be detected at the time of a planned or
matter of debate and ongoing research (Kosinski et al. emergency surgery or become visible on cross-sectional
2012). imaging. Particularly primary tumors reaching the serosal
surface or resulting in a perforation at the tumor are at high
ereditary Cancer Syndromes
H risk of tumor implants. Surgical intervention only rarely has
The most important among a much larger number of genetic a chance for lasting success and should therefore be exerted
cancer syndromes are Lynch syndrome (aka HNPCC, auto- with the respective restriction. Stoma creation, internal
somal dominant), familial adenomatous polyposis or its bypass, placement of a gastrostomy or jejunostomy tube, and
attenuated form (FAP, aFAP, autosomal dominant), or occasionally endoscopic stenting are among the limited
MUTH-associated polyposis (MAP, autosomal recessive) options. Only extremely rarely are cases suitable for cyto-
(Church and Simmang 2003; Church and Ashburn 2017). reductive surgery and heated intraperitoneal chemotherapy
The basic workup and management do not necessarily differ (HIPEC). This treatment requires surgical skills and interdis-
from sporadic colorectal cancer. However, hereditary cancer ciplinary expertise about appropriate disease and patient
syndromes test our intellectual fitness and demand sophisti- selection and should be limited to respective centers (Franko
cation because they have a huge potential for negligence and et al. 2012; Braam et al. 2015).
inadequate care. The genetics introduce additional levels of
complexity related to the extent and intensity of the immedi- olorectal Cancer Superimposed
C
ate care to be delivered, surveillance of the intestines as well on Inflammatory Bowel Disease
as non-intestinal organ systems, identification and manage- Inflammatory bowel disease is a recognized high risk con-
ment of known gene mutation carriers, family members at stellation for the development of colorectal cancer (Choi
et al. 2017). Routine surveillance with systematic biopsies Diverticulitis

aims at detecting dysplasia as cancer precursor and is recom-
mended to begin no later than 7–8 years after onset of the The clinical presentations of diverticulitis are wide-ranging
disease. However, detection of malignancy may be challeng- from asymptomatic, to mild, to complicated and even life-
ing (Verma et al. 2015) as it may not always form a visible threatening severity (Feingold et al. 2014). One should
“mass,” and (b) as multifocal cancers may arise. Any high always be aware that about 5% of typical diverticulitis symp-
grade dysplasia, raised lesion with dysplasia (RLD, formerly toms are in fact caused by a locally advanced cancer. For
known as “dysplasia-associated lesion or mass” or DALM), management and treatment of true diverticulitis in the short
colonic “stricture,” or multifocal low grade dysplasia war- and long run, it is of utmost importance to classify the dis-
rant a surgical intervention even if an invasive cancer has not ease. CT scans with at least oral and intravenous contrast,
(yet) been confirmed (Devaraj and Kaiser 2015b). In absence possibly even rectal contrast, are the gold standard imaging
of distant metastases or carcinomatosis, surgical resection is for diagnosis and classification of diverticulitis, whereas
the treatment of choice and entails a complete proctocolec- MRI or ultrasound are possible but less commonly used. On
tomy, with or without a restorative ileal J-pouch-anal anasto- the one hand, one should distinguish between an acute index
mosis (IPAA) (Ross et al. 2014). As the small bowel is very presentation and hospitalization as opposed to a patient pre-
radiation sensitive and imaging staging unreliable in the set- senting for possible elective management. Different classifi-
ting of colitis, any cancer involving the rectum should always cation systems have been suggested. The two preferred ones
undergo neoadjuvant chemoradiation prior to surgery. from a practical standpoint are (A) the Ambrosetti classifica-
tion and (B) the modified Hinchey classification. The
Ambrosetti classification aims at distinguishing uncompli-
Anal Cancer cated from complicated episodes of diverticulitis based on
the presence or absence of extra luminal air or radiographic
The pathology, pattern of spreading, the proximity to the pel- contrast. The modified Hinchey classification defines differ-
vic floor and sphincter complex, and last but not least the ent severity stages based on a combination of clinical, CT,
treatment concept make anal cancer distinctly different from and possibly intraoperative findings.
rectal cancer (Kaiser 2009). Even though it predated the HIV The overwhelming majority of patients with diverticulitis
epidemic, a dramatic increase has been observed since its do not need an operation. Their disease is mild, uncompli-
onset, particularly as the highly active antiretroviral therapy cated, and responds very quickly to a short course of antibi-
has dramatically reduced the mortality from the viral infec- otics. It is also clear that the most severe forms of diverticulitis
tion and immunosuppression as such. The overwhelming with perforation and diffuse peritonitis usually require a sur-
histopathology is squamous cell carcinoma which is associ- gical intervention. The standard approach for these severe
ated with oncogenic strains of the human papilloma virus. forms has been a Hartmann resection with creation of an end
Adenocarcinoma is rare and may arise from anal glands. colostomy. However, depending on the patient’s overall con-
Anal melanoma is the third most common melanoma loca- dition, the intraoperative findings, and the quality of the
tion and has frequently a dismal prognosis. bowels, alternative strategies may be pursued such as per-
The tumor staging of anal cancer is different from colorec- forming a primary anastomosis with or without proximal
tal cancer insofar as the T-stage is defined by size and not by diversion.
depth of invasion. If a lesion does is more external and does It becomes more of a decision-making challenge in
not reach the anal canal, it is treated like a skin cancer by defining the best route in patients with intermediate sever-
surgical excision. If the anal canal is involved with squamous ity disease or in patients who eventually recover from one
cell cancer, the primary treatment is chemoradiation (Nigro or several episodes of diverticulitis (Table 53.4). For the
protocol with mitomycin or cisplatin) whereas surgery in acute episode, it is usually advisable to define a limited
form of an abdomino-perineal resection is reserved for treat- period of conservative management by which a definitive
ment failures (Geh et al. 2017). improvement of all parameters should be observed
Nonsquamous cell malignancies of the anus have a much (72 hours of adequate treatment). The management could
worse prognosis. Anal adenocarcinoma is treated like distal consist of antibiotics alone, or be combined with placement
rectal cancer with chemoradiation, followed by an abdomi- of CT-guided drains to pericolonic or pelvic abscesses. If
noperineal resection. Select cases of early melanoma are cur- there has not been adequate improvement within that time-
able with the abdomino-perineal resection, but frequently the frame, it is best to proceed with a resective surgery—unless
disease is already systemic and the prognosis dismal. re-
imaging shows a drainable abscess at that point.
Immunotherapy and potentially radiation can be considered Laparoscopic lavage was temporarily en vogue as a nonre-
for palliation. sective surgery to clean out the abscess, but the results have
404 A. M. Kaiser
Table 53.4 Surgical management for diverticulitis

Emergency Urgent/non-resolving Elective
Surgery = default or MHC III/IV with MHC I –II managed medically without Multiple episodes with increasing
highly recommended diffuse peritonitis response in 72 hrs frequency or severity, particularly if
MHC III/IV initially managed requiring hospitalizations
conservatively but insufficient response Conservatively managed complicated
Complicated diverticulitis with abscess not diverticulitis MHC Ib, II, III, IV
amenable to CT-guided drainage, not Persistent pathology on imaging
improving or worsening Smoldering disease
Diverticular stricture with complete or Stricture
progressive LBO Fistulization (bladder, vagina, skin)
Fistulization with sepsis High-risk constellations
(immunosuppression, planned
chemotherapy)
Observation or medical Highly selected MHC MHC I –II and highly selected MHC III/IV Complete resolution of one or several
management III/IV with benign with benign clinical symptoms minor episodes
clinical symptoms Complicated diverticulitis with abscess Uncomplicated diverticulitis in young
amenable to CT-guided drainage, or patients
improving to initial medical management
Partial SBO/LBO
MHC Modified Hinchey classification, LBO Large bowel obstruction, SBO Small bowel obstruction
been clearly suboptimal such that the technique should be Elective surgery has a much higher probability of being
discouraged. The resection eliminates the inflamed bowel successfully done in minimally invasive approach and with-
and extends distally from the coalescence of the colonic out a temporary ostomy. More important than doing a fancy
tenia to where proximally to bowel consistency becomes operation though is to do a good and safe operation. If that
normal (regardless of whether diverticula are left behind) for specific reasons is not achievable with the minimally
(Feingold et al. 2014). A primary anastomosis may be rea- invasive surgery, a primarily open or conversion to open
sonable, if the patient is stable and the intraoperative find- approach is a prudent decision.
ings and bowel quality are of favorable condition; if not, a
Hartmann resection with end colostomy remains a prudent
choice. Wherever possible despite the active infection and Large Bowel Obstruction
altered anatomy, it is recommended to perform a resection
that would satisfy oncological benchmarks if the pathology There are a number of different pathologies that can lead to a
showed a cancer. large bowel obstruction. The most common ones include
For patients who have overcome an acute episode of cancer, a stricture resulting from diverticulitis, ischemia, pre-
diverticulitis, it is best practice to arrange for a colonoscopy vious surgery or inflammatory bowel disease, or a colonic
6 weeks after the episode to rule out (A) a cancer at the site volvulus. Colonic pseudo-obstruction (Ogilvie syndrome)
of the inflammation, and (B) synchronous colonic pathology. has similar symptoms and imaging features but lacks a phys-
In contrast to the past, recommendations about elective sur- ical site of obstruction and rather represents an acute colonic
gery rely less on the absolute age or an absolute number of dysmotility. Management of a true large bowel obstruction
episodes, rather than on signs of complications and persis- depends on the acuity and completeness of the obstruction
tent disease (Devaraj et al. 2016). One should keep in mind and to minor degree also on whether the ileocecal valve is
though that these sequelae are more likely to occur in patients competent and results in a more dangerous closed loop
whose initial presentation was more severe. Evidence of fis- obstruction. The obstruction interferes with the passage of
tulization (colo-vesicular or colo-vaginal), and stricture for- stool and may result in obstipation and distention of the pre-
mation with potentially obstructive symptoms are relatively stenotic bowel a with high stool burden. If this evolves
obvious surgery indications. Trickier to define and recognize slowly, the bowel may have time to gradually dilate substan-
are signs of smoldering disease with persistent and potentially without perforation; otherwise it potentially suffers
tially nonspecific symptoms, recurrent episodes after short impairment of the bowel wall perfusion, blood supply, and
periods of quiescence, or worsening symptom behavior. eventually its integrity resulting in pneumatosis coli or a per-
Evidence of an abscess or contained perforation have been foration. While the absolute diameter of the colon does not
associated with a high probability of recurrent attacks and strictly correlate with the risk of perforation, a diameter of
disease complications (Devaraj et al. 2016; Lamb and Kaiser more than 6 cm in the transverse colon and more than 10 cm
2014). in the cecum should be cause for concern.
The tools to address the cause and consequences of the common causes include diverticulitis, cancer, Crohn disease,
obstruction have to be individualized and tailored to the spe- radiation, or postsurgical complications from an enterotomy,
cific circumstances. In general terms, they include one of the anastomotic leak, or a stapler injury. Symptoms are not spe-
five options (Chang et al. 2012; Kaiser 2009): cific and include continuous or intermittent passage of
bacteria, gas, or obvious stool, and variable signs of infec-
1. Discontinuous resection (Hartmann resection) tion, sepsis, or obstruction.
2. Resection of the obstructing segment with primary anas- The diagnostic and management strategy depends on the
tomosis, with or with on-table lavage, and with or without acuity of local and systemic symptoms, the suspected or
a proximal protective stoma proven underlying disease process, and the interval to previ-
3. Proximal diversion alone ous interventions. It is crucial to define the location and exact
4. Resection of the obstructing segment and the entire dis- level of the fistula, particularly whether it originates from the
tended colon proximal to the obstruction (e.g., total mid to distal rectum or higher than that. This aspect may
abdominal colectomy for a sigmoid obstruction), either determine whether the problem is potentially accessible via a
with an ileostomy or ileo-colonic/-rectal anastomosis perineal approach or will require an abdominal approach. A
5. Endoscopic placement of a self-expanding metal stent as perineal/transanal approach for appropriate distal rectal
bridge to surgery or even as definitive treatment defects may entail a local repair, for example, by means of an
endorectal advancement flap or a muscle interposition. More
When defining the ultimate strategy in an individual proximal pathologies or very advanced distal pathologies
patient, it is important to safely avert the immediate danger, typically involve a surgical resection of the causative bowel
but to also keep quality of life aspects and the future treat- segment and depending on the underlying pathology the
ment needs in mind. This latter aspect can create a number of adjacent involved structures.
dilemmas. For example, a metal stent might seem an attrac- One of the key assessments to be made is to determine (A)
tive option for a patient with metastatic cancer because, in whether the pathology is amenable to cure, (B) whether res-
absence of a surgical wound, it allows for almost immediate toration of the intestinal continuity is possible and prudent,
initiation of palliative chemotherapy. However, one of the (C) whether that can be achieved in a single-stage surgery or
most effective biological anticancer drugs, bevacizumab, has will require a staged approach, and (D) what the optimal
a relative contraindication because of a substantially timeline would be. In particular, the surgeon needs to deter-
increased risk of stent perforation. Or, an ileostomy is often mine whether a definitive single-stage surgery can primarily
easier to manage than a transverse colostomy and hence the be carried out, or whether a 2-stage or even a temporizing
stoma of choice under elective circumstances. Under emer- measure only (stoma) will first be needed to gain time and
gency conditions, however, if only a stoma is created for the allow for symptoms and tissues to cool off. Technically, that
large bowel obstruction, a loop colostomy is preferred as an decision depends on whether there is a healthy receiving
ileostomy would neither decompress the colon quickly bowel segment and anatomy distal to the pathology to allow
enough nor at all, and it may not allow for a subsequent eval- for an anastomosis. In addition, the patient’s overall condi-
uation of the prestenotic colon. Creation of a loop colostomy tion, hemodynamic stability, nutritional status, as well as the
should be planned in a location that the patient can take care tissue quality have to be taken into consideration.
of, and it should again not become a handicap for subsequent To illustrate a few selected examples:
surgical interventions. Exact analysis of the current and
potentially future blood supply in light of past or future 1. Colo-vaginal/-vesical fistula from diverticulitis: These
resections should assure negative interferences by the tem- conditions are usually a chronic manifestation and can be
porary intervention. Examples could include disruption of addressed with a single-stage sigmoid resection whereby
the marginal blood supply from the middle colic artery dur- the colon is “pinched off” the corresponding structure.
ing creation of a left-sided transverse colostomy in a patient That defect on the vagina or bladder may be oversewn but
whose inferior mesenteric artery was or will be resected. usually heals without any problems.
2. Colo-vaginal/-vesical fistula from cancer: The resection
on the intestinal side should be the same oncological
Fistulization (Bladder, Vagina, Skin) resection, but on the bladder or vaginal side, a resection
with appropriate margins needs to be achieved.
A number of different diseases or conditions can result in 3. Recto-urinary/-vaginal fistula: Often times, when the
formation of an unintended direct communication between patient is highly symptomatic or within a critical time
the colon, rectum, and/or small intestine to a non-intestinal period after a previous intervention, it is prudent to first
structure such as the urinary system (bladder, urethra), perform a diverting stoma to allow tissues to cool off. An
female organs (vagina, uterus, tubes), or the skin. The most elective intervention can be planned after a few months
406 A. M. Kaiser
once a comprehensive workup has been completed and a the nutritional needs. If the extent of ischemia is too wide-
strategy developed. Exception would be a locally spread and not compatible with survival, palliative end-of-
advanced cancer which may need a radical multivisceral life measures are to be initiated.
resection or palliative diversion in conjunction with non-
surgical management.
Inflammatory Bowel Disease
Lower GI Bleeding One of the key parameters for surgical decision-making in

patients with inflammatory bowel disease is the nature and
Bleeding is an unspecific symptom from a wide spectrum of manifestation of the underlying disease. Ulcerative colitis is
different causes and locations anywhere in the GI tract. theoretically curable with surgery but only about 30% of
Minor bleedings or anemia is worked up on an outpatient patients require a resection. In contrast, Crohn disease is not
basis. Acute brisk and life-threatening lower GI bleeding curable as it can affect the entire gastrointestinal tract from
requires decisive actions to prevent a patient’s fatal deterio- mouth to anus; yet, at least 70–80% of patients need at least
ration (Newman et al. 2012; Strate and Gralnek 2016). If the one surgery in their lifetime, mostly for disease complica-
bleeding origin is clear (e.g., cancer, colitis), a targeted spe- tions rather than for cure. Additional factors include the acu-
cific intervention needs to be carried out. More difficult are ity of the presentation, short-term or long-term complications,
massive lower GI bleedings of unknown origin. Unfortunately, as well as the response to medical management.
characteristic locations vary for different bleeding causes.
For example, diverticular bleeding more commonly origi- Ulcerative Colitis
nates on the left-sided colon, whereas bleeding from arterio- The surgical approach to patients with ulcerative colitis is a
venous malformations typically stems from the right-sided primary or staged proctocolectomy, regardless of the extent
colon. Immediate resuscitation and transfusions aim at main- of inflammation (Ross et al. 2014). The goal is to achieve
taining hemodynamic stability and coagulation factors. If cure from the disease and/or from side effects of the medica-
possible, diagnostics aim at positively grossly identifying the tions, minimize disease-specific short- and long-term mor-
bleeding site; interventional radiology further has the poten- bidity and disability, and to carry out a safe reconstruction
tial to selectively stop a visible hemorrhage by means of with a high life-style quality. The most common form of
highly selective embolization. If the bleeding remains unlo- reconstruction with a greater than 90% success rate is an
calized and associated with extensive transfusions and hemo- ileal J-pouch-anal anastomosis (IPAA); but an end ileostomy
dynamic instability, a total colectomy needs to be carried or in select cases a continent ileostomy (Kock pouch,
out. T-pouch) may be preferable or appropriate. Based on the dis-
ease behavior and treatment response, there are four catego-
ries when a surgical intervention is indicated (Devaraj and
Ischemia Kaiser 2015a):
Ischemic colitis and enteritis are caused by an inadequate 1. Life-threatening complications, such as fulminant colitis,
blood flow to the viscera. The severity depends on the cause toxic megacolon, perforation, or uncontrolled bleeding
of the underperfusion, the location, level and extent, the acu- (rare).
ity of onset, and the presence of collaterals. The mucosa is 2. Colorectal cancer development: An estimated 18–20% of
commonly the most sensitive layer of the bowel wall. The patients develop cancer before the time when routine sur-
majority of intestinal ischemia does not result in transmural veillance is recommended (7–8 years post onset), and 2%
necrosis (nongangrenous ischemia). It may be transient or of patients develop a cancer despite regular surveillance.
become a chronic condition and turn into a stricture. Only an Surgical resection is invariably the treatment of choice for
estimated 15–20% of intestinal ischemias progress to gan- single or multifocal loco-regional colorectal cancers,
grenous ischemic colitis with a high mortality with or with- strictures, high grade dysplasia, or multifocal low-grade
out surgery. dysplasia that has been confirmed by an expert patholo-
The treatment ranges from conservative management for gist. A minor exception in regard to treatment sequence is
milder to moderate forms to a resection of the affected bowel a biopsy-proven cancer of the rectum, which—as stated
segments. For severe and life-threatening presentations, the in the rectal cancer section above—should trigger neoad-
extent of resection ought to be complete and may even reach juvant chemoradiation prior to surgery. More debated and
a total abdominal colectomy and small bowel resection as controversial is non-adenoma-like low grade dysplasia
long as there if sufficient residual small bowel to maintain that is not associated with regenerative atypia or detected
in flat mucosa. Some favor a colectomy while others lean A pouch procedure is generally not prudent in patients
towards a more conservative approach with short-interval with Crohn disease. Under comparably rare and favorable
monitoring. circumstances, the Crohn disease is limited to colitis without
3. Insufficient response to medical management, steroid- any evidence of small bowel or perianal disease. In such
dependence, or relevant side effects from medical man- selected patients, a restorative proctocolectomy with IPAA
agement: This largest category of patients to consider a may be considered at experienced centers with reasonable
colectomy is the least defined one. There are a few objec- short-term outcomes but a substantially higher rate of pouch
tive parameters of response (e.g., mucosal healing) or losses over time.
lack thereof (steroid-refractoriness, steroid dependence,
treatment-refractoriness). As long as there is no immedi- Indeterminate Colitis
ate danger, the decision when expectations are not met Pathological feature overlap occurs in up to 15% of patients
anymore should be left to the well-informed patient. The with inflammatory bowel disease. As absence of any small
decision to move toward surgery is not a defeat of the bowel disease or perianal disease is a defining necessity to
gastroenterologist, but a very reasonable and predictable distinguish it from Crohn disease, the management strategies
step toward elimination of the chronic illness. for indeterminate colitis are the same as for pure ulcerative
colitis. The long-term success and pouch retention rates,
Under elective circumstances and a fairly healthy patient however, are a bit lower though.
without excessive immunosuppression, a restorative total
proctocolectomy (with or without diverting loop ileostomy)
is the procedure of choice. Under suboptimal disease or C. difficile Colitis and Other Colitides
patient conditions, it is prudent to avoid the challenges of the
pelvic dissection and pouch creation at first. The project is Clostridium difficile infection (CDI), the leading cause of
split into stages with the goal to eliminate the majority of the hospital-acquired diarrhea, affects gastrointestinal surgeons
disease first (total colectomy with end ileostomy) and allow in two situations: (1) as a complication of unrelated treat-
the patient to recover and come off the medications. Only at ments, or (2) when severe and life-threatening colitis asks for
a later elective stage are the rectum removed and the pouch their judgment and surgical skills (Kaiser et al. 2015). Similar
created. to ulcerative colitis, C. difficile colitis and many other infec-
tious colitides are primarily managed conservatively. On a
Crohn Disease comparably rare occasion, however, any colitis can be com-
The primary management of patients with Crohn disease is plicated by a fulminant or toxic presentation which repre-
always medical. Introduction of biologicals has clearly sents the common final pathway of a decompensated colon.
added value to the armamentarium. Surgery is reserved If not swiftly addressed by a surgical intervention, the mor-
mostly for disease complications such as fibrostenotic dis- tality rate is typically very high. If the point of no return has
ease with stricture formation, suppurative disease with intes- already been crossed, even the surgical intervention may not
tinal or perianal abscess and fistula formation, bleeding, or be timely enough anymore to reverse the downhill spiral.
formation of a cancer (Strong et al. 2007). The surgical The actual decision-making process is frequently difficult. It
approach needs to be individualized and can consist of a needs to strike a balance between too aggressive and too pas-
resection with or without a primary anastomosis, a diversion sive in order to avoid unnecessary colectomies as much as
or staged proctocolectomy. The goal is to eliminate the dis- unnecessary deaths. Discrete signs of deterioration such
ease complication as such or to minimize the impact of stool, other organ failures need to be recognized (Kaiser et al.
both with the intent to allow for further medical manage- 2015).
ment. Perianal disease may often only be palliated, occasion- With few exceptions, the surgical management includes a
ally be cured; in very refractory situations, however, a total abdominal colectomy with creation of an end ileos-
proctectomy with stoma is needed. In a small contrast to tomy. Depending on the overall course of the patient and the
ulcerative colitis where an urgent intervention is limited to a underlying pathology, the patient at a later time may be a
total colectomy, Crohn patients with severe colitis need to be candidate for a restoration. In the case of ulcerative colitis,
assessed as to the future option to restore continuity or not. this would be a completion proctectomy with IPAA, in other
In the presence of rectal and severe perianal disease, a com- colitides an ileo-rectostomy.
plete proctocolectomy/ileostomy with mucosal stripping of For nontoxic refractory or relapsing C. difficile colitis,
the entire anal canal down to the anal verge should be done; less invasive interventions have included fecal microbiota
the pelvic floor and sphincter complex can be preserved but transfer (FMT) or creation of a loop ileostomy with colonic
are permanently closed. washouts.
408 A. M. Kaiser
Volvulus an increasingly visible positional instability that is either

limited to one of the three compartments or affects all of
A volvulus combines the symptomatology and pathophysiol- them to a degree. From a colorectal or general surgery stand-
ogy of a large bowel and intestinal ischemia. An axial rota- point, the rectal instability is obviously the primary focus
tion of the colon around its mesentery and vascular pedicle (Varma et al. 2011). But it is always important to inquire
results in a closed loop obstruction and strangulation of the about and assess the anterior and middle compartments as
volvulized segment as well as an obstruction of the colon well. Changes may occur at any age and evolve as a gradual
proximal to the volvulus. Untreated, both areas may progress or synchronous appearance of pelvic floor descent, rectocele,
to gangrene and perforation. The sigmoid colon is the most intussusception, hemorrhoidal, mucosal, or full thickness
common site (60–75% of the time), followed by the cecum rectal prolapse. Isolated rectal instability can affect both gen-
and the transverse colon. Early diagnosis and treatment are ders with no or only a limited number of specific risk factors
crucial before irreversible tissue injury occurs (Table 53.5). being identified (e.g., cystic fibrosis in children), whereby
Keys to successful management are connecting the dots parity is not typically associated with a higher incidence.
between potentially unspecific symptoms, clinical signs, and Multi-compartmental instability more commonly affects
radiographic images (plain, CT scans) (Vogel et al. 2016). women, specifically multiparous women who develop vari-
If there are established signs of advanced strangulation ous degrees of cystocele, uterine, or vaginal vault prolapse
with ischemia or perforation, a swift surgical exploration is (Le Normand et al. 2017).
inevitable. In absence of tissue injury, however, the immedi- A large number of such patients have associated func-
ate goal is to avert deterioration and irreversible bowel dam- tional problems, broadly labeled as pelvic floor dysfunc-
age. For sigmoid volvulus, a rigid or flexible sigmoidoscopy tion. They range from chronic constipation to irritable
as first measures is able to successfully detorse and decom- bowel syndrome, possible urinary and fecal urgency and
press the bowel in 85–90% of times. Because of the high rate incontinence. It cannot be distinguished with certainty
of recurrent volvulus, a (semi-) elective surgical intervention whether some of those functional problems are cause,
with resection is nonetheless recommended. The exception effect, or completely unrelated innocent bystanders, and
to a resection is a cecopexy which can be achieved with a vice versa the visible pathology does not necessarily cor-
temporary tube cecostomy. relate with a particular dysfunction. The one exception is
When there is evidence or suspicion for gangrene or per- the observation that chronic rectal prolapse over time
foration, an urgent or emergency exploration with a surgical almost invariably results in fecal incontinence as the
resection is always warranted. The extent and the type of sphincter complex suffers a continued and repeated stretch
reconstruction versus stoma creation depend on the condi- injury. Before committing on a particular strategy and sur-
tion of the remaining bowels and the patient’s overall gical treatment, it is therefore of utmost importance to clar-
condition. ify the various components and define treatment goals with
realistic expectations (Varma et al. 2011). To rule out a
“lead point” (e.g., tumor, polyp) or other synchronous
Pelvic Floor Dysfunction and Organ Prolapse colonic pathologies of higher priority, a flexible sigmoidos-
copy or colonoscopy should have been performed within a
The pathologies discussed in this section represent a combi- reasonable proximity to the decision-making. Furthermore,
nation of functional disorders with a morphological compo- it is prudent to involve respective specialists from the asso-
nent (Bordeianou et al. 2014). The pelvic organs can develop ciated disciplines of urogynecology or urology to define
Table 53.5 Surgical management of volvulus

Volvulus without
gangrene Volvulus with gangrene/perforation
Sigmoid Cecal/transverse colon Sigmoid Cecal/transverse colon
Urgent Rigid/flexible sigmoidoscopy Colonoscopic Surgery: Surgery with ileostomy vs
action decompression decompression Segmental resection with anastomosis:
If not successful: surgery vs anastomosis Ileocecal resection
Immediate surgery: Hartmann resection Right hemicolectomy
Resection Subtotal colectomy with
Tube cecostomy ileostomy or anastomosis
Elective Sigmoid resection Ileocecal resection n/a n/a
action Right hemicolectomy
Tube cecostomy
whether a combined approach might offer an opportunity proximal is also interrupted. The appropriate choice for such
and have a better chance of success. patients is therefore to either repeat a perineal repair or to
As for the rectal prolapse component, different surgical perform a suspension procedure.
approaches are possible, none of which has a 100% guaran- A recent trend in the management of rectal prolapse has
tee of success. Broadly, one can distinguish between a peri- been the introduction of the laparoscopic anterior mesh rec-
neal versus an abdominal approach (Varma et al. 2011; topexy, supposedly because it is less interfering with the
Hotouras et al. 2015). innervation and structure of the rectum than a posterior rec-
The perineal approaches are generally less invasive and topexy. Long-term comparisons between a poster and
better tolerated. This is a not negligible advantage for a sub- anterior mesh rectopexy or different types of implants are
group of rectal prolapse patients who are elderly, frail, and still pending.
have a reduced operability. If necessary to avoid a general The majority of patients who suffer from preexisting fecal
anesthesia, the surgery could be performed in spinal anesthe- incontinence may experience an improvement of their
sia. However, the success rates are substantially lower than sphincter function once the prolapse has been successfully
for an abdominal repair for rectal prolapse. The two main corrected. However, the extent of improvement can neither
techniques are the Delorme and the Altemeier procedure. be predicted nor promised as to whether it is sufficient to
The Delorme entails a mucosal stripping of the prolapsing provide the patient with adequate quality of life or whether
rectum with repositioning by means of a muscle plication. subsequent treatment will be needed. The value of preopera-
The Altemeier procedure is a perineal proctectomy and anas- tive anophysiology testing is rather limited as the distorted,
tomosis, which is often combined with a levatoroplasty. potentially swollen, and prolapsing rectum blurs many of the
There is no clear guidance which of the two to choose in a test parameters, such that the result is not superior to an edu-
particular patient, except that the Altemeier repair is the cated digital rectal exam. Comprehensive functional pelvic
treatment of choice for an incarcerated necrotic rectal floor testing is more appropriate after a sufficient period of
prolapse. recovery after a successful rectal prolapse repair. Only at that
The abdominal approaches are more successful, but also time may it help to strategize on further treatment options. A
more invasive as they require general anesthesia with often limited number of patients with rectal prolapse and severe
steep Trendelenburg positioning. Different access modalities and likely irreversible sphincter dysfunction may primarily
are utilized including open, laparoscopic, or robotic surger- elect to have a colostomy created rather than going to a num-
ies. Within the abdomen and pelvis, the strategies range from ber of procedures with persistent uncertainties.
a resection of the floppy redundant bowel with or without a
rectopexy, a rectopexy alone, typically with an implant (syn-
thetic mesh or biological graft), or they can entail a multi- Stoma Creation and/or Takedown
compartmental resuspension effort.
Generally speaking, synthetic implants provide a much An ostomy (aka stoma) is intentionally created to allow for a
better durability; despite negative publicity, the risk of infec- controlled decompression and elimination of waste, or to
tion is comparably low if there is no direct contact of the divert stool from a more distal area of concern (anastomosis,
mesh with for example the small bowel. Nonetheless, some inflammation, rectovaginal fistula, incompetent sphincter
surgeons and even some companies have been discouraged muscle, etc.). Ostomies remain one of the “necessary evils”
by the threat of litigation surrounding synthetic mesh of colorectal surgery. Much worse than having an ostomy is
implants. having a bad ostomy. Appropriate anticipation and planning
It has been a matter of controversy whether the resection help in optimizing the manageability of the ostomy. Critical
of the redundant sigmoid colon might prove beneficial parameters are the decision whether to do an ileostomy or a
beyond the prolapse correction as such for the management colostomy, either of which has distinct advantages and disad-
of the underlying constipation. In other contexts though, vantages. Furthermore, it is important to analyze the current
such a limited resection has rarely been effective to have a and future blood supply to all remaining bowel segments; it
meaningful impact on the constipation. The downside of a should be avoided under all circumstances to jeopardize the
resection not only relates to the simple fact that an anastomo- perfusion and create avascular bowel segments. An example
sis is created and potentially could leak but also that use of a could be a left-sided colon that after a low anterior resection
synthetic mesh is generally not recommended when open is dependent on the mid colic artery. Last but not least,
bowel is handled because of the risk of contamination. ostomy planning should assure that no unvented bowel seg-
Importantly, a resection is contraindicated in patients who ments be created that could blow out, for example, Hartmann
previously had a perineal resection as a non-perfused bowel resection that would leave behind a blind stump proximal to
segment could result if the unidirectional blood supply from a complete distal obstruction.
410 A. M. Kaiser
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Minimally Invasive Surgery (MIS)
in Colorectal Surgery 54
Sarah M. Popek, Rodrigo Rodriguez,
and Andreas M. Kaiser
tal surgery for many surgeons was not worth the perpetrated
Implementation and Benefits of MIS “benefit.”
Last but not least, the introduction of enhanced recovery
The introduction of laparoscopy in 1982 gave birth to the
programs in colorectal surgery has independently lowered
field of minimally invasive surgery and catalyzed a techno-
length of stay (LOS) and complication rates even for open
logical revolution which continues to the present day.
surgeries. The benefit of adopting of the laparoscopic
Minimally invasive surgery (MIS) has transformed the oper-
approach has therefore been blurred. Laparoscopic colorec-
ative and postoperative care of appendicitis and biliary dis-
tal surgery is associated with a reduced LOS and surgical site
ease. In contrast, the implementation of minimally invasive
infection rates; however, the combination of the laparoscopic
surgery for benign and malignant colorectal disease has been
approach with an enhanced recovery program had little
dramatically slower. And yet, almost 30 years since incep-
incremental impact.
tion—rebutting even the most ferocious critics—minimally
invasive surgery has consistently been shown to provide
short- and long-term value to patients and the healthcare sys-
ow Is MIS Approach Different From Open
H
tem alike. Minimally invasive technology is undoubtedly
Surgery?
here to stay—including in colorectal surgery.
Procedure-related benefits include accelerated postopera-
A minimally invasive approach changes access and visual-
tive recovery, improved cosmesis, a lower incidence of
ization, and more significantly, the technique and sequence
wound complications, incisional hernias, and the risk of
of the intra-abdominal surgical steps. The strategy in open
future adhesion-related small bowel obstructions. Most
surgery, supported by retractor equipment and assistants, is
importantly, however, the oncological outcomes for the most
to mobilize the entire colon from it retroperitoneal attach-
part mirrored these results and long-term data have proved to
ments in a lateral to medial fashion followed by division of
be largely equivalent if not more favorable.
vascular structures. The division of bowel is done at any time
For colorectal diseases, the minimally invasive approach
deemed appropriate.
faces unique challenges related to the multi-quadrant nature
In laparoscopic surgery, maintenance of visibility and ori-
of the anatomy, challenging pathologies, and complex surgi-
entation is of utmost importance. Knowledge and recogni-
cal steps such as vascular and bowel division, specimen
tion of anatomical landmarks is essential. Two important
extraction, and intestinal anastomosis that have no space for
factors help to achieve that goal. First, minimizing bleeding
error. Due to the degree of technical complexity, adoption of
is achieved by diligently following the avascular embryo-
the laparoscopic approach in colorectal surgery has been
logical planes and using energy or mechanical devices to
slow. The “cost” and learning curve of laparoscopic colorec-
divide vascularized structures. Second, mobilization of the
colon is carried out in a medial to lateral direction in order to
S. M. Popek · R. Rodriguez take advantage of existing attachments as natural retractors.
Department of Surgery, University of New Mexico, Often the vascular pedicles are isolated and transected early.
Albuquerque, NM, USA The retroperitoneal dissection is conducted to the most lat-
A. M. Kaiser (*) eral aspect prior to releasing any existing attachments.
Department of Surgery, Division of Colorectal Surgery, City of Division of the bowel with specimen removal, as well as the
timing and type of anastomosis need to be well thought out
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_54
414 S. M. Popek et al.
and planned ahead with the goal of minimizing instrument

exchange and interruption of pneumoperitoneum.
The laparoscopic approach promotes use of embryologi-
cal avascular planes, with the goal of achieving a complete
meso-colic and total resorectal excision in colorectal cancer.
Minimally Invasive Surgery (MIS) Platforms
The first laparoscopic assisted colectomy was performed in

1991 followed by development of variants of laparoscopic
surgery to minimize the complexity of laparoscopic colorec-
tal surgery: hand-assisted laparoscopic surgery, three-
dimensional laparoscopy, and robotic surgery. Additionally,
hybrid techniques combining laparoscopic and open tech-
niques have emerged and can help transition to the minimally
invasive approach.
Conventional Laparoscopic Surgery (CLS)
As discussed above, laparoscopic colorectal surgery is per-

formed in multiple abdominal quadrants and requires tran-
section of major vascular structures, extraction of large
specimens, and creation of anastomoses (Fig. 54.1). These
technical challenges have contributed to low laparoscopic
adoption rates in the United States. In 2010, only 41.6% of
colon resections were performed laparoscopically despite Fig. 54.1
increasing evidence of its advantages. Higher rates of the
laparoscopic approach have been observed in urban loca-
tions, in patients treated with diverticular disease, and those ease, tissue friability, and adhesions. However, MIS
undergoing right hemicolectomies. A concomitant rise in eventually gained acceptance as a safe option with similar
intraoperative conversion rates from laparoscopic to open benefits as seen in non-IBD colorectal conditions.
surgery may imply that more surgeons are incorporating 2. Colon cancer: In contrast to benign conditions, where the
laparoscopic surgery into their practice. focus could rest on the early postoperative recovery
Factors that have cultivated surgeons’ interest in acquir- period, the concern for cancer management was centered
ing skills in laparoscopic techniques include financial incen- around the long-term impact on oncological outcome
tives, advanced technological components, and creation of parameters and survival. More important than length of
dedicated teaching courses. The initial investment cost of stay, quality of life, or cosmesis were the questions
introducing laparoscopic surgery with specific equipment is whether laparoscopy would be able to achieve non-
high, and longer operative times may reduce the number of inferior oncological results. Risk of port-site metastases,
cases being performed. However, shorter LOS, lower com- lymphadenectomy with a lower yield of lymph nodes,
plication rates, and lower overall hospital cost fare favorably and unusual complications and patterns of recurrence
compared to open colorectal surgery. Newer laparoscopic comprised the initial concerns. Three major well-designed
vessel sealing devices, staplers, and articulating equipment prospective randomized trials delineated the equivalence
have enhanced the surgeon experience and made the laparo- of laparoscopic versus open colectomy: Clinical
scopic approach more attractive. Outcomes of Surgical Therapy (COST); COlon cancer
As much as the laparoscopic approach has become the Laparoscopic or Open Resection (COLOR); and
method of choice in many first-time surgeries, it remained Conventional versus Laparoscopic Assisted Surgery in
controversial in three specific colorectal diseases: Colorectal Cancer (CLASICC).
3. Rectal cancer: With the introduction of the concept of a
1. Inflammatory bowel disease (IBD): Early concerns cen- total mesorectal excision (TME) in the early 1990s,
tered around the possibility of missing segments of dis- excellence of a meticulous surgical technique had just
54 Minimally Invasive Surgery (MIS) in Colorectal Surgery 415
been recognized in open surgery as more important than back of open surgery while maintaining the pneumoperi-
adjuvant treatment in reducing local recurrence rates. toneum allowing a laparoscopic dissection. In addition to
Compromising on those newly gained improvements in conventional laparoscopic trocars, a 6–7 cm abdominal
outcomes was rightfully met with lots of resistance. incision is performed to place the hand port. This device
Circumferential radial margins, proximal and distal mar- provides a sealing mechanism that allows the surgeon to
gins, lymph node harvest, and intactness of the mesorec- insert a hand into the peritoneal cavity without losing
tal envelope are quality parameters used in rectal cancer pneumoperitoneum. The hand aids and accelerates the
surgical technique. Two multicenter randomized trials dissection and mobilization; it helps to maintain retrac-
published in 2015 failed to demonstrate noninferiority of tion, to keep a dry field, or to control unexpected bleeding
the laparoscopic compared to an open approach in regard (Fig. 54.2). The incision is conveniently used for speci-
to those aspects, with long-term oncological outcomes men removal, but is typically larger than normally required
pending analysis. More recently, a robotic approach has for this purpose.
been advocated by some to improve the accuracy of the Compared to conventional laparoscopy, HALS appears to
mesorectal dissection, improving rates of nerve preserva- preserve the benefits of minimally invasive techniques. There
tion, thus favorably influencing functional outcomes. has not been a reported difference in postoperative mortality
However, the impact of the laparoscopic or robotic or morbidity. Postoperative ileus, LOS, and the rates of anas-
approach on local recurrence and survival rates in rectal tomotic leaks, bleeding, surgical site infection including
cancer remains unclear until long-term data have become intra-abdominal abscess formation are comparable.
available. Advantages of HALS consist of lower conversion rates and
decreased operative times.
Compared to open surgery, HALS has been associated
Hand-Assisted Laparoscopic Surgery (HALS) with similar operative times, but lower operative blood loss,
less postoperative pain, shorter postoperative ileus, and
Hand-assisted Laparoscopic Surgery (HALS) is a hybrid shorter LOS; in addition, there is a decreased risk of wound
technique that preserves the tactile sensation and feed- infection.
Fig. 54.2
Three-Dimensional Laparoscopic Surgery ception without interfering with the normal view of the surgi-
cal field. One of the advantages of the laparoscopic 3D
One of the many challenges of conventional laparoscopy is technology is that all team members equally share the 3D
the reduction of a three-dimensional world and surgical field benefit—as opposed to the robotic systems where that privi-
into a two-dimensional image on the monitor. The loss of lege is limited to the surgeon at the console.
depth perception can be compensated by surgical experi-
ence: time and practice allow for a remarkable adaption in
translating the 2D image back into a recognition of spatial Single Incision Laparoscopic Surgery (SILS)
patterns and coordinated surgical movements.
The impetus behind development of three-dimensional The dream of incisionless surgeries has resulted in a push to
(3D) laparoscopy was to return the depth perception during eliminate trocar sites. The extreme version of that strategy,
laparoscopic surgery and decrease cognitive strain on the NOTES (natural orifice transluminal endoscopic surgery),
surgeon. Specifically, novices of the laparoscopic technol- has not been able to gain much traction due to technical chal-
ogy may benefit from the 3D vision and accelerate their lenges and complications. However, condensing all ports
learning curve. Hypothetically, 3D systems could reduce into a single access platform was introduced as single inci-
operative times, the incidence of technical difficulties, and sion laparoscopic surgery (SILS) which was more widely
surgeon fatigue. In addition, the improved spatial perception adapted. The primary goal is to improve cosmetic results and
allows for more challenging tasks such as intracorporeal patient satisfaction. SILS requires a specific port to accom-
suturing and knot tying. modate multiple instruments passing via a single fascial
3D laparoscopy requires special and more expensive opening. There are various access platforms currently avail-
equipment than conventional laparoscopy. The system able for SILS, most of which include a type of sleeve as a
includes a dual optics laparoscope, a tower with respective wound protector and allow up to five trocars to pass through
software to integrate the two images, and respective moni- the platform. The platform is placed in the umbilicus, the site
tors. All team members wear special glasses that merge the the planned specimen extraction, or the planned stoma site.
overlapping monitor images (Fig. 54.3) into a spatial 3D per- Cost differences are marginal compared to conventional
laparoscopic surgery. The true obstacle to implementation of
SILS is the fact that the setup violates the core principles of
laparoscopic ergonomics: triangulation of instruments with
the meeting point at the target. As all instruments enter at the
same zero point at the fascia, they cross over in an unnatural
mirrored fashion. Hence, they have to be moved externally in
the opposite direction than the desired internal movement.
The most common colorectal operations performed in
both conventional laparoscopic surgery and SILS are right
hemicolectomy and anterior resection, but even proctocolec-
tomies have been described. Low body mass index, as with
most procedures, facilitates performance with SILS. Data
including meta-analysis comparing SILS and CLS have not
shown a striking benefit to justify the struggle in most cases.
Robotic Surgery
The concept of reducing human error by means of technol-

ogy is not new. Moving the surgeon physically away from
the patient side to a console at a distance and yielding pri-
mary patient access to a machine (Fig. 54.4), however, is a
fairly new development. Since its approval by the FDA in
2000, robotic surgery (RS) has grown exponentially. It pro-
vides the surgeon with 3D vision and increased articulation
and versatility of instrument movements. These aspects are
particularly helpful when accessing limited spaces such as
Fig. 54.3 the deep pelvis. In addition to a more ergonomic body pos-
Fig. 54.4
ture for prolonged surgical interventions, the robot has institution are in evolution and subject to more comprehen-
enhanced the surgeon’s dexterity by eliminating the innate sive evaluation.
hand tremor and increased reproducibility of human hand
motions—at the cost of losing tactile feedback. Suturing and
intracorporeal anastomoses have been dramatically facili- trategies About Selection of the Surgical
S
tated, and the technology allows for assessment of the tissue Approach
perfusion by means of fluorescence imaging.
Disadvantages of RS compared to CLS or open surgery In order to determine which surgical approach is possible and
include the higher costs, longer operative times, and loss of appropriate on an individual basis, the operative steps should
tactile feedback. Furthermore, the range of motion through- be planned out ahead of the actual surgery and cross-checked
out multiple abdominal quadrants is limited and remains a with the preoperatively available information. Relevant factors
major challenge as it may necessitate re-docking of the robot include the extent of the target disease, the intended extent and
or reliance on performing parts of a procedure laparoscopi- components of the surgery, the patient’s current condition and
cally. Cause for concern remains the impact on oncological habitus, and the past surgical and medical history.
outcomes parameters, patterns of tumor recurrence, and the MIS requires safe access to the abdomen and creation of
potential for unusual complications. a sufficient working space. If the surgeon anticipates a need
Objective outcomes data on the robotic technology when for anatomical flexibility, a wider range of dissection within
compared to laparoscopic or open surgery remain limited the abdomen, or sequential on/off periods of the pneumo-
and mostly retrospective. There has so far not been a striking peritoneum, then a laparoscopic platform would be advised.
advantage throughout all quality assessment parameters. Vice versa, if the procedure requires maneuvering in limited
However, the technology as such, the surgical familiarity and space or intracorporeal suturing, 3D laparoscopy or robotic
routine, and the value for the patient, the surgeon, or the surgery greatly facilitates the surgical procedure.
If safe access and workspace are uncertain or the proce- greater than 40, previous surgeries with extensive adhe-
dure carries a high probability of a conversion, it might be sions, or recurrent disease?
preferable to plan for an initially limited laparoscopic
approach with a minimal number of equipment and dispos-
able materials. Instead of committing expensive equipment Training Aspects
and infrastructure that may not be used, this allows for a
quick decision about whether to proceed with a full laparo- The lack of a structured postgraduate training pathway has
scopic procedure or to immediately convert to an open sur- been identified as a barrier for implementation of the laparo-
gery. Hybrid operations may occasionally offer a specific scopic approach. To minimize these obstacles, professional
benefit, however, in general they tend to generate additional organizations (American Society of Colon and Rectal
cost without offering any measureable benefit such as a bet- Surgeons, American College of Surgeons, Society of
ter outcome. American Gastrointestinal and Endoscopic Surgeons) and
representatives from industry (Medtronic, Ethicon, Covidien,
Stryker, Storz) have partnered up to develop tools and educa-
Challenges tional programs that lead to certification and credentialing
skills and documentation.
The complexity of surgical management for colorectal dis-
eases relates to the details of the abdominal and pelvic anat-
omy, the non-sterile environment, multimodality treatment, Conclusion
functional and quality of life aspects, as well as multiple con-
founding patient factors and expectations. “Fancy” surgery Surgical technology evolves at a breathtaking pace. Choosing
does not necessarily equate to a good surgery; quality param- the best surgical modality should rely on fact-based benefits
eters must be prioritized. However, if a high quality surgery and value-based outcomes. It will be necessary to objectively
can be performed in a minimally invasive approach, neces- define the value of the various approaches. Value is expressed
sity and benefits pair up to achieve a better outcome. as the ratio of quality over cost (V = Q/C), whereby the chal-
Continued attention on a case-by-case basis and system- lenge is to determine the meaning of “quality.” Parameters
atic future research should address many questions, some of include disease outcomes, complications, patient satisfac-
which are listed here: tion, efficiency, as well as finances and reimbursements.
Value of a new platform typically increases over time, when
• What are the expected contributions and benefits of a spe- established routine decreases operating times and complica-
cific minimally invasive approach in contrast to other tion rates and when equipment prices fall.
methods? What steps during a complex multiphase opera-
tion need to be performed in that modality to maintain the
benefits? Further Reading
• When should the minimally invasive approach be
avoided? Abu Gazala M, Wexner SD. Re-appraisal and consideration of mini-
mally invasive surgery in colorectal cancer. Gastroenterol Rep
• Financial impacts: What are the direct and indirect cost (Oxf). 2017;5(1):1–10.
associated with a chosen pathway during and after the Blackmore AE, Wong MT, et al. Evolution of laparoscopy in colorec-
hospital stay; compare the higher technical cost and lon- tal surgery: an evidence-based review. World J Gastroenterol.
ger operative times in relation to the shorter length of stay, 2014;20(17):4926–33.
Clinical Outcomes of Surgical Therapy Study, G. A comparison of lap-
faster return to work, and potentially lesser long-term aroscopically assisted and open colectomy for colon cancer. N Engl
morbidity (e.g., hernia formation and adhesion-induced J Med. 2004;350(20):2050–9.
bowel obstructions). Curro G, Cogliandolo A, et al. Three-dimensional versus two-
• Complications: What are the specific complications asso- dimensional laparoscopic right hemicolectomy. J Laparoendosc
Adv Surg Tech A. 2016;26(3):213–7.
ciated with the various approaches and what is the respec- Ding J, Xia Y, et al. Hand-assisted laparoscopic surgery versus open sur-
tive price tag on those? gery for colorectal disease: a systematic review and meta-analysis.
• What are the long-term disease-related and functional Am J Surg. 2014;207(1):109–19.
outcomes, particularly in the context of cancer Fleshman J, Branda M, et al. Effect of laparoscopic-assisted resec-
tion vs open resection of stage II or III rectal cancer on pathologic
management? outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA.
• How do patient-related factors factor into the ability to 2015;314(13):1346–55.
perform the procedure by minimally invasive approach? Guillou PJ, Quirke P, et al. Short-term endpoints of conventional ver-
For example, morbid obesity with a body mass index sus laparoscopic-assisted surgery in patients with colorectal cancer
(MRC CLASICC trial): multicentre, randomised controlled trial. Moloo H, Haggar F, et al. Hand assisted laparoscopic surgery versus
Lancet. 2005;365(9472):1718–26. conventional laparoscopy for colorectal surgery. Cochrane Database
Jayne D, Pigazzi A, et al. Effect of robotic-assisted vs conventional Syst Rev. 2010;(10):CD006585.
laparoscopic surgery on risk of conversion to open laparotomy Podda M, Saba A, et al. Systematic review with meta-analysis of stud-
among patients undergoing resection for rectal cancer. JAMA. ies comparing single-incision laparoscopic colectomy and multiport
2017;318(16):1569–80. laparoscopic colectomy. Surg Endosc. 2016;30(11):4697–720.
Kaiser AM. McGraw-Hill Manual Colorectal Surgery. Access Surgery; Sorensen SM, Savran MM, et al. Three-dimensional versus two-
2009. Retrieved November 14, 2022, from https://accesssurgery. dimensional vision in laparoscopy: a systematic review. Surg
mhmedical.com/book.aspx?bookID=425. Endosc. 2016;30(1):11–23.
Kaiser AM. Evolution and future of laparoscopic colorectal surgery. Stevenson AR, Solomon MJ, et al. Effect of laparoscopic-assisted resec-
World J Gastroenterol. 2014;20(41):15119–24. tion vs open resection on pathological outcomes in rectal cancer: the
Liao G, Zhao Z, et al. Robotic-assisted versus laparoscopic colorectal ALaCaRT randomized clinical trial. JAMA. 2015;314(13):1356–63.
surgery: a meta-analysis of four randomized controlled trials. World Zelhart M, Kaiser AM. Robotic versus laparoscopic versus open
J Surg Oncol. 2014;12:122. colorectal surgery: towards defining criteria to the right choice. Surg
Memon S, Heriot AG, et al. Robotic versus laparoscopic proc- Endosc. 2018;32:24–38.
tectomy for rectal cancer: a meta-analysis. Ann Surg Oncol.
2012;19(7):2095–101.
Endoscopic Techniques for Colorectal
Lesions 55
Anna Skay and Jacques Van Dam
Indications • Discuss with the patient importance of a good bowel

preparation to avoid repeat procedures and to decrease
Colonoscopy is an invaluable tool in colorectal cancer diag- perforation risk due to poor visualization.
nosis and management. Detection and removal of colonic • All other instructions are the same as would be for any
neoplasms are the key elements in screening and prevention colonoscopy procedure.
of colorectal cancer. A high-quality colonoscopy remains the
main screening modality for colorectal cancer. Colonoscopy
with polypectomy was shown to decrease mortality from Pitfalls and Danger Points
CRC by 53%. Unfortunately, 2–6% of CRCs develop in the
interval between colonoscopies. A significant portion of • Inadequate removal of non-neoplastic lesions
these are believed to develop from missed polyps rather than • Failure to detect synchronous lesions
as new neoplastic lesions. Polyps can be missed due to inad- • Oncologically inferior management
equate bowel preparation, appearance of the polyps (as flat • Bleeding
polyps may resemble normal mucosa), and technical chal- • Perforation
lenges, if polyps are hidden behind folds. Several advances • Insufficient tattooing
in colonoscopy technique have improved visualization and
increased polyp detection. Endoscopic mucosal resection
(EMR) is becoming the standard of care for removal of large Operative Strategy
sessile or flat laterally spreading lesions.
Polyp Detection
Preoperative Preparation Recent developments in colonoscopy techniques have been

designed to improve detection of abnormal lesions in the
• EMR can be performed as a same-day outpatient colon. Certain techniques are used not only to distinguish
procedure. normal mucosa from abnormal but also to predict histology
• Counsel the patients to stop anticoagulation medication based on endoscopic appearance. Chromocolonoscopy,
for 7 days prior to procedure, with the plan to resume which can be performed with dye or with varying light fre-
5 days after the procedure. quency, not only characterizes abnormal mucosa but also can
act as an “optical biopsy” by predicting the lesion’s micro-
scopic morphology.
A. Skay Dye-Assisted Chromocolonoscopy

USC Digestive Health Center, Keck School of Medicine,
University of Southern California, Los Angeles, CA, USA
Chromoendoscopy enhances the observed image through
J. Van Dam (*) use of dye or optical techniques. It improves distinction of
USC Digestive Health Center, Department of Medicine, Keck
normal mucosa from neoplastic lesions by enhancing the
School of Medicine, University of Southern California,
Los Angeles, CA, USA borders and surface morphology of pathologic lesions.
e-mail: jvandam@usc.edu Chromoendoscopy also aids in distinction of adenomatous

https://doi.org/10.1007/978-3-030-81415-1_55
422 A. Skay and J. Van Dam
polyps from hyperplastic polyps. Small hyperplastic polyps sue for approximately 1 minute and lasts up to 20 minutes.
(of less than 5 mm) are generally considered benign without Both stains have been shown to be safe with no significant
risk of malignancy. As cost of colonoscopy is rising, predict- side effects. There was concern that methylene blue may
ing histology of small polyps can cut down on excessive cause DNA damage, but no clinically significant DNA injury
pathology fees. has been proven. The dye is applied upon reaching the cecum
White light endoscopy does not allow for clear distinction directly into the accessory channel using a 60-mL syringe or
between adenomatous and hyperplastic polyps. a spray catheter. The dye can also be diluted into 1 Liter of
Chromoendoscopy improves distinction of the mucosal mor- sterile water, attached to the irrigation port, and applied by
phology, allowing the endoscopist to predict histology. The the endoscopist by pressing the foot pedal of the water pump.
neo-angiogenesis of adenomatous polyps results in different Dyeless or digital chromocolonoscopy uses imaging-
“pit patterns” of the mucosa, which can be seen with dye or enhanced optical techniques. This technique uses optical
optical techniques. technology to enhance lesions. Narrow-band imaging (NBI)
Dye-based chromoendoscopy uses dyes that either absorb uses optical filters in the light source to enhance superficial
into the mucosa (vital dye) or remain on the surface of the and deep vessels. NBI utilizes the pit pattern and vascular
mucosa (non-vital). The dye can be applied to targeted areas pattern to distinguishing abnormal lesions (Figs. 55.2a–d
or to the entire colon (pan-chromoendoscopy). The dyes and 55.3a, b). The NICE (NBI International Colorectal
enhance topography of neoplastic lesions or the pit pattern. Endoscopic) classification was developed to differentiate
Kudo et al. showed the endoscopic pit pattern of dye type I (hyperplastic) from type II (adenomatous) lesions
enhanced lesions correlated to histology. Adenomatous based on appearance of color, surface pattern, and vessels
lesions have a gyrus-like pit pattern, while hyperplastic (Table 55.1).
lesions have an asteroid pit pattern.
Most commonly used dyes are indigo carmine and methy-
lene blue, which both have a blue appearance endoscopi- New Colonoscope Technology
cally. Both are equally effective to distinguish abnormal
mucosa. Indigo carmine is a non-vital dye that coats the Several devices have been developed to assist the endosco-
mucosa and outlines the pit pattern, enhancing the contrast pist to see behind folds and in flexures. The clear cap, the
between varying mucosal morphology. It is applied with a Endocuff, and the EndoRing have been studied and have
concentration of 0.03–0.5% and lasts a few minutes. Because shown some promise to decrease missed polyps, especially
it is not absorbed, it disappears as it becomes diluted through- diminutive polyps. At this time, the data is not strong enough
out the colon. Methylene blue is a vital dye, which actively to support these devices as routine standard of care.
absorbs into the intestinal epithelial cells. Neoplasia and New colonoscope platforms, such as the Fuse® full spec-
inflamed mucosa do not absorb the dye, making it appear trum endoscopy platform and NaviAid (Pentax Medical,
brighter than normal mucosa (Fig. 55.1a, b). It is applied at a Hamburg, Germany), and the wide angle colonoscope are
concentration of 0.1%. After application, the dye stains tis- designed to increase the field of view by improving optics
a b
Fig. 55.1
55 Endoscopic Techniques for Colorectal Lesions 423
a b
c d
Fig. 55.2
a b
Fig. 55.3
Table 55.1 Endoscopic classification system for small polyps • Indications

NICE • Characterization of the colonic lesion: size, location,
criterion TYPE 1 TYPE 2 appearance
Color Same or lighter than Browner relative to • Procedural details
background background
• Clipping
Vessels None or isolated lacy Brown vessels
vessels surrounding white • Tattooing
structures
Surface Dark or white spots of Oval, tubular, or
pattern uniform size or branched white structures Operative Technique
homogenous absence of surrounded by brown
pattern vessels
Likely Hyperplastic Adenoma EMR Technique
pathology
Adapted from Hewett DG, et al. Validation of a simple classification The size and protrusion of the colonic polyp into the lumen
system for endoscopic diagnosis of small colorectal polyps using dictate the instruments used. Polyps of less than 5 mm can be
narrow-band imaging. Gastroenterology. 2012;143(3):599–607, with removed with cold biopsy forceps. Diminutive polyps of
permission
5 mm or slightly larger can be removed with cold snare pol-
ypectomy. Use hot snare polypectomy for polyps over
and adding imagers. The Third Eye colonoscopy device uses 10 mm. Prior to performing EMR, assess the Paris classifica-
a second endoscope that is introduced into the working chan- tion and inspect the lesion for the Kudo pit pattern and Sano
nel of the colonoscope. This second endoscope can retroflex vascular pattern. This assessment will help predict lesion
and show the mucosa behind the folds and has also shown morphology and submucosal invasion. For larger lesions,
promise to improve ADR. Balloon colonoscopy with an inte- create a cushion underneath the polyp by performing a sub-
grated balloon on the end of the colonoscope successfully mucosal injection of a solution of low concentration epi-
showed to flatten folds and increase ADR. These novel nephrine (1:10,000) and methylene blue. Use CO2 insufflation
devices increased the endoscopist’s field of view but require if available. Remove lesions of 10–20 mm en bloc. Remove
having a different platform and may increase withdrawal larger polyps piecemeal.
time compared to standard colonoscopy.
Recurrent or Remaining Adenoma

Endoscopic Mucosal Resection
Large lesions over 40 mm are associated with higher rate of
Large sessile or flat laterally spreading colonic lesions recurrence, which can be detected with careful surveillance.
(LSLs) can be managed endoscopically with endoscopic Large lesions must be removed piecemeal, which is also
mucosal resection (EMR). EMR provides a minimally inva- associated with retained adenomatous tissue and recurrent
sive technique that cures large adenomas and possibly early adenomas. The nature of the technique does not allow en
cancers. This technique is less expensive than surgery and bloc resection if the lesions are more than 20–25 mm.
can be performed in an outpatient setting. It allows the Although remaining or recurrent adenoma remains a chal-
patient to maintain normal bowel anatomy and function. lenge, the recurrent lesions are often small and can be man-
Well-differentiated tumors with less than 1000 μm invasion aged endoscopically. Studies have shown a 6 month
below the muscularis mucosa can be resected with EMR, and follow-up colonoscopy after EMR improves detection of
surgery can be avoided. The cost of endoscopic resection remaining adenoma. Recent data suggests that evaluating the
fares favorably in comparison with the cost of abdominal EMR scar with white high-definition light as well as NBI can
surgery. Furthermore, the risk of postoperative morbidity improve detection of recurrence or remaining adenomas.
and mortality can be a relevant obstacle in this often-elderly
patient population.
Hemostasis
Documentation Basics Most frequent adverse event of EMR is clinically significant

bleeding, which occurs at higher rates in the right colon and
Coding for surgical procedures is complex. Consult the most frequently is delayed, mostly occurring within 48 hours of
recent edition of the AMA’s Current Procedural Terminology the procedure. Clinically significant bleeding is defined as
book for details (see references at the end). In general, it is bleeding resulting in emergency department visit, hospital-
important to document: ization, or repeat intervention. Prophylactic clipping of the
55 Endoscopic Techniques for Colorectal Lesions 425
EMR site immediately after resection has been frequently ticed widely in Asian countries and is now increasing in non-
performed. However, recent data may suggest that clipping Asian countries as well. ESD is a meticulous submucosal
of all sites may not be cost effective and should be performed dissection using an ESD knife for en bloc removal of large
for selective lesions, especially in the right colon, where pro- flat lesions with suspicion of superficial neoplasia. This tech-
phylactic clipping was found to be cost effective. nique is new to the West, with a high learning curve. It shows
After polyp resection, you can sometimes encounter visi- great promise in resection of larger lesions, circumferential
ble vessels, either actively bleeding or non-bleeding, in the lesions or polyps with localized neoplasia.
EMR defect. Active bleeding can be managed with argon
plasma coagulation, clipping, injection of epinephrine, or
coagulation. You can perform coagulation by using the snare Colonic Stent Placement
tip or a coagulation forceps to apply SOFT COAG. Confirm
the setting with your technician as ENDO CUT or FORCED Tumors can cause complete or partial obstruction, which can
COAG setting can result in a perforation. Prophylactic endo- be relieved with a colonic stent. Self-expanding metal stents
scopic coagulation of visible vessels within the EMR defect have had a high success rate in placement. Stents can be pal-
immediately after resection did not prevent clinically signifi- liative to relieve obstruction due to malignancy; or, they can
cant post-procedure bleeding in a recent publication. act as a bridge to surgery. Although the success rate is high in
placement, there is a high complication rate. Colonic stents
can result in perforation, obstruction, migration, or bleeding
Perforation due to ulcer formation. A recent study suggested stent place-
ment might be similar in efficacy to emergent surgery for
EMR of large LSLs has a higher perforation rate than resec- acute obstruction. For left colon obstructions, stenting as
tion of smaller polyps. Endoscopic closure of the EMR defect therapy to bridge to surgery has been shown to have lower
can manage the perforation and avoid surgery. Endoscopic rates of stoma, both permanent and temporary.
findings, such as the “target sign,” can suggest a perforation. Perform stent placement under fluoroscopic visualization
Such defects can be closed with endoclips or with an over the with wire guidance. CT scans can aid in determining the
scope clip. Carefully inspect the EMR defect after resection. length of the stent based on the length of the stricture. If the
scope cannot advance through the stricture, do not dilate it
due to the very high perforation risk associated. Covered and
Tattoo Placement uncovered stents are available. Covered stents have a higher
rate of migration, while uncovered stents have a higher risk
Marking the location of a large polyp or a resection site is of tumor ingrowth. If tumor ingrowth occurs, a stent can be
invaluable to future endoscopic procedures as well as for sur- placed within the obstructed stent.
gery. Inject the submucosa at a 45 degree angle. If tattoo
serves primarily at future endoscopic identification of the
site, the injection should be submucosal. However, if the tat- Postoperative Care
too is placed to guide a surgical resection, it is crucial to
inject the tattoo deep in three to four quadrants, even if it will • Instruct the patient to resume normal diet as tolerated.
technically cause a microperforation and spill into the perito- • Inform the patient about signs of complications: abdomi-
neum. Commonly used materials are India Ink and purified nal pain, bleeding, fevers, chills, etc.
carbon particles. The expert-recommended tattoo location is • Follow up on the pathology result and assess the timeline
the “four quadrant” injection distal to the lesion. Marking for surveillance or subsequent interventions.
multiple quadrants allows for circumferential visualization • Consider genetic counseling/testing in young patients,
at the time of surgery. patients with multiple polyps, or respective family
history.
Endoscopic Submucosal Dissection

Complications
Endoscopic submucosal dissection (ESD) of LSLs allows en
bloc resection of large colonic lesions. EMR, although effec- • Hemorrhage
tive, is limited in en bloc resection to 20–25 mm. Piecemeal • Perforation
polyp removal is associated with more recurrence, so en bloc • Incomplete excision
resection is preferred if technically possible. ESD is prac- • Retained positive lymph nodes
Further Reading He Q, et al. Cap-assisted colonoscopy versus conventional colonos-

copy: systematic review and meta-analysis. Int J Colorectal Dis.
2013;28(2):279–81.
Alptekin H, Yilmaz H, Kayis SA, Sahin M. Volume of excised speci-
Heitman SJ, Tate DJ, Bourke MJ. Optimizing resection of large colorec-
men and prediction of surgical site infection in pilonidal sinus pro-
tal polyps. Curr Treat Options Gastroenterol. 2017;15(1):213–29.
cedures (surgical site infection after pilonidal sinus surgery). Surg
Klein A, Bourke MJ. Management of colonic polyps: an advancing dis-
Today. 2013;43:1365–70.
cipline. ANZ J Surg. 2017;87(5):327–30.
Kudo S, et al. Colorectal tumours and pit pattern. J Clin Pathol.
®. Professional ed. Chicago: American Medical Association. 2013.
1994;47(10):880–5.
http://www.ama-assn.org/ama/pub/physician-resources/solutions-
Lee EY, Bourke MJ. EMR should be the first-line treatment for
managing-your-practice/coding-billinginsurance/cpt.page.
large laterally spreading colorectal lesions. Gastrointest Endosc.
Ahlenstiel G, Hourigan LF, Brown G, Zanati S, Williams SJ, Singh
2016;84(2):326–8.
R, Moss A, Sonson R, Bourke MJ, Australian Colonic Endoscopic
Nagorni A, Bjelakovic G, Petrovic B. Narrow band imaging versus
Mucosal Resection (ACE) Study Group. Actual endoscopic versus
conventional white light colonoscopy for the detection of colorectal
predicted surgical mortality for treatment of advanced mucosal
polyps. Cochrane Database Syst Rev. 2012;1:CD008361.
neoplasia of the colon. Gastrointest Endosc. 2014;80(4):668–76.
Rex DK, Hassan C, Bourke MJ. The colonoscopist’s guide to the vocab-
https://doi.org/10.1016/j.gie.2014.04.015. Epub 2014 Jun 7.
ulary of colorectal neoplasia: histology, morphology, and manage-
Arezzo A, Passera R, Lo Secco G, Verra M, Bonino MA, Targarona
ment. Gastrointest Endosc. 2017. pii: S0016–5107(17)31784–4.
E, Morino M. Stent as bridge to surgery for left-sided malignant
Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of
colonic obstruction reduces adverse events and stoma rate compared
self-expandable metal stents for malignant colonic obstruction:
with emergency surgery: results of a systematic review and meta-
long-term outcomes and complication factors. Gastrointest Endosc.
analysis of randomized controlled trials. Gastrointest Endosc. 2017.
2010;71(3):560–72.
pii: S0016–5107(17)31780–7.
Swan MP, Bourke MJ, Moss A, Williams SJ, Hopper A, Metz A. The
Dik VK, et al. Multicenter, randomized, tandem evaluation of
target sign: an endoscopic marker for the resection of the muscularis
EndoRings colonoscopy--results of the CLEVER study. Endoscopy.
propria and potential perforation during colonic endoscopic muco-
2015;47(12):1151–8.
sal resection. Gastrointest Endosc. 2011;73(1):79–85.
Floer M, Meister T. Endoscopic improvement of the adenoma detection
Yang M, Pepe D, Schlachta CM, Alkhamesi NA. Endoscopic tat-
rate during colonoscopy - where do we stand in 2015? Digestion.
too: the importance and need for standardised guidelines and
2016;93(3):201–12.
protocol. J R Soc Med. 2017:141076817712244. https://doi.
Gralnek IM, et al. Standard forward-viewing colonoscopy versus full-
org/10.1177/0141076817712244. [Epub ahead of print].
spectrum endoscopy: an international, multicentre, randomised,
Zauber AG, et al. Colonoscopic polypectomy and long-term prevention
tandem colonoscopy trial. Lancet Oncol. 2014;15(3):353–60.
of colorectal-cancer deaths. N Engl J Med. 2012;366(8):687–96.
Right and Extended Right
Hemicolectomy (Open, Laparoscopic) 56
Indications consider a combined endoscopic-laparoscopic surgery

(CELS).
• Colon cancer • Colonoscopy to determine the nature of the pathology
• Appendiceal cancer or neoplasm with unfavorable (benign vs malignant), assess whether it is amenable to
features endoscopic removal, and to exclude synchronous
• Large colon polyps, not amenable to endoscopic removal pathology.
• Ileocolic Crohn disease • Cross-sectional imaging (CT/MRI): Assess resectability
• Arteriovenous malformations, not amenable to endo- and rule out systemic disease.
scopic ablation • In patients on chemotherapy or immunosuppressants:
• Cecal volvulus Plan for optimal timing of surgery.
• Ischemia • Depending on the specifics (e.g., large tumor, severe
• Right-sided diverticulitis inflammation): possible ureteral stent placement.
• Mechanical bowel preparation: Not mandatory but advan-
The extent and approach may vary depending on the tageous if intraoperative colonoscopy planned, or to do
nature and location of the target pathology, possible underly- intracorporeal anastomosis.
ing risk constellations (hereditary cancer, inflammatory • Antibiotic prophylaxis (versus treatment).
bowel disease), and the chosen technique (open versus mini-
mally invasive).
Preoperative Preparation • Oncologically inferior resection

• Injury to duodenum, liver, and gallbladder
• Review the patient’s history, diagnosis, functional aspects, • Injury to right ureter
and appropriate indication for surgery (based on endo- • Hemorrhage: most dangerous from branches of the supe-
scopic, clinical, or radiographic means) as opposed to rior mesenteric vein or the mid colic artery
nonsurgical management (e.g., systemic chemotherapy). • Unplanned enterotomy or colotomy
• Ascertain the exact location of the pathology (endoscopy, • Retrorenal dissection
imaging); if the location is uncertain or if there is poten- • Anastomotic leak, or twist
tially a chance for an endoscopic removal of the lesion, • Internal hernia
plan for a repeat colonoscopy with EMR, tattooing, or
Operative Strategy
M. Zelhart
Department of Surgery, Tulane University, New Orleans, LA, USA Localization of Target Lesion
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of For any colon resection, exact localization of the target lesion
Hope National Medical Center/Comprehensive Cancer Center, is of utmost importance. Some lesions are large enough that
Duarte, CA, USA
they can be identified on a CT scan or other radiological

https://doi.org/10.1007/978-3-030-81415-1_56
images. Other lesions are visible on the same colonoscopy Often—and particularly in the case of laparoscopic sur-
image as definitive landmarks (ileocecal valve, appendiceal gery—it is advantageous to take the vascular supply early in
orifice). The remainder of lesions, however, requires preop- the case. That means that the knowledge of the anatomy in
erative localization and tattooing. The colonoscopic tattoos general and related to the specifics of the case needs to be
should be injected in three quadrants deeply into the bowel crystal clear.
wall to be visible on the serosal side. It should be clearly The right colon is supplied by the ileocolic and the middle
documented where the tattoos are placed in relation to the colic artery; a formal right colic artery is present in some
lesion (distal, at the site, etc.). Further, endoscopic clip place- cases. The middle colic artery branches early into the right
ment with immediate abdominal X-ray in the recovery room and left branches. The left branch forms the marginal artery
after endoscopy can be helpful in defining the tumor that connects to the left colic artery at the splenic flexure.
location. This is one of the known water-shed areas between superior
and inferior mesenteric artery, but the adequacy of this col-
lateralization is variable. Commonly, but not always, this
Surgical Approach redundant blood inflow allows the distal transverse colon to
survive after transection of the middle colic artery. If not, the
Traditionally, colon surgery including right colectomy was extended right colectomy needs to include the splenic flex-
approached and described as open surgery, for example, ure. Care must be taken not to damage the marginal artery
through a midline or a transverse incision. Minimally inva- during eventual anastomosis to ensure adequate oxygenation
sive approaches (laparoscopic or robotic surgery), however, to the anastomosis from this now sole blood supply.
have dramatically evolved and in many circumstances are Special analysis and planning of the resection extent are
considered the first choice. necessary if the inferior mesenteric artery has been previ-
ously ligated (e.g., after repair of an infrarenal aortic aneu-
rysm or a previous rectosigmoid resection) or is found to
Extent of the Resection lack adequate blood flow at the time of surgery.
One of the first decisions to be made is to define the extent of

the resection (Fig. 56.1a–c). In benign disease, the resection Colon Mobilization
is directly related to the immediate extent of the pathology.
In malignant or potentially malignant disease, quality param- In open surgery, the mobilization of the colon from retroperi-
eters include (1) the proximal, distal, and circumferential toneal attachments is the first step; it starts at the white line
margins, (2) an adequate lymph node harvest of at least 12 of Toldt and progresses in a lateral to medial fashion. In con-
nodes per colon segment, and (3) inclusion of the respective trast, laparoscopic and robotic surgeries preferably approach
omentum. The proximal resection is invariably at the ileum. the dissection from a medial to lateral approach. This allows
The distal extent depends on the location of the tumor. For a the lateral colon attachments to keep it up and out of the way,
cecal or ascending colon lesion, the resection should include aiding in exposure of the vascular pedicle. A gentle antero-
the right branch of the mid colic artery (Fig. 56.2a); for lateral retraction of the colon can flatten out the redundant
hepatic flexure or transverse colon lesions, the base of the mesentery and create a roadmap of the vascular supply to the
mid colic artery should be taken and the colon resection right colon. It is important to be mindful of the correct plane
extended to the distal transverse colon or even the descend- of dissection which should be largely avascular. Too poste-
ing colon (extended right hemicolectomy) (Fig. 56.2b). The rior dissection may result in mobilization behind the kidney
omentum should be resected to the same extent as the colon and increase the risk of duodenal and ureteral injury.
(Fig. 56.3).
Colon Resection
Vascular Transection
After transection of the vascular pedicles and the mesentery
A “high ligation” of the key vessels should be performed at up to the terminal ileum and the predetermined marking on
their point of origin. This allows for maximal nodal tissue to the colon, the resection follows. Depending on the chosen
be incorporated in the pathologic specimen. This remains approach this can be done on the exteriorized bowel or as an
one of the most dangerous portions of the case, and care intracorporeal resection and anastomosis. In select cases, an
must be taken not to lose control by poorly executed liga- anastomosis is either not possible or not advisable, and the
tions or by injury to the superior mesenteric artery or vein. terminal ileum is brought out as an ileostomy (see Chap. 50).
56 Right and Extended Right Hemicolectomy (Open, Laparoscopic) 429
a b
Fig. 56.1
a b
Fig. 56.2
Documentation Basics Operative Technique
Coding for surgical procedures is complex. Consult the most Positioning

book for details (see references at the end). In general, it is Regardless of the approach, place and secure the patient in
important to document: either supine position or in modified lithotomy on an anti-
sliding system that allows for dynamic repositioning during
• Findings and indication the case. Preferably arms are to be tucked to allow best access.
• Reasoning for choice and extent of surgical approach Place a urinary catheter to decompress the bladder and moni-
• Surgical approach tor intraoperative urine output. Prep and drape the patient.
• Blood vessels taken Monitors for laparoscopic surgery should be placed such that
• Type of anastomosis surgeon, target, and monitor form one line (Fig. 56.4).
placed at the umbilicus and later served as the extraction and

anastomosis site.
Placement of the robotic trocars depends on the platform.
For the most current generation of robots (the DaVinci Xi),
they are placed on an oblique line from the suprapubic area
to the left upper quadrant with an additional accessory port
in the left lateral quadrant (Fig. 56.5b).
Open Approach
For an open approach, make a midline incision staying on
the left side of the umbilicus, in the very rare event that an
ostomy needs to be made. Start with a 10 cm incision and
determine the individual anatomy. Depending on the needs
of the variable anatomy, the incision can be left as that or be
extended in one or the other direction. A wound protector is
desirable.
Alternative incisions include a right transverse incision;
occasionally, a right hemicolectomy is performed in con-
junction with a liver resection and can typically be carried
out through the hepatobiliary access.
Exploration
Once entry into the abdomen has been obtained (regardless

of the platform), explore the abdomen. Perform a thorough
examination of all quadrants and look for signs of tumor
manifestations, for example, liver metastases, carcinomato-
Fig. 56.3 sis, or Krukenberg tumors of the ovaries. Visualize or palpate
the liver to assess for any metastatic disease. Carcinomatosis
can be encountered in all quadrants but is particularly fre-
Operative Approach and Incisions quent in the pelvic cul-de-sac and the pericolonic gutters.
Next, find the site of the primary tumor, either by locating the
inimally Invasive Surgery
M tattoo or by gentle palpation through the colonic wall.
In regard to minimally invasive techniques, there are straight
laparoscopic, single port, hand-assisted, or robotic
approaches. Each platform employs a slightly different lay- Identification of the Ureter
out of their port placement. Depending on the past history,
insert the first 10–12 mm trocar using the Hasson or the It is never wrong to look for the ureter, but not mandatory for
Veress needle technique. Insert all subsequent ports under the right hemicolectomy. If you carry out the dissection in
visual control. the correct plane, the risk for a ureteral injury during a right
Pure laparoscopic techniques normally use 3–4 trocars. hemicolectomy is much smaller than during a rectosigmoid
Insert a camera port at the umbilicus. You can later expand resection. In patients without a lot of abdominal fat, the right
this incision to serve as an extraction site and to perform an ureter may be clearly visible upon entry into the abdomen. If
extracorporeal anastomosis (unless you prefer a different it is not easily visible, you may find it where it is crossing the
location). Place 2–3 working ports that triangulate onto the right common iliac artery near the bifurcation into the inter-
ascending colon. Our preference is one in the suprapubic nal and external branches. If it is still not visible, the top
midline, one in the left upper quadrant, and the third one layer of the peritoneum can be incised along planes that will
either in the left mid abdomen or in the right lower quadrant be used for further steps in the surgery. Often the ureter can
(Fig. 56.5a). be seen peristalsing (“vermiculating”) in the retroperitoneal
For single port or hand-assisted laparoscopy, the multi- fat, particularly in response to a mechanical stimulus. In
access port and the hand port, respectively, are typically order to avoid injury throughout the rest of the case, you may
Monitor Monitor
Surgeon
Assistant
Assistant
Equipment table
Mayo Table
Fig. 56.4
a b
Fig. 56.5
keep the location of the ureter in the mind’s eye or mark it for section to keep control of the vessel origin should the hemo-
example by placing a clip to the fat just anteriorly to it. stasis not be perfect.
The next step before moving on to the colon itself entails
dividing the mesentery to the terminal ileum, either by step-
Division of the Ileocolic Vessels wise clamping and ligating or by using an advance energy
device.
Grasp the mesentery at the ileocecal junction and elevate and
retract it to the side. This maneuver will accentuate the ileo-
colic vascular pedicle. In order to increase the amount of Colon Mobilization
lymphatic tissue in the specimen, plan on taking the ileocolic
pedicle as close as possible to its point of origin from the Medial to lateral approach Leave the lateral attachments in
superior mesenteric artery and vein without injuring either place until the posterior mobilization is largely done. The
one. Score the serosa over the top at the base of it. Continue attachments are a free assistant as they hold the colon up in
in cephalad direction to enter the retrocolic plane. Be mind- place while you can work underneath. Once the serosa along
ful during this step that the inferior portion of the duodenum the vascular pedicle is opened, you may elevate it and bluntly
is often directly superior to the pedicle. Gently sweep the separate the colon along the avascular embryological planes.
duodenum down and out of the surgical field. Complete a Again, pay attention to not injure the duodenum by rough
window around the pedicle. Sometimes, gentle dissection movements or hot instruments. Continue until the lateral
must be utilized to remove lymphatic and areolar tissue so peritoneal reflection has been reached, at which point the lat-
that you can safely identify the vascular structures. eral dissection is completed (Fig. 56.7a, b).
Transection of the ileocolic pedicle can be achieved in
different ways: (1) by clamping, sharp dissection, and suture
ligation; (2) isolation of each vessel, clipping, and sharp dis- Lateral to medial approach Historically and still in open
section; (3) vascular linear stapler; or (4) advanced energy surgery, the mobilization of the colon starts at the white line
devices (Fig. 56.6a, b). Whichever method you choose, make of Toldt which is incised with cautery. Move your nondomi-
sure to have a clamp ready on the proximal side of the tran- nant index finger underneath and retract the colon away from
a b
Fig. 56.6
a b
Vascular Retroperitoneum Duodenum

pedicle
Fig. 56.7
the structures underneath. Continue incising the serosa close to be divided. There are also collateral veins from the inferior
to the colon. Progress medially toward the pedicle (Fig. 56.8). pancreaticoduodenal vein to the middle colic vein that can
cause considerable bleeding. Carefully create a window
around the mid colic pedicle. Check that you are not includ-
Division of the Middle Colic Vessels ing the superior mesenteric vessels to the small bowel mes-
entery. Divide the middle colic pedicle between clamps and
Lift the gastrocolic ligament and start dividing layer by layer secure both sides with suture ligatures, clips, or a stapler.
until the avascular plane leading to the lesser sac is reached.
Move from the mid transverse colon backward to and around
the hepatic flexure and conjoin the lateral colon mobiliza- Mesentery and Omentum Roundup
tion. Identify the mid colic vessels, that is, the main trunk
and the right and left branch. For lesions in the proximal por- Complete the division of the mesentery up to the point where
tion of the ascending colon, it suffices to divide the right you intend to resect the colon. For malignant disease, divide
branch of the middle colic artery. For lesions at the hepatic the omentum from its caudad free border perpendicular
flexure or the transverse colon, the trunk of the middle colic toward the intended site of bowel transection. You can do
vessel should be taken. This is a dangerous step! You need to that either by stepwise clamp-clamp-cut-ligation or more
avoid losing control. There may be dense attachments conveniently with an advanced energy device. For benign
between the pancreas and the colonic mesentery that needs disease, resecting the omentum is optional; if you elect to
Fig. 56.8
Sup.mesenteric a.
Ileocolic a.
Paracolic
peritoneum
preserve the omentum, move it to the upper abdomen and Once division of the intestine has occurred, reexamine the
carefully dissect it off the transverse colon by finding the blood supply. If this is in question, use a knife to make a nick
avascular plane. It is often helpful to visualize the posterior in the bowel or mesentery to assess for bleeding. Alternatively,
side of the stomach to confirm that dissection is progressing the minimally invasive platforms allow for injection of ICG
in the correct plane. and fluorescence imaging to assess the tissue perfusion. If
the blood supply is insufficient or none, resect additional
bowel until good blood supply is reached. When confident in
Division of Ileum and Colon the blood supply, verify and achieve hemostasis.
Timing and type of bowel transection is less a question for

open surgery. When using the minimally invasive platforms, Ileo-colonic Anastomosis
the colon and ileum can be transected intracorporeally or
extracorporeally. The areas of transection should have been Hand-Sewn End-to-End
identified earlier and the mesentery should have already been Align the cut ends of the ileum and the transverse colon
dissected off of them. Transection for the intestine is usually together. Make a diagonal incision in the ileum to compen-
performed by a linear stapler device at this point. Before sate for possible size mismatch if needed (Fig. 56.10a, b).
extraction of the colon/specimen, place a wound protector to Approximate the two ends of the bowel with 3-0 Vicryl inter-
decrease the risk of port-site recurrence and/or infection rupted sutures. Attach hemostats to these two ends to flatten
(Fig. 56.9). the bowel ends and make subsequent sutures easier.
Now place a posterior layer of interrupted seromuscular

sutures in a linear fashion creating the back wall of the anas-
tomosis. This can be achieved directly or by flipping the
entire anastomosis for that step (Fig. 56.11a–c). For the
mucosal anastomosis, use a double-armed 3-0 PDS to start in
the middle of this back wall. With each needle, place a run-
ning suture in opposite directions. Place the full-thickness
sutures to incorporate a small edge of mucosa and a larger
edge on the serosal side. Once the back wall has been fin-
ished, continue these sutures along the anterior surface of the
anastomosis (Fig. 56.12a–d). Add interrupted seromuscular
3-0 Vicryl sutures to complete the outer layer of the front
wall (Fig. 56.13). Once all suture ends have been cut, gently
palpate the anastomosis between thumb and index finger to
assess potency and adequate size. Close the mesenteric
defect with a running 3-0 Vicryl, making sure to take ade-
quate but shallow bites of the mesentery to avoid injury to
the mesenteric blood supply.
tapled Functional End-to-End Anastomosis

S
Stapled anastomoses have become the most common tech-
nique because they are faster and convenient. Make sure that
both ends are mobile and free of adhesions. Aligned the two
bowel ends. You may place two holding stitches (optional) to
aid with placement of the staplers. Using Mayo scissors, cut
Fig. 56.9 the tips of the staple line on the anti-mesenteric side and
a b
Cheatle slit
Fig. 56.10
Ileum A Colon
a
b c
B
A
B A
Fig. 56.11
ensure hemostasis (Fig. 56.14a). Insert one jaw of the linear lines are shifted and are not directly opposing each other.
stapler into either bowel and rotate the anti-mesenteric edges Fire a second cartridge of the same cutting linear stapler or a
against each other. Check that the mesentery is not incorpo- non-cutting TA stapler in transverse direction to close the
rated in the stapler jaws (Fig. 56.14b). Close and fire the sta- remaining defect (Fig. 56.15a–d). Using interrupted absorb-
pler to create the common enterotomy. Place Allis clamps able sutures, invert the ends of the staple lines in with
over the remainder of the defect ensuring that two staple Lemberting sutures. Loosely oversewing the entire anasto-
B
a b
c d
Fig. 56.12
mosis is optional but may take some tension of the staples. and free of adhesions. Align the two bowels to overlap for
Close the mesenteric defect as described above. the length of a stapler cartridge. Place two holding stitches to
aid with placement of the staplers. Using the scissors, cut a
tapled Isoperistaltic Side-to-Side Anastomosis
S small enterotomy at the end of the small bowel and the
Particularly with the onset of the robotic intracorporeal directly adjacent area of the colon. Insert the laparoscopic/
approach, the stapled isoperistaltic side-to-side anastomosis robotic linear stapler with one jaw into either bowel. Rotate
has gained popularity. Make sure that both ends are mobile the anti-mesenteric edges against each other. Visually check
that the mesentery is not incorporated in the stapler jaws.

Close and fire the stapler to create the common enterotomy
(Fig. 56.16a, b). Using laparoscopic/robotic instruments and
technique, close the enterotomy in two layers using a run-
ning 3-0 PDS suture and oversew it with interrupted 3-0
Vicryl sutures.
Wound Closure
The operating team should discard soiled gloves and use new
instruments to close the surgical wounds. If available, cover
the anastomosis with the remaining omentum to aid in heal-
ing and deterrence of leak. Perform a last check of the abdo-
men. Remove the ports and/or close the fascia in routine
fashion. Irrigate the wound before closing the skin.
Postoperative Care
• Antibiotics: Routine coverage for the perioperative

indication.
bowel function.
• Nasogastric tube: No routine use in elective cases; keep it in
Fig. 56.13 non-elective cases until evidence of return of bowel function.
a b
Fig. 56.14
a b X Y
X Y X Y
c d
Fig. 56.15
• Enhanced recovery after surgery (ERAS) protocol: in lar injections of Vitamin B12. If return of bowel function
elective cases, initiate oral intake on day of surgery and delayed by more than 5 days, initiate parenteral
advance to solid food as patient demonstrates return of nutrition.
bowel function. • Incentive spirometry and early ambulation should be
• Nutritional support: If a substantial portion of ileum has encouraged.
been removed or short-cut, plan for monthly intramuscu-
Colon
Ileum
Fig. 56.16
Hohenberger W, Weber K, et al. Standardized surgery for colonic cancer:

Complications complete mesocolic excision and central ligation--technical notes and
outcome. Colorectal Dis. 2009;11(4):354–64; discussion 364–355.
• Anastomotic leak Lee KH, Lee SM, et al. Comparison of anastomotic configuration after
• Small bowel obstruction laparoscopic right hemicolectomy under enhanced recovery pro-
gram: side-to-side versus end-to-side anastomosis. Surg Endosc.
• Wound infection 2016;30(5):1952–7.
• Port-site hernia Matsuda T, Sumi Y, et al. Anatomy of the transverse mesocolon based
• Injury to superior mesenteric vessels with thrombosis or on embryology for laparoscopic complete mesocolic excision of
ischemia right-sided colon cancer. Ann Surg Oncol. 2017;24:3673.
Merkel S, Weber K, et al. Prognosis of patients with colonic carcinoma
before, during and after implementation of complete mesocolic
excision. Br J Surg. 2016;103(9):1220–9.
Parisi A, Scrucca L, et al. Robotic right hemicolectomy: analysis of
Further Reading 108 consecutive procedures and multidimensional assessment of
the learning curve. Surg Oncol. 2017;26(1):28–36.
Shapiro R, Keler U, et al. Laparoscopic right hemicolectomy with intra-
American Medical Association. Current procedural terminology: CPT corporeal anastomosis: short- and long-term benefits in comparison
®. Professional ed. Chicago: American Medical Association; 2022. with extracorporeal anastomosis. Surg Endosc. 2016;30(9):3823–9.
https://www.ama-assn.org/practice-management/cpt. Siani LM, Lucchi A, et al. Laparoscopic complete mesocolic excision
Bae SU, Jeong WK, et al. Robotic complete mesocolic excision with central vascular ligation in 600 right total mesocolectomies:
and intracorporeal anastomosis using a robotic stapler for right- safety, prognostic factors and oncologic outcome. Am J Surg.
sided colon cancer with reduced-port access. Dis Colon Rectum. 2017;214(2):222–7.
2017;60(4):456. van Oostendorp S, Elfrink A, et al. Intracorporeal versus extracorporeal
Hanna MH, Hwang GS, et al. Laparoscopic right hemicolectomy: anastomosis in right hemicolectomy: a systematic review and meta-
short- and long-term outcomes of intracorporeal versus extracorpo- analysis. Surg Endosc. 2017;31(1):64–77.
real anastomosis. Surg Endosc. 2016;30(9):3933–42. Ye K, Lin J, et al. Variation and treatment of vessels in laparoscopic
right hemicolectomy. Surg Endosc. 2018;32:1583–4.
Sigmoid Resection and Left
Hemicolectomy (Open, Laparoscopic) 57
Indications plan for a repeat colonoscopy with EMR; if endoscopic

removal not possible/prudent, perform adequate
• Colon cancer tattooing.
• Large colon polyps, not amenable to endoscopic removal • Colonoscopy to determine the nature of the pathology
• Diverticulitis (benign vs malignant), assess whether it is amenable to
• Stricture (Crohn, anastomotic, radiation, etc.) endoscopic removal, and to exclude synchronous
• Volvulus pathology.
• Ischemia • Cross-sectional imaging (CT/MRI): Assess resectability
and rule out systemic disease.
The extent and approach may vary depending on the • In patients on chemotherapy or immunosuppressants:
nature and location of the target pathology, possible under- Plan for optimal timing of surgery.
lying risk constellations (hereditary cancer, inflammatory • Depending on the specifics (e.g., large tumor, severe
bowel disease), and the chosen technique (open versus inflammation): possible ureteral stent placement.
minimally invasive). Whereas malignancies of the proximal • Mechanical bowel preparation: Debated in the literature,
three-fourths of the transverse colon are best addressed by but under elective circumstances still used by most sur-
a resection of the right and transverse colon, cancers of the geons; major advantage if intraoperative colonoscopy
distal transverse colon, splenic flexure, descending colon, planned, or to do intracorporeal anastomosis.
and sigmoid may be treated by a left-sided resection, that • Discussion and marking for possible ostomy.
is, a left hemicolectomy or a sigmoid resection (Fig. 57.1a • Antibiotic prophylaxis (versus treatment).
and b).

• Oncologically inferior resection
• Review the patient’s history, diagnosis, functional aspects, • Tenuous blood supply to the distal or proximal margins
and appropriate indication for surgery (based on endo- • Tension on the anastomosis
scopic, clinical, or radiographic means) as opposed to • Anastomotic leak, or twist
nonsurgical management (e.g., systemic chemotherapy). • Injury to ureter, spleen, and pancreas
• Ascertain the exact location of the pathology (endoscopy, • Injury to right ureter
imaging); if the location is uncertain or if there is poten- • Hemorrhage: spleen, inferior mesenteric vein, sacral ves-
tially a chance for an endoscopic removal of the lesion, sels, etc.
• Unplanned enterotomy or colotomy
• Retrorenal dissection
M. Zelhart
Department of Surgery, Tulane University, New Orleans, LA, USA • Internal hernia
A. M. Kaiser (*)
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_57
a b
Alternative line Line of transaction Line of transaction

of transaction for carcinoma at for carcinoma of
splenic flexure descending colon
Fig. 57.1
57 Sigmoid Resection and Left Hemicolectomy (Open, Laparoscopic) 445
Operative Strategy Vascular Transection
Localization of Target Lesion A “high ligation” of the key vessels should be performed at
their point of origin. This allows for maximal nodal tissue to
For any colon resection, exact localization of the target lesion be incorporated in the pathologic specimen. In case of a
is of utmost importance. Some lesions are large enough that resection that is limited to the sigmoid colon, it may suffice
they can be identified on a CT scan or other radiological to take the superior hemorrhoidal artery while leaving the
images. All other lesions, however, require preoperative left colic artery intact. However, if the target pathology is
localization and tattooing. The colonoscopic tattoos should more in the descending colon or splenic flexure, the ligation
be injected in three quadrants deeply into the bowel wall to should be carried at the run-off of the inferior mesenteric
be visible on the serosal side. It should be clearly docu- artery. In that case, it may be more elegant to ligate the infe-
mented where the tattoos are placed in relation to the lesion rior mesenteric vein separately at the lower edge of the
(distal, at the site, etc.). Further, endoscopic clip placement pancreas.
with immediate abdominal X-ray in the endoscopic recovery Often—and particularly in the case of laparoscopic sur-
room can be helpful in defining the tumor location. gery—it is advantageous to take the vascular supply early
Despite all efforts, a lesion and/or the tattoo may escape in the case. That means that the knowledge of the anatomy
detection in surgery. Having performed a bowel cleansing in general and related to the specifics of the case needs to
and availability of a colonoscope with CO2 insufflation are be crystal clear. The left colon is supplied by the inferior
crucial to reassess the colon if needed during the case to clar- mesenteric artery as well as the middle colic artery. The
ify the location. rectum has a triple blood supply which remains adequately
perfused even after ligation of the inferior mesenteric
artery. The left branch of the middle colic artery forms the
Surgical Approach marginal artery that connects to the left colic artery at the
splenic flexure. This connection between superior and
Traditionally, colon surgery including right colectomy was inferior mesenteric artery is one of the known water-shed
approached and described as open surgery, for example, areas. Care must be taken not to damage the marginal
through a midline incision. Minimally invasive approaches artery during eventual anastomosis to ensure adequate
(laparoscopic or robotic surgery), however, have dramati- oxygenation to the anastomosis from this now sole blood
cally evolved and in many circumstances are considered the supply.
first choice.
Colon Mobilization
Extent of the Resection
Appropriate colon mobilization is essential (1) for an opti-
One of the first decisions to be made is to define the extent of mized oncological resection and (2) to ascertain a tension-
the resection (Fig. 57.1a and b). In benign disease, the resec- free anastomosis. Mobilization and take-down of the splenic
tion is directly related to the immediate extent of the pathol- flexure is integral part of the left hemicolectomy, and possi-
ogy. In malignant or potentially malignant disease, quality ble ad hoc necessity for more distal resections (including a
parameters include (1) the proximal, distal, and circumferen- sigmoid resection) for the purpose of achieving a tension-
tial margins, (2) an adequate lymph node harvest of at least 12 free anastomosis.
nodes per colon segment, and (3) inclusion of the respective In open surgery, the mobilization of the colon from retro-
omentum. The resection is defined by the location and the peritoneal attachments is the first step; it starts at the white
respective blood supply from the two adjacent arteries. For a line of Toldt and progresses in a lateral to medial fashion. In
sigmoid colon lesion, the resection entails the sigmoid colon; contrast, laparoscopic and robotic surgeries preferably
for lesions involving the distal transverse colon or the approach the dissection through a medial to lateral approach.
descending colon, a left hemicolectomy from the left branch This allows the lateral colon attachments to keep it up and
of the mid colic artery down to the sigmoid or the rectosig- out of the way, aiding in exposure of the vascular pedicle,
moid junction would be appropriate. However, in regard to visualization of the ureter, and even the splenic flexure
bowel reach for the reconnection, it may on occasion be eas- mobilization. It is important to be mindful of the correct
ier to instead consider an extended right hemicolectomy or plane of dissection which should be largely avascular. Too
subtotal colectomy. A similar extent for different reasons may posterior dissection may result in mobilization behind the
be advantageous for obstructing lesions when the colon prox- kidney and increase the risk of ureteral and gonadal vessel
imal to the lesion could neither be cleaned out nor evaluated. injury.
Colon Resection Documentation Basics
After transection of the vascular pedicles and division of the Coding for surgical procedures is complex. Consult the most
mesentery up to the designated colorectal site, the actual recent edition of the AMA’s Current Procedural Terminology
bowel resection follows. The availability of modern cutting book for details (see references at the end). In general, it is
stapling devices has largely obviated the use of isolating important to document:
bowel ligations or clamps. Depending on the chosen
approach, the bowel transection is done in situ or on the exte- • Findings and indication
riorized bowel. For minimally invasive approaches, the distal • Reasoning for choice and extent of surgical approach
bowel is often transected internally and the proximal bowel • Surgical approach
after exteriorization. Rarely are both the proximal and distal • Blood vessels taken
resections and the anastomosis done intracorporeally. In • Type of anastomosis
select cases, an anastomosis is either not possible or not
advisable, and the proximal colon is brought out as an end
colostomy (Hartmann resection) (see Chaps. 58 and 65). Operative Technique
Positioning
The Difficult Reach
Regardless of the approach, place and secure the patient in
One of the difficulties of a left hemicolectomy is to ade- modified lithotomy on an anti-sliding system that allows for
quately mobilize the residual colon to achieve a tension-free dynamic repositioning during the case. Make sure that the
anastomosis. The small bowel loops are interposed between perineum is at the table end to allow for access to the anus
mid-transverse colon and the rectosigmoid junction, and the and that the hips can vary from flat (0 degree) to high lithot-
mid-colic artery further limits mobility. omy (90 degree). Preferably tuck both arms to allow best
Creative solutions to overcome the distance between the access. Place a urinary catheter to decompress the bladder
two bowel ends include: (1) to transect the middle colic and monitor intraoperative urine output. Prep and drape the
artery at its base to enhance mobility; (2) to guide the proxi- patient from nipple line to mid thighs and include the peri-
mal colon end through the small bowel mesentery as the neal area and in females the vagina. Monitors for laparo-
shortest distance; (3) to not only transect the middle colic scopic surgery should be placed such that surgeon, target,
pedicle but also to mobilize and rotate the right colon in and monitor form one line (see Chap. 56, Fig. 56.4).
counter-clockwise fashion on the ileo-cecal pedicle and that
way navigate around the bulk of small bowel loops.
Operative Approach and Incisions
Technique of Anastomosis inimally Invasive Surgery

M
In regard to minimally invasive techniques, there are straight
Numerous techniques are practiced. In contrast to an entero- laparoscopic, single port, hand-assisted, or robotic
enteric or an entero-colonic anastomosis, the use of func- approaches. Each platform employs a slightly different lay-
tional end-to-end anastomosis may have disadvantages for a out of their port placement. Depending on the past history,
colo-colonic anastomosis: (1) it creates a large iatrogenic insert the first 10–12 mm trocar using the Hasson or the
diverticulum in which the more formed stool may not easily Veress needle technique. Establish the pneumoperitoneum
pass and get trapped; (2) inspissated formed stool may gen- and insert the camera. Place all subsequent ports under visual
erate unpredictable gravitational forces; and (3) the resulting control.
acute angle of the bowel turn may complicate the passage of Pure laparoscopic techniques normally use 4–5 trocars.
a colonoscope. Insert a camera port at the umbilicus. You can later expand
For all these reasons, a true end-to-end anastomosis is this incision to serve as an extraction site and to perform an
always preferable on the left side of the colon. Occasionally, extracorporeal anastomosis (unless you prefer a different
an isoperistaltic side-to-side anastomosis is an acceptable location for extraction). Place 3–4 working ports that trian-
solution. If in reach of a circular stapling device, the end-to- gulate onto the sigmoid and descending colon. Our prefer-
end anastomosis can be stapled; otherwise a hand-sewn ence is one in the right lower quadrant, one in the right
anastomosis remains an excellent technique. In select cases, middle to upper quadrant, and a third one in the left mid
a reversed stapled anastomosis can be carried out. abdomen (Fig. 57.2a). If necessary for the mobilization of
a b
Fig. 57.2
the splenic flexure, an additional port can be inserted in the Alternative incisions include a suprapubic Pfannenstiel
epigastrium. incision as only access; occasionally, a left hemicolectomy
For single port or hand-assisted laparoscopy, the multi- or sigmoid resection is performed in conjunction with a liver
access port and the hand port, respectively, are typically resection. In that situation, it is good practice to discuss the
placed at the umbilicus and later serve as the extraction and needs of the different teams beforehand. Apart from a larger
anastomosis site, but there is variation among different open incision, an alternative could include to perform the
surgeons. colon resection laparoscopically and follow that with an
Placement of the robotic trocars depends on the platform. open liver resection. In that case mark the planned incision
For the most current generation of robots (the Da Vinci Xi), for the liver resection and consider placing slightly unusual
they are placed on an oblique line from the right iliac crest to laparoscopic ports along those lines.
the left upper quadrant with an additional accessory port in
the right upper quadrant (Fig. 57.2b). Exploration
Open Approach of the platform), explore the abdomen. Perform a thorough
For an open approach, make a midline incision staying on examination of all quadrants and look for signs of tumor
the left side of the umbilicus. Start with a 10 cm incision and manifestations, for example, liver metastases, carcinomato-
determine the individual anatomy (Fig. 57.3). Depending on sis, or Krukenberg tumors of the ovaries. Visualize or palpate
the needs of the variable anatomy, the incision can be left as the liver to assess for any metastatic disease. Carcinomatosis
such or be extended in one or the other direction. A wound can be encountered in all quadrants but—if present—is par-
protector is desirable. Alternatives include a self-retaining ticularly frequent in the pelvic cul-de-sac and the pericolonic
retractor such as a Bookwalter retractor. gutters. Next, find the site of the primary pathology, either by
tion and see the bare iliac vessels or the psoas muscle with its
white tendon. Reassess the dissection plane and go more
anteriorly. Once you have positively identified the ureter, you
may facilitate its subsequent localization throughout the case
by placing a clip just anteriorly to the fat.
Very rarely, the disease process is so dense that your best
efforts to visualize the ureters remain unsuccessful. One
option could be to have ureteral stents placed (best in antici-
pation of advanced disease). If you know from the workup
that the disease is not a cancer, a second option at the time of
surgery is that you perform a wedge colon resection rather
than a standard oncological resection. That means that you
follow the bowel wall and leave essentially the mesentery
and lymph nodes behind.
ivision of the Inferior Mesenteric Artery

D
Pedicle
Grasp the mesentery at the sigmoid and elevate and retract it

to the side. This maneuver will accentuate the inferior mes-
enteric artery pedicle. In order to increase the amount of
lymphatic tissue in the specimen, plan on taking the vascular
pedicle as close as possible to its point of origin. For a sig-
moid resection, it may suffice that you only take the superior
rectal artery but leave the left colic branch in place.
From the right-sided base of the vascular pedicle to the
beginning of the rectum at the pelvic brim, incise and score
Fig. 57.3 the peritoneum along the base of the mesentery (Fig. 57.4a
and b). This will open up the avascular plane right behind the
superior vascular arch. If you go too posterior, you risk injur-
locating the tattoo or by gentle palpation through the colonic ing the hypogastric nerve and get on the wrong track into the
wall. Even if there is little doubt regarding the location of the pelvis.
pathology, intraoperative colonoscopy with CO2 insufflation Use gentle but directed blunt dissection by tenting the cut
should be available in the event that the visualization or pal- edge of the peritoneum anteriorly and caudad to lift the mes-
pation is unable to find the tattoo or lesion. entery off the retroperitoneal structures (Fig. 57.4c and d).
Identify the left ureter, gonadal vessels, and hypogastric
nerves during this step of the procedure. It is a common error
Identification of the Ureter to be too deep in the retroperitoneum during this step, which
may cause the ureter and gonadal structures to tent up with
For a left-sided colectomy, make it a habit to always visual- the mesentery. You may reduce that risk by being mindful
ize the left ureter before transecting any relevant structures. and noting that retroperitoneal tissues often take on a pur-
In patients without visceral obesity, both ureters may be plish hue when compared to the mesentery. In obese patients
clearly visible without any dissection upon entry into the or patients with dense fibrosis, place a vascular clip near, but
abdomen. More often than not, however, you need to free up not on, the ureter to ease in identification during subsequent
the left ureter to see it peristalsing (“vermiculating”) in the steps.
retroperitoneal fat. You may find it where it is crossing the Once you identified the ureter and other retroperitoneal
left common iliac artery near the bifurcation into the internal structures, widen the space by more caudad blunt dissection
and external branches. If it is still not visible, you need to of the areolar tissue of the relatively avascular plane. If sig-
carry out a formal dissection which can either be a medial to nificant bleeding is encountered, reorient yourself and ensure
lateral retroperitoneal dissection (laparoscopic/robotic, that you are in the proper tissue spaces. It is not desirable to
Fig. 57.4a–d) or a lateral to medial dissection (open). One of skeletonize down to the anterior wall of the aorta, as it
the pitfalls is that you can get too far posterior in the dissec- impacts the hypogastric nerves and could result autonomic
a b
c d
Fig. 57.4
nerve dysfunction. Isolate the vascular pedicle by sharply Colon Mobilization

incising the peritoneum over the pedicle. Before transecting
it, visualize the ureter again. edial to Lateral Approach
M
Transection of the vascular pedicle can be achieved in dif- Leave the lateral attachments in place until the posterior
ferent ways: (1) by clamping, sharp dissection, and suture mobilization is largely done. The attachments are a free
ligation (Fig. 57.5a); (2) isolation of each vessel, clipping, assistant as they hold the colon up in place while you can
and sharp dissection; (3) vascular linear stapler (Fig. 57.5b); work underneath. Once the serosa along the vascular pedi-
or (4) advanced energy devices. Whichever way you choose, cle is opened, you may elevate it and bluntly separate the
make sure to have a clamp ready on the proximal side of the colon along the avascular embryological planes. Go as far as
vascular transection to keep control of the vessel origin you can up to the extent needed for the resection. Again,
should hemostasis not be perfect (Fig. 57.5d–g).
a b c
d e
f g
Fig. 57.5
take care not to get lost too posteriorly and avoid injury to Splenic Flexure Mobilization
adjacent structures such as kidney, the jejunum at the liga-
ment of Treitz, pancreas, or spleen by rough movements or The splenic flexure of the colon may be completely liberated
hot instruments. Continue until the lateral peritoneal reflec- without dividing a single blood vessel if the surgeon can rec-
tion has been reached, at which point the lateral dissection is ognize anatomic planes accurately. The only blood vessels
completed. Once the lateral side has been reached, you may going to the colon are those arising from its mesentery.
continue to open the serosa laterally and complete the lat- Bleeding during the course of this dissection arises from one
eral mobilization and if necessary the splenic flexure of the following sources: (1) avulsion of the splenic capsule,
takedown. (2) mesenteric vessels, (3) omentum, (4) and from veins in
the connective tissue along the surface of Gerota’s capsule
ateral to Medial Approach
L (“reno-colic ligament”).
Historically and still in open surgery, the mobilization of the There are three essential steps classically described by
colon starts at the white line of Toldt which is incised with Chassin to safe mobilization of the splenic flexure. First,
cautery (Fig. 57.6). Move your nondominant index finger incise the parietal peritoneum in the left paracolic gutter
underneath and retract the colon away from the structures going cephalad to the splenic flexure (Fig. 57.6). Second,
underneath. Continue incising the serosa close to the colon. dissect the left margin of the omentum from the distal trans-
Use blunt dissection with the finger or a sponge-stick to care- verse colon (Fig. 57.7) as well as from the left parietal peri-
fully deflect the retroperitoneal structures including the ure- toneum near the lower pole of the spleen (in patients who
ter as you progress medially toward the pedicle. have this attachment). And third, divide the renocolic liga-
ment between the renal capsule and the posterior mesocolon
using an energy device. In laparoscopic cases, develop the
retrocolic plane; in open cases, pass the index finger deep to
this ligament in the region of the splenic flexure (Fig. 57.8a
and b); this plane leads to the lienocolic ligament, which is
also avascular and may be safely divided by means of an
advanced energy device.
After the lienocolic ligament has been divided, carefully
follow the wall of the colon and continue to separate the
avascular plane. It is often helpful to delineate the dissection
Omentum
Epiploic
appendix
Incision in
paracolic
peritonium
Fig. 57.6 Fig. 57.7

a b
Spleen
Incision in
peritoneum
Pancreas
Radial ligament
Pericardial
ligament
Fig. 57.8
also from the transverse colon. Access the lesser sac and intended site of bowel transection. You can do that either by
either divide the gastrocolic ligament (if the omentum is stepwise clamp-clamp-cut-ligation or more conveniently
resected as well) or move the omentum cephalad and care- with an advanced energy device. For benign disease, resect-
fully dissect it of the colon. ing the omentum is optional; if you elect to preserve the
omentum, move it to the upper abdomen and carefully dis-
sect it of the transverse colon by finding the avascular plane.
Division of the Middle Colic Vessels It is often helpful to ensure that the posterior side of the
stomach is visible so that one can be confident that they are
Identify the middle colic vessels, that is, the main trunk and in the correct plane.
the right and left branch. For oncological purposes of a left
hemicolectomy, it suffices to divide the left branch of the
middle colic artery. For lesions at the splenic flexure or the Division of the Bowel
transverse colon or to increase the reach of the right-sided
colon, the trunk of the middle colic vessel should be taken. Timing and type of bowel transection is less a question for
This is a dangerous step! You need to avoid losing control. open surgery. When using the minimally invasive platforms,
There may be dense attachments between the pancreas and the colon can be transected intracorporeally or extracorpore-
the colonic mesentery that needs to be divided. There are ally. The areas of transection should have been identified ear-
also collateral veins from the inferior pancreaticoduodenal lier and the mesentery should have already been dissected off
vein to the middle colic vein that can cause considerable of them. Transection for the intestine is usually performed by
bleeding. Carefully create a window around the mid colic a linear stapler device at this point (Fig. 57.9a and b). Before
pedicle. Check that you are not including the superior mes- extraction of the colon/specimen, place a wound protector to
enteric vessels to the small bowel mesentery. Divide the mid decrease the risk of port-site recurrence and/or infection (see
colic pedicle between clamps and address the two sides with Chap. 56, Fig. 56.9).
suture ligatures, clips, or a stapler. Once division of the intestine has occurred, reexamine the
blood supply. If this is in question, use a knife to make a nick
in the bowel or mesentery to assess for bleeding. Alternatively,
Mesentery and Omentum Roundup the minimally invasive platforms allow for injection of ICG
and fluorescence imaging to assess the tissue perfusion. If
Complete the division of the mesocolon/mesorectum proxi- the blood supply shows a transition point and is insufficient
mally and distally and up to the point where you intend to or absent at the end, resect further bowel (Fig. 57.10a and b).
resect the colon. For malignant disease, divide the omentum When confidence in the blood supply has been established,
from its caudad free border perpendicular toward the verify and achieve hemostasis.
a b
Fig. 57.9
a b
Fig. 57.10
Anastomosis tapled End-to-End Anastomosis

S
The distal margin will be around the level of the rectosig-
For a left-sided colo-colonic or colo-rectal anastomosis, the moid junction (coalescence of the tenia). Place a non-crush-
distal margin will commonly be around the level of the rec- ing bowel clamp roughly 10 cm proximal to the stapled
tosigmoid junction (coalescence of the tenia). Part or the proximal bowel end. Cut off the staple line and assess the
entire anastomosis will have to be carried out extracorpore- bowel end for appropriate perfusion and bleeding. Grab the
ally. For laparoscopic cases, it is typically necessary to pause bowel end with two Allis clamps and place a full-thickness
the pneumoperitoneum and to exteriorize the bowel through purse-string suture using a monofilament 2-0 suture. Make
a wound protector. Cover the operative field with towels to sure to find the balance between too few and too many bites.
avoid spillage of stool into the peritoneal cavity. Secure the anvil of a circular EEA stapler (commonly
a b
c d
Fig. 57.11
between 29 and 33 mm, rarely 25 mm) with a hemostat in relaxing the bowel spasticity. Advance bowel sizers of
clamp. Gently insert it into the open proximal bowel and increasing size to the end of the rectal sump to ensure that
make sure not to cause any wall tears. Tie the purse-string there are no strictures, adhesions, or other defects that would
suture. Trim the edge of the proximal bowel by removing the impede the path of the stapling device. Insert the stapling
attached appendices. Ensure that no diverticula or other device with a gentle movement of the hand from high to
bowel wall defects are in the area of the anastomosis lower to account for the curvature of the sacrum. Exert
(Fig. 57.11a). For laparoscopic approaches, return the proxi- slight pressure against the top of the stump and deploy the
mal bowel with the anvil into the abdominal cavity and rees- stapler spike immediately next to the staple line (Fig. 57.11b).
tablish the pneumoperitoneum. In open or hand-assisted laparoscopic cases, grasp the prox-
Move between the legs to introduce the corresponding imal end and perform the connection. For laparoscopic
body of the circular stapling device into the rectum. Gently cases, an anvil grasper is helpful to connect the anvil (proxi-
dilate the sphincter complex with two fingers and insert a mal bowel) with the spike in the rectum (Fig. 57.11c). The
bowel sizer to accommodate the stapling device. Intravenous camera can be repositioned as needed so that the entire team
administration of glucagon by the anesthesiologist may aid
can visualize both the distal and proximal portion of the eversed Stapled Circular Stapler Anastomosis
R
anastomosis. In rare cases (e.g., unanticipated intraoperative consult and
Once coupled, verify the correct bowel axis and slowly need for resection), you may not have access to the anus to
close the stapling device. Target the middle area, if the specific insert the circular stapler. You may open the rectal stump and
stapling device offers a variable closing range; some devices place a purse-string suture. Insert the anvil and tie the purse-
have only a single firing position. During the slow closing string suture. About 10–15 cm from the end of the stapled off
maneuver, make sure that any extraneous tissue (appendages, proximal colon, perform a 3 cm longitudinal colotomy. Insert
urogenital structures) is actively reflected away, that there is no the stapler body through that opening and advance it to the
tension, and proper alignment prior to the firing. For females, stapled colon end. Deploy the spike and connect it with the
place a finger in the vagina and gently move the stapler side to anvil in the rectal stump. Carry out the anastomosis. Remove
side to ensure that no vaginal tissue is caught in the staple line. the stapler and close the colotomy in transverse direction.
Decisively fire the stapler. Partly open its mechanism with That can be done with a transverse stapler or handsewn in
three half-turns and gently remove the device. Routine over- two layers.
sewing of the anastomosis is optional (Fig. 57.11d).
To check the integrity of the anastomosis, submerge the
anastomosis under irrigation fluid. Gently compress the Wound Closure
colon proximal to the anastomosis using two fingers or a
non-crushing bowel clamp. Insufflate the rectum in con- The operating team should discard soiled gloves and use new
trolled fashion with air using a rigid or a flexible sigmoido- instruments to close the surgical wounds. If available, cover
scope. The latter is more equipment-intensive but has the the anastomosis with the remaining omentum to aid in heal-
advantage that you can also visualize the anastomosis. The ing and deterrence of leak. Perform a last check of the abdo-
abdominal team observes the anastomosis for air leaks. If men. Remove the ports and/or close the fascia in routine
leaks are present, your options are (1) to oversew and fashion. Irrigate the wound before closing the skin.
recheck, (2) to take down and redo the anastomosis, or (3) to
abandon the anastomosis. Even if you elect to divert the
anastomosis, it is advisable that you optimize it locally Postoperative Care
beforehand.
Hand-Sewn End-to-End 24-hour period. In case of an underlying infection/sepsis,
Align the cut ends of the proximal and distal bowel. continue respective therapeutic antibiotics for that
Approximate the two ends of the bowel with 3-0 Vicryl indication.
interrupted sutures. Attach hemostats to these two ends to • Intravenous fluids: Maintain adequate fluid until return of
flatten the bowel ends and make subsequent sutures easier. bowel function.
Now place a posterior layer of interrupted seromuscular • Nasogastric tube: No routine use in elective cases; keep it
sutures in a linear fashion creating the back wall of the anas- in non-elective cases until evidence of return of bowel
tomosis. This can be achieved directly or by flipping the function.
entire anastomosis for that step (Fig. 57.12a–d). For the • Enhanced recovery after surgery (ERAS) protocol: In
mucosal anastomosis, use a double-armed 3-0 PDS to start elective cases, initiate oral intake on day of surgery and
in the middle of this back wall. With each needle, place a advance to solid food as patient demonstrates return of
running suture in opposite directions. Place the full-thick- bowel function.
ness sutures to incorporate a small edge of mucosa and a • Nutritional support: If return of bowel function delayed
larger edge on the serosal side. Once the back wall has been by more than 5 days, initiate parenteral nutrition.
finished, continue these sutures along the anterior surface of • Incentive spirometry and early ambulation should be
the anastomosis (Fig. 57.13). Add interrupted seromuscular encouraged.
3-0 Vicryl sutures to complete the outer layer of the front
wall. Once all suture ends have been cut, gently palpate the
anastomosis between thumb and index finger to assess Complications
potency and adequate size. Close the mesenteric defect with
a running 3-0 Vicryl, making sure to take adequate but shal- • Anastomotic leak
low bites of the mesentery to avoid injury to the mesenteric • Anastomotic bleeding
blood supply. • Anastomotic stenosis
• Postoperative ileus or small bowel obstruction
• Surgical site infection
a b
c d
A B
B
Fig. 57.12
a b
A
B
B
A
B
A
Fig. 57.13
• Incisional, port-site, or internal hernia Bhakta A, Tafen M, et al. Laparoscopic sigmoid colectomy for compli-
• Collateral organ injury (ureter, small bowel, spleen, hypo- cated diverticulitis is safe: review of 576 consecutive colectomies.
Surg Endosc. 2016;30(4):1629–34.
gastric nerves) Dumont F, Da Re C, et al. Options and outcome for reconstruction after
extended left hemicolectomy. Color Dis. 2013;15(6):747–54.
Gervaz P, Inan I, et al. A prospective, randomized, single-blind com-
parison of laparoscopic versus open sigmoid colectomy for diver-
ticulitis. Ann Surg. 2010;252(1):3–8.
Further Reading Hohenberger W, Weber K, et al. Standardized surgery for colonic can-
cer: complete mesocolic excision and central ligation--technical
American Medical Association. Current procedural terminology: CPT notes and outcome. Color Dis. 2009;11(4):354–64. discussion
®. Professional ed. Chicago: American Medical Association; 2022. 364–355
https://www.ama-assn.org/practice-management/cpt. Midura EF, Hanseman DJ, et al. Laparoscopic sigmoid colectomy:
Beisani M, Vallribera F, et al. Subtotal colectomy versus left hemicolec- are all laparoscopic techniques created equal? Surg Endosc.
tomy for the elective treatment of splenic flexure colonic neoplasia. 2016;30(8):3567–72.
Am J Surg. 2018;216(2):251–4.
Discontinuous Colon Resection
(Hartmann Procedure) 58
Indications closed loop obstruction and blow-out; instead do a loop

colostomy or Prasad-type colostomy.
Acute
• Perforated colon pathology with severe local infection or Preoperative Preparation

diffuse purulent/feculent peritonitis (diverticulitis, cancer,
anastomotic leak) • Review the patient’s history, diagnosis, functional aspects,
• Large bowel obstruction (tumor, stricture, volvulus, etc.) and appropriate indication for resective surgery (based on
• Resection with systemic risk factors (hemodynamic insta- clinical, radiographic, and possibly endoscopic parame-
bility, chemotherapy, immunosuppression, malnutrition, ters) as opposed to other management options (e.g., anti-
metastatic disease, etc.) biotics, stent, proximal diversion, etc.).
• Nasogastric tube: Indicated for all emergency cases.
• Appropriate fluid resuscitation and stabilization of the
Elective patient.
• Mechanical bowel preparation: Not possible for emer-
• Colon pathology requiring resection where restoration is gency cases; routine for elective surgeries.
not desirable (poor function, persistent or metastatic • Antibiotic treatment (versus prophylaxis).
tumor, etc.). • Ureteral stents: Consider for challenging pathology (if
circumstances and setup allow).
The extent and approach may vary depending on the • Stoma marking: May not be possible or reliable in emer-
nature and location of the target pathology and the chosen gency patient.
technique (open versus minimally invasive). Removal of the
entire colon proximal to the pathology (i.e., total abdominal
colectomy) is described in Chap. 62. Pitfalls and Danger Points
• Ureteral injury: This is an utmost concern during the pro-

Contraindications cedure if there is extensive inflammation, tumor, or scar
tissue tethering blurring the dissection planes.
Hartmann resection proximal to a distal obstruction without • Intraoperative bleeding: Hypervascularity and possible
resection of the obstruction itself: This has the risk of a coagulopathy due to the inflammation and systemic ill-
ness; splenic injury during mobilization; most dangerous
are possible disease adherence to major retroperitoneal or
pelvic vessels and/or too posterior dissection.
M. Zelhart
Department of Surgery, Tulane University, New Orleans, LA, USA • Ischemia of the proximal colon: Avulsion of the marginal
artery, too narrow abdominal wall trephine.
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of • Stoma retraction or ischemia.
Hope National Medical Center/Comprehensive Cancer Center, • Oncologically inferior resection.
Duarte, CA, USA • Enterotomy or colotomy.

https://doi.org/10.1007/978-3-030-81415-1_58
Operative Strategy lower quadrant in safe planes. In some cases, you may in
addition have to free up the rectum first before tackling the
Surgical Approach more proximal pathology. Once you mobilized and poten-
tially even transected the rectum, you can then work your
Open surgery remains the most common approach as the way backward until you join with the dissection from
majority of these cases represent emergency or urgent indi- cephalad.
cations that benefit from fast and decisive action. Minimally
invasive approaches have overall evolved in the elective set-
ting, but remain of lesser value for this operative approach; Vascular Transection
they should be limited to selected circumstances only and be
categorically avoided in unstable patients. A “high ligation” should be performed to obtain a suffi-
cient lymph node harvest in the specimen in case the
pathology reveals cancer. In case of a sigmoid resection, it
Extent of the Resection may suffice to take the superior hemorrhoidal artery while
leaving the left colic artery intact. However, if the target
Wherever possible, the extent of the resection should satisfy pathology is more in the descending colon or splenic flex-
oncological principles and thus is defined by the location and ure, the ligation should be carried at the run-off of the infe-
the respective blood supply (see Chap. 54). In benign dis- rior mesenteric artery. The left branch of the middle colic
ease, the resection is directly related to the immediate extent artery forms the marginal artery that connects to the left
of the acute pathology. However, the emergency circum- colic artery at the splenic flexure. This connection between
stances often do not allow for a detailed workup and the superior and inferior mesenteric artery is one of the known
nature of the pathology may remain speculative. In malig- water-shed areas. Care must be taken not to damage the
nant or potentially malignant disease, quality parameters marginal artery during eventual stoma creation to ensure
include (1) the proximal, distal, and circumferential margins adequate oxygenation from this now unidirectional blood
and (2) an adequate lymph node harvest of at least 12 nodes supply.
per colon segment. The radial margin may be largely defined With extensive and dense inflammatory disease processes,
by the disease itself and already violated by a disease the dissection planes may be unrecognizable and the best
perforation. efforts to visualize the ureters remain unsuccessful. Rather
than risking injury to such relevant structures, it may on
occasion be necessary to compromise on the lymph node
Bowel Control and Decompression harvest and instead follow closely the bowel wall.
If there is a bowel perforation with continued loss of bowel

content into the field, aim at rapid source control (see Chaps. Colon Resection
7 and 8). In order to achieve an adequate working space and
allow for closure of the abdominal wall, it may be prudent The availability of modern cutting stapling devices has
and necessary to decompress the bowels in a controlled fash- greatly facilitated the bowel division. However, inflamed tis-
ion (see Chap. 40). sues are more prone to staple line dehiscence. It may be nec-
essary to oversew the line and to isolate it by covering it with
an omental flap. Furthermore, a rectal tube (e.g., a trimmed
Colon Mobilization chest tube) may be used to reduce the risk of a stump blow-
out by avoiding pressure buildup in the rectum.
Ideally, even under emergency conditions, the same mobi-
lization should be performed as in elective cases. However,
the tissue alteration may pose extra challenges. Rather than The Difficult Reach
pursuing a rigid approach in one or the other direction (see
Chap. 54), the mobilization may have to vary and alternate One of the difficulties when operating under emergency con-
back and forth until the goal is reached. It is advisable to ditions may be that the distended and inflamed bowels can-
avoid the most difficult part in the beginning and to start the not be easily mobilized to reach the abdominal wall for the
dissection where the anatomy remains identifiable. For a colostomy. Do not hesitate to enlarge the incision and per-
recto-sigmoid pathology, it may be necessary to come from form a better mobilization of the proximal colon; this is far
far cephalad and rather mobilize the entire descending preferable to creating a stoma that is doomed to retract or
colon and possibly the splenic flexure to approach the left become ischemic.
58 Discontinuous Colon Resection (Hartmann Procedure) 461
Documentation Basics Assess the integrity and viability of the residual bowel. If
the bowels are extremely distended, any manipulation may
Coding for surgical procedures is complex. Consult the most trigger a perforation. In those instances, decompress the
recent edition of the AMA’s Current Procedural Terminology bowel early in the case by means of a controlled colotomy
book for details (see American Medical Association 2022). and insertion of a large fenestrated catheter (e.g., chest tube).
In general, it is important to document:
• Findings and indication Colon Mobilization

• Reasoning for choice and extent of surgical approach
• Surgical approach Initiate the mobilization of the colon by incising the serosa at
• Blood vessels taken the white line of Toldt with cautery. It is prudent to begin in
• Tissue quality an area proximal to that of the inflammation. This can allow
you to identify the correct plane of dissection and follow it
toward the pathology. Move your nondominant hand under-
Operative Technique neath and gently retract the colon away from the structures
underneath (Fig. 58.1). Continue incising the serosa close to
Positioning the colon. Use blunt dissection with the finger or a sponge-
stick to carefully deflect the retroperitoneal structures includ-
Place and secure the patient in modified lithotomy. Make ing the ureter as you progress medially toward the pedicle.
sure that the perineum is at the table end to allow for access Whether or not you will have to free up the splenic flexure
to the anus and that the hips can vary from flat (0°) to high depends on the exact location of the pathology and the
lithotomy (90°). Preferably tuck both arms to allow best mobility of the colon proximal to it to safely reach the
access. Place a urinary catheter to decompress the bladder abdominal wall.
and monitor intraoperative urine output. Perform a rigid sig- Not uncommonly, the pathology may be very extensive
moidoscopy with limited air insufflation to verify that there with dense fibrosis and be difficult to free up, or there is a
is no rectal mass or inflammation. Prep and drape the patient contained perforation that is sealed off by the abdominal
from nipple line to mid thighs and include the perineal area, wall. In those situations, it is best to leave the difficult and
and in females the vagina. most contaminating part for last and not only mobilize the
proximal colon but to also attempt to mobilize and transect
the rectum distal to the pathology. For that approach, you
Incision gain access to the normal appearing rectum. At a level with
sufficient margin and soft tissue, you open the serosa on both
Make a generous midline incision staying on the left side of sides to develop a window in the mesorectum. After transec-
the umbilicus. If the location of a hollow viscus perforation tion of the bowel with a transverse cutting stapler, you can
is not certain, start with a 10 cm incision and determine the now elevate the rectum, continue the division of the meso-
most likely site. Depending on the respective needs and the
variable anatomy, extend the incision in one or the other
direction as needed. A wound protector is desirable.
Alternatives include a self-retaining retractor such as a
Bookwalter retractor.
Exploration
Explore the abdomen and perform a thorough examination

of all quadrants. Quickly identify the nature and extent of the
primary pathology. Place non-crushing bowel clamps proxi-
mal (and possibly distal) to a perforation until the respective
segment is mobilized and can be resected. Take cultures if
there is an abscess or free perforation. Furthermore, look for
signs of tumor manifestations, for example, carcinomatosis,
liver metastases, or Krukenberg tumors of the ovaries.
Fig. 58.1
rectum, and work your way backward to the vascular transverse linear stapler device for division of the intestine.
pedicle. Remove the specimen and have it opened and grossly exam-
ined on a back table for the presence or absence of a cancer.
Consider frozen sectioning by the pathologist if there is any
Identification of the Ureter doubt about the nature of the pathology and/or margins.
Make it a habit to visualize the left ureter before transecting

any relevant structures. In patients with altered anatomy due Hartmann’s Pouch Versus Mucous Fistula
to extensive pathology and fibrosis, it is even more important
that you approach the ureter with extra caution because its Most commonly for a discontinuous colon, the distal resection
location may have been tethered into the inflammatory pro- is completed with a transverse cutting stapler that leaves behind
cess. If a combination of lateral to medial, medial to lateral, a blind rectal stump (Fig. 58.2). Place 1–2 marking sutures
and caudad to cephalad dissection still does not allow you to (using 2-0 or 3-0 Prolene) to the rectal stump to facilitate future
identify the ureter, you need to consider other options. identification of that structure. You could further consider
One option could be to have ureteral stents placed, but suturing the apex of the Hartmann’s pouch to the pelvic fascia
that may not be possible in the emergency situation. A sec- near, or if possible higher than, the promontory of the sacrum
ond option is that you perform a wedge colon resection to prevent retraction low into the pelvis, which would make a
rather than a standard oncological resection. That means that secondary anastomosis more difficult. It is often times advis-
you closely follow the bowel wall rather than going after the able to place a rectal tube (e.g., a 30F chest tube) at the end of
vascular pedicle. This allows to stay at a distance to the pre- the case and leave it for a few days. This creates a path of least
sumed ureter location but essentially leaves the mesentery resistance, reduces the risk of pressure buildup in the rectum,
and lymph nodes behind. This approach has no downside, if and hence the risk of a stump blowout with sepsis.
the disease is not a cancer; if it is cancer though, you may in If the bowel wall is very inflamed and thick, you may not
these rare occasions have to compromise between radical even be able to close the stapler, or the staple line is prone to
surgery versus preservation of the important ureter. a dehiscence. You should consider alternative strategies. One
option is that you manually close the rectal stump by a con-
tinuous layer of locked sutures and invert this layer with a
ivision of the Inferior Mesenteric Artery
D second layer of continuous Lembert sutures; if possible,
Pedicle sequester the rectal stump from the abdominal cavity by
placing an omental flap over it.
One of the benchmarks of your progress is the isolation of Another option is to leave the distal bowel a bit longer and
the vascular pedicle. Unless benign disease is confirmed, bring it to the skin as a mucous fistula. However, there are
treat the pathology as if it was malignant. The scenario out-
lined in the previous section should remain the exception.
Once the colon has been safely mobilized and the ureter
visualized, create a window around the pedicle and place two
clamps across. Verify the ureter before dividing the pedicle.
Address both sides with suture ligatures. Alternatively, you
could use a vascular stapler or isolate and ligate each vessel
individually. Use of an advanced energy device alone may
often not be sufficient in the setting of inflamed tissue.
Division of Mesentery and Bowel
The timing of the bowel transection is not scripted. Do it

when there is opportunity to do it and to do it in the right
place. Select an area at a sufficient distance of the core
pathology where the tissues are either normal or substan-
tially better. Divide the mesentery serially between Kelly
hemostats, or alternatively, use an advanced vessel-sealing
energy device. Check its effectiveness as it may not com-
pletely seal in severely inflamed tissues. Use a straight or Fig. 58.2
58 Discontinuous Colon Resection (Hartmann Procedure) 463
substantial downsides to that approach. First, it is rare and anastomosis with the remaining omentum to aid in healing and
counterintuitive to have a stump long enough to reach above deterrence of leak. Perform a last check of the abdomen. Drains
the fascia; second, it is not wise to attempt to elongate the do not have a routine role anymore; you should decide based on
rectum for a mucous fistula by extensive presacral dissection the individual patient’s findings. Close the fascia in routine
as it opens new planes to potential sepsis and complicates fashion. Irrigate the wound. In severely infected/contaminated
future restoration attempts; and third, incorporation of the cases, it may be wise to leave the skin open; otherwise close it
bowel into the laparotomy wound closure (Fig. 58.3) and apply wound dressings according to your preference.
increases the risk of wound complications.
Postoperative Care
End Colostomy
At the level of the proximal transection, assess the viability 24-hour period. In case of an underlying infection/sepsis,
and the mobility of the colon. Continue the mobilization continue respective therapeutic antibiotics for that
until the bowel reaches the outside of the abdominal wall indication.
with ease. It is never recommended to bring the colostomy • Intravenous fluids: Maintain adequate fluid until return of
through the laparotomy incision itself. Create a separate tre- bowel function.
phine in the abdominal wall at the predesignated site through • Nasogastric tube: No routine use in elective cases; keep it
the left rectus muscle. For very obese patients, target a higher in non-elective cases until evidence of return of bowel
area than in a skinny patient. The incision should admit two function.
fingers, more if the colon is very distended. Bring out the cut • Enhanced recovery after surgery (ERAS) protocol: In
end of the colon and immediately suture it with seromuscular elective cases, initiate oral intake on day of surgery and
interrupted 3-0 PG stitches to the subcuticular layer of the advance to solid food as patient demonstrates return of
skin incision. Do not open the bowel until the main incision bowel function.
has been closed (see below) and the wound covered. Then • Nutritional support: If return of bowel function is delayed
excise the staple line and mature the stoma such that a mildly by more than 5 days, initiate parenteral nutrition.
protruding rosebud results. • Incentive spirometry and early ambulation should be
encouraged.
Wound Closure
Complications
The operating team should discard soiled gloves and use new
instruments to close the surgical wounds. If available, cover the • Postoperative ileus or small bowel obstruction
• Stoma complications (retraction, ischemia, prolapse,
hernia)
• Rectal stump leak
• Abdominal sepsis and abscess formation (interloop, pel-
vic, subdiaphragmatic, etc.)
• Fascial dehiscence and open abdomen
• Hernia formation (incisional, peristomal, internal, etc.)
• Collateral organ injury (ureter, small bowel, spleen, hypo-
gastric nerves)
Further Reading
Bhakta A, Tafen M, et al. Laparoscopic sigmoid colectomy for compli-
cated diverticulitis is safe: review of 576 consecutive colectomies.
Surg Endosc. 2016;30(4):1629–34.
Fig. 58.3
Binda GA, Serventi A, et al. Primary anastomosis versus Hartmann’s Tsuchiya A, Yasunaga H, et al. Mortality and morbidity after
procedure for perforated diverticulitis with peritonitis: an impracti- Hartmann’s procedure versus primary anastomosis without a
cable trial. Ann Surg. 2015;261(4):e116–7. diverting stoma for colorectal perforation: a nationwide observa-
Gervaz P, Inan I, et al. A prospective, randomized, single-blind com- tional study. World J Surg. 2018;42(3):866–75.
parison of laparoscopic versus open sigmoid colectomy for diver- Turley RS, Barbas AS, et al. Laparoscopic versus open Hartmann pro-
ticulitis. Ann Surg. 2010;252(1):3–8. cedure for the emergency treatment of diverticulitis: a propensity-
Molina Rodriguez JL, Flor-Lorente B, et al. Low rectal cancer: abdomi- matched analysis. Dis Colon Rectum. 2013;56(1):72–82.
noperineal resection or low Hartmann resection? A postoperative
outcome analysis. Dis Colon Rectum. 2011;54(8):958–62.
Total Mesorectal Excision/Low Anterior
Resection (Open, Laparoscopic) 59
Kyle G. Cologne, Anthony J. Senagore,
Indications diversion only or nonsurgical management (e.g., systemic

chemotherapy).
• Rectal cancer • Accurate systemic and local tumor staging including, as
• Large rectal polyps not amenable to less invasive approach appropriate:
• Rectal carcinoid with unfavorable size or pathological –– Computed tomography (CT) of the chest abdomen and
features pelvis
–– MRI scan (rectal cancer staging protocol)
The extent and approach (open versus minimally inva- –– Endorectal ultrasonography
sive) chosen for the standard total mesorectal excision (TME; • Colonoscopy to determine the nature of the pathology
aka low anterior resection, LAR) may vary depending on the (benign vs malignant), assess whether it is amenable to
specifics (e.g., size and stage) and the exact location of the endoscopic removal, and to exclude synchronous
target pathology (upper, middle, or lower third of the rec- pathology.
tum). Sphincter preservation, restoration of intestinal conti- • Verify and measure the exact tumor level by number and
nuity, temporary versus permanent ostomy, and respective in relation to the valves of Houston by means of an office
functional and quality-of-life aspects are relevant aspects to endoscopy (rigid or flexible sigmoidoscopy) even if stated
be considered. Invasion of the pelvic floor or sphincter mus- by a previous endoscopist (note: the tumor is often much
cle or of other structures may require a more extensive resec- lower than described).
tion (see Chaps. 50 and 51). Multimodality treatment and in • Multidisciplinary evaluation and discussion (particularly
some patients the presence of an underlying risk constella- important in locally advanced tumors).
tion (hereditary cancer, inflammatory bowel disease) may • Preoperative radiation and chemotherapy, if appropriate,
affect the decision-making and timing of surgery. to increase resectability of tumors with positive lymph
nodes or threatened margins.
• In patients on chemotherapy or immunosuppressants or
Preoperative Preparation after radiation: Plan for optimal timing of surgery.
• Depending on the specifics (e.g., large tumor, severe
• Review the patient’s history, diagnosis, functional aspects, inflammation): possible ureteral stent placement.
and appropriate indication for surgery (based on endo- • Discussion and marking for possible ostomy.
scopic, clinical, or radiographic means) as opposed to • Mechanical bowel preparation.
• Antibiotic prophylaxis (versus treatment).
K. G. Cologne
Los Angeles, CA, USA Pitfalls and Danger Points
A. J. Senagore
Kalamazoo, MI, USA • Oncologically inferior resection: violated mesorectal
envelope, positive distal, proximal, or circumferential
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of radial margin (CRM), insufficient lymph node harvest
Hope National Medical Center/Comprehensive Cancer Center, • Anastomotic complications related to the following: tenu-
Duarte, CA, USA ous blood supply to the distal or proximal margins, ten-

https://doi.org/10.1007/978-3-030-81415-1_59
466 K. G. Cologne et al.
sion on the anastomosis, axial twist, poor tissue quality

(e.g., after radiation)
• Collateral injury: ureters, vagina, spleen, pancreas, auto-
nomic nerves
• Hemorrhage: presacral veins, vascular pedicle, splenic
flexure mobilization
Left colic a.
Operative Strategy
Localization of Target Lesion
For any colorectal resection, exact localization of the target

lesion is of utmost importance. That is even more important
for rectal lesions, as the surgical approach and other treat-
ment modalities must be contemplated and are affected by
precise location. Rigid and/or flexible sigmoidoscopy is cru-
cial to define the distance from the anal verge, the relation-
ship to the valves of Houston, and the radial orientation. In Alternative line of
intersection for
contrast to colonic lesions, placement of tattoos in the rec- carcinoma of rectum
tum may result in blurring of dissection planes and on imag-
ing may suggest a more advanced than true T- and N-stage.
Availability of a flexible sigmoidoscope with CO2 insuffla-
tion during surgery is crucial to allow for assessment during
the case, to clarify the location, and also to visualize and test Fig. 59.1
the anastomosis.
ence between a ligation at the origin of the inferior mesen-
teric artery (Fig. 59.1) and a ligation at the run-off of the
Surgical Approach superior hemorrhoidal artery (Fig. 59.2). The decision about
which level to choose should balance the needs to achieve
Traditionally, rectal surgery was approached and described adequate mobility and preserve a good blood supply.
as open surgery, for example, through a midline incision. The proximal margin is generally not problematic as a
Minimally invasive approaches (laparoscopic or robotic sur- large amount of proximal rectum and sigmoid are routinely
gery), however, have dramatically evolved and in many cir- removed. Obtaining an adequate vessel ligation (usually just
cumstances are considered valid options. Safe surgery and about the junction of the inferior mesenteric artery with the
cancer cure always carry a higher priority than the type of left colic and superior rectal artery) is critical for obtaining a
approach. sufficient lymph node yield. For the distal margin, current
practice guidelines recommend 5 cm (if possible), though a
closer margin of 2 cm is acceptable. In some cases, in order
Oncologic Extent of Resection to preserve continence, up to a 1 cm distal margin is allowed
in tumors of the distal rectum. Functional considerations
Accurate preoperative staging and appropriate use of preop- must be discussed with the patient in these scenarios.
erative (neoadjuvant) chemotherapy and radiation therapy An adequate circumferential margin (defined as a mini-
are important for optimal oncologic outcomes. The quality mum of 2 mm from the tumor to the cut edge of the mesorec-
of the surgical resection for rectal cancer is defined by the tal envelope) is best achieved by the technique of total
lymph node harvest, and three critical margins: (1) the proxi- mesorectal excision (TME) in the “holy” plane of avascular
mal (including adequate vessel ligation), (2) the distal, and tissue that separates the fascia propria of the rectum from the
(3) the circumferential margin. endopelvic fascia. When properly performed, TME results in
The ability to achieve an adequate lymph node harvest excision of a rectal specimen surrounded by an intact glisten-
depends on a precise dissection along the mesorectal fascia ing envelope of fascia propria, in which lymphatics and asso-
(see below) and an appropriate division level of the vascular ciated lymph nodes are fully embedded. An adequate lymph
pedicle. From an oncological standpoint, there is no differ- node yield of at least 12 nodes should be reported; but after
59 Total Mesorectal Excision/Low Anterior Resection (Open, Laparoscopic) 467
The presacral fascia and the fascia propria of the rectum

are separated by a virtually avascular areolar tissue.
Dissection in that space not only avoids the dangerous presa-
cral vein plexus but also keeps the hypogastric nerve branches
intact. Posteriorly, the two layers fuse above the coccyx and
form Waldeyer’s fascia. If the dissection needs to be carried
further down, that fused fascia will need to be sharply divided
in order to continue in the correct plane and not damage the
rectum. Anteriorly, the rectal surface remains intraperitoneal
down to the peritoneal reflection, which needs to be opened
to follow the dissection along Denonvillier’s fascia. The lat-
eral dissection follows a line that connects the anterior and
the posterior dissection. Even though this remaining tissue is
often referred to as “lateral ligaments,” there are no relevant
ligament structures identifiable. At the level of the distal rec-
tum, however, they contain mid rectal arteries and branches
thereof.
Avoiding Collateral Damage
Line of transection for

Structures at risk during a low anterior resection include the
carcinoma of rectum ureters (left and right), the hypogastric nerves, the presacral
veins and branches of the interior iliac vessels, seminal ves-
sels, vagina, and urethra. If the colon needs to be mobilized
to allow for an anastomosis, the respective additional risks
(e.g., splenic flexure) come into play as well. The best strat-
egy to avoid injury to any of those structures is to understand
Fig. 59.2 their course as well as the various planes that are the result of
the embryological development. Most importantly, however,
neoadjuvant radiation, that number can occasionally be the surgeon must recognize landmarks of the correct as well
lower. Integrity of the mesorectal envelope is one of the qual- of an incorrect dissection. Repetitive verification particularly
ity parameters for the surgical specimen. prior to transection of substantial tissue portions helps to
TME is rendered more difficult by obesity, bulky tumors, minimize the respective risks. For example, the extra effort
use of preoperative chemotherapy and radiation, and failure to revisualize the left ureter prior to dividing the vascular
of the tumor to respond to preoperative therapy. TME is pedicle is several magnitudes smaller than dealing with the
facilitated by early entry into the proper plane posteriorly impact of a ureteral injury. It should be noted though that
and laterally and the use of precise dissection with adequate another potential point of injury to the ureter may be deep in
visualization and retraction. the pelvis at the lateral aspect of the seminal vesicles.
The correct plane of dissection can be accessed either
from the left or from the right side with a lateral-to-medial
Mesorectal Dissection and a medial to lateral approach, respectively. From the left,
the white line of Toldt is opened and the retroperitoneal
The concept of a total mesorectal excision (TME) technique structures carefully deflected. From the right side, it is easi-
should be applied to all rectal cancers. That standard est to incise the serosa in the triangle formed by the gently
approach requires that the surgeon carefully follows the elevated vascular pedicle and the retroperitoneum. The areo-
mesorectal fascia in a specimen-oriented fashion. The “total” lar space just behind the major vascular arcade opens and
mesorectal excision applies to tumors in the distal third of leads into the pelvis when all other structures are gently
the rectum. For higher tumors, the dissection is carried to an pushed backward. Extension of the dissection along the are-
appropriate level below the tumor (ideally 5 cm distal mar- olar tissue toward the left and the pelvis almost automati-
gin), where the mesorectum and the bowel are divided in per- cally develops the correct pelvic dissection plane. The left
pendicular direction to the axis of the bowel. ureter that crosses the common iliac artery and the gonadal
vessels will remain below the dissection. At the same time,
the autonomic nerve plexus that follows the aorta and forms ening the bowel wall. For optimal outcomes, transect
the hypogastric nerves before splitting into a right and left the mesorectum at a right angle to the proposed distal
branch can be avoided. Their active preservation is necessary transection site. In contrast, skiving in on the mesorec-
for normal bladder and sexual function. In males, injury tum prior to division of the bowel wall may either
causes retrograde ejaculation or even erectile dysfunction if result in ischemia (if too little mesorectum remains) or
injured low enough); in females, their sexual impact has not increased risk of local recurrence (if too much
been well studied. Visualization of the aorta, vena cava, or of remains).
the iliac vessels, the psoas tendon, or the bare sacrum indi- 4. Large diameter of the distal rectum and insufficient
cates that the dissection has gone too posterior into a wrong clearance of the bowel wall, necessitating use of several
and dangerous place. stapler cartridges. Ideally, the transection should be
Locally advanced tumors, tumors with complications completed with a single or at most two stapler firing(s).
(perforation, abscess, etc.), or a previous surgery in the area With increased number of stapler lines, the risk of isch-
renders the orientation and dissection clearly more difficult. emic corners and resulting leak goes up.
Big tumors possibly threaten the circumferential margin and 5. Failure to achieve perfect hemostasis in the pelvis may
may require an extra-mesocolic dissection plane. Ideally, this result in a hematoma which may get infected, develop
situation should be anticipated from the preoperative assess- into an abscess, and erode through the colorectal suture
ment and not be a surprise at the time of surgery. The chal- line or adjacent structures. Meticulous hemostasis is cru-
lenge of such a case is that the surgery may need to be more cial, possibly using topical hemostatic agents, energy
radical if cure is intended. Involved structures, including the devices, or sutures. Placement of a drain in the depen-
hypogastric nerves, urogenital or bony structures, ought to dent area is frequently recommended.
be taken en bloc with the specimen (see Chap. 51). The more 6. Size mismatch between rectal stump and proximal
radical the approach, the more likely are resulting functional colon, resulting in “dog ears.”
or anatomical alterations and dysfunctions, which are occa- 7. Tension on the anastomosis due to insufficient mobiliza-
sionally required and legitimate if necessary for adequate tion efforts.
margins and potential cure. It is important to analyze and 8. Compromised blood supply on the proximal colon end
recognize if a tumor has a local extent with invasion beyond as a result of denudation or aggressive mobilization
resectability and cure such that the optimal palliative mea- efforts.
sures have to be carried out. 9. Areas of weakness on the proximal or distal bowel, for
The pelvis can be a dangerous place. The biggest hazard example, tear from insertion of the stapler sizer, or anvil,
associated with its dissection is a massive hemorrhage which diverticula, etc.
can be sudden and life-threatening. The plexus of presacral 10. A leak test should be performed whenever possible after
veins or branches of the internal iliac veins are the most com- completion of the anastomosis.
mon sources. Prevention is the best, decisive and swift action
without panic the second-best approach to stay in control It has been the colorectal teaching all along that a divert-
(see later in section “Operative Technique”). ing stoma proximal to the pelvic anastomosis does not reduce
the incidence of an anastomotic leak but aims at reducing the
septic sequelae thereof. The more severe the local manifesta-
Prevention of Anastomotic Complications tions of a complication are, the more intense of a fibrotic and
stricturing response may ensue. If an anastomotic complica-
After a seemingly successful resection and intestinal restoration occurs, the chances to achieve a good functional out-
tion, anastomotic complications (bleeding, leak, stricture) come decrease significantly.
are among the highest concerns. Specific challenges for the
rectal anastomosis and areas for necessary investment of
attention include: The Difficult Reach
1. Difficult anatomic exposure, particularly in men, obe- One of the difficulties of a low anterior resection is to ade-
sity, and advanced or very low tumors. This interferes quately mobilize the proximal colon to achieve a tension-
with the dissection, the transection of the distal rectum, free reach for a safe anastomosis. The bowel should retain an
viewing of the anastomosing process, and visualization excellent blood supply to the very end and sufficient laxity to
and possible reinforcement of the anastomosis. follow the sacral curvature.
2. Poor tissue quality after chemoradiation: timing, inter- Mobilization steps include the following: (1) release of
val, and overall dose are important parameters. lateral and retroperitoneal attachments up to and around
3. Denudation of the distal rectum, leaving an insufficient the splenic flexure, (2) division of the left colic artery or
blood supply to the rectal stump and potentially weak- base of the inferior mesenteric artery, (3) division of the
inferior mesenteric vein at the lower edge of the pancreas, I ndications for Diverting Stoma (Colostomy or
(4) mobilization of the omentum and/or gastro-colic liga- Ileostomy)
ment, and (5) division of all attachments up to the middle
colic artery. As mentioned previously, low pelvic anastomoses are at
If that is still not enough mobility, more aggressive solu- increased risk for leakage. While proximal diversion does
tions to overcome the distance between the two bowel ends not decrease the risk of a leak, it may mitigate the conse-
include the following: (6) to transect the base of the middle quences of one. Unless the anastomosis is perfect in regard
colic pedicle for mobility reasons, (7) to guide the proximal to all aspects (tissue quality, lax reach, excellent blood sup-
colon end through the small bowel mesentery as the shortest ply, negative leak test), a fecal diversion should be consid-
distance, and (8) to not only transect the middle colic pedicle ered. Other relative indications for diversion include an
but also to mobilize and rotate the right colon in counter- anastomosis <7 cm from the anal verge, prior chemoradio-
clock fashion on the ileo-cecal pedicle and that way navigate therapy, and increased operative blood loss.
around the bulk of small bowel loops. Under most elective circumstances, a loop ileostomy is
Circulation through the marginal artery at a lower level preferable to a transverse colostomy, as it is easier to take
must be pulsatile. Brisk flow should also be seen from a down and does not tether the colon in any way should subse-
sharply cut edge of the colonic mucosa. Newer devices uti- quent colo-rectal surgeries become necessary.
lizing indocyanine green and fluorescence imaging technol- The diverting stoma may be closed as early as 6 weeks
ogy can also help determine the adequacy of the blood flow. after the low anterior resection if a healed anastomosis has
Poor blood supply leads to poor healing, the consequences of been documented and no other treatments (e.g., chemother-
which can be devastating. Stricture, anastomotic leak, and apy, radiotherapy) have priority.
other problems can result. Sometimes a mobilization step
results in underperfusion and demarcation of the most distal
segment of the proximal colon. Even if that part will have to Documentation Basics
be resected to a well-vascularized level, the net gain in length
may nonetheless be worth the effort and allow for a tension- Coding for surgical procedures is complex. Consult the most
free anastomosis. recent edition of the AMA’s Current Procedural Terminology
Technique of Anastomosis
• Findings and indication
The standard way to perform a pelvic anastomosis from an • Reasoning for choice and extent of surgical resection
abdominal approach is to use a transanally inserted circular • Surgical approach
stapler. In select cases, a reversed stapled anastomosis can be • Blood vessels taken
carried out. Hand-sewn anastomoses in the deep pelvis are • Type of anastomosis, leak test
not impossible but highly cumbersome and have largely been • Stoma creation
phased out. The exceptions are ultralow resections with colo-
anal anastomosis where the proximal colon can be pulled
through the pelvic floor to mature the anastomosis from a Operative Technique
perineal approach in hand-sewn fashion.
In addition to simply restoring the intestinal continuity, Positioning
functional aspects may have to be considered for the colo-
anal anastomosis. The loss of rectal reservoir function may Regardless of the approach, place and secure the patient in
be counteracted by some anastomotic modifications to aug- modified lithotomy on an anti-sliding system that allows for
ment the capacity and reverse the propulsive peristalsis: (1) dynamic repositioning during the case (Fig. 59.3a, b). Make
colonic J-pouch-anal anastomosis, (2) colo-rectal side-to- sure that the perineum is at the table end to allow for access
end anastomosis, or (3) transverse coloplasty. It should be to the anus and that the hips can vary from flat (0 degree) to
noted that these techniques are only appropriate after truly high lithotomy (90 degree). Preferably tuck both arms to
total mesorectal excisions with colo-anal anastomosis and allow best access. Place a urinary catheter to decompress the
should be avoided for higher rectal anastomoses. Furthermore, bladder and monitor intraoperative urine output. Prep and
the beneficial impact on bowel frequency and urgency is drape the patient from nipple line to mid thighs and include
most evident in the first 12–24 months; later the advantage the perineal area and, in females, the vagina. Monitors for
disappears, and some patients develop the opposite, that is, laparoscopic surgery should be placed such that surgeon, tar-
stool clustering with fecal outlet obstruction. get, and monitor form one line (see Chap. 54, Fig. 54.2).
a b
Fig. 59.3
Operative Approach and Incisions Open Approach

For an open approach, the surgeon works from the patient’s
inimally Invasive Surgery
M left side, with the assistant on the right and a second assistant
Each platform of minimally invasive techniques employs a (if needed) standing between the patient’s abducted thighs.
slightly different layout of their port placement. Depending Make a midline incision starting at the pubic bone and
on the past history, insert the first 10–12 mm trocar using the extending to the umbilicus. If this does not allow for suffi-
Hasson or the Veress needle technique. Establish the pneu- cient exposure, extend the incision into the epigastrium by
moperitoneum and insert the camera. Insert all subsequent left circumference of the umbilicus (Fig. 59.4). Exposure is
ports under visual control. maintained by means of a self-retaining retractor such as a
Pure laparoscopic techniques normally use 4–5 trocars. Bookwalter or Omni retractor with or without use of a wound
Insert a camera port at the umbilicus. For specimen extrac- protector. One advantage of keeping the incision below the
tion and to a stapler anvil for the anastomosis, you can either umbilicus is that you can much easier tuck away the small
later expand this incision or perform a separate access in a bowel by means of a marked surgical towel that is held in by
different location. Place 3–4 working ports that allow for tri- the upper abdominal wall alone.
angulation toward the pelvis, the rectosigmoid, and the Occasionally, a rectosigmoid resection is performed in
descending colon. Our preference is one in the right lower conjunction with a liver resection. In that situation, it is good
quadrant, one in the right middle to upper quadrant, and a practice to discuss the needs of the different teams before-
third one in the left mid abdomen (see Chap. 55,). If neces- hand. Apart from a larger open incision, an alternative could
sary for the mobilization of the splenic flexure, insert an include to perform the colorectal resection laparoscopically
additional port in the epigastrium. followed by an open liver resection (with an incision opti-
Placement of the robotic trocars depends on the platform. mized for that procedure). In that case mark the planned inci-
For the most current generation of robots (the DaVinci Xi), sion for the liver resection and consider placing a hand port
they are placed on an oblique line from the right iliac crest to and slightly unusual laparoscopic ports along those lines.
the left upper quadrant with an additional accessory port in the
right upper quadrant (see Chap. 55).
is opened, you may elevate it and bluntly separate the colon

along the avascular embryological planes. In order to pre-
serve the hypogastric nerve plexus, it is important that you
stay right underneath the vascular structures. Go as far as
you can up to the extent needed for the resection. Pay close
attention to not get lost too posteriorly where you could
injure adjacent structures such as kidney, the jejunum at the
ligament of Treitz, pancreas, or spleen by rough movements
or hot instruments. Continue until the lateral peritoneal
reflection has been reached. Only at that point, incise the lat-
eral serosa and complete the mobilization. If necessary for
reach purposes, you can continue the mobilization in proxi-
mal direction and perform a takedown of the splenic
flexure.
Lateral to medial approach Commonly used in open sur-

gery, this approach starts the mobilization of the sigmoid
colon at the white line of Toldt. Using cautery, carefully
incise the serosa along that line of embryological reflection
(Fig. 59.5). Gently retract the colon and using a sponge-stick
bluntly deflect the retroperitoneal structures including the
ureter and gonadal vessels. Extend the incision in the perito-
neum cephalad as far as the splenic flexure; then continue
toward the pelvis and incise the serosa on both sides of the
rectum. Use blunt dissection with a finger or a sponge-stick
to carefully deflect the structures as you progress medially
Fig. 59.4 toward the pedicle and in caudad direction toward the pelvis.
If you find yourself struggling, it is often because the dissec-
Exploration tion is in the wrong plane.
Once entry into the abdomen has been obtained (regardless of

the platform), explore the abdomen. Perform and document a
thorough examination of all quadrants and look for signs of
tumor manifestations, for example, liver metastases, carcino-
matosis, or Krukenberg tumors of the ovaries. Visualize or
palpate the liver and peritoneal surfaces to assess for any
metastatic disease. Carcinomatosis can be encountered in all
quadrants but—if present—is particularly frequent in the pel-
vic cul-de-sac and the pericolonic gutters. Next, optimize the
exposure to the primary pathology location. Even if there is
little doubt regarding the location of the pathology, intraop-
erative colonoscopy with CO2 insufflation should be available
in the event that the level needs to be reassured.
Initial Colorectal Mobilization
Medial to lateral approach Leave the lateral attachments in

place until the posterior mobilization is largely done. The
attachments are a free assistant during the laparoscopic
approach as they hold the colon up in place while you can
work underneath. Once the serosa along the vascular pedicle Fig. 59.5
Identification of the Ureters extravasation into the surgical field. Alternatively (and cer-
tainly if you anticipate difficulty in identifying the ureters),
For any rectosigmoid resection, make it a habit to always consider placement of ureteral stents.
visualize the left ureter before transecting any relevant struc-
tures. In patients without visceral obesity, both ureters may
be visible upon entry into the abdomen even without any dis- ivision of the Blood Supply (IMA Pedicle,
D
section. More often than not, however, you need to free up Mesentery)
the left ureter to see its wormlike peristalsis (“vermicula-
tion”) in the retroperitoneal fat. You may find it where it Grasp the mesentery at the sigmoid and elevate and retract it
crosses the left common iliac artery near the bifurcation into to the side. This maneuver will accentuate the inferior mes-
the internal and external branches. If it is still not visible, you enteric artery pedicle. In order to increase the amount of
need to carry out a formal dissection which can either be a lymphatic tissue in the specimen, plan on taking the vascular
medial to lateral retroperitoneal dissection (laparoscopic/ pedicle as close as possible to its point of origin. For a recto-
robotic) or a lateral to medial dissection (open). One of the sigmoid resection, it may suffice that you only take the supe-
pitfalls is that you get too posterior in the dissection and see rior rectal artery (aka superior hemorrhoidal artery) but leave
the bare iliac vessels or the psoas muscle with its white ten- the left colic branch in place. If the sigmoid colon does not
don. Reassess the dissection plane and go more anteriorly. seem to be very redundant and you anticipate a need to per-
Once you have positively identified the ureter, you may facil- form a systematic mobilization in order to perform a low
itate its subsequent localization throughout the case by plac- anastomosis, it may be prudent to rather take the inferior
ing a clip just anteriorly to the fat, or by tagging it with a mesenteric vessels at their origin (see below).
silastic vessel loop. Identify the course of the ureter well Incise and score the peritoneum along the base of the
down toward the lateral pelvic sidewall (Fig. 59.6). Not only mesentery from the right-sided base of the vascular pedicle
identify the left ureter but visualize the location of the right to the beginning of the rectum at the pelvic brim. This will
ureter as you open the serosa on that side. Remember also open up the avascular plane directly behind the superior vas-
that the ureters may suffer injury deeper in the pelvis when cular arch. If you go too far posterior, you risk injuring the
you dissect the lateral aspect of the seminal vesicles. hypogastric nerve and get on the wrong track into the
If you have doubt whether you might have caused an pelvis.
injury to the urinary tract, instruct the anesthesiologist to Use gentle but directed blunt dissection by tenting the cut
inject indigo carmine dye intravenously and look for blue edge of the peritoneum anteriorly and caudad to lift the mes-
entery off the retroperitoneal structures. Again identify and
push down the left ureter, gonadal vessels, and hypogastric
nerves during this step of the procedure. Using instrument or
finger dissection, widen the space by more caudad blunt dis-
section of the areolar tissue of the relatively avascular plane.
Any bleeding indicates that the dissection is either too high
within the mesocolon or too deep within the retroperito-
neum. If significant bleeding is encountered, reorient your-
self and ensure that you are in the proper tissue spaces. You
should feel or see posteriorly the aortic and/or iliac pulsation
and anteriorly the pulsation of the inferior mesenteric artery.
It is not desirable to skeletonize down to the anterior wall of
the aorta, as it impacts the hypogastric nerves and could
result autonomic nerve dysfunction.
Isolate the vascular pedicle by sharply incising the perito-
neum overlying the origin of the inferior mesenteric artery at
the junction to the left colic and superior rectal arteries. In
routine cases divide the inferior mesenteric vessels about
2 cm after the takeoff from the aorta. In obese patients, you
L. urter may need to thin out the pedicle by pinching it between your
fingers or stepwise dissect portions of the fat off. Before
L. hypogastric
transecting the pedicle, reidentify the ureter to ensure it is
n.
adequately dissected posteriorly downward and will not be
Fig. 59.6 caught up in any clamps or stapler applied to the pedicle.
Ureter
Hypogastric
n.
Inf. mesenteric
a.
L. colic a.
Fig. 59.7
Fig. 59.8
Transection of the vascular pedicle after triple checking
the location of the ureter can be achieved in different ways: aorta, (2) have mobilized all retroperitoneal attachments, (3)
(1) by clamping, sharp dissection, and suture ligation; (2) mobilize the splenic flexure, (4) divide the inferior mesen-
isolation of each vessel, clipping, and sharp dissection; (3) teric vein at the lower edge of the pancreas, and (5) free up
vascular linear stapler; or (4) advanced energy devices. all nonvascular tissue up to the middle colic artery while
Divide the intervening mesentery up to the bowel wall at carefully preserving the marginal blood supply.
the planned transection point by following the superior rectal In rare circumstances (mostly reoperative cases), you may
artery within the mesentery (Fig. 59.7). Keep all tissue asso- have to continue the mobilization much further and divide
ciated with this vessel in the planned resection specimen to the middle colic artery below the level where it branches into
ensure adequate lymph node yield. In nonobese patients, it is left and right. This aggressive mobilization will require that
feasible to incise the peritoneum up to the point where a ves- there is an adequate perfusion from the right colonic branches
sel is visualized and then apply hemostats directly to each and the marginal arteries.
vessel as it is encountered. Alternatively, an energy device or
clamp and tie method may be used throughout.
Pelvic and Presacral Dissection
Proximal Bowel Transection Maintaining the integrity of the mesorectal compartment

during a total mesorectal excision (TME) is a key element of
Once you have come across the marginal artery in a similar quality surgical technique and improves the outcome.
fashion and freed up the bowel wall, you may transect the Use scissors or monopolar electrocautery to continue
colon. Use of a linear stapler is advantageous as to minimize incising the peritoneal reflection along the left and right side
contamination of the surgical field (Fig. 59.8). Sweep the of the rectum down to the rectovesical or rectouterine pouch
proximal end of the colon away in the packing until later of Douglas. At the pelvic brim, identify the course of the left
when you prepare it for construction of the anastomosis. ureter and bluntly sweep this it out of the way using a sponge
stick, St. Mark’s retractor, or forceps. This will ensure it does
not get accidentally caught during later dissection. Recheck
Splenic Flexure Mobilization the position of the right ureter and carry the right serosal
incision down toward the peritoneal reflection. Optimize the
Depending on the level of the planned pelvic anastomosis, exposure and in front of the rectum, “connect the dots” of the
the splenic flexure of the colon may have to be completely serosal incisions previously made on the right and left sides
mobilized. You can do this either before the actual resection of the rectum (Figs. 59.9 and 59.10). If the exposure is not
in anticipation of the need to mobilize or you first do the yet adequate, delay this step until the presacral dissection
resection and reassess the factual needs at that point. allows to sufficiently elevate the rectum and bring the recto-
Additional steps to assure appropriate mobility to reach vesical pouch better into the field of vision. A uterine retrac-
include that you (1) divide the artery at the run-off from the tion suture can also aid the exposure, particularly if the
Fig. 59.11
impairment (Fig. 59.11). You should and can avoid the dan-
Fig. 59.9
gerous presacral vein plexus and the autonomic hypogastric
nerves which divide into two major trunks in the upper sacral
area and continue laterally to the right and left pelvic side
wall. Insert a retractor behind the rectum and carefully ele-
vate the mesorectum. Use gentle but decisive frontward trac-
tion to dissect the avascular “holy” presacral plane. Readjust
retraction every few centimeters, and the dissection should
rapidly proceed without much difficulty until the two fascial
layers fuse a few centimeters above the coccyx and form
Waldeyer’s fascia. In order to continue the posterior dissec-
tion further down, you will have to sharply divide the
Waldeyer’s fascia, which extends from the lower sacrum to
the posterior rectal wall (Fig. 59.12).
Readjust the retraction and extend the posterior dissection
toward the sides and continue to deflect the hypogastric
nerves. Make sure that by this point, you have incised the
entire serosa all the way to the peritoneal reflection.
Retraction of the rectosigmoid in cephalad and contralateral
R. hypogastric direction places the remaining lateral tissue (aka lateral “lig-
n. aments”) on stretch. On either side, divide this tissue between
the anterior and the posterior dissection along the pelvic
Fig. 59.10
sidewall. Advanced energy devices are enormously helpful
to do this fairly swiftly without causing any relevant
surgery is done with a minimally invasive platform. You can bleeding.
place this either in the uterus fundus or through the avascular Now direct your attention to the anterior dissection. Use a
part of the lateral ligaments and around its body. deep and potentially lighted retractor (e.g., St. Marks retrac-
Retract the proximal end of the rectosigmoid and develop tor) to pull the genito-urinary structures (men: bladder, semi-
the avascular plane with areolar tissue between the presacral nal vesicles, prostate; women: uterus, vagina) in an anterior
fascia and the fascia propria of the rectum. If you have and cephalad direction. Identification of Denonvillier’s fas-
entered the correct space at the level of the vascular pedicle cia in this lower portion is important for the total mesorectal
and follow it toward the pelvis, the transition to the correct excision (TME). Optimized retraction optimizes the dissec-
plane should be automatic. Staying in that plane is crucial to tion. In open surgery, you may apply one or more long Allis
avoid immediate complications and long-term functional clamps to the anterior lip of the incised peritoneum and pull
deepest tip of the retractor to separate the rectum from the

anterior structures. Continue the dissection until you reach a
sufficient level below the tumor. Ideally, that would be 5 cm,
but for tumors in the distal third of the rectum, 2 cm or even
less may be sufficient.
Pelvic Hemostasis
Pelvic blood loss should be minimal if the dissection follows

the correct TME planes. Very large tumors and previous radi-
ation may result in a general hypervascularity of the area.
Among the most feared causes of severe pelvic hemorrhage
are injuries to the presacral vein plexus or major branches of
the interior iliac vein. Hemostatic clips, suture ligations, and
targeted repair of a ripped larger vein are necessary to control
bleeding from a clearly identified source along the lateral wall
of the pelvis. Posteriorly in the presacral area, however, these
measures are not useful. Here the vessels consist of thin-
Waldeyer’s fascia walled veins, which are easily torn by metallic clips at the
time of application or during the act of sponging the area
Fig. 59.12 later. Almost invariably, presacral bleeding results from a tear
in one or more of the veins that drain into a sacral foramen.
Except in the case of a small, clearly defined bleeding point
that can be held in forceps, mechanical maneuvers (suturing,
clipping, cautery) may be hazardous, as they may act as a
scalpel and convert the bleeding point to a major venous
laceration.
If a major bleeding occurs, initiate a quick damage con-
trol sequence whereby a number of maneuvers can be carried
Seminal
out individually or in combination:
vesicle
• Pack the pelvis with firm pressure for 10–15 minutes and
until other maneuvers have been arranged for.
• Place the patient in more steep Trendelenburg position to
Denonvillier’s reduce the venous pressure.
fascia • Apply direct energy using cautery at high and arching set-
tings or bipolar sealer systems (e.g., Aquamantys™).
• Apply fast-acting hemostatic agents followed by contin-
ued packing.
• Apply thumbtacks.
• Harvest a 1 cubic cm muscle (e.g., from the abdominal
wall), press it against the bleeding area and applying high
Fig. 59.13 cautery energy.
• Isolate and clamp the iliac arteries to temporarily reduce
it to the front. When you retract at the same time the rectum the arterial inflow.
up and push it toward the sacrum, the proper tension and • Assure in discussion with the anesthesiologist that the
counter tension provide you with access to the anterior plane. patient has an appropriate coagulation profile. If not, con-
To separate the rectum from the seminal vesicles and pros- sider systemic administration of pro-coagulative factor
tate or from uterus and vagina, respectively, use sharp dissec- products.
tion along the visible lines of tension (Fig. 59.13). If no lines
of tension are seen, readjust the retraction until the plane Unless these maneuvers produce complete hemostasis,
becomes evident. Use a sweeping or rocking motion with the replace the dense sponge pack in the presacral space, abort
the further surgery, and transfer the patient to a monitored Anastomosis

unit. Plan for a reexploration 24–48 hours with removal of
the packs and ideally continuation of the resection. The type and approach for the anastomosis depends on the
level above the pelvic floor, the space within the pelvis, and
the mobility of the proximal colon. In the upper and mid rec-
Distal Rectal Transection tum, a stapled (or rarely hand-sewn) end-to-end anastomosis
is the typical approach. Only for the complete TMEs with a
The rectum in the upper and middle third is partially intra- “colo-anal” anastomosis just above the pelvic floor, you may
peritoneal and in the back accompanied by an often bulky consider an alternative to a straight end-to-end configuration
mesorectum that contains the arcade of the superior hemor- in order to increase the reservoir and reduce urgency. Among
rhoidal artery. In the distal completely extraperitoneal rec- the options are a side-to-end anastomosis (Baker), a colonic
tum, the mesorectum thins out while being more J-pouch, and a transverse coloplasty in stapled or hand-sewn
circumferential. If there is sufficient length below the tumor, sutured technique.
select a transection point that is 5 cm distal to its lower bor-
der; otherwise perform a total mesorectal excision. ouble Stapled Anastomosis (Abdominal
D
For a partial mesorectal excision, divide the mesorectum and Perineal Access)
at a right angle to the proposed transection point until the If you divided the rectum distal to the tumor by means of a
bowel wall with its longitudinal muscle fibers is visible all stapling device, the most straightforward anastomosis is
around. You can either use bipolar electrocautery, an done in a stapled end-to-end fashion (i.e., the name “double-
advanced energy device, or manual clamping and ligating. stapled”) as described for the sigmoid resection.
For total mesorectal excision (TME), continue to follow the Place a non-crushing bowel clamp roughly 10 cm proxi-
mesorectal envelope until the pelvic floor musculature is mal to the stapled proximal bowel end. Cut off the staple line
completely freed up. and assess the bowel end for appropriate perfusion and
In the majority of cases, divide the rectum by means of a bleeding. Grab the bowel end with two Allis clamps and
cutting stapler device (Contour, or endoscopic linear sta- place a full-thickness purse-string suture using a monofila-
pler), or place a large right-angle clamp across the entire ment 2-0 suture. Make sure to find the balance between too
lumen of the rectum and staple-close the rectum distal to it few and too many bites. Alternatively, you may use a dispos-
with a TA stapler, followed by scalpel division of the bowel. able purse-string device which you place close to the stapled
Your goal should be to come across the bowel with a few end, fire, and liberate the suture ends; trim the bowel flush to
stapler firings as possible. the device and at the same time remove the staple line. Secure
For ultralow resections, the last part of the dissection is the anvil of a circular EEA stapler (commonly between 29
performed transanally from a perineal approach. The and 33 mm, rarely 25 mm) with a hemostat clamp. Gently
abdominal dissection should have been completed down to insert it into the open proximal bowel and make sure not to
the pelvic floor. Then switch to the perineum, install a cause any wall tears. Tie the purse-string suture. Trim the
Lone-Star retractor and incise the lining at the dentate line. edge of the proximal bowel by removing the attached appen-
Depending on the oncological needs, the transanal dissec- dices. Ensure that no diverticula or other bowel wall defects
tion can lift the mucosa off the internal anal sphincter mus- are in the area of the anastomosis. For laparoscopic
cle before extending full-thickness through the distal rectal approaches, return the proximal bowel with the anvil into the
wall and connect with the abdominal dissection. abdominal cavity and reestablish the pneumoperitoneum.
Occasionally, short of an abdomino-perineal resection, you There should be sufficient slack in the colon to fill the hol-
may sacrifice the internal sphincter muscle and immedi- low of the sacrum on its way to the site of the anastomosis. If
ately target the intersphincteric groove to travel in cephalad not, perform additional lengthening maneuvers to achieve
direction. sufficient slack (high ligation of IMA pedicle, divide IMV at
inferior border of pancreas, mobilize splenic flexure and dis-
connect all retroperitoneal attachments, divide omentum off
Irrigation of Rectal Stump the colon wall, divide mesentery up to the superior rectal
artery, tunnel the bowel through window in small bowel mes-
If there is any question as to the adequacy of the bowel prep- entery for shorter route to pelvic floor).
aration, insert a rubber catheter and irrigate the area with One of the team members needs to move between the legs
dilute betadine. Beyond removing stool, there is surgical to introduce the corresponding body of the circular stapling
dogma but little scientific evidence that the irrigation as such device into the rectum. Gently dilate the sphincter complex
reduces local tumor recurrences by removing any free- with two fingers and insert a bowel sizer to accommodate the
floating tumor cells. stapling device. Intravenous administration of glucagon by
Check the completeness of the stapler donuts and the

integrity of the anastomosis: Fill the pelvis with irrigation
fluid. Gently compress the colon proximal to the anastomo-
sis using two fingers or a non-crushing bowel clamp.
Insufflate the rectum in controlled fashion with air using a
rigid or a flexible sigmoidoscope. The latter is more
equipment-intensive but has the advantage that you can also
visualize the anastomosis. The abdominal team observes the
anastomosis for air leaks. If leaks are present, your options
are (1) to oversew and recheck, (2) to take down and redo the
anastomosis, or (3) to abandon the anastomosis. Even if you
elect to divert the anastomosis, it is advisable that you opti-
mize it locally beforehand. If you have to redo the anastomo-
sis, but there is not sufficient space for a re-resection with the
stapler, it may be necessary to remove the residual rectum to
the dentate line and perform a hand-sewn colo-anal
anastomosis.
Fig. 59.14 and-Sewn Colo-anal Anastomosis (Perineal

H
Access)
the anesthesiologist may aid in relaxing the bowel spasticity. Once the abdominal dissection has reached the pelvic floor,
Advance bowel sizers of increasing size to the end of the switch to the perineal approach (as described above). With a
rectal stump to ensure that there are no strictures, adhesions, Lone-star retractor in place to expose the anal verge, finish the
or other defects that would impede the path of the stapling rectal mobilization and connect with the abdominal dissec-
device. Insert the stapling device and advance it to the end of tion. This allows you to pull the entire rectum downward. Prior
the staple line. to doing so, the abdominal dissection should have included an
Deploy the stapler spike immediately next to the staple adequate proximal mobilization such that the intended proxi-
line (Fig. 59.14). If the stump is thin or if the transverse sta- mal transection site easily reaches the anal verge.
ple line becomes disrupted, a 2-0 atraumatic Prolene over- Before shortening the bowel to appropriate length, verify
and-over whipstitch can be used on the rectal stump. Each the blood supply. If mobility allows, pull a little bit more out
bite should contain 4 mm of full-thickness rectal wall, and and start securing the bowel to the pelvic floor muscles using
the stitches should be no more than 6 mm apart to prevent a total of eight absorbable seromuscular sutures. Gradually
gaps when the suture is tied. transect the bowel at the appropriate level and send the resec-
In open or hand-assisted laparoscopic cases, grasp the tion specimen for gross inspection and a frozen section of the
proximal end and perform the connection. For laparoscopic distal margin. If the margin is negative, complete the colo-
cases, an anvil grasper is helpful to connect the anvil (proxi- anal anastomosis by placing interrupted full-thickness
mal bowel) with the spike in the rectum. The camera can be sutures between the four-quadrant sutures and potentially
repositioned as needed so that the entire team can visualize fine-tune the mucosa with a running 3/0 chromic suture
both the distal and proximal portion of the anastomosis. (Fig. 59.15).
Once coupled, verify the correct bowel axis and slowly close
the stapling device. Target the middle compression area, if Reversed Stapled Circular Stapler Anastomosis
the specific stapling device offers a variable closing range; (Abdominal Access)
some devices have only a single firing position. During the In rare cases (e.g., unanticipated intraoperative consult and
slow closing maneuver, make sure that any extraneous tissue need for resection), you may not have access to the anus to
(appendages, urogenital structures) is actively reflected insert the circular stapler. You may open the rectal stump
away, that there is no tension, and proper alignment prior to and place a purse-string suture. Insert the anvil and tie the
the firing. For females, place a finger in the vagina and gently purse-string suture. About 10–15 cm from the end of the
move the stapler side to side to ensure that no vaginal tissue stapled off proximal colon, perform a 3 cm longitudinal
is caught in the staple line. Decisively fire the stapler. Partly colotomy. Insert the stapler body through that opening and
open its mechanism with three half-turns and gently remove advance it to the stapled colon end. Deploy the spike and
the device. connect it with the anvil in the rectal stump. Carry out the
Transverse coloplasty You may insert the stapler anvil just

as if you do when performing a straight stapled anastomosis.
Before doing so, however, make a longitudinal roughly 4 cm
incision to the bowel (colotomy) roughly 4 cm proximal to
the anvil. Place two holding stitches on either side in the
middle of the colotomy and pull them aside. Close the colot-
omy in two layers in transverse fashion.
itfalls, Danger Points, and Troubleshooting

P
Stapled Anastomoses
Staplers have been a great asset for pelvic anastomosis which

overall have become safer and more predictable. However,
they cannot guarantee a perfect anastomosis. Keep in mind
that a proximal diversion does not compensate for a bad
anastomosis. It is best to fix problems right then and there
when everything has already been freed up. Consider how
bad the alternative of a future redo-surgery with dense adhe-
sions and an even more difficult pelvic dissection may be if
the first anastomosis does not heal favorably.
Fig. 59.15 Bleeding

Immediate bleeding may be related to incorporation of the
anastomosis. Remove the stapler and close the colotomy in mesentery. Delayed bleeding could indicate an anastomotic
transverse direction. That can be done with a transverse sta- leak or also be related to the staple line. If possible, a visual-
pler or handsewn in two layers. ization of a significant bleeding site should be considered
with clipping or suturing of the respective area.
ariations of Colo-anal Anastomosis (To

V Anastomotic failure
Improve Short-Term Function) Signs of an immediate anastomotic failure are an obvious
separation of the staple lines, tearing of the bowel wall proxi-
If there is sufficient space, sufficient length, and a colo-anal mal or distal to the anastomosis, incomplete donuts, and/or a
anastomosis needs to be fashioned, you can augment the res- positive leak test. If there is a leak, your options are (1) to
ervoir by one of these variations. The benefits are short term oversew and recheck, (2) to take down and redo the anasto-
(first 12–24 months). If the neorectum has a large diameter mosis (if necessary by complete pull-through and handsewn
such that it theoretically could easily accept a 33 mm circular colo-anal anastomosis), or (3) to abandon the anastomosis all
stapler anvil, use of these augmentations is not necessary together and perform a permanent stoma. Even if you plan
even if possible. on diverting the anastomosis, it is advisable to optimize it
locally beforehand.
Colonic J-pouch Instead of a straight anastomosis, you can
form a 5–6 cm long colonic J-pouch by folding it, opening Incorporation of urogenital structures
the apex and placing the two jaws of a linear stapler on either This is a severe technical complication which should be
side. Place a purse-string suture to the apical enterotomy, largely preventable. Prevention is better than correcting the
insert the stapler anvil and connect the J to the transanally issue. Before completely closing the stapler, verify that those
inserted stapler, or suture it transanally to the dentate line. structures are neither fully included nor even tethered in the
stapler. Reopen it if you are not sure. Only close the stapler
Baker anastomosis (side-to-end) Instead of inserting the to the firing range when you are sure that the urogenital
stapler anvil into the end of the proximal bowel, you attach structures are actively kept out of the closing stapler.
the spear to the anvil and insert that in backward direction to
the proximal end. Penetrate with the spear on the side. Staple Stapler insertion impossible
off the true open end of the bowel. Connect the anvil with the Analyze the reasons. If there is truly a stricture that for some
transanally inserted stapler. reasons you were not aware of, determine whether a hand-
sewn anastomosis or a reversed stapled anastomosis would means of the clinical exam, endoscopy, and a water-
be doable and have a chance for a good functional outcome, soluble contrast study.
or whether you should abandon the plan of an anastomosis.
Anastomosis not prudent Complications

Even if you originally planned a restorative pelvic or colo-
anal anastomosis, intraoperative specifics of the cancer or the • Collateral organ injury (ureters, pelvic urogenital struc-
anatomy may be unfavorable such that it may simply not be tures, hypogastric nerves, major vessels, spleen).
prudent to pursue the plan. Examples (other than the inabil- • Surgical site infection: superficial (abdominal wall) ver-
ity to reach) include persistent tumor along the pelvic pas- sus deep (anastomosis).
sage, extremely poor tissue quality, active pelvic infection, • Anastomotic leak/pelvic sepsis:
insufficient passage to allow the normal size colon to fit –– Pelvic sepsis secondary to an anastomotic leak is
through, and others. among the most serious and potentially lethal compli-
cations following a low colorectal anastomosis. It
should be suspected until proven otherwise in any
Wound Closure patient with fever, leukocytosis, tachycardia, and/or
nonresolving ileus. Clinical manifestations of this
The operating team should discard soiled gloves and use new complication may develop at any time, but not infre-
instruments to close the surgical wounds. If available, cover quently occur 5–9 days after surgery.
the anastomosis with the remaining omentum to aid in heal- –– A gentle digital examination of the rectum may be
ing and deterrence of leak. Consider placing a pelvic drain. diagnostic if the finger discloses a defect in the suture
Perform a last check of the abdomen. Remove the ports and/ line, which often is located on its posterior aspect.
or retractors. Close the fascia of any incision larger than 5 mm –– Careful endoscopic examination with minimal CO2
in routine fashion. Irrigate the wound before closing the skin. insufflation may disclose evidence of a defect in the
If a diverting stoma has been planned, mature it after all suture line and provide information about the perfu-
skin has been closed (see Chap. 45). sion of the two sides.
–– An abdomino-pelvic CT scan can almost always con-
firm the presence of pelvic sepsis, particularly when
Postoperative Care combined with administration of rectal contrast
through a catheter without balloon insufflation. The
• Antibiotics: Routine coverage for the perioperative CT modality may further aid in draining of pelvic fluid
24-hour period. In case of an underlying infection/sepsis, collections.
continue respective therapeutic antibiotics for that –– Vigorous management is important: The treatment
indication. depends on (1) the acuity of the patient and (2)
• Intravenous fluids: Maintain adequate fluid until return of whether the patient has already been diverted. Patients
bowel function. with mild systemic symptoms who are suspected of
• Nasogastric tube: No routine use in elective cases; keep it having a pelvic infection may be treated by bowel rest
in non-elective cases until evidence of return of bowel (nil per os), intravenous broad-spectrum antibiotics,
function. and possibly hyperalimentation. Stable patients can
• Enhanced recovery after surgery (ERAS) protocol: In be treated by CT-guided percutaneous catheter drain-
elective cases, initiate oral intake on day of surgery and age or trans-rectal drainage with or without proximal
advance to solid food as patient demonstrates return of diversion. A patient may have a pelvic abscess even in
bowel function. the absence of a definite defect in the suture line.
• Nutritional support: If return of bowel function delayed Consequently, a patient who is febrile and toxic should
by more than 5 days, initiate parenteral nutrition. undergo drainage of any septic process that is
• Incentive spirometry and early ambulation should be identified.
encouraged. –– Sick patient requiring ICU transfer or with signs of
• If adjuvant chemotherapy or radiation therapy is planned, sepsis require return to the operating room to clean out
this can usually be initiated 4–6 weeks after surgery. and drain, divert, or possibly take apart the
• A temporary stoma can be reversed after a minimum of anastomosis.
6–12 weeks if there are no other treatments that have pri- • Anastomotic bleeding: immediately (technical), early
ority (e.g., adjuvant chemotherapy), and if the integrity postoperative (staple line, leak), long term (ischemia,
and patency of the anastomosis has been documented by recurrence).
• Anastomotic stenosis (e.g., as a result of ischemia, scar- Celentano V, Ausobsky JR, et al. Surgical management of presacral
ring, particularly after previous leak). bleeding. Ann R Coll Surg Engl. 2014;96(4):261–5.
Fleshman J, Branda M, et al. Effect of laparoscopic-assisted resec-
• Postoperative ileus or small bowel obstruction. tion vs open resection of stage II or III rectal cancer on pathologic
• Autonomic nerve dysfunction (particularly after triple hit outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA.
by chemo- and radiotherapy and surgery): 2015;314(13):1346–55.
–– Bladder dysfunction may follow low anterior resec- How P, Shihab O, et al. A systematic review of cancer related patient
outcomes after anterior resection and abdominoperineal excision
tion, especially in men with benign prostatic hypertro- for rectal cancer in the total mesorectal excision era. Surg Oncol.
phy. Generally, the function resumes after 6–7 days of 2011;20(4):e149–55.
bladder drainage, possibly supported by an alpha- Monson JR, Weiser MR, et al. Practice parameters for the management
adrenergic antagonist. of rectal cancer (revised). Dis Colon Rectum. 2013;56(5):535–50.
Patel UB, Taylor F, et al. Magnetic resonance imaging-detected tumor
–– Sexual dysfunction in men may follow low anterior response for locally advanced rectal cancer predicts survival out-
resection, especially in patients with large tumors and comes: MERCURY experience. J Clin Oncol. 2011;29(28):3753–60.
who require extensive dissection of the presacral Peeters KC, Marijnen CA, et al. The TME trial after a median fol-
space, lateral ligaments, and prostatic area. low-up of 6 years: increased local control but no survival benefit
in irradiated patients with resectable rectal carcinoma. Ann Surg.
• Low-anterior-resection syndrome (LARS): bowel and 2007;246(5):693–701.
pelvic floor dysfunction with sometimes incapacitating Stevenson AR, Solomon MJ, et al. Effect of laparoscopic-assisted resec-
urgency, tenesmus, bowel frequency, incontinence, or tion vs open resection on pathological outcomes in rectal cancer: the
stool clustering. ALaCaRT randomized clinical trial. JAMA. 2015;314(13):1356–63.
Taylor FG, Quirke P, et al. Preoperative high-resolution magnetic reso-
• Incisional, port-site, or internal hernia formation. nance imaging can identify good prognosis stage I, II, and III rectal
cancer best managed by surgery alone: a prospective, multicenter,
European study. Ann Surg. 2011;253(4):711–9.
Further Reading van Gijn W, Marijnen CA, et al. Preoperative radiotherapy combined
with total mesorectal excision for resectable rectal cancer: 12-year
follow-up of the multicentre, randomised controlled TME trial.
American Medical Association. Current procedural terminology: CPT Lancet Oncol. 2011;12(6):575–82.
®. Professional ed. Chicago: American Medical Association; 2022. Vennix S, Pelzers L, et al. Laparoscopic versus open total meso-
https://www.ama-assn.org/practice-management/cpt. rectal excision for rectal cancer. Cochrane Database Syst Rev.
Bonjer HJ, Deijen CL, et al. A randomized trial of laparoscopic versus 2014;4:CD005200.
open surgery for rectal cancer. N Engl J Med. 2015;372(14):1324–32.
Abdominoperineal Resection (Open,
Laparoscopic) 60
Kyle G. Cologne, Sean J. Langenfeld,
Indications numerous factors, for example, the nature of the pathology, an

elective versus nonelective scenario, sphincter function, and
• Malignancy of distal rectum or anus (rectal cancer, anal others. Multimodality treatment and possibly the presence of
cancer, melanoma) not amenable to sphincter-preserving underlying risk constellations (hereditary cancer, inflamma-
techniques or that failed standard nonoperative manage- tory bowel disease) may affect the decision-making.
ment (e.g., persistent/recurrent anal squamous cell cancer
after Nigro protocol)
• Inflammatory bowel disease, including ulcerative colitis Preoperative Preparation
and Crohn’s colitis with intractable rectal involvement
that precludes restorative proctocolectomy • Review the patient’s history, diagnosis, functional aspects,
• Less common: failed restorative resection, rectal prolapse and appropriate indication for surgery (based on endo-
with severe sphincter dysfunction, fecal incontinence, scopic, clinical, or radiographic means) as opposed to
radiation proctitis, diversion proctitis not amenable to diversion only or nonsurgical management (e.g., systemic
stoma takedown chemotherapy and/or radiotherapy).
• Accurate systemic and local tumor-specific staging
Sacrificing the natural route of stool elimination is a seri- including, as appropriate:
ous decision that requires a solid justification based on pro- –– Computed tomography (CT) of the chest abdomen and
jected disease-specific needs to achieve local control, tissue pelvis
quality, as well as functional and quality-of-life aspects. –– MRI scan (rectal cancer staging protocol)
Less-aggressive sphincter-preserving approaches should be –– Endorectal ultrasonography
deemed inferior and associated with significant –– Positron emission tomography (PET)
disadvantages. • Colonoscopy to determine the nature of the pathology
The technique of an abdominoperineal resection may vary (benign vs malignant) and to exclude synchronous
depending on whether it is done either in oncological fashion pathology.
for distal rectal or anal malignancies or in a less extensive • Verify the exact axial and circumferential tumor location
form for a number of benign conditions. The extent and in relation to the pelvic floor, sphincter complex, and sur-
approach (open versus minimally invasive) further depend on rounding structures.
• Determine the extent of the perineal approach and plan—
K. G. Cologne if necessary—for advanced defect closure (e.g., flaps).
Department of Surgery, Division of Colorectal Surgery, Keck • Multidisciplinary evaluation and discussion (particularly
important in locally advanced tumors).
• Preoperative radiation and chemotherapy: depending on
S. J. Langenfeld
nature and stage of the tumor.
Department of Surgery, University of Nebraska Medical Center,
Omaha, NE, USA • In patients on chemotherapy or immunosuppressants or
after radiation: plan for optimal timing of surgery.
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of • Discussion and marking for possible ostomy.
Hope National Medical Center/Comprehensive Cancer Center, • Mechanical bowel preparation.
Duarte, CA, USA • Antibiotic prophylaxis (versus treatment).

https://doi.org/10.1007/978-3-030-81415-1_60
Pitfalls and Danger Points Surgical Approach
• Oncologically inferior resection: violated mesorectal Traditionally, rectal surgery including an abdominoperineal
envelope; specimen waist (instead of cylindrical appear- resection was approached and described as open surgery, for
ance); positive distal, proximal, or circumferential radial example, through a midline incision. Minimally invasive
margin (CRM); insufficient lymph node harvest approaches (laparoscopic or robotic surgery), however, have
• Collateral injury: urethra, vagina, ureters, autonomic dramatically evolved and in many circumstances are consid-
nerves ered valid options. Safe surgery and cancer cure always carry
• Hemorrhage: vascular pedicle, presacral veins, iliac veins, a higher priority than the type of approach.
mid rectal arteries
• Poor perineal wound healing (particularly in large and
radiated defects) Colostomy
• Stoma complications: poor site selection, necrosis, retrac-
tion, herniation, prolapse Worse than requiring a permanent colostomy is to end up
• Perineal hernia formation with a colostomy that is suboptimal in regard to location,
form, and function. Identify and mark possible stoma sites
before the operation. Involvement of an enterostomal ther-
Operative Strategy apist is desirable. Generally, a left lower quadrant place-
ment is preferred in an average habitus patient. In morbidly
Extent of the Perineal Resection obese patients with an apron-like pannus, a more cephalad
location in the left upper quadrant (above the heavy pan-
When the abdominoperineal proctectomy is performed for nus) will be needed, as a stoma at the regular location
a cancer, it is important to rank the cancer treatment would be impossible for the patient to see and care for. The
aspects higher than appearance and function. In malignant thickness of subcutaneous fat is also less in the upper
disease, this translates into a wide and cylindrical resec- abdomen, allowing for a safer delivery of the colon end
tion of the anus and the pelvic floor. If performed correctly, through the new aperture and reducing the risk of tension,
it should not be possible anymore to reapproximate the ischemia, or the need for an oversized abdominal wall
muscles from one to the other side. In females, it is stan- defect.
dard in advanced and particularly in anterior lesions to pri-
marily include the posterior vaginal wall into the excision.
In posterior lesions, it may be appropriate to remove the Perineal Dissection
coccyx.
For any indication other than cancer, the principles of Keeping the patient in the modified lithotomy position
oncologic resection with adequate resection margins do throughout the entire procedure is the most common setup
not have to be followed. The resection should therefore as it does not interrupt the flow of the operation. The
remain conservative and be limited to an intersphincteric abdominal and perineal phases can be carried out synchro-
dissection with elimination of all epithelial lining to the nously by two operating teams or sequentially by one team.
level of the anal verge. Every attempt should be made to Coordination or switching between the two sites can be
preserve the core structure of the pelvic floor and to avoid adjusted to what a particular step demands. It facilitates a
damage to adjacent structures, including nerves and adja- safe lateral dissection of large tumors and completes hemo-
cent organs. stasis in the pelvis. After removing the specimen, it is fairly
simple to simultaneously close the perineum while pro-
ceeding with the abdominal closure and stoma creation.
Abdominal Phase The concurrent approach may be even more relevant if a
complex reconstruction including mobilization of a myocu-
The initial abdominal phase of the dissection is essentially taneous flap is necessary.
identical to that performed for a low anterior resection, Turning the patient to a prone position for the perineal
with the exception that length to achieve a tension-free dissection may be advantageous or necessary for particularly
anastomosis is not a concern. See Chap. 59 for a detailed wide perineal resections or a partial sacrectomy. Some sur-
discussion of the strategy relevant to this phase, including geons advocate this approach even for routine circumstances
total mesorectal excision (TME) and Chap. 66 for the as it provides excellent exposure. However, the intraopera-
colostomy creation. tive change of position imposes a number of disadvantages
60 Abdominoperineal Resection (Open, Laparoscopic) 483
including prolonging the operative procedure and establish- Positioning

ing a full commitment to the perineal dissection without the
ability to provide further dissection or assistance from above. Regardless of the approach, place and secure the patient in
If the prone position is employed, it is often helpful to secure modified lithotomy on an anti-sliding system that allows for
the omental or myocutaneous flap to a sponge that is placed dynamic repositioning during the case (see Fig. 59.3). Make
behind the rectum in the pelvis or to the proximal portion of sure that the perineum is at the table end to allow for access
the surgical specimen: this facilitates to bring it into the peri- to the anus and that the hips can vary from flat (0 degree) to
neal wound during specimen extraction. high lithotomy (90 degree). Preferably tuck both arms to
allow best access. Place a urinary catheter to decompress the
bladder and monitor intraoperative urine output. Extend the
Pelvic Defect Management hair clipping to include the anus and the entire perineum.
Prep and drape the patient from nipple line to mid thighs and
In malignant disease, the removal of the rectum, pelvic floor, include the perineal area and, in females, the vagina.
and anus is defined by the needs of a curative resection but Monitors for laparoscopic surgery should be placed such that
may result in a potentially large defect. In some occasions surgeon, target, and monitor form one line (see also Chap.
when there is substantial infection, it may be necessary to 54, Fig. 54.4).
initially leave the wound or parts thereof open and consider
a closure only at a much later stage.
In anticipation of a wide defect, preoperative consultation Operative Approach and Incisions
with a plastic surgeon is often prudent. A pedicled vertical
rectus abdomini myocutaneous (VRAM) flap is typically the inimally Invasive Surgery
M
best option for an immediate reconstruction. Alternatively, As described in Chaps. 54 and 59, different layouts of port
and if there is a need for a staged closure, bilateral gracilis or placements are used. Depending on the past history, insert
gluteal flaps can be employed. the first 10–12 mm trocar using the Hasson or the Veress
It should be noted that the abdominal configuration may needle technique. Establish the pneumoperitoneum and
substantially change when such a flap is harvested. The pre- insert the camera. Insert the subsequent ports under visual
operative stoma markings hence only serve as a general idea control. Alternatively, you may establish access and the
but may require ad hoc adjustments. This is particularly pneumoperitoneum by first creating the abdominal wall
important in the instance of a pelvic exenteration, where opening for the colostomy and placing a mini gel port with a
bilateral stomas are potentially necessary. trocar.
Pure laparoscopic techniques normally use 4–5 trocars
(Fig. 60.1). Insert a camera port at the umbilicus. For speci-
Documentation Basics men extraction and to a stapler anvil for the anastomosis, you
can either later expand this incision or perform a separate
Coding for surgical procedures is complex. Consult the most access in a different location. Place 3–4 working ports that
recent edition of the AMA’s Current Procedural Terminology allow for triangulation toward the pelvis, the rectosigmoid,
book for details (see references at the end). In general, it is and the descending colon. Our preference is one in the right
important to document: lower quadrant and one in the right middle to upper quad-
rant. Place the third one in the left mid abdomen where the
• Findings and indication patient has been marked for the colostomy.
• Reasoning for choice and extent of surgical resection Placement of the robotic trocars for the most current Xi
• Surgical approach version are placed on an oblique line from the right iliac crest
• Blood vessels taken to the left upper quadrant with an additional accessory port
• Stoma creation in the right upper quadrant (see Chap. 54, Fig. 54.2).
• Defect closure
Open Approach
For an open approach, you will most commonly make a mid-
Operative Technique line incision starting at the pubic bone and extending to the
umbilicus. This would allow you to extend it further if
The first part of the operation follows the steps outlined for needed.
the total mesorectal excision (low anterior resection) as Alternatively, you may carry out a Pfannenstiel incision.
described in Chap. 59. For this approach, make a transverse suprapubic incision
about two finger breadths above the pubic bone or within an

existing scar. Cut through the abdominal wall fat down to the
fascia. Incise the anterior rectus sheath in transverse direc-
tion without injuring the rectus muscle. Dissect the fascia off
the muscle up to the umbilicus and down to the pubic bone.
Enter the abdomen vertically between the rectus muscles.
Maintain the exposure by means of a self-retaining retrac-
tor such as a Bookwalter or Omni retractor with or without
use of a wound protector.
Abdominal Dissection and Colostomy Creation

of the platform), explore the abdomen and initiate the rectal
dissection as described in Chap. 66. The steps include mobi-
lization of the vascular pedicle, identification of the ureters,
mobilization of the colon, division of the mesosigmoid and
proximal transection of the bowel (Fig. 60.2a and b), and
eventually the total mesorectal excision down to the pelvic
floor.
Prior to moving to the pelvic dissection, you should assure
an adequate mobilization of the proximal colon end such that
a well-vascularized bowel easily reaches a few centimeters
above the skin surface at the designated stoma site. To avoid
necrosis of the colostomy, confirm an excellent arterial blood
flow to exteriorized colon, equivalent to that required if an
anastomosis were made at this point. Even in the presence of
Fig. 60.1 an adequate arterial flow, the colostomy may become isch-
a b
Fig. 60.2
emic if an obese mesentery is constricted by a tight trephine

(abdominal wall opening).
The timing of when to initiate the first steps to the colos-
tomy creation depends on the flow of the surgery. Maturing
the stoma always has to wait until you have closed all skin
incisions. However, you may create a gap and pull the bowel
through the abdominal wall in open surgery at any time. In
laparoscopic or robotic surgery, you should secure the mobile
proximal bowel end with a grasper but wait to create the tre-
phine and pull the bowel through until the pneumoperito-
neum is not needed any further.
Another point for consideration is that you create an
omental flap if available as a vascularized tissue bulk in the
pelvis. If the omentum has a nice volume, it may help to
separate the bowel from the perineal wound closure and miti-
gate management issues if the wound later dehisces. It is
important to carefully mobilize the omentum off the trans-
verse colon to obtain sufficient length but leave a strong vas-
cular supply.
Fig. 60.3
ylindrical Abdominoperineal Resection
C
(Malignant) TM) retractor as well, though you should be careful with the
sharp hooks.
In contrast to the standard total mesorectal excision, the Landmarks for the perineal dissection include (1) anteri-
focus for the abdominoperineal resection lies in the last por- orly the perineal body and deeper the transverse perineal
tion where the tumor is located. For benign disease, this muscle, (2) posteriorly the coccyx, and (3) laterally the
does not apply (see Abdominoperineal resection [benign], ischial tuberosities.
below). In male patients, mark an elliptical incision beginning in
the mid perineum to the tip of the coccyx (Fig. 60.3). In
Abdominal Part female patients, the marking should anteriorly extend to
In a cancer case, when your total mesorectal dissection include the posterior vagina (Fig. 60.4a and b) except in very
approaches the pelvic floor, you should avoid “coning-in” on early or posterior lesions, where the incision can start from a
the most distal aspect of the rectum that contains the tumor, point just behind the vaginal introitus.
as this can result in a positive margin and increased local Incise the skin and dermis and grasp the opposing skin edges
recurrence rates. Instead, you should pursue the concept of a with a few Kocher clamps to have a handle and to create tension.
“cylindrical” resection specimen. At the pelvic floor, the dis- Carefully make sure to maintain perfect hemostasis. Divide the
section should transition to a wider plane through the levator ischioanal fat on either side with cautery or an advanced energy
fascia, without dissecting the last segments of the mesorectal device (Fig. 60.5). Particularly the use of an energy device with
envelope just cephalad to the anal canal. These attachments large jaws (e.g., LigaSure Impact™, Medtronic, Minneapolis,
are left in place, and the typical “waist” of the specimen at MN) has dramatically improved the ability to make fast prog-
this location is avoided. After dividing the abdominal portion ress with excellent hemostasis even across the inferior hemor-
of the levator fascia, you switch to the perineal phase. rhoidal vessels. Following a curvilinear or smiley-faced pattern
posteriorly, keep a straight line up to the levator muscles on
Perineal Dissection either side, again to avoid coning-in from this direction.
Re-desinfect the perineum as the abdominal manipulation Posteriorly, it is important that you do not fall behind the coc-
may have resulted in discharge of stool and possibly cancer cyx: identify the tip of the coccyx and target the anococcygeal
cells. Close the anus with two concentric heavy, purse-string ligament which you will have to sharply divide. Laterally follow
sutures. Typically, there is no need for any retractor. In very near the ischial tuberosities and march in cephalad direction.
obese patients with massive buttocks and gluteal folds, how- The most serious pitfall during perineal dissection is an
ever, it may be necessary to improve the exposure by placing injury to the urethra in males, and in females damage to the
several stay sutures to secure the gluteal folds to the lateral vagina beyond the planned incorporation into the resection.
thigh. Alternatively, you can use a self-retaining (LoneStar Both can largely be avoided if the anterior part of the dissec-
a b
Fig. 60.4
tion is delayed until the levator muscles have been bilaterally

divided throughout and the specimen everted (see below).
Furthermore, repeatedly palpate the prostate and check the
position of the Foley catheter which should be palpable at a
secure distance. Identify the transverse perineal muscle and
keep the dissection on a plane posterior to it but at the same
time make sure not to violate the integrity of the rectum.
Incise the levator fascia posteriorly, as the subsequent dis-
section becomes easier and the anatomy is most consistent at
this location. Use electrocautery or heavy scissors to divide
the anococcygeal ligament just anterior to the tip of the coc-
cyx. At this point, insert the index finger anterior to the tip of
the coccyx and follow the curvature of the sacrum to connect
with the abdominal dissection in the presacral space. If this
is not immediately possible, Waldeyer’s fascia with its robust
condensation between the posterior rectum and the presacral
and precoccygeal area may not have been divided yet. Avoid
tearing this fascia off the sacrum by blunt technique, as the
presacral venous plexus may be torn and result in massive
hemorrhage. Slide the index finger along the left side of the
levator diaphragm and use it as guidance to insert the
advanced energy device (Fig. 60.6). As noted before, the use
of such devices greatly limits the blood loss as you divide the
vascularized levator muscles. Continue on one side in step-
wise fashion from posterior to anterolateral, followed by the
Fig. 60.5 same maneuver on the right side.
rior aspect of the prostate gland and seminal vesicles—which

are normally covered by Denonvillier’s fascia. Another use-
ful landmark is the transverse perineal muscle. Your plane of
the anterior dissection should remain posterior to this muscle
(i.e., do not divide or resect the muscle with the specimen,
but leave it intact) There is a risk of urethral injury by carry-
ing the plane of dissection beyond this landmark. Finally,
divide the remaining attachments to the prostate and remove
the specimen (Fig. 60.8a and b).
In women, it depends whether the posterior wall of the
vagina is to be preserved or included in the resection. In the
former situation, your anterior dissection should follow a
plane just posterior to the vagina. It is often helpful to place
a finger or sponge stick in the vagina to identify the border of
this structure and stay in the correct plane. Avoid traumatiz-
ing or devascularizing the wall of the vagina during this dis-
Fig. 60.6 section, as it might lead to a vagino-perineal fistula and be
difficult to manage. It is preferable to excise the posterior
wall of the vagina and close the defect with absorbable
sutures than to devascularize it. If the posterior wall of the
vagina is to be removed, use electrocautery to continue the
perineal skin incision anteriorly across the vaginal introitus.
The vagina is very well vascularized and may bleed.
Complete hemostasis is easier attained when you incise the
vagina by electrocautery or an advanced energy device.
Leave a patch of posterior wall of the vagina that corresponds
to the threatened margin on the anterior wall of the rectum
attached to the specimen. Hemostasis should be complete
and is accomplished using electrocautery and ligatures from
the abdominal and from the perineal direction. Reconstruct
the vagina with a running absorbable suture in one or two
layers (Fig. 60.9).
anagement of Pelvic Floor

M
With few exceptions, close the perineum primarily.
Exceptions are active infections in the area. The use of drains
is not mandatory, but a closed-suction drainage catheter with
planned removal prior to discharge can limit the seroma for-
mation and seepage through the perineal wound (Fig. 60.10).
If you did a correct cylindrical excision, the levator dia-
phragm can typically not be reconstructed because the sides
Fig. 60.7 are too far apart. In most instances, the remainder of the peri-
neal closure can be accomplished in layers of interrupted
Once you developed the posterolateral connection in the absorbable suture within the subcutaneous fat. The skin can
pelvic floor, you can facilitate the anterior most risky dissec- be closed with staples or with absorbable sutures (interrupted
tion by delivering/everting the transected rectosigmoid spec- or running).
imen through (Fig. 60.7). Insert the index finger again and
hook the residual puborectalis muscle, as you continue to
carefully transect it with electrocautery. Make sure to follow Abdominoperineal Resection (Benign)
the correct plane and not damage the rectal wall integrity
(Fig. 60.8a and b). In contrast to the oncological total mesorectal excision, the
In men, repeatedly palpate the prostate and visualize it focus for the abdominoperineal resection for benign disease
from below. Make a projection of the plane along the poste- lies in removing the bowel wall and specifically all mucosa.
a Transverse b
perineal m.
Rectourethralis
m.
Fig. 60.8
The mesorectum, lymph node harvest, and pelvic floor are off the underlying muscular structures. Spare the entire pel-
not relevant as pathology quality parameters and should be vic floor muscle structures including the external anal
preserved. sphincter and the puborectalis and levator muscles. You can
either continue with the mucosal stripping to the upper end
Abdominal Part of the anal canal and at that point cut through the full thick-
In benign disease, you can, but do not have to, perform total ness, or you immediately target the intersphincteric groove
mesorectal dissection. You could also follow the bowel wall and follow that plane up to the abdominal dissection.
using an energy device and that way stay away from nerves
and presacral veins. Just above the pelvic floor, the mesorec- Closure of the Perineal Wound
tum starts to naturally taper. If you follow the rectum, the Irrigate the area and verify the hemostasis. Readapt the mus-
dissection continues without much effort toward the inter- cle layer with interrupted absorbable sutures. Leave the skin
sphincteric groove. Once you have circumferentially mobi- open.
lized the most distal rectum above the pelvic floor, switch to
the perineal portion of the dissection.
Abdominal Wound Closure
Perineal Dissection
Re-desinfect the perineum as the abdominal manipulation The operating team should discard soiled gloves and use new
may have resulted in discharge of stool. Place a self-retaining instruments to close the surgical wounds. In a correct onco-
(LoneStar TM) retractor such that the sharp hooks are located logical resection, there is typically not enough peritoneum to
just outside of the anal verge. Using the electrocautery, incise close that layer. If available, place the remaining omentum
the epithelial layer just at the anal verge and dissect the layer into the emptied pelvic space to aid in healing. Placing a
Colostomy
Mature the colostomy after all skin has been closed (see
Chap. 67). Briefly, excise a skin disk over the stoma mark-
ing, dissect through the subcutaneous fact, make a cruci-
ate incision in the anterior rectus sheath, split the rectus
muscle, open the posterior sheath and peritoneum, and
create a passage wide enough to insert two finger breadths.
Bring the colon end through it and secure it with inter-
rupted sutures to the fascia and dermis. Consider placing
a biologic mesh/graft behind the rectus muscle to reduce
the risk of parastomal hernia formation. If possible, close
the lateral aspect to the colostomy-bearing bowel by
attaching the peritoneum to the bowel using a running
absorbable suture. This reduces the risk that the small
bowel wraps around and strangulates the bowel to the
colostomy.
Once the skin incision is closed, excise the proximal sta-
ple line on what will be an end colostomy. Immediately
mature the colostomy, using interrupted sutures of 3-0
absorbable suture to attach the full thickness of the colon to
the subcuticular plane of the skin. Make sure to limit the
sutures to the dermis and not to go through the skin as the
latter could trigger annoying granulomas and mucosal
islands around the colostomy. A normal colostomy does not
Fig. 60.9 have to protrude as much as an ileostomy. Most commonly
you aim at a height of the “rosebud” comparable to the height
of the appliance waiver.
Postoperative Care

indication.
bowel function.
• Nasogastric tube: No routine use in elective cases; keep it
in nonelective cases until evidence of return of bowel
function.
• Enhanced recovery after surgery (ERAS) protocol: In
elective cases, initiate oral intake on day of surgery and
advance to solid food as patient demonstrates return of
bowel function.
Fig. 60.10 • Nutritional support: If return of bowel function delayed
by more than 5 days, initiate parenteral nutrition.
p elvic drain is optional. Perform a last check of the abdo- • Incentive spirometry and early ambulation should be
men. Remove the ports and/or retractors. Close the fascia of encouraged.
any incision larger than 5 mm in routine fashion. Irrigate the • If adjuvant chemotherapy or radiation therapy is planned,
wound before closing the skin. this can usually be initiated 4–6 weeks after surgery.
Complications perineal excision is associated with low morbidity. Color Dis.

2013;15(9):1177–83.
Chan S, Miller M, et al. Use of myocutaneous flaps for perineal closure
• Collateral organ injury (ureters, pelvic urogenital struc- following abdominoperineal excision of the rectum for adenocarci-
tures, hypogastric nerves, major vessels). noma. Color Dis. 2010;12(6):555–60.
• Surgical site infection: superficial (abdominal wall) ver- Colov EP, Klein M, et al. Wound complications and perineal pain after
extralevator versus standard abdominoperineal excision: a nation-
sus deep (pelvis, perineum) wide study. Dis Colon Rectum. 2016;59(9):813–21.
• Stoma complications: retraction, ischemia, stricture, pro- den Dulk M, Marijnen CA, et al. Risk factors for adverse outcome
lapse, hernia. in patients with rectal cancer treated with an abdominoperi-
• Postoperative ileus or small bowel obstruction. neal resection in the total mesorectal excision trial. Ann Surg.
2007;246(1):83–90.
• Autonomic nerve dysfunction (particularly after triple hit Han JG, Wang ZJ, et al. A prospective multicenter clinical study of
by chemo- and radiotherapy and surgery): extralevator abdominoperineal resection for locally advanced low
• Bladder dysfunction, especially in men with benign pros- rectal cancer. Dis Colon Rectum. 2014;57(12):1333–40.
tatic hypertrophy. Generally, the function resumes after Jorgensen ML, Young JM, et al. Assessment of abdominoperineal
resection rate as a surrogate marker of hospital quality in rectal can-
6–7 days of bladder drainage, possibly supported by an cer surgery. Br J Surg. 2013;100(12):1655–63.
alpha adrenergic antagonist. Kasparek MS, Hassan I, et al. Quality of life after coloanal anastomosis
• Sexual dysfunction in men, especially in patients with and abdominoperineal resection for distal rectal cancers: sphincter
large tumors and who require extensive dissection of preservation vs quality of life. Color Dis. 2011;13(8):872–7.
Klein M, Fischer A, et al. Extralevatory abdominoperineal excision
the presacral space, lateral ligaments, and prostatic (ELAPE) does not result in reduced rate of tumor perforation or rate
area. of positive circumferential resection margin: a nationwide database
• Incisional, port-site, or internal hernia formation. study. Ann Surg. 2015;261(5):933–8.
Lopez-Cano M, Serra-Aracil X, et al. Preventing parastomal hernia
using a modified sugarbaker technique with composite mesh during
laparoscopic abdominoperineal resection: a randomized controlled
Further Reading trial. Ann Surg. 2016;264(6):923–8.
Musters GD, Klaver CEL, et al. Biological mesh closure of the pelvic
American Medical Association. Current procedural terminology: CPT floor after Extralevator abdominoperineal resection for rectal can-
®. Professional ed. Chicago: American Medical Association; 2022. cer: a multicenter randomized controlled trial (the BIOPEX-study).
https://www.ama-assn.org/practice-management/cpt. Ann Surg. 2017;265(6):1074–81.
Barker T, Branagan G, et al. Vertical rectus abdominis myocutane- West NP, Anderin C, et al. Multicentre experience with extraleva-
ous flap reconstruction of the perineal defect after abdomino- tor abdominoperineal excision for low rectal cancer. Br J Surg.
2010;97(4):588–99.
Multivisceral Resections (Pelvic
Exenteration) 61
Indications • Definitive evidence of unresectability

• Coagulopathy
Multivisceral resections are indicated in the setting of locally
advanced primary or recurrent cancer if they increase the
chance of local or even systemic tumor control. An R0 resec- Preoperative Preparation
tion remains the best chance to achieve local tumor control,
potentially even survival. If achieving that goal requires • Discuss the patient’s history, diagnosis, and appropriate
resection of other involved organs, multivisceral resections indication for surgery (based on clinical, radiographic, or
are indicated and justified. In the case of locally advanced endoscopic means) in interdisciplinary conference.
primary or recurrent pelvic cancer (rectum, anus, urological, • If the patient never had radiation before, always consider
gynecological), this may necessitate a pelvic exenteration neoadjuvant treatment prior to surgery.
with or without restoration of continuity. • Review all preoperative images (CT/MRI/PET scans,
Intent to cure is the best indication for such an aggressive contrast enemas) to assess the local tumor extent (viscera,
approach, but these procedures may be offered to carefully soft tissues, sacrum, pelvic sidewall, etc.) and
selected highly symptomatic patients with incurable/meta- resectability.
static disease. In such cases, multivisceral resection may pro- • Colonoscopy to confirm the diagnosis and exclude syn-
vide palliation for intractable symptoms such as pain, chronous pathology.
fistulization, and bleeding. • Cystoscopy/colposcopy if concern for urinary or vaginal
While there have been recent improvements in the mor- involvement.
bidity and mortality, a pelvic exenteration remains a highly • Stoma marking for two stomas mandatory.
complex and challenging procedure. Multidisciplinary man- • Patient education about stoma function and expected life-
agement and planning in the pre-, intra-, and postoperative style modifications.
phases are essential for optimal patient outcomes. • Mechanical and bowel preparation.
• Routine antibiotic prophylaxis (unless therapeutic indica-
tion for active infection).
Contraindications • Type and cross blood and plasma products.
• Poor performance status with limited life expectancy

• Metastatic tumor, not amenable to potential cure (unless Pitfalls and Danger Points
no less aggressive options exist)
• More advanced pathology than anticipated, necessitating
change in plan
G. K. Low
• Injury and bleeding from major vasculature structures
Department of Surgery, University of Tennessee,
Knoxville, TN, USA • Collateral injury (nerves to lower extremities, vascular)
• Poorly selected stoma location
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of • Failure of anastomosis (enteric and urinary)
Hope National Medical Center/Comprehensive Cancer Center, • Prolonged recovery delaying adjuvant treatment and
Duarte, CA, USA allowing tumor progression

https://doi.org/10.1007/978-3-030-81415-1_61
Operative Strategy der. Anterior exenteration spares the lower rectum while
resecting the upper rectum, bladder, and reproductive
Anesthesia and Patient Positioning organs. Depending on their tumor proximity or invasion,
the anal canal/pelvic floor or the sacrum may be included in
These complex operations require general anesthesia. In the resection.
addition, placement of an epidural catheter may facilitate The reconstruction phase establishes the elimination
the postoperative pain management. Place the patient in the routes for stool and urine and addresses appropriate defect
modified lithotomy position, which, in most cases, will closures. An end colostomy and urinary conduit with uros-
allow the procedure to be performed without repositioning. tomy are common and predictable options. Depending on the
Wide exposure is essential to the operation, especially extent of resection, the pelvic floor may be preserved such
when operating in a deep or narrow pelvis. If myocutane- that restoration of intestinal and/or urinary continuity could
ous flaps are planned, their tentative outline should be even be considered (coloanal anastomosis; neobladder). If an
marked on the skin. orthotopic neobladder is not possible, a continent cutaneous
urinary reservoir may be an alternative; this allows the
patient to intermittently catheterize the reservoir rather than
continuously wearing a urostomy bag. The benefits of any
Operative Phases desired continence-restoring procedure need to be weighed
against the risks of complications (e.g., anastomotic leaks),
Multivisceral resections such as pelvic exenteration can be unsatisfactory function, and the need for a subsequent sur-
broadly divided into three major steps: (1) exploration, (2) gery (ileostomy takedown). Depending on the size and radia-
resection, and (3) reconstruction. A thorough understanding tion changes, closure of the perineal and possibly sacral
of the pelvic anatomy and detailed surgical planning are wound may require the expertise of a plastic surgeon.
essential to a successful operation. Options include local tissue rearrangement, the vertical rec-
The exploration phase aims at reevaluating the situation tus abdominis myocutaneous flap (VRAM), gracilis flap,
in comparison with the evidence from imaging in order to omental flap, or free flaps.
determine whether there are any findings that would make
the planned resection inadvisable. Potentially curable metas-
tases are not necessarily a contraindication to a radical resec- Documentation Basics
tion of the primary location. In that sense, a small number of
lung and liver metastasis may be considered resectable. Coding for surgical procedures is complex. Consult the most
However, if during exploration there is evidence of unresect- recent edition of the AMA’s Current Procedural Terminology
able metastatic disease such as diffuse carcinomatosis, the book for details (see references at the end). In general, it is
procedure should be aborted or converted to a palliative important to document:
intervention (e.g., stoma creation, urostomy).
The resection phase starts with assessment of the local • Indication and reasoning for choice of intervention.
resectability. It should be noted though that this may not be • Identification of different teams and their role.
certain until the tumor is worked on. Surgery may reach its • Findings: Document a thorough abdominal exploration
limit if a tumor leaves the confinement of the pelvis (lateral including evaluation of nodal stations, peritoneum, omen-
pelvic sidewall, pubic bone, sacrum). Sacral invasion tum, and pelvic sidewalls.
should be anticipated from preoperative imaging and as • Resection and reconstruction details: Clearly describe the
such is not always a contraindication to resection—unless pattern of invasion and the rationale behind why each pel-
above the level of S2. However, extending the resection to vic organ was resected.
include bony structures adds substantial morbidity related • Estimated blood loss and fluid measurement after the case
to the additional wound, defect coverage, and a potential to facilitate resuscitation in the immediate postoperative
functional impact. Pelvic sidewall invasion remains a red period.
flag and often represents a contraindication to a resection.
However, as some of the lateral pelvic structures can be
sacrificed, the ultimate determination depends on the depth Operative Technique
and level of pelvic sidewall involvement. Based on the
extent of resection, total pelvic exenteration refers to resec- Incision and Exploration
tion of the rectosigmoid, bladder, distal ureters, and repro-
ductive organs. Posterior exenteration involves resection of First, make a midline incision from the pubic symphysis to
the rectum and reproductive organs while sparing the blad- the level of the umbilicus. Perform a preliminary assessment.
61 Multivisceral Resections (Pelvic Exenteration) 493
Extend the incision as needed. There may be adhesive dis- Pelvic Dissection
ease due to previous operations or to the tumor itself. Perform
adhesiolysis until the anatomy is clear and access to the tar- The general strategy is to pursue the dissection where safe
get secured. Explore the abdomen for hepatic, peritoneal, progress can be made. That may very well result in fre-
omental, and nodal metastases. If dense adhesions in prox- quently changing the target circumferentially in short
imity to the tumor cannot be distinguished from tumor itself, sequences. If a cephalad-to-caudad dissection appears diffi-
err on resecting the area en bloc with the specimen to avoid cult in one quadrant, it may become more evident, if the dis-
leaving tumor behind. Inspect the primary tumor but avoid section can be carried in the other quadrants beyond that
manipulating it at this stage. point such that a retrograde dissection can be pursued.
Bleeding has to be expected and sometimes will continue
inevitably until the tumor is removed. You will have to decide
eritoneal Incision and Identification
P whether to stop and pack, fix the bleeding, or accelerate the
of the Ureters dissection to remove the tumor.
Incise the peritoneum lateral to the sigmoid in the direction osterior Pelvic Dissection
P
of the bladder along the pelvic brim. Identify the left ureter The presacral vein plexus are a potential source of major
high and mark it with a vessel loop before following it as it hemorrhage that is difficult to control and may require pack-
crosses the iliac vessels and as far distal as possible. ing the pelvis and aborting the procedure. In first-time resec-
Preoperative placement of ureteral stents is often warranted tions, identify the dissection plane by following just posterior
in reoperative fields. They may be less relevant if the ureters to the superior rectal artery and leaving the hypogastric
will be resected anyway. Extend the peritoneal incision nerves posterior to it. In re-do surgery, that may be wishful
medial to the sigmoid across to the sacral promontory and thinking and the bleeding risk goes up as the planes may
along the pelvic brim to right edge of the bladder. Inspect the have been distorted by surgery, radiation, or recurrent tumor.
retroperitoneum in the area of the aortic bifurcation for aor- If a plane is found, continue the dissection as distally as pos-
tocaval lymph node involvement, which would be a contrain- sible. If not, concentrate on the anterior and lateral pelvic
dication to further resection. Dissect and isolate the right dissection first.
ureter in similar fashion, starting high, marking it with a ves-
sel loop, and following it across the iliac vessels towards the ateral Pelvic Sidewall Dissection
L
pelvis. Begin the pelvic sidewall dissection at the previously incised
peritoneum along the edge of the psoas. Reflect the endopel-
vic fascia medially and dissect this layer off of the pelvic
Ligation of the Inferior Mesenteric Artery sidewall. Follow the iliac vessels to the bifurcation. Carefully
continue the dissection in this plane over the common and
Identify the inferior mesenteric artery (IMA) or what might external iliac vessels.
have been left after a previous resection and trace its course In females, identify the ovarian vessels as they cross over
to the run-off from the aorta. Identify the level where the the external iliac. Doubly clamp and ligate or clip relevant
bowel would have to be divided proximally (which could in vascular structures. Identify the round ligaments, the uterine
some cases be at a previously created colostomy). vessels within the cardinal ligament in females.
Successively divide the mesentery in the direction of the ori- In males, identify and preserve the testicular vessels as
gin of the IMA by means of sequential ligations or an they course lateral to the external iliac vessels. Identify,
advanced energy device. Doubly clamp and divide the IMA ligate, and divide the vas deferens near the deep ring. Dissect
using Kelly clamps, preserving the left colic branch if pos- the fascia off the obturator internus. Identify and protect the
sible. Suture ligate both ends. obturator nerve and artery as they pass through the obturator
canal. There is often a bed of lymphatic tissue in this area,
which should be included with the specimen.
Proximal Division of the Sigmoid Colon In select cases, there is a need for a systematic lateral pel-
vic lymph node dissection. Have a clear understanding of the
Complete the mobilization of the left-sided colon to the structures to be encountered that you need to preserve:
(neo-)rectum by incising along the Line of Toldt to the genito-fermoral nerve (lateral), ureter, common internal iliac
splenic flexure. Create a window through an avascular por- artery bifurcation (proximal), circumflex caudal iliac vein
tion of the sigmoid mesentery at a level that ensures a clear (distal), internal iliac vessels (umbilical artery and its supe-
proximal margin. Insert a linear cutting stapler into this win- rior cystic artery branch, obturator artery), obturator nerve
dow and divide the bowel. and obturator fossa (posterior).
Anterior Dissection
Extend the anterior peritoneal incisions along the abdominal
wall over the dome of the bladder. Leaving the urachus on
the bladder gives you a nice handle for traction. Follow it and
free the bladder from pubic bone. Take care to preserve the
inferior epigastric vessels as they course along the abdomi-
nal wall as they are frequently utilized in the reconstructive
phase of the operation. The vesical venous complex in this
area is a potential source of hemorrhage and is difficult to
control. The best approach to avoid this complication is to
stay in the plane adjacent to the pubic periosteum anteriorly
and along the obturator internus laterally. As the anterior
plane develops, the lateral ligaments of the bladder contain-
ing the vesical vessels will become apparent. Identify the
ureters at the level of these vascular pedicles. Divide the ure-
ters as distal as the tumor allows. Continuously clip or d oubly
clamp, divide, and suture ligate the lateral ligaments of the
bladder. At this point, the bladder is suspended anteriorly by
the dorsal venous complex and the puboprostatic ligament
(pubovesical ligament in females). Divide the fascia on
either side of the venous complex and then use a 0-vicryl to
ligate the dorsal venous complex.
Distal Transection Versus Abdomino-Perineal

Resection
If there is no indication that the pelvic floor is involved and
an adequate margin can be obtained, the remainder of the Fig. 61.1
resection may be completed from the abdominal incision.
Continue the dissection in the space of Retzius until the ure-
thra is identified. Divide the urethra sharply and any remain- and divide it with the energy device until the specimen is
ing attachments of the prostate or bladder. Divide the Foley completely free and can be delivered from the pelvis.
catheter and deliver it into the abdominal field to be used as
a means of retraction. Continue the dissection posteriorly. As
dividing the vagina may often cause significant oozing, an arvest of VRAM Flap and Abdominal Wall
H
advanced energy device may be useful for that step. Mobilize Reconstruction
the distal rectum just above the levator ani using a curved
transverse cutting stapler. Complete the circumferential dis- If there is a need to transpose a myocutaneous flap to the
section and remove the specimen. Close the vaginal cuff with perineal or sacral area, it will have to be harvested prior to
a 0 absorbable suture in a continuous fashion. placing the urostomy or colostomy/ileostomy (Fig. 61.2).
If the pelvic floor is tumor-involved, a perineal resection That part of the procedure is typically carried out by the plas-
is required. For most situations, that can be achieved with the tic reconstructive surgeon on the team. It should be noted
patient in lithotomy position. This has the benefit that the that the preoperative stoma markings are subject to change as
entire procedure including a possible flap reconstruction can the abdominal wall is reshaped.
be carried out without repositioning. Only rarely, however,
repositioning is necessary in order to achieve a proper resec-
tion of extensive perineal disease. Urinary Reconstruction
In males, make an elliptical incision extending from the
coccyx to the base of the scrotum. In females, the anterior Urinary diversion versus reconstruction can be done in a
boarder of the incision should include the vaginal opening variety of forms and are typically carried out by the urolo-
and urethra (Fig. 61.1). Use an advanced energy device to gist on the team. Most commonly, a urinary conduit with
limit bleeding when dissecting through the ischioanal space. a urostomy is created. For that purpose, a 15 cm segment
Extend the dissection posterior and divide the anococcygeal of ileum is isolated, and the small bowel continuity
ligament. Use your nondominant index finger as a guide to restored with a functional end-to-end anastomosis. Both
load the levator ani just in appropriate steps on your finger ureters are implanted to its proximal end of the conduit;
61 Multivisceral Resections (Pelvic Exenteration) 495
Fig. 61.2
the distal end is guided through an opening created at the omentum is of useful volume, it can be mobilized and
marking in the abdominal wall where it is eventually placed to the pelvis where it is secured with a few absorb-
matured. Typically, the urostomy is placed on the right able stitches. The perineal wound can be closed primarily if
side, unless the intestinal stoma needs to be a right-sided it is small. Major defects, however, are better served by
transverse colostomy rather than an ileostomy or end planning in advance a tissue transposition such as a VRAM
colostomy. flap, gluteal advancement flaps, or gracilis flap. Free flaps
Alternatives include creation of an orthotopic neobladder are not recommended.
if the pelvic floor could be preserved, or of a continent cuta- Close the midline fascia using 0 polydioxanone (PDS) in
neous urinary reservoir with a catheterizable stoma at the a running fashion from both the inferior and superior edges
umbilicus. For the latter, the right colon may have to be used. of the incision, reinforced with intermittent Vicryl sutures.
In carrying out its mobilization, it is crucial to maintain a Close the skin and subcutaneous tissue in multiple layers
blood supply to the remaining left-sided colon that likely using absorbable sutures. Mature the stomas after that.
depends of the mid colic artery.
Postoperative Care
Creation of Intestinal Stoma
• In the operating room, apply an adhesive-type transparent
If it was possible to restore intestinal continuity, create a stoma bag(s).
diverting ileostomy proximal to where the conduit had been • Antibiotics: Routine coverage for the perioperative
isolated. Alternatively, a right-sided transverse colostomy 24-hour period. In case of an underlying infection/sepsis,
may be appropriate with the advantage of a lesser impact on continue respective therapeutic antibiotics for that
fluid and electrolyte balance. If an abdomino-perineal resec- indication.
tion was necessary, create an end colostomy. Create a gap at • Diet: ERAS protocol.
the marked site, and create the stoma as outlined in Chaps. • Intravenous fluids: Maintain adequate fluid until return of
65 and 66, whereby maturing the stoma waits until all inci- bowel function.
sions otherwise are closed. • Unless for specific reasons, remove gastric tube at the end
of surgery and start diet after a few hours as tolerated.
• Stoma: Start early stoma teaching to avoid delaying dis-
Wound Closure and Reconstruction charge. Leave the bridge between 2 and 3 weeks to allow
for a good connection between the bowel and the abdomi-
The perineal wound is a potential source of serious morbid- nal wall.
ity after pelvic exenteration. Contributing factors are the • Plan for adjuvant chemotherapy after 4–6 weeks if appro-
size of the wound and the impact of radiation. It is always priate recovery.
helpful if the excess space in the pelvis can be filled. If the
Complications Brown KGM, Solomon MJ, et al. Pelvic exenteration surgery: the evo-
lution of radical surgical techniques for advanced and recurrent pel-
vic malignancy. Dis Colon Rectum. 2017a;60(7):745–54.
• Early postoperative complications: prolonged postopera- Brown WE, Koh CE, et al. Validation of MRI and surgical decision
tive ileus, leaks or stenosis of both the enteric and urinary making to predict a complete resection in pelvic exenteration for
reconstruction, deep vein thrombosis and pulmonary recurrent rectal cancer. Dis Colon Rectum. 2017b;60(2):144–51.
embolus, infection, dehiscence and flap necrosis, stoma 2009. Retrieved November 14, 2022, from https://accesssurgery.
complications mhmedical.com/book.aspx?bookID=425.
• Late complications: adhesive disease, small bowel Koh CE, Solomon MJ, et al. The evolution of pelvic exenteration prac-
obstructions, hernia formation, recurrent cancer, entero- tice at a single center: lessons learned from over 500 cases. Dis
Colon Rectum. 2017;60(6):627–35.
pelvic fistulization, pelvic lymphocele formation with Quyn AJ, Solomon MJ, et al. Palliative pelvic exenteration: clinical out-
chronic infection comes and quality of life. Dis Colon Rectum. 2016;59(11):1005–10.
Radwan RW, Jones HG, et al. Determinants of survival follow-
ing pelvic exenteration for primary rectal cancer. Br J Surg.
2015;102(10):1278–84.
Rausa E, Kelly ME, et al. A systematic review examining quality of
Further Reading life following pelvic exenteration for locally advanced and recurrent
rectal cancer. Color Dis. 2017;19(5):430–6.
American Medical Association. Current procedural terminology: CPT Sasikumar A, Bhan C, et al. Systematic review of pelvic exentera-
®. Professional ed. Chicago: American Medical Association; 2022. tion with en bloc sacrectomy for recurrent rectal adenocarcinoma:
https://www.ama-assn.org/practice-management/cpt. R0 resection predicts disease-free survival. Dis Colon Rectum.
Bhangu A, Ali SM, et al. Indications and outcome of pelvic exentera- 2017;60(3):346–52.
tion for locally advanced primary and recurrent rectal cancer. Ann Simillis C, Baird DL, et al. A systematic review to assess resection mar-
Surg. 2014;259(2):315–22. gin status after abdominoperineal excision and pelvic exenteration
for rectal cancer. Ann Surg. 2017;265(2):291–9.
(Sub-)Total Colectomy with Ileostomy
or Ileo-Rectal Anastomosis (Open, 62
Laparoscopic)
Kyle G. Cologne, Theodor Asgeirsson,

Indications • Slow-transit constipation (colonic inertia)

• Chronic treatment-refractory Crohn colitis (without rele-
Emergency vant rectal or perianal pathology)
• Severe/fulminant/toxic colitis regardless of the specific A (sub-)total abdominal colectomy involves resection of
etiology (idiopathic, infectious, ischemic, etc.) the entire or the majority of the intra-abdominal colon. Under
• Colitis with perforation optimal elective circumstances and when the residual col-
• Massive lower gastrointestinal bleeding of unknown orectum is to be preserved, the terminal ileum may be anas-
origin tomosed to the distal sigmoid or rectum. In emergency
• Obstructing left-sided tumor with complete large bowel situations or as first part of a three-stage proctocolectomy, an
obstruction and compromised integrity of the proximal ileostomy is created. The decision about immediate or future
colon restoration of continuity, timing, a staged approach, and the
platform (open versus minimally invasive) may vary depend-
ing on the disease and treatment specifics. If the creation of
Staged an ileal pouch-anal anastomosis is the ultimate goal, the
most complicated part of the proctectomy and pouch forma-
• Staged procedure for ulcerative colitis (with plan for sub- tion should be done under more optimal circumstances.
sequent proctectomy and ileal pouch)
Elective
All
• Adenomatous polyposis coli with rectal sparing (e.g.,
attenuated FAP) • Review the patient’s history, underlying diagnosis (includ-
• Lynch syndrome, serrated polyposis, etc. ing genetics where applicable), functional aspects, and
• Multicentric neoplasms, not appropriate for endoscopic appropriate indication for surgery (based on endoscopic,
management clinical, or radiographic means) as opposed to endoscopic
or nonsurgical management.
K. G. Cologne • Antibiotic prophylaxis (versus treatment).
Elective
T. Asgeirsson
Department of Colorectal Surgery, West Michigan Surgical
Specialists, Greenville, MI, USA • Mechanical bowel preparation
• Discussion and marking of possible ostomy sites
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of • In case of inflammatory bowel disease: small bowel eval-
Hope National Medical Center/Comprehensive Cancer Center, uation (MRI enterography, capsule, endoscopy, etc.)
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_62
• Reevaluation of the rectum (rigid/flexible sigmoidoscopy) a subsequent low pelvic anastomosis very difficult if not
to rule out a rectal cancer or to document disease involve- impossible due to the loss of domain within the deep pelvis.
ment and the degree of inflammation
• Stoma marking
Surgical Approach
Emergency Traditionally, colorectal surgery was approached and

described as open surgery, for example, through a midline
• Weigh prognosis with versus without surgery in light of incision. This remains the preferred access under emergency
the known or suspected diagnosis, hemodynamic and conditions because it can be extended as needed and allows
functional aspects. for the fastest possible completion of the surgery.
• Swift resuscitation and—if indication confirmed—timely Under elective circumstances, alternative incisions (e.g.,
proceeding to surgery before window of opportunity Pfannenstiel incision) are possible in selected patients. More
closes. importantly, however, minimally invasive approaches (lapa-
roscopic, hand-assisted laparoscopic, or robotic surgery)
have dramatically evolved and in many circumstances are
Pitfalls and Danger Points considered valid options. Safe surgery and sufficient access
to handle the bowel gently (see below) always carry a higher
• Poor patient selection and definition of immediate and priority than the type of approach. If a minimally invasive
long-term anatomical and functional goals. approach is chosen, the surgeon should have a good concept
• Mortality in emergency situations is less related to the of the various steps and among other considerations define
surgery as such but to a delayed decision for surgery. beforehand how to handle (a) the transection of the terminal
• Underestimation of the patient’s illness, including hemo- ileum, (b) the level of the distal transection (sigmoid versus
dynamic instability, sepsis, deconditioning, malnutrition, rectum), (c) the extraction of the specimen, and (d) the anas-
high-dose immunosuppression, or morbid obesity. tomosis versus ileostomy creation. The extraction can be
• Operative contamination of the peritoneal cavity with achieved through the designated ileostomy site or through a
colonic contents, leading to sepsis (with toxic separate incision, for example, at the umbilicus or in supra-
megacolon). pubic location.
• Improper construction of ileostomy or anastomosis.
• Anastomotic leak.
• Rectal stump blowout. Bowel Manipulation
The colon in cases of severe colitis and toxic megacolon may

Operative Strategy have the consistency of wet tissue paper and can be ruptured
by even minimal manipulation, causing massive and poten-
General tially fatal contamination of the abdominal cavity. Attempts
to dissect the omentum off the transverse colon may unseal a
When choosing an emergency operation for a patient with perforation. Controlled intraoperative tube decompression
local or systemic complications of their disease (hemor- (e.g., using a large chest tube) of a distended colon may
rhage, perforation, toxic megacolon, sepsis, systemic inflam- decrease the risk of perforation. In Crohn’s disease, one
matory response syndrome (SIRS), etc.), it is important to often finds a fistula to the adjacent bowel or to the skin. Toxic
act swiftly and to strike a balance between source control for megacolon may result in areas of perforation. In some cases,
the immediate problem (see Chaps. 7 and 8), while consider- paracolic abscesses are encountered, making gross contami-
ing the long-term options. This typically translates to a total nation of the peritoneal cavity inevitable.
abdominal colectomy and creation of an end ileostomy. If
they survive and recover, most of these patients are eventu-
ally candidates for restoration of continuity with an ileo- Extent and Steps of the Resection
rectal anastomosis or a sphincter-sparing completion
proctectomy and ileal pouch-anal anastomosis (see Chap. The goal of the operation is to remove the entire colon but to
63). Whenever possible, the pelvic dissection should be per- leave the rectum and the pelvic planes untouched. The length
formed at a later date as a complete proctocolectomy and of the ileum should be preserved as much as possible. The
ileostomy without an immediate restorative procedure make ileum is transected just proximal to the ileocecal valve (e.g.,
62 (Sub-)Total Colectomy with Ileostomy or Ileo-Rectal Anastomosis (Open, Laparoscopic) 499
at the fat pad of Treeves) to preserve the absorptive functions • Blood vessels taken
of the distal ileum. • In case of anastomosis: type and level, leak test
The steps of the colon mobilization and resection follow • Stoma creation
those outlined in the previous chapters for each segment. If
there is a known cancer, a high probability of a cancer, or if
that aspect is not fully known, the respective segment dissec- Operative Technique
tion or even the entire mobilization should follow the
described oncological principles, and the pathologist should Positioning
sample the lymph nodes separately for the different seg-
ments. In contrast, if the resection is not for cancer, there is If you do not intend to perform an anastomosis (emergency
no need for a minimum lymph node harvest; and if the dis- setting or first stage of three-stage IPAA), you may in the
section follows the bowel wall more closely in some seg- interest of time and ease place the patient in supine position
ments, the risk of bleeding or a negative functional impact as it is the fastest and allows you to complete the abdominal
may be somewhat reduced. dissection and ileostomy creation. You may, however, in the
The sequence of steps can be individualized. The diffi- end want to get access to the anus to irrigate the rectum and
culty of the complex multistep surgery depends on the nature place a large drain for the first 3–5 days to reduce the risk of
of the disease, the degree of colon distention and the stool a rectal stump blowout.
load, or presence of a perforation. Under clean circum- In elective settings, when you (regardless of the approach)
stances, the safe mobilization and resection of the transverse plan to restore intestinal continuity with an ileo-rectal or
colon and the splenic flexure mobilization pose the biggest ileo-sigmoid anastomosis, access to the anus is desirable
challenge. In absence of cancer in the respective segments, throughout the case. Hence, place and secure the patient in
the omentum can be preserved, but it may be faster to divide modified lithotomy on an anti-sliding system that allows for
the gastrocolic ligament and resect the omentum to liberate dynamic repositioning during the case. Make sure that the
and preserve it. perineum is at the table end to allow for access to the anus,
and that the hips can vary from flat (0°) to high lithotomy
(90°). Preferably tuck both arms to allow best access.
Anastomosis Versus Ileostomy For all cases, place a urinary catheter to decompress the
bladder and monitor intraoperative urine output. Prep and
An ileo-rectal or ileo-sigmoid anastomosis should only be drape the patient from nipple line to mid thighs. In elective
done in elective situations when the goal is to preserve the cases in modified lithotomy, include the perineal area and in
rest of the rectum or rectosigmoid. It is generally discour- females the vagina. Monitors for laparoscopic surgery should
aged to perform an anastomosis and divert it with a loop be placed such that surgeon, target, and monitor form one
ileostomy. Under less than perfect or emergency circum- line.
stances or if the distal large intestine is affected by disease
and eventually needs to be removed, an anastomosis should
be avoided, and an end ileostomy created instead. Minimize Operative Approach and Incisions
postoperative ileostomy problems by constructing a viable
ileostomy nipple that protrudes from the abdominal wall for Open Approach
at least 2 cm. The residual rectum or rectosigmoid is best left For an open approach, make a midline incision centered
as a blind ending stump, or occasionally brought out as a around the umbilicus, typically with left circumvention
mucous fistula. thereof. Start out with 12–15 cm, but in emergency situa-
tions, do not struggle with exposure through a small incision;
if the initial incision does not allow for sufficient exposure
Documentation Basics particularly when the bowels are very distended, extend the
incision further into the epigastrium and/or toward the pubic
Coding for surgical procedures is complex. Consult the most bone. Maintain exposure with handheld or self-retaining
recent edition of the AMA’s Current Procedural Terminology retractors. Also consider using a large wound protector to
book for details (see references at the end). In general, it is avoid subcutaneous tissue contamination if limited areas of
important to document: perforation or abscess exist.
• Findings and indication inimally Invasive Surgery

M
• Reasoning for choice and extent of surgical approach For minimally invasive platforms, different surgeons employ
• Surgical approach slightly different layouts of their port placement. Safely
insert the first 10–12 mm trocar at the umbilicus. Decide advance it across the ileocecal valve into the cecum. After
based on the past history whether to use a Hasson or the decompressing the colon, remove the tube and tie the purse-
Veress needle technique. Establish the pneumoperitoneum string suture.
and insert the camera. Insert the subsequent 3–4 working
ports under visual control, typically in a trapezoid or rhom-
boid configuration that allow for triangulation toward all Mobilization and Resection
quadrants. For the latter, place a total of four ports to provide
good working access, two on the right and two on the left. Total Colectomy
The ports should be placed approximately 2 cm from the Perform the complete mobilization of the colon from the
anterior superior iliac spine and one handbreadth cephalad to ileocecal junction to the sigmoid colon (Fig. 62.1). The indi-
this, and modified to be slightly more medial in obese vidual open or laparoscopic steps have been described in the
patients. For stapler insertion, you will need at least one chapters for the right hemicolectomy (Chap. 56) and the left
12 mm port, the rest can be 5 mm. Even though the right hemicolectomy and sigmoid resection (Chap. 57). In sum-
lower quadrant port could be placed at the planned ileostomy mary, the steps that you need to perform include the mobili-
site, there is often an insufficient distance to the camera zation of the entire colon from its retroperitoneal attachments,
resulting in a bit more of a struggle; a separate port has little which you can do in medial to lateral or in lateral to medial
morbidity and substantially improves your maneuverability. fashion (Figs. 62.2 and 62.3). When mobilizing both flex-
For specimen extraction and to insert a stapler anvil for the ures, stay close to the colon. Last but not least, you have to
anastomosis, you can either expand one of the port sites (e.g., divide the vascular supply to the colon which can focus on
left lower quadrant) or perform a separate access in a differ- the main pedicles, or in benign disease could also follow the
ent location (e.g., Pfannenstiel incision or at the site for the bowel wall.
ileostomy). Always place a wound protector before remov-
ing the specimen through it to limit the risk of surgical site
infection.
Exploration
Once you gained safe entry into the abdomen (regardless of

the platform), explore the abdomen and look for signs of (1)
disease complications, (2) related disease manifestations,
and (3) unrelated coexisting pathology. Perform and docu-
ment a thorough examination of all quadrants in regards to
perforation with contamination, tumor, small bowel disease,
liver pathology, or any other finding that could change your
decision to proceed or be relevant for the management and/
or outcome.
Evacuation of Stool
In an emergency operation with severe colon distention

(toxic megacolon, large bowel obstruction, etc.), there is a
high risk of rupturing the bowel during the necessary manip-
ulation. It is often easier and safer to manipulate a non-
dilated colon. In order to carry out a controlled decompression
of air and liquid stool from within the colon, insert a purse-
string suture on the anterior surface of the terminal ileum or
in an area of the ascending colon through a tinea. Using scis-
sors, make a small enterotomy in the center of the purse-
string suture. Never use the cautery for this step as there may
be combustive gas within the colon. Insert a large catheter
such as a chest tube or Poole-tip sucker through it and Fig. 62.1
Fig. 62.2
In an open approach, transect the ileum within 1–2 cm of

the ileocecal valve (Fig. 62.1). If the case is done laparo-
scopically, it may be advantageous to leave the ileum con- Fig. 62.3
nected until the entire specimen is exteriorized.
As previously mentioned, in benign disease you can
preserve the omentum (Fig. 62.4). In emergency cases,
however, when the colon wall is paper-thin, make no
attempt to do so and as dissecting the omentum off the
Omentum
transverse colon may unseal a perforation. Specifically in
that situation, rather than dissecting it off the transverse Appendices
colon, divide the gastrocolic ligament along the transverse epiploicae
colon using an advanced energy device. Remove the omen- Colon
tum as part of the specimen. Move the mobilization and
devascularization further until the descending colon is
completely free.
Distal Bowel Transection

At the rectosigmoid junction, the approach varies depending Fig. 62.4
on the specific circumstances and goals. Most commonly,
you should plan on performing a bowel transection at the In regards to the vascular pedicle of the inferior mesen-
pelvic entry without leaving behind too much colon length teric artery (IMA), you will have to decide whether to in fact
above the coalescence of the tenia. The two—relatively divide it as for a regular sigmoid resection, or whether you
rare—exceptions are when you perform the surgery for want to intentionally leave the superior hemorrhoidal arcade
colonic inertia with slow-transit constipation or when you in place. When you perform the surgery for a malignant
plan to leave sufficient length to allow for creation of a tumor or severe bleeding, you have to address the IMA ped-
mucous fistula. In those situations, it may be desirable to icle in an oncologically appropriate fashion and resect it. In
leave a bit of the sigmoid colon in place. other circumstances, particularly when you plan a comple-
tion proctectomy in the future, it may be easier to get into the complex, as you could otherwise tear the wall of the rectal
correct presacral plane when the pedicle is still in place. stump. If necessary, gently dilate the sphincter complex with
two fingers to accommodate the stapler head. Once the sta-
pler body nicely sits in the rectal stump underneath the staple
Anastomosis Versus Ileostomy line, advance the spike under direct vision to come through
just posterior to it. Connect the anvil to the spear with an
I leo-Rectal (Ileo-Sigmoid) Anastomosis “audible click.” Close the stapler and continuously monitor
Although this anastomosis could be hand-sewn (Chap. 42), it that no other structures are caught in the stapler. Finally,
is overwhelmingly done as a stapled anastomosis or not done check the orientation of the bowel to ensure the cut edge of
at all. You can typically carry out a stapled anastomosis in the ileal mesentery is straight and not twisted. Fire the stapler
three different ways: true end-to-end, functional end-to-end and check the donuts for completeness. Perform an air-leak
(side-to-side), or a side-to-end fashion (Baker technique). test of the anastomosis: fill the pelvis with water and sub-
Keep in mind that under adverse circumstances or when the merge the anastomosis while gently compressing with two
result of an attempted anastomosis is less than perfect, rather fingers the bowel proximal to the anastomosis. Insert a rigid
avoid or take down the anastomosis and create an end ileos- or flexible sigmoidoscope from the anus and insufflate air. In
tomy than to divert a suboptimal anastomosis. the event that you see any air bubbles, perform troubleshoot-
ing with oversewing or redoing the anastomosis, unless you
Side-to-side If you plan on leaving some of the sigmoid to elect to take it down completely.
perform an ileo-sigmoid anastomosis, you can do this in a
side-to-side fashion which does not require access to the
anus for the stapler insertion. Rotate the small bowel in Side-to-end The EEA anvil, equipped with the detachable
counter-clock direction such that it aligns with the sigmoid spear, can also be inserted in opposite direction through the
colon in a natural fashion. Perform the anastomosis as open end of the ileum. Push the spear through the lateral
described for the right hemicolectomy (Chap. 56). Create a bowel wall about 2 cm from the open end. Staple off the open
small enterotomy in each of the aligned bowel ends, insert a end of the bowel, ensuring enough length so that the circular
linear stapler, and create the side-to-side connection. Remove and linear staple lines will not intersect. Continue with the
the stapler, grasp the open at the end with Allis clamps, and stapled EEA anastomosis as described above.
fire a second linear stapler across to close the enterotomies.
You may decide to oversew the staple lines with absorbable End Ileostomy
sutures. If an anastomosis is not possible, create an end ileostomy (see
details in Chap. 50). In elective situations, a preoperative
stoma marking provides guidance for a good stoma location.
End-to-end Particularly if you do a true ileo-rectal anasto- In emergency situations, however, the marking may either be
mosis, a side-to-side connection as described above is not impossible due to the patient’s condition, or it is unreliable
only unpractical, but is strongly discouraged. Instead, carry when the abdominal shape is expected to substantially change
out the anastomosis as was described for a rectosigmoid postoperatively, for example, after resection of a megacolon.
resection (Chaps. 56 and 57). You try to use a 29-mm anvil, In that situation, you will have to use an “educated guess”
but if the small bowel is very tiny, you might have to use a based on the patient’s overall habitus to define an acceptable
25-mm anvil or perform a Baker side-to-end anastomosis location. Create a gap (trephine) in the abdominal wall and
(see below). Place two Allis clamps to the edge of the open pull the end of the ileum through, making sure to not compro-
proximal bowel end and insert a purse-string suture using an mise its blood supply. Secure the bowel to the fascia and/or
“outside-in” monofilament suture. Make sure with each dermis. But wait with maturing the ileostomy until the
stitch to grab a full-thickness bite from 3 to 5 mm on the abdominal incisions have been closed. Aim at creating at least
outside to the mucosal edge on the inside. Travel with each a 2 cm symmetric nipple to prevent skin breakdown (see
stitch about 5 mm until you are completely around and Chap. 50). Take care with this stoma; it is quite possible that
reverse the direction of the last stitch to “inside-out.” The gastrointestinal continuity will never be restored.
bowel edge has a tendency to evert itself and create addi-
tional tissue that can get caught up in the stapler line and I leostomy and Mucous Fistula
create an incomplete donut. Insert the anvil into the proximal In acute cases, when an anastomosis is not advised, the best
end and tie down the purse string. Insert the stapler through and most common approach is to perform the distal transec-
the anus and gently advance it to the end of the rectal stump. tion at the pelvic entry and create a proximal ileostomy. If
Be careful to do this in a very controlled fashion and to avoid appropriately managed, for example, also including a tempo-
using too much force to overcome the often tight sphincter rary rectal tube, the risk of a rectal stump blowout is fairly
low. If you have substantial concern about the tissue quality, of bowel function; in emergency cases, individualize the
it may on fairly rare occasions be preferable that you leave management.
a bit more of the distal bowel and bring it out as a mucous • Nutritional support: In case of severe malnutrition or if
fistula through a separate site. Do not incorporate it into the return of bowel function delayed by more than 5 days, ini-
most caudad portion of the midline incision (as was done tiate parenteral nutrition.
commonly in the past). The management is always d ifficult, • Monitor ileostomy output and initiate appropriate hydra-
and the poor-quality bowel has a high incidence of triggering tion measures if output is >1200–1500 mL per 24 hours.
surgical site infections. Ensure adequate home health is set up for ostomy
supplies.
• Immunosuppression: Stop all nonsteroid immunosup-
Drains pressive medications immediately, plan a slow steroid
taper over the following several weeks.
In elective cases, routine drains are not necessary. In emer- • A subsequent surgery can be considered after a minimum
gency situations, however, you have to individualize the of 3–6 months, if the patient has completely recovered
placement of abdominal drains depending on the extent of and normalized all nutritional or physical handicaps, if
contamination of the surgical field. there are no other treatments that have priority, and if all
Beyond abdominal drains, it may be advisable to irrigate immunosuppressants including prednisone have been
the blind rectal stump and to place a large diameter drain to tapered off.
reduce the risk of a rectal stump blowout. A shortened chest • If the rectum has been left in place, continue monitoring
tube is well suited and can be secured to the anal verge with it appropriately.
1–2 absorbable drain stitches. After 5 days, the drain can be
removed.
Complications
Wound Closure • Collateral organ injury (duodenum, spleen, pancreas,

small bowel).
Make sure that all loops of bowel lie naturally in the abdo- • Surgical site infection: Intra-abdominal abscess forma-
men, without twisting. Verify hemostasis. Remove the ports tion is more common after emergency resections, whereby
and/or retractors. The operating team should discard soiled immunosuppression, contamination, malnutrition, and
gloves and use new instruments to close the surgical wounds. low performance status increase the risks.
Close the fascia of any incision larger than 5 mm in routine • Anastomotic leak or rectal stump blowout: Act swiftly to
fashion. Irrigate the wound before closing the skin. determine the cause; a CT scan with rectal contrast is
If an ileostomy has been planned, mature it after all skin typically diagnostic. In case of a major leak, perform an
has been closed (see Chap. 50). immediate reexploration with takedown of the anastomo-
sis and creation of an end ileostomy; in less acute situa-
tions, image-guided drain placement may be appropriate.
Postoperative Care • Anastomotic bleeding.
• Incisional, port-site, or internal hernia formation.
24-hour period. In case of significant contamination or an
underlying infection/sepsis, continue respective therapeu-
tic antibiotics for that indication. Further Reading
• Incentive spirometry and early ambulation should be
encouraged. Alves-Ferreira PC, de Campos-Lobato LF, et al. Total abdominal
colectomy has a similar short-term outcome profile regardless of
• Nasogastric tube: No routine use in elective cases; in indication: data from the National Surgical Quality Improvement
emergency cases, continue NGT until return of bowel Program. Am Surg. 2011;77(12):1613–8.
function. American Medical Association. Current procedural terminology: CPT
• Intravenous fluids: Maintain adequate fluid until return of ®. Professional ed. Chicago: American Medical Association; 2022.
bowel function. Fichera A, Zoccali M, et al. Total abdominal colectomy for refractory
• Enhanced recovery after surgery (ERAS) protocol: In ulcerative colitis. Surgical treatment in evolution. J Gastrointest
elective cases, initiate oral intake on the day of surgery Surg. 2011;15(11):1909–16.
and advance to solid food as patient demonstrates return Gu J, Stocchi L, et al. Factors associated with postoperative mor-
bidity, reoperation and readmission rates after laparoscopic total
abdominal colectomy for ulcerative colitis. Color Dis. 2013;15(9): Renkonen-Sinisalo L, Seppala TT, et al. Subtotal colectomy for colon
1123–9. cancer reduces the need for subsequent surgery in lynch syndrome.
Gu J, Stocchi L, et al. Total abdominal colectomy vs. restorative total Dis Colon Rectum. 2017;60(8):792–9.
proctocolectomy as the initial approach to medically refractory Riss S, Herbst F, et al. Postoperative course and long term follow up
ulcerative colitis. Int J Color Dis. 2017;32(8):1215–22. after colectomy for slow transit constipation – is surgery an appro-
Kaiser AM, Hogen R, et al. Clostridium difficile infection from a surgi- priate approach? Color Dis. 2009;11(3):302–7.
cal perspective. J Gastrointest Surg. 2015;19(7):1363–77. Strate LL, Gralnek IM. ACG clinical guideline: management of patients
Li Y, Stocchi L, et al. Long-term outcomes of sphincter-saving pro- with acute lower gastrointestinal bleeding. Am J Gastroenterol.
cedures for diffuse Crohn’s disease of the large bowel. Dis Colon 2016;111(4):459–74.
Rectum. 2016;59(12):1183–90.
Moghadamyeghaneh Z, Hanna MH, et al. Comparison of open, laparo-
scopic, and robotic approaches for total abdominal colectomy. Surg
Endosc. 2016;30(7):2792–8.
Proctocolectomy with Ileal Pouch-Anal
Anastomosis (IPAA) or End Ileostomy 63
(Open, Laparoscopic)
Kyle G. Cologne, Anthony J. Senagore,

complex surgery requires expertise as it entails the removal

Indications for Proctocolectomy of the entire colon and rectum, followed either by (1) a con-
tinence restoration with creation of an ileoanal pouch-anal
• Chronic ulcerative colitis (treatment-refractoriness, (pre-) anastomosis (IPAA, restorative proctocolectomy) or (2) cre-
malignant transformation) ation of an ileostomy. The decision about the approach (open
• Chronic treatment-refractory Crohn colitis (with/without versus minimally invasive), continence restoration, timing,
perianal manifestations) and staging (single, two-, or three-stage) may vary depend-
• Adenomatous polyposis coli (familial adenomatous pol- ing on the disease and treatment specifics. The most compli-
yposis, FAP; MYH-associated polyposis, MAP) cated part of the proctectomy and pouch creation should be
• Possibly other hereditary or polyposis syndromes (Lynch, reserved to be performed under optimal conditions.
serrated polyposis, etc.)
• Multicentric neoplasms, not appropriate for endoscopic
management Preoperative Preparation
• Review the patient’s history, underlying diagnosis (includ-

Contraindications for Pouch Creation ing genetics where applicable), functional aspects, and
appropriate indication for surgery (based on endoscopic,
• Crohn’s disease with small bowel involvement or perianal clinical, or radiographic means) as opposed to endoscopic
fistulas or nonsurgical management.
• Distal rectal cancer (oncologically not allowing for • In case of inflammatory bowel disease: small bowel eval-
sphincter preservation) uation (MRI enterography, capsule, endoscopy, etc.).
• Pelvic and anorectal fibrosis and stricturing • Reevaluation of the rectum (rigid/flexible sigmoidoscopy)
• Poor sphincter function to rule out a rectal cancer.
• In case of known cancer: accurate systemic and local
A complete or staged proctocolectomy is the surgical tumor staging; preoperative (neoadjuvant) radiation and
treatment for treatment-refractory colitis (ulcerative colitis, chemotherapy for all rectal cancers to avoid radiating the
Crohn colitis), polyposis coli (FAP, MAP), and other heredi- radiation-sensitive ileal pouch.
tary or multicentric advanced neoplasias or cancers. The • Multidisciplinary evaluation and discussion (particularly
important invasive cancers or inflammatory bowel
disease).
K. G. Cologne
• In patients on chemotherapy or immunosuppressants, or
Department of Surgery, Division of Colorectal Surgery|, Keck
School of Medicine of the University of Southern California, after radiation: plan for optimal timing and possible stag-
Los Angeles, CA, USA ing of surgery.
A. J. Senagore • Nutritional assessment and optimization.
Kalamazoo, MI, USA • Discussion and marking of possible ostomy sites.
A. M. Kaiser (*) • Mechanical bowel preparation (except for completion
Department of Surgery, Division of Colorectal Surgery, City of proctectomy after previous total colectomy/ileostomy).
Hope National Medical Center/Comprehensive Cancer Center, • Antibiotic prophylaxis (versus treatment).
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_63
Pitfalls and Danger Points handle (a) the transection of the terminal ileum, (b) the tran-
section of the distal rectum, (c) the extraction of the speci-
• Choosing the wrong patient, wrong disease, or wrong men, and (d) the pouch creation and anastomosis. Most
time point to attempt the ileoanal pouch creation: The best surgeons fashion the pouch extracorporeally and return it to
chance to achieve a functional pouch is at the first attempt. the abdomen for the actual anastomosis. This can be achieved
In particular, general emergency, deconditioning, general- through the designated ileostomy site or through a separate
ized illness, malnutrition, high-dose immunosuppression, incision, for example, at the umbilicus or in suprapubic
Crohn disease, and morbid obesity are warning flags as location.
they may decrease the chance for success. A staged
approach may be preferable to allow for optimizing the
condition. Extent and Steps of the Resection
• Collateral injury: Duodenum, pancreas, spleen, small
bowel blood supply, ureters, vagina, autonomic nerves The goal of the operation is to remove the entire colon and
with resulting morphological or functional impact (e.g., rectum from the terminal ileum to the distal rectum. However,
pouch-vaginal fistula, sexual dysfunction, infertility). most commonly, when a restoration with ileal pouch is car-
• Leaving too long of a rectal stump, which results in con- ried out in double-stapling technique, a 2–3 cm cuff of resid-
tinued disease activity and possible outlet obstruction. ual rectum proximal to the dentate line is left behind. The
• Pouch too large or too small, increasing functional rational is the (a) the reproducible technical ease and reli-
problems. ability of the stapling, (b) the functional benefit of leaving
• Failure to obtain adequate bowel/mesenteric lengthening the sensory zone and improve the ability to discern between
with insufficient reach for a tension-free anastomosis. fecal and gas content, (c) the lower risk of a stricture, and
• Anastomotic leak: Risk factors include tension, poor most importantly (d) that the cuff only rarely causes relevant
blood supply, poor tissue quality, immunosuppression, symptoms. A mucosectomy down to the dentate line is only
obesity, prior radiation; leak may result in pelvic sepsis, necessary in select cases that include a rectal cancer, polyps,
stricture or fistula formation, pouch loss. or dysplasia. If a restorative resection is not planned and/or
• Failure to regularly monitor the pouch and cuff/anal tran- contraindicated, the mucosa should be stripped from the
sition zone (ATZ) for pouchitis, cuffitis, dysplasia, or can- entire anal canal to the level of the anal verge.
cer (even if a mucosectomy has been performed). The steps of the colon and rectal mobilization and resection
• Pouchitis (acute, recurrent, chronic) versus secondary follow those outlined in the previous chapters for each segment.
Crohn disease (ulcerations proximal to the pouch). If there is a known cancer, a high probability of a cancer, or if
• Decreased pouch retention rates in Crohn disease or inde- that aspect is not fully known, the respective segment dissection
terminate colitis. or even the entire mobilization should follow described onco-
• Twisting of the pouch (axial malrotation). logical principles, and the pathologist should sample the lymph
nodes separately for the different segments. In contrast, if the
resection is not for cancer, there is no need for a minimum
Operative Strategy lymph node harvest; and if the dissection follows the bowel wall
more closely in some segments, the risk of bleeding or a nega-
Surgical Approach tive functional impact may be somewhat reduced.
The sequence of steps can be individualized. The most
Traditionally, colorectal surgery including a restorative proc- challenging phases of the complex multistep surgery are the
tocolectomy was approached and described as open surgery, mobilization and resection of the transverse colon, the
for example, through a midline incision. Alternative inci- splenic flexure mobilization, and the pelvic dissection. In a
sions (e.g., Pfannenstiel incision) are possible in selected staged approach, the total colectomy may already have been
patients. More importantly, however, minimally invasive performed and an end ileostomy or ileorectal anastomosis
approaches (laparoscopic, hand-assisted laparoscopic, or created, and the procedure is limited to the completion proc-
robotic surgery) have dramatically evolved and in many cir- tectomy and pouch creation (with or without diversion). For
cumstances are considered valid options. Safe surgery and a complete proctocolectomies, it may be prudent to start in the
quality pouch creation always carry a higher priority than the upper abdomen to set the tone. In absence of cancer in the
type of approach. If a minimally invasive approach is chosen, respective segments, the omentum can be preserved, but it is
the surgeon should have a good concept of the various steps often faster to come along the gastrocolic ligament and resect
and among other considerations define beforehand how to the omentum than to liberate and preserve it.
63 Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA) or End Ileostomy (Open, Laparoscopic) 507
Terminal Ileal Dissection The Difficult Reach
The length of the ileum should be preserved as much One of the difficulties of an ileal pouch-anal anastomosis
as possible. The ileum is transected just proximal to (IPAA) is to adequately mobilize the small bowel to achieve
the ileocecal valve (e.g., at the fat pad of Treeves) a tension-free reach for a safe anastomosis. The apex of the
to preserve the absorptive functions of the distal terminal bowel loop should reach at least two fingerbreadths
ileum. In a three-stage approach, the previous ileos- beyond the pubic bone, should retain an excellent blood sup-
tomy has to be taken down very carefully, again to ply to the very end, and have sufficient laxity to follow the
preserve as much terminal ileum as possible. sacral curvature.
Mobilization steps include: (1) mobilization of the mes-
enteric root to the duodenum, (2) transillumination of the
Rectal Dissection mesentery with release (division) of nonvascular mesenteric
tissue, (3) parallel release incision of the mesenteric serosa
The pelvic dissection can be performed exactly as described overlying major vascular supply, and (4) controlled division
in Chap. 58, particularly if there is a rectal cancer. Since the of apical vascular arcades to allow for diagonal elongation of
majority of cases are done for a benign pathology, it is the pouch (Fig. 63.1).
acceptable, particularly if the planes are markedly dis- In rare circumstances, a reach may not be achieved.
torted, to err on the side of the rectal wall in order to pre- Obesity or short vascular arcades may contribute to the dif-
serve autonomic nerve fibers. A close-rectal dissection ficulty. If the proctectomy has not been done yet, it might be
plane just outside the muscular wall is not a bloodless plane prudent to leave the pelvic anatomy untouched. If the proc-
but has the advantage of avoiding injury to the autonomic
nerve plexus that are essential for bladder and normal male
sexual function. Anteriorly, the dissection follows the rectal
wall and stays posterior to the seminal vesicles and
Denonvilliers’ fascia.
As tumor staging in ulcerative colitis and polyposis is
very difficult, any biopsy-proven cancer should be consid-
ered for neoadjuvant chemoradiation if a pouch is planned,
as the small bowel is too radiosensitive to tolerate adjuvant
radiation and will lose any functionality.
Continence Factors
In general, the condition of the sphincter should be clini-

cally assessed prior to the surgery. Patients who need a
proctocolectomy for inflammatory bowel disease often
have a strong sphincter complex as a result of the chronic
diarrhea.
Postoperative fecal continence depends on a careful pres-
ervation of these muscles, the sensory zone of the anal canal,
as well as the pouch reservoir function itself. The latter
depends on an appropriate size and elasticity, and the
J-construction helps reversing the propulsive wave and form-
ing a low-pressure reservoir. In addition to morphological
factors, inflammatory changes in the pouch (pouchitis) or the
residual cuff (“cuffitis”) can contribute to dysfunction.
A complete mucosectomy not only removes the sensible
zone but also more often is associated with stricture forma-
tion, which can lead to incomplete pouch emptying and per-
sistent urgency/frequency. Fig. 63.1
tectomy has already been performed, an ileostomy might be • Findings and indication
inevitable. But one option to avoid losing the space is to • Reasoning for choice, extent, and timing of surgical
place the non-reaching pouch (apex closed off) into the approach
empty pelvis and divert proximal to it. The gravity may help • Surgical approach
to elongate the pouch mesentery, and a second attempt at a • Extent and level of dissection
later time may be more successful. • Type of pouch and anastomosis
• Stoma creation
Constructing the Ileal Reservoir (Pouch)

Operative Technique
Numerous ileal pouch designs have been suggested in the past,
but the J-pouch is by far the most common one because from Positioning
a technical standpoint it is comparably simple, and it retains
the functional advantages with excellent outcomes. An Regardless of the approach, place and secure the patient in
S-pouch design is said to have less difficulty to reach but is modified lithotomy on an anti-sliding system that allows for
associated with a notorious incidence of outlet obstructions. dynamic repositioning during the case. Make sure that the
A roughly 12–15 cm J-pouch is created by means of suc- perineum is at the table end to allow for access to the anus,
cessive firings of 2 ½ cartridges of a 75-mm linear stapler and that the hips can vary from flat (0 degree) to high lithot-
that is inserted from its apex of the terminal loop. The open omy (90 degree). Preferably tuck both arms to allow best
apical enterotomy is either used to insert a circular stapler access. Place a urinary catheter to decompress the bladder
anvil or pulled through for a hand-sewn anastomosis. and monitor intraoperative urine output. Prep and drape the
patient from nipple line to mid thighs and include the peri-
neal area, and in females the vagina. Monitors for laparo-
Technique of Pouch-Anal Anastomosis scopic surgery should be placed such that surgeon, target,
and monitor form one line (see Chap. 54, Fig. 54.4).
The standard to perform the pouch-anal anastomosis is to use
a transanally inserted circular stapler which is connected
with the anvil in the created J-pouch. In select cases, the O perative Approach and Incisions
pouch is hand-sewn to the dentate line via a perineal-
transanal approach. Minimally Invasive Surgery
Each platform of minimally invasive techniques employs a
slightly different layout of their port placement. Depending
Indications for Diverting Ileostomy on the past history, insert the first 10–12 mm trocar using the
Hasson or the Veress needle technique. Establish the pneu-
The pouch creation is a complex construct and has an moperitoneum and insert the camera. Insert all subsequent
increased risk for a leak. The leaks occur (a) at the pouch- ports under visual control.
anal ring, (b) the blind end of the J, and (c) anywhere in Pure laparoscopic techniques normally use 4–5 trocars.
between. While proximal diversion does not decrease the Insert a camera port at the umbilicus. For specimen extrac-
risk of a leak, it may mitigate the consequences of one. tion and to insert a stapler anvil for the anastomosis, you can
Unless both the patient and the anastomosis are equally per- either later expand this incision or perform a separate access
fect in regards to all aspects (nutrition, health, body habitus, in a different location (Pfannenstiel incision or at the site for
tissue quality, lax reach, excellent blood supply, negative the ileostomy). Place four working ports in trapezoid con-
leak test), a fecal diversion should be considered. figuration that allow for triangulation toward all quadrants as
The diverting stoma may be closed as early as 6 weeks well as the pelvis. Our preference is two 5–12 mm ports in
after the pouch creation if the patient has well recovered, the the right and left lower quadrant, and two 5 mm ports in the
pouch integrity has been documented (pouchogram, right and left upper abdomen. Even though the right lower
pouchoscopy), all immunosuppressants tapered off, and if no quadrant port could be placed at the planned ileostomy site,
other treatments (e.g., chemotherapy) have priority. there is often an insufficient distance to the camera; a sepa-
rate port has little morbidity and substantially improves your
maneuverability.
Open Approach
Coding for surgical procedures is complex. Consult the most For an open approach, make a midline incision starting at the
recent edition of the AMA’s Current Procedural Terminology pubic bone and extending to the umbilicus. In skinny patients
book for details (see references at the end). In general, it is and/or if you are able to see the greater curvature of the stom-
important to document: ach, that is often enough. If this does not allow for sufficient
exposure, extend the incision into the epigastrium by going

to the left of the umbilicus. Maintain exposure with handheld
or self-retaining retractors.
Exploration

of the platform), explore the abdomen. Perform and docu-
ment a thorough examination of all quadrants and look for
signs of tumor manifestations, small bowel disease, liver
pathology, or any other finding that could change your deci-
sion to proceed.
Mobilization and Resection
Total Colectomy
Perform the complete mobilization of the colon from the
ileocecal junction to the sigmoid colon. The individual lapa-
roscopic or open steps have been described in the chapters
for the right hemicolectomy (Chap. 56) and the left hemico-
lectomy and sigmoid resection (Chap. 57). As previously
mentioned, you can carefully dissect the omentum off the
transverse colon in order to preserve it. Alternatively, you
may divide the gastrocolic ligament along the transverse
colon using an advanced energy device and remove the
omentum as part of the specimen. Move the mobilization and
devascularization toward the rectosigmoid junction. Fig. 63.2
Complete the liberation and transection of the IMA pedicle.
In an open approach, transect the ileum within 1–2 cm of past the prostate or the mid to lower vagina, respectively, down
the ileocecal valve (Fig. 63.2). If the case is done laparo- to the pelvic floor. Be careful not to injure the anterior struc-
scopically, it may be advantageous to leave the ileum con- tures. At that level of the pelvic floor, the mesorectum natu-
nected until the entire specimen is exteriorized. rally thins out. Clear the rectum circumferentially to allow for
placement of a stapling device. In open surgery, you may use
roctectomy
P the curved transverse cutting Contour stapler or a TA stapler.
Carry out the proctectomy either in continuation of the proc- Make sure after tentative closing of the device that the level is
tocolectomy or as a completion proctectomy after previous truly low enough, that is, within 2–3 cm of the anal verge. In
total colectomy with an end ileostomy or an ileorectal anas- laparoscopy, either place a roticulating linear stapler under
tomosis. Use the same degree of care to identify the ureters visual laparoscopic control or insert one of the two other sta-
and to get safely into the avascular plane. In case of a cancer plers through a small suprapubic Pfannenstiel incision.
and depending on its level, perform a formal total mesorectal Attempt to come through the bowel with as few stapler firings
excision without or with removal of the pelvic floor or anus. as possible, ideally not more than two.
If the anatomy is blurred from past interventions or nonma- If you need to perform a complete mucosectomy and
lignant disease, you may follow with the dissection directly hand-sewn anastomosis, first dissect as low as you can from
along the bowel wall. the abdominal approach and then switch to the perineum.
The decision to preserve and restore or to sacrifice intes- Place a LoneStar® retractor (Cooper Surgical, Trumbull,
tinal continuity is primarily dictated by the nature and mani- CT) and incise the mucosa at or close to the dentate line
festations of the disease, and you should—with very few (Fig. 63.3a and b). Elevate the mucosa and carefully dissect
exceptions—have determined that preoperatively. it in cephalad direction off the muscular structures of the
Restorative proctocolectomy: In the majority of the patients, sphincter complex and pelvic floor. Continue until you con-
the goal is to restore continuity. You continue the dissection nect with the abdominal dissection (see also Chap. 60).
Total proctocolectomy (with permanent ileostomy): In that has the longest reach and will serve as the future site of
case there is no plan for continence preservation, do the the ileoanal anastomosis: if you can bring this point 6 cm
upper and mid rectal dissection as outlined above. As you beyond the pubic bone, you can be assured that there will be
approach the lower pelvis and the pelvic floor, the further no tension on the anastomosis.
steps depend on whether the disease is malignant or benign Elongate the mesentery to ensure that reach (Fig. 63.1).
(see details in Chap. 62). For the former, you will have to Using Metzenbaum scissors, carefully incise the front and
carry out a formal excision of the anus and the pelvic floor to back side of the mesenteric serosa in a series of parallel lines
achieve negative margins. In contrast, the excision for benign that are perpendicular to the main vascular pedicle (trans-
disease can be limited to a deepithelialization of the anal verse to direction of the traction). With each serosal incision,
canal down to the level of the anal verge. For both of these you may gain a centimeter of mesenteric length. Be patient
situations, you will have to switch to a perineal approach. and take care not to damage any of the underlying vascula-
Once you removed the specimen and verified hemostasis, ture. Place as many incisions as needed and recheck the
close the perineum (see Chap. 62). length. If additional length is still required, transilluminate
the mesentery, and selectively divide vascular branches to
allow for a rhomboid elongation of the tip without jeopardiz-
Constructing the Ileal Reservoir (J-Pouch) ing the overall blood supply to the apex of the pouch through
lateral collaterals. If the mesentery is thickened from scar
Construct the ileal J-pouch with the last loop of the staple- tissue or obesity, you may have to de-fat some of it. This can
closed terminal ileum. In case of a complete proctocolec- be challenging if not impossible. Care is important as a
tomy, the terminal ileum is stapled off just next to the bleeding vessel that retracts into the mesentery not only may
ileocecal valve. In patients who are managed in a three-stage result in a tense hematoma and risk ileal ischemia, but it
approach and had a total colectomy with end ileostomy as counteracts the elongation efforts.
the first step, you have to take down the ileostomy first by In the rare event that your combined efforts fail to achieve
carefully dissecting the ileum away from the abdominal wall. sufficient length, you can place the blind ending pouch or the
Preserve as much ileum as possible as you fire a linear cut- respective bowel loop into the pelvis without an anastomosis
ting stapler across the very last portion of the terminal ileum. and divert upstream to it. Cover the pelvic inlet with
A critical step is to liberate the cut edge of the small bowel Seprafilm and return a few months later, at which point the
mesentery of the ileum from its retroperitoneal attachments weight of mucous within the pouch will usually pull it down-
up to the edge of the duodenum. Transilluminate the small ward and elongate the mesentery. A tension-free anastomosis
bowel mesentery to define which tissue portions along its may then be constructed at this later date. The alternative of
lateral free edge do not contain any relevant vessels and can creating an S-pouch with the thought to gain some additional
be removed or thinned out. Now select a point on the ileum length has a high potential of physical or functional failure if
a b
Dentate line
Fig. 63.3
a b c Stapled anastomosis: Place two Allis clamps to the edge

of the enterotomy at the apex of the pouch and insert a
purse string suture using an “outside-in” monofilament
suture. Make sure with each stitch to grab a full-thickness
bite from 3–5 mm on the outside to the mucosal edge on the
inside. Travel with each stitch about 5 mm until you are
completely around and reverse the direction of the last
stitch to “inside-out.” The bowel edge has a tendency to
evert itself and create additional tissue that can get caught
up in the stapler line and create an incomplete donut. Use
an appropriate stapler size (usually between a 29 and
33 mm, rarely a 25 mm). Insert the anvil into the pouch and
tie down the purse string. Insert the stapler through the anus
into the rectal cuff. Be careful to do this in a very controlled
fashion and to avoid using too much force to overcome the
often tight sphincter complex, as you could otherwise dis-
rupt the distal transverse staple line. If necessary, gently
dilate the sphincter complex with two fingers to accommo-
date the stapler head. Do not staple unless the stapler has
passed the sphincter complex as inclusion of the anal canal
and muscle will cause significant pain and discomfort and
possibly incontinence. Once the stapler body nicely sits in
the rectal stump underneath the staple line, advance the
spike under direct vision to come through just posterior to
Fig. 63.4
it. Particularly in females, this is important so as not to get
any vaginal mucosa caught in the circular stapling device.
you lack extensive experience and have not done a good Connect the anvil to the spear with an “audible click”
number of these before. (Fig. 63.4c). It is crucial to avoid catching onto anterior
Create a roughly 12–15 cm J-pouch by means of successive structures during the stapler closing phase. In open cases,
firings of 2 ½ cartridges of a 75–80 mm linear stapler with place your hand (palms up) like a retractor such that the
2.3–3.5 mm thickness (Fig. 63.4a and b). Align the distal nail side of your fingers rests on the stapler body; close the
ileum in the shape of a J with each limb measuring about stapler and feel the anvil pass posteriorly to your protecting
12-15 cm. Insert a GIA stapler through a small enterotomy at hand. In laparoscopic cases, watch the closing with direct
the apex of this loop and carry out a side-to-side stapled anas- visualization. Double-check that no surrounding tissues
tomosis between the antimesenteric aspects of the ascending have been caught up in the staple line. Perform a vaginal
and descending limbs of this J. Before each of the sequential exam to ensure that the vaginal is not tethered into the sta-
firings, insert your finger behind the bowel and push the mes- pler. Finally, check the orientation of the pouch to ensure
entery away to ensure that it is not trapped in the stapler. the cut edge of the ileal mesentery is straight and not
Usually the mesentery is pushed downward. However, if the twisted. Fire the stapler and check the donuts for complete-
posterior wall of the vagina has a weakness from the dissec- ness. Perform a digital exam to verify the level of the anas-
tion or a previous fistula, keep the mesentery on the anterior tomosis. In the event that you feel any defects, place a
side. This makes creation of the pouch more challenging (as it LoneStar retractor and suture- reinforce the anastomosis
is upside-down during creation), but it reduces the risk of a with absorbable sutures.
pouch-vaginal fistula. Avoid a long blind limb at the end of the Hand-sewn anastomosis: Optimize access and exposure
J. Resect that part if necessary with an additional fire of the of the perineum and anus by readjusting the stirrups, so the
stapler. The ileal reservoir is now complete. Again check the thighs are flexed on the abdomen. Place a LoneStar anal
blood supply and its ability to reach the pelvic floor. retractor to the anal canal. Insert two long Babcock clamps
through the anus and grasp the dependent portion of the ileal
reservoir. Bring this segment of ileum into the anal canal and
Ileoanal Anastomosis perform the anastomosis in two layers. Place 6–8 seromus-
cular sutures to the sphincter complex and then mature the
The open apical enterotomy is either used to insert a circular mucosal connection with a second row of interrupted 3–0 PG
stapler anvil for a double-stapled anastomosis, or you can sutures (Fig. 63.5). You may fine-tune the mucosa with a run-
pull it through and perform a hand-sewn anastomosis. ning chromic suture. Release the LoneStar retractor.
Anastomosis not prudent: Even if you originally planned

a restorative pouch-anal anastomosis, intraoperative specif-
ics of the disease or the anatomy may be unfavorable such
that it may simply not be prudent or impossible to pursue the
plan. Examples (other than the inability to reach) include
persistent tumor along the pelvic passage, extremely poor
tissue quality, active pelvic infection, insufficient passage to
allow the normal size pouch to fit through, and others.
Loop Ileostomy
Protect the pouch with a temporary diverting loop ileostomy

(see details in Chap. 51). If the patient already has a defect in
the abdominal wall from a previous ileostomy, it is generally
possible to use the same site for the loop ileostomy.
Otherwise, create a gap at the marked site.
Fig. 63.5 The pouch tends to tether the small bowel mesentery
somewhat, so select a location on the bowel that is as distal
itfalls, Danger Points, and Troubleshooting
P as possible but easily reaches the abdominal wall without
Stapled Anastomoses creating undue tension on the pouch. This may be a much
more proximal location. Create a mesenteric gap and mark
Staplers have been a great asset for pelvic anastomosis which the bowel for an absolute orientation with a suture or a clip
overall have become safer and more predictable. However, (so that the grasper and suture give you two points of refer-
they cannot guarantee a perfect anastomosis. Keep in mind ence). Consider wrapping the bowel loop with an antiadhe-
that a proximal diversion does not compensate for a bad sive product (e.g., Seprafilm). Once the bowel is brought
anastomosis. It is best to fix problems right then and there through the abdominal wall, you may place a preliminary
when everything has already been freed up. Consider how suture to fix the efferent limb to the subcutaneous tissues and
bad the alternative of a future redo-surgery with dense adhe- thus ensure not to mature the wrong end.
sions and an even more difficult pelvic dissection may be if Mature the ileostomy only once the abdominal incisions
the first anastomosis does not heal favorably. have been closed. Aim at creating at least a 2 cm symmetric
Bleeding: Immediate bleeding may be related to incorpo- nipple to prevent skin breakdown (see Chap. 51).
ration of the mesentery. Delayed bleeding could indicate an
anastomotic leak or also be related to the staple line. If pos-
sible, a visualization of a significant bleeding site should be Wound Closure
considered with clipping or suturing of the respective area.
Anastomotic failure: Signs of an immediate anastomotic We typically place a drain in the pelvis behind the pouch to
failure are an obvious separation of the staple lines, tearing prevent seroma formation. This is removed within
of the bowel wall, incomplete donuts, and/or concerning 24–48 hours. Arrange the bowels to avoid any twists. Verify
palpation. hemostasis. Remove the ports and/or retractors.
Incorporation of urogenital structures: This is a severe The operating team should discard soiled gloves and use
technical complication which should be largely preventable. new instruments to close the surgical wounds. Close the fas-
Prevention is better than correcting the issue. Before com- cia of any incision larger than 5 mm in routine fashion.
pletely closing the stapler, verify that those structures are Irrigate the wound before closing the skin.
neither fully included nor even tethered in the stapler. Reopen If a diverting stoma has been planned, mature it after all
it if you are not sure. Only close the stapler to the firing range skin has been closed (see Chap. 51).
when you are sure that the urogenital structures are actively
kept out of the closing stapler.
Stapler insertion impossible: Analyze the reasons. If there Postoperative Care
is truly a stricture that for some reasons you were not aware
of, determine whether a hand-sewn anastomosis or a reversed • Antibiotics: Routine coverage for the perioperative
stapled anastomosis would be doable and have a chance for 24-hour period. In case of significant contamination or an
a good functional outcome, or whether you should abandon underlying infection/sepsis, continue respective therapeu-
the plan of an anastomosis. tic antibiotics for that indication.
• Incentive spirometry and early ambulation should be until proven otherwise in any patient with fever, leuko-
encouraged. cytosis, tachycardia, and/or nonresolving ileus. Clinical
• Nasogastric tube: No routine use in elective cases. manifestations of this complication may develop at any
• Intravenous fluids: Maintain adequate fluid until return of time, but not infrequently occur 5–9 days after surgery.
bowel function. –– An existing diverting ileostomy does not prevent the
• Enhanced recovery after surgery (ERAS) protocol: In leak but typically reduces the severity of clinical
elective cases, initiate oral intake on the day of surgery manifestations.
and advance to solid food as patient demonstrates return –– A gentle digital rectal examination may be diagnostic
of bowel function. if the finger discloses a defect in the suture line.
• Nutritional support: If return of bowel function delayed –– Careful endoscopic examination with minimal CO2
by more than 5 days, initiate parenteral nutrition. insufflation may disclose evidence of a defect in the
• Monitor ileostomy output and initiate appropriate hydra- suture line and provide information about the perfu-
tion measures if output is >1200–1500 mL per 24 hours. sion of the two sides.
Ensure adequate home health is set up for ostomy –– An abdomino-pelvic CT scan can almost always con-
supplies. firm the presence of pelvic sepsis. The CT modality
• If adjuvant chemotherapy is planned, this can usually be may further aid in draining of pelvic fluid collections.
initiated 4-6 weeks after surgery. –– Vigorous management is important. Treatment
• The temporary stoma can be reversed after a minimum of depends on (1) the acuity of the patient, and (2)
6–12 weeks, if there are no other treatments that have pri- whether the patient has already been diverted. Patients
ority (e.g., adjuvant chemotherapy), if all immunosup- with mild systemic symptoms who are suspected of
pressants including prednisone have been tapered off, and having a pelvic infection may be treated by bowel rest
if the integrity and patency of the anastomosis has been (nil per os), intravenous broad-spectrum antibiotics,
documented by means of the clinical exam, endoscopy, and possibly hyperalimentation. Stable patients can be
and a water-soluble contrast study (pouchogram). The treated by CT-guided percutaneous catheter drainage
pouch should follow the contour of the sacrum; anterior or transrectal drainage. A patient may have a pelvic
displacement or severe induration may indicate a leak, abscess even in the absence of a definite defect in the
abscess, hematoma, or tumor, and further imaging is indi- suture line. Consequently, a patient who is febrile and
cated (CT scan). toxic should undergo drainage of any septic process
• Following closure of the loop ileostomy: set realistic that is identified.
patient expectations with a goal of having 4-8 bowel –– Sick patient requiring ICU transfer or with signs of sep-
movements per day with good control; fine-tuning may sis require return to the operating room to clean out and
require dietary adjustment, fiber supplements, and antidi- drain, divert, or possibly take apart the anastomosis.
arrheal medications. Recommend perianal skin care with • Anastomotic bleeding, hematoma in pelvis or in
a barrier cream. Explain symptoms and treatment (antibi- reservoir.
otics) if symptoms of pouchitis occur. • Mesenteric or portal vein venous thrombosis.
• Pouch surveillance (every 1–3 years) with pouchoscopy • Anastomotic stenosis (e.g., as a result of ischemia, scar-
including biopsies of the anal transitional zone (ATZ). ring, particularly after previous leak and pelvic sepsis).
Even if a mucosectomy has been performed, surveillance • Postoperative ileus or small bowel obstruction.
is still required as small islands of mucosa inevitably • Autonomic nerve dysfunction:
remain and can be a source of future neoplastic transfor- –– Bladder dysfunction may follow a deep pelvic dissec-
mation. Patients with familial polyposis syndromes may tion, especially in men with benign prostatic hypertro-
form polyps in the ATZ and in the ileal reservoir. phy. Generally, function resumes after 6–7 days of
bladder drainage, possibly supported by an alpha
adrenergic antagonist.
Complications –– Sexual dysfunction in men (e.g., retrograde ejacula-
tion, erectile dysfunction) and reduced fecundity/fertil-
• Collateral organ injury (ureter, small bowel, spleen, pan- ity in women may follow a deep pelvic dissection.
creas, hypogastric nerves). • Incisional, port-site, or internal hernia formation.
• Surgical site infection. • Ileoanal dysfunction with frequency/urgency/inconti-
• Anastomotic leak/pelvic sepsis: nence: related to pouchitis, pouch stricture, pouch pro-
–– Pelvic sepsis secondary to an anastomotic leak is among lapse, cuffitis, irritable pouch syndrome, secondary
the most serious and potentially lethal complication fol- transformation to Crohn disease (look for inflammation/
lowing a pelvic anastomosis. It should be suspected ulcerations proximal to the pouch).
Further Reading Khasawneh MA, McKenna NP, et al. Impact of BMI on ability to suc-
cessfully create an IPAA. Dis Colon Rectum. 2016;59(11):1034–8.
Kiran RP, da Luz Moreira A, et al. Factors associated with sep-
tic complications after restorative proctocolectomy. Ann Surg.
2010;251(3):436–40.
Kuruvilla K, Osler T, et al. A comparison of the quality of life of ulcer-
Ahmed Ali U, Shen B, et al. The management of anastomotic pouch
ative colitis patients after IPAA vs ileostomy. Dis Colon Rectum.
sinus after IPAA. Dis Colon Rectum. 2012;55(5):541–8.
2012;55(11):1131–7.
Beyer-Berjot L, Maggiori L, et al. A total laparoscopic approach
Lovegrove RE, Constantinides VA, et al. A comparison of hand-
reduces the infertility rate after ileal pouch-anal anastomosis: a
sewn versus stapled ileal pouch anal anastomosis (IPAA) follow-
2-center study. Ann Surg. 2013;258(2):275–82.
ing proctocolectomy: a meta-analysis of 4183 patients. Ann Surg.
Fasen GS, Pandian TK, et al. Long-term outcome of IPAA in patients
2006;244(1):18–26.
presenting with fulminant ulcerative colitis: a matched cohort study.
Mallick IH, Hull TL, et al. Management and outcome of pouch-vaginal
World J Surg. 2015;39(10):2590–4.
fistulas after IPAA surgery. Dis Colon Rectum. 2014;57(4):490–6.
Fazio VW, Kiran RP, et al. Ileal pouch anal anastomosis: analy-
McKenna NP, Mathis KL, et al. Obese patients undergoing Ileal pouch-
sis of outcome and quality of life in 3707 patients. Ann Surg.
anal anastomosis: short-and long-term surgical outcomes. Inflamm
2013;257(4):679–85.
Bowel Dis. 2017;23(12):2142–6.
Cecostomy: Surgical Legacy Technique
64
Cecostomy is an alternative to resection with the goal to • Selecting the wrong patient.
decompress and vent a distended colon before the dilation • Cecostomy may fail to produce adequate decompression.
results in structural damage to the colon wall (e.g., pneumato- • Limited exploration through a small incision may miss an
sis) or perforation. A cecostomy is never appropriate for fecal area of perforation elsewhere.
diversion, but may be justified in rare situations. The only two • Fecal matter may spill into the peritoneal cavity.
accepted urgent conditions are nonresolving Ogilvie syn-
drome (colonic pseudoobstruction) or a cecal volvulus where
the cecostomy would also result in a cecopexy. Colonoscopic Operative Strategy
decompression and/or a resective surgery are generally the
better initial approaches. Cecostomy comes in as an option There are two kinds of cecostomy: (A) tube cecostomy or
when other nonsurgical methods (endoscopic, pharmacologi- (B) surgical creation of a cecal colostomy.
cal) have failed or more aggressive surgery (resection) would A tube cecostomy can be placed either colonoscopically
appear to result in a too severe negative impact. Historically assisted (analogous to a percutaneous endoscopic gastros-
and now largely abandoned, a cecostomy was also created as tomy) or through open or laparoscopically assisted surgery.
one of several Turnball blowholes for fulminant colitis. Even a large tube primarily allows decompression of gas and
Under elective circumstances, a tube cecostomy (as alter- liquid, but fecal debris easily plugs the system, which needs
native to an appendicostomy) may be created for patients frequent servicing/flushing to assure patency. The main
with functional disorders (incontinence, constipation). advantage of a tube cecostomy apart from bowel preserva-
Contraindications to a cecostomy include mechanical tion and a potentially intended cecopexy is that the tube can
large bowel obstruction, or established structural colon dam- eventually be removed without further intervention, and the
age (pneumatosis, perforation). temporary fistula most commonly closes spontaneously.
The skin-sutured cecostomy (cecal colostomy or blow-
hole) described here provides more certain decompression
Preoperative Preparation but requires a formal surgical closure. In an attempt to avoid
fecal contamination of the abdominal cavity during this
• Perioperative antibiotics operation, the cecum is sutured to the external oblique apo-
• Urgent surgery: Nasogastric suction, fluid resuscitation neurosis before being incised.
• Elective surgery: Routine
A. M. Kaiser
Hope National Medical Center/Comprehensive Cancer Center, Coding for surgical procedures is complex. Consult the most
Duarte, CA, USA recent edition of the AMA’s Current Procedural Terminology
C. E. H. Scott-Conner (*) book for details (see references at the end). In general, it is
Department of Surgery, University of Iowa Carver College important to document:

https://doi.org/10.1007/978-3-030-81415-1_64
516 A. M. Kaiser and C. E. H. Scott-Conner
• Indications and findings absorbable monofilament purse-string suture and insert a

• Justification for choosing this rather than alternative man- 16-gauge needle attached to the suction or an empty 50 cc
agement or surgical approaches syringe. After this has been accomplished, remove the needle
and tie the suture. Elevate the abdominal wall with a retractor
to expose the anterior and lateral walls of the cecum. If the
Operative Technique exposure is inadequate, make a larger incision. If a necrotic
patch of cecum can be identified, use this region as the site
Tube Cecostomy for the cecostomy and excise it during the procedure.
Access the peritoneal cavity either through laparoscopy, a Cecal Fixation

formal laparotomy, or a right lower quadrant incision. Suture the wall of the cecum to the external oblique aponeu-
Check for evidence of perforation or structural damage to rosis with a continuous 3–0 PG suture on a fine needle to
the bowel wall. Insert two concentric purse-string sutures prevent any fecal spillage from reaching the peritoneal cavity
in a circular fashion on the anterior wall of the cecum using (Fig. 64.1). If the incision in the external oblique aponeurosis
3–0 atraumatic PG. The diameter of the inner circle should is longer than 4–5 cm, narrow it with several PG sutures.
be 1.5 cm. Through a separate stab wound at least 3 cm Narrow the skin incision also to the same length with several
away from the other incision(s), insert a large soft rubber fine PG subcuticular sutures. Circumferentially suture the
tube with inflatable balloon (e.g., Foley catheter) to the edge of the bowel to the dermis.
peritoneal cavity. Using scissors, make a small colotomy in
the center of the purse-string sutures. Do not use electro- Mucocutaneous Suture
cautery to open the colon as combustive gases may explode. Make a transverse incision in the anterior wall of the cecum
Advance the catheter for about 5–6 cm into the ascending 4 cm long (Fig. 64.2) and aspirate liquid stool and gas. Then
colon and inflate the balloon. Tie the two purse-string suture the full thickness of the cecal wall to the subcuticular
sutures around the rubber tube such that the second purse- layer of the skin with a continuous or interrupted suture of 4–0
string suture inverts the first. PG on an atraumatic needle (Fig. 64.3). Place a properly fitted
Suture the cecum to the peritoneum around the stab ileostomy bag over the cecostomy at the conclusion of the
wound. Use four interrupted 3–0 PG atraumatic sutures to operation.
keep the peritoneal cavity free of any fecal matter that may
leak around the tube. Insufflate the balloon and pull the cath-
eter back to sit just underneath the abdominal wall. Secure it
externally to the skin with a drain stitch. Close the abdominal
incision or port-sites in standard fashion.
The percutaneous endoscopically assisted tube cecos-
tomy is placed under colonoscopic guidance and is usually a
much smaller diameter.
Skin-Sutured Cecostomy
Incision
Make a transverse incision about 4–5 cm long over
McBurney’s point and carry it in the same line through the
skin, external oblique aponeurosis, the internal oblique and
transversus muscles, and the peritoneum. Do not attempt to
split the muscles along the line of their fibers.
Exploration of Cecum
Rule out patches of necrosis in areas beyond the line of inci-
sion by carefully exploring the cecum. To accomplish this
without the danger of rupturing the cecum, perform a needle
decompression to release some of the pressure. Place an Fig. 64.1
64 Cecostomy: Surgical Legacy Technique 517
It may be removed after 2–3 weeks if it is no longer

needed.
• Manage the skin-sutured cecostomy in the operating
room by applying an adhesive-backed disposable stoma
appliance to it.
Complications
• The major postoperative complication is a lack of adequate

decompression, delayed manifestation of bowel necrosis, or
perforation with a need for a reexploration and resection.
• Peristomal sepsis as a result of bacterial contamination of
Fig. 64.2 the abdominal incision cannot be completely eliminated
but is much less common than one would anticipate with
an operation of this type.
Further Reading
®.Professional ed. Chicago: American Medical Association; 2013.
Donkol RH, Al-Nammi A. Percutaneous cecostomy in the manage-
ment of organic fecal incontinence in children. World J Radiol.
2010;28:463–7.
Fig. 64.3 Duh QY, Way LW. Diagnostic laparoscopy and laparoscopic cecostomy
for colonic pseudo-obstruction. Dis Colon Rectum. 1993;36:65.
Koyfman S, Swartz K, Goldstein AM, Staller K. Laparoscopic-assisted
Postoperative Care percutaneous endoscopic cecostomy (LAPEC) in children and
young adults. J Gastrointest Surg. 2017;21:676–83.
Rodriguez L, Flores A, Gilchrist BP, Goldstein AM. Laparoscopic
• The tube cecostomy requires repeated irrigation with assisted percutaneous endoscopic cecostomy in children with defe-
saline to prevent it from being plugged by fecal particles. cation disorders (with video). Gastrointest Endosc. 2011;73:98–102.
Creation of Transverse Colostomy
(Loop, Prasad-Type) 65
Indications • Assure that there is no evidence for perforation, pneuma-

tosis intestinalis, or ischemia.
• Large bowel obstruction between left colon and anus, not • Review preoperative images (CT scan, plain X-ray film of
amenable to stenting or primary resection of the the abdomen) to identify the position of the transverse
obstruction colon in relation to anatomical landmarks (umbilicus,
• Diversion of fecal stream in case of pelvic sepsis, fistuli- costal margin) and possibly overlaying structures (e.g.,
zation, or postsurgical complication (leak) distended loops of small bowel, carcinomatosis).
• Prophylactic fecal diversion for colorectal/coloanal anas- • In urgent/emergency situation, provide adequate fluid
tomosis (largely superseded by loop ileostomy for this resuscitation.
purpose), but sometimes easier than ileostomy • Insert indwelling bladder catheter for adequate fluid
(super-obesity) management.
• Place a nasogastric tube and decompress stomach (if
bowel obstruction or ileus is present).
Contraindications • Routine antibiotic prophylaxis (unless therapeutic indica-
tion for active infection).
• Evidence of perforation, pneumatosis, or ischemia • Stoma marking: While mandatory for elective stoma cre-
• More proximal obstruction, previously altered transverse ations, it is usually not helpful when the abdominal con-
colon anatomy, or blood supply, such as right or extended figuration is severely altered secondary to acute illness
right or left hemicolectomy, antecolic Roux-Y and distention.
reconstruction
• Presence of acute upper abdominal pathology (e.g., pan-
creatitis, tumor, carcinomatosis) Pitfalls and Danger Points
• Performing a transverse colostomy where other forms of

Preoperative Preparation ostomy (sigmoid colostomy, ileostomy) would be
preferable.
• Study the patient’s history and verify the diagnosis and • Anatomic disorientation or confusion as to which part of
appropriate indication by clinical, radiographic, or endo- the gastrointestinal tract is being “ostomized,” and what is
scopic means. Tools can include computed tomography proximal versus distal. A redundant sigmoid colon, small
(CT), water-soluble contrast enema, or colonoscopy. bowel, or even the gastric antrum may reach the same
location as the transverse colon, especially when a small
incision is made to perform the procedure.
C. P. Spanos • Failure to recognize established or impending bowel wall
Department of Surgery, Aristotelian University School of damage or perforation (e.g., cecal) for which a transverse
colostomy is an inadequate operation.
A. M. Kaiser (*) • Previous surgeries and pathologies that may limit the
transverse colon mobility.
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_65
520 C. P. Spanos and A. M. Kaiser
• Interruption of marginal blood supply to distal bowel seg- For most cases of left colon obstruction, the colon may be
ments that depend on the mid colic artery, for example, approached through a small transverse incision through the
after previous rectosigmoid resection with ligation of the right rectus muscle half way between the costal margin and
inferior mesenteric artery. the umbilicus. This allows a traditional right-sided transverse
colostomy to be fashioned. Under a limited number of cir-
cumstances, a left-sided transverse colostomy may be prefer-
Operative Strategy able. For either location, the incision should be made for the
colostomy alone; the assumption is that the rest of the
Choice of Procedure abdominal cavity does not have to be explored.
Exceptions to this rule are patients with uncertain bowel
Loop ileostomy or a sigmoid colostomy are better alterna- viability with impending or established cecal rupture, or
tives for many patients, especially under elective circum- when this small incision reveals evidence for peritonitis,
stances such as prophylactic diversion of high-risk distal ischemia, or other pathology that warrant a more formal
colorectal anastomoses or as most distal diversion for incon- exploration through a midline incision with extended resec-
tinence, rectovaginal/−urinary fistulas. The primary situation, and damage control. It is important to resect all com-
tions in which a transverse colostomy is preferable are urgent promised bowel segments and yet making sure not to leave
or emergency conditions when the colon is not empty and behind a closed loop between the obstruction site and the
cannot be emptied prior to surgery, when there is danger in distal resection. Hence, the strategy in these more difficult
dissecting too close to a pelvic or lower abdominal catastro- situations needs to shift to a Hartmann-type approach with a
phe area (e.g., anastomotic leak after a recent resection with proximal creation of an end stoma (e.g., ileostomy) and
dense adhesions from the infection and previous surgery). either a blind stump distal to the resected obstruction or a
The alternatives for a newly diagnosed left-sided large mucous fistula proximal to the obstruction.
bowel obstruction (see Chap. 69) include endoscopic stent-
ing (definitive or as bridge to surgery), a Hartmann type
resection with end colostomy (see Chap. 58), a resection Diversion of Fecal Stream
with anastomosis (with or without on-table lavage, see Chap.
57), or a subtotal resection including the distended proximal If the purpose of the colostomy is to decompress and vent the
large intestine with ileostomy or entero-colonic anastomosis colon, equal sized openings for the afferent and efferent seg-
(see Chap. 62). ment can be created. If, on the other hand, the goal is to
This chapter describes both the traditional loop transverse achieve the most complete diversion of stool from a critical
colostomy with equally sized afferent and efferent limb, as distal area (leak, reconstruction, fistula) that does not have a
well as the Prasad modification. For the Prasad modification, current obstruction or a risk for a developing a stricture, the
the distal limb is defunctionalized and either completely efferent limb can either be closed with a noncutting stapler or
stapled off or incorporated a mini-mucous fistula into an a Prasad-type pseudo-loop colostomy can be created. For the
edge of the stoma. This is different from a Hartmann-type latter, the proximal end is brought out as a functional end
stoma where there may be a substantial distance between the colostomy, and a tiny edge of the distal stapler-transected
proximal and distal bowel. The Prasad technique allows for a end is either fixed to the afferent limb or brought out as a
better colostomy to be fashioned (functional end colostomy) mini-mucous fistula in the same opening. This construction
with the added benefits of a (near) complete diversion while is a little bit less prone to hernia formation and prolapse than
preserving the ease of a local stoma takedown. a traditional loop colostomy, even with the stapler fired
across the distal segment. Both will require resection and
anastomosis for closure, rather than closure by a simple
Access “plastic” procedure as may be feasible for a traditional loop
colostomy.
When a temporary transverse colostomy is required as an
isolated procedure, usually a single small incision (through
which the ostomy is fashioned) is sufficient. Sometimes, Documentation Basics
when the transverse colon is not the most anterior structure,
its identification and mobilization may be facilitated by Coding for surgical procedures is complex. Consult the most
either laparoscopy or a small epigastric midline laparotomy. recent edition of the AMA’s Current Procedural Terminology
It should be noted though that severe abdominal distention or book for details (see references at the end). In general, it is
hemodynamic instability may limit the application of laparo- important to document:
scopic techniques.
65 Creation of Transverse Colostomy (Loop, Prasad-Type) 521
• Findings and indications. Carry the incision through the subcutaneous fat down to
• Bowel viability. the level of the anterior rectus fascia. Avoid creating dead
• Construction details: loop, Prasad-type, loop with stapled space in the fat during this step. Make a small transverse
limb. incision on the anterior rectus fascia with electrocautery.
• Tacking (or absence) of colon to fascia. Expose the rectus muscle. Insert a Kelly or Duval clamp
• Use of stoma bridge. between the muscle belly and lift the anterior rectus sheath
• It is important to document technical details when fash- such that the transverse incision can be extended without
ioning any type of stoma. This will facilitate the stoma cutting the muscle. Again use a clamp to spread the center of
reversal. the rectus muscle in vertical direction without injuring the
epigastric vessels. Do not transect the muscle. Enter the
abdomen with Metzenbaum scissors in the usual manner by
Operative Technique incising the posterior rectus sheath and peritoneum. This is
called by some the colostomy “trephine.”
Incision
Make a transverse incision of 4–5 cm roughly in the middle I dentification and Exteriorizing of Transverse
of a line between the umbilicus and the costal margin at the Colon
mid-clavicular line (Fig. 65.1). Take care not to make an
incision close to the right costal margin, as this may make Key landmarks to be used for identifying the transverse
application of the ostomy bag difficult. When no previous colon are the omentum and the taenia. After entering the
laparotomy has been performed, it is usually easy to find the peritoneal cavity, find the omentum. Be gentle with the dis-
transverse colon using this incision. tended bowel and free up adhesions with the anterior abdom-
inal wall or abdominal contents that may interfere with
mobilizing the transverse colon.
After identifying the omentum, use it as a reference point
to (a) find the transverse colon at its upper edge and (b) to
maintain the orientation in regards to proximal and distal. If
the omentum is very thin, you can easily exteriorize it, draw
it cephalad, and find the transverse colon with its taeniae at
its undersurface. If the omentum is very fatty, though, it may
be necessary that you divide it in approximately vertical
direction using an energy device or between ligatures on
either side. Once the edge of the colon is found, use gentle
traction to bring it toward the incision. Confirm that the loop
you have identified is colon by visualizing haustra and tae-
niae—these are not a feature of small intestine or stomach.
Optional step: If the colon is extremely distended, you
may decompress it. Place a purse-string suture on the ante-
rior side that will eventually matured. Connect a large-bore
needle or angiocatheter (14–16 gauge) to suction and punc-
ture the colon in the center of the purse-string (Fig. 65.2).
Decompress air and remove the needle while tying the suture.
Slide the index finger underneath along the posterior
bowel wall. While this step can be largely done blindly, be
careful when the colon is very distended. Create a small win-
dow in the meso-colon, directly over the index finger
(Fig. 65.3). Take a large clamp and hold its tip directly onto
the tip of the now visible index finger and follow with the
clamp as you withdraw the finger. Advance that clamp under-
neath to the other side until it can sit on the skin and serve as
a temporary bridge. Alternatively, pull in a penrose or a rub-
ber catheter (Fig. 65.4). Dissect some of the omentum off the
Fig. 65.1 colon on both sides for about 5 cm (Fig. 65.5).
Fig. 65.2
Fig. 65.4
Fig. 65.3
Choice of Bridge
Analyze your options for the definitive stoma bridge: pre-

manufactured plastic bridges versus large catheter (24 F).
The plastic bridges sit on top of the skin where they are fixed
with anchoring stitches (Fig. 65.6). They are easy to do, are
Fig. 65.5
strong, but routinely make it difficult to fit an ostomy bag. A
catheter-based bridge can be sutured on the cephalad and
caudad end to the dermis, which makes it easier to fit the patients. The downside, however, is that the entire stoma
appliance all the way to the mucocutaneous junction. You may retract if the sutures break (rare). Once you decide
may further vary a bit more, how much traction to put on the which approach to use, grab the end of that bridge with the
colon which may prove to be an advantage in very obese temporary bridge clamp and pull/slide it to the other side.
65 Creation of Transverse Colostomy (Loop, Prasad-Type) 523
Fig. 65.7
Fig. 65.6
Maturation of Colostomy
Using 2–0 or 3–0 atraumatic Vicryl sutures, circumferen-

tially attach the abdominal wall structures to the colon to
prevent spillage of stool into the peritoneal cavity once it is
opened. Start in a deeper layer with the posterior rectus
sheath and peritoneum, followed by a more superficial layer
of dermis to the colon serosa. Tacking the stoma to the
abdominal wall does not really increase the difficulty of
mobilization during a subsequent closure of the colostomy.
If additional incisions (laparoscopy or midline) are present,
close these in standard fashion before maturing the stoma. Fig. 65.8
Once all incisions are closed, make a small colotomy
with the scissors and allow the gases to escape. Do not use
electrocautery to avoid triggering an explosion of com- with a linear-cutting stapler (transection only or with resec-
bustive bowel gases. After the first opening and venting tion). Be careful to correctly identify the proximal and distal
bowel gas, you can use cautery to extend the incision. stapled ends as there is no room for error. Bring the full
Both directions (longitudinal or across) have been used. diameter of the proximal bowel and the antimesenteric sta-
Create a 5- to 6-cm longitudinal incision along the ante- pled corner of the distal bowel out of the same colostomy
rior wall of the colon, preferably in the taenia (Fig. 65.7). trephine incision (described in a previous section). Using
Then evert the bowel wall and mature it with interrupted with 3–0 PG sutures, tack both the proximal bowel and the
3–0 PG sutures to the subcuticular layer of the skin distal bowel edge in two layers to (a) the posterior rectus
(Figs. 65.8 and 65.9). Avoid placing sutures through the sheath/peritoneum and (b) the dermis. The distal end can
skin, as to avoid stich abscesses or granulomas. Attach a either be left closed at the skin edge (pseudo mucous fistula),
disposable colostomy bag. or a 2–3 mm opening is created and matured. Once all other
incisions are closed, remove the entire staple line of the
proximal bowel. Suture the full thickness of the bowel to the
Prasad-Type Colostomy subcuticular layer of the skin using 3–0 PG sutures to mature
the proximal stoma. If an aperture is created in the distal
In some cases, where relative certainty about fecal diversion bowel, place a full thickness suture between the proximal
with minimized risk of overflow is desired, the surgeon may and the distal apposed bowel walls. Document in detail the
choose to fashion a pseudo-loop Prasad-type end colo- technique used to fashion the stoma in the operative note.
colostomy. The proximal and distal side have been closed This is to avoid confusion when the stoma is reversed.
• Stoma necrosis or retraction, particularly in very obese

patients.
• Prolapse of both the defunctionalized or the active limb is
fairly common in a loop colostomy. It is best managed by
restoring intestinal continuity including removal of the
original site of obstruction; alternatively, it can be con-
verted into an end or Prasad-type colostomy.
• Parastomal hernias: the rule rather than the exception.
Further Reading
Bergren CT, Laws HL. Modified technique of colostomy bridging. Surg
Gynecol Obstet. 1990;170:453.
Cataldo PA. Technical tips for stoma creation in the challenging patient.
Doberneck RC. Revision and closure of the colostomy. Surg Clin North
Am. 1991;71:193.
Fitzgibbons RJ Jr, Schmitz GD, Bailey RT Jr. A simple technique for
Fig. 65.9 constructing a loop enterostomy which allows immediate placement
of an ostomy appliance. Surg Gynecol Obstet. 1987;164:78.
Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen
HG. Temporary decompression after colorectal surgery: random-
Postoperative Care ized comparison of loop ileostomy and loop colostomy. Br J Surg.
1998;85:76.
• In the operating room, apply an adhesive-type colostomy 2009. Retrieved November 14, 2022, from https://accesssurgery.
bag. mhmedical.com/book.aspx?bookID=425.
• Antibiotics: Routine coverage for the perioperative Majno PE, Lees VC, Goodwin K, Everett WG. Siting a transverse
24-hour period. In case of an underlying infection/sepsis, colostomy. Br J Surg. 1992;79:576.
continue respective therapeutic antibiotics. Hull TL, Read TR, Saclarides TJ, Senagore AJ, Whitlow CB, edi-
• Intravenous fluids: Maintain adequate fluid until return of tors. The ASCRS textbook of colon and rectal surgery. 3rd ed.
bowel function. New York: Springer; 2016. p. 971–1013.
• Keep the nasogastric tube to suction until the colostomy Morris DM, Rayburn D. Loop colostomies are totally diverting in
adults. Am J Surg. 1991;161:668.
functions. Ng WT, Book KS, Wong MK, Cheng PW, Cheung CH. Prevention
• Diet: Start diet once NG tube discontinued. of colostomy prolapse by peritoneal tethering. J Am Coll Surg.
• Stoma: Start early stoma teaching to avoid delaying dis- 1997;184:313.
charge. Leave the bridge between 2 and 3 weeks to allow
for a good connection between the bowel and the abdomi-
nal wall.
Complications
• Peristomal sepsis is surprisingly uncommon. Treatment

requires incision and drainage either into the stoma bag or
far enough to be outside the waver of the appliance.
Massive sepsis may require stoma relocation.
Laparoscopic Versus Open Creation
of Sigmoid Colostomy (Loop, 66
Prasad-Type, End)
Indications Laparoscopy:
• A sigmoid colostomy as the sole procedure is performed • Patients with severe cardiac and restrictive pulmonary
for temporary or permanent fecal diversion when the disease for whom the carbon dioxide pneumoperitoneum
stoma should be as distal as possible to minimize the and Trendelenburg position may impair the cardiac output
impact on fluid balance. or create intolerable acidosis.
• Specific indications for sigmoid colostomy include • Severe intraabdominal adhesions.
obstructing rectal or anal cancer, severe pelvic floor dys- • Bleeding disorders.
function (fecal incontinence, fecal outlet obstruction), • Pregnancy (the enlarged uterus can obstruct the view).
pelvic trauma, recto-urinary or rectovaginal fistulas, peri-
anal or rectal Crohn disease, and congenital anomalies.
• The laparoscopic approach is preferred in absence of con- Preoperative Preparation
traindications as it allows the surgeon to readily mobilize
the sigmoid to reach the abdominal wall, verify the cor- • Study the patient’s history and verify the diagnosis and
rect orientation, or to use a different solution (transverse appropriate indication by clinical, radiographic, or endo-
colostomy, ileostomy), should the sigmoid colon prove scopic means.
not be suited for diversion. • Review preoperative images if available (CT scans, plain
x-ray films, contrast enemas).
• Mark the site for the stoma: this is mandatory for elective
Contraindications stoma creations.
• Educate the patient about stoma function and lifestyle
Sigmoid (as opposed to other locations): modifications.
• Routine antibiotic prophylaxis (unless therapeutic indica-
• Previously eliminated sigmoid loop (e.g., after rectosig- tion for active infection).
moid resection).
• Acute or chronic pathology in the left lower quadrant.
• Superobesity: a transverse colostomy may be more likely Pitfalls and Danger Points
to reach to the skin without tension.
• Poorly selected stoma location
• Short sigmoid mesentery with risk for stoma retraction
• Narrow fascial opening with risk of stoma necrosis or out-
let obstruction
C. P. Spanos
• Wide fascial opening with risk of prolapse, or peristomal
Medicine, Thessaloniki, Greece herniation
• Obesity
A. M. Kaiser (*)
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_66
• Maturing the “wrong end” of the colon as a result of a blowout of the segment distal to the stoma and proximal to
bowel orientation confusion the obstruction. If the goal of creating a colostomy is to
• Ureteral injury achieve the most complete diversion of stool from a non-
• Previous surgeries and pathologies that limit the sigmoid obstructed distal area (reconstruction, fistula, incontinence),
colon mobility the efferent limb can either be closed completely with a sta-
pler or a Prasad-type pseudo-loop colostomy can be created.
For the latter, the proximal end is brought out as a functional
Operative Strategy end colostomy, and a tiny edge of the distal stapler-transected
end is either fixed to the afferent limb or brought out as a
Choice of Procedure and Site mini-mucous fistula in the same opening. This construction
has the advantage over a true loop that it is less prone to her-
A sigmoid colostomy or a loop ileostomy is the preferred alter- nia formation and prolapse (but it will require a resection and
native to a transverse colostomy for the majority of elective situ- anastomosis for closure).
ations. Under urgent/emergency circumstances, when a
Hartmann type resection is performed, the creation of the end
colostomy may follow similar principles except it is preceded by Documentation Basics
a bowel resection and/or damage control. In selecting the right
location and type of stoma, it is important to consider all past, Coding for surgical procedures is complex. Consult the most
current, and future interventions that may interfere with the cur- recent edition of the AMA’s Current Procedural Terminology
rent creation or which may be handicapped by the new stoma. book for details (see references at the end). In general, it is
Identification of an optimal stoma site will reduce local important to document:
complications such as skin erosion, stoma trauma, and
retraction. Use all positions (standing, supine, and sitting) to • Findings and indication for diversion.
mark the stoma site. Ideally this should lie on a vertical line • Reasoning for choice of type and site.
within the boundaries of the rectus muscle. Remember that • Construction details: loop, Prasad-type, end, Hartmann
in obese patients, a comparably much higher (cephalad) type.
stoma site needs to be selected as the pannus may shift down- • Tacking (or absence) of colon to fascia.
ward and bury a classical “left lower quadrant” location. • Use of stoma bridge.
Creation of a loop colostomy may jeopardize the mar- • Use of abdominal wall reinforcement.
ginal artery blood flow and potentially devascularize the dis- • It is important to document technical details when fash-
tal colon. This again is critical when considering a stoma ioning any type of stoma. This will facilitate the reversal
proximal to a previous anastomosis. of a temporary stoma.
Access Operative Technique
The segment of intestine chosen for the ostomy formation When constructing a sigmoid colostomy of any type, place
must reach to the skin without tension, and the mesentery must the patient in a modified lithotomy and moderate
not be twisted during stoma formation. Even though the sig- Trendelenburg position with both arms tucked. Assure ready
moid can in some cases be directly pulled up through a small access to the rectum and have a rigid or flexible sigmoido-
single-incision open approach (sometimes termed a “trephine” scope available.
colostomy), that cannot be anticipated from outside. In fact
not infrequently, the sigmoid is less mobile than one would
expect, and the laparoscopic approach allows for safe mobili- I ncision, Identification, and Mobilization
zation under direct view to achieve adequate reach. of the Sigmoid Colon
Open—Through Laparotomy
Type of Fecal Diversion A standard laparotomy allows you to perform a controlled lysis
of adhesions, release attachments, and positively identify and
If the purpose of the colostomy is to decompress and vent a mobilize the target segment (as if a resection were to be per-
colon obstructed by anorectal pathology, a loop colostomy formed). Once you have verified that it will reach your stoma
with equal weight openings for the afferent and efferent seg- marking, you can proceed with creating the gap at the colostomy
ment should be created. If the colon is empty but at risk for site. This is done in the same fashion as described in the next
an obstruction, a small mucous fistula is sufficient to prevent paragraph, but with the luxury of access from inside as well.
66 Laparoscopic Versus Open Creation of Sigmoid Colostomy (Loop, Prasad-Type, End) 527
pen—Through Colostomy Site Only

O
Make a circular incision at the stoma site marking. To make
a perfect circle, use the plunger handle of a 60 cc syringe to
make an impression on the skin. When no previous laparot-
omy has been performed, it may—depending on the body
habitus—be easy to find the sigmoid colon using this inci-
sion. Incise the subcutaneous fat down to the level of the
anterior rectus fascia without creating dead space. Make a
cruciate incision of 2–4 cm long in either direction on the
anterior rectus fascia with electrocautery. Expose the rectus
muscle and spread its fibers all the way to the posterior rectus
sheath by inserting and opening a clamp, followed by the
retractors. Avoid injury to the inferior epigastric vessels; oth-
erwise, suture-ligate them. Enter the abdomen by incising
the posterior rectus sheath and peritoneum. This is the colos-
tomy “trephine,” which should be wide enough to accom-
modate at least 2 fingerbreadths. Feel for adhesions between
the anterior abdominal wall and abdominal contents by
sweeping the index finger through the incision. If necessary,
take them down in a controlled fashion.
Key landmarks to identify the sigmoid colon are the tenia
and the epiploic appendages. After entering the peritoneal
cavity, push the omentum and hence the transverse colon
cephalad from the operative field with a sponge-on-a-stick.
Identify the sigmoid colon and gently deliver it through the
trephine using a Babcock clamp. Identify the margin of the
colon with its mesocolon and open a small defect with elec-
trocautery. Use a tonsil clamp to dissect through the mesoco-
Fig. 66.1
lon and complete a window. Bring a red Robinson or a
Penrose drain through the defect and use this as a temporary
bridge for the colostomy.
If it does not easily reach the anterior abdominal wall, mobi-
Laparoscopic lize the sigmoid by freeing up adhesions and releasing the
As with all laparoscopic procedures, the surgeon, target area, lateral peritoneal attachments (using cautery or an energy
and primary video monitor should all be in one line device) (Fig. 66.4). Dissect from the inferior lateral part of
(Fig. 66.1). The surgeon stands at the right side; the monitor the sigmoid up to the splenic flexure until there is sufficient
hence will be on left side at the level of the patient’s hip/ mobility for a tension-free colostomy. Create a small win-
knee. Access and creation of the pneumoperitoneum are dow in the mesocolon and slide in a small Penrose drain.
done using an appropriate and safe standard approach start- Loop it and secure it with a locking laparoscopic grasper.
ing at the umbilicus: (1) open cut-down (Hasson technique) Clearly mark afferent versus efferent limb in any absolute
or (2) Veress needle technique with optical trocar insertion. fashion of your preference. For example, place two marking
Two additional ports are inserted under visual control with clips proximal and one clip distal to the gap in the
one in the right lower quadrant and one through the planned mesocolon.
stoma site (Fig. 66.2) . If a Hartmann type colostomy is planned, the bowel can
Alternatively, you can create the trephine first (as be divided intracorporeally with a laparoscopic stapler
described in the previous section) and insert a mini-gel port (Fig. 66.5). You may have to divide the mesentery a bit more
with trocar. Two additional trocars are placed under visual to allow for good mobility. Secure the proximal bowel with a
control at the umbilicus and the right lower quadrant. locking atraumatic grasper.
Quickly examine the entire abdomen; then place the Remove the trocar at the stoma site and create the tre-
patient in Trendelenburg position with left side up 30° to phine as described in the previous section. Pause and deflate
move the small bowel out of the pelvis and expose the sig- the pneumoperitoneum. Pull the Penrose drain with the
moid colon. bowel loop up. Reinsufflate the abdomen to confirm the
Grasp the sigmoid colon with a Babcock clamp through reach, correct position, and rotation of the loop and to verify
the stoma site trocar (Fig. 66.3). Draw it toward the trocar. hemostasis.
Fig. 66.4
Fig. 66.2
Fig. 66.5
Fig. 66.3
66 Laparoscopic Versus Open Creation of Sigmoid Colostomy (Loop, Prasad-Type, End) 529
Stoma Orientation
If a loop colostomy is created, there is no special need to ori-

ent the bowel—as long as it is not unduly twisted. Otherwise
and if it was not possible to mark and orient the bowel inter-
nally, you must correctly identify afferent versus efferent
limb. Gently lift the exteriorized bowel with the Penrose
drain. Clamp off the bowel lumen with one click of a non-
crushing bowel clamp. Inflate the rectum with a rigid or flex-
ible sigmoidoscope. The distal (efferent) sigmoid loop will
inflate. Mark it with a Vicryl suture. Remove the bowel
clamp.
bdominal Wall Reinforcement (Hernia

A
Prevention)
Parastomal hernia formation is inevitable if the stoma

remains in place long enough. If the stoma is planned for
more than just a short period of time, it may be worthwhile
to reinforce the abdominal wall with a biological implant Fig. 66.6
(collagen sheath). Before pulling through the bowel, you
may place a rectangular piece with a central cruciate incision
anterior to the posterior rectus sheath (behind the rectus mus- really increase the difficulty of mobilization during a subse-
cle). Secure it to that fascia with a few interrupted stitches. quent closure of the colostomy. If additional incisions (lapa-
roscopy or midline) are present, close these in standard
fashion before maturing the stoma.
Choice of Bridge
Loop Colostomy
Depending on the patient’s body habitus, a stoma bridge may Make a small colotomy with the scissors and allow the gases
not always be necessary for a loop sigmoid colostomy. But in to escape. Do not use electrocautery to avoid triggering an
many instances, the bridge helps to prevent the bowel from explosion of combustive bowel gases. After the initial vent-
retracting (Fig. 66.6). Analyze your options for the definitive ing, you can use cautery to extend the incision. Both direc-
stoma bridge: premanufactured plastic bridges versus large tions (longitudinal or perpendicular to the bowel axis) have
catheter (24 F). The plastic bridges or rods sit on top of the been used. For the former, create a 5- to 6-cm longitudinal
skin where they are fixed with anchoring stitches. They are incision along the anterior wall of the colon, preferably in the
easy to do and strong, but routinely make it difficult to fit an tenia. For the latter, open roughly two thirds of the bowel
ostomy bag. A catheter-based bridge can be sutured on the circumference. Then evert in either case the bowel wall and
cephalad and caudad end to the dermis, which makes it eas- mature it with interrupted 3–0 PG sutures to the subcuticular
ier to fit the appliance all the way to the mucocutaneous junc- layer of the skin (Fig. 66.6). Avoid placing sutures through
tion. Once you decide which approach to use, grab the end of the skin, as to avoid stich abscesses or granulomas.
that bridge with the temporary bridge clamp and pull/slide it
to the other side. Prasad-Type Colostomy
In some cases where relative certainty about fecal diversion
with minimized risk of stool overflow is desired, you may
Maturation of Colostomy choose to fashion a pseudo-loop Prasad-type end colo-
colostomy. The proximal and distal side have been closed
Using 2–0 or 3–0 atraumatic Vicryl sutures, circumferen- with a linear-cutting stapler (transection only or with resec-
tially attach the abdominal wall structures to the colon to tion). Verify the correct bowel orientation for the proximal
prevent spillage of stool into the peritoneal cavity once it is and distal stapled ends as there is no room for error. Bring the
opened. Start in a deeper layer with the rectus sheath, fol- full diameter of the proximal bowel and the antimesenteric
lowed by a more superficial layer of dermis to the colon stapled corner of the distal bowel out of the same trephine
serosa. Tacking the stoma to the abdominal wall does not (described in a previous section). Using with 3–0 PG sutures,

indication.
bowel function.
• Diet: Start diet as tolerated.
• Stoma: Start early stoma teaching to avoid delaying dis-
charge. Leave the bridge in place between 2 and 3 weeks
to allow for good healing between the bowel and the
abdominal wall.
Complications
• Peristomal abscess and sepsis is rare. Treatment requires

incision and drainage either into the stoma bag or far
enough to be outside the waver of the appliance. Massive
sepsis may require stoma relocation.
• Stoma necrosis or retraction, particularly in very obese
patients: If the stoma appears dusky or dark, evaluate it by
inspecting the mucosa above and below the fascia. If the
Fig. 66.7 viability is compromised below the fascia, the stoma
needs to be revised immediately. If it only affects the
tack both the proximal bowel and the distal bowel edge in bowel part above the fascia, it will likely stricture; timing
two layers to (a) the posterior rectus sheath/peritoneum and of a stoma revision versus takedown can be
(b) the dermis. The distal end can either be left closed at the individualized.
skin edge (pseudo-mucous fistula), or a 2–3 mm opening is • Prolapse of both the defunctionalized or the active limb is
created and matured. Once all other incisions are closed, fairly common in a loop colostomy. It is best managed by
remove the entire staple line of the proximal bowel. Suture restoring intestinal continuity including removal of the
the full thickness of the bowel to the subcuticular layer of the original site of obstruction; alternatively, it can be con-
skin using 3–0 PG sutures to mature the proximal stoma verted into an end or Prasad-type colostomy.
(Fig. 66.7). If an aperture is created in the distal bowel, place • Parastomal hernias: The rule rather than the exception.
full-thickness sutures between the proximal and the distal • Skin dermatitis from intestinal content leakage.
apposed bowel walls. Document in detail the technique used
to fashion the stoma in the operative note. This is to avoid
confusion when the stoma is reversed.
Further Reading
End Colostomy
The process is exactly the same as in the previous section American Medical Association. Current procedural terminology: CPT
except that there is either no distal segment or it is left a blind https://www.ama-assn.org/practice-management/cpt.
stump in the abdomen. Cataldo PA. Technical tips for stoma creation in the challenging patient.
Corman ML. Intestinal stomas. In: Corman ML, editor. Bergamaschi
Postoperative Care Rectal surgery. sixth ed. Philadelphiaffig: Lippincott Williams &
Wilkins; 2012. p. 1396–450.
• In the operating room, apply an adhesive-type transparent Kaiser AM. McGraw-Hill Manual Colorectal Surgery. Access Surgery;
colostomy bag. 2009. Retrieved November 14, 2022, from https://accesssurgery.
• Antibiotics: Routine coverage for the perioperative McGee MF, Cataldo PA. Chapter 55: intestinal stomas. In: Steele SR,
24-hour period. In case of an underlying infection/sepsis, Hull TL, Read TR, Saclarides TJ, Senagore AJ, Whitlow CB, edi-
tors. The ASCRS textbook of colon and rectal surgery. 3rd ed.
New York: Springer; 2016. p. 971–1013.
Closure of Temporary Loop Colostomy
or Ileostomy 67
Indications • Routine bowel cleansing for colostomy takedown; clear

liquid diet only for ileostomy takedown
A temporary ostomy can be closed when it is no longer • Enemas to cleanse the inactivated left colon segment may
needed. Wait a minimum of 6–12 weeks after creation of the be required as well, particularly if residual stool or con-
stoma to allow for the adhesions to soften. Never close an trast is present
ostomy before evaluating the distal gastrointestinal tract in • Perioperative systemic antibiotics
general and particularly the distal bowel (with particular
attention to the region of concern that prompted creation of
the stoma). Thus, adequate healing of a distal anastomosis, Pitfalls and Danger Points
fistula repair, or other type of reconstructive surgery, as well
as absence of a distal obstruction and resolution of any signs • Enterotomy of stoma-bearing bowel or adjacent small
of sepsis, should be demonstrated by physical, endoscopic, bowel
and radiographic examinations. Loop ostomies may be • Dense peritoneal adhesions, inability to exteriorize bowel
closed by the techniques described in this chapter. loop
• Abdominal compartment syndrome if large hernia
repaired as well
Contraindications • Surgical site infections
• Bowel obstruction
• Non-resolved distal pathology • Incisional hernia
• Unfavorable operability criteria • Reactivation of distal area of concern (e.g., former anas-
• Superobesity tomotic leak or fistula)
• Water-soluble contrast enema radiography to demonstrate Keep in mind three key points for success with these proce-
patency of distal colon and integrity of a distal dures: adequately mobilize the bowel to ensure a tension-
anastomosis free closure or anastomosis, use well-vascularized and
• Flexible sigmoidoscopy or colonoscopy if the radio- healthy tissue for closure, and take care not to create inadver-
graphic result is not pristine tent bowel wall injuries.
Adequate lysis of the adhesions between the bowel and
surrounding structures allows a sufficient segment of bowel
C. P. Spanos
to be mobilized, avoiding tension on the suture line. If neces-
Medicine, Thessaloniki, Greece sary, the incision in the abdominal wall should be enlarged to
provide exposure. If the tissue in the vicinity of the ostomy
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of has been devascularized or injured by operative trauma, do
Hope National Medical Center/Comprehensive Cancer Center, not hesitate to resect a segment of bowel and perform an end-
Duarte, CA, USA to-end anastomosis instead of a local reconstruction. Proper

https://doi.org/10.1007/978-3-030-81415-1_67
sutured closed, creating dead space. Avoid this problem by

leaving the skin open at the conclusion of the operation.

Fig. 67.1
• Indications
• Findings justifying stoma takedown
• Extent of adhesions
• Resection of bowel
• Type of anastomosis (end-to-end, side-to-side)
• Stapled or hand-sewn
• Hernia repair (with or without collagen implant)
• Wound closure or not
Operative Technique
General anesthesia is needed for the procedure. Place the

patient in supine position unless there is a specific need to
have access to the anus or left-sided colon. Always carry out
Fig. 67.2
a digital rectal exam prior to prepping the patient to verify
patency of a distal anastomosis.
suturing or stapling of healthy bowel wall and minimizing
fecal contamination combined with perioperative antibiotics
help prevent formation of abscesses. Incision
The technical steps and methods to actually restore the
intestinal continuity are the largely the same for the closure Using a scalpel, make a transverse elliptic skin incision
of a loop ileostomy and a loop colostomy. A stapled side-to- around the stoma that tangentially cruises along the upper
side (functional end-to-end) anastomosis is easy, safe, and and lower mucocutaneous junction at 1–2 mm distance and
fast and is the method of choice for closure of a loop ileos- extends 1–1.5 cm on the sides (Fig. 67.1). Use electrocautery
tomy. However, the method creates an iatrogenic giant diver- to stop any skin bleeders. Place Kocher or Allis clamps to
ticulum, which functionally may not be a problem in the each of the lateral skin tongues, potentially also from the
small intestine. In the colon with its more formed stool, how- upper to the lower lip, and gently lift them up.
ever, it could potentially result in stool accumulation (termed Deepen the incision with the cautery until the seromuscu-
“clustering”) and make subsequent colonoscopies more lar layer of the bowel. Switch to fine Metzenbaum scissors,
challenging. For that reason and in contrast to the other loca- and separate the bowel wall from the subcutaneous fat with
tions, it is our preference to do colo-colonic anastomoses in meticulous sharp dissection (Fig. 67.2). Take care not to
an end-to-end fashion, or sometimes in an isoperistaltic side- injure the bowel wall. Continue down to the point where the
to-side configuration. bowel meets the anterior rectus fascia.
Infection of the operative incision is expected following
colostomy closure, owing in part to failure to minimize the
bacterial inoculum into the wound. Another phenomenon Fascial Dissection
that contributes to wound infection is retraction of subcuta-
neous fat that occurs around the colostomy. This can produce Continue the dissection carefully and with patience.
a gap between the fascia and the epidermis when the skin is Anticipate that the anatomical layers will be distorted; often
67 Closure of Temporary Loop Colostomy or Ileostomy 533
there is a hernia sac and the fascia not immediately visible. most commonly accomplish this through a fairly small defect
The more difficult the dissection seems, the more you should in the abdominal wall.
preserve control and avoid any undue traction or blunt finger
dissection, as it may create a bowel injury in the depth of the
wound that (1) you may not notice or that (2) you would Strategies for the Difficult Dissection
extremely difficult to repair. Follow the bowel wall circum-
ferentially and dissect it off the fascial ring and muscle layer In the event that you encounter an unexpected degree of
until the peritoneal cavity is entered. If the bowel was previ- adhesions that result in a recognized problem (e.g., enterot-
ously sutured to the fascia, do not hesitate to cut the fascia omy) or in serious difficulty to make any progress, keep two
(err on the side of fascia) to release the bowel. Facilitate this salvage strategies in mind:
dissection by placing Kocher clamps on the edge of the fas-
cia and gently lifting it (Fig. 67.3). 1. Extend the incision laterally by dividing the remainder of
the rectus muscle with electrocautery for a distance ade-
quate to accomplish the dissection safely.
Peritoneal Dissection 2. Perform a formal laparotomy and perform the lysis of
adhesions from inside.
Once the peritoneal cavity has been identified and partially
entered, it is often possible to insert an index finger and gen-
tly expose areas with residual adhesions. For the reasons Bowel Anastomosis
mentioned above, it is better to divide them under visual con-
trol than to bluntly free the bowel with the finger. The ulti- Carefully inspect the wall of the mobilized bowel for any
mate goal is to safely free the bowel from any abdominal injury. A few small superficial patches of serosal damage are
wall structures, hernia sac, or peritoneal adhesions in the of no significance so long as they are not accompanied by
vicinity of the ostomy until a sufficient exteriorization of the devascularization.
stoma-bearing bowel segment has been achieved. You can
esection with Stapled Side-to-Side (Functional
R
End-to-End) Anastomosis
This is the most common technique for an entero-colonic or
entero-enteric anastomosis, hence also for ileostomy take-
down. As long as the bowel more proximal and more distal
look less traumatized, this approach allows you to discard
the bowel segment that was roughed up by the dissection
through the abdominal wall. Identify the level on either side
where you plan to transsect the bowel. Divide the mesentery
up to those points, using either stepwise ligation or an energy
device. Align the bowels side by side. Use scissors to create
an enterotomy on either side in the part that will eventually
be resected. Gently insert a cutting linear stapler (70–80 mm
long). Assure that the two bowel loops meet on their antimes-
enteric sides and the mesentery is not caught into the stapler.
Fire the stapler to create the main connection. Grasp the
edges of the enterotomies with Allis clamps. Fire 1-2 reloads
of the same stapler across the end below the Allis clamps.
That will close off and at the same time resect the ostomy-
bearing bowel segment. Alternatively, the end may be stapled
closed with a noncutting linear TA stapler and manually
amputated with a knife. Send the specimen to pathology.
Assure that the diameter of the actual anastomosis is at least
a bit larger than the smaller of the two bowel diameters.
While many surgeons would stop here, it is our preferred
practice to routinely oversew the staple lines with seromus-
cular absorbable 3/0 sutures and close the mesenteric defect.
Fig. 67.3
Fig. 67.4
imple Closure of Antimesenteric Bowel Wall

S Fig. 67.5
Opening
This technique is commonly used for a loop colostomy take-
down with healthy bowel wall in immediate proximity to the
excised mucocutaneous junction. As the backwall already
exists, there is no benefit in dividing the bowel and perform-
ing a full end-to-end anastomosis. If the adjacent bowel wall
has a normal texture and thickness, it suffices to completely
excise the skin edge that is still attached to the bowel. Close
the opening in the transverse direction, carefully making
sure not to narrow the lumen throughout the area. Initiate the
closure by placing two seromuscular holding stitches on
either end of the transverse closure and pull them in opposite
direction. Close the defect from one to the other end using a
common technique for bowel anastomosis (Fig. 67.4). Our
own preference is to close it in two layers: the first full-
thickness layer using a running absorbable monofilament 3/0
suture (PDS, polydioxanone) is placed such that the bowel
wall is nicely inverted; the second seromuscular layer with
interrupted 3/0 Vicryl approximates the two sides and takes
of some tension from the first layer (Fig. 67.5). Make sure to Fig. 67.6
avoid too excessive inversion of the bowel wall which could
cause a narrowing of the anastomosis. Because of the trans- (cutting or noncutting, Fig. 67.7); the other option is to
verse direction of the suture line, the lumen of the colon apply a curved cutting stapler. In both settings, verify that
more often is quite large at the conclusion of the closure. there are no gaps and consider oversewing the staple line
There should be no tension whatever on this suture line. with an absorbable suture.
If the colon wall is of normal consistency and the bowel Variations of the hand-sewn technique are also applicable
lumen very large, transverse stapling is an excellent to a loop ileostomy with a nipple. This may come in handy,
method for closing the colon defect, and the risk of an when adhesion makes it very difficult to obtain sufficient
obstruction is very low. Use Allis clamps or holding mobility to do a stapled anastomosis. As first step, you will
stitches to align the two lips of the opening in transverse have to undo the Brooke eversion of the nipple. Once that is
fashion (Fig. 67.6). One option is that you close the open- achieved, you can complete the end-to-end reconnection the
ing with two triangulated cartridges of the linear stapler same steps as described above.
67 Closure of Temporary Loop Colostomy or Ileostomy 535
Align the two staple-closed bowel ends to be conjoined in

isoperistaltic fashion with a 5–6 cm overlap. Make a small
enterotomy at one end of the overlap and insert the linear
cutting stapler jaws to create the connection. Close the enter-
otomy in two layers as described in the previous section.
Closure of Abdominal Wall
Irrigate the area. Remove residual hernia sac and dissect the
subcutaneous fat off the anterior wall of the fascia for a width
of 1–2 cm until a clean rim of fascia is visible all around.
Assess whether to primarily close the abdominal wall defect
or to address a major hernia defect by placing and securing a
firm collagen sheath in underlay technique. In the latter case,
position a biological mesh (collagen sheath) of adequate size
on the inside of the abdominal wall closure and place a series
of transfascial holding stitches under visual control.
Otherwise, reapproximate the muscle layer with a few inter-
rupted absorbable sutures, followed by a closure of the fascia
layer.
Management of Skin Wound

Fig. 67.7 Frequently the colostomy can be closed without enlarging
the skin incision. If a very large hernia had to be reduced and
Resection and End-to-End Anastomosis fixed as well, you may have to trim the redundant skin to
This technique with an end-to-end anastomosis is the method avoid an unnatural folding. Closing of the wound is associ-
of choice for takedown of a colostomy (less common of an ated with a 20–25% incidence of wound infection. Many sur-
ileostomy) where there is a need to reconnect to separate geons therefore leave the skin open for healing by secondary
bowel ends. That situation may arise if the tissue is of inad- intention. Since 75–80% do not get infected, you might con-
equate quality for a simple transverse closure or if a Prasad- sider closing it with the plan to observe the wound carefully
type colostomy is being taken down. A stapled side-to-side and open it if signs of infection develop. In both scenarios,
(functional end-to-end) is a suboptimal configuration for a you would manage the open wound by placing loosely
colo-colonic anastomosis. packed moist gauze into the subcutaneous space to keep the
Mobilize the bowel—if necessary by enlarging the inci- tissue separated.
sion in the abdominal wall or performing a formal laparot-
omy—and resect the nonviable bowel. Gently free up the
two bowel ends without devascularizing it, and remove Postoperative Care
excessive appendages or omentum. Align the two ends and
construct an end-to-end anastomosis by the usual two-layer • Postoperative routine antibiotics limited to 24 hours.
suture technique. • Enhanced recovery after surgery (ERAS).
• Wound care: monitor closed wound for signs of infection;
open if necessary. Open wound: wet-to-dry dressings,
Resection and Isoperistaltic Side-to-Side mild packing, healing by secondary intention.
Anastomosis • Bowel function: Previously diverted bowel (diversion
colitis) may need a few weeks to months to recondition;
This technique is a hybrid form for a complete reconnection avoid too much intervention in the first 10–14 days other
that combines the speed of stapling and avoiding the down- than fiber supplements, afterward antidiarrheal or laxative
sides of the functional end-to-end anastomosis in the colon. medications as needed.
Complications Camacho-Mauries D, Rodriguez-Diaz JL, et al. Randomized clinical

trial of intestinal ostomy takedown comparing pursestring wound
closure vs conventional closure to eliminate the risk of wound infec-
• Anastomotic leak tion. Dis Colon Rectum. 2013;56(2):205–11.
• Enterotomy of adjacent bowel Hain E, Maggiori L, et al. Persistent asymptomatic anastomotic leakage
• Wound abscess after laparoscopic sphincter-saving surgery for rectal cancer: can
diverting stoma be reversed safely at 6 months? Dis Colon Rectum.
• Intra-abdominal abscess or formation of entero−/colocu- 2016;59(5):369–76.
taneous fistula Hendren S, Hammond K, et al. Clinical practice guidelines for ostomy
• Bowel obstruction, prolonged postoperative ileus surgery. Dis Colon Rectum. 2015;58(4):375–87.
• Reactivation of distal area of concern (e.g., former anas- Herrle F, Sandra-Petrescu F, et al. Quality of life and timing of stoma
closure in patients with rectal cancer undergoing low anterior resec-
tomotic leak or fistula) tion with diverting stoma: a Multicenter longitudinal observational
• Coloanal dysfunction (incontinence, low anterior resec- study. Dis Colon Rectum. 2016;59(4):281–90.
tion syndrome, outlet obstruction) Hsieh M-C, Kuo L-T, et al. Pursestring closure versus conventional pri-
• Need for rediversion mary closure following stoma reversal to reduce surgical site infec-
tion rate: a meta-analysis of randomized controlled trials. Dis Colon
• Incisional hernia (frequent) Rectum. 2015;58(8):808–15.
Kaiser AM, Israelit S, et al. Morbidity of ostomy takedown. J
Further Reading Gastrointest Surg. 2008;12(3):437–41.
American Medical Association. Current procedural terminology: CPT Hull TL, Read TR, Saclarides TJ, Senagore AJ, Whitlow CB, edi-
®. Professional ed. Chicago: American Medical Association; 2022. tors. The ASCRS textbook of colon and rectal surgery. 3rd ed.
https://www.ama-assn.org/practice-management/cpt. New York: Springer; 2016. p. 971–1013.
Hartmann Reversal (Open,
Laparoscopic) 68
Kasim L. Mirza and Andreas M. Kaiser
Indications • Weight loss: As the stoma reversal is most commonly

optional and elective, insist—for the purpose of safety
A Hartmann procedure is performed under adverse circum- and success—on appropriate weight loss (through dietary
stances for a variety of acute indications, most commonly for modification or bariatric surgery).
complicated diverticulitis, perforated or obstructing left- • Thoroughly review the patient’s history with particular
sided colon cancers, trauma, ischemia, and volvulus attention to the diagnosis, pathology report, and indica-
(Figs. 68.1 and 68.2). A reversal of such a colostomy is med- tion for reversal.
ically not necessary, and hence, in the majority of situations, • Evaluate prior operative reports including the index oper-
a purely elective quality-of-life choice. Sufficient time must ation. Patients may have undergone emergency surgery
have passed, and complete recovery must be documented by another surgeon, thus knowing the operative details is
prior to considering a surgery. Other treatments that have particularly important. Look for margins of the prior
higher priority (e.g., chemotherapy) need to have been com- resection, extent and length of the rectal stump, and pres-
pleted, and the general operability optimized. This chapter ence of a nonabsorbable marking stitch.
describes the laparoscopic and open approach to the reversal • In cases of advanced colorectal cancer, review and discuss
of a Hartmann-type end colostomy. appropriate restaging tests.
• Assess the colon and rectum by colonoscopy and flexible
sigmoidoscopy through stump. Rule out evidence of any
Contraindications residual or synchronous pathology.
• Order and review contrast enemas through the rectum and
• Persistent general illness, low performance status, high the colostomy to obtain a roadmap of the residual large
operative risks intestine anatomy.
• Ongoing need for other treatments (chemotherapy) • Preoperative mechanical bowel cleansing.
• Superobesity • Perform a rectal lavage in the operating room before prep-
• Pregnancy (elective surgery not justifiable) ping and draping.
• Routine antibiotic prophylaxis.
• Ureteral stents are not routinely necessary, but desirable
reoperative Preparation
P in select cases.
• Wait at least 3–6 months after index operation.

K. L. Mirza • Obesity: Limiting view, access, and reach, increased peri-

operative morbidity
Los Angeles, CA, USA • Dense adhesions that interfere with (1) clarifying the
anatomy without collateral damage, (2) freeing up the
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of rectal stump, and (3) the sufficient mobilization of the
Hope National Medical Center/Comprehensive Cancer Center, proximal colon
Duarte, CA, USA • Injury to ureters, bladder, vagina, spleen

https://doi.org/10.1007/978-3-030-81415-1_68
538 K. L. Mirza and A. M. Kaiser
Lateral view
Abdominal
Colostomy
wall Pubic bone
Colon
A
Rectum
Fig. 68.2
that the patient lose a specifically stated amount of weight

(by whatever method) prior to offering surgery. However, it
Fig. 68.1 is important to clarify with the patient and their family that
your request does not reflect discrimination against obese
individuals as such. It is in the patient’s own interest in gen-
• Devascularization of proximal colon (marginal artery, left eral but specifically for carrying out the specific elective sur-
colic, or middle colic artery) gery. After successful takedown, the surgeon does not have
• Strictured rectal stump: inability to advance stapler, rectal an opinion about the patient’s weight anymore.
perforation
• Suboptimal anastomosis with need for re-diversion or
aborting the plan altogether Choice of Approach: Open Versus Laparoscopic
A previous abdominal disaster such as a bowel perforation

Operative Strategy have definite potential to result in substantial peritoneal
adhesions and incisional hernia formation. However, there
Decision to Offer Hartmann Reversal is no test to accurately predict the individual extent of
intraabdominal adhesions by any means. Exceptions exist
In absence of any active problems with the colostomy other such as the personal knowledge from a prior reexploration
than its existence as such, it is important to notice that you do in a specific patient or a history of skin-grafting an open
not have to offer surgery if the overall chances for a favorable abdomen with a minuscule layer of hernia sac and skin on
outcome are less than promising. The patient cannot demand top of the herniating bowels.
this type of surgery. The surgical community will be more Dynamic herniation (e.g., peristomal, incisional) or an
accommodating if the patient actively participates as a team intermittent stoma prolapse in fact usually suggests a low
member in optimizing the circumstances. A prime example degree of peritoneal adhesions. A substantial incisional or
is superobesity which in itself might have been a contribut- peristomal hernia are not an argument against a laparoscopic
ing factor for doing a Hartmann procedure rather than an approach. It may be prudent to defer plans to address the
anastomosis. Obesity is a documented obstacle to success for hernia until the stoma has been successfully reversed. A
the planned surgery. It is absolutely legitimate to demand durable hernia repair will require a synthetic mesh implant
68 Hartmann Reversal (Open, Laparoscopic) 539
which ought to be avoided at the time of a surgery with ostomy, the colon may or may not reach the rectal stump for
exposed open bowel. a tension-free anastomosis. Splenic flexure mobilization
Apart from patient factors such as the aforementioned, the should only be performed when necessary, as this step is
decision to manage a Hartmann reversal via a laparoscopic associated with potential morbidity including injury to the
rather than an open approach mostly depends on surgeon spleen, distal pancreas, and duodenum, depending on the
experience. In retrospective studies and meta-analyses, extent of mobilization.
laparoscopic Hartmann reversal compared to open reversal
was associated with favorable outcomes, including shorter
length of hospital stay, faster return of bowel function, Rectal Stump Mobilization
decreased blood loss, and fewer cardiopulmonary complica-
tions. However, it remains a technically challenging proce- Often the decisive challenge sits in the pelvis. The stump
dure, and conversion rates to open are reported in the range may have sunken down, be still encased by scarring, and the
of 20–25%. Nonetheless, it is a good strategy not to rely on adjacency to relevant structures (urogenital, presacral veins)
assumptions but to start the procedure laparoscopically with and loss of elasticity increase the difficulty. Sharp entry
a limited amount of equipment (particularly disposable lapa- might have to be forced until a natural appearing plane opens
roscopic instruments and accessories, to limit cost), verify up to guide the further dissection.
the feasibility of the approach, and early to either convert or
to proceed full core with the laparoscopy.
Diverting Fecal Stream
Laparoscopic Access
Given the high likelihood of abdominal wall adhesions and It is very important that the patient goes into the operation
risk of hollow viscus injury with a Veress needle, access with the understanding to potentially wake up with an
should be always gained via an open, cut-down (Hasson) ostomy. Rarely, it is just not feasible to perform the recon-
technique. The area with the highest likelihood of adhesions nection. More common, however, is the scenario that the
is underneath the previous scar. The first port to start insuffla- anastomosis is done but does not pass quality assessment.
tion should therefore be placed away from the midline. One For example, a positive leak test or patient factors, such as
option is to begin by taking down the ostomy and using the immunosuppression, might trigger the decision to create a
fascial defect to insert a wound protector, gel port, and a tro- proximal diversion (diverting ileostomy, occasionally right-
car for insufflation. The downside of this approach is that at sided transverse colostomy).
that early moment, it cannot be guaranteed that the pelvis can
be freed up to allow for an anastomosis; if not, the stoma
might have to be brought up again. An alternative approach Documentation Basics
that leaves all options on the table is to place a Hasson trocar
in the right mid-clavicular line, followed by subsequent ports Coding for surgical procedures is complex. Consult the most
under visual control. From there, the midline adhesions and recent edition of the AMA’s Current Procedural Terminology
pelvic entry can be freed up, followed by mobilization of the book for details (see references at the end). In general, it is
rectal stump and the proximal colon, leaving the colostomy important to document:
takedown to last.
• Justification for takedown
Open Access • Findings: type and location of access, extent of adhesions,
If the laparoscopic approach is either not considered or after hernias, mobilization
the first trocars is noted not to be feasible, open the midline, • Open or laparoscopic approach
performing sharp dissection of the adhesions. Adequate • Type and level of anastomosis, leak test
exposure will require a lower midline incision. It may be • Hernia repair, use of biological implant
desirable to extend the old incision cephalad for several cen-
timeters to allow access through an area with fewer
adhesions. Operative Technique
Regardless of the approach, place and secure the patient in

Colonic Mobilization modified lithotomy on an anti-sliding system that allows for
steep Trendelenburg positioning. Preferably, tuck the arms to
The margins of residual colon present at the time of reversal allow best access. Ensure that the hips and anal verge are
will depend on the indication for the index operation (perfo- positioned at edge of bed for access to anal canal. Place a
rated diverticulitis, trauma, perforated colon cancer, etc.). urinary catheter to decompress the bladder and monitor
After mobilizing the proximal colon leading to the end intraoperative urine output. Irrigate the rectal stump to get
rid of any inspissated stool or contrast. Prep and drape the Abdominal
wall Pubic bone
patient and tape-cover the stoma.
Resceted
colostomy
Abdominal
Open Hartmann Reversal wall wound
Colon
Using the scalpel, make a lower midline laparotomy inci-
sion. Carefully enter the abdomen avoiding bowel injury by Anvil
anticipating small bowel adhesions. Divide adhesions using
a combination of blunt dissection, cautery or another energy
device, or sharp dissection with a scalpel or scissors as
needed to define the anatomy and visualize structures on the
left side of the abdomen and the pelvic entry. Once the
abdominal wall is freed up and the small bowel adequately
mobilized, place a self-retaining retractor. Optimize the
exposure toward the pelvis by packing and retracting the
small bowel away. Stapler
Turn your attention to identifying and mobilizing the rec-
Fig. 68.3
tal stump. If a nonabsorbable marking suture was placed at
the index surgery, it may now lead the way. Identify and
avoid both ureters, which may have shifted medially from Colon Anvil Stapler
their natural location. If the adhesions are dense, you could
consider temporarily filling the bladder through the urinary
catheter, and placing a sizer into the vagina and/or the rectal
stump to clarify the boundaries of the individual structures.
It may be necessary that you sharply enter the overlying scar
tissue which carries some risks of getting into bleeding but
may open up one of the natural planes.
You may have to resect the end of the rectal stump to
obtain a soft tissue for the anastomosis. Also—particularly if
the disease necessitating the Hartmann resection was diver-
ticulitis—you should assure that all sigmoid has been
resected to the level of the coalescence of the tenia. Verify
that a sizer or stapler could be advanced all the way to the
end of the rectal stump. If you need to resect, open the serosa
on both sides at the appropriate level of the rectum and create
a window in the mesorectum. Transsect the rectum using a
transverse cutting stapler. Divide the residual mesorectum/
mesocolon of the part you wish to resect and remove the
Fig. 68.4
specimen. Last but not least, it may—after a very difficult
dissection—be worthwhile to do an air leak test on the rectal
stump to rule out an unrecognized injury. (1) check for axial malrotation of the proximal bowel and (2)
Only now comes the time to address the proximal colon to actively hold fat, mesentery, and anterior urogenital struc-
(Fig. 68.3). Even though you could formally take down the tures out of the locking zone as the stapler is closing. Fire,
stoma, it may be cleaner (if there is sufficient length) to ini- remove the stapler, and check the two donuts for intactness
tially leave it under the cover and internally staple the bowel (Fig. 68.5).
off, flush to the inside of the abdominal wall. Mobilize the Perform an air leak test by placing the patient in slight
colon as much as necessary to reach the rectal stump without reversed Trendelenburg and filing the pelvis with irrigation
tension. fluid. Gently compress the bowel proximal to the anasto-
Open the end of the proximal colon, place a purse-string mosis with two fingers and instruct the assistant to insuf-
suture, and insert the anvil of a circular stapler. Insert the flate air into the rectum using a rigid or flexible
stapler body through the anus and carry out the anastomosis sigmoidoscope. Your clamping fingers allow to feel the
in standard fashion (Fig. 68.4). Safety measures include to insufflation while looking for air bubbles. If bubbles
68 Hartmann Reversal (Open, Laparoscopic) 541
reduce all contents back into the abdominal cavity, and clear
the fascial edges of hernia sac.
After thorough irrigation and suction of the peritoneal
cavity, reassess the entire abdomen, run the small bowel, and
check for any enterotomies. Confirm hemostasis, remove
any laparotomy pads, and rearrange the small bowel mesen-
tery such that it is free of torsion.
Close the laparotomy incision including the skin (see
Chap. 4). Remove the cover from the stoma site. Make an
elliptic incision around the stoma and dissect out the short
remnant of the bowel and hernia sac. Irrigate the area and
close in layers. Whether to close or leave open the wound is
a matter of debate and personal preference.
Laparoscopic Hartmann Reversal
If the surgery is done laparoscopically, the strategy and steps

A beyond getting access and developing a sufficient working
space are exactly the same. After you placed your first one or
B
two ports and have decided to pursue the laparoscopic route,
start taking down the midline adhesions and work toward the
left and the pelvis. Liberally place additional ports as needed
and space permits. Allow the table position to help you in
elevating the current working area. Reassess on a regular
basis whether your progress is adequate. Conversion is not a
failure but a judgment. One step before conversion could be
to truly takedown the colostomy and place a hand port for
Fig. 68.5 hand-assisted dissection. As described for the open approach,
your subsequent steps to achieve laparoscopically in broad
terms are the following:
escape, your options include to oversew the anastomosis,
redo the anastomosis, and/or divert proximally (see Chap. • Identify the rectal stump and mobilize an adequate end
4). Even if the air leak test was negative, it may still be that can be reached with the transanal sizer/stapler.
beneficial to reinforce the staple line with a few absorbable • Shorten the rectosigmoid stump if necessary.
interrupted Lembert stitches and to place mobilized omen- • Free up the colon leading to the colostomy. If that seg-
tum as an omental flap around it. Decide whether to place ment hangs down and obstructs your view, you have two
a drain in the pelvis. options: (1) transsect the colon underneath the abdominal
Close the stoma site internally—even if you left the last wall or (2) pause the insufflation, take down the colos-
bit of bowel to the colostomy still in there; you can remove it tomy, and seal the site with a gel port device.
at the end from outside. Use absorbable monofilament #1 • Obtain adequate mobility of the proximal colon.
sutures to close the muscle and fascia layer. If the abdominal • Through the colostomy site/gel port, place a circular sta-
wall defect is large, consider placing a collagen sheath in pler anvil to the proximal bowel.
underlay technique and securing it circumferentially with • Restore the pneumoperitoneum and perform an intracor-
interrupted sutures. poreal anastomosis with air leak test. You can optionally
Once that is achieved, make a limited transverse elliptic oversew the anastomosis with interrupted Vicryl sutures.
incision around stoma, touching the mucocutaneous junction • If you would like to leave a drain, it could be inserted
at the superior and inferior aspects of the stoma. Completely through an additional temporary 5 mm port in the left
mobilize the stoma circumferentially. Carefully dissect adhe- lower quadrant.
sions between the serosa, subcutaneous tissue, and fascia to • Level the patient and quickly readjust the bowels to avoid
avoid enterotomies that may necessitate further bowel resec- major twists.
tion and foreshortening of the proximal colon. If a parasto- • Remove the trocars and close the fascia of all 10-mm or
mal hernia sack is identified, dissect it out circumferentially, 12-mm trocar sites as well as the ostomy site fascia. Close
the skin at all the ports and decide whether to close or Arkenbosch J, Miyagaki H, et al. Efficacy of laparoscopic-assisted
approach for reversal of Hartmann’s procedure: results from
leave open the wound at the former stoma site. the American College of Surgeons National Surgical Quality
Improvement Program (ACS-NSQIP) database. Surg Endosc.
2015;29(8):2109–14.
Postoperative Care Corman ML. Intestinal stomas. In: Corman ML, editor. Bergamaschi
Rectal surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins;
• Antibiotics: Routine coverage for the perioperative 2012. p. 1396–450.
24-hour period. Feigel A, Sylla P. Role of minimally invasive surgery in the Reoperative
• Intravenous fluids: Maintain adequate IV fluid until return abdomen or pelvis. Clin Colon Rectal Surg. 2016;29(2):168–80.
of bowel function. 2009. Retrieved November 14, 2022, from https://accesssurgery.
• Urinary catheter: removed on postoperative day one. mhmedical.com/book.aspx?bookID=425.
• Venous thromboembolism prophylaxis: Follow Surgical Leroy J, Costantino F, et al. Technical aspects and outcome of a stan-
Care Improvement Project (SCIP) guidelines. Routinely dardized full laparoscopic approach to the reversal of Hartmann’s
procedure in a teaching Centre. Color Dis. 2011;13(9):1058–65.
start appropriate VTE prophylaxis before or within Lin FL, Boutros M, et al. Hartmann reversal: obesity adversely impacts
24 hours of surgery unless contraindicated. outcome. Dis Colon Rectum. 2013;56(1):83–90.
• Diet: Start liquid diet as soon as tolerated and advance Onder A, Gorgun E, et al. Comparison of short-term outcomes after
accordingly. laparoscopic versus open Hartmann reversal: a case-matched study.
Surg Laparosc Endosc Percutan Tech. 2016;26(4):e75–9.
Pei KY, Davis KA, et al. Assessing trends in laparoscopic colostomy
reversal and evaluating outcomes when compared to open proce-
Complications dures. Surg Endosc. 2017;
Siddiqui MR, Sajid MS, et al. Open vs laparoscopic approach for
reversal of Hartmann’s procedure: a systematic review. Color Dis.
• Early: Bleeding, enterotomy, anastomotic leak, intraab- 2010;12(8):733–41.
dominal abscess, surgical site infection Toro A, Ardiri A, et al. Laparoscopic reversal of Hartmann’s procedure:
• Late: Small bowel obstruction, anastomotic stricture, state of the art 20 years after the first reported case. Gastroenterol
unsatisfactory anorectal function, incisional hernia Res Pract. 2014;2014:530140.
Zarnescu Vasiliu EC. N. O. Zarnescu, et al. morbidity after reversal of
formation Hartmann operation: retrospective analysis of 56 patients. J Med
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Zimmermann M, Hoffmann M, et al. Laparoscopic versus open rever-
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Further Reading
Surgeries for Large Bowel Obstruction
69
Joseph Nunoo-Mensah, Vita Klimasauskiene,
Introduction Preoperative Preparation
Large bowel obstruction is a partial or complete occlusion of • Review the patient’s history, diagnosis, functional aspects,
the lumen of the large bowel by a pathological process. The and appropriate indication for surgery (based on clinical,
condition may quickly amount to an emergency if not swiftly radiographic, and potentially endoscopic means) as
recognized and managed. The failure to pass flatus and/or opposed to nonsurgical management.
stool results in progressive distension, cramping abdominal • Define the exact location of the pathology (by imaging or
pain, nausea and vomiting, and ultimately in necrosis and endoscopy); if the location is uncertain or if there is
perforation with peritonitis, sepsis, and septic shock. potentially a chance for an endoscopic stenting of the
The main causes of adult large bowel obstruction are lesion, an understanding of the location/configuration of
malignancy, chronic stricture (diverticulitis, ischemic), and the obstruction is important.
volvulus of the sigmoid colon. In the West, colorectal cancer • Look for possible signs of compromised bowel integrity
or a benign stricture are the prevalent conditions, whereas in proximal to the obstruction (e.g., perforation, Pneumatosis
Africa and Eastern Europe (“volvulus belt”), sigmoid volvu- coli).
lus is substantially more common and accounts for up to • Colonoscopy to determine the nature of the pathology
40% of cases. Left-sided locations more frequently cause (benign vs. malignant) and—if appropriate and possi-
acute obstructions because of the relative distribution of ble—potential stenting.
colorectal cancer in the various segments and because the • Cross-sectional imaging (CT/MRI): Assess resectability
stool is already firmer and more difficult to pass than on the and rule out systemic disease.
right side. A very proximal lesion near the ileocecal valve • If applicable, define the interval since the last treatments
may produce radiological features suggestive of a small in patients on chemotherapy or immunosuppressants.
bowel obstruction with decompressed large intestine. If the • Mechanical bowel preparation: Under nonelective cir-
ileocecal valve is incompetent, both the small and large cumstances, not possible or contraindicated.
bowel become distended, whereas a competent valve may • Marking for possible ostomy: Unreliable if there is sub-
lead to a closed-loop colonic obstruction with more rapid stantial abdominal distention.
decompensation. Based on the physics law of Laplace (T = P • Antibiotic prophylaxis (versus treatment).
x R, where P is the transmural pressure, R the radius, and T
the wall tension), the cecum is the most likely site of a perfo-
ration (other than the tumor itself). Pitfalls and Danger Points
Stenting
J. Nunoo-Mensah
King’s College Hospital, London, UK
1. Technical failure: Inability to successfully place the stent
V. Klimasauskiene
Faculty of Medicine, Vilnius University, Vilnius, Lithuania across the obstructing segment
2. Clinical failure: Inability to achieve successful decom-
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of pression after successful deployment of stent
Hope National Medical Center/Comprehensive Cancer Center, 3. Stent-induced tumor perforation
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_69
544 J. Nunoo-Mensah et al.
4. Chronic stent erosion (more common with bevacizumab tive measures only. The more complete the obstruction at
treatment, which thus is contraindicated) presentation, the less time there is to lose. Evidence of bowel
5. Stent migration impairment or even perforation represent an emergency.
6. Reobstruction by tumor ingrowth (if stent is left in place)
Choice of the Platform

on-resective Approach (Stent, Diverting
N
Stoma) There are five surgical/interventional options for the man-
agement of large bowel obstruction:
1. Unrecognized presence of ischemic/damaged bowel with
later perforation/sepsis • Endoscopic placement of self-expanding metal stenting:
2. Interruption of marginal artery blood supply at the stoma as temporary bridge to surgery or for permanent
site palliation.
3. Creation of stoma in too close proximity to the malig- • Proximal diverting stoma (loop colostomy; rarely Prasad-
nancy such that the stoma site is seeded with tumor type stoma in which an end ostomy is constructed, with a
small distal vent incorporated).
• Hartmann procedure (discontinuous resection with blind
Resection distal stump and proximal end stoma).
• Colonic resection with primary anastomosis, with/with-
1. Inability to achieve a complete resection of the primary out on-table colonic lavage, with/without proximal
tumor due to involvement of surrounding structures diversion.
2. Inability to resect damaged/ischemic bowel as well as the • Subtotal colectomy with ileostomy or ileo-colonic/ileo-
site of obstruction, leaving a closed-loop segment rectal anastomosis.
3. Performing anastomosis when the tissue quality or patient
condition is suboptimal In addition, there is a sixth option for patients with volvu-
lus and no signs of tissue compromise: therapeutic rigid or
flexible sigmoidoscopy detorsion of the volvulus as an
Operative Strategy immediate intervention to allow for decompression and reso-
lution of the acute obstruction.
Conservative Management The selection of the appropriate approach primarily
depends on the overall condition of the patient and of the
Diagnostic and first therapeutic measures must be initiated distended bowel. Furthermore, however, the strategy needs
simultaneously. The workup aims at quickly defining (a) to incorporate the immediate and long-term management
whether there is an immediate indication to proceed to sur- priorities. For example, in case of a large bowel obstruc-
gery, (b) the suspected nature of the obstruction (and distin- tion and metastatic disease, the overall prognosis is defined
guishing it from a pseudo-obstruction), (c) the degree of by the systemic disease. Initiation of systemic chemother-
impairment of the proximal large and small intestine, (d) apy is therefore more important than the resection of the
aggravating intrinsic circumstances such as hemodynamic primary tumor. Hence, the choice of intervention will
instability and organ dysfunctions, fluid, electrolyte, and rather aim at a quick recovery that does have lowest risk to
metabolic imbalances, (e) comorbidities, and (f) extrinsic delay the chemotherapy. A diverting stoma as a limited
factors (chemotherapy, immunosuppression, intervention avoids the risk associated with a resection
anticoagulation). and/or an anastomosis, whereas a Hartmann resection
Initial management includes rapid resuscitation with eliminates the primary tumor with possible complications
intravenous rehydration and correction of electrolyte imbal- while avoiding an anastomosis. A successful stent place-
ances, nasogastric decompression, and possible enemas, as ment in general allows for averting the acute emergency
well as potential administration of antibiotics. and optimizing the various parameters such that a (semi-)
elective resection with a decreased probability of a stoma
can ultimately be performed. However, the presence of a
Decision for Surgery metal stent limits the choices for chemotherapy. In particu-
lar, the use of biologicals, such as bevacizumab, should be
A persistent mechanical large bowel obstruction inevitably avoided as these medications are associated with a sub-
represents an indication for surgery unless the patient’s gen- stantially increased incidence of stent complications, spe-
eral condition and underlying life expectancy ask for pallia- cifically perforations.
69 Surgeries for Large Bowel Obstruction 545
pecific Considerations for the Stated Options

S Colonic Resection with Primary Anastomosis, with/
Are as Follows Without On-Table Colonic Lavage, with/Without
Stent Placement Proximal Diversion
The best indication for a stent is a left-sided malignant From a patient perspective, this represents the best approach
obstruction that is located between mid to upper rectum but should also be reserved for favorable circumstances. The
and the splenic flexure. For more distal locations, the stent stool burden from the obstruction and other potentially
may cause discomfort at the pelvic floor; and for more aggravating factors (tissue quality, hemodynamic stability
proximal obstructions, an extended right hemicolectomy etc.) pose a risk for an anastomotic leak. The former can be
would be more definitive and often does not require a reduced by on-table lavage, whereas the latter should either
stoma. Benign obstructions (inflammation, ischemia) are trigger a Hartmann resection (see above) or the decision to
not commonly addressed with a stent, although occasion- protect the anastomosis with a proximal diversion.
ally an endoscopic balloon dilation may be feasible. The
patients who benefit most from a stent are those where the Subtotal Colectomy
surgical risk and probability of a stoma for a desirable This is the necessary approach for an obstructed colon
resection can be reduced and the chances for a minimally with impairment of the bowel wall (see above). The goal is
invasive resection increased, or in whom there is no good to remove all damaged bowel as well as the obstruction
alternative surgical option available (e.g., carcinomatosis). site. If the small bowel and the colorectum distal to the
It should be noted though that the potential risk of upstag- obstruction have good quality, an anastomosis is rational.
ing the tumor by the mechanical force of the stent has not This is parenthetically also the approach for obstructions
been completely clarified. proximal to the splenic flexure, which can typically be
addressed with an extended resection and anastomosis.
Proximal Diverting Stoma However, if the tissue quality or the patient’s overall con-
The typical indication for only creating a diverting stoma is dition are poor, the small bowel should be brought out as
the patient with an obstruction without evidence for tissue an end ileostomy (Chap. 50).
compromise (necrosis/perforation/pneumatosis) but either Only in rare circumstances, the damage affects only the
with distant metastases or with advanced pelvic disease that most proximal bowel segments, and the colon proximal to
would necessitate neoadjuvant treatment or planning of mul- the obstruction has good viability and sufficient length to
tivisceral resections (Chap. 61). The goal is to relieve the allow for formation of a venting mucous fistula. There is no
obstruction without burning any bridges for future surgical apparent benefit of that approach except if the resection of
interventions. It should therefore be positioned to preserve the obstruction would otherwise seem too extensive for the
the blood supply to more distal segments. While an ileos- given circumstances. A “Hartmann resection” with leaving
tomy is often preferred under elective circumstances, an behind the obstruction and stapled off colon proximal to it
urgent or emergency situation asks for a loop colostomy should be avoided (closed loop with risk of perforation in the
(Chaps. 65 and 66) such that both sides can decompress. The rectal stump).
presence of a competent ileocecal valve would potentially
interfere with that goal. herapeutic
T Rigid/Flexible Sigmoidoscopy with
Detorsion of Volvulus
iscontinuous Resection (Hartmann Procedure)
D The diagnosis is typically established from clinical and radio-
The discontinuous Hartmann resection (Chap. 58) offers logical features. In absence of any signs for tissue compromise,
the safety of eliminating the obstruction and preserving a rigid or flexible sigmoidoscopy are the first therapeutic step,
colon length without taking on the risks of anastomotic that is, less for diagnostic purposes than in hope to detorse the
complications. From the patient’s perspective, the stoma volvulus and allow for a later elective management. A venting
is an undesirable price. There remains the option of a rectal tube may prove helpful to maintain the decompression
future Hartmann reversal which in itself may pose some beyond the immediate maneuver. If endoscopic decompression
challenges (Chap. 68). The approach is a good choice for fails, an emergency laparotomy is required.
a patient with adequate but not perfect operability and
hemodynamic stability, no evidence of metastatic dis-
eases, but overall reversibly compromised tissue quality, Setup and Patient Positioning
excessive stool burden, or a potentially contaminated
field. As this situation most commonly requires a laparot- The endoscopic procedures (stent placement, detorsion of
omy, there will be a non-negligible incidence of incisional volvulus) can be done in the endoscopy or the X-ray/fluoros-
hernia formation. copy suite. Typically, conscious sedation is sufficient. Only
if there is a high probability of endoscopic failure, it is pref- appropriate stent length (as short as possible but as long as nec-
erable to set up the endoscopy in the operating room with essary). Depending on the specific circumstances, you may use
anesthesia and surgery readiness. one of two ways to deliver the stent: through the scope alone (if
All other interventions require a full operating suite with a lumen is easily visible) or more commonly over a guide-wire.
anesthesia. Depending on the patient’s condition, postsurgi- Verify that the wire is longer than the sum of the scope and
cal monitoring in the intensive care unit should be stent deployment system lengths together. As the obstruction is
anticipated. typically in the left-sided colorectum, you do not have to use a
full-length colonoscope. However, you must verify that work-
ing channel of the shorter scope is able to accommodate the
Documentation Basics stent delivery system.
Advance the colonoscope up to the site of obstruction
Coding for surgical procedures is complex. Consult the most (Fig. 69.1a–d). You may not be able to identify with certainty
recent edition of the AMA’s Current Procedural Terminology the location of the lumen. Place a wire insertion support
book for details (see references at the end). In general, it is guide into the working channel and insert the soft tip of the
important to document: wire. Do not forget to remove the guide before feeding the
stent system onto the wire. Attempt to advance the wire past
• Indications and rational for chosen surgical approach the obstruction. You can be quite persistent, even at the risk
• Description of the lesion (size, location, relationship to of a wire perforation, as failure to successfully advance the
and involvement of other structures) wire would in any event mandate surgical exploration. Check
• Description of the bowel quality and viability proximal to the position of the wire by fluoroscopy.
the site of obstruction (colon and small bowel) Once the wire is placed, feed the lubricated deployment
• Statement about presence/absence of other related or system over the wire. Carefully advance it without ever losing
unrelated pathology control of the wire. Once the stent exits the scope, start to care-
• Curative versus palliative approach fully push it into and through the obstruction. If necessary, you
• Extent and integrity of the specimen can inject contrast through the deployment system. However,
• Closure of wound (if performed) this will require removing the wire, and risk difficulty reinsert-
• Stoma type and location ing it if necessary. Advance the stent under fluoroscopy until
the radiopaque markings are equally distanced to the center of
the obstruction. Start to slowly deploy the stent while synchro-
Operative Technique nously pulling back the scope and the wire. This is a critical
step as blind deployment risks pushing the stent too proximal.
Positioning Ideally, the stent will symmetrically overlap the obstruction
proximally and distally. If necessary, the stent can be pulled
For colonoscopic stenting, place the patient in the left lateral back into the protective sheath to optimize the position. But be
position on an X-ray/fluoroscopy table. Reposition the aware of the “point of no return” at which the stent cannot be
patient for fluoroscopy or procedural purposes as needed. pulled back and will deploy. When an obstruction is particu-
For emergency surgeries, a supine position may be suffi- larly long, it may be necessary to fire a first more distal stent
cient and provides the advantage of being setup relatively and deploy a more proximal second stent such that its ends
fast. overlap a bit. If such an approach is necessary, it is crucial to
In general, however, the modified lithotomy position is not remove the wire as it may be virtually impossible to assure
associated with the best flexibility as it allows you to access that the wire would be correctly reinserted without going
to the anus should an intraoperative need arise. Preferably through the mesh of the first stent itself.
tuck both arms to allow best access. Place a urinary catheter Once the stent is successfully deployed, it may take a
to decompress the bladder and monitor intraoperative urine while until gas and liquid stool start to flow and up to
output. Prep and drape the patient from nipple line to mid 24–72 hours for full expansion of the stent. Take final X-rays
thighs and include the perineal area. to confirm the proper location and to document that there is
no evidence of free air that would suggest a perforation.
Colonic Stenting
Creation of Colostomy
Various types of self-expandable metal stents (SEMS) are com-
mercially available. They all are radiopaque and most com- The steps to create a loop colostomy have been described in
monly are “uncovered,” that is, without an inner plastic sheath Chap. 47.
that seals the openings in the woven metal mesh. Choose the
a b
c d
Fig. 69.1
iscontinuous Resection with Creation

D egmental Resection with Intraoperative
S
of a Stoma Colonic Lavage and Anastomosis
Hartmann-type segmental resection with creation of an end The steps to perform a segmental resection have been
colostomy or a (sub-)total colectomy with an end ileostomy described in Chap. 63. However, in the context of a large
are described in Chaps. 58 and 68, respectively. bowel obstruction, one of the added difficulties is the stool
burden which may increase the risk of performing an
anastomosis.
Segmental or Subtotal Resection If the other circumstances (tissue quality and patient sta-
bility) seem to be favorable, you can consider lavaging the
The steps to perform (extended) right hemicolectomy, a sub- colon. Complete the resection as you would for a Hartmann
total or a total colectomy with enterocolonic or ileorectal resection with the bowel stapled off distally and proximally.
anastomosis, have been described in Chaps. 56 and 57, Remove the specimen.
respectively. Get a corrugated tube (as used by the anesthesiologist to
connect parts of the ventilator circuit) onto the field. As such
a tube is typically clean but not sterile, it may be disinfected • Intravenous fluids: Maintain adequate fluid until return of
by submerging it in a disinfecting solution in a sterile tray for bowel function.
a few minutes before use. Using sponges, shield the proxi- • Nasogastric tube: Keep it with continued suction at
mal end of the colon from the rest of the abdomen. Milk the least 24 hours or until evidence of return of bowel
most distal stool proximally and place a non-crushing bowel function.
clamp at a distance of roughly 10 cm. With a suction device • Enhanced recovery after surgery (ERAS) protocol: Needs
ready, cut off the proximal staple line and quickly insert the to be adapted to the individual needs after this urgent/
corrugated tube. Tightly secure it with the strongest available emergency intervention. Advance to the diet not based on
tie or an umbilical tape. Pass the other end of the tube to the rigid time frames but as tolerated by the patient.
circulator which will tape that end into a trash bag at the side • Nutritional support: Initiate parenteral nutrition if return
of the operating table. This creates a closed system such that of bowel function delayed by more than 5 days or if there
there is virtually no smell in the room. Remove the non- is a substantial malnutrition.
crushing bowel clamp. • Incentive spirometry and early ambulation should be
For the lavage, you will need to insert a large-bore cathe- encouraged.
ter into the proximal end. Place a non-crushing bowel clamp • Postoperative DVT/PE prophylaxis.
on the ascending colon and shield the cecum with sponges • Stoma teaching.
from the rest of the abdomen. If the appendix is present, per- • Await the pathology and define further treatment necessi-
form an appendectomy. Place a purse-string suture at the ties and follow-up.
base of the appendix or—if the patient had an appendec-
tomy—at the cecal pole. Excise the appendix at its base or
perform a small colostomy in the center of the purse-string Complications
suture and place a big catheter (large Foley, chest tube, red
Robinson catheter) through the stump. Secure the tube with For most procedure-related complications, see respective
a single knot and hold it in place. Connect the catheter to a chapters.
3 L sterile normal saline bag, remove the bowel clamp, and Colonic stenting:
allow the saline to run through the bowel to the drainage
device. Manually assist the lavage by gently massaging the • Technical failure of procedure, requiring surgical
bowel contents toward the distal end. It is often necessary exploration
that you mobilize the hepatic and the splenic flexure for just • Clinical failure (inadequate colonic decompression),
that purpose. To make the lavage run more easily, you may requiring surgical exploration
tilt the table toward the patient’s left side with the cecum • Bleeding
elevated. Use as much irrigation as necessary to achieve a • Bowel perforation
clear output. • Stent migration
Once satisfactorily completed, again place a non-crushing • Stent obstruction with ingrowth of tumor
clamp to the ascending colon. Shield the cecum with polyvi-
done iodine-soaked sponges and have towels ready to receive
the dirty catheter. Remove the catheter and swiftly tie the
purse-string suture. Secure the closure with additional sero- Further Reading
muscular sutures or by firing a linear stapler across the base.
Reevaluate the situation as to whether an anastomosis is American Medical Association. Current procedural terminology: CPT
still reasonable. Use a reload of the linear stapler to cut off https://www.ama-assn.org/practice-management/cpt.
the distal end with the dirty tube in place. Remove all sponges Arezzo A, Balague C, Targarona E, et al. Colonic stenting as a bridge
and irrigate the abdomen. Perform the anastomosis as previ- to surgery versus emergency surgery for malignant colonic obstruc-
ously described in Chap. 62. tion: results of a multicentre randomised controlled trial (ESCO
trial). Surg Endosc. 2017;31(8):3297–305.
Imbulgoda A, Maclean A, Heine J, et al. Colonic perforation with
intraluminal stents and bevacizumab in advanced colorectal can-
Postoperative Care cer: retrospective case series and literature review. Can J Surg.
2015;58(3):167–71.
• Antibiotics: Routine coverage for 24-hour period. In case 2009. Retrieved November 14, 2022, from https://accesssurgery.
of an underlying infection/sepsis, continue respective mhmedical.com/book.aspx?bookID=425.
therapeutic antibiotics for that indication.
Park J, Lee HJ, Park SJ, et al. Long-term outcomes after stenting as a Varadarajulu S, Roy A, Lopes T, et al. Endoscopic stenting versus sur-
bridge to surgery in patients with obstructing left-sided colorectal gical colostomy for the management of malignant colonic obstruc-
cancer. Int J Color Dis. 2018;33(6):799–807. tion: comparison of hospital costs and clinical outcomes. Surg
Sagar J. Colorectal stents for the management of malignant colonic Endosc. 2011;25(7):2203–9.
obstructions. Cochrane Database Syst Rev. 2011;11:CD007378. Young CJ, Zahid A. Randomized controlled trial of colonic stent inser-
Van Hooft, JE, Van Halsema, EE, Vanbiervliet, G, et al. Self- tion in non-curable large bowel obstruction: a post hoc cost analysis.
expandable metal stents for obstructing colonic and extracolonic Color Dis. 2018;20(4):288–95.
cancer: European Society of Gastrointestinal Endoscopy (ESGE) Zhao XD, Cai BB, Cao RS, et al. Palliative treatment for incur-
Clinical Guideline. Gastrointest Endosc. 2014;80(5):747–761 able malignant colorectal obstructions: a meta-analysis. World J
e741–775. Gastroenterol. 2013;19(33):5565–74.
Surgery for Colonic Fistula to Bladder,
Vagina, or Skin 70
Indications • Definitive evidence of inoperability or unresectability

• Liver failure, particularly if associated with severe portal
Most fistulizing pathology from or into the colon require hypertension
some surgical intervention as it creates a set of secondary • Coagulopathy
problems and symptoms related to the passage of stool and
bacteria. The spectrum of severities ranges from minimal
symptoms, to annoying, to handicapping or even life- Preoperative Preparation
threatening. Depending on the involved organ, symptoms
include chronic or acute urinary tract infections, pneumatu- • Review the patient’s history, diagnosis, functional aspects,
ria, fecaluria, vaginal discharge with vaginitis or vulvitis, or and appropriate indication for surgery (based on clinical,
skin discharge with irritation and management difficulties. In radiographic, or endoscopic means).
some cases, the condition prevents other treatments such as a • Review all preoperative images to define the anatomy,
transplant or chemotherapy. The differential diagnosis is localize the fistulous tract, and confirm or rule out a local
wide and whenever possible important to clarify prior to a tumor. CT scans are the imaging of choice; MRI is an
surgical intervention. The most frequent causes are compli- alternative cross-sectional imaging of value; additional
cated diverticulitis, malignancies, Crohn disease, or postsur- contrast studies, such as fistulograms, gastrografin ene-
gical complications. mas, and cystograms, serve as adjuncts.
This chapter describes the strategies and operative tech- • Colonoscopy to determine the nature of the pathology
niques for the management of colonic fistulas to other ana- (benign vs. malignant) and exclude synchronous
tomical structures. Emphasis is placed on perioperative pathology.
considerations and the approach to the involved structures. • Depending on the specifics: possible cystoscopy and/or
colposcopy.
• Mechanical bowel preparation.
Contraindications • Antibiotic prophylaxis versus treatment.
• Lack of symptoms (with or without diversion)

• Poor performance status with limited life expectancy Pitfalls and Danger Points
• Metastatic tumor, not amenable to potential cure (unless
no less aggressive options exist) • Ureteral injury
• Involvement of the trigone of the bladder
• Oncologically inferior resection
M. P. Duldulao • Surgery to early after previous surgery
Los Angeles, CA, USA • Recurrent or aggravated fistula
• Anastomotic leakage
A. M. Kaiser (*)
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_70
Operative Strategy mally invasive approach (robotic, laparoscopic), or whether

a formal laparotomy would be more appropriate. Many colo-
Decision for Surgery vesical/−vaginal fistulas represent more chronic sequelae of
a previously acute disease (e.g., complicated diverticulitis).
Liquid effluent through the fistula is the source of clinical Except for the immediate neighborhood of the fistula, the
symptomatology. However, these symptoms may only reflect tissues are often normal and hence amenable to a minimally
the tip of the iceberg, that is, underlying a complex abdomi- invasive approach. Remember that even in benign disease,
nal pathology. In absence of any striking contraindications, chronic inflammation with fibrotic changes can be among
surgical intervention is advisable, but proper timing and ade- the hardest tissue dissections that sometimes are simply too
quate workup are prudent to understand the nature of the dense for laparoscopic instruments.
pathology and the anatomical details. The most common If you are not sure whether to proceed laparoscopically or
goal will be to achieve a definitive treatment for the causative open, you may start with one or two trocars and assess the
pathology. However, if the extent or onset of the fistulizing situation before making a quick decision to immediately
pathology are not suited for an immediate corrective inter- convert or to continue laparoscopically. In the latter scenario,
vention (e.g., shortly after a previous low anterior resection), set yourself benchmarks of progress and do not hesitate to
it might be advisable to offer temporizing measures only. In convert should you not be able to achieve them.
that situation, you should consider creating a diverting stoma
first to allow for optimization and potentially an intervention
in the future. Supportive measures include antibiotic treat- Diversion
ment and skin care.
The default approach to a colo-vaginal/−vesical fistula is to
perform a segmental resection with primary anastomosis. It
Definitive Surgery depends on the intraoperative details, however, whether that
seems prudent, or whether you should carry out a discontinu-
In order to correct the fistulizing process, the focus has to be ous resection (Hartmann procedure), or perform an anasto-
on source control. You will need to resect the colonic origin of mosis with proximal diversion.
the fistula. You should always aim at performing a resection
that would satisfy oncological standards if a cancer was even-
tually found. Non-resective repairs are prone to failure and Documentation Basics
may miss the true cause (cancer, foreign body, etc.) of the
fistula. The extent of resection of other involved anatomical Coding for surgical procedures is complex. Consult the most
structures depends on whether the underlying pathology is recent edition of the AMA’s Current Procedural Terminology
“benign” or malignant. If there is no evidence of cancer, it book for details (see references at the end). In general, it is
usually suffices that you address the colon; the counterpart on important to document:
bladder, vagina, or skin will dry up and close without specific
repair. In contrast, if a cancer is the cause of the fistula, you • Findings
will have to perform an oncological resection that primarily • Nature and extent of the pathology
reflects the organ of origin whereas the secondary structures • Type of access
can be addressed with a sufficiently wide excision. • Details of the surgery: bowel resection, resection of blad-
For example, in the case of a colovesical fistula from colon der/vagina/uterus)
cancer, you will need to carry out a formal colon resection but • Anastomosis, diversion, tissue interposition (e.g., omen-
only a wedge excision of the bladder dome. In contrast, a for- tal flap)
mal cystectomy and pelvic lymph node dissection would be
needed if the colovesical fistula was caused by a bladder can-
cer. In case of more extensive pathology, multivisceral resec- Operative Technique
tions might be more appropriate (see Chap. 60). For extensive
colo−/enterocutaneous fistulas, also refer to Chap. 45. Access
Create access to the peritoneal cavity according to standard

Access procedures of your chosen platform (laparotomy versus first
trocar placement). Perform a systematic four quadrant explo-
The extent, complexity, and nature of the visible pathology ration to confirm the preoperative assessment and rule out
as well as the patient’s past history are key elements to help unexpected synchronous findings. Establish exposure to the
you decide whether to perform the surgery through a mini- target pathology.
70 Surgery for Colonic Fistula to Bladder, Vagina, or Skin 553
Definitive Bowel Resection of interrupted absorbable suture (Fig. 70.3). Retest the repair
for documentation purposes. Plan on leaving a Foley catheter
Once you have achieved adequate exposure, start mobilizing for 1–3 weeks.
the respective colon segment in oncological fashion. The Similarly, the vaginal or abdominal wall defect can be
critical steps are to identify the ureter(s), mobilize, and safely debrided to healthy tissue and the defect repaired primarily.
transsect the vascular pedicle. If you encounter substantial If available, an omental flap is always a good idea to separate
adhesions and inflammatory tissue alteration with fibrosis, the two corresponding anastomosis/repair areas. Mobilize
you may need to alternatingly come from medial to lateral the omentum to obtain sufficient length while preserving its
(similar to a standard laparoscopic approach) or from lateral blood supply and place it to the pelvis between large intes-
(like in a standard open approach). If your difficulties persist, tine and the middle or anterior compartments.
you have a number of choices: (1) to start the dissection
higher up and move from known to unknown territory, (2) to
place ureteral stents as a guidance tool, or (3) if there is no
evidence for a malignancy to carry out a nononcological
resection that follows closely the bowel wall.
Define the levels of bowel transection: particularly in case
of diverticulitis, the distal margin should be at or below the
coalescence of the tenia; determine the proximal margin as
where the tissue quality normalizes. In malignant disease,
aim for at least 10 cm proximal and 5–10 cm distal margin if
possible.
Management of the Other Organ
How to address the “other side” of the fistula largely depends

on whether or not its formation is caused by cancer.
Malignant
As stated above, in that case, an en-bloc resection of the
Fig. 70.1
involved organ structures (wedge or complete) and appropri-
ate reconstruction are necessary. Often times, anticipation
and involvement of respective colleagues from those special-
ties is advisable. The danger zone is the trigone of the blad-
der: if the tumor resection gets too close or into it, a complete
cystectomy or a bladder augmentation with reimplantation
of the ureters may be needed.
Benign
In contrast, if the fistula is the result of benign diseases
(diverticulitis, Crohn, postsurgical), an en-bloc resection is
not necessary and you can separate the two organ structures
by “pinching off,” that is, squeezing the tissue connection
with reasonable force between your fingers until they come
apart. The remaining hole in bladder, vagina, or skin may not
need any specific treatment unless there is residual foreign
material (staples). But it is not unreasonable to test the blad-
der for leaks. Clamp the Foley and instill 250–300 ml of
saline mixed with a few drops of methylene blue to distend
the bladder. Assess the bladder for extravasation (Fig. 70.1).
If there is a leak, consider a limited debridement and oversew
the opening in the bladder with a running absorbable suture
(Fig. 70.2). Reinforce the primary repair with a second layer Fig. 70.2
• Enhanced recovery after surgery (ERAS) protocol: Oral

intake is initiated on the day of surgery and advanced to
solid food as patient demonstrates return of bowel
function.
• Patients, who receive a protective diverting stoma (ileos-
tomy, colostomy), require education on ostomy care.
• Maintain the Foley after a bladder repair for 1–3 weeks. If
you have placed drains, check the output for creatinine.
Also perform a retrograde cystogram prior to removing
the Foley.
Complications
• Anastomotic leak/dehiscence
• Recurrent fistula
• Wound infection
Fig. 70.3 • Ileus/bowel obstruction
• Hernia
• Bladder leak
If there is a large fascial defect, a component separation
may be necessary, or coverage with a biologic mesh in an
underlay or inlay fashion can bridge the patient to a defini-
tive hernia repair in the future (see also Chap. 108). Further Reading
Diversion https://www.ama-assn.org/practice-management/cpt.
Badic B, Leroux G, et al. Colovesical fistula complicating diverticu-
In the majority of colorectal resections for colovesical or lar disease: a 14-year experience. Surg Laparosc Endosc Percutan
colovaginal fistulas, you can carry out a primary anastomosis Tech. 2017;27(2):94–7.
Bhakta A, Tafen M, et al. Laparoscopic sigmoid colectomy for compli-
with two healthy bowel ends. However, you should use good cated diverticulitis is safe: review of 576 consecutive colectomies.
judgment in conjunction with testing the anastomosis to Surg Endosc. 2016;30(4):1629–34.
determine whether an anastomosis should be done in the first Cannon JA. Chapter 16: rectovaginal fistula. In: Steele SR, Hull TL,
place and whether for safety concerns (tissue quality, perfu- Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, editors. The
ASCRS Textbook of Colon and Rectal Surgery. Springer; 2016.
sion, contamination, etc.) a temporary diversion would seem https://doi.org/10.1007/978-3-319-25970-3_16.
prudent. Devaraj B, Liu W, et al. Medically treated diverticular abscess associ-
In some cases, creation of a diverting ostomy is the only ated with high risk of recurrence and disease complications. Dis
reasonable intervention at the time of presentation, and more Colon Rectum. 2016;59(3):208–15.
Hall J. Chapter 39: diverticular disease. In: Steele SR, Hull TL, Read
radical surgery is either not possible or needs to be post- TE, Saclarides TJ, Senagore AJ, Whitlow CB, editors. The ASCRS
poned for a sufficient length of time to optimize the patient Textbook of Colon and Rectal Surgery. Springer; 2016. https://doi.
and the tissues. org/10.1007/978-3-319-25970-3_39.
Lynn ET, Ranasinghe NE, et al. Management and outcomes of colo-
vesical fistula repair. Am Surg. 2012;78(5):514–8.
Mahmoud NN, Riddle EW. Minimally invasive surgery for complicated
Postoperative Care diverticulitis. J Gastrointest Surg. 2017;21(4):731–8.
Mbadiwe T, Obirieze AC, et al. Surgical management of complicated
• Antibiotics: Routine coverage for the perioperative diverticulitis: a comparison of the laparoscopic and open approaches.
J Am Coll Surg. 2013;216(4):782–8. discussion 788-790.
24-hour period. In case of an underlying infection/sepsis, Smeenk RM, Plaisier PW, et al. Outcome of surgery for colovesi-
continue respective therapeutic antibiotics for that cal and colovaginal fistulas of diverticular origin in 40 patients. J
indication. Gastrointest Surg. 2012;16(8):1559–65.
• Intravenous fluids: Maintain adequate fluid until return of Wen Y, Althans AR, et al. Evaluating surgical management and out-
comes of colovaginal fistulas. Am J Surg. 2017;213(3):553–7.
bowel function.
Abdominal Repair of Rectal Prolapse
and Pelvic Organ Descent (Open, 71
Laparoscopic)
Joongho Shin, Gregory K. Low, and Andreas M. Kaiser
Indications ply, previous implants, as well as degree and location of

instability.
• Full-thickness rectal prolapse • Colonoscopy to rule out other pathology in colon.
• Pelvic organ descent and positional instability involving • Accurate clinical exam and individualized workup to pos-
at least the posterior compartment sibly include:
–– Dynamic pelvic MRI (MRI defecography); alterna-
Managing rectal prolapse and pelvic organ descent through tively conventional defecating proctogram.
an abdominal approach is regarded as more durable than a –– Endorectal ultrasonography.
perineal repair (Delorme, Altemeier, see Chap. 82). The indi- –– Anophysiology testing: Even in patients with inconti-
vidual selection and type of approach (open versus minimally nence, it is often better to plan for such a workup after
invasive, extent of mobilization, type of fixation) may vary the prolapse has been corrected to avoid negative
depending on the specifics of the pathology, previous surgical interference.
repairs, functional aspects, as well as surgeon preference. The • Multidisciplinary evaluation and discussion for multi-
presence of underlying risk constellations (e.g., immunosup- compartmental descent and prolapse.
pression, cachexia, need for bowel resection, etc.) may affect • Mechanical bowel preparation.
the pre- and intraoperative decision-making. • Antibiotic prophylaxis (versus treatment).
Preoperative Preparation Pitfalls and Danger Points
• Review the patient’s history, diagnosis, functional aspects, • Collateral injury: Ureters, vagina, autonomic nerves
and appropriate indication for surgery (based on clinical, • Hemorrhage: Presacral veins, vascular pedicle
functional, and radiographic means) as opposed to non- • In case of resection: anastomotic complications (leak,
surgical management. stricture); creation of an ischemic segment in case of pre-
• Review previous colorectal and anorectal surgeries and vious perineal repair
establish a clear understanding of the current blood sup- • Mesh erosion and fistula formation
J. Shin Operative Strategy

Concept of the Repair
G. K. Low
Rectal prolapse patients have a characteristic pelvic anatomy
Department of Surgery, University of Tennessee,
Knoxville, TN, USA with less fixation and embedding and more laxity. On one
hand, there is typically a very deep cul-de-sac with the perito-
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of neal reflection sometimes being at the level of the pelvic floor;
Hope National Medical Center/Comprehensive Cancer Center, on the other hand, the mesorectum is very thin and encom-
Duarte, CA, USA passes much less of the mid to distal circumference than in an

https://doi.org/10.1007/978-3-030-81415-1_71
556 J. Shin et al.
average person. This results in the rectosigmoid being almost Dissection in that space not only avoids the dangerous
completely intraperitoneal, which is accompanied by a variable presacral vein plexus, but also keeps the hypogastric
degree of rectosigmoid redundancy. The resulting posterior nerve branches intact. Posteriorly, the two layers fuse
instability may be associated with a widening of the space above the coccyx and form Waldeyer’s fascia. The dissec-
between the rectum and the vagina (enterocele), bulging of the tion needs to be carried further down by sharply dividing
distal rectovaginal septum (rectocele), or a more broad-based the fused fascia to continue past the coccyx to the pelvic
positional instability of the middle and anterior pelvic compart- floor.
ment (cystocele, vaginal/uterine descent or prolapse). In the context of a posterior mobilization, there is no need
There are two basic concepts that aim at correcting this for an anterior dissection and the peritoneal reflection does
anatomical variation from a colorectal surgery perspective: not need to be opened.
(1) attachment of the rectum to the sacrum (rectopexy) and
(2) resection of the redundancy. These options may be used Anterior
independently or in combination and each may employ dif- Anteriorly, the rectal surface remains intraperitoneal down to
ferent techniques. The rectopexy may be done without or the peritoneal reflection. More recently, the concept of a ven-
with an implant, which may be synthetic or biological and tral mesh rectopexy has evolved and gained a lot of traction.
which may be secured to the rectum in a number of different It aims at correcting the anterior instability and thus correct
ways. Historically, a resection has been advocated in the set- prolapse, intussusception, or obstructed defecation, while
ting of constipation; however, the hope of correcting any avoiding the negative nerve impact from the posterior and
underlying constipation lacks evidence, and the benefit of a lateral mobilization. It should be understood though that
resection in the context of a rectal prolapse operation is likely even the anterior mobilization carries a risk of jeopardizing
less than originally thought. Inclusion of a resection, how- the invisible nerve plexus that travel along the anterior
ever, adds the risk of an anastomotic leak and limits the use rectum.
of synthetic implants because of the risk of bacterial con- For this anterior approach (ventral rectopexy), the serosa
tamination and infection. is opened between the posterior vagina and the anterior rec-
tum to carefully separate the two structures well into the rec-
tovaginal septum. All posterior attachments are all left
Surgical Approach untouched, and there should therefore not be any risk of pre-
sacral venous hemorrhage.
Rectal prolapse surgery is typically limited to the pelvis and an
open operation can be approached through a transverse supra-
pubic Pfannenstiel incision or through a lower midline inci- Avoiding Collateral Damage
sion if the patient has a preexisting scar. Minimally invasive
approaches (laparoscopic or robotic surgery) in many circum- The pelvis can be a dangerous place. The biggest hazard
stances are considered equivalent or even superior options. associated with its dissection is a massive hemorrhage which
can be sudden and life-threatening. The plexus of presacral
veins or branches of the internal iliac veins are the most com-
Rectal Mobilization mon sources. Prevention is the best, decisive action without
panic is the second best approach (see Chap. 59). Further
Posterior structures at risk include the ureters, the hypogastric nerves,
The traditional approach (with or without resection) entails a and the vagina.
complete posterior rectal mobilization, such that the reposi- The easiest place to initiate the posterior dissection is at or
tioned rectum can form a broad-based fibrotic scar along the above the promontory. If the space is opened just behind the
sacrum. The posterior dissection extends from the sacral major vascular arcade leading to the pelvis, all other struc-
promontory to pelvic floor. During this step, division of the tures can often be bluntly pushed to the back. Extension of
lateral attachments should be minimized but may be neces- the dissection along the areolar tissue toward the left and the
sary to some degree to straighten the distal rectum. It has pelvis almost automatically develops the proper pelvic dis-
been speculated that both steps could aggravate postopera- section plane. The ureters and the gonadal vessels cross the
tive autonomic nerve dysfunction and result in constipation, common iliac artery and travel toward the high pelvic side-
defecatory, and voiding difficulties, as well as sexual dys- wall. They are therefore typically not at risk in the pelvic
function. Particularly in male patients, it could be function- mobilization. The autonomic nerve plexus necessary for nor-
ally safer to only mobilize one and not both sides. mal bladder and sexual function follow the aorta and form
The presacral fascia and the fascia propria of the rec- the hypogastric nerves before splitting into a right and left
tum are separated by a virtually avascular areolar tissue. branch.
71 Abdominal Repair of Rectal Prolapse and Pelvic Organ Descent (Open, Laparoscopic) 557
Selection of Implant and b). Make sure that the perineum is at the table end to
allow if necessary for access to the anus, and that the hips
The major decision to be made is whether to use a synthetic can vary from flat (0 degree) to high lithotomy (90 degree).
mesh or a biological implant. A synthetic implant is easier to Preferably tuck both arms to allow best access. Place a uri-
handle and has a substantially better durability. The biggest nary catheter to decompress the bladder and monitor intraop-
concern, which has also attracted the attention of lawyers, erative urine output. Prep and drape the patient from nipple
stems from cases of infection and mesh erosion, which line to mid thighs and include the perineal area, and in
necessitate a removal of the mesh. Particularly with a soft females the vagina. Monitors for laparoscopic surgery should
and macroporous mesh design, however, the risk of compli- be placed such that surgeon, target, and monitor form one
cations objectively is fairly low and outweighed by the ben- line (see Chap. 54, Fig. 54.4).
efits. Nonetheless, mesh should be avoided in direct contact
with small bowel and in contaminated fields (for example,
when a bowel resection is carried out or an enterotomy Operative Approach and Incisions
occurs).
Biological mesh implants are thought to serve as a matrix inimally Invasive Surgery
M
for tissue ingrowth. They are less problematic if a complica- Each minimally invasive surgery platform (laparoscopic,
tion or infection occurs as the material can be naturally robotic) employs a slightly different layout of their port
degraded. Unfortunately, however, the material strength may placement. Depending on the past history, insert the first tro-
deteriorate over time even without an infection such that the car at the umbilicus using Hasson or Veress needle technique.
repairs are less durable than with synthetic implants. A 10–12 mm trocar accommodates the standard 10 mm cam-
Biological implants come in a large variety from different era; however, if you have a high-quality 5 mm optic avail-
sources and manufacturers. They represent acellular colla- able, a smaller port may suffice. Establish the
gen matrices that have been processed and cross-linked to pneumoperitoneum and insert the camera. The subsequent
enhance strength. No particular product has demonstrated ports are inserted under direct vision.
superiority, and the choice represents the surgeon’s Pure laparoscopic techniques normally use 3–4 trocars.
preference. Insert a camera port at the umbilicus. For needle and mesh
insertion, it is best to have at least one 10–12 mm trocar that
is independent from the camera port. Place 2–3 working
Documentation Basics ports that allow for triangulation toward the pelvis. Our pref-
erence is one in the right and one in the left lower quadrant,
Coding for surgical procedures is complex. Consult the most as well as possibly one suprapubic location for insertion of a
recent edition of the AMA’s Current Procedural Terminology tacker.
book for details (see references at the end). In general, it is Placement of the robotic trocars depends on the platform.
important to document: The ports are either placed on a transverse (Xi) or a curved
(Si) line at or slightly above the umbilicus with an additional
• Findings and indication accessory port in the right upper or right lateral quadrant.
• Surgical approach
• Type and extent of rectal mobilization, how much perito- Open Approach
neum was opened, preservation or division of lateral For an open approach, the surgeon works from the patient’s
stalk(s) left side, with the assistant on the right. As the surgery is
• Resection yes/no essentially limited to the pelvis, both a Pfannenstiel and a
• Type and location of suspension lower midline incision are equally possible. The Pfannenstiel
• Type of implant and method of fixation incision is preferable from a cosmetic standpoint and should
be used unless the patient already has a midline scar.
Pfannenstiel incision: If the patient already has a
Operative Technique Pfannenstiel scar, use the same incision. Otherwise, identify
a natural skin crease approximately 2 fingerbreadths above
Positioning the pubis (Fig. 71.1). Make a 10 cm transverse incision and
extend it to the level of the anterior fascia. Maintain good
Regardless of the approach and comparable to the setup for a hemostasis. Open the anterior fascia transversely along the
low anterior resection (Chap. 59), place and secure the length of the incision without dividing the underlying rectus
patient in modified lithotomy on an anti-sliding system that muscle (Fig. 71.2). Grasp the superior fascial edge with two
allows for dynamic repositioning during the case (Fig. 59.3a Kocher clamps and retract it upward. Carefully deflect the
558 J. Shin et al.
Fig. 71.3
the peritoneal incision over the inserted finger up and down.

Avoid injury to the dome of the bladder during this step.
Midline incision: If the patient already has a midline scar,
Fig. 71.1
use that same incision, starting at the pubic bone and extend-
ing toward the umbilicus. Carefully dissect sharply through
all layers until a safe entry into the peritoneal cavity is
assured.
Both: Quickly explore the abdomen. Subsequently focus
on optimizing the pelvic field. A wound protector often pro-
vides adequate exposure, but occasionally a Bookwalter or
Omni retractor may be required. Place the patient in
Trendelenburg position. Lift the small bowel out of the pel-
vis toward the upper abdomen and tuck it out of the operative
field with a moist marked laparotomy pad.
Posterior Rectal Mobilization and Fixation
osterior Rectopexy with Mesh (Wells)

P
The most common approach is to completely mobilize the
rectum posteriorly, followed by its fixation to the sacrum
by means of a mesh implant. This technique allows for
Fig. 71.2 reduction in redundancy and the formation of a broad-
based fibrotic scar between the repositioned rectum and
sacrum.
muscle fibers from the fascia up to the level of the umbilicus Retract the rectum anteriorly and superiorly. Using elec-
using a combination of blunt dissection and electrocautery. trocautery, incise the peritoneum on both sides of the recto-
Repeat this process for the inferior fascia down to the pubic sigmoid from the level of the sacral promontory down to the
bone. Identify the midline and bluntly dissect to the level of pelvis. In contrast to a low anterior resection, you do not
the peritoneum. Using Metzenbaum scissors, divide the peri- have to connect the two sides anteriorly in the cul-de-sac.
toneum between two tonsil clamps and gain access to the Identify and visually follow the ureters where they cross the
peritoneal cavity (Fig. 71.3). Use electrocautery to extend iliac vessels and run along the pelvic sidewall.
a b
Fig. 71.4
Maintain anterior retraction on the rectum, and then initi- on both sides with roughly four interrupted stitches to the
ate the posterior dissection at the level of the sacral promon- mesh. To minimize rectal mobility, it is important that you
tory. Open the avascular plane between the presacral fascia pull the rectum up while you put the implant on gentle trac-
and fascia propria of the rectum and continue dissection tion toward the pelvis as you place the securing stitches. Use
toward the pelvis. It is important to stay within this plane and a 2–0 absorbable suture to first go through the mesh followed
to minimize division of the lateral attachments to avoid post- by a seromuscular bite on the side of the rectum. Alternate
operative autonomic dysfunction and vascular injuries at this between the right and the left side until there are at least four
portion of the procedure. Insert a sponge stick or St. Mark’s sutures on each side (Fig. 71.5a and b).
retractor posterior to the rectum. Elevate the mesorectum to If done laparoscopically or robotically, introduce the
maintain tension and allow for a combination of blunt dis- mesh through the 10–12 mm port. You may use a laparo-
section and electrocautery within the avascular plane. Avoid scopic tacker to fix a synthetic mesh to the sacrum (Fig.
a too posterior dissection which carries the risk of life- 71.4b). Alternatively, and for a biological collagen sheet, you
threatening bleeding from the presacral veins. Continue this need to intracorporeally place the Prolene stitches as
dissection through Waldeyer’s fascia to the level of the pelvic described above as the tackers are not strong enough to go
floor. Keep the anterolateral dissection as minimal as possi- through the thickness of the implant.
ble, but as much as necessary, to straighten out the redundant Confirm adequate hemostasis, then close the peritoneum
rectum. For retraction of the mobilized rectum, it may be over the mesh with running absorbable suture to avoid any
helpful to pass either a broad penrose drain or an opened contact with the small bowel (Fig. 71.6).
gauze and use it as a temporary sling.
Select the type of implant (synthetic mesh versus biologi- osterior Suture Rectopexy (without Implant)
P
cal collagen graft) and prepare a roughly 10 x 6 cm rectangu- Complete the posterior dissection as described above. Retract
lar piece. Place three to four 2–0 Prolene sutures to the the rectosigmoid in cephalad direction until the laxity is
promontory and upper sacrum. This is a dangerous step and eliminated. Instead of placing an implant and securing the
needs to be done very carefully to avoid massive bleeding. rectum to the implant, you directly place a series of 2–0 non-
Alternatively, a stapler gun may be used to tack the mesh to absorbable sutures from the promontory and sacrum lateral
the promontory (Fig. 71.4a). Guide the pre-laid sutures to the peritoneal edge and the bowel wall. Be careful with
though the transversely positioned implant and tie the sutures each stitch as it may trigger presacral bleeding. In absence of
down. Pass the implant posterior to the rectum to the other an implant, the reperitonealization is optional.
side. Make sure that at least one third of the rectal circumfer- Keep in mind that a suture rectopexy alone has a high
ence remains free anteriorly. Retract the rectum cephalad chance of failure. It is reasonable only if combined with a
until the laxity is eliminated. Secure the repositioned rectum sigmoid resection to eliminate the redundancy.
560 J. Shin et al.
a b
Fig. 71.5
The procedure is considered obsolete as the mesh sling

and the sacrum form a nonelastic passage that tends to
shrink and is notoriously associated with severe
constipation.
Ventral Mesh Rectopexy
For this approach that has gained increasing popularity, the

posterior mobilization is not needed. Instead, incise the
peritoneum overlying the pouch of Douglas with electro-
cautery and carefully open the rectovaginal septum.
Continue dissection in this plane to the level of the pelvic
floor. Frequently, the cul-de-sac is very deep, and only min-
imal dissection is required to reach this level. Confirm ade-
quate hemostasis.
Measure the distance between the exposed pelvic floor
and the sacral promontory and then trim the mesh to length.
Secure one end of the mesh to the anterior rectal wall as dis-
tally as possible with two rows of three interrupted 2–0
Fig. 71.6 absorbable sutures.
Incise the peritoneum overlying the sacral promontory in
order to clear it of fat and expose the iliac bifurcation. Pull
egacy Procedure: Ripstein Rectopexy (Obsolete)
L the loose end of the mesh toward the sacral promontory and
The Ripstein operation also involves the placement of poly- secure it with multiple 2–0 permanent sutures passed from
propylene mesh to fix the rectum to the presacral fascia. the mesh into the presacral connective tissue. Trim the excess
However, in contrast to the above-mentioned posterior wrap, mesh above these fixation sutures.
the Ripstein approach secures the mesh on one side of the Due to the deep cul-de-sac and redundancy, it is often
rectum to the sacrum, guides it anteriorly around the rectum, beneficial to excise the excess peritoneum before closing it
and again secures it on the other side to the sacrum. over the mesh with a running 2–0 Vicryl.
Segmental Colon Resection with Rectopexy Wound Closure
For this approach, you combine a posterior rectal mobilization Perform a last check of the abdomen and make sure there is
with a sigmoid resection in order to decrease the colonic redun- no exposed mesh. Confirm hemostasis. Rearrange the small
dancy. The sigmoid resection is performed so that the anasto- bowel back to its natural position. Remove the ports and/or
mosis will be just above the promontory (see Chap. 55). The retractors. Avoid a pelvic drain as a routine measure, but
posterior rectal mobilization is carried all the way to the pelvic use it on a select basis if the field is not perfectly dry. For
floor as described above and similar to a low anterior resection closure of the Pfannenstiel incision, readapt the rectus mus-
(see above and Chap. 59). As the condition is a benign one, cles with a loose running absorbable suture. A thin drain on
there is no need to perform a lymphadenectomy and the blood top of the rectus muscle and behind the fascia may reduce
supply to the rectum may be preserved. This is especially the formation of a seroma. Close the fascia of any incision
important if the patient previously had a perineal resection. larger than 5 mm in routine fashion. Irrigate the wound and
Open the peritoneum on both sides of the sigmoid and close the skin with absorbable subcuticular sutures (cosme-
rectum starting from the beginning of the redundancy to the sis counts).
pelvic floor. Identify and protect the ureters where they cross
the iliac vessels. Avoid a more proximal colon mobilization
as you do not want to unnecessarily increase the redundancy Postoperative Care
and laxity of the bowel. Perform a posterior rectal mobiliza-
tion as described in the sections above. Attempt to preserve • Antibiotics: Routine coverage for the perioperative
the lateral attachments to the rectum. Using an advanced 24-hour period.
energy device, take the blood supply within the mesocolon • Intravenous fluids: Maintain adequate fluid until return of
and the upper mesorectum close to the bowel to preserve the bowel function.
collateral flow. The distal extent of resection should be just • Incentive spirometry and early ambulation should be
above the promontory when the rectum is pulled out of the encouraged.
pelvis. The proximal extent of the resection is adjusted so • Enhanced recovery after surgery (ERAS) protocol: In
that the redundancy in the region is reduced without creating elective cases, initiate oral intake on the day of surgery
excess tension. Perform a rectosigmoid anastomosis with and advance to solid food as patient demonstrates return
either a stapled or hand-sewn technique as previously of bowel function.
described (see Chaps. 55 and 59). • Avoidance of constipation: Use oral laxatives from the
If performed minimally invasively, you need a 12 mm first day and titrate backward to the individual optimal
port in the right lower quadrant to accommodate the inser- dose that avoids straining versus excessive bowel
tion of the laparoscopic stapler. Deliver the specimen through frequency.
a predetermined extraction site in the suprapubic, left lower • Instruct the patient to avoid lifting more than 15 pounds
quadrant, or periumbilical location. for 6 weeks.
Given the inevitable (even if minimal) contamination of
the field, use of a synthetic mesh is discouraged. Hence,
either perform a suture rectopexy with 2–0 nonabsorbable Complications
suture from each lateral stalk to the sacral promontory or
utilize a biologic mesh that is fixed to the sacrum and • Collateral organ injury (ureters, pelvic urogenital struc-
wrapped around the posterior two thirds of the rectum. tures, hypogastric nerves, major vessels)
• Surgical site infection: Superficial (abdominal wall) ver-
sus deep (pelvis, including mesh erosion or mesh infec-
Multicompartmental Resuspension tion with fistulization)
• Postoperative ileus or small bowel obstruction
When the middle and anterior compartments require resus- • Autonomic nerve dysfunction may follow extensive dis-
pension as well (with or without a hysterectomy), it is best to section of the presacral space, lateral ligaments
first correct the posterior resuspension but to leave the mesh • Bowel dysfunction: Constipation, incontinence
at the sacral promontory exposed. That way, the colleagues • Incisional complications:
from Urogynecology may anchor their resuspension to the –– Seroma formation (particularly in Pfannenstiel
same mesh. Once their part is done, all synthetic mesh needs wound)
to be covered by a peritoneal surface to avoid direct contact –– Port-site, incisional, or internal hernia formation
with the small bowel. • Recurrent prolapse/descent
562 J. Shin et al.
Further Reading rent rectal and pelvic organ prolapse. Female Pelvic Med Reconstr
Surg. 2017.
Lundby L, Iversen LH, et al. Bowel function after laparoscopic pos-
terior sutured rectopexy versus ventral mesh rectopexy for rectal
prolapse: a double-blind, randomised single-Centre study. Lancet
Gastroenterol Hepatol. 2016;1(4):291–7.
Dulucq JL, Wintringer P, et al. Clinical and functional outcome of
Nygaard I, Brubaker L, et al. Long-term outcomes following
laparoscopic posterior rectopexy (Wells) for full-thickness rec-
abdominal sacrocolpopexy for pelvic organ prolapse. JAMA.
tal prolapse. A prospective study. Surg Endosc. 2007;21(12):
2013;309(19):2016–24.
2226–30.
Russell MM, Read TE, et al. Complications after rectal prolapse sur-
Dyrberg DL, Nordentoft T, et al. Laparoscopic posterior mesh rec-
gery: does approach matter? Dis Colon Rectum. 2012;55(4):450–8.
topexy for rectal prolapse is a safe procedure in older patients:
Tou S, Brown SR, et al. Surgery for complete (full-thickness) rectal pro-
a prospective follow-up study. Scand J Surg. 2015;104(4):
lapse in adults. Cochrane Database Syst Rev. 2015;11:CD001758.
227–32.
van Iersel JJ, Formijne Jonkers HA, et al. Robot-assisted ventral mesh
Jallad K, Ridgeway B, et al. Long-term outcomes after ventral recto-
Rectopexy for rectal prolapse: a 5-year experience at a tertiary refer-
pexy with sacrocolpo- or hysteropexy for the treatment of concur-
ral Center. Dis Colon Rectum. 2017;60(11):1215–23.
Part VI
Anus, Rectum, and Pilonidal Region
Andreas M. Kaiser
Concepts in Surgery of the Anus,
Rectum, and Pilonidal Region 72
Introduction Anatomy and Physiology
The anorectal area at the intersection of endoderm and ecto- The anorectum transitions from the terminal portion of the
derm is one of the most complex body regions. Taken for gastrointestinal tract to the outside. Embedded in the osseous
granted by most, the intertwined complexity of anatomy, pelvis and surrounded by urogenital organs, there are impor-
function, and a variety of diseases pose an unparalleled chal- tant neuromuscular, lymphovascular, ligamentous, and con-
lenge. Anorectal surgery is one of the most distinct ways to nective tissue structures that are covered by a changing
recognize quality in a surgeon. From a patient perspective, epithelial layer. The complex functional unit maintains fecal
all problems in the area are “hemorrhoids.” It remains up to continence by providing both a stopper-equipped rectal res-
the educated surgeon to take a systematic yet sensible history ervoir and a controlled expulsion mechanism for feces.
and perform a thorough physical exam to replace simplifica- The rectum represents the distal approximately 12–15 cm
tions with specific information. A knowledgeable differential of the large intestine that forms the reservoir and extends
diagnosis is the guide to an appropriate workup. With great from the sacral promontory to the anorectal ring. From the
opportunity for success, there are also traps and pitfalls that abdominal perspective, its proximal start is defined as the
result in poor outcomes, pain, and functional impairment. confluence of the taeniae coli. The anterior portion of the
This chapter provides an overview from a surgical per- proximal two-thirds of the rectum is covered by peritoneum
spective of the anatomy, function, and diseases combined while the remaining rectum is extraperitoneal. The mesorec-
with the intellectual, technical, and decision-making chal- tum lies posterior to the rectum and contains the blood, ner-
lenges that characterize anorectal surgery. It defers compre- vous, and lymphatic supply to the rectum.
hensive disease presentations and review of Definitions of the anal canal vary between surgeons and
pathophysiological and epidemiological details to respective anatomists. The surgical anal measures up to 4 cm from the
texts. The focus here is to emphasize specific aspects that are anorectal junction to the anal verge. The physiological anal
relevant for establishing safe practice patterns and allowing canal represents the high-pressure zone of 2–4 cm length.
for a structured development of surgical strategies. And last, the anatomical-histological definition is centered
Experience shows that optimized outcomes of anorectal sur- around the dentate line with a transition from columnar to
geries are more often a matter of the whether, when, how transitional cuboidal above, and from modified squamous
much, and the type of surgical approach. Diligence and epithelium without appendages to regular skin with hair and
restriction are equally necessary to allow for continued non- glands distal to it.
surgical management. The dentate line, as the embryologic fusion point between
the endoderm and ectoderm, marks the border between vis-
ceral and somatic innervation, and a change in direction of
the lymph drainage. Furthermore, it is the location where the
R. Hogen
cryptoglandular complex of 4-8 apocrine anal glands coming
Department of Surgery, Keck School of Medicine of the University
of Southern California, Los Angeles, CA, USA from the intersphincteric space enters the anal canal.
The anorectum receives its major blood supply from the
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of superior, inferior, and, to a lesser degree, middle hemor-
Hope National Medical Center/Comprehensive Cancer Center, rhoidal arteries that form a wide intramural network of col-
Duarte, CA, USA laterals and collect in arteriovenous plexus. The submucosal

https://doi.org/10.1007/978-3-030-81415-1_72
566 R. Hogen and A. M. Kaiser
hemorrhoidal cushions above the dentate form the basis for or masses. Pain with retraction of the buttocks should also be
internal hemorrhoids and communicate with the smaller noted. If patients experience significant pain on external exam,
external hemorrhoidal plexus. There are three primary posi- a digital exam or instrumentation should be avoided; if neces-
tions: left lateral, right anterior, and right posterior. sary, an examination under anesthesia or sedation should be
The pelvic floor (pelvic diaphragm) is a funnel-shaped arranged for in the operating room. If tolerated though, a gen-
musculo-tendineous termination of the pelvic outlet and is tle digital rectal examination (DRE) should then be performed
formed by striated skeletal muscles that are innervated by which not only entails the insertion of typically the index fin-
S3-S4 nerve branches. At the hiatus for passage of the ano- ger into the rectum but counterpressure from the opposing
rectal and urogenital viscera, it transitions to the voluntary thumb on the outside (bi-digital rectal exam) to compress the
U-sling of the puborectalis and the concentric ring of exter- tissue and look for indurations. An educated DRE may allow
nal anal sphincter (EAS) muscle. Both contribute to the rest- for identification of multiple abnormalities such as masses, fis-
ing tone and the voluntary incremental squeeze tone of the tulas, abscesses, strictures, pain trigger points (levator spasm,
anal canal. The internal anal sphincter (IAS) is an involun- coccydynia, prostatitis), integrity, strength/weakness, or dis-
tary smooth muscle in continuation of the muscularis propria coordination of the sphincter complex. The anal sphincter tone
of the rectum and is innervated by autonomic nerves; it con- should be assessed at rest and squeeze, as well as during a
tributes to the resting sphincter tone. The groove between Valsalva maneuver.
internal and external sphincter is palpable within the anal Instrumentation aims at a visualization of the mucosa and
canal, distal to the dentate line. either confirming or ruling out a specific pathology. Defining
Important from a disease aspect are the perianal spaces the extent (anoscopy vs. rigid/flexible sigmoidoscopy)
that are defined by fascial compartmentation. The ischioanal should rely on previously documented evaluations as well as
space on either side of the anal canal is bounded by the leva- the immediate and future need for visualization of a specific
tor ani muscles superiorly and the ischial tuberosities later- pathology or the colon. An instrumentation beyond a simple
ally; the two sides connect posteriorly through the superficial anoscopy typically requires administering 1-2 enemas before
and the deep postanal spaces of Courtney between the ano- the procedure. In many situations, and depending on the indi-
coccygeal ligament and the levator ani muscles. The supral- vidual age and risk constellation, a complete colon clearance
evator space lies superior to the levator ani muscles and should be recommended prior to a nonurgent anorectal
surrounds the rectum posteriorly; medial to the ischial spine, intervention.
it can communicate with the ischioanal space via the fascia
of the obturator internus and Alcock’s canal.
Imaging
Diagnostics For most anorectal cases, imaging is not necessary to estab-

lish the diagnosis. Selectively on a case-by-case basis, a need
Anorectal Examination for cross-sectional imaging (e.g., ultrasound, CT, MRI, PET
scan) may be recognized depending on the circumstances
Visual inspection, digital rectal examination, and anoscopy and the expected or confirmed nature of the pathology.
or proctoscopy are the key components of a complete ano- For evaluation of the pelvic floor and sphincter integrity,
rectal examination. Equal attention should be paid to mor- the ultrasound is by far the best modality. For more extensive
phological and functional aspects. The physical exam can be or intrapelvic conditions (tumors, suppurations/fistulas, etc.),
performed with the patient in either a lateral decubitus or the a static MRI or CT scan may be superior. For dynamic
prone jackknife position. The latter can be further optimized assessment of any positional instability of the pelvic organs
by using a hydraulic exam table that allows flexion at the (pelvic organ prolapse) and the evacuation efforts, a dynamic
hips and Trendelenburg positioning. Excellent lighting is pelvic MRI or a defecating proctogram is best situated to
crucial for a meaningful exam. provide the link between morphology and function.
The perianal skin and anal area should first be inspected
with the buttocks retracted laterally. The overall anatomy is
assessed for gross abnormalities, asymmetries in shape, color Functional Testing
and texture, defects (skin, perineal body, anal verge, etc.), pro-
lapse (rectal, vaginal), or a visually evident lack of sphincter For objective evaluation of the pelvic floor and sphincter
tone (“patulous anus”). The visual inspection and external pal- function, a set of diagnostic modules can be utilized. Anal
pation check for scars, erythema or other skin pathology, manometry includes the measurement of resting and squeeze
swelling and/or induration, thrombosis, hemorrhoidal enlarge- pressures over the length of the anal canal, anorectal volume
ment, prolapse, fissures, fistulas, specific pain trigger points, tolerance, and rectal compliance, and the presence or absence
72 Concepts in Surgery of the Anus, Rectum, and Pilonidal Region 567
of the recto-anal inhibitory reflex (RAIR). Additional tests or anxiety are better served with an examination and man-
may include measurement of the pudendal nerve terminal agement in the operating room.
motor latency (PNTML), electromyography (EMG), or a Success in either setting often does not require extrava-
balloon retention and expulsion test. gant tools but comes easiest with standard instruments, ade-
quate lighting, optimal positioning, and a trained team to
provide a smooth and predictable process.
Management It should be noted though that even for anorectal and
endoluminal cases, the armamentarium of surgical tools con-
Nonsurgical Treatments tinues to rapidly expand. There is a wide range of new plat-
forms aimed at facilitating the approach or allow for less
Management of patients with anorectal disorders almost invasive procedures. The booming growth unquestionably
always includes nonoperative measures. The most pressing has expanded horizons, but the individual roles are yet to be
goals are (a) to optimize the stool consistency and evacua- defined in many instances. Where appropriate, these tech-
tion, (b) to address any acute pathology (wound, thrombosis, nologies are discussed in the respective chapters.
inflammation), and (c) to care for the surrounding skin.
Specific complex diseases (cancer, inflammatory bowel dis-
ease) are beyond the scope of this chapter and require inter- Anesthesia and Positioning
disciplinary attention.
Dietary changes and possible fiber supplementation are For surgical procedures, the choice of anesthesia and patient
intended to identify and avoid unfavorable nutritional habits. position is determined by surgeon preference. Conscious
Bowel and potentially behavioral habit training may be sedation and local anesthetic often work very well; however,
important to maintain regularity and minimize obsessive pat- spinal block anesthesia or general anesthesia can afford
terns. Sitz baths aim at cleaning the area from stool or—in superior relaxation and paralysis for young muscular male
case of a wound/inflammation—from debris, pus, and fibrine patients. Prone jackknife positioning allows better exposure
buildup. Supportive measures include application of barrier and decreases the venous congestion of the hemorrhoid
creams to protect the perianal skin. plexus. The buttocks can be retracted laterally with tape in
Systemic antibiotics are not routinely needed but utilized the prone jackknife position for better exposure. In super-
selectively. More commonly, medications are introduced for obese patients, however, any position may prove to be
pain control, to soften the stool (stool softeners, laxatives), to exceedingly difficult, and sometimes, a lateral position offers
slow down the bowels (antidiarrheal medications), to bind the best compromise.
bile acids (cholestyramine), or to reduce the reflectory Local anesthesia using a long-acting local anesthetic
sphincter relaxation (antidepressants such as amitriptyline). (e.g., bupivacaine) can be used for office procedures or in
Patients with incontinence may benefit from reducing the support of sedation/anesthesia in the operating room (pre-
stool load through scheduled rectal enemas. emptive analgesia). On either side, on a transverse line
While there are abundant over-the-counter topicals, the through the anus, a deep injection of 5 cc of the anesthetic
majority of them have no proven benefit and may in fact targets the ischioanal fossa—lateral to the sphincter com-
cause harm (e.g., steroids or topical anesthetics). Rational plex, that is, 1–1.5 cm away from the anal opening. A more
topical medications are limited and include sphincter tone superficial circumferential block is added around the anus. In
reducing medications (nitroglycerine or calcium antagonists) case of a single quadrant office procedure, a few milliliters of
or occasionally antibiotic creams (metronidazole). local anesthetic may be injected just around and under the
Physical therapy and biofeedback training aim at optimiz- respective target lesion (thrombosed hemorrhoid, wart, skin
ing the pelvic floor and sphincter function including reten- biopsy, etc.).
tion or evacuation by either strengthening, coordination, or
relaxation exercises.
Perioperative Management
Surgical Tools Most anorectal procedures require only minimal preparation.

One to two enemas just prior the surgery typically suffice,
The majority of anorectal conditions and surgeries can be unless a full colonic evaluation is planned or specific reasons
managed and carried out in an outpatient setting. Minor ask for a full bowel cleansing. Single dose of antibiotic may
interventions may be suited for the office/clinic when there is be administered but for many procedures do not seem to add
an appropriate setup of equipment, materials, and staff as any benefit. Due to the short nature of the surgeries, there is
well as a willing patient. Patients with severe anorectal pain no indication for pharmacological thromboembolic prophy-
laxis. And as long as the intravenous fluid administration is (skin-covered), which is not graded and should not be mis-
kept at a minimum, there is also no routine need for a Foley taken as prolapse.
catheter. Treatment of internal hemorrhoids varies based on the
severity of disease. The initial goal of therapy is to minimize
straining and reduce constipation. This can be accomplished
Clinical Conditions with dietary fiber supplementation, stool softeners, and suf-
ficient fluid intake. Often no further treatment is necessary
Anorectal Pain for Grade I internal hemorrhoids. If symptoms persist, addi-
tional therapy may be required. Grade I, II, and some Grade
Pain may have a wide differential diagnosis, but the most III internal hemorrhoids can be treated with a variety of
common causes are (1) anal fissure (chronic, aggravated by office-based procedures, including rubber band ligation,
defecation), (2) thrombosed external hemorrhoid (days to sclerotherapy, and infrared coagulation. Persistent symptoms
1–2 weeks), or (3) a perirectal abscess (gradual increase). or larger grade III internal hemorrhoids require operative
Other causes include functional, neoplastic, neurogenic/ treatment with either an excisional or stapled hemorrhoidec-
referred pain conditions, and others. tomy or trans-anal Doppler-guided hemorrhoidal artery liga-
tion. Incarcerated internal hemorrhoids require an excisional
hemorrhoidectomy, particularly if there is tissue necrosis.
Hemorrhoids External hemorrhoids arise distal to the dentate line and
are covered with squamous epithelium. They frequently are
Internal hemorrhoids are a common anorectal condition. chronic and only rarely give cause to symptoms. Rarely, they
They arise from the hemorrhoidal cushions above the dentate are so redundant that the patients have difficulty with the
line, and hence they are covered by a mucosal epithelium and local hygiene. Occasionally, there may be an acutely throm-
are devoid of somatosensory nerves. The anal cushions are a bosed external hemorrhoid with a sudden onset and a limited
part of normal anorectal anatomy and contribute to conti- period of pain. There is no bleeding from external hemor-
nence. Symptoms develop when there is pathological rhoids, except if an acute thrombosis spontaneously ruptures
engorgement of these cushions as a result of chronic consti- and the clot evacuates. Bleeding and chronically “painful
pation as well as an individual predisposition. hemorrhoids” more often represent an anal fissure with sen-
Symptoms of internal hemorrhoids are characteristi- tinel skin tag.
cally painless rectal bleeding or prolapse whereas itching External hemorrhoids should only be excised if the patient
is not considered a specific symptom. The bleeding is opts for an excisional hemorrhoidectomy for cosmetic/
typically bright red and can be noted either on toilet paper esthetic purposes or if they are diagnosed in the acute phase
or drip into the toilet bowel. Most bleeding episodes are of thrombosis. In the latter situation, surgical treatment
self-limited. Internal hemorrhoids are not associated with within 72 hours from the onset of pain may hasten recovery;
pain except when there is an acute Grade IV (incarcerated after 72 hours, the thrombosis begins to be organized and
internal hemorrhoids); presence of pain more likely sug- absorbed and the palpable lump softens and becomes less
gests a fissure or an acutely thrombosed external painful. Conservative treatment with a high-fiber diet, stool
hemorrhoid. softeners, sitz baths, pain control, and sufficient fluid intake
Internal hemorrhoids are classified according to the is more appropriate beyond 72 hours.
degree of mucosa-covered prolapse: Grade I is characterized
by bleeding without prolapse, Grade II by prolapse with
straining that spontaneously reduces, Grade III by prolapse Anal Fissure
that requires manual reduction, and Grade VI by prolapse
that cannot be reduced. The Grade IV is acute and painful An anal fissure is a short longitudinal tear between the den-
and represents an emergency if the sphincter tone is very tate line and the anal verge associated with high internal anal
tight, and the hemorrhoids become incarcerated, throm- sphincter tone. Anal fissures are most commonly located in
bosed, and eventually risk at developing tissue necrosis; the the midline, usually posteriorly and less commonly anteri-
Grade IV is chronic when the sphincter tone is very lax, and orly. Eccentric or long anal fissures are concerning for other
while the hemorrhoids can be reduced, they immediately re- pathophysiology including Crohn’s disease, HIV, tuberculo-
prolapse. The degree of prolapse is on one hand obtained by sis, or immunocompromised status. Risk factors for anal fis-
the patient’s history, but otherwise can be evaluated by sures include chronic diarrhea and constipation, but anal
instructing the patient to perform a Valsalva maneuver either fissures may develop in the setting of normal bowel move-
in the lateral decubitus position or on the toilet. Internal hem- ments. Patients usually present with pain with defecation.
orrhoids may be associated with an external component Sometimes acute fissures can be associated with bright red
blood per rectum, but traces of blood on toilet paper are more in the office. Larger ischiorectal abscesses, horseshoe
characteristic. Anal fissures can be defined as acute or abscesses, supralevator abscesses, or patients with signifi-
chronic. Acute fissures have new onset related to an episode cant pain on exam may be more comfortably treated under
of diarrhea or constipation. Chronic fissures are character- anesthesia in the operating room (if there is no undue
ized by greater than 3 months of symptoms or morphologic delay). Drainage is performed by incising the skin over the
signs of chronicity such as a sentinel skin tag, exposed abscess as close to the anus as possible to ensure that the
sphincter muscle, or hypertrophic anal papilla. The majority resulting fistula is short. Intersphincteric abscesses are
of acute anal fissures will heal with conservative manage- drained by incising the internal sphincter over the area of
ment. Some acute anal fissures will develop into chronic anal fluctuance. Treatment of supralevator abscesses depends on
fissures associated with a vicious cycle of increased internal the source of the infection and may require intraabdominal
anal sphincter tone, increased pain, and increased source control of the infection. Antibiotics are only required
constipation. in the treatment of anorectal abscess if there is associated
The goal of treatment is to decrease the sphincter tone and cellulitis or systemic sepsis or if the patient is
improve stool regularity. Patients should be placed on fiber immunocompromised.
supplements, stool softeners, and increase their fluid intake. Anorectal fistula is the chronic sibling disease of the
Reduction of the sphincter tone can be achieved by topical abscess and may persist in roughly 50% after spontaneous
medications (nitroglycerin or calcium antagonists), a Botox rupture or surgical drainage of an abscess. A substantial por-
injection into the internal anal sphincter muscle (chemical tion of patients do not recollect having an abscess and simply
sphincterotomy), or most effectively but irreversibly by a lat- present with a draining opening. Patients with anorectal fis-
eral internal sphincterotomy (with or without a tula usually present with cyclic anorectal pain and drainage.
fissurectomy). The course of the fistula can be evaluated with thin silver
probes or hydrogen peroxide injection into the fistula tract
and assessment for bubbles at the internal opening. The
Anorectal Suppurative Diseases internal opening is most commonly found at the dentate line
along the cryptoglandular complex.
Anorectal abscesses are common and usually present with Anal fistulas are classified and treated according to their
anal or perianal pain, erythema, and tenderness. Signs of sys- relationship to the external sphincter. There are five main
temic sepsis may also be present. types of fistulas: superficial, intersphincteric, transsphinc-
Anorectal abscesses arise from the anal glands and crypts teric, suprasphincteric, and extrasphincteric. Superficial fis-
along the dentate line. Historically, they were invariably tulas travel from the primary to the secondary opening
caused by enteric bacteria, but recently other strains (includ- without interfering with any of the muscle structures.
ing methicillin-resistant Staphylococcus aureus) have been Intersphincteric fistulas course through the intersphincteric
isolated. plane but not the external sphincter muscle. Transsphincteric
The location and depth of the abscess determines the clin- fistulas pass from the intersphincteric plan through at least a
ical findings on physical exam. Perianal abscesses are usu- portion of the external sphincter muscle. Suprasphincteric
ally located close to the anus. Ischiorectal abscesses can be fistulas extend cephalad within the intersphincteric plan to
larger and deeper, and they may be more difficult to recog- above the level of the external sphincter muscle and pass
nize and hence can result in more severe infection. around the external sphincter muscle to enter the ischioanal
Intersphincteric abscesses present with anal pain and fluctu- fossa. Extrasphincteric fistulas pass from the skin of the
ance in the anal canal but often lack external signs of an perineum through the ischiorectal fossa and levator muscles
infection. Supralevator abscesses characteristically originate before penetrating the rectal wall.
from an intraabdominal/pelvic disease process that finds its Numerous techniques have been described for anal fistu-
way to the deep postanal and ischioanal spaces. las. Superficial fistulas and intersphincteric fistulas can be
In general, anorectal abscesses can be diagnosed on phys- safely treated with fistulotomy. For transsphincteric fistulas,
ical exam alone (external palpation or bi-digital rectal exam). however, a balance between cure of the fistula and preserva-
Blood work or imaging is not routinely needed but may be tion of the sphincter strength must be found. Techniques
useful if there is a suspicion for complex disease or if an include from least to most successful: fibrine glue injection,
abscess is suspected without external physical exam insertion of a collagen fistula plug, ligation of the inter-
findings. sphincteric fistula tract (LIFT), endorectal advancement flap
Treatment of anorectal abscess is invariably surgical and (ERAF), or a cutting seton. Sometimes, a fistula may be con-
consists of incision and drainage with the goal of relieving trolled or matured but not eliminated by placement of a
pressure and pain and allowing pus to drain freely. This can draining seton. That option is relevant for Crohn disease,
often be performed with local anesthesia at the bedside or immunocompromised patients, patients on chemotherapy,
and others in whom a definitive treatment is not immediately Rectal Prolapse

advisable.
Supralevator fistulas are frequently associated with an Rectal prolapse is full-thickness protrusion of the rectum
underlying abdominal pathology; they are usually not ame- below the anal verge. This is distinguished from partial rectal
nable to standard local anorectal procedures and require mucosal prolapse, which can occur with hemorrhoidal dis-
addressing the underlying disease. ease. Full-thickness rectal prolapse is identified by the exter-
nal appearance of concentric rectal folds, whereas partial
rectal mucosal prolapse has a radial pattern. Rectal prolapse
Pilonidal Disease may develop as isolated pathology or in the context of multi-
compartmental pelvic organ prolapse. There is often a pri-
Pilonidal disease is a common condition that is included mary or secondary weakness or lack of the pelvic suspension
with other anorectal diseases because of its proximity to the structures such as a low peritoneal reflection, underdevel-
area. It has features and some overlap with hidradenitis oped mesorectum, lack of lateral attachments, or pelvic dia-
suppurativa and/or with perirectal fistulas. Pilonidal dis- phragm dysfunction. A rectal tumor, polyp, or ulcer can
ease most commonly occurs in young adults. It usually sometimes act as a lead point and cause the prolapse.
presents with pain, erythema, swelling, and drainage from The prolapse can usually be reproduced on exam by ask-
pits in the sacrococcygeal region. It is thought to develop as ing the patient to perform a Valsalva maneuver in left lateral
a foreign body reaction and infection secondary to hair position or on the toilet. The clinical evaluation should at
nests beneath the skin surface, which may be the result of least include a sigmoidoscopy to evaluate for a lead point.
secondary penetration and primary development. Acute Most commonly, a rectal prolapse represent a chronic
abscesses should primarily be drained utilizing local anes- condition. Occasionally, it becomes an acute event if the pro-
thesia. Further, elective surgery is indicated if there is a per- lapse cannot be reduced. An incarcerated prolapse without
sistent activity (sinus, fistula, induration) or if there are tissue necrosis should be reduced with application of table
recurrent episodes of acute infections. In the short course, sugar to reduce edema or a perianal/pudendal nerve block for
the disease management solely focuses on symptom con- sphincter relaxation. If there is impaired tissue viability, a
trol. In the long run, however, there emanates a risk of perineal proctectomy will be necessary.
squamous cell cancer if smoldering and fistulizing disease Rectal prolapse can be treated with a variety of proce-
persists over 20–30 years. dures which can broadly be grouped into perineal or abdomi-
A wide range of surgical options of variable extent have nal surgical techniques. The choice of procedure depends on
been described, none of which combines all goals in one the patient’s health (frailty), history, and preference of the
(recurrence-free recovery, fast recovery, limited impact on patient. Perineal surgeries are less invasive and better toler-
activity, pain-free, etc.). The details are described in the ated but have a higher recurrence rate. For patients with a
respective chapter. reasonable risk, abdominal procedures are more effective.
Abdominal procedures come in various forms, through dif-
ferent types of access (open or minimally invasive modali-
Hidradenitis Suppurativa ties), with or without bowel resection, with or without
implants (synthetic or biological), and with variable location
Hidradenitis suppurativa is a fistulizing inflammatory proof the implant (ventral vs posterior rectopexy). In pan-
cess that typically arises in the buttock, perianal and peri- compartmental pelvic organ prolapse, the rectopexy can be
neal, groin, and suprapubic areas as well as the underarm combined with a sacrocolpo- and cystopexy.
pits. The disease appears to originate from the apocrine For patients who are not surgical candidates, banding,
sweat glands. It represents a chronic smoldering infection improvement in stool regularity, or sclerosing agents can be
with superimposed acute exacerbations with multifocal sup- used and occasionally is quite effective.
puration and abscess formation. Over time, there may be a
significant fibroplastic reaction with occasionally grotesque
scarring and tissue deformation. Anorectal Stricture
Mild forms may respond to medical management,
whereas more extensive disease requires surgical interven- Anorectal stricture/stenosis is a pathologic narrowing of the
tions to unroof the fistula tracts. Due to the chronically recur- anal canal or distal rectum. The cause may be a malignancy
rent nature of the disease, there is on occasion a need to or a series of benign conditions. The most common etiolo-
perform several sequential debridements until an area comes gies for the latter include prior anorectal surgery, complica-
to complete quiescence. tions from pervious rectal surgeries (leak), external beam
radiation therapy, Crohn’s disease, or a functional outlet area; others occur in the context of a disseminated disease
obstruction. Patients with an anorectal stricture often com- (e.g., psoriasis) or a specific infection (HPV, fungus, sexually
plain of constipation, ribbonlike stools, painful defecation, transmitted infections, tuberculosis, etc.). There are benign
and the inability to perform enemas. or premalignant conditions with or without a potential for
The management of an anorectal stricture depends on the malignant transformation (e.g., dysplasia), as well as malig-
etiology, the severity, the stricture length and configuration, nant conditions (squamous cell cancer, basal cell cancer,
and the patients’ ability to compensation by means of coping melanoma, and others).
mechanisms.
For mild anal stenosis, a bowel regimen including laxa-
tives may suffice. The next level of intervention would entail Further Reading
and manual anal dilatation. For more severe forms of steno-
sis, a first dilation may require an exam under anesthesia. Alonso-Coello P, Marzo-Castillejo M, Mascort JJ, et al. Clinical prac-
Ideally, subsequent dilations are done by the patient on a fre- tice guideline on the treatment of hemorrhoids and anal fissure
quent basis by means of a dilator or a candle (as a cheaper (update 2007). Gastroenterol Hepatol. 2008;31(10):668–81.
American Gastroenterological A, Bharucha AE, Dorn SD, et al.
version of a dilator). American Gastroenterological Association medical position state-
A surgical correction is indicated for the most severe ment on constipation. Gastroenterology. 2013;144(1):211–7.
forms or when previous dilations do not result in a durable Bordeianou L, Paquette I, Johnson E, et al. Clinical practice guide-
improvement. The choice of treatment depends on the length lines for the treatment of rectal prolapse. Dis Colon Rectum.
2017;60(11):1121–31.
of the stricture and the surrounding tissue quality. Patients Bordeianou LG, Carmichael JC, Paquette IM, et al. Consensus state-
with fecal impaction or large bowel obstruction may require ment of definitions for anorectal physiology testing and pelvic floor
a proximal fecal diversion prior to other interventions for the terminology (revised). Dis Colon Rectum. 2018;61(4):421–7.
stenosis. For patients with Crohn’s disease and neoplasm, the Chapple CR, Cruz F, Deffieux X, et al. Consensus Statement of the
European Urology Association and the European Urogynaecological
underlying condition should be the focus of initial Association on the use of implanted materials for treating pel-
management. vic organ prolapse and stress urinary incontinence. Eur Urol.
The mainstay of surgical treatment for an anorectal stric- 2017;72(3):424–31.
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Office Procedures for Internal
Hemorrhoids (Sclerotherapy, Infrared 73
Coagulation, and Rubber Band
Ligation)
Non-incarcerated symptomatic internal hemorrhoids with • Use of the “o’clock” system to describe the location of
bleeding, fullness, or intermittent hemorrhoidal prolapse. hemorrhoids or of treatment applications should be
strongly discouraged as this varies depending on the
patient’s position (i.e., prone, lithotomy, left lateral decu-
Contraindications bitus, or Sim’s position). The preferred terminology is
based on four quadrants (left/right, anterior/posterior).
• Asymptomatic hemorrhoids • Failure to perform appropriate age- and risk-adjusted
• Symptoms more consistent with other anorectal pathol- evaluation of the colon (anoscopy, flexible sigmoidos-
ogy (fissure, fistula, levator ani spasm) copy, colonoscopy) prior to any elective intervention.
• Rectal prolapse • Carrying out treatments for internal hemorrhoids when
• Strangulated internal hemorrhoids the symptoms are caused by a different anorectal pathol-
• External hemorrhoids ogy (e.g., fissure).
• Thrombosed external hemorrhoids • Performing therapy in the area below the dentate line,
• Presence of fistulas, anal fissures, tumors, or skin tags which is densely innervated by the somatic sensory
• Uncorrected coagulopathy (including liver failure) nerves, is associated with significant pain.
• Failure to recognize signs and symptoms of pelvic sepsis
(disproportionate pain, urinary retention, fevers, etc.).
Preoperative Preparation • In patient’s being evaluated for gastrointestinal bleeding,
ensure that a thorough and complete workup is performed
• Enema preparation prior to intervention is adequate for prior to interventions. This workup may also include a
most in-office procedures. screening colonoscopy.
• Depending on patient’s clinical presentation and colorec-
tal cancer risk factors, screening colonoscopy or sigmoid-
oscopy may be indicated. Operative Strategy
Perform a thorough visual, digital, and anoscopy exam and

document location (left lateral, right anterior, right posterior)
and grade of hemorrhoidal disease (Grade I–IV). Ensure that
there is no evidence of any fissures, fistulas, other inflamma-
M. P. Duldulao tory or neoplastic process before performing any procedures.
If the patient complains of pain before the procedure, stop
Los Angeles, CA, USA right there, reexamine the patient, and if necessary initiate
further workup.
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of If no contraindication is noted, keep the anoscope in and
Hope National Medical Center/Comprehensive Cancer Center, determine the level at which to carry out the office interven-
Duarte, CA, USA tion. Typically target the apex of the hemorrhoidal piles at

https://doi.org/10.1007/978-3-030-81415-1_73
least 10–15 mm above the dentate line and not the point of
maximum hemorrhoidal engorgement. You may test the
somatic sensory innervation by pinching the anal mucosa at
the apex of the hemorrhoidal column. This should be toler-
ated, but in some patients, pain sensation may extend even
more proximal than that. In these situations, it is advised to
abandon the office procedure in preference for the operating
room with controlled anesthesia.
In patients with multiple enlarged hemorrhoid columns, it
is usually safe and equally well tolerated to deliver three
applications in the same session without aggravating any
symptoms. More treatment may still be necessary in the case
of voluminous disease. In that case, it may be advisable to
plan for subsequent treatments after intervals of at least
4–6 weeks. If well tolerated but the hemorrhoidal disease is
too substantial for it to be effective, it is essentially up to the
patient to define how many sessions are acceptable or when
true surgical strategies in the operating room should be
pursued.
Prior to performing any procedure, administer an enema
to reduce stool burden within the rectal vault and allow for
best visualization of the anal canal and hemorrhoids.
Instillation of lidocaine gel may mitigate the early postproce-
dural urge and discomfort. Fig. 73.1
Documentation Basics line. Insert the needle above the dentate line and access the
hemorrhoidal plexus either at the bottom or the apex of each
Coding for surgical procedures is complex. Consult the most pile (Fig. 73.1). Inject 0.5 ml of the sclerosant agent.
recent edition of the AMA’s Current Procedural Terminology Blanching of the pedicle indicates successful injection,
book for details (see references at the end). In general, it is whereas pain should prompt you to stop. A maximum of
important to document: 3 ml can be injected in each column. It is advisable to treat
all hemorrhoid columns in the first session.
• Symptomatology to justify an intervention
• Type and findings of preoperative colorectal evaluation
• Degree and severity of hemorrhoids Infrared Coagulation
• Number and anatomic location of hemorrhoids
This therapy is indicated for the treatment of enlarged and
bleeding internal hemorrhoids without a significant compo-
Operative Technique nent of prolapse. It may also be used for delayed bleeding
after preceding banding.
Sclerotherapy Prepare the infrared coagulator and place the disposable
sheath around the applicator. Adjust the infrared coagulator
Position the patient in jack-knife prone or left lateral posi- to deliver 1.5 second pulses. Position the patient in the jack-
tion. Use a slotted (fenestrated) or angled opening anoscope knife prone or left lateral position. Insert a slotted or fenes-
as this allows best visualization of the hemorrhoidal column. trated anoscope. Inject 0.5% bupivacaine at the apex of the
Prepare a 10 ml syringe with sclerosant, either 5% phenol hemorrhoid column proximal to the dentate line. Apply up to
with vegetable oil or sodium morrhuate and sodium tetra- five pulses in star pattern within the proximal portion of the
decyl sulfate (i.e., Sotradecol). Attach the syringe to a long hemorrhoid column. An application produces coagulation
angled needle or long spinal needle. Use one hand to main- 3 mm wide and 3 mm deep (Fig. 73.2). Smaller hemorrhoid
tain the position of the anoscope and the other to introduce columns can be treated with fewer pulses, but at least 3
the needle at the apex of the hemorrhoid column. Make sure pulses are advised. Additional treatments can be repeated
to avoid injecting within the sensitive region of the dentate after 4–6 weeks, earlier if there is active bleeding.
73 Office Procedures for Internal Hemorrhoids (Sclerotherapy, Infrared Coagulation, and Rubber Band Ligation) 575
style integrated single use systems (CRH O’Regan system).

The difference is single versus multiple use and how the
hemorrhoid tissue is pulled into the applicator:
• Manual rubber band applicator (McGivney): Applicator

ring with loaded bands through which the hemorrhoid
needs to be pulled in by means of a mechanical grasper
• Suction rubber band applicator (McGown, CRH O’Regan
System): Closed applicator cone with loaded bands, con-
nected to a suction or the integrated syringe-like suction
mechanism
Load two rubber bands on to the ring/drum of the respec-

tive rubber band applicator, place it on target at the apex of
the hemorrhoidal pile, pull in the tissue, pull the trigger to
deploy the rubber band, release the trigger (Fig. 73.3a–c).
Remove the applicator to get reloaded for rounds 2 and 3.
Observe the patient for 20–30 minutes. If the patient
experiences mild discomfort, inject topical lidocaine gel. If
there is severe pain, remove the rubber bands with the cutting
hook. If more applications are required, have the patient
return after no less 4–6 weeks.
Fig. 73.2 Postoperative Care
• Instruct the patient on maintaining a healthy bowel regi-

On rare occasion, infrared coagulation can also be uti- men by advising them on appropriate diet, bulking agents,
lized to treat small external hemorrhoids in a similar fashion and/or stool softeners.
if the patient desires for cosmetic reasons. However, apply • Provide the patients with adequate information about
local anesthetic prior to initiating any treatment to external acceptable symptoms versus concerning/alarming symp-
hemorrhoids. toms. For example, small amount of bleeding is to be
expected immediately following treatment, and again
later when the rubber-banded tissue sloughs off.
Rubber Band Ligation • If re-treatment is needed, it is usually prudent to wait
4–6 weeks in-between to allow the tissues to normalize
Position the patient in jack-knife prone or left lateral posi- again.
tion. Plan for placement of three rubber bands per session,
unless not all three piles are enlarged. Prior to banding, you
should assure that you have at hand also a rubber band cutter, Complications
that is, a small hook with a blade on its inside curve. If it
should become necessary to remove a fired band, the tip of • Too distal treatment application
the hook can be inserted into the deployed rubber band; a • Persistent burning sensation or chronic pain
small traction on the hook will cut through the band and • Thrombosis and necrosis of treated hemorrhoid
removed it. • Abscess formation, pelvic sepsis
Use a slotted or fenestrated anoscope and identify the • Slippage of hemorrhoid bands (not a complication, just a
engorged internal hemorrhoid piles. Have an assistant to sta- treatment failure)
bilize the anoscope in position. There are different types of • Delayed hemorrhage
rubber band ligators, for example, with suction (McGown), • Anal stricture
with need to grasp the hemorrhoid (McGivney), or syringe- • Recurrent hemorrhoids
a b
Fig. 73.3
Further Reading Shanmugam V, Muthukumarasamy G, Cook JA, Vale L, Watson AJ,

Loudon MA. Randomized controlled trial comparing rubber band
ligation with stapled hemorrhoidopexy for Grade II circumferential
haemorrhoids: long-term results. Color Dis. 2010;12:579.
Ambrose NS, Morris D, Alexander-Williams J, et al. Randomized
trial of photocoagulation or injection sclerotherapy for the treat-
Giamundo P, Salfi R, Geraci M, et al. The hemorrhoid laser procedure
ment of first- and second-degree hemorrhoids. Dis Colon Rectum.
technique vs rubber band ligation: a randomized trial comparing 2
1985;28(4):238–40.
mini-invasive treatments for second- and third-degree hemorrhoids.
Brown SR, Tiernan JP, Watson AJM, et al. Haemorrhoidal artery liga-
Dis Colon Rectum. 2011;54(6):693–8.
tion versus rubber band ligation for the management of symp-
Armstrong DN. Multiple hemorrhoidal ligation: a prospective, ran-
tomatic second-degree and third-degree haemorrhoids (HubBLe):
domized trial evaluating a new technique. Dis Colon Rectum.
a multicentre, open-lable, randomized controlled trial. Lancet.
2003;46(2):179–86.
2016;388(10042):356–64.
Corman ML. Chapter 11. Hemorrhoids. In: Corman ML, Bergamaschi
Tokunaga Y, Sasaki H, Saito T. Evaluation of sclerotherapy with a
RCM, Nicholls RJ, Fazio VW, editors. Corman’s colon and rec-
new sclerosing agent and stapled hemorrhoidopexy for prolapsing
tal surgery. Philadelphia: Lippincott Williams & Wilkins; 2013.
internal hemorrhoids: retrospective comparison with hemorrhoidec-
p. 272–345.
tomy. Dig Surg. 2010;27:469–72.
Marques CF, Nahas SC, Nahas CS, et al. Early results of the treat-
Yano T, Yano K. Comparison of injection sclerotherapy between 5%
ment of internal hemorrhoid disease by infrared coagulation and
phenol in almond oil and aluminum potassium sulfate and tannic
elastic banding: a prospective randomized cross-over trial. Tech
acid for grade 3 hemorrhoids. Ann Coloproctol. 2015;31(3):103–5.
Coloproctol. 2006;10(4):312–7.
Excisional Hemorrhoidectomy
(Ferguson, Milligan-Morgan, 74
Whitehead)
Joseph Nunoo-Mensah, Vita Klimasauskiene,

• Relative contraindications: Portal hypertension, inflam-

Indications matory bowel disease, bleeding disorders, fecal
incontinence
• Symptomatic Grade I internal hemorrhoids (that failed or
are not suited for other management options, or if the For patients who do not worry about the external compo-
patient desires to have external component addressed as nent or those with bleeding disorders or portal hypertension,
well) a stapled hemorrhoidectomy (Chap. 75) is often a more
• Grade II–III internal hemorrhoids (particularly if failed desirable procedure.
other management options and if the patient desires to
have external component addressed as well)
• Grade IV internal hemorrhoids (acute incarcerated, Evaluation and Preparation
chronic)
• Rectal mucosal prolapse • Review the patient’s history, rule out other diseases, and
• External hemorrhoids: match diagnosis of symptomatic hemorrhoids with clini-
–– Early stage of acute thrombosis of external cal and functional aspects to define the goals of the hem-
hemorrhoid orrhoid treatment (operative versus nonoperative,
–– Prevention of recurrent thrombosis of external excisional versus non-excisional).
hemorrhoid • Anorectal exam including anoscopy: Evaluate the internal
–– Patient desire for anal “landscaping.” hemorrhoids and the degree of prolapse (patient-reported
and during Valsalva maneuver), assess the degree of any
external hemorrhoid component, and define their impact
Contraindications with the patient (that is, are the hemorrhoids the cause of
the symptoms or are they an innocent bystander).
• Other diagnosis explaining the patient’s symptoms • Single-dose prophylactic antibiotics.
(fissure, abscess/fistula, condylomata, rectal varices) • Bowel cleansing: Administration of two fleet enemas
• Known or suspected anorectal malignancy prior to the procedure; full bowel preparation (if full colo-
• Previous radiation treatment noscopy planned at the same time). In emergency cases
• Neutropenia, active chemotherapy (incarcerated/grade IV hemorrhoids), neither cleansing
• Severe anal stenosis may be tolerated.
• Colon evaluation: (1) In emergency cases, perform a rigid
or flexible sigmoidoscopy if the stool load allows. (2) In
J. Nunoo-Mensah elective situations, perform evaluation either prior to or as
King’s College Hospital, London, UK first part of the procedure based on general guidelines;
V. Klimasauskiene colonoscopy: history of rectal bleeding and age above
Faculty of Medicine, Vilnius University, Vilnius, Lithuania 40 years; flexible sigmoidoscopy for younger patients.
A. M. Kaiser (*) • Preoperative shaving of the perianal area is preferred by
Department of Surgery, Division of Colorectal Surgery, City of some surgeons but is not necessary.
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_74
Pitfalls and Danger Points again the complaints and symptoms and match them with the
clinical findings. Biopsy all ulcerations and atypical lesions of
• Doing too much rather than too little the anal canal and label each by location when submitting
• Inadequate hemostasis and control of bleeding at staple them for pathological examination.
line
• Narrowing the lumen of the anus, thereby inducing anal
stenosis Anesthesia and Positioning
• Trauma to the sphincter mechanism that may cause a
degree of fecal incontinence The choice of anesthesia and patient position is determined
• Inclusion of posterior vaginal wall causing rectovaginal by surgeon’s preference. Conscious sedation and local anes-
fistula in female patients thetic are often work very well; however, spinal block anes-
• Failing to identify associated pathology (e.g., inflamma- thesia or general anesthesia can afford superior relaxation
tory bowel disease, leukemia, portal hypertension, coagu- and paralysis for young muscular male patients. Prone jack-
lopathy, squamous carcinoma of the anus) knife positioning allows better exposure and decreases the
• Failure to manage postoperative bowel function venous congestion of the hemorrhoid plexus.
Operative Strategy Avoiding Anal Stenosis
Considering Alternative Pathologies The most serious error when performing hemorrhoidectomy
is failure to leave adequate bridges of mucosa and anoderm
Even though hemorrhoidectomy is considered a minor oper- between each site of hemorrhoid excision. Preserving viable
ation, it can only be successful if done for the right condition. anoderm is much more important than removal of all exter-
Patients, and sometimes referring physicians, tend to ascribe nal hemorrhoids and redundant skin. The risk of developing
any symptomatic/painful anorectal problems to “hemor- anal stenosis is minimized if at least 1.0–1.5 cm of viable
rhoids.” A complete history and careful physical examina- anoderm are left intact between each site of hemorrhoid
tion are necessary to confirm the diagnosis of symptomatic excision. A practical approach is to close each wound before
hemorrhoids as opposed to other pathologies in the area. For moving to the next pile, while having a medium-sized retrac-
example, a fissure with sentinel skin tag may be falsely tor in place.
termed a longstanding “painful hemorrhoid.” Other benign
anorectal diseases are fairly easily recognized.
More challenging may be to rule out important systemic Achieving Hemostasis
diseases such as leukemia. Leukemic infiltrates in the rectum
can cause severe pain and can mimic hemorrhoids and anal It is important to control bleeding various sources along the
ulcers. Operating erroneously on an undiagnosed acute leu- entire excision. Placing a solid apical (suture) ligature to the
kemia patient is fraught with the dangers of bleeding, failure hemorrhoid “pedicle” is unquestionably central. But there
to heal, and sepsis. Crohn disease should always be in the are numerous small arteries that enter the operative field
differential diagnosis if the presentation is not straightfor- from the mucosal edges or penetrate the internal sphincter. A
ward; it must be suspected and be ruled out by history, local hemorrhoidal cushion is a vascular complex with multiple
examination, and sigmoidoscopy, as well as biopsy in doubt- channels fed by many small vessels. A convenient method
ful situations. for accomplishing hemostasis is careful, accurate application
Other extremely important conditions include anorectal of electrocautery to perform the hemorrhoidectomy.
malignancies, most commonly anal squamous cell cancer, Advanced energy devices such as the LigaSure or harmonic
anorectal adenocarcinoma, or anal melanoma. They are some- scalpel can be used as well, but specific care has to be taken
times overlooked during the course of hemorrhoidectomy as not to accidentally incorporate any muscular structures.
the neoplasm may resemble nothing more than a small ulcer-
ation or discoloration on what appears to be a hemorrhoid.
Any hemorrhoid that demonstrates a break in the continuity of Avoiding Fecal Incontinence
the overlying mucosa should be suspected of being a malig-
nancy, as should any ulcer of the anoderm, except for the clas- Any anorectal surgery may affect the fecal continence func-
sic anal fissure located in the posterior or anterior midline of tion. As the normal hemorrhoid cushions contribute to the
the anal canal. Before scheduling a hemorrhoidectomy, review fine-tuning of continence, their removal may inevitably
74 Excisional Hemorrhoidectomy (Ferguson, Milligan-Morgan, Whitehead) 579
cause some impact. However, from a technical standpoint, sia. As the incisions extend into the perianal area, it is often
more relevant is to minimize any injury to the anal sphincter advantageous (even though not mandatory) that you shave
complex during the hemorrhoidectomy. The incidence of the perianal area before prepping. You do not need to place a
this complication is below 2% in the literature but likely Foley catheter, but should communicate with the anesthesi-
underreported. To avoid this complication, it is essential to ologist to minimize the intravenous fluid administration.
know the anatomy and to identify and spare any of the trans-
versely running sphincter muscle fibers during
hemorrhoidectomy. During a conventional excisional hem- Local Anesthetic Block
orrhoidectomy, this muscle is easily identified as white mus-
cle fibers running transversely just deep to the submucosa. Before starting the actual excision, place a perianal anesthe-
The use of advanced energy devices to perform the hemor- sia block using a long-acting local anesthetic (e.g., bupiva-
rhoidectomy without layer-by-layer dissection may pose an caine). Even if the procedure is done under general anesthesia,
extra risk. the measure helps to relax the sphincter muscle and, as pre-
emptive analgesia, contributes to the postoperative pain
management for a number of hours.
Documentation Basics On either side on a transverse line through the anus, inject
5 cc of the anesthetic deep into in the ischioanal fat—lateral
Coding for surgical procedures is complex. Consult the most to the sphincter complex, that is, 1–1.5 cm away from the
recent edition of the AMA’s Current Procedural Terminology anal opening. Take another 10 cc syringe with anesthetic and
book for details (see references at the end). In general, it is perform a circumferential superficial block. Perform one
important to document: injection in the anterior and one in the posterior midline and
fan the needle to either side while administering one fourth
• Findings and specific indication of the volume to each of the quadrants.
• Internal versus external hemorrhoids If you excise a single external hemorrhoid under just local
• Presence or absence of strangulation anesthesia, a few milliliters of local anesthetic may be
• Ligation versus excision versus incision injected just around and under the respective hemorrhoid.
• Closure of mucosa
• Hemostasis
Excisional Hemorrhoidectomy
Operative Technique Ferguson Technique (Closed Wounds)

This procedure is also known as closed hemorrhoidectomy.
General Setting It is essentially the same as the subsequently described tech-
nique of Milligan-Morgan except that the wounds are closed.
The most common setting is to perform an excisional hemor- Place an anal retractor into the anal canal and visualize
rhoidectomy as outpatient procedure, under general anesthe- the hemorrhoids. Define how many excisions you plan on
sia and in a real operating room. Small mostly external performing. The maximum is three piles. In order to avoid a
hemorrhoidectomies may though be performed under local stenosis, you should always finish the entire process for a
anesthesia in the office. Alternatives to general anesthesia pedicle including the wound closure before you move on to
include conscious sedation in combination with local anes- address the next excision. It is sometimes advisable that you
thesia or spinal anesthesia. combine two piles into one excision, that is, that you perform
a left lateral hemorrhoidectomy as well as a right lateral that
combines the right anterior and right posterior column.
Positioning and Setup Grasp the first hemorrhoid with a Kelly or Allis clamp.
Using a 3-0 PG, place a suture ligation at the apex of the
Place the patient into the position of your preference. hemorrhoidal pile. Secure the needle and leave both the long
Lithotomy is possible and comparably fast. However, con- and short end uncut. Using a scalpel, incise the perianal skin
sider the advantages of the prone jackknife position which in in a V-shape fashion at the external edge of the hemorrhoid
conjunction with taping the buttocks aside allows you and and carefully continue with a narrow mucocutaneous inci-
your team relaxed access and optimized visualization, and sion toward the ligated pedicle (Fig. 74.1a and b). Start to
also reduces the venous congestion. The left lateral position dissect the mucocutaneous tissue from outside toward the
(also known as modified Sims position) may be suitable for apex of the hemorrhoid. You may use scissors, the scalpel, or
excision of minor external hemorrhoids under local anesthe- electrocautery. Some surgeons advocate advanced energy
a b
Fig. 74.1
Fig. 74.3
the line of excision. Continue the dissection up to the base of

Fig. 74.2 the hemorrhoidal pedicle. Use the previously placed suture
ligation, wrap the ends again around the pedicle, and tie it.
devices. Gently elevate the anoderm and mucosa with the Only then cut the hemorrhoid tissue off and have it placed in
hemorrhoidal plexus and dissect them off the external/inter- a pathology container.
nal sphincter muscle (Fig. 74.2). The external and internal Cut the short end of the suture ligature, but keep the long
sphincter muscle both run in a transverse direction but have end with the needle (Fig. 74.3). Close the defect by running
slightly distinct colors with pink and white muscle fibers, that suture from the pedicle toward the outside (Fig. 74.4a
respectively. Push any transverse fiber down and away from and b). Try to always include a tiny bit of the wound base
74 Excisional Hemorrhoidectomy (Ferguson, Milligan-Morgan, Whitehead) 581
a b
Fig. 74.4
with the muscle layer to achieve hemostasis and avoid a sub- Start the procedure by placing a Lone-Star retractor to the
mucosal cavity. Make sure that you match the level of the anal canal. Incise the lining at or just a bit proximal to the
dentate line on both sides of the wound. You may leave a dentate line. Carefully dissect the mucosa and the hemor-
small section of the outside wound open for possible rhoidal plexus of the underlying muscle layer. The dissection
drainage. Verify hemostasis and if necessary place individual is similar to a Delorme procedure except that the rectum can-
interrupted figure of eight sutures. not be everted. Always assess how much tissue laxity there
Once the first pile is finished, you move to the next one or is. Once you reach the upper level of the hemorrhoids, split
two piles and proceed in identical fashion. Again make sure the sleeve at one point and start to cut it off at its proximal
to leave a sufficient mucocutaneous bridge between the exci- end. Continuously suture the proximal end to the cut end
sion sites. At the end, place a hemostatic sponge (e.g., near the dentate line. The key to avoid failure and the reported
Gelfoam) into the anal canal to support hemostasis. deformity is to avoid overcorrecting the mucosal advance-
ment. Completely mature the “anastomosis” all around.
Milligan-Morgan Technique (Open Wounds) Verify hemostasis and place a hemostatic sponge to the anal
The Milligan-Morgan hemorrhoidectomy is also known as canal. Remove the Lone-Star retractor.
open hemorrhoidectomy. The procedure follows exactly the Theoretically, this method could be combined with an
steps described above, except that the wounds are not closed. excision of an external component (Fig. 74.5a and b).
The final result is that the wounds should look like the leaf of However, that should generally be avoided. Similarly to the
a clover. decision-making for a stapled hemorrhoidectomy, you
should clarify with the patient what goals should be pursued.
Whitehead Hemorrhoidectomy If those include external landscaping, rather employ one of
The Whitehead hemorrhoidectomy is in some way the open the two other methods of excisional hemorrhoidectomy.
correlate to the stapled hemorrhoidectomy (Chap. 75) as it
involves the circumferential removal of the internal hemor-
rhoids. The approach has been largely abandoned by many Postoperative Care
because of the complication of resulting in a mucosal ectro-
pion (Whitehead’s deformity). However, when proper tech- • Discharge: Excisional hemorrhoidectomy is routinely
nique is being used, the Whitehead’s hemorrhoidectomy performed as an outpatient surgery, though short stay hos-
may remain a valuable option to treat circumferential inter- pitalization for observation as determined by surgeon dis-
nal hemorrhoids. cretion is also appropriate.
a b
Fig. 74.5
• Fluid management: Restrict fluid administration to mini- tube and over a pack of gauze. Reexplore the anus for
mize risk for urinary retention. If the patient is unable to surgical control of bleeding.
void within 6 hours, an indwelling catheter should be • Urinary retention.
placed, attached to a gravity drainage leg bag and a void- • Excessive postoperative pain.
ing trial attempted in 24 hours. • Delayed postoperative wound healing (more than
• Diet: The patient may resume their regular diet when 3 months).
recovered from anesthesia. • Thrombosed external hemorrhoids.
• Stool management: Instruct the patient to maintain soft • Pelvic sepsis.
bulked stools with use of fiber and stool softeners as • Anal canal stenosis.
needed. Prescribe supplemental laxatives to be used as
needed to avoid constipation.
• Pain management: Consider a multimodal approach to
pain control; oral analgesics are sufficient in most cases. Further Reading
• Wound care: Recommend warm sitz baths several times a
day, especially following each bowel movement. American Medical Association. Current procedural terminology: CPT
Aytac E, Gorgun E, et al. Long-term outcomes after circular stapled
Complications hemorrhoidopexy versus Ferguson hemorrhoidectomy. Tech
Coloproctol. 2015;19(10):653–8.
Giordano P, Gravante G, et al. Long-term outcomes of stapled hemor-
Overall complication rates are similar for all hemorrhoid rhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of
interventions: randomized controlled trials. Arch Surg. 2009;144(3):266–72.
Joshi GP, Neugebauer EA. Evidence-based management of pain after
• Bleeding: Minor rectal bleeding after hemorrhoidectomy haemorrhoidectomy surgery. Br J Surg. 2010;97(8):1155–68.
is common. Severe bleeding during the postoperative 2009. Retrieved November 14, 2022, from https://accesssurgery.
period is rare. If bleeding is brisk, the patient should be mhmedical.com/book.aspx?bookID=425.
returned to the operating room to have the bleeding point Katdare MV, Ricciardi R. Anal stenosis. Surg Clin North Am.
suture ligated. If for some reason the patient cannot be 2010;90(1):137–45, Table of Contents.
Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoid-
immediately returned to the operating room expeditiously, ectomy for patients with symptomatic hemorrhoids. Cochrane
it may be necessary to achieve at least temporary hemo- Database Syst Rev. 2009;1:CD006761.
stasis by inserting a Foley catheter into the rectum, blow Rivadeneira DE, Steele SR, et al. Practice parameters for the man-
up the balloon to 60–80 cc. Pull on the catheter downward agement of hemorrhoids (revised 2010). Dis Colon Rectum.
2011;54(9):1059–64.
and apply counterpressure by placing a clamp across the
Stapled Hemorrhoidectomy/-opexy
75
Indications Evaluation and Preparation
• Grade II–III internal hemorrhoids (particularly if failed • Review the patient’s history, rule out other diseases, and
other management options). match diagnosis of symptomatic hemorrhoids with clini-
• Select patients with Grade IV internal hemorrhoids, for cal and functional aspects to define the goals of the hem-
example. orrhoid treatment (operative versus nonoperative).
• Chronically prolapsing. • Anorectal exam including anoscopy: Evaluate the internal
• Temporarily incarcerated with subsequent reduction and hemorrhoids and the degree of prolapse (patient-reported
resolution of thrombosis/edema. and during Valsalva maneuver), assess the degree of any
• Reducible after induction of anesthesia and little external hemorrhoid component, and define their impact
thrombosis. with the patient (relevant versus innocent bystander).
• Rectal mucosal prolapse. • Single-dose prophylactic antibiotics.
• Bowel cleansing: Administration of two fleet enemas
prior to the procedure; full bowel preparation if full colo-
Contraindications noscopy planned at the same time).
• Colon evaluation: Either prior to or as first part of the pro-
• Severe anal stenosis preventing proper insertion of the cedure based on general guidelines; colonoscopy: history
anoscope/stapling device of rectal bleeding and age above 40 years; flexible sig-
• Active infection at or near the operative site (e.g., abscess, moidoscopy for younger patients.
fistula)
• Grade IV hemorrhoids with extensive thrombosis or
gangrene Pitfalls and Danger Points
• Previous radiation treatment to the anorectum
• Neutropenia, active chemotherapy • Inadequate protection of the anal canal with the retractor
• Previous anal surgery involving the anal canal leading to excision too close to the dentate line causing
• Inflammatory bowel disease significant postoperative pain.
• Anoreceptive intercourse • Placement of staple line too proximal to hemorrhoidal
apex leading to inadequate resection and increased risk
for recurrence.
• Gaps between purse-string suture bites result in incom-
plete resection and greater risk for recurrence.
• Improper deep suture bites result in full-thickness tran-
section rather than mucosal and submucosal excision.
• Inclusion of posterior vaginal wall in staple line causing
rectovaginal fistula in female patients.
E. R. Noren · S. W. Lee (*)
Department of Surgery, Division of Colorectal Surgery, Keck • Inadequate hemostasis and control of bleeding at staple
School of Medicine of the University of Southern California, line.
e-mail: sangwl@med.usc.edu

https://doi.org/10.1007/978-3-030-81415-1_75
• Stapled hemorrhoidopexy is not indicated for repair of Avoiding Postoperative Complications

full-thickness rectal prolapse.
Ensure full insertion of the anal dilator for protection of the
dentate line and internal sphincters. The transparent dilator
Operative Strategy allows for visualization of the dentate line location. Failure
to protect these structures may result in significant postop-
Anesthesia and Positioning erative pain, stenosis, or impaired continence.
Placement of the purse-string suture is critical. It should
The choice of anesthesia is determined by surgeon prefer- be located 1–2 cm above the hemorrhoid apex and 3–4 cm
ence. The authors’ preference is to perform the procedure above the dentate line with bites limited to the mucosa and
under conscious sedation and local anesthetic setting; how- submucosa.
ever, spinal block anesthesia or general anesthesia can afford Palpate the posterior vaginal wall in female patients.
superior relaxation and paralysis for young muscular male Verify that it has not been incorporated in the closed stapler.
patients.
Stapled hemorrhoidopexy can be effectively performed in
either lithotomy or prone jackknife patient positions. The Documentation Basics
surgeon should choose the position with which he or she is
most comfortable operating. Coding for surgical procedures is complex. Consult the most
lacement of the Retractor and Reduction
P important to document:
of Prolapse
• Findings and indications
Correct positioning of the circular anal dilator sets up the • Specific indication
operation for success. It is important for protection of sensi- • The distance of purse-string suture placement with respect
tive tissues as well as optimal positioning of prolapsed to the top of the hemorrhoid pedicles and dentate line
mucosa and hemorrhoid cushions for resection. The anal • Mucosal and submucosal placement of the purse-string
dilator is secured in the optimum position with stay sutures sutures
for the entirety of the operation to facilitate visualization of • Vaginal examination in female patients prior to firing of
the dentate line and protection of the internal sphincters. the stapler
• Macroscopic appearance of resected specimen for com-
plete tissue ring
urse-String Suture Placement
P • Staple line unity and location relative to dentate line
and Transection of the Rectal Mucosa • Hemostasis
A purse-string suture is employed to pull the redundant

mucosa and hemorrhoid cushions into position for resection. Operative Technique
Meticulous submucosal suture bites avoid incorporation of
excessive muscle tissue in the resection. Identify the correct Stapler Sets and Instruments
location within the rectum, avoid gaps between bites, and be
mindful of the natural tendency to inadvertently shift succes- Stapled hemorrhoidopexy stapler sets are available from two
sive bites distally, toward the anal verge. The quality and manufacturers: Proximate® PPH Circular Stapler Set
location of the purse string determine the quality of the (Ethicon, Johnson & Johnson, Cincinnati, OH) and EEATM
resected specimen. hemorrhoid and prolapse stapler set with DST Series TM
A specialized circular stapler is employed for concurrent (Covidien, Medtronic™, Norwalk, CT). Choice of the device
excision of redundant rectal mucosa, devascularization of the will depend on surgeon preference and institution contract-
remaining hemorrhoids, and restoration of the hemorrhoidal ing. The technique described below is based on the use of the
cushions to their normal anatomical position. A series of Covidien device.
important safety maneuvers when closing and firing the sta- EEATM Hemorrhoid and Prolapse Stapler Set comes
pler device are designed to minimize risk and ensure ade- with a hemorrhoid stapler, detachable anvil, and nested anal
quate excision. The technique is described in the following dilator. The anal dilator consists of an anoscope with a
sections. bridge, an obturator, and a winged suture port (Fig. 75.1).
75 Stapled Hemorrhoidectomy/-opexy 585
Fig. 75.1 (©2020 Medtronic. All rights reserved. Used with the per-
mission of Medtronic)
mission of Medtronic)
A limited number of surgical instruments are required to
perform the procedure: a pair of long DeBakey forceps, a
long needle holder, a pair of suture scissors, 2-0 Surgipro®
suture with V-20 needle (Covidien), and a pack of 3-0
Polysorb pop-offs with V-20 needles.
lacement of the Retractor and Reduction

P
of Prolapse
Following induction of conscious sedation and positioning

according to surgeon preference, apply perianal block with a
local anesthetic (see Chap. 74, Excisional Hemorrhoidectomy
for details of technique). Insert the lubricated obturator; this
will often help reducing the prolapsed mucosa and hemor- mission of Medtronic)
rhoids. Remove the obturator and reinsert it, nested within
the anoscope and the suture port. Ensure that the wings of the
suture port line up anteriorly and posteriorly in order to avoid urse-String Suture Placement
P
limited access caused by contact with ischial tuberosity and Transection of the Rectal Mucosa
(Fig. 75.2). Prior to suturing and throughout the procedure,
the suture port must be in place. It may be sutured in place, Place the tail end of the purse-string suture (2-0 Surgipro®)
at the surgeon’s preference. It is critical to ensure that the through the lumen and over the bridge of the anoscope. The
suture port is fully inserted and covers the dentate line and tail end of the suture will rest between the anoscope and the
anoderm. Milking out the anoderm by countertraction to suture port during the purse-string suture placement
ensure full insertion can be helpful. Withdraw the obturator. (Fig. 75.3).
Confirm, with direct visualization, that the anal port com- Insert the suture anoscope via the anal dilator and identify
pletely covers and protects the dentate line and sphincters. the location within the rectum for purse-string suture place-
The anoderm must not be visible through the channel of the ment, 1–2 cm above the hemorrhoid apex and 3–4 cm above
anal port. the dentate line. Place a circumferential purse-string suture
In patients with a recessed anus, it may be difficult to fully using 2-0 monofilament suture, taking 8–12 submucosal
place the anal port and to completely retract the anoderm out bites. Take great care to avoid incorporating deeper layers
of the surgical field. In this case, four interrupted effacing (Fig. 75.4). With Covidien stapler set, it is not necessary to
sutures can be placed between the skin at the anal verge and remove and reposition the suture anoscope between each
anal margin several centimeters away from the anus. This bite. It is important to not leave gaps by starting each bite
will allow the anoderm to be everted out and away from the near the exit point of the previous. Utilize the graduated
field. markings on the anoscope to maintain a consistent level
Fig. 75.4 (©2020 Medtronic. All rights reserved. Used with the per- Fig. 75.6 (©2020 Medtronic. All rights reserved. Used with the per-
mission of Medtronic) mission of Medtronic)
Fig. 75.5 (©2020 Medtronic. All rights reserved. Used with the per- Fig. 75.7 (©2020 Medtronic. All rights reserved. Used with the per-
mission of Medtronic) mission of Medtronic)
within the rectum. Upon completion, a careful manual and

visual inspection of the purse-sting suture is required to ver-
ify that there are no gaps. If the purse-string suture is not
correct, remove and reapply it (Fig. 75.5).
Lubricate the anvil and insert it past the purse-string
suture by gently angling it. Straighten the anvil post within
the anal canal once it is above the purse-string suture. Cinch
the purse-string suture and tie it around the post of the anvil.
Inspect the entire suture again to ensure that there is no gap.
Insert the two ends of the purse-string suture in opposite
directions through one of several holes in the center rod. The
choice of the particular hole is tissue and surgeon dependent.
In most cases, the second hole on the anvil post may be
appropriate for optimal tissue removal (Fig. 75.6). mission of Medtronic)
After attaching the anvil to the stapler, close the device. At
this point, it is critically important to digitally inspect the
posterior vaginal wall in female patients. Slight back and between 3 and 4 cm. If the marking is less than 2 cm, the
forth motion of the stapler should confirm that the vaginal level of the staple line is probably too close to the dentate
wall is free of entanglement (Fig. 75.7). The final verification line and the purse-string suture may need to be replaced
of the staple line distance away from the anal verge can be (Fig. 75.8).
accomplished by inspecting the marking at the outer side of Maintain the stapler handle in line with the anal canal
the stapler. The marking at the anal verge should read while tightening. Wait 30 seconds with stapler in the closed
75 Stapled Hemorrhoidectomy/-opexy 587
• Stool management: Instruct the patient to maintain soft

bulked stools with use of fiber and stool softeners as
needed.
• Pain management: Consider a multimodal approach to
pain control, whereby oral analgesics are sufficient in
most cases.
• Wound care: As there is no external wound, there is no
need for specific wound care. Sitz baths may support
relaxation.
Complications
mission of Medtronic) Overall complication rate is similar to traditional
hemorrhoidectomy:
position prior to firing to minimize edema and promote • Bleeding

hemostasis. Release the safety feature and fire the stapler by • Urinary retention
firmly squeezing the handle. Avoid twisting or torqueing the • Excessive postoperative pain—incorporation of dentate
stapler during firing. It is important to completely close the line
device handle with single squeeze. In order to facilitate this, • Thrombosed external hemorrhoids
firing the stapler in standing position is recommended. After • Rectovaginal/rectourethral fistula
firing, the stapler can be removed following three half turns • Pelvic sepsis
of the black handle (Fig. 75.9). • Anal canal stenosis
I nspection for Hemostasis and Removal

of Retractor Further Reading
Open the stapler and remove the resected specimen for American Medical Association. Current procedural terminology: CPT
inspection. Proper technique yields a robustly cylindrical http://www.ama-assn.org/ama/pub/physician-resources/solutions-
donut which—upon cutting it open and laying it on a flat managing-your-practice/coding-billinginsurance/cpt.page.
surface—has a rectangular appearance with smooth edges Burch J, Epstein D, Baba-Akbari A, et al. Stapled haemorrhoidopexy
and no or only a minimal amount of visible muscle fibers. for the treatment of haemorrhoids: a systematic review. Color Dis.
2009;11:233–44.
Replace the anoscope without the surgical port and care- Giordano P, Gravante G, Sorge R, Ovens L, Nastro P. Long-term out-
fully inspect the staple line for bleeding. Control staple line comes of stapled hemorrhoidopexy vs conventional hemorrhoidec-
bleeding with 3-0 absorbable sutures in a figure of eight tomy: a meta-analysis of randomized controlled trials. Arch Surg.
fashion, avoiding use of electrocautery when possible. Dress 2009;144(3):266–72.
Kaiser AM. McGraw-Hill manual: colorectal surgery. Access Surgery;
with ABD pad and a stretch mesh brief. 2009. Retrieved 12 Aug 2017, from http://accesssurgery.com/
resourceToc.aspx?resourceID=211.
Pescatori M, Gagliardi G. Postoperative complications after procedure
Postoperative Care for prolapsed hemorrhoids (PPH) and stapled transanal rectal resec-
tion (STARR) procedures. Tech Coloproctol. 2008;12(1):7–19.
Rivadeneira DE, Steele SR, Ternent C, et al. Practice parameters for
• Discharge: PPH is routinely performed as an outpatient the management of hemorrhoids (revised 2010). Dis Colon Rectum.
surgery, though short stay hospitalization for observation 2011;54:1059–64.
as determined by surgeon discretion is also appropriate. Tjandra JJ, Chan MK. Systematic review on the procedure for prolapse
and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum.
• Fluid management: Restrict fluid administration to mini- 2007;50:878–92.
mize risk for urinary retention. If the patient is unable to Tucker H, George E, Barnett D, Longson C. NICE technology appraisal
void within 6 hours, an indwelling catheter should be on stapled haemorrhoidopexy for the treatment of Haemorrhoids.
placed, attached to a gravity drainage leg bag, and a void- Ann R Coll Surg Engl. 2008;90(1):82–4.
ing trial attempted in 24 hours.
• Diet: The patient may resume their regular diet when
recovered from anesthesia.
Doppler-Guided Hemorrhoidal Artery
Ligation 76
• Interventional treatment for hemorrhoids needs to define • Establish a correct diagnosis for the patient’s complaints.
the treatment goals before any particular technique. In • Define the patient’s goals and expectations.
particular, determine the particular indication: internal • Include potential alternative measures in the consent
hemorrhoid symptoms of recurrent bleeding, or dynamic document.
hemorrhoidal prolapse, or whether the patient asks for a • Advise the patient to discontinue aspirin and other non-
“landscaping” of the external appearance of the anus. steroidal anti-inflammatory drugs.
Pain is not a prime symptom of grade I-III internal hemor- • Two sodium phosphate packaged enemas (fleet) are ade-
rhoids, but more likely caused by a fissure, abscess, or quate cleansing (unless combined with a colonoscopy).
thrombosed external hemorrhoid. • Sigmoidoscopy or colonoscopy are done as indicated by
• Persistent bleeding from Grade I internal hemorrhoids. the patient’s symptoms, age, and risk constellation (either
• Grade II-III internal hemorrhoids. before the procedure or as part of the procedure).
• Selected chronic forms of grade IV hemorrhoids. • Routine preoperative blood coagulation profile (partial
thromboplastin time, prothrombin time, platelet count) is
performed if there is any suspicion of liver disease.
Contraindications • Routine antibiotic prophylaxis is recommended but not
mandatory.
• External hemorrhoids
• Grade IV hemorrhoids, particularly acute form
• Active anal pathology (fissure, abscess/fistula, throm- Pitfalls and Danger Points
bosed external hemorrhoid)
• Anal canal neoplasia • Inadequate application of ultrasound gel may impair
• Proctitis (idiopathic inflammatory bowel disease, infec- Doppler signal
tious, radiation) • Bleeding and hematoma
• Portal hypertension with rectal varices • Suturing of anal canal epithelium causing pain
• Pregnancy • Deep anterior bites involving vagina (female) or urethra
(male)
Operative Strategy
C. P. Spanos
The principle of this operation is not an excision of the
Medicine, Thessaloniki, Greece enlarged hemorrhoids but to decrease their size by ligating
the terminal branches of the superior hemorrhoidal arteries
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of that feed the hemorrhoidal cushions. On average, there are
Hope National Medical Center/Comprehensive Cancer Center, 6–8 such arteries. In both the prone jackknife and lithotomy
Duarte, CA, USA position, their typical locations in the lower rectum are usu-

https://doi.org/10.1007/978-3-030-81415-1_76
local anesthesia are suited for the procedure. Prone jackknife

position is preferred because it allows the surgeon to tape the
buttocks apart, provides ergonomic access to the surgical
team, and decreases vascular congestion of the hemorrhoid
cushions.

• Indications
Fig. 76.1
• Findings
• Internal versus external hemorrhoids
ally at 1, 3, 5, 7, 9, and 11 o’clock. A modified anoscope with • Presence or absence of strangulation
a built-in Doppler probe facilitates identifying their location. • Ligation versus excision versus incision
Several types of these anoscopes are commercially available • Number of ligations performed
and often come as a kit (Fig. 76.1) consisting of:
• Doppler-probe equipped anoscope Operative Technique

• Customized needle driver
• 2-0 PG sutures on a 5/8-inch taper-cut needle Doppler-Guided Ligation
• Customized knot-pusher
Apply an abundant amount of ultrasonic gel perianally, in the
Immediately distal to the Doppler probe, these anoscopes lower rectum and on the Doppler electrode of the modified
have a “working window.” That opening allows placement of anoscope. Gently place the anoscope through the anal canal
sutures to ligate the arteriole branches and—if indicated—to up to the lower rectum, approximately 7–8 cm from the anal
facilitate a hemorrhoidal mucopexy. Depending on the verge. Start the procedure at the anterior lower rectum. Turn
model, a sliding or rotating mechanism of the anoscope the Doppler probe on. Gently rotate the anoscope left and
gradually exposes the mucosa of the lower rectum in a con- right until the Doppler signal is audible. Tilt the anoscope to
trolled manner and facilitates the suturing. optimize contact with the lower rectal wall and improve the
signal. A triphasic or biphasic signal is optimal. Take care to
let the rectal mucosa “settle” in one position. With the suture
Selection of the Treatment Method loaded at ¾ from the needle tip, place the first stich bite in
the rectal mucosa. In a female, check the posterior vaginal
The suitability of the patient’s individual findings for this or wall, so as to avoid catching it with the stitch. After placing
any other treatment method should be established and dis- the needle through the rectal mucosa, pull on the stitch and
cussed before the operation and not during the operation. listen for a diminished or absent Doppler signal. Then place
Nonetheless, perform again a thorough exam of the anal a second bite in a figure-of-eight or “Z” fashion. Tie 3–4
canal at the beginning to confirm the plan and to rule new knots outside of the anoscope and push them into position
anorectal pathology. When considering a non-excisional pro- with the knot pusher. Cut the suture if mucopexy will not be
cedure, bear in mind that the hemorrhoidal disease may performed. Gently turn the anoscope in one direction and
appear more advanced with reduced resting sphincter tone repeat ligations at all the necessary points. On average,
under general anesthesia. approximately 6–8 sutures will be needed. After placement
of all sutures, carefully repeat Doppler-guided surveillance
of the lower rectum for possible placement of additional
Anesthesia and Positioning sutures.
Remove the modified Doppler anoscope and insert a regu-
General anesthesia, regional anesthesia (epidural/spinal), or lar bullet retractor. Carefully examine the entire site for
a combination of monitored anesthesia care (MAC) with bleeding and place additional sutures in a conventional man-
76 Doppler-Guided Hemorrhoidal Artery Ligation 591
ner, as needed. Place a hemostatic plug in the lower rectum. torn through the mucosa or necrosis of the mucosa. If sig-
External dressings are not needed. nificant, the patient must be evaluated and treated
immediately.
• Sepsis: Infections are remarkably rare after Doppler-
Mucopexy guided hemorrhoid artery ligation. As in any anorectal
procedure, cardinal signs and symptoms of perineal sep-
If excision of prolapsing redundant mucosa is the indication, sis are increasing pain, fever, and urinary retention.
mucopexy can be performed. To do this, ligate the hemor- Immediate evaluation and treatment are needed.
rhoidal artery as described in the previous section. Do not cut • Anorectal dysfunction: Flatus incontinence and fecal soil-
the suture. Clamp the tail end of the stitch outside the ano- ing are also rare and usually resolve completely within a
scope. Depending on the model used, turn or slide the modi- few weeks.
fied anoscope to gradually expose the redundant and • Pain: Postoperative pain is fairly limited after Doppler
prolapsing rectal mucosa. Place a running suture starting at ligation only, but more common and greater with concur-
the ligated mucosa and ending just above the proximal anal rent mucopexy. This results from the suture being placed
canal epithelium at the dentate line. Gently tie the two ends close to the somatically innervated anal canal epithelium.
of the suture. Discomfort in the form of tenesmus and an urge to defe-
cate are more common.
• Rectovaginal fistula: Extremely rare if proper technique
Postoperative Care and safety checks are performed. If truly present, the
patient may need a colostomy until the area has cooled off
• Postoperative antibiotics are not needed. and can be fixed.
• Discharge the patient the same day.
• Instruct the patient to take well-hydrated fiber supple-
ments (e.g., psyllium), a stool softener, and if necessary a
laxative to avoid constipation. Further Reading
• Prescribe a mild analgesic, such as paracetamol or acet-
aminophen, every 4–6 hours in the initial postoperative American Medical Association. Current procedural terminology: CPT
period. https://www.ama-assn.org/practice-management/cpt.
• Instruct the patient to take warm sitz baths once or twice Felice G, Privitera A, Ellul E, et al. Doppler-guided hemorrhoid artery
daily to relieve pain and reduce pelvic muscle spasm. ligation; an alternative to hemorrhoidectomy. Dis Colon Rectum.
2005;48:2090–3.
Giordano P, Overton J, Madeddu F, et al. Transanal hemorrhoidal
dearterialization; a systematic review. Dis Colon Rectum.
Luchtefeld M, Hoedema RE. Chapter 12: Hemorrhoids. In: Steele
• Bleeding: A small amount of bleeding is anticipated after SR, Hull TL, Read TR, Saclarides TJ, Senagore AJ, Whitlow CB,
editors. The ASCRS textbook of colon and rectal surgery. 3rd ed.
most anorectal procedures. Major postoperative hemor- New York: Springer; 2016. p. 183–214.
rhage may be observed at any point in the initial postop- Ratto C, Donisi L, Parello A, et al. Evaluation of transanal hemorrhoid
erative period. This may result from a ligature that has artery dearterialization as a minimally invasive therapeutic approach
to hemorrhoids. Dis Colon Rectum. 2010;53:803–11.
Surgical Management of Anorectal
Abscess and Fistula 77
Perirectal abscess and fistula are related to each other as they • Analyze symptoms and clinical findings as to the possi-
represent the acute and chronic manifestation of anorectal bility of Crohn’s disease, cancer, bowel habits, prior
suppurative disorders. Their complexity lies in the proximity incontinence, and prior surgeries.
to and various degrees of sphincter involvement. Any ano- • Clinical exam looking for erythema, induration, and cur-
rectal abscess should be promptly drained upon diagnosis to rent or former fistula openings.
prevent the development of systemic sepsis. There is no role • For elective interventions: Preoperative anoscopy, sig-
for conservative management except in neutropenic patients moidoscopy, or full colonic evaluation to rule out colorec-
without an identifiable abscess. tal pathology or per screening guidelines prior to or at the
Anorectal fistula, the chronic form, can cause persistent time of surgery.
or intermittent drainage, pain, or pruritus, or it may be com- • Imaging (e.g., pelvic MRI) is usually not necessary, but
plicated in the short term by recurrent abscess formation. In should be considered for atypical presentations, recurrent
the long run, after 20–30 years, cancer may develop. Surgery or complex fistulas, or in patients with confirmed or sus-
is indicated in symptomatic fistulas except in rare pected Crohn’s disease.
situations. • Bowel cleansing: None for acute abscess drainage; two
Countless methods to treat anorectal fistulas have been enemas for elective surgeries; full mechanical bowel
described, reflecting the observation that none of them is per- cleansing for advancement flap or if procedure combined
fect. Placement of draining seton(s) aims at reducing the risk with colonoscopy.
of recurrent flare-ups without addressing the fistula as such. • Antibiotic prophylaxis; antibiotic treatment in higher risk
Fistulotomy or placement of a cutting seton involves imme- patients.
diate or delayed division of portions of the sphincter.
Sphincter-sparing procedures include endorectal advance-
ment flap (ERAF), ligation of intersphincteric fistula tract Pitfalls and Danger Points
(LIFT), and insertion of an anal fistula plug.
Contraindications to surgical treatment of fistulas (other • Failure to diagnose anorectal sepsis
than just placement of a draining seton) include active • Poor choice of drainage site, resulting in unfavorable fis-
Crohn’s disease, significant coagulopathy, anorectal cancer, tula tract
immunosuppression, or chemotherapy. • Delay in incision and drainage or insufficient drainage
• Failure to diagnose or control systemic disease (Crohn’s
disease, cancer, tuberculosis, leukemia)
R. Hogen • Impact on anal sphincter muscles resulting in fecal
incontinence
Los Angeles, CA, USA • Formation of false tracts
• Formation of rectovaginal/-urinary fistula
A. M. Kaiser (*)
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_77
Operative Strategy Next, insert an anal retractor into the anus and expose the
area of the suspected primary opening. Inject hydrogen per-
Choice of Anesthesia oxide, blue dye, or a combination thereof into the secondary
opening and monitor the primary opening for bubbling or
Drainage of superficial anorectal abscesses can often be per- blue dye. Insert a thin silver probe into the secondary open-
formed using local anesthesia in clinic. ing and gently advance in the direction indicated by
For more extensive pathology and elective interventions, Goodsall’s rule. If that is not immediately successful,
general anesthesia or intravenous sedation with local anes- straighten the fistula tract by placing a Kocher clamp on the
thesia is preferable. secondary opening and apply traction away from the anus.
A pudendal and perianal nerve block using 15–20 cc of For complex fistulas, endorectal ultrasound with peroxide
local anesthetic in addition to general anesthesia may further injection or magnetic resonance imaging (MRI) may be
relax the anal sphincter muscles and help with postoperative needed.
pain control.
Preserving Fecal Continence

Positioning
Exert extreme caution before deciding to divide any sphinc-
The prone jackknife position is the ideal position for the sur- ter muscle and err on the side of being too conservative rather
gical management of anorectal abscesses and fistulas. It than too aggressive, and rather continue with one of the
allows access and provides good exposure to all the perianal described methods that does not immediately divide the
compartments, and it decreases congestion of the hemor- muscle. The basic philosophy is that if the patient ends up
rhoidal plexus. with incontinence after a fistulotomy, it could be because the
However, simple incision and drainage of visible relative amount of involved sphincter tissue was underesti-
abscesses can be performed in any position in which the mated; on the contrary, however, if an alternative method is
patient is comfortable. chosen because too extensive sphincter involvement was rec-
ognized, the incontinence has to be interpreted more as the
result of the unfavorable disease than the surgical approach.
Localizing Fistula Tracts In making that intraoperative assessment, be aware of the
fact that the normal external and internal sphincter at best
Successful treatment necessitates correct identification of the have a thickness of 7–10 mm and of 2–3 mm, respectively. If
fistula geography. The primary opening of a fistula tract is for some reason, it is only noted at the time of surgery that
located internally while the secondary opening(s) is or are the fistula is more complex than previously known, you can
located in the perianal skin. As most fistulas are of crypto- always choose to simply place a draining seton to allow reas-
glandular nature, the primary opening is typically located at sessment, imaging, and re-discussion with the patient.
the dentate line where the anal glands originate.
Goodsall’s rule helps identifying some repetitive patterns.
An imaginary transverse line through the anus distinguishes ombining Fistula Surgery with Drainage
C
between anterior and posterior. If the secondary opening is of Anorectal Abscess
anterior to the transverse line and less than 3 cm from the
anal verge, the tract usually has a straight radial course to the Since perianal abscess and fistula are linked, one might argue
dentate line. However, if it is posterior or more than 3 cm to address the fistula at the time of an acute perianal abscess
away from the anal verge, the tract usually curves to the pos- drainage. This combination of operations, however, is not
terior midline. Multiple secondary openings (particularly recommended for two reasons. First, many patients who
when bilateral) also point to a primary opening in the mid- undergo simple drainage of an abscess never develop a fis-
line, but should also raise suspicion for unusual pathology tula. It is likely that the internal orifice of the anal duct has
such as Crohn’s disease, tuberculosis, hidradenitis, or piloni- become occluded before the abscess is treated. Second, the
dal disease. acute inflammation and edema surrounding the abscess make
Physical exam can further aid in localizing the fistula accurate detection and evaluation of the underlying fistula
tract. First, palpate the perianal skin to try to distinguish the difficult and increase the risk of creating false passages. The
fibrous and thicker fistula tract from the surrounding normal majority of anorectal abscesses are amenable to drainage
tissue. Perform a bi-digital exam with the index finger in the under local anesthesia in the office, which removes the temp-
anal canal and the thumb on the outside to identify areas of tation to address the fistula on the spot. However, in patients
asymmetry and induration. Sometimes, the primary opening who require the drainage to be done under general anesthe-
can be palpated as an unevenness at the dentate line. sia, a gentle assessment and possible definitive placement of
77 Surgical Management of Anorectal Abscess and Fistula 595
draining or even a cutting seton may be preferable to two ally (horseshoe abscess). A perirectal abscess can accumu-
separate surgeries. late a significant volume of pus without necessarily showing
signs of “fluctuance,” but simply pain, induration, and poten-
tially visible erythema. Many abscesses can be drained
norectal Infections in Crohn’s Disease
A in local anesthesia, particularly if an abscess component is
and Leukemia visible externally. Inject the local anesthesia slowly as it ini-
tially may increase the pressure and pain before taking effect.
Anorectal fistula should be approached more conservatively Very large and deep ischioanal infections may be associated
in patients with Crohn’s disease as they are often more com- with significant pain, limited external signs, and often require
plex in their configuration and associated with poor wound intravenous sedation or general anesthesia.
healing and high rates of recurrent disease. Acute abscesses The goal of the incision and drainage is to create an
equally need to be drained, and simple fistulas in absence of opening that is big enough to relief the pressure and pain
active proctitis or anal stenosis can be managed surgically and to not immediately close again as to allow the area to
with the above-mentioned strategies. Complex or recurrent cool off. Select the point of maximal inflammation or indu-
fistulas, however, may do better with palliation (placement ration closest to the anus. This will ensure that any result-
of long-term draining setons) than with frustrate attempts at ing fistula is short. For very large and deep abscesses, you
cure. A small percentage of complex Crohn’s fistulas may may have to create one or two counter-incisions and leave a
ultimately need diversion or proctectomy to control perianal drain.
sepsis. If electrocautery is available, excise a 1–2 cm skin circle;
Patients with acute leukemia or neutropenia are at if it is not available, make a cruciate incision with a scalpel
increased risk for systemic sepsis from anorectal infections. and excise the edges to have a wound center without skin.
Acute anorectal abscesses should be drained, but neutrope- Success is defined by pus draining freely. Cultures are not
nic patients may develop painful perianal infections without usually needed, but you may take some if the presentation is
forming abscesses. If an abscess cannot be identified despite atypical. Avoid “breaking loculations” with a finger as it may
a suspicion for anorectal sepsis, management should focus be associated with negative impact on continence.
on broad-spectrum antibiotics, bone marrow stimulating A penrose drain or mushroom catheter can be used in
growth factors, sitz baths, and stool management. patients with larger or recurrent abscesses or with Crohn’s
disease to prevent the skin from closing. Either sew it in
place or—if you created a counter-incision or if the primary
Documentation Basics fistula opening is obvious—loop and tie it to itself. An
absorbing dressing is sufficient. Avoid packing as it can
Coding for anorectal procedures is complex. Consult the block pus from draining, and it is difficult and painful for
most recent edition of the AMA’s Current Procedural patients to change. Instead, encourage sitz baths or showers
Terminology book for details (see references at the end). In at least twice a day post-procedure.
general, it is important to document the following:
• Findings Intersphincteric Abscess

• Any associated abscess
• Number of fistulous tracts An intersphincteric abscess often presents as persistent anal
• Relationship to sphincters pain without signs of external infection. If there is neither a
• Relationship to the levator muscle fissure nor a thrombosed hemorrhoid, a deeper abscess
• Fistulotomy or not should be suspected. A patient may have both an anal fissure
• Seton or not and an intersphincteric abscess.
Fluctuance, a fullness, or a small mass can be palpated in
the anal canal at the location of the abscess. Exam under
Operative Technique anesthesia may be required to confirm the diagnosis and
drain the abscess. Palpate the location of the abscess. Then
Perianal and Ischioanal Abscess insert an anal retractor and search for any internal opening to
the intersphincteric abscess, which is often located near the
A typical perianal abscess is located fairly close to the anal dentate line and may drain a few drops of pus. Perform an
verge and can be drained with local anesthesia in an office internal sphincterotomy over the site of the abscess and drain
setting. An ischioanal (also termed ischiorectal) abscess is it internally into the rectum. Avoid external drainage which
usually larger, deeper, and not infrequently extends bilater- can create a transsphincteric fistula.
Supralevator Abscess ply presents with a draining opening. Interval treatment of

anorectal fistulas should generally be recommended once the
Supralevator abscesses are rare. They are typically associ- acute infection has cooled off but an opening persists. Not all
ated with primary abdominal pathology such as previous sur- abscesses require a subsequent surgical intervention for a fis-
gery, Crohn’s disease, diverticulitis, or cancer, rather than tula as some may close spontaneously after adequate
being an extension of unrecognized infralevator infection. drainage.
Gluteal and perineal pain in conjunction with signs of sys- While most authors have traditionally based their recom-
temic sepsis are often the lead presentation (Figs. 77.1 and mendations on Parks’ classification with rather theoretical
77.2). The diagnosis may be suspected from the abdominal courses of fistula tracts, you should start by distinguishing
history and symptomatology. The times of theory-guided but simple from complicated fistulas (Table 77.1).
more or less blind transperineal, transgluteal, or transrectal Based on the course of the fistula tract in relation to the
drainage procedures are over. Modern diagnostics and treat- sphincter and pelvic floor muscles, there are five main types
ment heavily rely on cross-sectional imaging and interven- of fistulas: superficial, intersphincteric, transsphincteric,
tional radiology with image-guided drain placements. suprasphincteric, and extrasphincteric.
Abdominal problems need abdominal solutions. Superficial fistulas travel from the primary to the second-
ary opening without interfering with any of the muscle struc-
tures. A simple fistulotomy is the only necessary treatment.
Anorectal Fistula Intersphincteric fistulas have a tract within the inter-
sphincteric plane, involving some of the internal but not the
Anorectal fistulas may persist after spontaneous rupture or external sphincter muscle. The tract can extend from the den-
surgical drainage of an abscess. A substantial number of tate line and open into the skin of the perineum, rectum, and
patients does not recollect an episode of an abscess and sim- pelvic cavity, or extend cephalad and form a blind tract
Fig. 77.1
Fig. 77.2
Table 77.1 Distinction between simple and complicated fistulas

Simple fistula Complicated fistula(s)
Number of tracts 1 >1 or with additional features:
Branching of tracts, blind sinuses
High origin
Other than cryptoglandular
Nature of disease Cryptoglandular Other than cryptoglandular:
Crohn’s
Specific infection (tuberculosis, actinomycosis,
lymphogranuloma venereum, etc.)
Cancer
Postsurgical (other than abscess drainage), after
trauma
Congenital
Location of primary opening Dentate line Variable:
Dentate line
Other locations
Number of primary openings 1 ≠1
Number of secondary openings 1 ≠ 1:
Blind sinus
Multiple tracts
Fistula configuration and behavior Narrow diameter and only draining clear Large diameter and/or draining stool
fluid or pus
Course of fistula tract Superficial Superficial with additional features
(in relation to sphincter and pelvic Intersphincteric Intersphincteric with additional features
floor muscles) Transsphincteric Transsphincteric with additional features
Suprasphincteric
Extrasphincteric
Fig. 77.3
Fig. 77.4
(Figs. 77.3 and 77.4). Fistulotomy is generally a safe way to sphincter muscle and pass around the external sphincter to
treat intersphincteric fistulas. enter the ischioanal fossa. Typical examples are fistulas involv-
Transsphincteric fistulas pass from the intersphincteric ing the deep postanal space (e.g., horseshoe fistulas). Avoid a
plane through at least a portion of the external sphincter mus- complete fistulotomy, but you may have to perform a partial
cle. Fistulotomy should be avoided in transsphincteric fistu- fistulotomy to open the intersphincteric space. Temporary or
las if more than 20% of the muscle is involved because definitive seton management may often be necessary to allow
incontinence can result. Alternative methods without imme- drainage of any residual abscesses. Alternatively, advance-
diate muscle division should be considered. ment flap, fistula plug, or LIFT can be used.
Suprasphincteric fistulas extend cephalad within the inter- Extrasphincteric fistulas pass from the skin of the perineum
sphincteric plane to a level above the level of the external through the ischiorectal fossa and levator muscles before pen-
etrating the rectal wall. Extrasphincteric fistulas are highly

complicated, frequently associated with an underlying abdom-
inal pathology, and often not amenable to local standard ano-
rectal interventions but require addressing the underlying
disease. You may have to rely on palliative drainage proce-
dures (see abscess section in this chapter), followed by com-
prehensive diagnostic and therapeutic brainstorming.
Fistulotomy Versus Seton Placement
Fistulotomy is a technique to lay open the fistula tract for

superficial fistulas that do not traverse a relevant portion of
the external sphincter (less than 20%). Fistulotomy should
generally be avoided in the presence of active infection as
there is a tendency to create false tracts in inflamed, friable
tissues; however, abscess drainage with simultaneous fistu-
lotomy can be performed for simple anal fistulas.
Alternatively, setons can be placed into the fistula tract to
drain active suppuration.
Depending on whether the strategy is to use the seton as a
temporary/palliative measure or a definitive fistula treatment,
there are two types of seton managements: draining or cut-
ting seton. Draining setons are used to drain or reduce the Fig. 77.5
risk of recurrent abscess formation. Draining setons allow
the tract to close down around the seton. While some fistulas there is active infection, you can also use a small penrose
may eventually close if a draining seton is removed, there is drain prior to definitive management.
a good chance that the fistula persists and may need other Draining setons can also be useful in patients with recur-
interventions. In that sense, a draining seton can be used to rent infections, such as Crohn’s disease patients or to mature
prepare for a subsequent alternative procedure (plug, LIFT, a fistula tract for definitive management in the future.
ERAF). Sometimes fistulas will close spontaneously after treatment
A cutting seton is placed around the transsphincteric por- with a draining seton. To place a draining seton, place a thin
tion of a fistula with the goal of slowly eroding through the silver probe into the fistula tract. Do not divide the skin and
sphincter. If tightened slowly enough, cutting setons have a mucosa between the primary and secondary opening. Secure
greater than 90% success rate and a less than 10% rate of the seton to the end of the probe. Pull the seton into the tract
incontinence. and loosely tie the seton to itself (Fig. 77.5).
Avoid both definitive seton management and fistulotomy Cutting setons are used for transsphincteric or extrasphinc-
in the setting of a rectovaginal or rectourinary fistulas. teric fistulas. The concept is to reduce incontinence by per-
Consider alternative strategies if the anal sphincter muscles forming a slow-motion fistulotomy when the seton over
are already weakened. weeks to months slowly erodes through muscle tissue and
Start by assessing the fistula. Identify the primary and keeps the muscle ends together by creating scar tissue as it
secondary openings of the fistula. Insert a blunt-tipped mal- passes. To place a cutting seton, you have to divide the muco-
leable probe and assess the amount of sphincter involvement cutaneous layer and nonmuscular tissue between the primary
by careful palpation. If the fistula is superficial or involves and secondary openings. Do not tighten the seton over intact
less than 20% of the external sphincter, a fistulotomy can be skin. Insert the probe as described before. Pull a suture tied
performed: use the electrocautery and divide all tissue over- to a gauze into the fistula tract with a blunt malleable probe.
lying the probe from the secondary to primary opening. Debride the fistula tract by pulling in the edge of a gauze
Avoid a fistulotomy if the fistula involves greater than through it. After that, pull the actual seton into the fistula
20% of the external sphincter or if there are multiple separate tract. Tie the seton snuggly down around the muscle with
fistulas and consider instead placement of one or several three silk sutures, taking care not to strangulate the muscle.
setons. You can use various materials as setons, but elastic In monthly intervals, bring the patient back to clinic and
vessel loops have excellent properties for this situation. If tighten the cutting seton by slight traction at the end of the
seton and placing a new central silk tie. Repeat this until it facilitate drainage. Irrigate the tract with peroxide. Mobilize
cuts through the involved sphincter complex and falls out. the mucosal edge at the primary opening if it is recessed.
Rehydrate the collagen plug-in antibiotic solution for 2 min-
utes. Tie the tip of the plug to the end of the silver probe and
Endorectal Advancement Flap (ERAF) pull in the plug from the primary toward the secondary open-
ing until it just fits snugly into the fistula tract. Fix the plug at
An endorectal advancement flap closes the primary fistula the primary opening with a transmuscular absorbable fixa-
opening by excising the primary opening, raising a flap, pli- tion suture. Trim any excess plug at the primary and second-
cating the muscle layer, and advancing the flap past that pri- ary openings. Inject some local anesthesia for pain control.
mary internal opening. Endorectal advancement flaps are
indicated for transsphincteric fistulas, larger diameter fistu-
las, or rectovaginal or rectourinary fistulas. Active proctitis is Ligation of Intersphincteric Fistula Tract (LIFT)
a relative contraindication to endorectal advancement flaps.
Endorectal advancement flaps have an 80% success rate in Ligation of the intersphincteric fistula tract is indicated in the
patients without Crohn’s disease and a less than 60% success setting of a transsphincteric perirectal fistula and aims at
rate in patients with Crohn’s disease. avoiding damage to the external sphincter. The goal is isola-
First, identify the primary and secondary openings of the tion and ligation of the intersphincteric portion of the fistula
fistula. Consider using a Lone Star Retractor to improve tract without division of the external sphincter muscle.
exposure. Excise or widen the secondary opening of the fis- Variable outcomes have been reported with success rates
tula tract to facilitate drainage. Debride the fistula tract with ranging between 50 and 70%.
a gauze or curette. Mark a broad-based, U-shaped flap within Consider preoperative maturation of the fistula tract with
the anal canal. Make the base of the flap in the anorectal a draining seton for a few months but that step adds an addi-
canal 4–6 cm proximal to the primary fistula opening. Make tional surgery/anesthesia. Identify the primary and second-
the width of the base at least one-quarter to one-third of the ary openings. Probe the fistula tract with a blunt malleable
circumference of the canal. Occasionally, you may choose to probe. Make a limited incision along the intersphincteric
do a complete circumferential flap (sleeve advancement groove at the site of the fistula. Carefully separate the muscle
flap). Extend the flap distally in the anorectal canal to a nar- fibers of the internal and external sphincters to isolate the
rower apex to include the primary opening. Raise the partial fibrotic fistula tract with the probe inside it. Remove the
thickness flap with electrocautery. Perform careful hemosta- probe and use nonabsorbable suture material (e.g., silk) to
sis but avoid excessive electrocautery damage to the flap. double ligate the fistula tract on either side. Then divide the
Excise the distal aspect of the flap that includes the primary tract. The tract can be simply divided, or enhanced by several
opening. Remove the epithelialized fistula tract within the maneuvers such as interposing a biograft between the inter-
muscle layer. Close the muscular defect with interrupted 2-0 nal and external sphincter muscle layers, placing a collagen
Vicryl sutures. Pull the flap down and cover the primary plug, or coring out the external fistula tract to facilitate drain-
opening without tension. Use two layers to suture the flap in age. Irrigate and then close the skin with absorbable suture.
place: a deep muscular layer using Vicryl suture and a muco-
sal layer using interrupted 3-0 Vicryl suture.
More Extensive Surgeries
Insertion of Fistula Plug Complex and recurrent fistulas, particularly if related to an

underlying abdominal disease (Crohn’s disease, cancer), or
A manufactured collagen or synthetic biodegradable plug previous trauma including major surgeries may—in case of
can be used in the setting of a transsphincteric perirectal failed nonsurgical management—require extensive abdomi-
fistula to avoid damage to the external sphincter muscle. The nal surgeries (see respective chapters) to address the primary
concept relies on being more durable than fibrin glue injec- disease, create a stoma, or to completely remove the anus
tion and hoping that a sufficient contact time of the fistula and rectum.
and plug allow it to scar in. The fistula plug is associated
with a 20-50% success rate at best.
Consider maturing the fistula tract with a draining seton Postoperative Care
prior to plug placement but that step adds an additional sur-
gery/anesthesia. Insert an anal retractor and identify the pri- • Diet: Regular according to the patient’s baseline.
mary and secondary openings. Insert a blunt malleable probe • Bowel management: Routine fiber supplementation, ade-
into the fistula. Excise or enlarge the secondary opening to quate hydration, and stool softeners. Potentially, a mild
laxative such as milk-of-magnesia can be used to achieve • Thrombosis of external hemorrhoids

soft but formed bowel movements. • Anal stenosis
• Wound care: On day 0, the dressings are left in place. On
day 1, the patient is instructed to perform either warm sitz
baths or showers two or three times daily and after every
bowel movement. No wound packing is needed. The Further Reading
patient may use an absorbing pad to protect the clothes.
• Activity: Unless for specific uncommon concerns, all American Medical Association. Current procedural terminology: CPT
activities that the patient tolerates using common sense https://www.ama-assn.org/practice-management/cpt.
are permitted. Bondi J, Avdagic J, Karlbom U, et al. Randomized clinical trial com-
• Antibiotics: Beyond the routine perioperative prophy- paring collagen plug and advancement flap for trans-sphincteric
laxis, antibiotics are not routinely needed. Exceptions are anal fistula. Br J Surg. 2017; https://doi.org/10.1002/bjs.10549.
de Groof EJ, Cabral VN, Buskens CJ, et al. Systematic review of evi-
substantial cellulitis, systemic sepsis, or patients with dence and consensus on perianal fistula: an analysis of national and
underlying systemic illnesses, such as diabetes, immuno- international guidelines. Color Dis. 2016;18(4):O119–34.
suppression, hematological malignancies, or Kaiser AM. McGraw-Hill Manual Colorectal Surgery. Access Surgery;
chemotherapy. 2009. Retrieved November 14, 2022, from https://accesssurgery.
Rosen DR, Kaiser AM. Definitive seton management for transsphinc-
teric fistula-in-ano: harm or charm? Color Dis. 2016;18(5):488–95.
Complications Sirany AM, Nygaard RM, Morken JJ. The ligation of the intersphinc-
teric fistula tract procedure for anal fistula: a mixed bag of results.
Dis Colon Rectum. 2015;58(6):604–12.
• Urinary retention Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandu-
• Postoperative hemorrhage (acute or delayed) lar or Crohn’s fistula-in-ano. Dis Colon Rectum. 2010;53:486–95.
• Fecal incontinence Vogel JD, Johnson EK, Morris AM, et al. Clinical practice guideline for
• Sepsis including cellulitis and recurrent abscess the management of anorectal abscess, fistula-in-ano, and rectovagi-
nal fistula. Dis Colon Rectum. 2016;59(12):1117–33.
• Recurrent fistula
Rectovaginal Fistula Repair
78
Rahila Essani and Andreas M. Kaiser
Indications Contraindications
Rectovaginal fistulas—as opposed to colo-vaginal fistulas— • Lack of symptoms (with or without diversion)
are defined as being located in the mid to low rectum. They • Poor performance status with limited life expectancy
result from a variety of etiologies that often reflect an obstet- • Metastatic tumor, not amenable to potential cure (unless
rical or surgical history, a complex disease (e.g., Crohn’s dis- no less aggressive options exist)
ease), radiation, or tumor. Almost always, they cause • Definitive evidence of unresectability
significant symptoms and represent a challenge for both the • Coagulopathy
patient and the surgeon.
Most rectovaginal fistulas require some surgical interven-
tion to either repair the defect or divert the stool in order to Preoperative Preparation
mitigate the immediate symptomatology. Management of
the fistula itself depends on a number of factors including the • Review the patient’s history, diagnosis, functional aspects,
timing and type of previous repair attempts, tissue quality, and appropriate indication for surgery (based on clinical,
presence or absence of inflammatory bowel disease or tumor, radiographic, or endoscopic means).
as well as current and prospective functional aspects. • Review all available preoperative imaging studies and
Observation is an acceptable approach in patients who are tests to confirm and identify the location of the fistula,
asymptomatic (e.g., after diversion), have evidence of an inflammatory changes, or local tumor.
incurable malignancy, or are poor surgical candidates. • Define preexisting functional aspects related to the fistula
Symptomatic patients with a life expectancy greater than as such and the underlying sphincter condition (e.g.,
6 months should be offered a repair, reconstruction, resec- ultrasound, manometry).
tion, or diversion. • Depending on the patient’s age and underlying pathology:
Numerous operative techniques and approaches are Partial or full colonic evaluation to confirm the diagnosis
described for repair based on location, size, and etiology of and exclude synchronous pathology.
the rectovaginal fistula. These include local repairs, sliding • Colposcopy.
advancement flaps, or sphincter-preserving transabdominal • Mechanical bowel preparation.
repairs. • Antibiotic prophylaxis versus treatment.
• Local repair in presence of poor tissue quality (Crohn,

R. Essani
radiation, scarring, infection, etc.) or tumor.
Department of Surgery, Texas A&M University, Baylor Scott and
White Health Care, Temple, TX, USA • Surgery too early after previous attempt.
• Failure to study and document the anal sphincter function
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of may lead to a poor choice of repair and unmet patient
Hope National Medical Center/Comprehensive Cancer Center, expectations if the fecal incontinence postoperatively
Duarte, CA, USA persists.

https://doi.org/10.1007/978-3-030-81415-1_78
604 R. Essani and A. M. Kaiser
• Presence of multiple fistulas (e.g., in Crohn’s disease). tum and vagina. Examples include mobilization and interpo-
• Failure to recognize concomitant fistula etiologies (e.g., sition of the gracilis or a gluteus muscle.
IBD and obstetrical injury).
Abdominal Approach
Operative Strategy
Consider an abdominal resective approach in very high fistu-
Timing of the Repair las (see Chap. 77), or in complicated or recurrent rectovagi-
nal fistulas that have failed and exhausted less invasive local
Choosing the right time is as important as selecting a particu- repairs, involve cancer, or have a poor tissue quality (e.g.,
lar approach. Attempts to repair a fistula too soon after the after radiation). Depending on the local specifics, a mini-
original injury or any subsequent repairs are a frequent cause mally invasive (laparoscopic, robotic) or an open approach
for failure. If circumstances allow, it is advisable to wait at would be feasible. The extent of the resection always entails
least 6 months and allow for tissue inflammation to subside a resection of the faulty bowel segment (rectum), occasion-
before planning any (re-)intervention. ally of the anus (APR), and to varying degrees of the middle
compartment (uterus, vagina); extensive pathology may
necessitate a full pelvic exenteration (see Chap. 61). The out-
Immediate Symptom Control come after the rectal resection may be a permanent stoma or
a restoration of continuity. For the latter, for example, a pull-
Temporary fecal diversion should be considered in all through procedure in standard fashion or in a two-stage anas-
patients who are highly symptomatic and difficult to manage tomosis in Turnball-Cutait technique could be envisioned.
while not (yet) being a candidate for a local repair. The deci- Wherever possible, interposition of well-vascularized tissue
sion to divert is made on a case-by-case basis but is espe- (omentum) may help to fill pelvic space and separate adja-
cially important in individuals with poor tissue quality due to cent suture lines.
radiation, longstanding inflammation, or a recent surgery.
In some patients with benign fistulas, temporary fecal
diversion alone may occasionally suffice to allow the fistula Documentation Basics
to close. Some patients may not heal the fistula but with the
diversion are asymptomatic and choose not to pursue further Coding for surgical procedures is complex. Consult the most
corrective surgery. recent edition of the AMA’s Current Procedural Terminology
Permanent diversion is advisable for patients with a fis- book for details (see references at the end). In general, it is
tula due to completely untreatable malignancy, or for patients important to document:
with high risk of failure or poor functional outcome.
• Findings: location, tissue quality, sphincter condition
Common Local Rectovaginal Repairs • Approach and type of repair
For fistulas with healthy tissues and no evidence of malig-

nancy, a number of local approaches may be considered. Operative Technique
These include endorectal advancement flap, episioproctot-
omy with fistula excision and layered closure, bulbocaverno- Perineal Approaches
sus flap, rectal sleeve advancement, or inversion of the fistula
tract. Only selected inflammatory fistulas are amenable to a General Considerations
local repair if the inflammation is entirely localized and qui- For most perineal approaches, place the patient in the prone
escent. Seton management or fistula plugs have high proba- jackknife position and separate the buttocks with tape to
bility of failure or a negative functional impact and are not expose the anus. Exceptions are combined abdomino-
recommended for rectovaginal fistulas. perineal approaches, primarily vaginal access, or a need to
mobilize muscle from the lower extremity (e.g., gracilis
muscle). Carefully clip the pubic hair around the labia and
Radical Local Repair Operations the perineum. Place a urinary catheter and routinely disinfect
both the vagina and the anus. In addition to the perianal field
More complex repair options entail interposition of more block, perform a submucosal and intramuscular injection of
distant sources of well-vascularized tissue between the rec- 0.25% marcaine with 1:200,000 epinephrine.
78 Rectovaginal Fistula Repair 605
Visualize and expose the fistula opening on the anterior and a portion of the circular muscle layer). In order to avoid
rectal wall either by means of handheld retractors, a Lone excessive collateral damage from the electrocautery, it is
Star retractor, or by using a transanal endoscopic microsur- preferable to primarily use a knife or Metzenbaum scissors
gery (TEMS) system. A headlight may be invaluable to and limit the cautery for selective applications to maintain
achieve good illumination. hemostasis. The flap should have excellent viability and be
sufficiently mobile to extend past the fistula opening
Endorectal Advancement Flap (ERAF) (Fig. 78.1b). Due to the attenuation of the rectovaginal sep-
Sharply excise the entire tract and any surrounding inflam- tum and perineal body (Fig. 78.1c), it is sometimes easier to
matory tissue. Mobilize the surrounding anterior rectal wall start the dissection along the lateral portion of the flap and
off the posterior vaginal wall in order to gain length for a work centrally toward the fistula. De-epithelialize the receiv-
tension-free closure. Debride the fistula tract rather than ing area caudad to the fistula. Close the deeper layers of the
excising it. Close the vagina transversely using interrupted defect using a 3-0 absorbable sutures (Fig. 78.1d). Advance
3-0 or 4-0 absorbable sutures. the flap and secure it in place overlapping the previous clo-
Next, create the endorectal advancement flap (Fig. 78.1a– sure, using again a 3-0 absorbable suture in interrupted or
e). This flap should maintain an adequate blood supply and running fashion (Fig. 78.1e).
avoid tension. Outline the flap with a base that is twice the Variations of the ERAF include a circumferential mobili-
width of the apex (Fig. 78.1a). Incise and raise a partial- zation and a circumferential rectal sleeve advancement.
thickness rectal wall flap (consisting of mucosa, submucosa, Make a circumferential incision at the dentate line and
a b
c d e
Fig. 78.1
606 R. Essani and A. M. Kaiser
deepen it through the submucosa. Continue this plane proxi- Gracilis muscle flap The gracilis muscle can be mobilized
mally exposing the internal anal muscle. Once the anorectal through three separate 5 cm incisions along the medial aspect
ring is reached, continue dissection in full thickness until of the thigh. The critical step is to avoid injury to the cepha-
healthy non-scarred tissue is reached. It is imperative that the lad neurovascular bundle. Attach a strong suture to the distal
healthy tissue reaches down to the dentate line without ten- gracilis tendon. Create a tunnel from the proximal leg inci-
sion. Pull the rectum though the anal canal, excise the dis- sion to the perineal incision. Pass a clamp and gently pull the
eased segment, and suture healthy tissue in two layers to the holding suture toward the perineal incision. Position and
pelvic floor structures and the anoderm using interrupted 3-0 secure the muscle in-between the two suture lines. Close all
absorbable sutures. incisions in layers.
pisioproctotomy with Layered Closure

E iscellaneous Perineal Approaches
M
This is a great approach and provides excellent exposure. It Fistula inversion For a small matured fistula, particularly if
is particularly well suited for patients with an existing the perineal body and the sphincter muscle are intact, you
sphincter defect and may be considered for patients with a may consider simply excising and inverting the fistula by
failed ERAF. means of a purse string and close the wall layers underneath.
Expose the fistula and insert a silver probe from anus to Suture is usually performed through the vagina. With the
the vagina. Divide the entire tissue overlying the probe which patient in prone jackknife position, place an index finger in
essentially converts the rectovaginal fistula into a fourth the rectum pressing the fistula forward in to the vagina.
degree laceration. Excise the epithelialized tract. Mobilize Incise the vaginal mucosa very close to the fistula and mobi-
the sphincter muscle on either side. Separately reconstruct lize the tract through the rectovaginal septum. Avoid injuring
the rectovaginal septum by first suturing both the rectal and the fibrous fistula tract. Place a suture to the vaginal fistula
the vaginal wall in two layers using absorbable sutures. end and pull the entire tract toward the rectal side while
Perform an overlying sphincteroplasty by prelaying inter- inverting it. Close the rectovaginal septum with interrupted
rupted sutures and subsequently tying them. Finish up by absorbable sutures. On the inverted rectal side, tie off the end
reconstructing the perineal body. of the inverted fistula, but do not shorten it.
erineal Access and Muscle Interposition

P
Place the patient in high lithotomy position and prep the Excision of fistula with layered closure This is a hybrid
patient from the umbilicus to the knees. Make a 5 cm trans- option between the fistula inversion and the ERAF. In con-
verse incision midway in the perineal body. Use electrocau- trast to the previous description, the fistula tract is excised in
tery to carry this incision through the subcutaneous toward its entirety and the rectovaginal septum including the rectal
the rectovaginal septum. Do not divide the anal sphincter. and the vaginal mucosa are closed in different layers.
Carefully separate the posterior vagina anteriorly and the
anterior rectal wall posteriorly. Remember that previous
treatments have altered and fused the natural planes. The fis- Seton While a great option for cryptoglandular fistula in
tula tract is readily identifiable in this plane. Circumferentially ano, you should avoid this modality for rectovaginal
dissect, isolate, and divide the fistula tract. Excise the fistula fistulas.
area itself and send it to pathology. Close either side (rectum,
vagina) in transverse direction, using 3-0 or 4-0 absorbable
imbricating sutures. Continue the dissection a bit higher to Fistula plug The poor long-term experience does not justify
have adequate space for a muscle interposition. this option on a routine basis.
Bulbocavernosus muscle flap Make an incision just lateral

to the labia. Be careful to assure good hemostasis as there is Abdominal Approach
a rich network of venous plexus. Identify the bulbocaverno-
sus muscle which in many instances has a rather adipose Consider an abdominal approach in complicated or recurrent
appearance. Maintain its posterior blood supply and trans- fistulas, those involving cancer or poor tissue quality, or
sect it as anterior as possible. Create a tunnel to the perineal when less invasive modalities have failed. You will typically
incision and rotate the mobilized muscle in that direction. have to carry out a resection which could be limited to the
Secure it in place with absorbable sutures such that the ante- rectum alone, or include some or all of the anterior anatomi-
rior and posterior repairs are separated. Close the incisions in cal structures—with or without respective reconstruction
layers. (see Chap. 61). In some patients, you may consider a
78 Rectovaginal Fistula Repair 607
Turnball-Cutait technique: you perform a (limited) segmen- local wound care and antibiotics, but they may be the first
tal resection of the damaged rectum from proximal of the signs of a leak or fistula recurrence.
immediate area of the fistula down to the dentate line. You • Depending on the surgical approach, the rectal wall clo-
mobilize the left-sided colon such that it can easily pulled sure may leak and result in abscesses and/or fistula
toward the pelvic floor. Pull the mobilized rectum through formation.
the pelvic floor and sphincter complex such that it goes past • Persistent, recurrent, or aggravated rectovaginal fistula.
the anal verge by several centimeters. Secure it in place with • Need for ostomy in patients who have not already been
interrupted seromuscular sutures to the pelvic floor struc- diverted.
tures. However, wait with trimming the excess tissue to allow
for some healing. Plan a second step operation 1–3 week(s)
later, trim the bowel, and mature the colo-anal anastomosis.
Further Reading
Postoperative Care American Medical Association. Current procedural terminology: CPT

• Antibiotics: Continue beyond the perioperative 24-hour de Parades V, Dahmani Z, et al. Endorectal advancement flap with mus-
prophylaxis period. cular plication: a modified technique for rectovaginal fistula repair.
• Diet: Perineal cases—resume regular diet; abdominal Color Dis. 2011;13(8):921–5.
Hull TL, El-Gazzaz G, et al. Surgeons should not hesitate to perform
cases—ERAS protocol. episioproctotomy for rectovaginal fistula secondary to cryptoglan-
• Bowel management: Aim at getting soft but not watery dular or obstetrical origin. Dis Colon Rectum. 2011;54(1):54–9.
stools; consider fiber supplementation. No specific man- Park SO, Hong KY, et al. Treatment of rectovaginal fistula with graci-
agement is needed for patients who already have a lis muscle flap transposition: long-term follow-up. Int J Color Dis.
2017;32(7):1029–32.
colostomy. Pitel S, Lefevre JH, et al. Martius advancement flap for low rectovaginal
• Remove the urinary catheter at the end of the case. fistula: short- and long-term results. Color Dis. 2011;13(6):e112–5.
• Prior to possible stoma takedown: Wait at least 3 months; Vogel JD, Johnson EK, et al. Clinical practice guideline for the manage-
reevaluate all areas with endoscopy and imaging for ment of anorectal abscess, fistula-in-ano, and rectovaginal fistula.
Dis Colon Rectum. 2016;59(12):1117–33.
definitive evidence of fistula resolution. Discuss with the Wang D, Chen J, et al. Surgical repair of rectovaginal fistula using the
patient that the stoma takedown may reactivate a fistula. modified Martius procedure: a step by step guide. J Minim Invasive
Gynecol. 2017;
Zhong Q, Yuan Z, et al. Restorative resection of radiation rectovaginal
fistula can better relieve anorectal symptoms than colostomy only.
Complications World J Surg Oncol. 2017;15(1):37.
• Surgical site infection: Closely monitor the wounds in the

postoperative period for signs of infection or wound
breakdown. Minor infections are often treatable with
Rectourinary Fistula Repair
79
• Definitive evidence of unresectability

Indications • Coagulopathy
Rectourinary fistulas, defined as being below the trigone of

the bladder, are overall rare. They are manifestations of a Preoperative Preparation
complex disease and surgical history. They can result from a
variety of etiologies, such as postsurgical (prostatectomy), • Review the patient’s history, diagnosis, functional aspects,
radiation, or tumor. Almost always, they cause symptoms and appropriate indication for surgery (based on clinical,
and represent a challenge for both the patient and surgeon. radiographic, or endoscopic means).
Most rectourinary fistulas require some surgical interven- • Review all preoperative images to define anatomy and
tion, starting with a diversion of the stool (colostomy) and confirm or rule out local tumor.
possibly the urine (Foley catheter, percutaneous nephros- • Colonoscopy to confirm the diagnosis and exclude syn-
tomy tubes) to mitigate the immediate symptomatology. chronous pathology.
The definitive management of the fistula itself depends on • Cystoscopy.
a number of factors including presence or absence of tumor, • Mechanical bowel preparation.
tissue quality, timing and type of previous repair attempts, as • Antibiotic prophylaxis versus treatment.
well as current and prospective functional aspects.
Observation is an acceptable approach in patients who are
asymptomatic (e.g., after diversion), have no evidence of a Pitfalls and Danger Points
treatable malignancy, or are poor surgical candidates.
Symptomatic patients with a life expectancy greater than • Local repair in presence of tumor or poor tissue quality
6 months should be offered an operation to repair, recon- • Surgery too early after previous attempt
struct, or resect one or both sides of the problem. • Poor function
Contraindications Operative Strategy

• Lack of symptoms (with or without diversion) Immediate Symptom Control
• Poor performance status with limited life expectancy
• Metastatic tumor, not amenable to potential cure (unless Temporary fecal and urinary diversion should be considered
no less aggressive options exist) in all patients prior to definitive repair. The decision to divert
is made on a case-by-case basis but is especially important in
individuals with poor tissue quality due to radiation or long-
G. K. Low
Department of Surgery, University of Tennessee, standing inflammation, or a recent surgery. In patients with
Knoxville, TN, USA benign low-flow fistulas, a temporary fecal and urinary
A. M. Kaiser (*) diversion alone may occasionally suffice to allow the fistula
Department of Surgery, Division of Colorectal Surgery, City of to close. Some patients may not heal the fistula but after
Hope National Medical Center/Comprehensive Cancer Center, diversion are asymptomatic and do not desire further sur-
Duarte, CA, USA
gery. Those patients with persistent fistulas (with and with-

https://doi.org/10.1007/978-3-030-81415-1_79
out symptoms while diverted) and a strong desire to address Operative Technique
the primary problem can be evaluated after a sufficient wait
time for the options described below. Perineal Approach
Transanal Access
Perineal Local Rectourinary Repair Place the patient in the prone jackknife position and separate
the buttocks with tape to expose the anus. Access and pro-
For small low fistulas with no evidence of malignancy, a num- vide exposure to the fistula opening on the anterior rectal
ber of local approaches via perineal, transanal, p arasacral, or wall either by means of handheld retractors, a Lone Star
transsphincteric access may be considered. Of these approaches, retractor, or by using a transanal endoscopic microsurgery
the parasacral-transsphincteric approach (York- Mason) or (TEMS) system.
transanal approach (TEMS) are preferred due to their compara- Sharply excise the entire tract and any surrounding
bly superior exposure. A transperineal approach may be used to inflammatory tissue. The urinary catheter will be visible
separate the two sides and interpose a muscle flap. within the urethra. Mobilize the surrounding anterior rectal
wall off the urinary tract in order to gain length for a tension-
free closure. Close the urethra transversely using interrupted
Abdominal Local Rectourinary Repair 3-0 or 4-0 absorbable sutures.
Raise a superiorly based partial-thickness rectal advance-
A local repair can also be orchestrated via an abdominal ment flap with a base that is twice the width of the proximal
approach. Robotic technology has allowed the surgeon to end. The flap should have excellent viability and be suffi-
access and work in the deep and narrow pelvis. Obstacles to ciently mobile to extend past the fistula opening.
a successful repair is the lack of exposure of the actual defect, De-epithelialize the receiving area caudad to the fistula.
often as a result of the bladder being in the way. Hence, in Close the deeper layers of the defect using a 3-0 absorbable
order to visualize the fistula and perform a layered closure, sutures. Advance the flap and secure it in place overlapping
the bladder needs to be (1) split in half down to the level of the previous closure, using again a 3-0 absorbable suture in
the fistula or (2) be taken down with or without prostatec- interrupted or running fashion.
tomy from the base of the urethra and moved in cephalad
direction. In both scenarios, the maneuvers allow for the rec- arasacral-Transsphincteric Access (York-Mason)
P
tal defect to be directly accessed and repaired. Interposition Place the patient in the prone jackknife position. Clip the hair
of omentum will add to the separation of the reconstructed and mark the intended incision. Separate the buttocks with
compartments. tape but avoid too close proximity to the parasacral area.
Irrigate the rectum with povidone iodine, then prep and drape
the patient.
Abdominal and Abdomino-perineal Resection Make an incision starting lateral to the sacrococcygeal
joint and extending to the posterior midline of the anal verge.
Large fistulas, very poor tissue quality, poor functional out- Essentially perform a controlled division of all tissues
look, or underlying malignancy will require resection of the between the skin and the lumen of the rectum. The art of the
bladder, the rectum, or both (see also Chap. 59). Depending approach lies in marking corresponding structures with
on the local specifics, a restoration of one or both can be sutures of various colors to later allow for an adequate reap-
considered. For the rectal side, that would entail a pull- proximation of each layer. The structures to be divided
through procedure in standard fashion or in a two-stage anas- include the inferior portion of the gluteus maximus muscle,
tomosis in Turnball-Cutait technique. fat, the levator ani/puborectalis muscle, the external anal
sphincter, the internal anal sphincter, and the bowel wall.
Identify, resect, and close the fistula tract as detailed in the
Documentation Basics transanal operative technique section above.
Close the divided and tagged structures layer by layer
Coding for surgical procedures is complex. Consult the most using absorbable sutures. Reconstruct the sphincter struc-
recent edition of the AMA’s Current Procedural Terminology tures using interrupted sutures. For the other layers, running
book for details (see references at the end). In general, it is suturing is appropriate and faster.
Perineal Access and Muscle Interposition
• Indication and reasoning for choice of intervention Place the patient in high lithotomy position and prep the
• Findings patient from the umbilicus to the knees. Make a 5 cm trans-
• Approach and type of repair verse incision midway between the anus and the base of the
79 Rectourinary Fistula Repair 611
scrotum. Use electrocautery to carry this incision through the Postoperative Care
subcutaneous tissue and perineal body. Do not divide the
anal sphincter. Identify the rectoprostatic (Denonvillier’s) • Antibiotics: Continue beyond the perioperative 24-hour
fascia anteriorly and the anterior rectal wall posteriorly. prophylaxis period.
Remember that previous treatments have altered and fused • Diet: Perineal cases—resume regular diet; abdominal
the natural planes. The fistula tract is readily identifiable in cases—ERAS protocol.
this plane. Circumferentially dissect, isolate, and divide the • Bowel management: Only needed for patient without
fistula tract. Excise the fistula area itself and send it to pathol- colostomy.
ogy. Close either side (rectum, urethral) in transverse direc- • Keep the urinary catheter in place for 6–8 weeks. Prior to
tion, using 3-0 or 4-0 absorbable imbricating sutures. catheter removal, plan for contrast studies (contrast
Continue the dissection a bit higher to have adequate space enema, cystourethrogram) and cystoscopy.
for a muscle interposition. • Prior to possible stoma takedown: Reevaluate all areas
The gracilis muscle can be mobilized through three sepa- with endoscopy and imaging for definitive evidence of
rate 5 cm incisions along the medial aspect of the thigh. The fistula resolution.
critical step is to avoid injury to the cephalad neurovascular
bundle. Attach a strong suture to the distal gracilis tendon.
Create a tunnel from the proximal leg incision to the perineal Complications
incision. Pass a clamp and gently pull the holding suture
toward the perineal incision. Position and secure the muscle • Closely monitor surgical sites in the postoperative period
in-between the tow suture lines. Close all incisions in for signs of infection or wound breakdown. While these
layers. routine surgical site infections are often treatable with
local wound care and antibiotics, they may be the first
signs of a leak or fistula recurrence.
Abdominal Approach • Genitourinary complications postoperatively may include
urethral stricture, incontinence, impotence, and urinary
Consider an abdominal approach in complicated or recurrent tract infections. These complications frequently present
fistulas, those involving cancer or poor tissue quality, or after urinary catheter removal and should prompt follow-
when less invasive modalities have failed. In absence of can- up with a urologist.
cer, a local repair could be attempted. The robotic approach • Bladder stone formation: particularly around remnants of
has the unique combination of 3D-visualization, access, and suture material.
maneuverability in the deep and narrow pelvis: This not only • Depending on the surgical approach, the rectal wall clo-
facilitates the dissection but also allows previously impossi- sure may leak and result in abscesses and/or fistula
ble approaches with salvage prostatectomy, retroflexion of formation.
the bladder, and layered repair of the fistula followed by • Negative functional impact: if the anal sphincters are
omental interposition and anastomosis of the bladder with divided, there is a risk of incontinence after reversal of
the urethra. fecal diversion (which is typically less severe than the rec-
Alternatively, you will have to carry out a resection which tal discharge of urine prior to the repair).
could be limited to the rectum alone, the bladder alone, or
encompass both—with or without respective reconstruction
(see Chap. 59). In some patients, you may consider a
Turnball-Cutait technique: you perform a (limited) segmen- Further Reading
tal resection of the damaged rectum from proximal of the
immediate area of the fistula down to the dentate line. You American Medical Association. Current procedural terminology: CPT
then pull through the mobilized rectum such that it goes past https://www.ama-assn.org/practice-management/cpt.
the anal verge by several centimeters. Secure it in place with Hanna JM, Turley R, et al. Surgical management of complex recto-
seromuscular sutures to the pelvic floor structures. However, urethral fistulas in irradiated and nonirradiated patients. Dis Colon
wait with trimming the excess tissue to allow for some heal- Rectum. 2014;57(9):1105–12.
Hechenbleikner EM, Buckley JC, et al. Acquired rectourethral fistulas
ing. Plan a second step operation one week later, trim the in adults: a systematic review of surgical repair techniques and out-
bowel, and mature the anastomosis. For further details, see comes. Dis Colon Rectum. 2013;56(3):374–83.
the references at the end of this chapter.
Kaufman DA, Zinman LN, et al. Short- and long-term complications Munoz-Duyos A, Navarro-Luna A, et al. Gracilis muscle interposition
and outcomes of radiation and surgically induced rectourethral fis- for rectourethral fistula after laparoscopic prostatectomy: a pro-
tula repair with buccal mucosa graft and muscle interposition flap. spective evaluation and long-term follow-up. Dis Colon Rectum.
Urology. 2016;98:170–5. 2017;60(4):393–8.
Keller DS, Aboseif SR, et al. Algorithm-based multidisciplinary Nunoo-Mensah JW, Kaiser AM, et al. Management of acquired rec-
treatment approach for rectourethral fistula. Int J Color Dis. tourinary fistulas: how often and when is permanent fecal or urinary
2015;30(5):631–8. diversion necessary? Dis Colon Rectum. 2008;51(7):1049–54.
Lee KH, Lee MR, et al. Robotic-assisted laparoscopic segmental Sotelo R, Mirandolino M, et al. Laparoscopic repair of rectourethral
resection with rectoanal anastomosis: a new approach for the man- fistulas after prostate surgery. Urology. 2007;70(3):515–8.
agement of complicated rectourethral fistula. Tech Coloproctol.
2013;17(5):585–7.
Lateral Internal Sphincterotomy with/
Without Fissurectomy for Chronic Anal 80
Fissure
patient, a mild cathartic the night before surgery may be

Indications preferable to perioperative enemas as the latter can cause
exacerbation of the pain.
Painful chronic anal fissure not responsive to optimized • Sigmoidoscopy or colonoscopy are done as indicated by
bowel regimen and medical management with topical mus- the patient’s symptoms, age, and risk constellation (for
cle relaxants (ointments with nitroglycerin or calcium chan- example, as part of the procedure).
nel blockers) or pharmacologic paresis with injection of • Routine antibiotic prophylaxis is recommended.
botulinum toxin.

Contraindications
• Injury to external sphincter
• Preexisting fecal incontinence or hypotonic sphincter • Inducing fecal incontinence by overly extensive
• Active anorectal pathology (e.g., abscess/fistula) sphincterotomy
• Anal canal neoplasia • Bleeding and hematoma
• Underlying diarrhea • Atypical fissures
• Idiopathic inflammatory bowel disease • Fistulized fissures (subcutaneous fistula)
• Perianal wounds/ulcers in immunosuppressed patients • Previous sphincterotomy
(HIV, leukemia, chemotherapy) • Previous obstetrical sphincter injury
• Unfavorable bowel function (diarrhea)
Operative Strategy
• Establish a correct diagnosis for the patient’s complaints.
• Determine underlying functional aspects (bowel habits, Patient Selection
fecal control).
• Define the patient’s goals and expectations. A surgical sphincterotomy is by far the fastest and most suc-
• Advise the patient to discontinue aspirin and other non- cessful treatment for chronic anal fissures, but it is irrevers-
steroidal anti-inflammatory drugs. ible, and even in experienced hands, there is a low (but not
• Bowel cleansing for lateral internal sphincterotomy is negligible) risk of incontinence or nonhealing. Reserving
optional dependent on the pain level; if tolerated by the surgery until all nonsurgical measures have been exhausted
is therefore desirable. Be aware of atypical or recurrent pre-
sentations or circumstances and suspect underlying
C. P. Spanos
pathology.
A. M. Kaiser (*)
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_80
Goal of Surgery position is preferred because it allows the surgeon to tape the
buttocks apart and provide ergonomic access to the surgical
The white internal anal sphincter is responsible for the ele- team, and it decreases the vascular congestion of the anal
vated anal resting tone that is associated with the nonhealing canal.
of a fissure. The key point in the procedure is to only cut the
internal anal sphincter up to the level of the fissure.
Characteristically, in fissure patients, the internal sphincter is Closed Sphincterotomy
hypertonic, hypertrophied, and easily palpable at the
intersphincteric groove. The sphincterotomy should be per- Gently insert a lubricated bullet retractor. Quickly visualize
formed in lateral location and should not be done through the the entire circumference of the anal canal. Then expose the
fissure itself. right or left lateral margin of the anal canal and palpate the
groove between the internal and external sphincters. Once
this has been clearly identified, insert a Beaver blade or a No.
Optional Steps 11 scalpel blade through a stab incision and advance it into
this groove (Fig. 80.1). During this insertion, keep the flat
A fissurectomy is not routinely necessary. However, in select portion of the blade parallel to the internal sphincter. Once
cases, it may be beneficial to excise and refreshen the tissue the blade has reached the level of the cephalad end of the fis-
edges if the fissure is very deep, hypoactive (anergic), or sure, rotate the blade 90°, so its sharp edge rests against the
hyperactive (granulation tissue). That may be combined with internal sphincter muscle (Fig. 80.2). Insert the nondominant
an excision of a sentinel hypertrophic anal papilla (on the index finger into the anal canal opposite the scalpel blade.
cephalad end of the fissure) or a particularly large sentinel Then, with a gentle sawing motion, transect the lower por-
skin tag (on the caudad end of the fissure) that may be cause tion of the internal sphincter muscle. There is a gritty sensa-
for irritation or result in an unfavorable wound configuration, tion, while the internal sphincter is being transected, followed
respectively. by a sudden “give” when the blade has reached the mucosa
In closing the internal aspect of the excision wound and adjacent to the surgeon’s palpating index finger. Take care
leaving the outside open, the location of the most painful not to injure the anal canal epithelium. Rotate the blade back
area may be shifted away from the original site in the anal to the original position and remove the knife and palpate the
canal more to the outside. area of the sphincterotomy with the left index finger. Any
remaining muscle fibers are ruptured by lateral pressure
exerted by this finger. In the presence of bleeding, apply

important to document the following:
• Indications
• Preoperative fecal control
• Findings
• Extent of sphincterotomy
• Open or closed technique
• Excision of hypertrophied papilla
• Excision of sentinel skin tag
Operative Technique
General anesthesia, regional anesthesia (epidural/spinal), or

a combination of monitored anesthesia care (MAC) with
local anesthesia are suited for the procedure. Prone jackknife Fig. 80.1
80 Lateral Internal Sphincterotomy with/Without Fissurectomy for Chronic Anal Fissure 615
Fig. 80.2
pressure to this area for at least 5 minutes. The best way to do

this is to “pinch” the area of the sphincterotomy, with the Fig. 80.3
index finger in the anal canal and the thumb on the anal
verge, on the incision site. It is rarely necessary to make an
incision in the mucosa to identify and coagulate a bleeding ing tissues. Achieve hemostasis with careful application of
point. Irrigate the wound and close it with an absorbable run- electrocautery. Either leave the wound open or close it with a
ning suture. running 3/0 or 4/0 absorbable suture. No dressing is needed.
The alternative method of inserting the blade between the
anal canal epithelium and the internal sphincter and then
turning and cutting the muscle from the inside to the outside issurectomy and Removal of the Sentinel Pile
F
is not recommended. That method has no advantage, but due and/or Hypertrophic Anal Papilla
to lack of control, there is an increased risk of injuring the
mucosa or the external sphincter muscle. If the patient has a sentinel pile more than a few millimeters
in size, a large hypertrophic papilla, or a very deep, “angry”
appearing or hypoactive/anergic fissure, some optional land-
Open Sphincterotomy scaping may be indicated. Remove the hypertrophic anal
papilla using electrocautery. Suture ligature is needed in
Gently insert a lubricated bullet retractor. Quickly visualize some occasions to avoid bleeding. For the sentinel skin tag,
the entire circumference of the anal canal. Then expose the lift it up with forceps and perform a narrow base excision
right or left lateral margin of the anal canal and palpate the using either scissors, a knife, or cautery. If a fissurectomy is
groove between the internal and external sphincters. Once done as well, continue the excision to the edges of the fis-
this has been clearly identified, make a radial incision in the sure. Close the inside of wound with a running absorbable
anoderm from a point just distal to the dentate line and carry suture up to the level of the anal verge, but leave the outside
it across the caudal border of the internal sphincter on the skin defect unsutured.
anal verge. Using cautery, divide the connective tissue over-
lying the sphincter structures. Identify the intersphincteric
groove with a whitish appearing internal and a pink external Concomitant Hemorrhoidectomy
sphincter muscle. Use a fine hemostat or right-angle clamp
to gently dissect and lift the distal portion of the internal In addition to the chronic anal fissure, some patients have
sphincter (Fig. 80.3). Slowly divide the distal internal sphinc- truly symptomatic prolapsing internal hemorrhoids that will
ter between the jaws of the slightly opened clamp. Use the require surgery as well. Large grade II-III internal hemor-
electrocautery carefully to avoid burn injury to the surround- rhoids may acutely prolapse after sphincterotomy and prog-
ress to grade IV incarcerated ones, although it is not common. sphincterotomy than they had before operation, or they
For that reason and to avoid a second operation, a simultane- may have some fecal soiling of their underwear; but gen-
ous hemorrhoidectomy may be performed in conjunction erally, these complaints are temporary, and the problems
with the lateral internal sphincterotomy. Preferably, a stapled rarely last more than a few weeks.
hemorrhoidectomy (or a hemorrhoid banding) is carried out • Recurrent/persistent fissure: Allow for sufficient time to
to avoid negating the pain-relieving effect of the fissure assess. Rather than immediately repeating the procedure,
surgery. consider starting with topical creams, Botox, or to per-
form an advancement flap.
Postoperative Care
• Postoperative antibiotics are not needed. Further Reading

• Discharge the patient the same day.
• Instruct the patient to take well-hydrated fiber supple- Abcarian H. Surgical correction of chronic anal fissure: results of lateral
internal sphincterotomy vs fissurectomy—midline sphincterotomy.
ments (e.g., psyllium), a stool softener, and if necessary a Dis Colon Rectum. 1980;23:31.
laxative to avoid constipation. American Medical Association. Current procedural terminology: CPT
• Prescribe a mild analgesic, such as paracetamol or acet- ®. Professional ed. Chicago: American Medical Association; 2022.
aminophen, every 4–6 hours in the initial postoperative https://www.ama-assn.org/practice-management/cpt.
period. 2009. Retrieved November 14, 2022, from https://accesssurgery.
• Instruct the patient to take warm sitz baths once or twice mhmedical.com/book.aspx?bookID=425.
daily to relieve pain and reduce pelvic muscle spasm. Lasheen AE, Morsy MM, Fiad AA. Segmental internal sphincter-
otomy – a new technique for treatment of chronic anal fissure. J
Gastrointest Surg. 2011;15:2271.
Metcalf AM. Anal Fissure. Surg Clin North Am. 2002;82:1291.
Complications Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl
S. Operative procedures for fissure in ano. Cochrane Database Syst
• Hematoma or bleeding (rare). Rev. 2011;11:CD002199.
Notaras MJ. The treatment of anal fissure by lateral subcutaneous inter-
• Perianal abscess and fistula (rare): Typically, these are not nal sphincterotomy: a technique and results. Br J Surg. 1971;58:96.
transsphincteric and may simply be laid open to allow for Sinha R, Kaiser AM. Efficacy of management algorithm for reduc-
healing by secondary intention. ing need for sphincterotomy in chronic anal fissures. Color Dis.
• Flatus and fecal soiling: Some patients complain that they 2011;10:1463.
have less control over the passage of flatus following
Anoplasty for Anal Stenosis
81
Andreas M. Kaiser
the sphincter complex. Due diligence prior to initiating the

Indications operation includes defining the nature, configuration, and
length of the stricture, determining whether it is in the ano-
Symptomatic fibrotic stricture of the anal canal or distal rec- derm or the distal rectal mucosa and ruling out contraindica-
tum, not responsive to stool management and single or serial tions. Particularly, if the stricture is the result of an operation
(self-) dilations. performed by another surgeon, it might be desirable to obtain
information about the condition of the sphincter complex
before or during the surgery (possible intraoperative ultra-
Preoperative Preparation sound once the area is widened). Flap reconstructions should
be avoided in patients who are amenable to dilation in the
• Bowel cleansing: Depending on the degree of obstruction OR and self-dilation or in patients who are clinically
and the planned extent of the surgery. For minor interven- asymptomatic.
tions, 2 Fleet enemas may suffice. For more complex The concept of the intervention is to excise part of the
reconstructions, a full bowel cleansing is recommended, fibrotic stricture and to advance healthy elastic tissue from
which may need to be spread over 2–3 days. the inside or the outside across that stricture level. A sphinc-
• Antibiotic prophylaxis. terotomy should be avoided under any circumstances.
• Limit perioperative fluid administration to 500 cc.
Coding for anorectal procedures is complex. Consult the
• Fecal incontinence most recent edition of the AMA’s Current Procedural
• Recurring stricture Terminology book for details (see references at the end). In
• Flap dehiscence or necrosis general, it is important to document the following:
• Delayed wound healing
• Patient selection, unrealistic expectations • Indication
• Etiology of the stricture • Findings
• Length of the stricture • Nature of flap
• Sphincter assessment?
• Sphincterotomy or not?
Operative Strategy
The goal of the surgical intervention is to refashion an Operative Technique

appropriate-sized anal opening to allow for easy passage of
formed stool while preserving the integrity and function of After induction of general anesthesia, position the patient in
prone jackknife position and retract the buttocks laterally by
A. M. Kaiser (*) means of adhesive tape. It is better to perform a precise inci-
Division of Colorectal Surgery, City of Hope National Medical sion of the stricture than to have an uncontrolled breakdown
Center/Comprehensive Cancer Center, Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_81
618 A. M. Kaiser
by a rough digital dilation. In the area of the planned flap or Postoperative Care
flaps (see below), expose the area of the fibrotic stricture and
perform a radial incision. Excise a small amount of the stric- Fluids
ture for pathology. If there is enough space to accommodate
the ultrasound probe, perform an ultrasound to verify the Discontinue all intravenous fluids in the recovery room. In
integrity or document preexisting damage to the sphincter conjunction with limiting the overall intravenous fluid to
complex. Carefully dissect the strictured epithelial layer off 500 cc for the entire case, this practice may reduce the inci-
the underlying sphincter structures without damaging them. dence of postoperative urinary retention.
Avoid a sphincterotomy or sphincter damage under any
circumstances. Sphincterotomy is reserved for surgical treat-
ment of fissures only, unless it is part of a superficial Wound Care
fistulotomy.
• It is not necessary to remove the Gelfoam because it either
dissolves or is eliminated with the first bowel activity.
Mucosal Advancement Flap • The wound does not need to be protected: Neither a
wound packing nor any dressing are necessary. However,
If the strictured area is located above the original dentate line a gauze or absorbing pad may protect the patient’s clothes.
and limited to the mucosa, a mucosal partial-thickness flap • Starting on the day following the operation, the patient
can be raised and advanced to be placed into the previously should either rinse/shower the area quickly twice per day
strictured area. For that purpose, incise a mucosal flap of suf- and after bowel movements, or alternatively perform
ficient width (2–3 cm) and free it up extending proximally short sitz baths. Wiping with toilet paper should be
far enough to provide mobility without undue tension. avoided for the first roughly 2 weeks.
Advance it past the area of the excised stricture and suture it
in place with interrupted absorbable sutures. Assure that the
rectal mucosa is not advanced past the normal location of the Regular Diet
dentate line, as an ectropion may result which can cause
annoying chronic mucus secretion in the perianal region. • Maintain regular diet.
Hemostasis should be perfect. Insert a Gelfoam pack into
the anal canal and consider injecting local anesthesia.
Stool Management
Anocutaneous Advancement Flap (V-Y Plasty) The goal is to avoid hard and bulky bowel movements. Well-
hydrated fiber supplements, adequate hydration, stool soft-
Mark the flaps with a pen onto the skin. Spend a little time eners, and potentially some mild laxatives (e.g., Milk of
in selecting the best site. Depending on the patient’s anat- Magnesia) are among the commonly used tools to avoid con-
omy, good locations are the lateral and the posterior areas. stipation in the postoperative period (particularly if opiate
Use the anterior circumference only in rare circumstances. pain killers are used).
Plan a sufficiently large advancement flap, 4–5 cm × 3–4 cm
in width. Incise the previously marked flap on the skin and
dissect deeper without undermining it and cutting off its Pain Management
blood supply. Releasing the most peripheral part around the
flap will allow it to automatically drop into the anal canal. A combination of ketorolac (or other NSAID) and some opi-
Maintain excellent hemostasis. Once sufficient mobility of ate medication for breakthrough pain is usually sufficient.
the flap has been obtained, pull its most central part past the Rarely, addition of gabapentin may facilitate the
area of the excised stricture and suture the base of the flap management.
in place with a series of interrupted absorbable sutures.
Follow the maturation of the flap on the two sides.
Ultimately, close the harvest area in V-Y fashion Complications
(Fig. 81.1a–d). Verify the size of the opening and decide
whether a similar flap will have to be performed on the • Urinary retention
opposite side. Repeat the same procedure if necessary. • Bleeding (immediate versus delayed, for example, when
Insert a rolled-up Gelfoam pack into the anal canal and pro- flap dehisces)
vide a boost of local anesthesia. • Hematoma
81 Anoplasty for Anal Stenosis 619
a b
c d
Fig. 81.1
• Flap dehiscence internally (rare) Farid M, Mohamed Y, Nakeeb E, et al. Comparative study of the house
• Dehiscence of harvest area externally (frequent) advancement flap, rhomboid flap, and y-v anoplasty in treatment
of anal stenosis: a prospective randomized study. Dis Col Rectum.
• Restricturing 2010;53:790–7.
Katdare MV, Ricciardi R. Anal stenosis. Surg Clin North Am.
Further Reading 2010;90:137.
Khubchandani IT. Anal stenosis. Surg Clin North Am. 1994;74:1353.
Perineal Operations for Rectal Prolapse
82
Indications • Prolapsing colo-anal anastomosis after ultralow-anterior

resection
Rectal prolapse surgery aims at correcting the morpho- • Young male patients wishing to avoid sympathetic or
logical problem while preserving or improving functional parasympathetic nerve injury of an abdominal approach
aspects. Both abdominal and perineal approaches play a (relative indication)
role in the management of these patients. There are pros • Hostile abdomen (e.g., superobesity, aortic aneurysm,
and cons for each approach, and no approach provides an adhesions, and others)
absolute guarantee of success. Perineal operations for rec-
tal prolapse are the surgery of choice in emergencies, and
under elective circumstances, they may be preferable in Contraindications
frail patients who might not tolerate an abdominal proce-
dure and/or full anesthesia. There are three perineal oper- Do not perform a perineal prolapse surgery in patients with a
ations: (1) perineal proctosigmoidectomy with previous rectosigmoid resection (unless the anastomosis
levatoroplasty (Altemeier procedure), (2) mucosal resec- forms part of the prolapse) as there is a high risk of creating
tion with muscular cuff plication (Delorme procedure), an avascular segment. Descent or prolapse of all compart-
and (3) the surgical legacy procedure of an anal encircle- ments (such as associated vaginal/uterine and/or bladder pro-
ment (a.k.a. Thiersch operation). lapse) is better served with an abdominal approach. Severely
You may choose one of these as opposed to an abdominal constipated patients may be more appropriately treated by an
procedure under the following circumstances: abdominal procedure (resection rectopexy, laparoscopic ven-
tral rectopexy.
• Incarcerated full-thickness rectal prolapse (with/without
thrombosis or ischemia)
• Full-thickness rectal prolapse (for patients who are not Preoperative Preparation
candidates for or opt against an abdominal approach)
• Poor-risk patients unable to tolerate open or laparoscopic • A full or at least partial colon evaluation is imperative
abdominal approach, or general anesthesia for all elective and desirable for urgent cases. Rule out
• Recurrence after a non-resective abdominal operation a “lead point” (e.g., tumor or polyp), and biopsy any
(rectopexy) for rectal prolapse abnormal areas. Some inflammatory changes are com-
• Prolapse with severe sphincter weakness mon in the prolapsing segment (solitary rectal ulcer
syndrome, friability, pseudopolyp formation) and must
be differentiated from cancer or true inflammatory
C. P. Spanos bowel disease.
Department of Surgery, Aristotelian University School of • It is crucial to weigh pros and cons of the different opera-
Medicine, Thessaloniki, Greece tions; tailor the “best choice” to the individual patient (see
A. M. Kaiser (*) Further Reading); set realistic expectations.
Department of Surgery, Division of Colorectal Surgery, City of • Accurately assess and document the degree of preopera-
tive continence; a history and digital exam to assess rest-
Duarte, CA, USA

https://doi.org/10.1007/978-3-030-81415-1_82
ing and squeeze tone are typically sufficient; anorectal Operative Strategy
manometry is unreliable with an actively prolapsing rec-
tum and may provide more relevant data after the pro- Choice of Procedure
lapse has been corrected.
• Evaluate for concurrent descent or prolapse for the Unfortunately, there are not many evidence-based guidelines
anterior compartments (vagina/uterus, bladder). as to the choice of the best operation. Factors you should
• Consider colonic transit times (Sitzmark study) if severe consider are: the patient’s overall condition and past surgical
constipation is present. and medical history, the degree of rectal and pelvic organ
• Bowel preparation for all elective procedures: In case of prolapse, primary versus recurrent prolapse, sphincter func-
severe constipation, cleanse the colon over a period of a tion, and underlying bowel function (constipation, diarrhea).
few days (including cathartics and enemas). Generally, abdominal surgeries are associated with lower
• Standard intravenous perioperative antibiotic prophylaxis recurrence rates, but perineal approaches cause less of an
upon induction of anesthesia. impact on the patient’s overall condition and allow for minor
enhancements of poor sphincter function. It is probably a
myth that any particular operation has a better chance to
Pitfalls and Danger Points improve constipation.
• When surgery is considered for recurrent prolapse (e.g.,

after failure of an abdominal procedure which may have Patient Positioning
included a resection), the blood supply from the perineal
direction will be interrupted, leaving an avascular seg- The prone jackknife position is preferred as it has the advan-
ment that will necrose. tage of better access for the surgeon and assistants, better
exposure, and less vascular congestion. Lithotomy position
is possible as well, but ergonomically more of a challenge
Altemeier Procedure for the surgical team.
• Injury to vagina or urethra (in a male).

• Stool spillage into the accessed peritoneal cavity. Anesthesia
• Loss of vascular control and internal bleeding when trans-
secting the mesorectum. All perineal prolapse surgeries can be performed with gen-
• When performing the Altemeier procedure, a “tight” leva- eral or regional anesthesia (spinal, epidural). Injection of a
toroplasty may cause obstruction. local anesthesia block to the anus may be used to enhance the
• Undue tension on the remaining bowel and the postoperative pain control.
anastomosis.
• Devascularization of bowel used for anastomosis.
Operative Tactics
Delorme Procedures erineal Proctosigmoidectomy (Altemeier

P
Procedure)
• Dissecting in the wrong plane may cause full-thickness
bowel wall injury and necessitate conversion into an With this approach, you resect the redundant rectosigmoid
Altemeier procedure. and perform a colo-anal anastomosis, often enhanced by a
• Injury to vagina or urethra (in a male). levatoroplasty. The dentate line and the anal transition zone
are preserved. A Lone Star retractor greatly improves expo-
sure of the anal verge. The redundant rectum is everted (pro-
Thiersch Procedure: Pitfalls and Danger Points lapsed), at which point it consists of two layers with the
mesentery in-between. It is safer to address one layer at a time
• Too tight encirclage causes fecal outlet obstruction and rather than to cut through all at once. The peritoneal cul-de-
fecal impaction. sac is characteristically very low; hence, the peritoneal cavity
• Wound infection with need to remove encirclage. is typically opened anteriorly allowing for mobilization of the
• Injury or erosion of vagina or rectum with rectovaginal redundant rectosigmoid. The blood supply is more posterior
fistula formation. and needs to be divided in a controlled fashion. Before start-
82 Perineal Operations for Rectal Prolapse 623
ing to shorten the redundant colon, the first seromuscular • Findings and indications
layer of the colo-anal anastomosis and a levatoroplasty are • Bowel viability
carried out to secure the bowel and prevent it from retracting. • Sphincter condition and tone
Of paramount importance is to avoid a stenosis. Only then is • Levatoroplasty performed or not
the bowel trimmed to appropriate length, and the anastomosis • Document examination of the vagina in females
completed. Even though this is a true hand-sewn colo-anal • Implant yes or no
anastomosis, a diverting ileostomy is not needed.
Operative Technique
ucosal Sleeve Resection with Muscular Cuff
M
Plication (Delorme Procedure) ltemeier Procedure: Perineal
A
Proctosigmoidectomy
This approach aims at stripping the mucosa off the prolapsing
rectum. The muscular layer is preserved and subsequently pli- After induction of anesthesia, place the patient in the prone
cated to the level of the anal canal before the mucosa is jackknife position, with the buttocks taped apart. Place a
readapted. Patience is a virtue, supported by gentle traction on Foley catheter in the urinary bladder. Prep and drape in the
the mobilized mucosa and sometimes saline/epinephrine usual fashion, which in female patients includes the vagina.
injections. Once the hemorrhoid area has been passed, the Perform a perianal block with a local anesthetic. Place a
careful circumferential dissection should essentially be blood- Lone Star retractor to expose the anal verge. Deliver the pro-
less in the avascular submucosa at the edge of the white mus- lapse by inserting a sponge-on-a-stick through the anus, then
cularis propria. You should under any circumstances avoid pulling it out. Gently continue the eversion by placing non-
getting too deep into the bowel wall and essentially converting traumatic clamps to fully demonstrate the prolapse. Avoid
the Delorme into an Altemeier procedure. The dissection is injuring the mucosa and causing unnecessary bleeding.
continued until there is no further giving. Plicating absorbable Using the cautery tip, mark a circumferential dotted line
muscle sutures are pre-laid. Only then is the redundant mucosa on the rectal mucosa about 1 cm above the dentate line.
trimmed step-by-step to appropriate length, and the plicating Connect the dots. Start in one location (typically in the pos-
are sutures tied. As last step, the mucosa is readapted. terior midline) to make a full-thickness incision through the
outer layer of the two-layered prolapse (Fig. 82.1). Continue
in that plane without damaging the blood supply or the inner
hiersch Operation (Surgical Legacy
T layer. An energy device may be used to divide the bowel wall
Procedure) with minimal bleeding. You may choose to place four full-
The concept of this legacy approach is to encircle the anal

canal with an implant with the goal to narrow it sufficiently
such that the rectum cannot prolapse through that area any-
more. Implant choices can range from four-ply layer of
polypropylene mesh, Dacron-impregnated Silastic sheet
(Dow Corning No. 501–7), the wide end of a JP drain, or
biological collagen sheaths. The approach and its risks
(infection, erosion) are similar to artificial implants for
fecal incontinence. The tunnel around the anal canal and
the implant should have sufficient width to decrease the
likelihood of tissue erosion. If the band is too tight, there
will be stenosis and fecal impaction; if it is too loose, pro-
lapse is not prevented.

important to document the following: Fig. 82.1
thickness sutures in each quadrant (keeping the needles) for the inner bowel wall (Fig. 82.3). Anteriorly, expect to enter
retraction and subsequent use for the colo-anal anastomosis. the peritoneal reflection as if it was a hernia sac. Place an
Look for the yellowish color of the mesorectum index finger in the vagina to confirm that it is not incorpo-
(Fig. 82.2). Divide the mesorectal/mesosigmoid vessels rated in this membrane before you incise it. Opening the
between clamps and safely ligate them. Remember that the peritoneum will expose the serosa of the sigmoid colon.
mesorectum will retract to the inside and insufficient ligation Avoid spillage of any stool into the peritoneum. Palpate the
may result in internal bleeding. Also take care not to injure intraperitoneal contents making sure that they do not pro-
lapse into the incision. The prone jackknife position allows
gravity to assist, by encouraging the small bowel to fall away
from the perineum. Mobilize the bowel, by applying gentle
proximo-distal traction (Fig. 82.4). Keep dividing the vessels
until the redundant bowel has been adequately mobilized and
there is resistance to this traction. Resect excess hernia sac
tissue and close with an absorbable 3-0 PG suture.
When no further redundant bowel can be delivered
through the anus, consider whether or not to plicate the leva-
tor sling. Draw the bowel anteriorly. The posterior levator
muscles are easily visualized, having a “U” configuration.
Place two to three 2-0 nonabsorbable sutures to plicate the
muscles. Place sutures in the anterior levators to further nar-
row the anal canal, if needed. When doing this, place a finger
in the vagina so as to avoid suturing through the vaginal wall.
Leave sufficient space that the bowel can easily pass through
this residual aperture—snug, but not tight.
Fig. 82.2
Fig. 82.3 Fig. 82.4

Before shortening the bowel to appropriate length, verify Also start by marking a circumferential dotted line on the
to what level the mobilized bowel remains perfused. If nec- rectal mucosa about 1 cm above the dentate line and connect
essary, open the posterior bowel wall from the point of resec- the dots. You may inject saline with dilute epinephrine
tion of the outer layer toward the level of ultimate transection (1:200,000) into the mucosa/submucosa of the prolapsed
and splay the bowel open. This will reveal a demarcation line bowel to facilitate its dissection off the muscle layer. Avoid
between the perfused and ischemic bowel. Secure the bowel using lidocaine/bupivacaine to prevent systemic pharmaco-
to the pelvic floor using a total of eight absorbable seromus- logic toxicity. Make sure the circular incision remains lim-
cular sutures. Gradually transect the rest of the redundant ited to the mucosa and does not violate the whitish circular
bowel wall. If you previously pre-laid sutures, you may now fibers of the muscle layer (Fig. 82.8). Dissect the mucosa/
use them to place the first full-thickness bites of the anasto- submucosa off the muscularis using a low setting of the elec-
mosis (Figs. 82.5 and 82.6). Complete the colo-anal anasto- trocautery. Once the correct plane is followed past the hem-
mosis by placing interrupted sutures between the
four-quadrant sutures (Fig. 82.7) and potentially fine-tune
the mucosa with a running 3/0 chromic suture.
elorme Procedure: Mucosal Sleeve Resection

D
with Muscular Plication
Anesthesia, patient positioning, delivery of prolapse, and

exposure of the anus are identical to perineal
proctosigmoidectomy.
Fig. 82.6
Fig. 82.5 Fig. 82.7

plicating sutures carefully; an assistant can simultaneously

reduce the prolapse using a sponge-on-a-stick at this junc-
ture. After plication of the muscular cuff, complete the
mucosal anastomosis by placing roughly eight interrupted
3-0 absorbable sutures. Potentially fine-tune the mucosa with
a running 3/0 chromic suture.
hiersch Operation (Surgical Legacy

T
Procedure)
This operation may be done under general or regional anes-

thesia with the patient in the prone jackknife or the lithotomy
position. As in the previous sections, we would prefer the
prone position; however, keep in mind that the patient’s poor
operability is the reason for this choice of (inferior) opera-
Fig. 82.8 tion and do not hesitate to use the lithotomy position, if safer
from the anesthesia standpoint.
Make two roughly 2 cm radial incisions in antero-lateral
location and gently develop a tunnel around the anus. Be
careful not to injure the rectal or the vaginal wall.
Choose your implant: for example, Silastic mesh, Prolene
mesh, the wide end of a JP drain, or a biological collagen
sheath. Cut it to a band of appropriate width and length
(approximately 1.5 × 20.0 cm). Insert a large curved clamp
into the incision on the one side and pass it through the tun-
nel until it emerges from the opposite incision. Insert one end
of the implant into the jaws of the clamp and draw without a
twist to the clamp insertion point (Fig. 82.9). Then pass the
hemostat through the other incision and the other half of the
tunnel until it emerges again at the first incision. Insert the
end of the implant again into the jaws of the hemostat and
draw it without a twist back along this path (Fig. 82.10). At
this time, the entire anal canal has been encircled by the
implant, and both ends protrude through the same incision.
Fig. 82.9 Keep the band flat.
Apply a second sterile glove on top of the previous
glove on the left hand. Insert the left index finger into the
orrhoidal level, the dissection should remain bloodless and anal canal. Apply a hemostat to each end of the encircling
clean, if not highly aesthetic, process. Carry the dissection band and ask the assistant to increase the tension gradually
from the anorectal “base” toward the apex of the prolapse. by overlapping the two ends of mesh. When the band feels
Maintain gentle traction by gradually applying Allis clamps snug around the index finger, ask the assistant to insert a
on four quadrants of the dissected mucosa/submucosa and 2-0 Prolene suture to maintain this tension. After the suture
continue the circumferential dissection until tension is has been inserted, recheck the tension of the band. Then
encountered. Leave the redundant mucosa in place until the remove the index finger and remove the contaminated
plicating sutures have been pre-laid. Place eight plicating glove. Insert several additional 2-0 Prolene interrupted
suture using a nonabsorbable 2-0 stitch. Start at the cut sutures or a row of the shortest non-cutting linear stapler
mucosal end above the dentate line and take always the same (e.g., 30 mm TA stapler) to secure the two ends of the
number of consecutive muscular bites (3–4) up to the end of implant. Amputate and discard the excess length. The
the mucosal dissection. Every time the last bite is to be patient should now have a 1.5 cm wide, untwisted band of
placed, amputate that level of the mucosa. You remove the an implant encircling the anal canal at midpoint with suf-
specimen just before the last stitch. Tying these sutures will ficient tension to be snug around an index finger in the rec-
cause a “concertina” effect, reducing the prolapse. Tie the tum (Fig. 82.11).
Fig. 82.10
Fig. 82.12
• Wound care: Formal sitz baths are not necessary but it

may be prudent to rinse rather than wipe the area after
each bowel movement.
Complications
Altemeier/Delorme Procedure:
• Pelvic sepsis (abscess/fistula)

• Bleeding (internal vs. external)
• Anastomotic dehiscence
• Bowel ischemia/necrosis
Fig. 82.11 • Stricture formation
• Rectovaginal fistula
Irrigate both incisions thoroughly with a dilute antibiotic • Recurrent prolapse
solution. Close the deep perirectal fat with interrupted 3-0 • Constipation/impaction
PG interrupted sutures in both incisions. Close the skin with • Incontinence
interrupted or continuous subcuticular sutures (Fig. 82.12)
and seal it with a skin glue. Thiersch Band:
• If the patient develops a wound infection, it is typically

Postoperative Care necessary to remove a synthetic but not a biological
implant.
• Routine perioperative antibiotics for 24 hours. • Some patients experience perineal pain following surgery,
• Prescribe a bulk-forming laxative such as Metamucil but it usually diminishes in time. If the pain is severe and
plus any additional cathartic that may be necessary to unrelenting, the implant must be removed. If removal can be
prevent fecal impaction. Periodic fleet enemas may be postponed for 4–6 months, there may be enough residual
required. perirectal fibrosis to prevent recurrence of the prolapse.
Further Reading Garland B, Zutchi M. Chapter 60: Rectal prolapse. In: Steele SR, Hull
TL, Read TR, Saclarides TJ, Senagore AJ, Whitlow CB, editors.
The ASCRS textbook of colon and rectal surgery. 3rd ed. New York:
Springer; 2016. p. 1077–90.
Glasgow SC, Birnbaum E, Kodner IJ, Fleshman JW Jr, Dietz
DW. Recurrence and quality of life following perineal proctectomy
Bordeianou L, Hicks CW, et al. Rectal prolapse: an overview of clini-
for rectal prolapse. J Gastrointest Surg. 2008;12:1446.
cal features, diagnosis, and patient-specific management strategies.
Habr-Gama A, Jacob CE, Perez RO, Proscurshim I. Rectal prolapse:
J Gastrointest Surg. 2014;18(5):1059–69.
perineal approach. In: Fisher JE, editor, Jones DB, Pomposelli
Cirocco WC. The Altemeier procedure for rectal prolapse: an operation
FB, Upchurch GR, Klimberg VS, Schwaitzberg SD, Bland KI,
for all ages. Dis Colon Rectum. 2010;53:1618.
Assoc editors. Fischer’s mastery of surgery, 6th ed. Philadelphia,
Corman ML. Rectal prolapse. (Internal and external), solitary rectal
Lippincott Williams & Wilkins; 2012. pp. 1778–86.
ulcer, descending perineum syndrome, and rectocele. In: Corman
ML, editor, Bergamaschi RCM, Nicholls RJ, Fazio VW, Assoc
editors. Corman’s colon and rectal surgery, 6th ed. Philadelphia,
Lippincott Williams & Wilkins; 2012. pp. 644–97.
Varma M, Rafferty J, et al. Practice parameters for the management of
rectal prolapse. Dis Colon Rectum. 2011;54(11):1339–46.
Operations for Pilonidal Disease
83
Indications • Incomplete wound healing with recurrent disease
Recurrent intermittent or persistent opening with smoldering

infections, pain, swelling, and purulent drainage. After a first Operative Strategy
abscess, there is still a chance that the area will completely
cool off and no further intervention will be required. Under acute conditions, drain any abscess with an adequate
incision and drainage prior to performing any definitive sur-
gical excision. In most cases, minimizing the inflammation
Preoperative Preparation will minimize bleeding complications and reduce extent of
excision. In some cases, patients can solely be treated with a
• Consider differential diagnosis (particularly if patient simple incision, drainage, and curettage of the pilonidal
older than 45): Always perform a digital rectal exam to abscess.
rule out a rare presacral tumor that mimics a pilonidal cyst In elective situations, the goal is to remove the entire sys-
infection. There may also be an overlap between pilonidal tem of embedded hair nests, including the fistulous or sinus
disease and hidradenitis suppurativa. extensions. Missing the most cephalad or most caudad pit is
• Prior to excision, control acute infection (abscess) with a common cause for recurrent disease.
incision and drainage; antibiotics do not replace surgery The excision can either be planned with a wound that is
and are not usually indicated except to temporarily sup- primarily left open, or a wound closure is done. Closure of
press smoldering infectious activity until surgery. the symmetric wound in the midline is an option but by
• Remove a 4-inch-wide strip of hair surrounding the natal nature of the buttock movements prone to unrest. Many clo-
cleft and educate the patient regarding maintenance and sure strategies therefore aim at avoiding the midline wound
grooming. and instead rather flattening the gluteal cleft. This essentially
eccentric closure of the primary defect may be attained
through a variety of tissue transpositions or flaps.
• Inadequate removal of all pilonidal cysts/sinuses Documentation Basics

• Unnecessary radical excision
M. P. Duldulao book for details (see references at the end). In general, it is
Department of Surgery, Division of Colorectal Surgery, Keck important to document:
• Findings and indication
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of • Reasoning for choice of surgical approach
Hope National Medical Center/Comprehensive Cancer Center, • Operative technique—primary closure or
Duarte, CA, USA marsupialization
e-mail: akaiser@COH.org • Flaps and length of wound

https://doi.org/10.1007/978-3-030-81415-1_83
Infiltrate the area with a local anesthetic. If available, use

electrocautery to excise a skin disk over the maximal indura-
tion and get deeper until pus starts to drain from the abscess
cavity. If cautery is not available, you may do a cruciate inci-
sion with the scalpel instead. There is no need to digitize the
cavity as long as the created opening allows for free drain-
age. Place an edge of gauze into the wound; major packing is
not beneficial. The alternative approach of making a small
incision and inserting a small Malecot catheter from the side
has little merit and is not recommended.
Excision of Sinus Pits with Lateral Drainage

Fig. 83.1
In this procedure, only the pits are excised while a lateral
incision is used to excise the hair nests and surrounding
inflammatory system. The goal is to facilitate wound healing
by lateralizing the wound away from the midline.
Position the patient prone. Clip the hair in the operative
field. Prep the natal cleft and inject the region with local
anesthetic. Insert a probe within the pilonidal cyst cavity to
determine its most lateral extent. The probe should be pal-
pable at the lateral extent. Make an incision parallel and lat-
eral to the midline cleft. Open the pilonidal cyst through this
lateral incision (Fig. 83.1) and curette out all granulation tis-
sue and hair. Excise each individual pit with either with an
11-blade scalpel (Fig. 83.1) or with a circular blade (as used
for punch biopsies). Close the small defects with a subcu-
ticular absorbable stitch. If there was no pus in the depth of
the pilonidal system, it is okay to reapproximate the wound
with absorbable stitches. Otherwise, pack the lateral wound
with gauze and instruct the patient regarding open wound
care.
rimarily Wide Open Excision with/Without

P
Marsupialization
The goal of this approach is to remove the entire pilonidal

system and to create a favorable open wound configuration
that can heal by secondary intention. The obvious advantage
Fig. 83.2
is that there are no activity restrictions as wound healing is
not dependent on resting.
Operative Technique Position the patient in the prone jackknife position. It is
usually preferable not to retract the buttocks laterally to pre-
Abscess Drainage Without Excision serve the natural configuration of the cleft. Using a clipper,
remove all hair in the surgical field.
Most incision and drainages can be performed in local anes- Insert a probe within the sinuses and demarcate the com-
thesia in the office or at bedside within the emergency room. municating tracts. Additional pits can be identified with
Position the patient prone or in the left lateral decubitus injection of hydrogen peroxide in one of the communicating
position. Palpate the area of maximal tenderness; fluctuance sinuses. Unroof the sinus tract along the entire length of the
may not always be present even if there is a substantial pilonidal cavity by incising over the midline or by making an
amount of pus. elliptical incision around the pits. Curette the underlying
83 Operations for Pilonidal Disease 631
Fig. 83.3
Fig. 83.4
granulation tissue and remove any hair from the cavity of the
pilonidal cyst (Fig. 83.2). Use electrocautery to control any cleft (Fig. 83.4). Deepen the incision along each side of the
bleeding points for hemostasis. Make sure that the wound in pilonidal sinus. Dissect the specimen away from the under-
the end has a nice shallow configuration. In necessary, mar- lying fat. It is not necessary to expose the sacrococcygeal
supialize the wound by approximating the skin edge to the ligament. Use electrocautery to achieve hemostasis. Only a
underlying fibrous lining at the base of the wound utilizing narrow elliptical wound should be present. Use a probe to
interrupted absorbable sutures (Fig. 83.3). This will flatten help identify any residual sinus tracts and excise them from
the edges of the wound and the natal cleft. Infiltrate the sur- the surrounding tissue. Irrigate the wound with copious
rounding region with local anesthetic and apply a loose amounts of saline. Eliminate dead space by placing subcu-
packing of the wound. taneous interrupted absorbable sutures (Fig. 83.5). The
subcutaneous fat should approximate without tension.
Close the skin with interrupted vertical mattress nylon
Excision with Primary Closure sutures.
Ideally, excision with primary closure is reserved for limited

disease and timed to when the inflammation is the least. Excision with Flap Closure
Position the patient in prone jackknife. Lateral retraction of
the buttocks in this situation is often time a disadvantage and A number of flap designs have been utilized to advance tis-
hence discouraged. Clip a wide region of the natal cleft and sue into the excision area, relief tension, flatten the cleft, lat-
remove the surrounding hair. Prep the natal cleft, perineal eralize, or change the direction of the wound. The most
region, and upper buttocks and back. common ones are Bascom (“cleft lip” repair), Karydakis,
Insert a probe within the sinus pits. Make a narrow ellip- Limberg, other Z-plasties, or VY advancement flaps. They
tical incision encompassing all the pits within the natal are more complex and beyond the focus of this book.
• Hemorrhage: Even if meticulous hemostasis resulted in a

perfectly dry area, some bleeding may occur in the fol-
lowing hours or days; if the wound was primarily closed,
bleeding may herald wound dehiscence. Most bleeding
care can be managed with local pressure or silver nitrate
applications.
• Delayed wound healing and recurrence: Often the result
of incomplete excision, wound dehiscence, or poor
grooming.
Further Reading
Alptekin H, Yilmaz H, Kayis SA, Sahin M. Volume of excised speci-
men and prediction of surgical site infection in pilonidal sinus pro-
cedures (surgical site infection after pilonidal sinus surgery). Surg
Today. 2013:1365–70.
Horwood J, Hanratty D, Chandran P, Billings P. Primary closure or
rhomboid excision and Limberg flap for the management of primary
sacrococcygeal pilonidal disease? A meta-analysis of randomized
controlled trials. Color Dis. 2012;14:143–51.
Johnson EK. Chapter 17. Pilonidal disease and hidradenitis suppurativa.
In: Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow
Fig. 83.5
CB, editors. The ASCRS textbook of colon and rectal surgery.
Springer; 2016. https://doi.org/10.1007/978-3-319-25970-3_17.
Postoperative Care Karakayali F, Karagulle E, Karabulut Z, Oksuz E, Moray G, Haberal
M. Unroofing and marsupialization vs. rhomboid excision and
Limberg flap in pilonidal disease: a prospective, randomized, clini-
• Instruct the patient and caregiver regarding proper groom- cal trial. Dis Colon Rectum. 2009;52:496–502.
ing and wound care. Lorant T, Ribbe I, Mahteme H, Gustafsson UM, Graf W. Sinus exci-
• Open wound care: Instruct the patient to remove the sion and primary closure versus laying open in pilonidal disease: a
prospective randomized trial. Dis Colon Rectum. 2011;54:300–5.
dressing and shower the wound twice daily. Discourage Milone M, Di Minno MN, Musella M, Maietta P, Ambrosino P, Pisapia
tight packing but suggest placing a loose gauze to sepa- A, Slavatore G, Milone F. The role of drainage after excision and pri-
rate the skin edges, followed by an absorbing pad. Keep mary closure of pilonidal sinus: a meta-analysis. Tech Coloproctol.
the hair clipped about 2 inches around the wound. 2013;17:625–30.
Onder A, Girgin S, Kapan M, Toker M, Arikanoglu Z, Palanci Y, Bac
• Closed wound care: In patients who underwent an exci- B. Pilonidal sinus disease: risk factors for postoperative complica-
sion with primary closure or an advanced flap procedure, tions and recurrence. Int Surg. 2012;97:224–9.
observe the wound closely for signs of infection. Restrict Rao MM, Zawislak W, Kennedy R, Gilliland R. A prospective random-
major physical activity for 2–3 weeks. If localized infec- ized study comparing two treatment modalities for chronic pilonidal
sinus with a 5-year follow-up. Int J Color Dis. 2010;25:395–400.
tion appears, open the area of the wound and allow Sevinc B, Karahan O, Okus A, Ay S, Aksoy N, Simsek G. Randomized
drainage. prospective comparison of midline and off-midline closure tech-
niques in pilonidal sinus surgery. Surgery. 2016;159:759–4.
Complications
• Infection: Well controlled with open drainage; local cel-

lulitis can be controlled with topical and/or oral
antibiotics.
Overlapping Sphincteroplasty
84
Fecal incontinence with identified sphincter defect: • Failure to achieve continence

• Lack of durability
• Failed conservative management (optimized stools/hab- • Sphincteroplasty in presence of poor tissue quality
its, physical therapy). (Crohn, radiation, scarring, infection, etc.), tumor, or
• Absence of more promising alternatives (e.g., sacral nerve severely diminished rectal reservoir function
stimulation, etc.). • Surgery too early after the injury or a previous surgery
• Pudendal nerve injury
• Wound healing issues (dehiscence, abscess, fistula forma-
Contraindications tion, etc.)
• Sphincter defect without clinical symptoms

• Incontinence without sphincter defect Operative Strategy
• Incontinence primarily caused by other condition (diar-
rhea, fistula, prolapse, etc.) General Considerations
• Pelvic malignancy
Overlapping sphincteroplasty is a successful treatment for
patients with fecal incontinence secondary to sphincter dis-
Preoperative Preparation ruption or injury. Incontinence may be the result of obstetric,
surgical, or accidental trauma. Cases of incontinence have
• Review the patient’s history, diagnosis, functional aspects, been described after anorectal procedures including hemor-
and appropriate indication for surgery (based on inconti- rhoidectomy, sphincterotomy, fistulotomy and incision, and
nence scores, clinical exam, imaging, and anophysiology drainage of abscess. Sphincter disruption after vaginal deliv-
testing). An endoanal ultrasound is needed to plan the sur- ery remains the most common indication for overlapping
gery and the incision. An anal manometry may be done to sphincter repair and may arise from an episiotomy, pro-
rule out an evacuation disorder and to differentiate if the longed second stage of labor, or the use of forceps. Symptoms
internal anal sphincter damage is excessive. range from involuntary emission of flatus to loss of complete
• Depending on the patient’s age: partial or full colonic bowel movements. Regardless of the degree, incontinence is
evaluation to exclude synchronous pathology. often a distressing and embarrassing sequel to sphincter
• Mechanical bowel preparation versus enemas (surgeon trauma. These symptoms may appear acutely if the sphincter
preference). disruption is large (fourth degree tear) and not adequately
• Antibiotic prophylaxis. repaired or may occur many years after the event.
Evidence of sphincter disruption may be demonstrated on
preoperative imaging using endoanal ultrasound to precisely
M. Dean · M. Zutshi (*) locate the location and size of tears. Sphincteroplasty can
Department of Colorectal Surgery, Digestive Disease & Surgery however correct only the mechanical component responsible
Institute, Cleveland Clinic Foundation, Cleveland, OH, USA for the development of fecal incontinence. The other com-
e-mail: ZUTSHIM@ccf.org

https://doi.org/10.1007/978-3-030-81415-1_84
634 M. Dean and M. Zutshi
plex mechanisms of continence need to be considered and significant improvement in sphincter function. Age should
addressed to determine the suitability of this surgical not be considered a predictor of poor outcome.
technique.
Persistent Incontinence
Timing of the Repair
The use of biofeedback and pelvic floor exercises can help to
Choosing the right time is as important as selecting a particu- avoid deterioration of function over time. Kegel exercises
lar approach. Attempts to repair the sphincter too soon after should be started about 6 weeks after surgery. Electrical stimu-
the original injury or any preceding surgeries are a frequent lation may also be helpful. Many devices are now available to
cause for failure. It is advisable to wait at least 3–6 months improve the functional outcome. These include the Prometheus
and allow for tissue inflammation to subside before planning Morpheus system® which is electrical stimulation and the
any (re-)intervention. Intone® device which is a guided Kegel exercising device.
A repeat overlapping sphincteroplasty may be performed
with good results if the initial reports were encouraging. At
Technical Considerations least 3 months should elapse before further repairs are
attempted. If the outcome is poor in the short term, sacral
The operative technique was first described by Parks and neuromodulation may be advised.
McPartlin in 1971, and later modified by Slade et al.
Historically alternatives to overlapping repair included end-
to-
end approximation and separate internal and external Documentation Basics
repair. Results for end-to-end approximation were poor due
to suture disruption. The overlapping repair addresses this Coding for surgical procedures is complex. Consult the most
issue by increasing the contact surface area for tissue adher- recent edition of the AMA’s Current Procedural Terminology
ence of the scarred muscle ends. book for details (see references at the end). In general, it is
Some controversies remain regarding the technique, important to document:
including the need for diversion, method for closure, and the
long-term durability of repair. • Indication and reasoning for choice of intervention
• Findings: location, tissue quality, sphincter condition
• Approach and type of repair
Measuring the Results
Outcomes of overlapping sphincter repair have been Operative Technique

described in the literature; however, they are difficult to com-
pare due to the varied methods of outcome assessment. No General Setting
one method of measuring quality of life and severity of fecal
incontinence is accepted. Broadly these methods can be The most common setting is to perform an overlapping sphinc-
divided into descriptive measures, severity measures, and teroplasty under general or regional anesthesia and to admit
impact measures. Studies more commonly used the Jorge the patient for 2–3 days. Additional local anesthetic infiltration
and Wexner incontinence score, the Parks fecal incontinence with long-acting agent (with or without epinephrine) allows
classification, or various quality of life assessment tools such for sphincter relaxation and improved hemostasis.
as the Fecal Incontinence Quality of Life Scale (FIQLS).
Overall success rates are quoted up to 70–86% in studies
with shorter follow-up. Many patients will experience Positioning and Setup
decreased fecal continence in the long term, with 10-year fol-
low-up studies describing decreased continence and increasing Place the patient into the position of your preference.
fecal accidents. Despite this, many patients report good rates of Lithotomy is possible and comparably fast. However, con-
satisfaction, possibly because although recurrent incontinence sider the advantages of the prone jackknife position with the
occurred patients were still satisfied compared to their initial buttocks taped aside, which allows you and your team
condition and had learnt to cope with the symptoms. relaxed access and optimized visualization, and reduces
Several studies have assessed outcomes in older age venous congestion in the surgical area.
groups. A successful outcome after sphincteroplasty is Shave all hair in the surgical site and disinfect the skin,
achievable in the older age group and is associated with a the vagina, and the anal canal with betadine.
84 Overlapping Sphincteroplasty 635
sphincter are disrupted, carry out an en-bloc repair. If the

sphincter is very lax, you may plicate the muscles in floor of
the wound with a few interrupted 2-0 Vicryl sutures. Maintain
meticulous hemostasis and periodically irrigate the wound
with an antibiotic solution.
Reconstruction
Grasp the two ends with atraumatic tissue forceps and over-
lap them in a vest over pants method. Use interrupted 2-0
PDS sutures in a vertical mattress fashion (Fig. 84.3). It is
preferable to place and hold the sutures before tying them
down. This allows you to pull up on the sutures to check the
orifice again and ensure proper placement with good tighten-
ing but without excessive narrowing of the sphincter com-
plex. Two to three sutures may be taken depending on the
length of muscle mobilized. Take care when tying the sutures
Fig. 84.1 to avoid excessive tension to prevent muscle necrosis.- If an
overlap is not possible due to tension on the muscle, an end
Incision to end repair may be undertaken using the same sutures and
technique as described above.
The description which follows refers to the most common
situation, in which the disruption is related to obstetrical
trauma and may need to be modified for the individual Wound Closure
anatomic situation. Use a 15 blade to make a transverse cur-
vilinear incision over the perineal body between the rectum Irrigate the wound prior to wound closure. Approximate the
and the introitus of the vagina, parallel to the outer edge of tissues in two layers and make sure to avoid any dead space.
the external sphincter (Fig. 84.1). The incision length is Approximate the skin with absorbable sutures (Fig. 84.4).
based on the extent of the sphincter disruption with a longer You may leave a small opening in the center to allow for
incision for defects of 180 degrees. However, a generous drainage and prevent infection. Alternatively, you may leave
incision is recommended. The incision site may need to be a small Penrose drain in the wound for 24 hours. Consider
modified if the sphincter disruption is not anteriorly located. performing a vaginal packing for 24 hours to help ensure
hemostasis.
Mobilization
Postoperative Care
Using electrocautery and sharp dissection, mobilize the scar
and underlying sphincter complex from the anoderm and • Antibiotics: Limit to the 24-hour prophylaxis.
anal mucosa posteriorly and from the vagina anteriorly, or • Discharge: Admit the patient for 1–3 days, mainly to
surrounding tissues (if the defect is not anterior). Palpation in avoid major activity and for pain control.
the anal canal and vagina is essential to avoid buttonholing. • Fluid management: Restrict fluid administration to mini-
Identify and grab the edges of the disrupted external anal mize risk for urinary retention. If the patient is unable to
sphincter with Babcock clamps (Fig. 84.2). Dissect the mus- void within 6 hours, an indwelling catheter should be
cle, taking care during lateral dissection to preserve the placed, attached to a gravity drainage leg bag and a void-
branches of the pudendal nerve. Continue the mobilization to ing trial attempted in 24 hours.
the proximal edge of the anorectal ring and laterally the peri- • Diet: The patient may resume their regular diet when
rectal fat pads. Keep in mind that adequate mobilization is recovered from anesthesia.
vital to allow a tension-free wrap repair. If the muscle is held • Stool management: Instruct the patient to maintain soft
by scar tissue in the midline, divide this and dissect the mus- bulked stools with use of fiber and stool softeners as
cle. Do not excise the scar tissue from the severed muscle needed. Prescribe supplemental laxatives to be used as
ends, and do not attempt to separate the internal and external needed to avoid constipation.
sphincter muscles. If both the internal and external anal
Retracted
flap
External
anal
sphincter
muscle
Scar tissue
in midline
Fig. 84.2
Fig. 84.3
• Pain management: Consider a multimodal approach to pain Complications

control, whereby oral analgesics are sufficient in most cases.
• Wound care: Recommend warm sitz baths following each • Surgical site infection: Closely monitor the wound in the
bowel movement and routinely once or twice per day if postoperative period for signs of infection or wound
the wound is open; metronidazole cream may be applied breakdown. Patients may complain of offensive dis-
topically. charge, prolonged pain, or persistent poor wound healing.
• Drains: Remove any drains no later than on the fifth post- Minor infections are often treatable with local wound
operative day. care; occasionally topical antibiotic creams (e.g., 0.75%
• Follow-up: Plan for frequent enough visits to examine the metronidazole cream) may be applied; systemic antibiot-
wound in regular intervals. ics are rarely needed.
84 Overlapping Sphincteroplasty 637
• Bleeding/postoperative hematoma: Maintain meticulous

hemostasis; consider use of a drain and/or vaginal pack-
ing to prevent the development of this complication. Treat
a significant hematoma by opening the wound and evacu-
ation of the hematoma.
• Fistula formation: Seepage of stool from the wound or the
vagina represents a significant complication with loss of
integrity of the rectal wall. Analyze the situation to define
the respective individual needs.
Further Reading
Fig. 84.4 El-Gazzaz G, Zutshi M, Hannaway C, Gurland B, Hull T. Overlapping
sphincter repair: does age matter? Dis Colon Rectum.
2012;55(3):256–61.
Glasgow S, Lowry A. Long-term outcomes of anal sphincter repair
• Pelvic sepsis: Symptoms of increasing pain, urinary for fecal incontinence: a systematic review. Dis Colon Rectum.
retention, and fever are concerning red flags. Such patients 2012;55(4):482–90.
should be admitted to hospital and treated with IV fluid, Mevik K, Norderval S, Kileng H, et al. Long term results after
anterior sphincteroplasty for anal incontinence. Scand J Surg.
antibiotics, and Foley catheter; it may be necessary to 2009;98:234–8.
debride the wound, and in worst cases to perform a fecal Oom DM, Gosselink MP, Shouten WR. Anterior sphicteroplasty for
diversion. fecal incontinence: a single center experience in the era of neuro-
• Injury to the pudendal nerve: Avoid extending the dissec- modulation. Dis Colon Rectum. 2009;52:1681–7.
Zutshi M, Hull T, Bast J, Halverson A, Na J. Ten year outcome after
tion to the posterolateral regions, where the pudendal anal sphincter repair for fecal incontinence. Dis Colon Rectum.
nerves are laterally located. 2009;52:1089–94.
Sacral Nerve Stimulation for Fecal
and Urinary Incontinence 85
Indications and anophysiology testing may be available but are not

mandatory as they do not predict success.
Fecal incontinence with or without identified sphincter • Depending on the patient’s age: partial or full colonic
defect: evaluation to exclude synchronous pathology.
• Mechanical bowel preparation: not needed.
• Average of two or more episodes of fecal incontinence • Antibiotic prophylaxis.
per week
• Failed conservative management (optimized stools/hab-
its, physical therapy) Pitfalls and Danger Points
• FI symptoms for at least 6 months
• Interval since vaginal delivery of at least 12 months • Difficulty accessing the sacral foramina.
• Interval since rectal (abdominal) surgery of at least • Abnormal or altered anatomy: Can be avoided by preop-
6 months erative marking and image-guided insertion.
• Failure to achieve continence.
• Loss of efficacy: Battery life 3–6 years; lead migration,
Contraindications fracture or erosion of leads: assuming the settings are oth-
erwise optimized, further investigations include X-rays,
• Local infection reimplantation is possible and may improve symptoms.
• Mechanical outlet obstruction • Electromagnetic interference (rare, preventable by atten-
• Incontinence for diarrheal stool only tion): Exposure to strong electromagnetic interference
• Anatomic abnormalities that preclude electrode (including MRI) could heat the implanted Interstim com-
placement ponents and cause tissue damage or even death.
• Inability to operate the device • Wound healing issues (dehiscence, abscess, fistula forma-
• Predictable need for MRI scans tion, etc.).
• Pregnancy (safety not yet determined)
• Pediatric patients <16 years (safety not yet determined)
Allergy to metals Operative Strategy
General Considerations
Although the device may be implanted for treatment of both
• Review the patient’s history, diagnosis, functional aspects, urinary and fecal incontinence, this chapter deals primarily
and appropriate indication for surgery (based on inconti- with its use for management of fecal incontinence. The
nence scores, bowel diary, and clinical exam). Imaging implantation technique is identical for either indication.
Sacral nerve stimulation (SNS) has been used with suc-
M. Dean · M. Zutshi (*) cess for the treatment of fecal incontinence (FI) in patients
Department of Colorectal Surgery, Digestive Disease & Surgery with sphincter weakness and/or sphincter damage. In the
Institute, Cleveland Clinic Foundation, Cleveland, OH, USA USA, the device InterStim™ (Medtronic) obtained FDA
e-mail: ZUTSHIM@ccf.org

https://doi.org/10.1007/978-3-030-81415-1_85
approval for use in patients with urinary incontinence in to provide fluoroscopy in the PA and lateral position. Pillows
2003 and for bowel incontinence in 2011. A staged proce- should be placed under the chest, hips, and knees and shins.
dure is the accepted and recommended standard practice, This has the effect of flattening the sacrum and allows the
consisting of a test phase (stage 1), followed by implantation toes to dangle freely. Buttocks are taped apart to allow visu-
of the device in responders (stage 2). This technique involves alization of the anal verge. Toes should overhang the table to
the placement of a multipoint electrode under fluoroscopic be visible to the person monitoring the reflex. The skin is
control to the sacral foramen of S3 (occasionally S2). In shaved, prepped, and draped in the usual manner using
stage 1, this electrode is internally connected to a percutane- chlorhexidine preparation solution. This position is identical
ous extension which leads to an external Bluetooth transmit- for both Phase 1 and Phase 2 of the procedure.
ter that is paired to the programmable stimulator device for
peripheral nerve evaluation (PNE). If fecal incontinence
improves over a test phase of 2 weeks, the patients are offered Phase 1
insertion of the permanent internal stimulator device. This
device resembles in size and form a cardiac pacemaker; it Preoperative marking and fluoroscopy are vital to ensure
contains a battery with an expected battery life of 5–8 years. accurate electrode placement. Laterality is not relevant for
If the response in the test period is not satisfactory, the elec- the functional outcome, but some patients may express a
trode and its extension are both removed. preference of position of the neurostimulator to facilitate
The exact mechanism of action is unclear and likely mul- accessing the location for transcutaneous reprogramming or
tifactorial. Fibers from S2-S4 contain autonomic fibers that simply to fit their sleeping habits. After successful electrode
innervate the left colon, rectum, and internal anal sphincter placement, the wire is tunneled to a subcutaneous pocket cre-
(IAS) and somatic fibers from the pudendal nerve that con- ated in the upper buttock area under Scarpa’s fascia to house
tain afferent sensory fibers from the internal anal sphincter at stage 1 the temporary internal connector and after stage 2
and afferent sensory fibers from the external anal sphincter the permanent stimulator. From that pocket, the lead is retun-
and pelvic floor. Activation of the somatic afferent likely nelled to exit on the far opposite side. The wire is connected
enhances IAS and EAS activity via somato-visceral reflexes. to a Bluetooth transmitter that connects to the external stimu-
Patients should receive pre-procedure counseling regard- lator. The external device and the wire are taped to the patient
ing expected outcomes and need for further surgery. The and protected with a padded dressing. Postoperatively, the
majority of patients experience immediate and sustained patient is instructed on the use of the wireless external stimu-
improvement in fecal incontinence and associated quality of lator. Patients are sent home the same day and are asked to
life. After 12 months of follow-up, 83% of patients reported keep a diary documenting their bowel habits.
a greater than 50% reduction in number of fecal incontinence
episodes per week. Furthermore, complete continence was
achieved in 40% of patients. Long-term results after a mini- Phase 2
mum of 5 years follow-up showed a greater than 50%
improvement and complete continence in 89% and 36% of The patient is again positioned in the prone position and the
patients, respectively. Even for patients older than 65 years, previous incision over the pocket in the upper buttock area is
SNS proved to be an effective treatment option. The battery reopened. The connection between lead and extension is
life is in the range of 3–6 years (necessitating an exchange), undone and the percutaneous portion removed underneath
and up to 20% of patients will require a re-operation to the sterile drapings from the opposite side. The end of the
explant the device or for electrode revisions. actual multipoint lead is now inserted and secured into the
neurostimulator. Last, the device is placed in the existing
subcutaneous pocket in a position that avoids pressure
Anesthesia and Positioning against bony landmarks and not superficial.
MAC anesthesia is preferable, although some centers will

perform test stimulation electrode insertion in the office set- Documentation Basics
ting under local anesthesia. Advise the anesthesiologist to
not use any muscle relaxants as the muscle response is essen- Coding for surgical procedures is complex. Consult the most
tial for successful lead placement. recent edition of the AMA’s Current Procedural Terminology
The patient is placed in a prone position on operating bed book for details (see references at the end). In general, it is
with the bed positioned to allow the C-arm to be positioned important to document:
85 Sacral Nerve Stimulation for Fecal and Urinary Incontinence 641

• Preoperative investigations
• Severity of symptoms (bowel diary)
• Signs of correct electrode placement: Bellows sign (con-
traction of levators) and plantar flexion of the big toe
• Site of insertion
• Site of implant
Operative Technique
Phase 1
See Operative Strategy for details of prone positioning for

both phases. Note that the toes must hang free and be visible
to the person responsible for monitoring the response to the Fig. 85.1
stimulation. The buttocks are strapped apart and after prep-
ping covered with a plastic sheet such that the anal reflex
(bellows sign) can be visualized.
Plan Incision
Prior to incision, mark the skin to show the bony landmarks
of the vertebral midline, the sacroiliac notches, and the
medial foramina borders using fluoroscopy guidance
(Fig. 85.1). The S3 foramen is identified by palpation and by
fluoroscopy in the anteroposterior and lateral view. The cor-
rect position in the S3 foramen is confirmed by external
stimulation which elicits a pelvic floor contraction (bellows
response) and plantar flexion of the great toe. S2 placement
will result in plantar flexion of the calf and entire foot with
lateral rotation. S4 placement will result in no lower extrem-
ity response despite a bellows response.
Localizing the Foramina

Position the fluoroscopy C-arm into posteroanterior position
to define the midline of the vertebrae. Mark the sacroiliac
notches and medial foramina. Move the C-arm into the lat-
eral position to image the area of the sacral promontory to
the coccyx (Fig. 85.2).
The 5 cm needle is used to explore the S3 foramina. A
longer 7 cm needle may be used in patients with a high
BMI. The S3 foramina can be located 2 cm above the sac-
roiliac notch and 1 cm lateral to the vertebral midline, feel-
ing for the foraminal margins (Fig. 85.3). The sensation of Fig. 85.2
hitting the bone versus the foramen is apparent. Confirm
the depth of the needle position using fluoroscopy. The
needle tip should be placed such that it is just exiting the can be observed by changes of perineum indicating pelvic
foramen. floor contraction, seen as perineal “lifting” or “bellowing”
and observation of plantar flexion of the great toe at a low
onfirming Needle Position
C voltage of less than 2 mV. The needle is placed at the fora-
Test the needle by touching it with an electrode attached to men and not deep into it to allow the electrode to be in con-
an external stimulator box. A favorable stimulation response tact with the nerve.
Fig. 85.3 Fig. 85.4
I ntroducing Wire, Dilator, and Lead

Remove the needle stylet and insert a directional guide wire
(Fig. 85.4), with position checked using fluoroscopy. Make
an incision on either side of the directional guide wire and
pass a dilator and introducer sheath over the directional
guide wire and direct it into the foramina until the opaque
marker of the dilator is seen on the anterior rim of the
sacrum. Unlock and remove the dilator. Check the position
again using fluoroscopy. Introduce the curved stylet with
the curve pointing laterally under fluoroscopy until three
electrodes are visible below the sacrum and one is at the
foraminal opening (Fig. 85.5). Sequentially, test each of the
four electrodes for visualization of bellows response and
plantar flexion of great toe (and possibly negative patient
sensation). Remove the electrode sheath while carefully
holding the electrode in place so that its position remains
unchanged.
Make a 3–4 cm incision over the area intended for stimu-
lator placement, that is, posterior and inferior to the iliac
crest (as per the preoperative discussion with the patient).
Create a subcutaneous pocket by means of blunt dissection Fig. 85.5
85 Sacral Nerve Stimulation for Fecal and Urinary Incontinence 643
Fig. 85.6 Fig. 85.7
until the Scarpas’s fascia is identified. The pocket should be chlorhexidine and draped such that the wire exit site is
below Scarpa’s fascia. It is important that you achieve excel- underneath the drapes outside the sterile field. Open the
lent hemostasis by means of electrocautery. incision over the previously created pocket. Using blunt
Utilize the provided tunneling tool to pass the leads sub- dissection, identify and elevate connector between the per-
cutaneously into that pocket. Remove the tunneling tool and manent sacral lead and the temporary extension. Cut the
feed any remaining lead to the pocket site. Clean the lead of sutures holding the protective boot and retract it. Use a hex
body fluids and a place a boot over the lead. Insert the lead wrench to loosen the exposed setscrews and remove and
into the temporary extension and align the metal bands. discard the boot. Cut the percutaneous extension and have
Tighten the four setscrews with a hex wench. Push the boot the operating room circulator remove it underneath the
over the connection and use Prolene ties to secure to the boot draping from the field.
on grooves located on either side of the connection to prevent
body fluids from entering the connection (Fig. 85.6). Create onnecting the Lead to the Neurostimulator
C
another tunnel from the pocket to an exit site above the con- Clean the integrated end of the multipoint electrode of all
tralateral buttock. Pass the extension cable through this tun- body fluid and insert it into the socket of the neurostimulator.
nel which is attached to the wireless stimulator. Advance it until the white lead tip is visualized at the distal
window and all the metal portions come to lie within their
respective spot. Again utilizing the hex wrench, tighten the
Wound Closure single set screw (Fig. 85.7).
Place the neurostimulator into the subcutaneous pocket
Irrigate the wound and close it in the manner described below with the etched identification side placed upwards. Check
and use steristrips and gauze to cover the incision, wire, and the impedance to ensure adequate lead placement such that
cable connection. Close the midline needle insertion site the parameters are within the expected limits.
with a single suture. Postoperatively, provide the patient with After implantation of the neurostimulator is completed,
instructions on using this prior to discharge. Advise the programming is performed by the company representative
patient to keep a bowel diary until the return appointment to based on impedance values. Normal impedance levels are
discuss results of the stimulation. greater than 50 and less than 4000.
Phase 2 Wound Closure
emoving the Temporary External Lead

R Irrigate the wound with saline and an antibiotic solution and
Extension close in layers using 2-0 Vicryl subcutaneous suture and 4-0
Place the patient in the prone position, and after MAC, Vicryl subcuticular suture. Cover the wound using steristrips
anesthesia is administered and the area is cleaned with and gauze.
Postoperative Care • Urinary incontinence (8%)

• Diarrhea (8%)
• Antibiotics: Not needed beyond single-dose perioperative • Migration of implant (2.5%)
prophylaxis. • Implant site pain (25%)
• Diet: The patient may resume their regular diet when • Implant site paresthesia (19%)
recovered from anesthesia.
• Stool management: Instruct the patient to resume indi-
vidual routine and to continue the bowel diary for docu-
mentation of efficacy. Further Reading
• Activity: Instruct the patient to avoid physical activities
(including heavy lifting, bending, or stretching) that may American Medical Association. Current procedural terminology: CPT
cause damage to the implant site or dislodge parts of the http://www.ama-assn.org/ama/pub/physician-resources/solutions-
system in the healing period. managing-your-practice/coding-billinginsurance/cpt.page.
• Wound care: Instruct the patient to avoid showering Bielefeldt K. Adverse events of sacral neuromodulation for fecal
between stage 1 and stage 2, and bathing for 3 weeks after incontinence reported to the federal drug administration. World J
Gastrointest Pharmacol Ther. 2016;7(2):294–305.
stage 2. Cracco AJ, Chadi SA, et al. Outcomes of sacral neurostimulation lead
• Follow-up: Instruct the patient to call the office if there is reimplantation for fecal incontinence: a cohort study. Dis Colon
excessive pain, redness, or fever. Plan for routine follow- Rectum. 2016;59(1):48–53.
ups for monitoring of efficacy and program optimization. George AT, Kalmar K, et al. Sacral nerve stimulation in the elderly.
Color Dis. 2012;14(2):200–4.
Gourcerol G, Vitton V, et al. How sacral nerve stimulation works in
patients with faecal incontinence. Color Dis. 2011;13(8):e203–11.
Complications Hull T, Giese C, et al. Long-term durability of sacral nerve stimula-
tion therapy for chronic fecal incontinence. Dis Colon Rectum.
2013;56(2):234–45.
Complications of the procedure are minor. A study reporting Kaiser AM, Orangio GR, et al. Current status: new technologies for
the long-term outcomes of SNS insertion reported the fol- the treatment of patients with fecal incontinence. Surg Endosc.
lowing adverse events: 2014;28(8):2277–301.
Wexner SD, Coller JA, et al. Sacral nerve stimulation for fecal incon-
tinence: results of a 120-patient prospective multicenter study. Ann
• Implant site infection (10%) Surg. 2010;251(3):441–9.
• Change in sensation of stimulation (11%)
Transanal Local Excision of Rectal
Lesions (TEMS, TAMIS, TAE) 86
Christine Hsieh and Andreas M. Kaiser
Indications –– Absent negative features (lympho-vascular invasion,

perineural invasion)
The parameters for transanal local excisions fall into three –– Less than 4 cm in diameter
categories: (1) technical feasibility, (2) pathological appro- –– Less than 40% of the luminal circumference
priateness, and (3) the general condition and life expectancy –– Complete excision with margins >2 mm
of the patient. • Other symptomatic lesions in patients with reduced
General: Technically amenable lesions in reach of the operability
chosen platform. • Nonneoplastic lesions, for example, high rectovaginal or
Good indications: recto-urinary fistula
• Benign rectal polyps Poor indications:

• Small rectal carcinoid
• Benign lesions that are too large or too bulky, or too high
Diagnostic, possibly therapeutic indications: up
• Invasive cancer with negative features (T2, T3, LVI, PNI,
• Lesions with uncertain benign versus malignant too large, too high)
pathology
• Polyp site after endoscopic removal of cancerous polyp The conventional transanal excision (TAE) has significant
with uncertain margin technical limitations, but several different platforms (trans-
• Tumor site after possibly complete response post neoad- anal endoscopic microsurgery, TEMS; transanal minimally
juvant chemoradiation invasive surgery, TAMIS) have evolved to improve visualiza-
tion, instrumentation, and reach.
Individualized indications: Beyond the technical aspects, more essential for favorable
outcomes remain appropriate selection of pathology and the
• Early invasive cancer in selected patients (see comment patient. Ideal candidates for a local excision of rectal lesions
below): are those with benign, premalignant, or at most early stage
–– TIS or T1 lesion (Tis or T1) cancers without high-risk features found on ini-
–– Well differentiated tial endoscopic biopsy. The local approach spares properly
selected patients the more invasive oncological resection
with its potential morbidity and mortality and remains the
treatment of choice for amenable benign lesions of the rec-
C. Hsieh tum. For invasive cancer, however, the risk of local recur-
rence is disproportionally increased for at least two reasons:
Los Angeles, CA, USA (1) potentially affected lymph nodes are left behind; and (2)
cancer cells may implant into the excision wound. Since the
A. M. Kaiser (*)
Department of Surgery, Division of Colorectal Surgery, City of treatment success hinges largely upon not completely reli-
Hope National Medical Center/Comprehensive Cancer Center, able preoperative sampling and staging tools, local excision
Duarte, CA, USA in unclear situations may serve as an excisional biopsy to

https://doi.org/10.1007/978-3-030-81415-1_86
646 C. Hsieh and A. M. Kaiser
allow for definitive assessment of the pathologic nature. • Anterior dissection (mid to high rectum): entry into
Submission of an intact and properly fixated specimen with peritoneal cavity with risk of tumor spillage or peritoni-
limited confounding factors (e.g., cautery artifacts) provides tis/sepsis; if closure of the rectal defect cannot be
the best opportunity for a high-quality assessment of the his- accomplished transanally, a transabdominal closure
tologic features and differentiation, margins, or lympho- may be necessary; if there is a leak, a stoma might be
vascular and perineural invasion. needed.
For patients with significant medical comorbidities, • Defect closure: Too large of a defect, insufficient tissue
advanced disease, or who are otherwise unfit for surgery, laxity for closure of the defect, dehiscence of defect clo-
local excision may provide meaningful symptomatic relief. sure, narrowing of the lumen.
• Implantation of tumor cells into site with local
recurrence.
Contraindications • Stretch injury to the sphincter complex.
• Anorectal stricture
• Not fully accessible or visible lesion Operative Strategy
• Poor matchup of patient selection with pathology
Depth of Excision
Preoperative Preparation Full-thickness excision of any rectal lesion down to the peri-
rectal fat has commonly been advocated. For malignant
• Review the patient’s history, diagnosis, functional aspects, lesions, this approach may be problematic insofar as the full-
and appropriate indication for a local excision (based on thickness excision violates the anatomic planes and therefore
endoscopic, pathological, clinical, or radiographic means) runs the risk of seeding adjacent tissues and effectively
as opposed to an oncological resection. upstaging the tumor. For that reason, we advocate against
• Cross-sectional imaging: Local staging (MRI or endorec- local excision of known malignant lesions except under very
tal ultrasound); rule out systemic disease (computed select circumstances. Instead, we suggest performing a
tomography or PET/CT scan). partial-
thickness dissection which remains limited to the
• Colonoscopy to determine the nature of the pathology mucosa alone or at most shaves part of the muscle layer. This
(benign vs. malignant), assess whether it is amenable to approach is sufficient and curative for a benign lesion, and
endoscopic removal, and to exclude synchronous for an uncertain lesion allows for complete histologic assess-
pathology. ment without burning any bridges in regard to subsequent
• Ascertain the exact location of the pathology in the rec- treatment.
tum by endoscopy and imaging: the level from the anal
verge and dentate line is relevant for the choice of plat-
form; the position on the circumference defines the posi- Choice of the Platform
tioning of the patient.
• Mechanical bowel preparation: A complete cleansing is Several factors should be considered such as tumor location
necessary to assure optimal visibility and elimination of (level from the anal verge, circumferential position), size in
combustive gases. circumferential as well as proximo-distal extent, volume,
• Antibiotic prophylaxis. and relationship to valves of Houston. The best suited plat-
form is the one that allows for best reach and visualization to
assure removal of an intact lesion.
ransanal Excision (TAE)
T
• Under-staging of a lesion. TAE requires no specialized equipment and is typically used
• Inability to adequately visualize the entire lesion. for very distal rectal lesions. A variety of retractors may be
• Inability to place TEM working anoscope or TAMIS used to optimize exposure and facilitate a complete excision.
access port (preexisting stricture, covering part of the The downside of the approach is not only the limited reach
lesion with the device). but also that the exposure is often less than perfect; in order
• Variability of pneumorectum with inconsistent exposure. to compensate, the lesion is exposed to more mechanical
• Anterior dissection (low rectum): Injury to vagina, pros- traction and manipulation which increases the risk of speci-
tate, or membranous urethra. men fragmentation and possibly seeding.
86 Transanal Local Excision of Rectal Lesions (TEMS, TAMIS, TAE) 647
laparoscopic technology. Multiport access systems (e.g.,

GelPOINT Path, Applied Medical, Rancho Santa Margarita,
CA; SILS Port, Covidien, Mansfield, MA) serve to seal the
rectum, establish a pneumorectum, and allow for insertion of
standard laparoscopic equipment. TAMIS does not require
the purchase of an integrated system (as with TEMS) and
offers increased flexibility in patient positioning and setup.
Prerequisite is familiarity with laparoscopic dissection and
suturing to closing rectal wall defects. An advantage is that
the camera can be used more dynamically to adjust the view.
A disadvantage may be that the access port system itself cov-
ers the distal rectum and hence may not be appropriate for
fairly low lesions.
ransanal Total Mesorectal Excision (taTME)

T
The most recent approach is still in evolution and exceeds
the scope of the current edition.
Fig. 86.1
Anesthesia
ransanal Endoscopic Microsurgery (TEMS)

T General anesthesia is recommended for all procedures to
TEMS emerged in 1983 when Gerhard Buess in Germany allow for optimal access and exposure for a safe dissection.
applied laparoscopic minimally invasive technology to the Establishing and maintaining a pneumorectum (TEMS/
transanal route. It requires specific sealed equipment that TAMIS) may result in substantial abdominal distention that
allows for creation of a pneumorectum to provide workspace would not be sufficiently addressed with local or regional
and improved exposure (Fig. 86.1). The equipment consists anesthesia.
of a 4-cm-wide proctoscope that ranges in length from 7.5 to Nonetheless, there is value of supplementing the general
20 cm, has a flat or beveled end, and a faceplate with ports anesthesia with a local anesthesia block to the anus to
for instrument insertion. A magnifying video-optic camera enhance sphincter relaxation for port or retractor insertion,
allows for visualization of low, mid, and upper rectal lesions, as well as for preemptive analgesia.
but it should be noted that the camera position is fixed and
can be varied only in limited fashion by adjustments to the
entire proctoscope. Depending on the system used, the optic Patient Positioning
provides a direct stereoscopic or a video-enhanced image of
the operative field in 2-D or 3-D. Once the proctoscope is Accurate preoperative localization of the lesion is manda-
inserted into the anus, the entire apparatus is secured to the tory, as this affects patient positioning and equipment speci-
operating table with an adjustable mechanical arm. This cre- fications in the operating room.
ates a stable field without the need for an assistant. The dis- TAE offers more flexibility in setup, so long as exposure
section borrows from laparoscopic technology but is carried of the lesion is adequate for operator and assistant, if appli-
out by means of a set of specially designed instruments that cable. The prone jackknife position is often preferred to pro-
are inserted through the ports and allow for dissection and vide surgeon and assistant with comfortable access and
suturing alike. TEMS has a steep learning curve but, once decrease vascular congestion of the field. That mostly holds
mastered, allows safe excision of circumscribed lesions up to true even for posterior lesions which may easily be accessed
15 cm from the anal verge with suture closure of the defect. in that position; some surgeons, however, prefer the
The approach may not work well for very large and bulky lithotomy.
lesions, lesions that involve too much of the circumference, Rigid platforms such as TEMS generally require that the
or lesions that cannot be fully visualized because they extend operator “look down” onto the lesion using an angled scope
past and the upper valve of Houston. which sits within a beveled proctoscope. The patient there-
fore has to lie on the table in the same direction as the lesion
ransanal Minimally Invasive Surgery (TAMIS)
T is located on the circumference. In the case of anterior
TAMIS, first described in 2009, evolved from TEMS lesions, a split-leg table improves ergonomics as it allows the
approaching it with equipment developed for single-incision surgeon to stand directly in line with the equipment.
Occasionally, the surgeon may need to reposition the scope Anal Block
to center the lesion and allow optimal range of motion of the
various instruments used in the dissection. Prep and drape in the usual fashion. Then perform a puden-
TAMIS typically uses a single-incision laparoscopic mul- dal/perianal nerve block with 15–20 cc of local anesthetic to
tiport with an angled laparoscope. This allows for more flex- improve relaxation of the anal sphincter muscles. Inject 5 cc
ibility in positioning the patient and instruments. Some of anesthetic on either side deep into the ischioanal fat (total
surgeons prefer to position all patients in lithotomy position 10 cc) and an additional 10 cc more superficially around the
for ease of set up and ergonomics for both operator and assis- anus.
tant; others may find that anterior lesions are more easily
accessed in the prone position.
Surgical Excision
Documentation Basics Transanal Excision

For a very distal lesion (e.g., right at the dentate line), a hand-
Coding for surgical procedures is complex. Consult the most held retractor may be sufficient. However, placement of a
recent edition of the AMA’s Current Procedural Terminology Lone Star retractor (Cooper Surgical, Inc. Trumbull,
book for details (see references at the end). In general, it is Connecticut, United States) often improves exposure
important to document: (Fig. 86.2). Take the LoneStar ring and place 8 hooks cir-
cumferentially to just distal to the dentate line. Be careful
• Indications for local excision and avoid injuring yourself with the sharp hooks. Sometimes,
• Rationale behind particular surgical technique employed you may still need a hand-held retractor in addition.
• Patient positioning Place a holding suture proximal to the lesion to maintain
• Description of the lesion (size, location on the rectal wall, control to the proximal excision edge even if it should retract.
degree of circumferential involvement, distance from anal Using the cautery tip, mark a dotted line around the target
verge, mobility relative to surrounding structures) lesion to outline a 0.5–1 cm margin. Incise the mucosa at the
• Margin of resection most distal edge of the marked line and dissect down to, but
• Integrity of specimen and depth of resection not through, the muscular layer for a partial-thickness exci-
• Orientation for pathologic examination sion. Visualization of perirectal fat occurs with full-thickness
• Closure of wound (if performed)
Operative Technique
Positioning
Regardless of the approach, define and discuss the planned

position (as discussed above) with the anesthesiologist and
the operating room team. If there are uncertainties, you
may do a quick examination prior to definitive positioning.
Secure the patient in the desired position to the table such
that pressure points are avoided, mechanical aspects of the
support are addressed, and that some table repositioning
can be done safely during the case. Place a urinary catheter
to decompress the bladder and monitor intraoperative urine
output. Consider irrigating the rectum with polyvidone
iodine. Prep and drape the patient making sure to have
access to the table rail to attach the support system.
Monitors for TEMS or TAMIS should be placed such that
surgeon, target, and monitor form one line, that is, over the
patient’s trunk. Fig. 86.2
dissection. Deliberate traction on the holding suture will pro- open even if mesorectal fat was visible. The preference
lapse the lesion into the field for easier dissection. Maintain though is to close it if possible. Remove the TEMS equip-
good hemostasis throughout the procedure. For bigger ment. Before concluding, verify with a rigid or a flexible sig-
lesions, you may find using an advanced energy device moidoscope that the lumen has not been narrowed.
advantageous.
Irrigate the wound bed with dilute povidone-iodine solu- ransanal Minimally Invasive Surgery (TAMIS)
T
tion. Close the defect transversely full-thickness with run- You may use one of two common platforms: GelPOINT Path
ning or interrupted absorbable sutures. Confirm hemostasis (Applied Medical, Rancho Santa Margarita, CA, United
before removing the Lone Star retractor. States) or SILS Port (Covidien, Mansfield, MA). Prepare the
TAMIS device with three working ports arranged in a trian-
ransanal Endoscopic Microsurgery (TEMS)
T gle configuration. Gently dilate the anal canal and insert the
Attach the supporting arm to the rail of the operating table. TAMIS port so that it sits just above the puborectalis mus-
Set up and insert the operating rectoscope/obturator apparatus cles. The working ports should accommodate a 5 mm laparo-
and stabilize its preliminary position. Remove the obturator scope and 2 instruments. Secure the port to the perineal skin
and replace it with the sealing end with the camera and three with sutures. Connect the CO2 insufflation and smoke evac-
working ports. Connect the CO2 and initiate the pneumorec- uation tubing. Commence insufflation with a maximal pres-
tum with a maximal pressure of 12 mm Hg. Insert the camera sure of 15 mmHg.
and optic and optimize the exposure. Ideally, center the The camera position may be adjusted as needed depending
lesion horizontally and vertically place it in the lower half of on the location of the lesion. Angled or 3D scopes provide
monitor image. Finalize and stabilize the instrument arm and excellent visualization. Using a cautery device such as the
attachment (Fig. 86.1). laparoscopic pinpoint cautery, mark a 0.5–1 cm margin around
Accessing the rectum under visual control through the the target lesion. Beginning at the most distal margin, connect
three working ports, use a combination of instruments (nee- the dots and incise the mucosa to perform a partial-thickness
dle tip cautery, suction-irrigator, graspers) to visualize the excision unless specific circumstances demand a full-thick-
target lesion. Mark a dotted line with electrocautery around ness excision. Visualization of perirectal fat indicates a full-
it to outline a 0.5–1 cm margin. Incise the mucosa at the most thickness dissection. Be careful when excising anterior lesions
distal aspect of the marked margin and carry this down to, not to violate the rectovaginal septum or prostate or enter the
but not through, the muscular layer for a partial-thickness peritoneal cavity. Dissipation of pneumorectum should alert
excision. Visualization of the yellow perirectal fat occurs you to a potential perforation. Maintain meticulous hemosta-
with full-thickness dissection which may be necessary under sis throughout this procedure, as frequent instrument
specific circumstances. Be careful when excising anterior exchanges for suctioning alter the pneumorectum, hinder visu-
lesions to not enter the peritoneal cavity or violate the recto- alization, and impede progress. As stated for the TEMS, exten-
vaginal septum or prostate. As you continue the circumferen- sive usage of the electrocautery may cause too much smoke;
tial dissection, avoid traumatizing or fragmenting the lesion advanced energy devices may avoid that and contribute to a
by only holding the included free edge but not the lesion dry surgical field. As you continue the circumferential dissec-
itself. Ensure careful hemostasis at all times. Extensive usage tion of the lesion, avoid traumatizing or fragmenting it by only
of the electrocautery may cause too much smoke; advanced holding the included free edge but not the lesion itself. Ensure
energy devices may avoid that and contribute to a dry surgi- careful hemostasis at all times. Immediately remove the speci-
cal field (Fig. 86.3a–c). Once the entire lesion is completely men and process it as outlined below.
freed up, avoid loss of the specimen. Immediately retrieve it Irrigate wound bed with dilute povidone-iodine solution
by removing the entire sealing port cap with the locked and close the defect as described for the TEMS.
grasper on the tissue. Process it as outlined below.
Irrigate the wound bed with dilute povidone-iodine solu-
tion. Close the defect transversely using absorbable suture Specimen Handling
with full-thickness running or interrupted suture. Start on
one end or from both ends and march toward the other side. For best pathological assessment of the lesion, it is important
This is more easily accomplished using a pre-knotted suture to have an intact specimen that is properly fixated and ori-
and endoscopic suturing device, by placing a suture clip at ented to allow for evaluation of the margins. If the specimen
the end of the suture line, or utilizing a barbed suture such as is simply placed in a formalin jar, the edges will roll in and
V-Loc (Covidien, Minneapolis, MN, United States). Confirm assessment of the margins will become virtually impossible.
hemostasis before removing the instruments. It should be Frozen sections are notoriously inferior than permanent sec-
noted that a fully extraperitoneal excision site could be left tioning and should only be used if an immediate change of
a b
Fig. 86.3
the procedure (e.g., conversion to an abdominal procedure) Postoperative Care

would be contemplated.
Proper specimen management is therefore essential. Once • Antibiotics: Routine coverage for the perioperative
you have completely freed up the target lesion (ideally in a 24-hour period. Extended antibiotics only in special
single piece), retain the grasper on it—knowing which edge circumstances.
you are holding on to. Immediately remove the access device • Local excision is well tolerated by most patients and does
cap and retrieve the specimen. Secure it to a cork/wax board not require inpatient convalescence; overnight observa-
by means of multiple pins to flatten out the edges of lesion. tion is generally sufficient in most cases.
Mark or scratch on the board the proper orientation of the • Intravenous fluids: Limit intravenous fluid until resump-
specimen as left/right or anterior/posterior, as well as proxi- tion of oral intake.
mal and distal margins. Place the pinned down specimen into • Diet: Resume regular diet after post-anesthesia grace
formalin and send it for permanent fixation and processing. period (unless specific intraoperative events demand an
If there is any uncertainty about the margins, it is better not individualized approach).
to send the main specimen for frozen sectioning but to • Bowel management: Advise the patient to maintain soft
re-excise additional margins and send those for immediate stools with typical over-the-counter medications and
evaluation. supplements.
• Caution: There is no need for any routine postoperative • Perforation into peritoneal cavity (immediate or delayed):
imaging. Nonetheless, be aware that if a CT was per- if symptoms are uncertain, err on the side of an early
formed for potentially other specific reasons, air from the reevaluation with contrast imaging, possible endoscopy
pressurized pneumorectum may have spread to far loca- or abdominal exploration with possible stoma creation.
tions including the mediastinum—without having any • Recurrent pathology (cancer, polyp, etc.).
pathological impact. Hence, interpret any such findings
with care and correlate with the clinical impression.
• Pathology follow-up: Check the final pathology and plan
further management accordingly. Especially if the lesion Further Reading
proves to be malignant, plan a multidisciplinary
discussion. In absence of relevant contraindications, an American Medical Association. Current procedural terminology: CPT
oncological resection should be considered after a healing https://www.ama-assn.org/practice-management/cpt.
period of about 6 weeks. If other modalities (chemother- Albert MR, Atallah SB, deBeche-Adams TC. Transanal Minimally
apy, radiation) are planned, define the timing and typi- Invasive Surgery (TAMIS) for local excision of benign neoplasms
cally do not start for about 4 weeks. and early-stage rectal cancer: efficacy and outcomes in the first 50
patients. Dis Colon Rectum. 2013;56:301–7.
• Surveillance: Routine follow-up may include short inter- Devaraj B, Kaiser AM. Impact of technology on indications and limita-
val imaging and endoscopic surveillance. tions for transanal surgical removal of rectal neoplasms. World J
Surg Proced. 2015;5(1):1–13.
Hakiman H, Pendola M, Fleshman JW. Replacing transanal excision
with transanal endoscopic microsurgery and/or transanal minimally
Complications invasive surgery for early rectal cancer. Clin Colon Rectal Surg.
2015;28:38–42.
• Bleeding (including delayed hemorrhage). Kaiser AM. McGraw-Hill Manual Colorectal Surgery. Access Surgery;
• Urinary retention. 2009. Retrieved November 14, 2022, from https://accesssurgery.
• Suture line dehiscence. Moore JS, Cataldo PA, et al. Transanal endoscopic microsurgery is
• Infection (phlegmon, abscess, sepsis, fistulization) more effective than traditional transanal excision for resection of
• Stricture formation, possibly with constipation or even rectal masses. Dis Colon Rectum. 2008;51:1026–31.
fecal impaction. Morino M, Arezzo A, Allaix ME. Transanal endoscopic microsurgery.
Tech Coloproctol. 2013;17(01):S55–61.
• Incontinence (in most cases temporary only). You YN, Roses RE, et al. Multimodality salvage of recurrent dis-
• Collateral damage (e.g., sphincter complex, rectovaginal ease after local excision for rectal cancer. Dis Colon Rectum.
septum, prostate, urethra). 2012;55(12):1213–9.
Part VII
Hepatobiliary Tract
Umut Sarpel
Concepts in Hepatobiliary Surgery
87
Umut Sarpel and H. Leon Pachter
Biliary Surgery pain of cholecystitis is persistent and lasts 1–2 days if

untreated. On physical examination, tenderness will be pres-
Bile and associated products produced in the liver drain ent due to the infection and inflammation of the gallbladder.
through the biliary tree into the duodenum, with the gallblad- A classic Murphy’s sign describes the focal gallbladder ten-
der serving as a storage area off the main trunk. Disorders derness that is elicited when, upon taking a deep breath, the
along this system are common and can usually be handled patient abruptly halts inspiration due to the sudden pain that
uneventfully. However, advanced management of the biliary occurs when the descending gallbladder hits the examiner’s
system requires a clear understanding of the anatomy and hand, which is pressed into the right subcostal margin. Fever
physiology involved in order to have a successful outcome. and mild leukocytosis are typically present, consistent with
infection. Importantly, liver function tests should be entirely
normal, except for in rare cases of Mirizzi syndrome where a
Biliary Colic and Cholecystitis large stone impacted in the gallbladder infundibulum can
compress the adjacent common bile duct (CBD). The treat-
Cholelithiasis is most frequently asymptomatic and is not in ment of cholecystitis consists of antibiotics, bowel rest with
itself an indication for surgery (Muhrbeck and Ahlberg intravenous hydration, pain control, and cholecystectomy.
1995). However, once patients develop symptoms of biliary In the past, delayed cholecystectomy was advocated as
colic or cholecystitis, they should be evaluated for cholecys- safer than cholecystectomy performed during the acute
tectomy since recurrent episodes tend to occur. inflammatory phase. However, a meta-analysis of 12 pro-
In biliary colic, gallstones intermittently obstruct the cys- spective, randomized trials showed that prompt cholecystec-
tic duct, causing pain that lasts 4–6 h and is usually self- tomy does not result in higher rates of CBD injury and
limited. Nausea is often present, and vomiting may occur, actually results in significantly shorter length of stay and
but this is not the dominant symptom. It is important to note lower hospital costs (Johansson et al. 2003; Velasco et al.
that while obstruction of the cystic duct is present, infection 1982). Therefore, unless there are medical contraindications,
is not. Therefore, true abdominal tenderness should be early cholecystectomy should be performed.
absent. Bowel rest, intravenous fluids, and pain control are In evaluating a patient for biliary disorders, ultrasound is
the treatment; cholecystectomy should be performed to pre- the method of choice for visualizing stones in the gallblad-
vent future symptoms. der. A hepatobiliary scintigraphy scan is the most specific
In cholecystitis, the offending gallstone is lodged in the test for cholecystitis, and a patent cystic duct on this study
cystic duct, and stasis of bile within the gallbladder allows virtually rules out acute cholecystitis (Fig. 87.1) (Papi et al.
for bacterial proliferation and infection. These patients will 2004). Although CT scans are widely performed, they are
present with complaints similar to biliary colic; however, the not optimal for evaluating the gallbladder for two reasons.
First, approximately one-third of gallstones are not radi-
opaque and will be missed on CT scans; therefore, the
U. Sarpel (*)
Division of Surgical Oncology, Department of Surgery, Icahn absence of stones on a CT cannot be used to rule out their
School of Medicine at Mount Sinai, New York, NY, USA presence (Barakos et al. 1987). Second, CT scans are often
e-mail: umut.sarpel@mountsinai.org too sensitive for nonspecific findings such as gallbladder
H. L. Pachter wall thickening or pericholecystic fluid, which are not neces-
Department of Surgery, New York University School of Medicine, sarily indicative of acute cholecystitis.
New York, NY, USA

https://doi.org/10.1007/978-3-030-81415-1_87
656 U. Sarpel and H. L. Pachter
Fig. 87.1
Cholecystitis During Pregnancy bidities when the gallbladder cannot be definitively ruled out
as a source of infection, ultrasound-guided percutaneous
Cholecystitis is common during pregnancy and is the sec- placement of cholecystostomy tube is often the safest tempo-
ond most frequent non-gynecologic abdominal complaint rizing treatment (Byrne et al. 2003). This both relieves cho-
after appendicitis (Date et al. 2008). The natural hesitancy lecystitis if present and spares the patient the physiologic
of clinicians to image and treat a pregnant patient can lead insult of surgery if the source of infection lies elsewhere.
to a delay in diagnosis and intervention. This delay can be The exception to this is acalculous cholecystitis or gan-
more harmful to the mother and fetus than the cholecystitis grenous cholecystitis, a condition typically seen in severely
itself. ill patients on vasopressor support. This condition is thought
If possible, patients should be treated with bowel rest and to develop from hypotension and ischemic end-organ injury
intravenous antibiotics so that the pregnancy can be brought and can result in necrosis of the gallbladder (Warren 1992).
to term. However, if cholecystectomy is necessary during Once tissue necrosis has set in, simple cholecystostomy tube
pregnancy, it is ideally performed during the second trimes- placement will not ameliorate the condition; cholecystec-
ter since surgery during the first trimester risks fetal loss and tomy is needed to debride the necrotic infected tissue (Fagan
surgery during the third trimester may induce preterm labor et al. 2003).
(Date et al. 2008).
Cholecystectomy
Cholecystitis in the Hospitalized Patient
The vast majority of cholecystectomies can be performed
The surgeon is often asked to consult on the possibility of laparoscopically. As surgeons have become more facile at
cholecystitis as the source of infection in hospitalized managing difficult cholecystectomies laparoscopically, the
patients with a fever of unknown origin. This suspicion may only absolute indications that remain for conversion to open
be prompted by an investigatory CT scan showing mild gall- cholecystectomy are brisk hemorrhage and an inability to
bladder wall thickening. Many times this finding is nonspe- clarify biliary anatomy. In these cases, prompt conversion to
cific and no cholecystitis is present, as previously noted. If open cholecystectomy should not be considered a technical
feasible, biliary scintigraphy can be used to definitively rule failure, but a demonstration of sound clinical judgment. Any
out the gallbladder as the source of infection; however, the surgeon operating on the biliary tract must be confident with
unwieldy nature of this test makes it difficult to perform in the technique for open cholecystectomy, as described in sub-
severely ill patients. In a septic patient with multiple comor- sequent chapters.
87 Concepts in Hepatobiliary Surgery 657
Intraoperative Cholangiography
The purpose of cholangiography is twofold: first to confirm

the biliary anatomy and second to identify unsuspected
stones in the CBD. During cholecystectomy, some surgeons
use intraoperative cholangiography on a selective basis and
others advocate for its routine use.
Selective users perform cholangiography based on certain
criteria. Preoperative indications for cholangiography
include jaundice or hyperbilirubinemia, history of gallstone
pancreatitis, or the finding of biliary dilatation. If these
indications are not present, and the intraoperative anatomy is
straightforward, no cholangiogram is performed.
However, proponents of routine cholangiography state
that approximately 6% of asymptomatic patients are found
to have incidental CBD stones (Majeed et al. 1999) which
should be removed due to the potentially severe conse-
quences of gallstone pancreatitis or cholangitis. Routine
cholangiography also provides a permanent record of the
state of the common bile duct at the time of surgery. Fig. 87.2
Advocates of selective cholangiography respond that
incidentally discovered stones are typically small and would detailed classification of biliary injuries by Strasberg et al.
pass spontaneously. Furthermore, cholangiography is not (1995) and Bismuth (1982) outlines the varieties of biliary
entirely without risk, including false positives caused by the tree injuries that can occur during cholecystectomy. The sur-
inadvertent introduction of air bubbles within the CBD that geon must always be on the alert for potential CBD injury
are subsequently mistaken for stones. even during apparently straightforward cases. In fact, it is
Regardless of personal preference, there is universal often anecdotally said that CBD injury happens on the easy
agreement that any confusion about the biliary anatomy or cases, when attention tends to wane. As a matter of practice,
concern for an iatrogenic bile duct injury mandates an imme- no structure should be divided until its identity is certain.
diate intraoperative cholangiogram for evaluation. The classic mechanism of injury is failure to recognize
that the structure being dissected is not the cystic duct, but is
in fact the common bile duct. This tends to occur when the
Use of Drains cystic duct has not been thoroughly dissected out or when
excessive traction straightens out the cystic duct/common
The use of closed suction drains is not indicated after routine bile duct junction, as discussed in the following chapters.
cholecystectomy. However, it is wise to leave a drain when Often a dual injury can occur, and surgeons must be aware of
bile leakage is considered possible, such as in cases when this pattern: the common bile duct is mistaken for the cystic
closure of the cystic duct stump is tenuous due to severe duct, and – as a part of the illusion – the right hepatic artery
inflammation. If a bile leak should develop, the use of a drain is mistaken for the cystic artery. Both structures are unknow-
allows for a controlled biliary-cutaneous fistula. This is well ingly clipped and divided. Therefore, in all cases of iatro-
tolerated and provides the luxury of time, since most bile genic bile duct injury, it is important to also investigate the
leaks are from the cystic duct stump and will resolve sponta- patency of the right hepatic artery (Strasberg et al. 1995;
neously or with ERCP-guided sphincterotomy (Massoumi Davidoff et al. 1992).
et al. 2007). In contrast, an undrained bile collection is both If a common bile duct injury is recognized at the time of
very irritating to the peritoneal cavity and can become surgery, it is wise to recruit the assistance of a hepatobiliary
infected, requiring emergent imaging-guided percutaneous surgeon to aid in the reconstruction. Even if the original
drainage. operating surgeon is skilled in biliary repair, the emotional
toll of having caused an iatrogenic injury clouds judgment,
and therefore assistance should be sought. A limited, non-
Iatrogenic Biliary Injury thermal, sharp injury to the common bile duct detected at the
time of surgery may be repaired over a T-tube; however, most
The most feared complication of cholecystectomy is that of laparoscopic bile duct injuries result in complete discontinu-
iatrogenic injury to the common bile duct (Fig. 87.2). A ity of the biliary tree and will require a Roux-en-Y hepatico-
jejunostomy. Cautery and crush injuries should absolutely common bile duct; however, the stricture may recur over
not be repaired primarily since the area of tissue damage time. Elective Roux-en-Y hepaticojejunostomy may ulti-
always extends beyond what is immediately apparent. mately be necessary for long-term relief.
Most instances of injury to the biliary tree are not recog-
nized at the time of surgery (Lillemoe et al. 1997).
Postoperative manifestations may be that of a bile leak, bili- Choledocholithiasis and Cholangitis
ary obstruction, or both – depending on the nature of the
injury. Any patient who develops abdominal pain, fever, or Choledocholithiasis refers to the presence of stones in the
jaundice following cholecystectomy has a biliary injury until common bile duct. In the majority of cases, these stones
proven otherwise. The most important initial steps in manag- originate from the gallbladder. Most small stones will pass
ing these patients are to determine the exact anatomy of the uneventfully through the ampulla of Vater into the duode-
injury and to ascertain whether any bile leak is controlled or num; however, they can also cause serious illness such as
not. Imaging is the first step in the evaluation of these gallstone pancreatitis or cholangitis. These can be life-
patients. A CT scan of the abdomen may reveal the presence threatening, and in order to prevent them, even asymptom-
of intrahepatic biliary dilatation and/or a fluid collection in atic incidentally discovered CBD stones should be removed.
the liver bed. If a biloma is detected, it should be drained Cholangitis occurs when a stone becomes lodged at the
percutaneously by interventional radiology, and a closed ampulla and the obstructed column of upstream bile becomes
suction drain should be left at the site. If the bilious output infected. The presentation of cholangitis is described by
fails to resolve promptly, this should be investigated by Charcot’s Triad: fever, jaundice, and right upper quadrant
endoscopic cholangiography. pain. Because the liver is a highly vascular organ, infection
If a CBD injury is ultimately diagnosed, reconstruction of the biliary tree rapidly leads to bacteremia. Reynaud’s
with a Roux-en-Y hepaticojejunostomy is necessary to Pentad – the addition of hypotension and mental status
restore biliary-enteric continuity. Over 90% of these patients changes – heralds the onset of sepsis.
will do well, but some may suffer from anastomotic stricture Laboratory values will demonstrate leukocytosis and a
and bouts of cholangitis over their lifetime (Lillemoe et al. direct hyperbilirubinemia, often accompanied by mildly ele-
2000). The timing of repair is an important consideration. If vated transaminases. Ultrasonography will typically reveal
the leak or obstruction is diagnosed expeditiously and the intrahepatic biliary dilatation due to downstream obstruc-
patient is stable, it is best to proceed with Roux-en-Y hepati- tion. However, it is important to point out that it can take
cojejunostomy promptly. However, if the diagnosis has been 24–48 h for appreciable biliary dilatation to develop.
delayed and a prolonged or uncontrolled bile leak has been Therefore, the absence of biliary dilatation on initial imaging
present, the patient may be quite ill. Bile peritonitis creates a studies does not rule out obstructive cholangitis. If uncer-
hostile abdomen which can cause bowel edema and compli- tainty exists, an MRI/MRCP can identify the presence and
cate Roux-en-Y hepaticojejunostomy. In these cases, it may location of stones. However, if the clinical suspicion for
be optimal to temporize the patient with a stent and drain(s) cholangitis is high, it is best to proceed directly to ERCP,
to allow the inflammation to resolve before proceeding with which can both diagnose and treat the condition.
definitive repair. In cases of iatrogenic ligation of the CBD,
without a leak, some surgeons advocate delayed repair to
allow the CBD remnant to dilate, which allows for a larger Ductal Drainage Procedures
anastomosis. However, this approach obligates the presence
of a transhepatic biliary drainage catheter for weeks and is Antibiotic administration for cholangitis is necessary but not
not ideal. sufficient for its treatment. It is critical to underscore that the
The development of a biliary stricture following chole- urgently needed treatment for cholangitis is decompression
cystectomy is usually the result of iatrogenic injury to the (Kinney 2007). This is especially true once suppurative chol-
common bile duct. This may be the result of direct compres- angitis has developed, where the mortality is 100% if the
sion of the bile duct by a surgical clip that was placed too CBD is not drained. Similar to lancing an abscess, drainage
close to the CBD. Another common mechanism of injury is absolutely necessary – antibiotics alone are insufficient to
results from aggressive dissection near the junction of the treat the infection.
cystic duct with the CBD; this skeletonization of the duct can Drainage of the common bile duct can be accomplished
lead to a delayed ischemic stricture which presents as pro- by one of four approaches: (Muhrbeck and Ahlberg 1995)
gressive jaundice weeks after cholecystectomy. Similarly, endoscopic, (Johansson et al. 2003) transhepatic, (Velasco
the use of cautery too close to the CBD can result in a ther- et al. 1982) laparoscopic, and (Papi et al. 2004) open CBD
mal injury with delayed stricturing. ERCP with balloon dila- exploration. In general, the endoscopic approach is the first
tion and stenting can be attempted for strictures of the choice since it is the least invasive. However, if a qualified
gastroenterologist is not promptly available, there should be Gallbladder Carcinoma

no hesitation to pursue percutaneous transhepatic drainage.
Similarly, if interventional radiology is not available, then The discovery of early-stage gallbladder carcinomas has
the surgeon must pursue operative options without delay. become increasingly common due to the rise in the number
This approach is described in subsequent chapters. of cholecystectomies performed in the era of laparoscopic
surgery. Patients with incidentally discovered gallbladder
cancer typically have early-stage disease and may have a
T-Tube Management favorable long-term prognosis. However, patients who pres-
ent with symptomatic gallbladder cancer almost always have
Following CBD exploration, a T-tube should be placed to advanced disease with nodal metastases.
allow access to and provide drainage of the common bile Patients with the finding of T1a disease following chole-
duct. Even though the obstructing stone was removed at cystectomy can be observed without further intervention.
CBD exploration, operative instrumentation of the ampulla Patients with T1b or greater disease should undergo extended
results in edema that can cause transient obstruction and cholecystectomy, which includes a resection of the liver bed
increased pressure in the biliary system. A T-tube allows the and complete hepatoduodenal lymphadenectomy. If the cys-
surgeon to decompress the system, thus preventing the bile tic duct margin was positive for malignancy, a resection of
leak that might have occurred if the duct had been closed the bile duct should also be performed (Miller and Jarnagin
primarily. 2008). Patients whose preoperative imaging demonstrates
Initially, a T-tube should be placed to straight drainage to distant metastases or malignant adenopathy outside the
allow for decompression. However, once the period of acute region of lymphadenectomy are not helped by surgical
inflammation has passed, the T-tube should be capped, which resection.
frees the patient of the biliary drainage bag and allows for the
return of normal bile-aided absorption of GI contents.
Bilirubin levels should be checked 24 h after capping to Cholangiocarcinoma
ensure that bile flow out the ampulla is not obstructed.
Prior to removal of a T-tube, it is advisable to obtain a Malignancy of the extrahepatic bile ducts typically presents
cholangiogram. This confirms that the biliary system is pat- with jaundice. Subsequent imaging reveals the presence of
ent and intact, and that there are no remaining stones present. biliary dilatation up to the point of malignant involvement.
If necessary, interventional radiologists can use the T-tube to Unfortunately, most patients will already have intrahepatic
access the common bile duct to remove any residual stones. metastases or distant lymphadenopathy on presentation.
When a catheter that is 14 French in size is used, stones up to However, a small percentage of patients can be cured with
5 mm can be removed via the T-tube (Blumgart 2006). surgical resection. The common bile duct is resected in con-
In general, T-tubes should not be removed prior to about junction with either a liver resection or a pancreaticoduode-
6 weeks. This is due to the fact that removal of the tube nectomy, depending on whether the tumor is located
leaves behind an open hole in the CBD. The only reason that proximally or distally in the biliary tree. Perineural invasion
this does not lead to bile peritonitis is that a fibrous tract has and lymphovascular invasion are typical of cholangiocarci-
developed around the path of the T-tube, excluding it from noma and, therefore, isolated CBD resections are usually too
the peritoneal cavity. Removing the tube before this tract has limited to accomplish tumor clearance. A complete portal
had a chance to become established increases the risk of a lymphadenectomy is also performed as part of the
free bile leak. procedure.
Even when removed at the appropriate time, some patients In advanced stages, palliative biliary drainage should be
will nonetheless develop sudden, severe abdominal pain, performed to relieve the symptoms of obstruction. Although
indicating a bile leak. These patients should be admitted, ERCP can be attempted, in most patients with advanced
made NPO with intravenous fluids, and provided pain medi- extrahepatic cholangiocarcinoma, the right and left biliary
cation. Thankfully, most of these leaks are mild and self- systems become isolated from each other due to tumor infil-
limited, with resolution of pain within hours. Persistent pain tration of the bifurcation, making the endoscopic approach
should be treated the same as de novo bile leaks, with prompt ineffective. Ultimately, these patients often require bilateral
IR drainage and ERCP with stent placement. transhepatic drains for relief.
Hepatic Surgery Ablative procedures can also be curative for small lesions
(<3 cm in size) but is operator dependent and should be per-
Liver resection has become increasingly common due to the formed by centers with experience. Radioembolization and
rising incidence of hepatocellular carcinoma as well the chemoembolization are additional locoregional therapies
improvements in survival achieved with hepatic metastasec- that can slow the progression of the tumor but are rarely
tomy of colorectal tumors. These indications, coupled with curative (Bruix et al. 2011).
the improved safety of hepatic surgery, have expanded the In patients with HCC secondary to underlying hepatitis B
pool of patients undergoing liver resection. infection, it is important to measure the viral load and initiate
antiviral treatment as indicated. Not only has this been
proven to reduce recurrence of HCC following resection
Hepatocellular Carcinoma (Kubo et al. 2007), but studies demonstrate that regeneration
of the liver remnant is improved if the viral load is kept low
Hepatocellular carcinoma (HCC) is the fifth most common in the postoperative period (Li et al. 2010).
cancer in the world and is one of the few cancers in the
United States whose incidence continues to rise (Jemal et al.
2005; El Serag et al. 2001). HCC usually occurs due to the Colorectal Liver Metastases
presence of an underlying liver disease – although advanced
age may be a risk factor in itself. Cirrhosis due to alcohol Resection of hepatic metastases has become increasingly
abuse, hepatitis C infection, or nonalcoholic steatohepatitis common as modern chemotherapeutic regimens have
represents the most common etiology for HCC in the United allowed for improved long-term survival of patients with
States and Europe. Notably, chronic hepatitis B infection can colorectal cancer. Liver metastases usually appear as simple,
cause HCC even in the absence of cirrhosis, and this virus is round, nonenhancing lesions, although long-standing or
the most common cause of HCC development in Asia and in treated lesions can show areas of necrosis or calcification
sub-Saharan Africa. No biopsy is indicated in the evaluation (Fig. 87.4).
of HCC since the diagnosis can be definitively made by the The key to successful metastasectomy is proper patient
radiologic criteria of arterial enhancement and venous wash- selection. The patients who will benefit the most from
out (Fig. 87.3) (Bruix et al. 2011). hepatic resection are those with metachronous disease, a
The best curative therapies for HCC are hepatic resection node-negative primary tumor, a single metastatic lesion,
or liver transplantation and should therefore be the first and low carcinoembryonic antigen levels, which are sur-
choice. In general, transplantation is preferred for patients rogate markers of indolent tumor biology (Fong et al.
with multifocal disease or underlying cirrhosis. Resection is 1999).
preferred in patients with a single-lesion and well-preserved When a patient presents with resectable liver metastases,
liver function, since it avoids the morbidity of transplanta- a limited course of neoadjuvant chemotherapy prior to sur-
tion and the need for lifelong immunosuppression (Bruix gery may be considered. This approach serves two purposes.
et al. 2011). First, it allows a period of time for the tumor to declare its
Fig. 87.3
Fig. 87.4
Fig. 87.5
biology; if the lesion continues to grow on treatment, or
other lesions develop, this suggests that the patient would not fluid boluses or those needing repeated blood transfusions to
benefit from metastasectomy and should remain on systemic maintain hematocrit levels should also be explored.
treatment. Second, in cases where there is a postoperative At laparotomy, most hemorrhage can be controlled by
complication of hepatectomy, providing chemotherapy perihepatic packing (Pachter and Feliciano 1996). To pro-
upfront ensures that the patient has seen some systemic vide sufficient compression, this maneuver requires the
treatment. placement of laparotomy pads lateral, anterior, and superior
The parenchymal transection itself tends to be more to the liver. The Pringle maneuver can be applied by place-
straightforward for colorectal metastases, since – unlike ment of an atraumatic vascular clamp across the porta hepa-
HCC – patients with metastases tend to have noncirrhotic tis. This provides the surgeon the ability to visualize and
livers. Ablative procedures can also be used as an alternative repair the site of injury. Liver resection is only indicated in
or to supplement resection. Following metastasectomy, patients with shattered or devascularized hepatic lobes.
patients should be closely followed with imaging surveil- Retrohepatic injuries to the inferior vena cava are fre-
lance. If recurrences develop, repeat interventions can be quently fatal even with prompt exploration since the mobili-
considered. zation of the liver required to access this portion of the cava
is time consuming. Attempts to mobilize the liver may exac-
erbate bleeding by decompressing the pericaval space that
Hepatic Trauma was serving to partially tamponade the bleeding. For this rea-
son, these injuries are often best controlled by packing and
The liver is the largest intra-abdominal organ and the most resuscitation. The abdomen can be closed with laparotomy
frequently injured by trauma. Fortunately, the liver is also pads in place using a temporary vacuum dressing allowing
very resilient, and as a result, most hepatic trauma can be for stabilization in an intensive care unit.
managed nonoperatively provided that the patient is hemo-
dynamically stable. Minor bile leaks after nonoperative man-
agement are not unusual, but these can be effectively Concepts in Liver Resection
managed by percutaneous drainage.
The focused assessment by ultrasound for trauma (FAST) The choice of an anatomic resection versus a nonanatomic
is frequently the first diagnostic tool used in the emergency (or wedge) resection depends on both the tumor type and the
room. However, the presence of free fluid on FAST is not in patient’s underlying liver reserve. In general, it is wise to
itself an indication for laparotomy, since as mentioned, preserve liver parenchyma when feasible – particularly in
minor injuries are self-limited. Stable patients should pro- patients with borderline liver function. However, some data
ceed to CT imaging with intravenous contrast, which is the suggest that for primary liver cancer, an anatomic resection
best modality to visualize the extent of liver injury. of the functional liver unit provides improved survival
For more serious hepatic injuries (Fig. 87.5), the decision (Wakai et al. 2007). This concept does not hold for meta-
to operate is guided by the clinical picture. Tachycardic or static colorectal lesions which arrived by hematogenous dis-
hypotensive patients, or those with clear peritonitis mandate semination and are not based within a functional hepatic unit
prompt exploration. Patients with a transient response to (Sarpel et al. 2009).
Determining Resectability have proven consistently useful or superior. These methods

include direct measurement of portal pressures, the use of
In determining resectability, strict rules as to the number and indocyanine green clearance, and the calculation of liver
location of hepatic lesions have not proven to be useful in remnant volume by imaging (Schulick 2006). Certain
guiding decision-making. In certain cases, the resection of patients with borderline liver function can be optimized by
massive or multifocal tumors is easily accomplished, while portal vein embolization to induce hypertrophy of the future
in other settings, even small tumors can prove to be liver remnant (Abulkhir et al. 2008).
unresectable.
In general, the determination of whether a liver lesion is
resectable can be guided by ascertaining “inflow, outflow, Hemostasis
and parenchyma.” In other words, if the proposed hepatec-
tomy were to be performed, the surgeon should consider Mortality following liver resection should be rare, with rates
whether there will remain blood inflow to the remnant liver, of 1–3% at high-volume centers (Torzilli et al. 1999). The
venous outflow from the remnant, and sufficient hepatic major intraoperative risk of hepatectomy is that of massive
parenchyma to support liver function. Inflow may be the hemorrhage. Intimate knowledge of the intrahepatic vascula-
concern when, for example, a cholangiocarcinoma encases ture – specifically the hepatic veins – is necessary to plan
the bifurcation of the hepatic artery or portal vein. lines of transection and to prevent inadvertent injury. Control
Occasionally, outflow makes a tumor unresectable, as in the of hepatic inflow by clamping the hepatoduodenal ligament,
case of a large hepatocellular carcinoma that involves the known as the Pringle maneuver, is useful to limit bleeding
confluence of the hepatic veins and the vena cava. Most fre- during transection. The Pringle maneuver can be applied
quently, however, the limiting factor is the parenchyma. safely for 15 min in cirrhotics and indefinitely in noncirrhot-
In a noncirrhotic patient with normal liver function, ics allowing for periods of intermittent reperfusion (Sakamoto
approximately 80% of the liver can be resected without con- et al. 1999).
cern for liver failure. A hepatic trisegmentectomy for multi- In addition, hepatic resection should be performed under
focal colorectal liver metastases is an example of this type of low central venous pressure (e.g., CVP of 1–5 mmHg).
massive resection of parenchyma that can be performed with While this may at first seem counterintuitive, maintenance of
low morbidity and mortality in experienced hands. However, low intravascular volume leads to lower blood loss during
this amount of tissue loss would not be tolerated in a cir- hepatic transection (Wang et al. 2006). This is due to the fact
rhotic patient where even a limited wedge resection can lead that although the surgeon can control hepatic inflow using
to fatal postoperative liver failure. the Pringle maneuver, back bleeding of the inferior vena
The determination of precisely how much parenchymal cava through the hepatic venous branches still occurs. This
loss will be tolerated is a matter of experience. The Child- bleeding is exacerbated when aggressive infusion of intrave-
Turcotte-Pugh score is a useful starting point, since liver nous fluids leads to a full vena cava. Maintenance of low
resection is uniformly morbid in Child C cirrhotics, and intravascular volume requires good communication between
only the most limited resections are tolerated in select Child the surgical and anesthesia teams; objective measurement of
B patients. However, the Child A designation is a large central venous pressure with a central line is not mandatory
umbrella term and contains too wide of a group of patients but may be useful.
to be sufficiently sensitive to guide resection (Poon and Fan There are several acceptable techniques for performing
2005). transection of the liver parenchyma, based on surgeon pref-
In these patients, certain laboratory values can be used as erence. Following transection, localized bleeding from tran-
surrogate markers of the presence of cirrhosis and can help sected vessels should be ligated with gentle figure-of-eight
guide decision-making. A validated rule of thumb is that sutures. Generalized oozing from the cut surface of the liver
patients with a platelet count of <100 × 109/L will not toler- is usually self-limited and responds to pressure and patience.
ate liver resection (Poon et al. 2004). Significant hepatic Argon beam cautery and thrombin-soaked foam sponges can
fibrosis leads to portal hypertension; the back pressure into be useful adjuncts, but cannot be relied upon to remedy sur-
the splanchnic circulation leads to splenomegaly, which in gical bleeding.
turn causes platelet sequestration. Through this mechanism,
thrombocytopenia serves as a surrogate marker for hepatic
fibrosis. The presence of esophageal varices is an alternate Use of Drains
marker of portal hypertension resulting from the same patho-
physiologic process. The use of drains following liver resection is at the discretion
More sophisticated methods of quantifying the function of the operating surgeon. Although published reports in the
of the future liver remnant have been investigated, but none literature have not demonstrated a benefit to routine drainage
(Gurusamy et al. 2007), bile leaks from the cut surface are Byrne MF, Suhocki P, Mitchell RM, et al. Percutaneous cholecystos-
not uncommon following major liver resection, and many tomy in patients with acute cholecystitis: experience of 45 patients
at a US referral center. J Am Coll Surg. 2003;197:206–11.
hepatic surgeons advocate the routine use of contained self- Date RS, Kaushal M, Ramesh A. A review of the management of
suction drains to prevent biloma formation. In addition, gallstone disease and its complications in pregnancy. Am J Surg.
patients with borderline liver function often develop ascites 2008;196(4):599–608.
in the postoperative period. The use of a drain in these Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson RD, Baker
ME, Newman GE, Cotton PB, Meyers WC. Mechanisms of major
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dehiscence. hepatocellular carcinoma between 1977 and 1996 in the United
States. Hepatology. 2001;33:62–5.
Fagan SP, Awad SS, Rahwan K, Hira K, Aoki N, Itani KM, Berger
DH. Prognostic factors for the development of gangrenous chole-
Postoperative Management cystitis. Am J Surg. 2003;186:481–5.
Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score
for predicting recurrence after hepatic resection for metastatic
The major complication of hepatectomy in the postoperative colorectal cancer: analysis of 1001 consecutive cases. Ann Surg.
period is liver failure. All patients will demonstrate a transa- 1999;230(3):309–18. discussion 318–21
minitis following hepatectomy, but the levels of these Gurusamy KS, Samraj K, Davidson BR. Routine abdominal drainage
enzymes should begin to normalize promptly. Patients with for uncomplicated liver resection. Cochrane Database Syst Rev.
2007;18:CD006232.
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In borderline patients, the postoperative maintenance of Clin N Am. 2007;17(2):289–306.
low intravascular volume is once again a key point. Kubo S, Tanaka H, Takemura S, Yamamoto S, Hai S, et al. Effects of
Overburdening the remnant liver with high volumes is lamivudine on outcome after liver resection for hepatocellular carci-
noma in patients with active replication of hepatitis B virus. Hepatol
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cirrhotics, many hepatic surgeons allow relatively low urine Li N, Lai EC, Shi J, Guo WX, Xue J, et al. A comparative study of
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completely replace the resected volume. This process begins ment. Ann Surg. 1997;225:459–68.
Lillemoe KD, Melton GB, Cameron JL, Pitt HA, Campbell KA,
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Open Cholecystectomy
88
Shanel B. Bhagwandin and Umut Sarpel
Symptomatic cholelithiasis, when laparoscopic cholecystec- • Informed consent of risks/benefits/indications

tomy is not feasible: • Diagnostic confirmation of gallbladder disease
• Preoperative ERCP for patients with choledocholithiasis
• Acute cholecystitis, both calculous and acalculous
• Gallbladder colic
• Choledocholithiasis Pitfalls and Danger Points
• Gallstone pancreatitis
–– Gallbladder polyps • Injury to common bile duct
–– Trauma • Hemorrhage from cystic artery, hepatic artery, or from
–– Incidental removal during laparotomy for another liver parenchyma
indication • Injury to duodenum or colon
Failed laparoscopic cholecystectomy (“conversion”):

Operative Strategy
• Unclear anatomy
• Hemorrhage Anomalies of the Extrahepatic Bile Ducts
• Previous right upper quadrant surgery with extensive
adhesions Anomalies, major and minor, of the extrahepatic bile ducts
are quite common. A surgeon who is not aware of the varia-
tional anatomy of these ducts is much more likely to injure
Relative Contraindications them during biliary surgery.
Important cystic duct anomalies (Fig. 88.1a) include a
• Pregnancy (first/third trimester) short cystic duct (Fig. 88.1b), a low insertion of the cystic
• Inability to tolerate general anesthesia (cardiopulmonary duct (Fig. 88.1c, d), a high insertion of the cystic duct in the
disease or hemodynamic instability) right hepatic duct (Fig. 88.1e), and a cystic duct that enters
• Cirrhosis/portal hypertension the left side of the CBD (Fig. 88.1f).
Another common anomaly is a low-inserting right poste-
rior hepatic duct that may insert into the common hepatic
duct (Fig. 88.2a), or the cystic duct (Fig. 88.2b), or the com-
mon bile duct (CBD) (Fig. 88.2c). Division of this segmental
duct without ligation may result in a postoperative bile fistula
S. B. Bhagwandin
Department of Surgery, Division of Surgical Oncology, Jupiter that drains as much as 500 ml of bile per day. Ligation, rather
Medical Center Physician, Group, Jupiter, FL, USA than preservation, is the appropriate management if a small
U. Sarpel (*) segmental duct is injured (≤3 mm).
Division of Surgical Oncology, Department of Surgery, Icahn Another extremely important anomaly of which the sur-
School of Medicine at Mount Sinai, New York, NY, USA geon should be aware is the presence of a short cystic duct
e-mail: umut.sarpel@mountsinai.org

https://doi.org/10.1007/978-3-030-81415-1_88
666 S. B. Bhagwandin and U. Sarpel
a b
c d
Fig. 88.1
88 Open Cholecystectomy 667
e f
Fig. 88.1 (continued)
that inserts onto the right hepatic duct (Fig. 88.3). In this cystic duct. It is important to remember that the diameter of
case, dividing and ligating the cystic duct at its apparent the normal CBD may vary from 2 to 10 mm. It is easy to
point of origin early in the operation results in occlusion of clamp, divide, and ligate a small CBD under the erroneous
the right hepatic duct. With careful dissection and high liga- impression that it is the cystic duct. The surgeon who makes
tion of the cystic duct at the level of the gallbladder, this this mistake will also end up dividing the common hepatic
accident can be avoided. duct before the gallbladder is freed from all its attachments.
Rarely, an anomalous bile duct enters the gallbladder This leaves a 2- to 4-cm segment of common and hepatic
directly from the liver bed, for example, a Duct of Luschka. duct attached to the specimen (Fig. 88.4). The dome-down
Such ducts should be suture ligated or clipped to avoid postop- approach often used in open cholecystectomy minimizes the
erative bile drainage. However, upon encountering such a chance of biliary injury because division of the cystic duct is
structure, the surgeon should first and foremost reassess the the last step in the procedure. When the back wall of the
anatomy. It is far more common to have normal anatomy with gallbladder is being dissected away from the liver, it is
a disoriented surgeon, than to have a rare anatomic variant. important carefully to dissect out each structure that may
enter the gallbladder from the liver. As previously alluded to,
the low insertion of a right sectoral hepatic duct into the
Avoiding Injury to the Bile Ducts common hepatic duct (Fig. 88.5) or the cystic duct increases
the risk of inadvertent injury. Any structure that resembles a
Most serious injuries of the bile ducts are not caused by con- bile duct must be carefully delineated by sharp dissection. In
genital anomalies or unusually severe pathologic changes. In no case should the surgeon apply a hemostat to a large wad
most cases, iatrogenic trauma results because the surgeon of tissue running from the liver to the gallbladder, as it may
who mistakenly ligates and divides the CBD believes it is the contain important structures.
a b
Fig. 88.2
Fig. 88.3 Fig. 88.4
Inadvertent Ligation of the Hepatic Artery Avoiding Hemorrhage
Misidentification of the cystic duct is commonly associated In most cases, hemorrhage during the course of cholecystec-
with misidentification of the cystic artery, with resultant liga- tomy is due to inadvertent injury to the cystic artery. If the
tion of the right hepatic artery. Thus, there is often a paired bleeding artery is not distinctly visible, do not apply any
injury. Careful dissection prevents injury or inadvertent liga- hemostats. Rather, perform a Pringle maneuver by grasping
ture of the right hepatic artery. However, if this vessel should the hepatoduodenal ligament between the index finger and
be ligated accidentally, this complication is not ordinarily thumb of the left hand. This measure compresses the com-
fatal because hepatic viability can usually be maintained by mon hepatic artery and should temporarily stop the bleeding.
the remaining portal venous flow. This is true only if the After adequate exposure has been achieved, it is generally
patient has normal hepatic function and there has been no possible to identify the bleeding vessel, which is then suture
jaundice, hemorrhage, shock, trauma, or sepsis. Although ligated. Occasionally, the cystic artery is torn off flush with
hepatic artery ligation generally has a low mortality rate, it is the right hepatic artery. If so, the defect in the right hepatic
not zero. Consequently, if there is intraoperative recognition artery must be closed with a vascular suture such as 5-0
of injury to the right or main hepatic artery, end-to-end arte- Prolene. On rare occasions, it is helpful to occlude the hepa-
rial reconstruction should be considered if technical exper- toduodenal ligament by applying an atraumatic vascular
tise is available. Variations in the anatomy of the hepatic clamp. It is safe to perform this maneuver for as long as
arteries are shown in Fig. 88.6A–D. 30 min in a non-cirrhotic patient.
tion (dilated CBD, gallstone pancreatitis, hyperbilirubine-

mia). Intraoperative indications for cholangiography include
delineation of unclear anatomy.
ommon Errors of Operative Cholangiography

C
Inability to cannulate the cystic duct Occasionally, the
valves of Heister frequently prevent passage of the catheter.
A method that facilitates intubating the cystic duct is isola-
tion of the proximal portion of the duct, including its junc-
tion with the gallbladder. Here the duct is large enough to
permit introduction of the catheter at a point proximal to the
valves of Heister, simplifying the entire task. If the cystic
duct is not patent or difficult to identify, perform cholangiog-
raphy through a 25-gauge venipuncture needle inserted
directly into the CBD.
Injecting too much contrast material When a large dose of

contrast material is injected into the ductal system, the duo-
denum is frequently flooded with dye, which may obscure
stones in the distal CBD.
Dye too concentrated Especially when the CBD is some-

what enlarged, the injection of concentrated contrast mate-
rial can mask the presence of small radiolucent calculi.
Consequently, dilute the contrast material 1:2 with normal
saline solution when the CBD is large.
Fig. 88.5 Air bubbles Compulsive attention is necessary to eliminate

air bubbles from the syringe and the plastic tubing leading to
The second major cause of bleeding during the course of the cystic duct. Also, never try to aspirate bile into this tub-
a cholecystectomy is hemorrhage from the gallbladder bed in ing, as the ligature fixing the cystic duct around the cholan-
the liver. Significant bleeding may occur when the plane of giography cannula may not be airtight and air may be sucked
dissection is too deep and entry is made into a branch of the into the system and later injected into the CBD. It may then
middle hepatic vein. This complication may be prevented if be impossible to differentiate between an air bubble and a
the cystic plate is left intact. On the other hand, when this calculus.
fibrous plane has been removed with the gallbladder and
liver parenchyma is exposed, the surface is irregular and the Poor technical quality If the radiograph is not of excellent
blood vessels retract into the liver substance. In this case, quality, there is a greater chance of a false negative interpre-
apply a layer of topical hemostatic agent to the bleeding sur- tation. It is useless to try to interpret a film that is not techni-
face and cover it with a dry gauze pad; use a retractor to cally satisfactory. One technical error is easily avoided by
apply pressure to the gauze pad. After 15 min, carefully elevating the left flank of the patient about 8–10 cm so the
remove the gauze pad. The topical hemostatic agent may image of the bile ducts is not superimposed on the patient’s
then be carefully removed or left in place. vertebral column. If the hepatic ducts have not been filled
with contrast material, repeat the image after injecting addi-
tional dye into the cystic duct. If the hepatic ducts will not fill
Cholangiography because the contrast empties distally, it is sometimes helpful
to administer morphine sulfate, which induces sphincter
We do not routinely perform cholangiography during chole- spasm, allowing the dye to fill the hepatic ducts. Alternatively,
cystectomy, but recognize that there are indications to per- during open cholecystectomy, it is also easy to place a bull-
form one and advocate a liberal use. Pre-op indications for dog clamp across the distal CBD to force dye into the hepatic
the use of cholangiography include signs of biliary obstruc- ducts.
a Cystic Left hepatic Common b Cystic Left hepatic

artery artery hepatic artery artery artery Celiac axis
Right hepatic Replaced Splenic

artery right hepatic artery
artery
Superior
mesentric
artery
Common Left hepatic

c hepatic artery d artery
Accessory
anomalous right
hepatic artery
Right hepatic Superior
artery mesentric
artery
Fig. 88.6
Decompressing the Gallbladder too inflamed, a T-tube can be placed through the defect. If the
Occasionally, modifications in the operative strategy are use- cystic duct has been avulsed and its orifice in the CBD can-
ful in cases of acute cholecystitis. Tense distension of the not be located due to severe inflammation, simply leave a
gallbladder due to cystic duct obstruction can interfere with closed suction drain in the field.
exposure of adjacent vital structures. Insert a trocar or an
18-gauge needle attached to suction and aspirate bile or pus
from the gallbladder, allowing the organ to collapse. After Subtotal Cholecystectomy
the needle has been removed, close the puncture site with a
purse-string suture or a large hemostat. If at any time during the course of dissecting the gallbladder
such an advanced state of fibrosis or inflammation is encoun-
anagement of the Difficult Cystic Duct
M tered that continued dissection may endanger the bile ducts
Occasionally, the cystic duct is so inflamed it is easily or other vital structures, all plans for completing the chole-
avulsed from its junction with the CBD. If possible, suture cystectomy should be abandoned. In this situation, the sur-
the resulting defect in the CBD with a 5–0 monofilament geon has two options. (1) Subtotal fenestrating
suture, taking care not to narrow the lumen. If the tissues are cholecystectomy: the anterior wall of the gall bladder can be
filleted off and the gallbladder contents evacuated. This do an open operation with laparoscopic instruments. Do not
should allow clear visualization of the orifice of the cystic try to incorporate the trocar incisions unless they lie along
duct (identified by the presence of bile leakage), which can the planned open incision described below: proper exposure
be suture ligated from the inner aspect of the gall bladder. If trumps the esthetics of separate trocar scars. Generally, a
no bile production is seen, the surgeon should not throw top-down dissection is safest since the surgeon can follow
blind stitches. In this case, the cystic duct is likely occluded the gallbladder down and identify the critical structures
by a stone or inflammation and a postoperative bile leak is before any ligations are performed. Do not hesitate to do a
unlikely. The mucosa of the posterior wall should be ablated cholangiogram if the anatomy is unclear. Subtotal cholecys-
to prevent secretion of mucous. (2) Subtotal reconstituting tectomy is an excellent salvage maneuver in the difficult situ-
cholecystectomy: the surgeon can resect the majority of the ation. Asking a colleague to assist may be useful especially if
gall bladder that is a safe distance from the critical structures, the conversion to open is due to hemorrhage or a potential
leaving behind a short segment of gallbladder that is adher- biliary injury. An important adage is that conversion to open
ent to critical structures. Although unconventional, this can cholecystectomy is not an admission of poor technical skills,
even be performed with a stapler fired across the base of the instead it is a demonstration of good clinical judgment.
gall bladder. The advantage of this approach is that the field
remains uncontaminated by bile and stones; the disadvantage
of the reconstituting cholecystectomy is the potential for Operative Technique
recurrent infection of the small remnant, although this is
rare. Incision
We prefer to make a subcostal incision for open cholecystec-

onversion to Open Cholecystectomy After
C tomies because of the excellent exposure afforded in the
Failed Laparoscopic Cholecystectomy region of the gallbladder bed and cystic duct. The incision
should be parallel to and 4 cm below the costal margin.
If laparoscopic cholecystectomy has failed and conversion to Continue for a variable distance depending on the patient’s
open cholecystectomy is required, it is important for the sur- body build.
geon to remember that a difficult laparoscopic cholecystec- In a patient with a narrow costal arch, or when necessary
tomy will likely be a difficult open cholecystectomy too. in obese patients, a Kehr hockey-stick modification is useful
Several things may facilitate successful completion of the (Fig. 88.7A, B). This incision starts at the tip of the xiphoid,
operation. First, obtain an open biliary tray; do not attempt to proceeds down the midline for 3–4 cm, and then curves later-
a b
Fig. 88.7
Flush the tubing and then check to see that the entire sys-
tem – the syringe, plastic tubing, and cholangiogram cathe-
ter – is absolutely free of air bubbles. Pass the catheter into
the cystic duct for a distance of 5 mm (Fig. 88.9b). Tie the
previously placed 2-0 ligature just above the bead at the ter-
mination of the cholangiogram catheter (Fig. 88.9c).
Alternatively, if the cystic duct is not patent or cannot be
safely identified, a cholangiogram can be obtained using a
25G needle directly into the CBD.
Ligating the Cystic Artery
Following cholangiography, continue with the next step in

the operation: that is, to ligate and divide the cystic artery if
the anatomy is not in question. Gentle dissection in the
Triangle of Calot reveals the cystic artery, which may cross
over or under the common or right hepatic duct on its way to
the gallbladder. It frequently divides into two branches, one
Fig. 88.8 anterior and one posterior. Confirmation of the identity of
this structure is obtained by tracing the artery up along the
ally in a direction parallel to the costal margin until the width gallbladder wall and demonstrating the lack of any sizable
of the right belly of the rectus muscle has been encompassed. branch going to the liver (Fig. 88.10). Often the anterior
This vertical extension of the incision often markedly branch of the cystic artery can be seen running up the medial
improves exposure. Place laparotomy pads above and behind surface of the gallbladder. Ligate this artery in continuity
the liver to help bring the gallbladder into the field. after passing a 4-0 silk ligature around it with a Mixter right-
angle hemostat. Apply a clip to the gallbladder side of the
vessel and transect the cystic artery (Fig. 88.11).
Dissecting the Cystic Duct
If a cholangiogram is not being performed, the surgeon can Dissecting the Gallbladder Bed
begin directly with dissection of the gallbladder off the liver
bed (see section below). The description which follows is Next, dissect the gall bladder off of the liver bed. If a cholan-
applicable to the case in which cholangiography is to be giogram was not performed, the surgeon can start with this
done. Have the first assistant retract the duodenum away “dome-down” approach, which decreases the likelihood of
from the gallbladder. This move places the CBD on stretch injury to hilar structures. Apply an empty ring clamp on the
and opens the hilum. Place a ring clamp on Hartmann’s dome of the gallbladder and place it on gentle traction. Use
pouch. Use of anterio-lateral traction on the gallbladder will electrocautery to score the peritoneum covering the gallblad-
open up the hepatocystic triangle. Score the peritoneum and der to enter the correct plane.
use a Mixter clamp to dissect area between the wall of the Dissect the gallbladder away from the liver bed, leaving
gallbladder and the CBD (Fig. 88.8). Carefully expose the the cystic plate on the liver side. This is best achieved by dis-
cystic duct beneath and dissect it circumferentially. secting in the submucosal plane of the gallbladder. If the
gallbladder is severely scarred, it is safer to create a plane of
dissection within the thickened wall, rather than to go into
Cystic Duct Cholangiography the liver. When the plane of dissection is deep to the cystic
plate, raw liver parenchyma will be seen, which can lead to
Then milk any stones up out of the cystic duct into the gallblad- bleeding. If oozing from raw liver is difficult to control with
der by gentle distal pressure with the clamp and ligate the gall- electrocoagulation, pressure with moist gauze or application
bladder with a 2-0 silk ligature (Fig. 88.9a). Pass another 2-0 of a small sheet of Surgicel to the raw liver surface can pro-
ligature loosely around the cystic duct. Make a small scalpel vide excellent hemostasis.
incision in the gallbladder near the entrance of the cystic duct. Near the termination of this dissection along the posterior
At this point, attach the cholangiogram catheter and plas- wall of the gallbladder, a bridge of tissue is found connecting
tic tubing to a 50-ml syringe that has been filled with a saline. the gallbladder with the liver bed, known as the gall bladder
a b
Fig. 88.9
mesentery. Use a Mixter clamp to elevate the bridge of tissue, With the gallbladder hanging suspended only by the cys-
and then dissect out its contents carefully (Fig. 88.12A, B). tic duct, the surgeon can be confident of the anatomy. Ligate
In cases where excessive fibrosis has prevented identifica- the cystic duct with a 2-0 silk tie; transect the duct and pass
tion and ligature of the cystic artery, there is generally, at this the gallbladder off the field. Achieve complete hemostasis of
stage of the dissection, no great problem identifying this ves- the liver bed with electrocautery (Fig. 88.13). In unusual
sel coming from the area near the hilus of the liver toward the cases, leave a sheet of topical hemostatic agent in the liver
back wall of the gallbladder. bed to control venous oozing.
Drainage and Closure
Drain placement following cholecystectomy is only necessary

in cases where the closure of the cystic duct stump is thought
to be tenuous due to severe inflammation of the tissue.
Close the abdominal wall in routine fashion. We prefer to
close in two layers using the posterior, then anterior rectus
sheath, combined with a single layer midline closure if there
was extension up toward the xiphoid.
Postoperative Care
Complications
• Bile leak If a drain is present, bilious output can indi-

cate a leak from the cystic duct stump, injury to the
CBD, or inadvertent transection of an anomalous duct,
such as the one draining the posterior segment of the
right lobe. Endoscopic retrograde cholangiopancreatog-
raphy (ERCP) can help delineate the anatomy. A leak
from the cystic duct stump may be self-limited; sphinc-
terotomy and stenting may hasten resolution. If no drain
is present, significant bile leaks can present several days
after cholecystectomy with symptomatic abdominal
pain and fevers. Imaging will reveal a fluid collection in
the gallbladder bed. A percutaneous drain should be
Fig. 88.10
placed to create a controlled fistula, and then the evalua-
tion can proceed as above. Major injuries to the CBD
will require expert consultation, reoperation, and
hepaticojejunostomy.
• Hemorrhage If the cystic artery has been accurately
ligated, postoperative bleeding is rare except in cirrhotic
patients. Occasionally, oozing from the liver bed contin-
ues postoperatively and may require relaparotomy for
control.
• Spillage of stones Stone spillage into the abdominal
cavity can lead to abscess formation, bowel obstruction,
and fistulae. If stone spillage does occur, it is important to
retrieve any stones from the abdominal cavity.
• Jaundice Postcholecystectomy jaundice is usually due
to either inadvertent ligation of the CBD or a retained
CBD stone. MRCP is indicated to identify the etiology. In
the case of a retained stone, ERCP should be performed to
relieve the obstruction.
Fig. 88.11
Fig. 88.12
Further Reading
Morgenstern L, Wong L, Berci G. Twelve hundred open cholecystecto-
mies before the laparoscopic era: a standard for comparison. Arch
Surg. 1992;127:400.
Olsen DO. Mini-lap cholecystectomy. Am J Surg. 1993;165:400.
Roslyn JJ, Binns GS, Hughes EFX, et al. Open cholecystec-
tomy: a contemporary analysis of 42,474 patients. Ann Surg.
1993;218:129.
Smadja C, Blumgart LH. The biliary tract and the anatomy of biliary
exposure. In: Blumgart LH, editor. Surgery of the liver and biliary
tract. 2nd ed. Edinburgh: Churchill Livingstone; 1994.
Steiner CA, Bass EB, Talamini MA, Pitt HA, Steinberg EP. Surgical
rates and operative mortality for open and laparoscopic cholecys-
tectomy in Maryland. N Engl J Med. 1994;330:403.
Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. Subtotal chole-
cystectomy-“Fenestrating” vs “reconstituting” subtypes and
the prevention of bile duct injury: definition of the optimal
procedure in difficult operative conditions. J Am Coll Surg.
2016;222(1):89–96.
Fig. 88.13
Laparoscopic Cholecystectomy
89
Cindi Sulzbach and Randall Zuckerman
Indications Choledocholithiasis
• Cholelithiasis with biliary colic The management of patients with suspected common bile
• Acute or chronic cholecystitis duct (CBD) calculi will vary depending upon local expertise
• Biliary dyskinesia and the degree of suspicion. As discussed in Chap. 87,
• Gallstone pancreatitis patients who present with acute cholangitis require urgent
• Porcelain gallbladder decompression of the bile duct, best obtained by ERCP and
• Gallbladder polyp larger than 10 mm, or showing rapid endoscopic papillotomy with stone removal followed, in
increase in size or flow on Doppler most cases, by laparoscopic cholecystectomy several days
• Choledocholithiasis later. Patients who have a dilated CBD, or those with hyper-
bilirubinemia, may be candidates for intraoperative cholan-
giography or preoperative ERCP to clear the stones. An
Contraindications MRCP may be warranted to confirm the diagnosis of com-
mon bile duct stones if it is unclear. If the team is skilled at
• Inability to tolerate pneumoperitoneum (severe COPD or laparoscopic common bile duct exploration, that is a cost
CHF). effective and efficient solution.
• Prior major surgery of the upper abdomen (relative
contraindication).
• Cirrhosis and bleeding disorders (relative Pitfalls and Danger Points
contraindications).
• Known gallbladder cancer: While open, radical cholecys- • Anatomic variants
tectomy is the procedure of choice for gallbladder cancer, • Poor visualization
simple polyps may be managed by laparoscopic cholecys- • Bleeding
tectomy with frozen section if needed. • Misidentification of biliary anatomy resulting in ductal
injury
Operative Strategy
• Ultrasonography demonstrating the presence of gallblad-
der calculi Avoiding Bleeding
• Biliary dyskinesia: HIDA scan demonstrating ejection
fraction <35% at 20 min Meticulous hemostasis is essential for laparoscopic chole-
• Gallstone pancreatitis: Normalization of pain and/or pan- cystectomy, not only to avoid blood loss but because bleed-
creatic enzymes ing impairs the visibility necessary to perform this operation
safely and with precision. Careful use of electrocautery can
C. Sulzbach · R. Zuckerman (*) accomplish this end.
Department of Surgery, Pullman Regional Healthcare, Pullman, Great care must be exercised with any source of energy,
Washington, USA especially in the triangle of Calot (cystohepatic triangle), as
e-mail: rzuckerman@krmc.org

https://doi.org/10.1007/978-3-030-81415-1_89
678 C. Sulzbach and R. Zuckerman
there have been reports of strictures of the common and continuously proceeds from the gallbladder downward
hepatic ducts presumably due to careless application of elec- toward the cystic duct. Think about dissecting the inferior
trocautery in this area. When employing cautery near the bile aspect of the gallbladder free, rather than diving into the tri-
ducts, use a hook cautery and elevate the peritoneum above angle of Calot. If Calot’s node obscures this area, always ini-
any underlying structures in Calot’s triangle before applying tiate the dissection above Calot’s node, since the area below
energy. This practice minimizes potential damage to the bile the node may in fact be at the level of the CBD. Second, as
ducts. To further ensure safety when using electrocautery, the gallbladder ampulla and infundibulum have been cleared
dissect layer by layer ensuring you can see the tip of your of areolar tissue and fat, retract the gallbladder in an anterio-
hook before employing energy. It is reasonable to accept lateral angle toward the patient’s right, as seen in Fig. 89.2A.
minor bleeding until the anatomy becomes clear to ensure This helps restore the normal anatomy of the common and
critical structures are not put at risk. hepatic ducts and serves to open up the triangle of Calot and
the space between the cystic and common hepatic ducts.
An important step of the case involves identifying the
Preventing Bile Duct Damage “critical view of safety.” To achieve this view, you must clear
the hepatocystic triangle of fat and fibrous tissue until the
As discussed in section “Complications” at the conclusion of liver bed can be seen (Fig. 89.2B). The borders of this trian-
this chapter, the most serious bile duct injuries result from the gle are the cystic duct laterally, the common hepatic duct
surgeon’s mistaking the CBD for the cystic duct, resulting in medially, and the inferior edge of the liver superiorly. At this
transection of the CBD and occasionally excision of the CBD point, there should only be two structures seen entering the
up to the right and left hepatic duct junction. Normally the gallbladder both from the anterior and posterior view. By
CBD and common hepatic duct are aligned in a straight line definition, these structures then are the cystic duct and cystic
ascending from the duodenum to the liver. However, with artery and can safely be divided. If by mistake one had initi-
forceful cephalad retraction of the gallbladder infundibulum, ated the dissection by freeing up the CBD caudal to its junc-
the CBD appears to run in a straight line with the cystic duct tion with the cystic duct, as the dissection proceeded cephalad
directly into the gallbladder, as illustrated in Fig. 89.1A, B. In toward the gallbladder, the common hepatic duct would be
this situation, the common hepatic duct appears to join this encountered joining the cystic duct on its medial aspect. The
straight line at a right angle. It is dangerous to initiate dissec- surgeon may also opt for an additional “time-out” at this
tion in the region of the bile ducts, as it may lead to the mis- point of the case to ensure the entire surgical team is in
take of assuming that the CBD is indeed the cystic duct. agreement and the critical view of safety has been obtained.
Two precautions must be taken to avoid this error. First, If there is any doubt, you should always perform a cholan-
always initiate the dissection on the gallbladder and remove giogram to confirm all anatomy prior to transection of any
all areolar tissue in a downward direction so the dissection structure.
a b
Fig. 89.1
89 Laparoscopic Cholecystectomy 679
a b
Fig. 89.2
Aberrant Anatomy
To ensure the safety of laparoscopic cholecystectomy, it is

crucial that the surgeon be aware of the variants of normal
anatomy that may be encountered. The cystic artery most
commonly arises as a branch of the right hepatic artery.
Alternative sites of origin of the cystic artery include the
common hepatic, gastroduodenal, or superior mesenteric
artery. The length of the cystic artery varies, and in 15% of
patients, a double cystic artery occurs in which the superfi-
cial and deep branches do not share a common origin.
Be aware that some patients have a short cystic duct,
which increases the risk of CBD damage. Again, if the dis-
section is initiated to free the posterior wall of the g allbladder
and its infundibulum, expose the common hepatic duct
behind the gallbladder early during the dissection (Fig. 89.3).
This should prevent misidentification of the anatomy. If one Fig. 89.3
suspects the presence of a short cystic duct but is not certain,
perform intraoperative cholecystocholangiography by inject-
ing contrast material into the gallbladder with a long needle. the cystic artery. The right hepatic artery may cross anterior
In the case of a short cystic duct, there is often a stone to the common bile duct as well. For diagrams and further
impacted in the duct which should be milked distally into the discussion of aberrant anatomy, please refer to the section
gallbladder before proceeding with transection. “Further Reading” in chapter entitled “Anatomy Relevant to
Other common variants in anatomy include a narrow Cholecystectomy.”
CBD with an increased risk of injury if the duct is <3 mm.
There may an unusual position or loop of the cystic duct or
the right branch of the hepatic artery. There may be aberrant Ensuring Good Exposure
hepatic ducts or a low insertion of the posterior right duct.
There may be an accessory duct into the bed of the gallblad- Because excellent visibility is essential to prevent unneces-
der. The cystic duct may take an aberrant path passing poste- sary damage, do not hesitate to install an additional cannula
riorly to the CBD and descending on its left side. There are and use a retractor to depress the transverse colon or to ele-
multiple variants of the hepatic artery with the most common vate the liver when necessary. It is always better to pause and
being the right hepatic artery branching off the superior mes- adjust to provide better exposure than to proceed without
enteric artery, which is associated with an aberrant course of optimal view of the surgical field. This may also involve
positioning of the operating table to encourage the intestine (Veress needle) or open (Hassan cannula) technique. Some
to fall out of the way of the operative field. Standard posi- surgeons prefer a 30 angled laparoscope for biliary surgery,
tioning consists of reverse Trendelenburg with the table air- but the operation can comfortably be performed with a
planed left so the right side of the patient is elevated. straight (0°) laparoscope.
Insert the laparoscope into the cannula. Inspect the organs
of the pelvis and posterior abdominal wall. Look for unex-
Intraoperative Cholangiography pected pathology and evidence of trauma that might have
been inflicted during needle insertion to the vascular struc-
Many experienced laparoscopic surgeons believe that an tures or the bowel. If no evidence of trauma is seen, aim the
intraoperative cholangiogram, obtained as soon as the cystic laparoscope at the right upper quadrant and make a prelimi-
duct is identified, is an excellent means for ascertaining the nary observation of the upper abdominal organs and
exact anatomy of the biliary tree. This confirms identification gallbladder.
of the cystic duct and detects an anomalous hepatic duct in
time to avoid operative trauma. Consider cholangiography
whenever the anatomy is unclear. Insertion of Secondary Trocar Cannulas
Insert a second 5- or 10- to 11-mm cannula (size depends upon

Conversion to Open Cholecystectomy surgeon preference and instrumentation) in the epigastrium at
a point about one-third the distance between the xiphoid pro-
Whenever there is any doubt about the safety of a laparo- cess and the umbilicus. It generally is placed just to the right
scopic cholecystectomy, whether because of inflammation, of the midline to avoid the falciform ligament. Some surgeons
scarring, poor visibility, equipment deficiencies, or any other prefer entering through the falciform ligament with the trocar
reason, do not hesitate to convert the operation to an open coming out toward the liver. With a finger, depress the abdomi-
cholecystectomy. Every patient’s preoperative consent form nal wall in this general area and observe with the laparoscope
should acknowledge the possibility that an open cholecystec- to define the exact location at which to insert the trocar. Make
tomy may be necessary for the patient’s safety. Conversion to a 1-cm transverse skin incision at this point and insert the tro-
open cholecystectomy is not an admission of failure but an car cannula under direct vision by aiming the laparoscope at
expression of sound judgment by a surgeon who gives first the entry point of the trocar. Apply even pressure with no sud-
priority to the safe conduct of the operation. Conversion is den motions. Serious injuries of the liver and other organs
usually required in only difficult cases, but the laparoscopic have been reported following vigorous insertion of the trocar.
surgeon should be prepared at any time to convert to open. This site constitutes the main operating port. Some surgeons
They should familiarize themselves with the technique and opt to insert a 5-mm port in this position if a 5-mm clip applier
the material in Chap. 88. is available, reducing the size of incision and resulting scar.
There is sufficient access to safely perform the procedure, but
may require switching to a 5-mm laparoscope when extracting
Operative Technique the gallbladder.
Establish two secondary ports, one in the midclavicular
This chapter describes the basic, four-trocar technique of line about 2–3 cm below the costal margin and the other in
laparoscopic cholecystectomy. Variations involving smaller the anterior axillary line at a point about level with the umbi-
numbers of trocars, including the single-site approach, are licus. These two 5-mm ports are mainly used for grasping
described in references at the end. The room setup, entry into and retraction. These standard port sites may need to be
the peritoneal cavity, and first steps for any laparoscopic pro- altered depending on the anatomy encountered upon inspec-
cedure are described in Chap. 9. tion and patient’s body habitus. Make every effort to analyze
where the retraction will be most beneficial and choose these
sites for the trocars. Insert a trocar in each of these ports
Initial Inspection of the Peritoneal Cavity making a 5-mm skin incision. Observe and control the entry
of these trocars carefully by watching the monitor. The
Plan the initial trocar site either just above or below the objective is to position the ports so the surgeon can manipu-
umbilicus in a natural skin crease. This decision should be late the dissecting instruments at a point in front of and
based on the habitus of the patient and length of the torso. If roughly at right angles to the laparoscope. Figure 89.4A–C
the patient has a short torso and the distance from the umbi- illustrates a typical arrangement of cannulas. In an obese
licus to the xiphoid is relatively short, consider an infraum- patient, the trajectory should follow the anticipated path of
bilical incision. Gain access to the abdomen via a closed the trocar through the abdominal wall.
a b
Fig. 89.4
issecting the Gallbladder to Expose

D The surgeon should use a two-handed technique, operat-
the Cystic Duct ing through the midclavicular and epigastric ports. In this
situation, the assistant controls the camera and holds static
To expose the gallbladder, elevate the head of the table to a retraction on the upper edge of the gallbladder. This allows
30° reverse Trendelenburg position. If the stomach appears to the operating surgeon to have dynamic control of the gall-
be dilated to the point that it may interfere with safe dissec- bladder retraction. This retractor should move often, con-
tion, request insertion of a nasogastric or orogastric tube, stantly attempting to offer the best exposure and visualization
placed to suction and removed at the end of the operation. for dissection.
Insert a grasping forceps through the right lateral port and The first objective is to expose the gallbladder infundibu-
grasp the upper edge of the gallbladder. Push the gallbladder lum by dissecting away any adherent omentum and other
in a cephalad direction anterior to the liver. Utilizing the structures (Fig. 89.5). Cautery is often not required here, but
midclavicular port, insert a second grasping forceps to grasp if used care should be taken with this technique as the duo-
the gallbladder infundibulum and apply anterolateral trac- denum can be injured. Next, hook electrocautery is used to
tion, while the surgeon uses an appropriate dissecting for- divide the peritoneum that covers the hepatocystic triangle.
ceps inserted through the upper midline port. Use the hook dissector to liberate the lower portion of the
Fig. 89.5
Fig. 89.7
Fig. 89.6
Fig. 89.8
gallbladder from its attachment to the liver and begin to care-

fully dissect away the fatty and fibrous tissues. Next work on angiography, many variations in catheter types exist. Insert
the posterior aspect of the gallbladder by reflecting the infun- the catheter percutaneously and adjust the angle of the cath-
dibulum gently toward the patient’s left. Incise the perito- eter tip as necessary. Thread the catheter into the cystic duct
neum on this side of the gallbladder – this will impart greater incision for no more than 1 cm (Fig. 89.8). Tentatively inject
mobility to the gallbladder and allows better exposure of the some saline to confirm there is no leakage. You can then feel
triangle of Calot. After dissecting on both sides of the cystic confident to inject contrast. Use C-arm fluoroscopy to moni-
duct, pass a right-angled Maryland dissector or a right-angle tor the injection.
dissector behind the cystic duct and free up several centime- If passage of the cholangiogram catheter is obstructed by
ters so there is complete exposure of the continuum of the the valves of Heister, the obstruction may be corrected by
posterior cystic duct going up to the infundibulum and the inserting the tip of the scissors into the cystic duct. Keep the
lower portion of the gallbladder (Fig. 89.6). scissors closed upon entering the duct and open them with
mild force to dilate the valves.
A satisfactory intraoperative cholangiogram must show
Cystic Duct Cholangiogram intact bile ducts from the right and left hepatic ducts down to
the duodenum. If the cholangiogram demonstrates a calculus
Now that the cystic duct has been identified, the decision in the CBD, perform a laparoscopic CBD exploration if the
must be made whether an intraoperative cholangiogram is technology and skill are available (see Chap. 90 and the
necessary. If there is any question of anatomy or the patient’s References). If the stones appear to be less than 3–4 mm in
preoperative history is suggestive of common duct stones, diameter, it may be possible to mechanically flush the stones.
you should proceed with cholangiography. When certain that Request that Anesthesia give 1.0 mg of IV glucagon. This
the cystic duct has been identified, apply an endoscopic clip helps to relax the sphincter of Oddi and can facilitate the pas-
on the gallbladder side and use endoshears to make an inci- sage of small stones. Wait for 4 min, and then flush the cath-
sion in the cyst duct just below the clip (Fig. 89.7). For chol- eter with saline and repeat the cholangiogram. If the duct is
clear, proceed with the planned procedure. If presumed only the anterior branch. Be alert during the latter part of the
stones persist, options include open cholecystectomy and dissection for a posterior branch that must often be clipped
choledocholithotomy, laparoscopic common duct explora- and divided when the infundibulum of the gallbladder is
tion and cholecystectomy, or proceeding with laparoscopic freed. If this branch is small enough, it may be handled by
cholecystectomy and scheduling the patient for a postopera- electrocautery instead of clipping.
tive ERCP for stone extraction. If the stone is exceedingly There are two main types of clips available. A disposable
large (approaching 2 cm), an open choledocholithotomy is clip applier can be used that deploys metallic clips. The sec-
preferable. This is also the case if the patient has a large ond option is a Weck Hem-o-lok clip which is a plastic poly-
number of stones or has had a previous Billroth II gastrec- mer clip that is applied using a reusable endoscopic clip
tomy or gastric bypass, making endoscopic papillotomy not applier. The decision of which clips to use is largely based on
feasible. surgeon’s preference and availability. When placing the clip
If the proximal ducts do not fill, place the patient in applier around the target structure, ensure the tip of the clip
Trendelenburg position which may help in visualization of applier can be visualized on the other side before the deploy-
the hepatic ducts. Gentle compression in the area of the distal ing the clip. It should also be examined to ensure the clip
CBD can also be used to encourage contrast to fill p roximally. goes all the way across the duct or artery confirming com-
Morphine may also be administered to induce spasm of the plete occlusion.
sphincter of Oddi, thus retaining the contrast in the biliary
tree to aid in filling of the upstream ducts. If the proximal
ducts still do not fill, suspect a CBD injury. Removing the Gallbladder
After you are satisfied with the cholangiogram, attention
should be turned to ensuring the critical view is obtained Now continue to dissect the gallbladder away from the liver
before transecting any structures. The cystic artery should with electrocautery. Divide the peritoneum between the gall-
become apparent slightly cephalad to the cystic duct and bladder and the liver on each side of the gallbladder if this
running through the triangle of Calot. Skeletonize the artery has not already been completed. Then continue the dissec-
using the Maryland dissector or hook electrocautery. tion on the posterior wall of the gallbladder. Maneuver the
Confirm there are only two structures entering the gallblad- medial grasping forceps to expose various aspects of the
der with only the liver visible behind them. At this point, it gallbladder and apply countertraction, using the right hand
is safe to proceed with clipping and transection of the for dissection through the epigastric port. This portion of the
structures. procedure necessitates constant countertraction as cautery
Remove the cholangiogram catheter and apply two clips will only divide at sites of tension. Change the position of
on the proximal portion of the cystic duct. Divide the cystic retraction often and dissect in the areas of most tension. You
duct with scissors. Next, levate the cystic artery with either a can use the hook exclusively from its tip, hooking each layer
Maryland dissector or a hook so at least 1 cm is dissected before applying electrocautery or use the back end and con-
completely from surrounding structures. Then apply on tinuous electrocautery along the border of the gallbladder.
endoscopic clip distally and two clips proximally, and divide Staying in the right plane avoids any unwanted bleeding that
the artery with scissors (Fig. 89.9A, B). Note that the point at may result from getting into the liver and getting into the
which the cystic artery divides into its anterior and posterior gallbladder resulting in leakage of bile. It may be necessary
branches can be somewhat variable. When you think you to vent a port intermittently to evacuate the accumulating
have divided the main cystic artery, you may have divided smoke to ensure continued visualization.
a b
Fig. 89.9
Postoperative Care
Remove the nasogastric or orogastric tube and urinary cath-

eter (if placed) before the patient leaves the operating room.
Mild pain medication may be necessary. Ambulate the
patient as soon as he or she awakens. A regular diet may be
ordered unless the patient is nauseated. If the case was per-
formed on an elective procedure, patients can typically be
discharged on the same day. Certain criteria should be met
including pain control, tolerance of oral intake without nau-
sea, and ability to ambulate. Patients are expected to regain
their normal level of activity within 1 week. They should
have a postoperative visit in 1–2 weeks following surgery
and if they are recovering as expected can then be seen on an
as needed basis.
Complications
Fig. 89.10 Needle or Trocar Damage
Before the gallbladder is totally free of its attachment to Retroperitoneal bleeding from damage to one of the great
the liver, use it to facilitate retraction and carefully inspect vessels during insertion of the initial trocar can be fatal.
the liver bed for bleeding points. You may choose to irrigate There may be damage to aorta, vena cava, or iliac vessels
the area especially if there has been bile leakage. If there are (see Chap. 9). A retroperitoneal hematoma noted during lap-
any bleeding points in the liver bed, they can be stopped aroscopy requires open exploration for great vessel injury.
using electrocautery. Finally, elevate and divide the gallblad- Remember, even with disposable trocars that have plastic
der from its final attachment to the liver (Fig. 89.10). Leave shields, forceful collision of the shielded trocar with the vena
the gallbladder in position over the dome of the liver being cava may result in perforation of this vessel. Bleeding from
held in the lateral port grasper. the great vessels constitutes the main cause of the rare fatal-
Remove the laparoscope from the umbilical cannula and ity that follows laparoscopic cholecystectomy.
place it through the upper midline port. If a 5-mm cannula Bowel injury can result from introducing the Veress nee-
was inserted in the epigastrium, it will be necessary to switch dle or a trocar, especially if the trocar is passed through
to a 5-mm camera at this point. Another option is to continue adherent bowel. Careful inspection of the abdomen by lapa-
with the camera in the umbilical port site and extract the gall- roscopy after inserting the initial trocar and again before ter-
bladder through the epigastrium. This is especially feasible if minating the operation is essential if these injuries are to be
the gallbladder is small. The gallbladder is removed from the detected early and then repaired.
abdomen using an endoscopic retrieval bag. The bag is
inserted into the umbilical port and positioned over the dome
of the liver. The lateral grasper is then used to place the spec- Insufflation-Related Complications
imen in the bag. The bag is then closed and removed from
the abdomen. See Chap. 9.
If the laparoscope has been transferred to the epigastric
port, return it to the umbilical cannula and make a last inspec-
tion of the abdominal viscera, pelvis, and gallbladder bed. ile Duct Damage: Injury of Common
B
Carefully observe the withdrawal of each cannula to ascer- and Hepatic Ducts
tain the absence of bleeding in each case. Finally, permit the
escape of carbon dioxide from the abdominal cavity and The classic laparoscopic biliary injury includes resection of
remove the final cannula. Insert sutures of heavy Vicryl in the large sections of the CBD and the common hepatic duct
fascia of the periumbilical incision. The 5-mm incisions do together with the cystic duct and the gallbladder (Fig. 89.11).
not require closure. Close the skin with subcuticular sutures Injury results from mistaking the CBD for the cystic duct and
and sterile adhesive tape or skin glue. applying clips to the CBD. The CBD is then dissected in a
Fig. 89.11
Fig. 89.12
cephalad direction as though it were the cystic duct with
transection of the proximal hepatic ductal system with or Another common pattern of CBD injury is illustrated in
without clip ligation. As seen in Fig. 89.11 (modified from Fig. 89.13. Here clips were applied to the CBD just below
Davidoff et al. (1992)), if one dissects the proximal divided the junction with the cystic duct, but the transection took
end of the CBD in a cephalad direction, it is not possible to place across the distal portion of the cystic duct. In this case,
remove the gallbladder without transecting the common the patient will have a free biliary leak into the peritoneal
hepatic duct. Significant leakage of bile into the operative cavity. If a common bile duct injury is recognized, drain the
field is a danger sign that should not be ignored. Inadequate patient well and transfer to a center with hepatobiliary
visualization of the surgical field often contributes to these expertise.
errors. Finally, late strictures of the CBD can occur, presumably
One factor contributing to injury is fibrosis or scarring in due to thermal damage, during dissection.
Calot’s triangle, as shown in Fig. 89.12. The cystic duct is In summary, prevention of damage to the bile ducts
densely adherent to the common hepatic duct for several cen- requires good visibility (facilitated by use of a 30° angled
timeters above the junction of the cystic and common ducts. laparoscope), anterolateral traction on the infundibulum of
Regardless, injury does not occur if the dissection is initiated the gallbladder to separate the cystic duct from the common
at the distal gallbladder and if the posterior portion of the hepatic duct, directing the dissection from the distal gall-
gallbladder infundibulum is dissected away from the liver bladder downward toward the cystic duct rather than the
before dissecting the cystic duct. Dissection should always reverse, using electrocautery with caution, applying cholan-
progress from the gallbladder toward the cystic duct, com- giography liberally, and converting to open cholecystectomy
pletely freeing the entire circumference of the infundibulum whenever there is any doubt concerning the safety of the
of the gallbladder and the cystic duct. laparoscopic cholecystectomy.
Fig. 89.14
Intraoperative Hemorrhage from Cystic Artery
Occasionally brisk bleeding results when the cystic artery is

cut or torn. It is generally a minor complication during open
Fig. 89.13 cholecystectomy because grasping the hepatic artery between
two fingers in the foramen of Winslow (Pringle maneuver)
Bile Leak ensures prompt if temporary control of bleeding. With lapa-
roscopic cholecystectomy, however, losing 30–40 ml of
Leakage of bile into the right upper quadrant following laparo- blood may be serious because the blood obscures visibility
scopic cholecystectomy does not necessarily indicate an injury through the laparoscope.
to the bile duct. It may simply mean that the occluding clips Frequently it is possible to control cystic artery bleeding
have slipped off the cystic duct or that a minor accessory bile by grasping the gallbladder ampulla near the bleeding vessel
duct is leaking. Symptoms generally develop a few days after and pushing firmly against the liver (Fig. 89.14). If this
laparoscopic cholecystectomy and consist of generalized maneuver successfully controls the bleeding, insert one or
abdominal discomfort, anorexia, fatigue, and sometimes jaun- more additional cannulas for suction and retraction and
dice. Ultrasonography or CT imaging can reveal the presence attempt to localize and clip the bleeding vessel. It is not
of fluid in the subhepatic space. A HIDA scan demonstrates worth spending much time on occluding this bleeder laparo-
the presence of bile outside the biliary tree, and ERCP demon- scopically because making a subcostal incision affords an
strates the point of leakage. In the absence of obstruction in the opportunity to localize and control the bleeder quickly with
CBD, these leaks generally heal spontaneously. Healing may no risk.
be expedited by percutaneous insertion of a drainage catheter Bleeding may also be due to avulsion of the posterior
into the right upper quadrant and insertion of a stent into the branch of the cystic artery that has not been properly
CBD following endoscopic papillotomy. Of course, major identified.
ductal injury requires surgical reconstruction, generally by the
hepaticojejunostomy Roux-en-Y procedure.
Further Reading Hope WW, Fanelli R, Walsh DS, Price R, Stefanidis D, Richardson
WS. Clinical spotlight review: intraoperative cholangi-
ography – a SAGES guideline. 2016. Retrieved April 27,
Ansaloni L, Pisano M, Coccolini F, et al. 2016 WSES guidelines on
2017, from https://www.sages.org/publications/guidelines/
acute calculous cholecystitis. World J Emerg Surg. 2016;11:25.
sages-clinical-spotlight-review-intraoperative-cholangiography/.
https://doi.org/10.1186/s13017-016-0082-5.
Hori T, Oike F, Furuyama H, et al. Protocol for laparoscopic cho-
Avoiding pitfalls in cholecystectomy – a SAGES Wiki article. n.d.
lecystectomy: is it rocket science? World J Gastroenterol.
Retrieved April 27, 2017, from https://www.sages.org/wiki/
2016;22(47):10287–303. https://doi.org/10.3748/wjg.v22.
avoiding-pitfalls-in-cholecystectomy/.
i47.10287.
Bhandarkar D, Mittal G, Shah R, Katara A, Udwadia TE. Single-
Karanikas M, Bozali F, Vamvakerou V, et al. Biliary tract injuries
incision laparoscopic cholecystectomy: how I do it? J Minim Access
after lap cholecystectomy – types, surgical intervention and tim-
Surg. 2011;7(1):17–23. https://doi.org/10.4103/0972-9941.72367.
ing. Ann Transl Med. 2016;4(9):163. https://doi.org/10.21037/
Blohm M, Österberg J, Sandblom G, Lundell L, Hedberg M, Enochsson
atm.2016.05.07.
L. The sooner, the better? The importance of optimal timing of cho-
Kaya B, Fersahoglu MM, Kilic F, Onur E, Memisoglu K. Importance
lecystectomy in acute cholecystitis: data from the National Swedish
of critical view of safety in laparoscopic cholecystectomy: a sur-
Registry for Gallstone Surgery, GallRiks. J Gastrointest Surg.
vey of 120 serial patients, with no incidence of complications.
2017;21(1):33–40. https://doi.org/10.1007/s11605-016-3223-y.
Ann Hepatobiliary Pancreat Surg. 2017;21(1):17–20. https://doi.
Mechanisms of major Billiary Injury During Lapascopic
org/10.14701/ahbps.2017.21.1.17.
Cholecystectomy, Davidoff et all, Ann Surg, March, 1992.
Nagral S. Anatomy relevant to cholecystectomy. J Minim Access Surg.
Guidelines for the clinical application of laparoscopic biliary tract sur-
2005;1(2):53–8. https://doi.org/10.4103/0972-9941.16527.
gery – a SAGES guideline. 2010, January. Retrieved April 27, 2017,
The SAGES safe cholecystectomy program – strategies for minimizing
from https://www.sages.org/publications/guidelines/guidelines-for-
bile duct injuries. n.d. Retrieved April 27, 2017, from https://www.
the-clinical-application-of-laparoscopic-biliary-tract-surgery/.
sages.org/safe-cholecystectomy-program/.
Gupta N. Role of laparoscopic common bile duct exploration in the
Davidoff et al. Mechanisms of major Billiary Injury During Lapascopic
management of choledocholithiasis. World J Gastrointest Surg.
Cholecystectomy. Ann Surg. 1992.
2016;8(5):376–81. https://doi.org/10.4240/wjgs.v8.i5.376.
Open and Laparoscopic Common Bile
Duct Exploration 90
Juliane Bingener, Michael G. Sarr,
Indications Adequate cholangiography can prove or disprove the pres-

ence of CBD stones in many situations that were listed
Multiple, less invasive alternatives have largely replaced formally as relative indications for CBD exploration.
open common bile duct (CBD) exploration. Endoscopic ret-
rograde cholangiography (ERC) with endoscopic sphincter-
otomy provides access to the extrahepatic biliary tree for Preoperative Preparation
extraction of stones and biliary decompression. Laparoscopic,
transcystic CBD exploration or laparoscopic choledochot- Computed tomography (CT), transabdominal or endoscopic
omy are alternatives when common duct stones are found at ultrasonography, or more recently MRCP is used. Generally
laparoscopic cholecystectomy or when ERC expertise is not CT, endoscopic ultrasonography (EUS), or MRCP is per-
available. Open CBD exploration is still needed occasionally formed as the next diagnostic maneuver when dilated ducts
when these methods are not available or fail. The principles are seen; endoscopic intervention (sphincterotomy and stone
of safe access to the extrahepatic biliary tree will be described extraction) may obviate the need for open CBD exploration.
here. The indications for CBD exploration are as follows: One must check for and correct abnormalities of the coagula-
tion system (increase in INR/prothrombin time) preoperatively
• Fever, jaundice, and occasionally chills prior to operation with administration of vitamin K or fresh frozen plasma (FFP).
are present in about 90% of cases requiring CBD explora- When CBD exploration is planned, the patient should
tion for calculi. receive prophylactic, perioperative intravenous antibiotics
• Palpation of a calculus in the CBD. within 1 h prior to operation, because choledocholithiasis is
• Acute suppurative cholangitis with Charcot’s triad of associated with bacterobilia in >80% of cases. The choice of
fever, jaundice, and right upper quadrant pain. antibiotic varies with local hospital flora, but generally
• Finding of a calculus/filling defect on cystic duct cholan- involves a third- or fourth-generation cephalosporin or an
giography, preoperative ERC, percutaneous transhepatic aminoglycoside. When the patient has acute cholangitis,
cholangiography, or magnetic resonance cholangiogra- anaerobic coverage is also strongly suggested.
phy (MRCP).
• Access to the CBD is sometimes required during the
course of other procedures in this region (e.g., to delineate Pitfalls and Danger Points
the course of the CBD or the exact location of the ampulla
of Vater during a difficult ulcer operation, a distal duode- • Injuring the bile duct at the site of the choledochotomy
nal resection, the need for an operative sphincterotomy/ leading to a later biliary stricture
sphincteroplasty, or a periampullary polypectomy). The • Creating a false passage or perforating the CBD when
principles described here apply in those situations as well. probing/exploring the CBD, damaging the ampulla or pan-
creatic sphincter and inducing postoperative pancreatitis
J. Bingener · M. G. Sarr • Perforating a periampullary duodenal diverticulum
Department of Surgery, Mayo Clinic, Rochester, MN, USA • Sepsis
C. E. H. Scott-Conner (*) • Failing to remove all of the biliary calculi (leading to
Department of Surgery, Roy J. and Lucille A. Carver College of retained CBD stones)
Medicine, Iowa City, IA, USA • Failure to recognize acute cholangitis

https://doi.org/10.1007/978-3-030-81415-1_90
690 J. Bingener et al.
Operative Strategy the duodenum; this diversion of the bile from the traumatized
distal bile duct and pancreas may prove lifesaving. Also,
Avoiding Postoperative Pancreatitis insert a closed-suction drain behind the duodenum and pan-
creatic head to divert any ongoing leak of pancreatic secre-
Postoperative acute pancreatitis can be lethal. Use routine, low- tions. In contrast, when the perforation is small, some
pressure cholangiography to minimize the potential for reflux consideration should be given to diverting the bile with a
into the pancreatic duct; if the contrast agent does reflux into the stent or T-tube in the supraduodenal CBD in association with
pancreatic duct, avoid further contrast studies if at all possible. a retroduodenal, closed-suction drain.
Explore the distal duct with delicacy and meticulous care to If the CBD is perforated at an accessible point proximal to
avoid trauma to the ampulla or pancreatic sphincter region, the head of the pancreas, the laceration can be sutured with
which may induce pancreatitis. Keeping a hand behind the duo- 5-0 absorbable suture with strong consideration of placing a
denum after a Kocher maneuver will to help to guide the T-tube proximally and a closed-suction drain.
exploration and minimize such complications. Interventional
gastroenterologists prescribe 100 mg indomethacin per rectum
prior to ERCP for the prevention of ERCP-induced pancreatitis Locating and Removing Biliary Calculi
and utilize lactated Ringer’s solution periprocedurally. Data to
conclude that these recommendations also apply for open CBD A cystic duct cholangiogram should be obtained before explor-
exploration are not available. ing the CBD not only to avoid overlooking biliary calculi but
also to get an idea of how many stones are present, any unusual
anatomy of the biliary tree, and to visualize the intrahepatic
CBD Perforations ducts and the distal CBD. If the hepatic ducts are not seen
because the dye runs into the duodenum, first, place the patient
Another serious and occasionally fatal error is to perforate in a Trendelenburg position and repeat the cholangiogram. If
the distal CBD and penetrate either the pancreas or the retro- still unsuccessful, intravenous morphine can be given to induce
peritoneal, retroduodenal region with an instrument such as spasm of the sphincter of Oddi and the cholangiogram repeated.
the metal Bakes dilator. Many surgeons avoid these “dila- If still unsuccessful, the CBD can be opened, and an 8 Fr Foley
tors” and prefer a biliary Fogarty catheter because of its soft, catheter can be inserted into the CBD and threaded proximally
flexible tip. When the surgeon experiences any difficulty into the region of the common hepatic duct, the balloon gently
negotiating the ampulla with an instrument, duodenotomy inflated, and a radiograph of the intrahepatic ducts obtained.
and direct exposure of the ampulla may be preferable to Before beginning the CBD exploration, a Kocher maneuver
repeated blunt trauma from above. Never forcefully dilate should be performed. This maneuver allows palpation of the
the sphincter of Oddi bluntly; this procedure serves no useful distal CBD for stones and guidance of any instruments inser-
purpose, and the trauma to the ampulla not only increases the tions distally (toward the duodenum) into the duct, mobilizes
risk of postoperative acute pancreatitis, but it can produce the duodenum anteriorly, thereby markedly facilitating the
lacerations and hematomas of the ampulla. exploration, and helps to straighten out the CBD making explo-
If an instrument has perforated the distal CBD into the ration much easier. When beginning the CBD exploration, it is
head of the pancreas or – rarely – in the retroduodenal por- usually best to free up the retroduodenal CBD to allow place-
tion of the CBD, the site of perforation may be detected ment of the choledochotomy as far distally as possible to allow
when the CBD is irrigated with saline by noting the leakage a choledochoduodenostomy if necessary (Fig. 90.1); also,
of saline from the posterior surface of the duodenum where because a T-tube will usually be required and one wants a
the Kocher maneuver has been performed. The perforation straight pathway out of the abdomen, the choledochotomy
may also be detected by cholangiography. This type of should be on the right lateral wall of the CBD. The placement
trauma, which leads to extravasation of bile directly into the of stay sutures before performing a choledochotomy is also
region of the head of the pancreas or the retroperitoneum, helpful on the medial and lateral side of the choledochotomy.
can cause a fatal retroperitoneal infection. For this reason, Some thought should be given to whether the incision into the
when this complication is identified, there are several options CBD should be truly longitudinal or angled: the latter is espe-
depending on the severity of the perforation and the status of cially helpful in a dilated duct when one is contemplating a
the CBD. If stenting is not possible, one option is to divide choledocho-duodenostomy and facilitates and lengthens any
the CBD in its supraduodenal portion at the pancreaticoduo- subsequent bilio-enteric anastomosis. If one is planning an end
denal sulcus, close the distal end of the duct, and anastomose to side choledocho-jejunostomy, then an angled incision is not
the proximal end of the CBD to a Roux-en-Y segment of helpful. Prior to incising the CBD, be absolutely certain that
jejunum or if feasible depending on the diameter of the CBD, you have exposed the anterior surface of the CBD and not the
90 Open and Laparoscopic Common Bile Duct Exploration 691
Fig. 90.1
portal vein; insert a small gauge #23 or 25 needle and aspirate

bile if there is any concern.
The CBD duct should then be incised as far distally as Fig. 90.2
possible with a small incision using a scalpel, and then the
duct can be opened further using the Potts scissors fully
under vision. It is prudent to obtain a culture of the bile
before starting any further instrumentation.
Once the choledochotomy is performed, the safest, most
effective initial means of removing any stones is to flush the
duct both proximally and distally with a soft, latex-free 16 or
18Fr soft-tipped catheter, allowing the saline to extravasate
via the choloedochotomy and watching for stones; initial use
of any invasive metal device, such as a scoop, a stone for-
ceps, or a Bake’s dilator, can cause unnecessary injury or
spasm of the ampullary sphincter. Using the left thumb and
index finger around the hepatoduodenal ligament, milk any
palpable stones from the CBD retrograde back into the cho-
ledochotomy incision. This maneuver often delivers several
calculi into the choledochotomy.
After flushing the duct, the safest catheter to use next is
the biliary Fogarty catheter; its soft tip can usually be maneu-
vered through the ampulla into the duodenum, the balloon
inflated, and pulled back until the balloon becomes lodged in
the ampulla (Fig. 90.2). Next, the balloon is carefully
deflated, the catheter is pulled back a short distance into the
distal CBD, and the balloon inflated again and pulled back
out the choledochotomy, hopefully stripping out retrograde
any residual stones (Fig. 90.3). This maneuver can be
repeated several times, especially if any stone material is
retrieved. Then the catheter can be passed into the right and Fig. 90.3
a b
3Fr
2.4Fr
Fig. 90.4
left common hepatic ducts in a similar fashion. Although

some surgeons advocate use of the Randall stone forceps,
scoops, or the Bake’s dilators, with our current ability to
visualize the lumen of the extrahepatic biliary tree via cho-
ledochoscopy (see below), use of these rigid instruments has
gone out of favor for fear of ductal perforation.
When the distal CBD contains an impacted stone (usually
near the ampulla in the intrapancreatic portion of the CBD)
that cannot be removed by the usual methods, consider first
performing choledochoscopy and visualizing the stone
directly. If you can visualize the stone, often you can pass a
type of Dormia basket (Fig. 90.4A, B) or a Fogarty balloon
catheter past the stone and retrieve it in the under vision. If
this is not successful, then strongly consider performing a
transduodenal sphincterotomy and if necessary a sphinctero-
Fig. 90.5
plasty to extract the stone under direct vision, especially if
the CBD is small in diameter and not dilated; this approach
avoids the potential trauma of repeated blind attempts at omy. Second, remember that the T-tube can be used as a
stone removal via the choledochotomy with the possibility of pathway for the interventional radiologists to access the bili-
excessive trauma to the distal CBD and the possibility of ary tree about 4–6 weeks postoperatively should a retained
postoperative pancreatitis or perforation. stone be seen prior to T-tube removal. A 16 Fr or greater
Once you are convinced that the biliary tree is free of stones T-tube brought out the abdominal wall in as straight a path-
(it is always a good idea to perform a choledochoscopy, see way as possible will make the radiologists job much easier
below), place a 16 Fr or greater T-tube into the duct keeping the than a smaller T-tube.
arms of the T-tube short, about 2 cm, and cutting off the back
50% of the circumference longitudinally to facilitate its later
percutaneous removal (Fig. 90.5). When closing the choledo- Documentation Basics
chotomy, interrupted absorbable sutures (4-0 or 5-0) can be
placed but not tied until the tube is in place, thereby allowing a • Cholecystectomy performed
tight closure and being certain that you do not include the • Details of cholangiogram and findings
T-tube with your sutures near the tube exit site. Flush the tube • Findings at exploration
gently to ensure as watertight a seal as possible. • Size and type of T-tube placed, other drains
At this point, a completion cholangiogram through the
T-tube is the final maneuver to minimize the chance of any
retained stones. Open CBD Exploration: Operative Technique
Several points warrant discussion. First, if the CBD is
really small in diameter (3–5 mm), one might consider first a Cholangiography
transduodenal CBD exploration via a sphincteroplasty,
because attempts to place a T-tube into such a small duct may If for some reason the cystic duct is not a suitable route for
eventuate in a biliary stricture at the site of the choledochot- cholangiography or the patient has had a prior cholecystec-
tomy and there is no cystic duct stump, a 23-gauge needle

can be inserted into the CBD, and after aspirating bile to con-
firm its placement, a cholangiogram can be obtained.
Kocher Maneuver
After the gallbladder has been removed and it is determined

Vena cava
that CBD exploration is indicated, a Kocher maneuver is
performed (Figs. 90.6, 90.7, and 90.8) by incising the lateral Gerota’s
peritoneal attachments along the entire length of the first, fascia
second, and proximal part of the third portion of the duode-
R.renal v.
Pancreas
Fig. 90.8
num. The posterior duodenum can be mobilized bluntly

such that your hand can pass medially behind the head of
the pancreas and anterior to the vena cava, thereby maxi-
mizing the anterior elevation of the duodenum. With the left
index and middle fingers behind the pancreas and duode-
num and the thumb applied to the anterior wall of the duo-
denum, the distal CBD and the ampulla can be palpated for
a stone or mass.
Choledochotomy Incision
Several considerations apply to the choledochotomy. Pay

attention to the possibility that the cystic duct and CBD may
Fig. 90.6 share a common wall for a distance of 2 cm or occasionally
even more down the CBD. If the incision is made in the
vicinity of this common wall, and especially if made near the
presumed external entrance of the cystic duct with the CBD,
it is possible to open the cystic duct instead of the CBD,
markedly complicating the remainder of the procedure. It is
for this reason as well as the concern of a possible stricture
later at the site of the choledochotomy that we recommend
the choledochotomy being made in the distal lateral part of
the mobilized retroduodenal CBD; should a stricture occur,
the entire proximal common hepatic duct and the more prox-
imal CBD are preserved.
Incision in
peritoneum
Choledochoscopy
Choledochoscopy is an integral part of any CBD exploration.

This procedure can visualize and retrieve stones or visualize
and biopsy ductal tumors. The standard instrument is a flex-
ible fiberoptic scope. If a fiberoptic scope is not available, for
Fig. 90.7 example, when working overseas in underdeveloped coun-
tries or in a very small hospital, a nephroscope (either flexi- the right system takes off anteriorly. Both ductal systems
ble or rigid) will work. Saline is used to perfuse and distend should be explored.
the lumen of the bile duct to allow adequate visualization. Next the scope is oriented into the distal CBD. By plac-
By crossing the two stay sutures over the choledochotomy ing slight caudal traction with the left hand around the
incision, the CBD can be maintained in a state of distension region of the ampulla, the surgeon can help to elongate and
by preventing the exit of the lumenally perfused saline, pro- straighten the course of the CBD slightly, maximizing the
viding optimal visualization. A metal instrument channel visualization. There are two methods for positively identify-
attached to the choledochoscope allows passage of a flexible ing the distal termination of the CBD. One is passage of the
forceps (7 Fr size), a Dormia stone basket, or a small biliary choledochoscope through a patulous ampulla (rarely possi-
Fogarty catheter under vision to aid ductal clearance. ble) and into the duodenum; the knobby duodenal mucosa is
To use the choledochoscope, it is usually easier to stand markedly different from the smooth epithelium of the
on the left side of the patient (Fig. 90.9). Also we emphasize CBD. The second method is to pass a biliary Fogarty cath-
the benefit of a full Kocher maneuver before the CBD explo- eter into the duodenum, inflate the balloon, and draw back
ration which helps to straighten out the CBD facilitating on the catheter. By advancing the scope over the catheter
visualization. down to where the catheter disappears into the duodenum,
Pass the horizontal limb of the rigid scope or the flexible you can be certain that the entire CBD has been visualized
scope up into the common hepatic duct; the bifurcation of and that there are no calculi in the distal, pancreatic portion
the right and left ducts will be seen. Remember to think of of the CBD.
the hepatic ducts as a trifurcation (not a bifurcation) with the Not infrequently, especially if there has been cholangitis,
posterior branch of the right main duct most often opening the distal CBD contains shreds of fibrin or what looks like
posteriorly into the right hepatic duct but on occasion either ductal mucosa hanging off the wall and partially obscuring
into the bifurcation of the right and left hepatic ducts or into the lumen of the duct. Flushing the lumen may help to
the proximal posterior aspect of the left hepatic duct. debride this evidence of inflammation. Choledochoscopy is
Generally the left duct lies in the same plane horizontally or probably the most accurate single method for detecting CBD
a bit more posteriorly than the common hepatic duct, while stones.
If stones are seen, remove the choledochoscope and
attempt to remove the stones as before; if this is not success-
ful, reinsert the choledochoscope and use a Fogarty catheter
or a stone basket under direct visual control via the
choledochoscope.
If a suspicious mucosal lesion is identified, insert a flexi-
ble biopsy forceps and obtain a sample. Sometimes, although
very rarely, an ampullary or distal bile duct neoplasm (or a
stricture) is diagnosed in this manner.
CBD exploration with removal of calculi is accompanied
by a 3–5% incidence of retained stones. Choledochoscopy
decreases the incidence of residual stones to 0–2%. Using
choledochoscopy routinely during CBD exploration adds no
more than 10 min to the procedure and occasionally detects
a stone missed by all other modalities.
Transduodenal Sphincterotomy/
Sphincteroplasty for Impacted Stones
After ensuring a complete Kocher maneuver, pass a biliary

Fogarty catheter into the choledochotomy incision and down
to the distal CBD and into the duodenum if possible. By pal-
pating the balloon of the catheter through the anterior wall of
the duodenum, you can appreciate the exact location of the
ampulla. Then elevate the duodenum anteriorly and rotate it
a bit toward the left side of the patient to bring the true lateral
Fig. 90.9 wall of the second portion of the duodenum more anteriorly.
Make a 4 cm longitudinal incision (a transverse incision

markedly limits the visibility) in the lateral wall of the duo-
denum directly opposite the ampulla after placing 2 stay
sutures; be certain that you do not make this duodenotomy
on the anterior wall of the duodenum, because it will mark-
edly complicate exposure of the ampulla. After visualizing
the ampulla, the stone often can be palpated or at least appre-
ciated by its presence in the intraduodenal portion of the
CBD distending the ampulla. Start by placing two small
caliber, stay sutures at 3 and 9 o’clock just outside the ampul-
lary mucosa; these will help with exposure. If the biliary
catheter has passed through the ampulla, start by making a
small, 5 mm incision in the ampulla at 10 o’clock (this will
be as far away from the entrance of the pancreatic duct as
possible) and lengthening this incision with Potts scissors
under vision. Usually the stone can be removed easily there-
after. If the papillotomy incision must be extended further to
provide adequate exposure, a sphincteroplasty probably
should be done after the stone is removed, which is described
further in Chap. 91. Then insert the T-tube into the CBD
incision.
Checking for Ampullary Stenosis
Before completing the CBD exploration, the diameter of the

distal common bile duct and ampulla of Vater should be
determined by passing a small diameter catheter or a biliary Fig. 90.10
Fogarty catheter to rule out stenosis, which can lead to bili-
ary stasis and the formation of primary choledocholithiasis. angiography 7–8 days after the CBD exploration, but also to
If a 10 Fr rubber catheter passes through the ampulla, no allow the interventional radiologist to access the extrahepatic
further intubation is necessary. Many times such a catheter is biliary tree should a retained stone be seen. Use at least a 16
too soft, and the Fogarty catheter with a flexible albeit some- Fr T-tube to facilitate extraction of any residual stones post-
what stiffer tip is needed; attempts to pass a Bakes dilator is operatively through the T-tube track. Whether the duct is
contraindicated, because the metal Bakes dilator can easily large or small, excise half the circumference from the hori-
perforate the bile duct by the less experienced biliary sur- zontal limb of the tube as illustrated in Fig. 90.5. Also, the
geon. In the absence of malignancy, we have found it rare to length of the two limbs of the T-tube should be short (no
be unable to pass a catheter through the ampulla using gentle more than 2 cm), and certainly the distal limb should not be
manipulation. If the pre-exploration cystic duct cholangio- made long enough to enter the duodenum; such a long limb
gram showed dye passing through the duodenum, failing to can fold back on itself because the tube material is very soft
pass a 3 mm instrument through the ampulla is not by itself and the limb can obstruct the pancreatic duct causing pancre-
an indication for sphincteroplasty or biliary-intestinal atitis. After inserting the T-tube, close the choledochotomy
bypass. incision with a 4-0 absorbable suture (Fig. 90.10). Make this
In any case, never use excessive force when attempting to closure snug around the T-tube to avoid leakage during chol-
pass any instrument through the ampulla. angiography and subsequent leakage of bile. Put the exit site
of the T-tube as far distally in the choledochotomy as possi-
ble, because the most common site of stenosis secondary to
Insertion of the T-Tube leak is where the T-tube exited the CBD; should a stenosis
occur, you will preserve another centimeter or two of the
Although it is possible in some situations to avoid draining more proximal CBD.
the CBD after either stone removal or a negative CBD explo- One precaution is offered. If the CBD is extremely small
ration, we believe that a T-tube should be inserted almost in diameter (4 mm or less), one should reconsider a formal
routinely not only to decompress the CBD and to allow chol- CBD exploration and consider doing a transduodenal schinc-
terotomy to remove the stone in contrast to opening such a Drainage and Closure
small CBD- so, ask yourself, is there hard evidence of a CBD
stone such as after a cholangiogram, which would be unusual Exteriorize the T-tube through a straight path via a stab
with such a small CBD, or should you be doing a transduo- wound near the anterior axillary line. Place a closed-suction
denal CBD exploration rather than making a choledochot- drain through a separate stab wound and position it near the
omy in such a small CBD? CBD. Place omentum over the CBD and under the incision.
Suture the T-tube securely to the skin, leaving enough slack
between the T-tube site of fixation and the skin of the abdom-
Completion Cholangiogram inal wall to allow for any abdominal distension.
Try to evacuate the air in the long limb of the T-tube by with-
drawing some bile or by letting it drain bile spontaneously. aparoscopic CBD Exploration: Operative
L
Place the patient in a small degree of the Trendelenburg Technique
position and rotate the patient a bit to the left. Stand behind a
lead screen covered with sterile sheets and obtain the cholan- Laparoscopic CBD exploration may be indicated when a CBD
giogram by first injecting only 4 ml of diluted (50/50) contrast stone is encountered during laparoscopic cholecystectomy.
medium for the first radiograph; this small amount of contrast The goals of the laparoscopic exploration are the same as the
agent will not “hide” a small stone. Then inject an equal open CBD exploration. The major procedural difference is the
amount for the second and third pictures. Fluoroscopy with a technical and technologic expertise required by the surgical
C-arm (if available) allows the surgeon to watch the flow of team in order to accomplish the laparoscopic approach safely.
contrast and facilitates the procedure. Despite fluoroscopy, it Setup: A CBD stone is usually discovered during cholan-
always helps to obtain a formal cholangiogram as well. For a giography; thus, access to the biliary tree has already been
very large diameter duct (>15 mm), use a more dilute solution obtained. The majority of laparoscopic CBD explorations
to avoid obscuring small stones within a dense column of dye. will be performed through the cystic duct (transcystically).
The goal of the completion cholangiogram is to visualize The passage of gallstones from the gallbladder into the com-
flow of contrast into the duodenum and to visualize the intra- mon bile duct usually leads to a somewhat dilated cystic
hepatic ducts to exclude a retained stone proximally. If the duct, enabling adequate transcystic access.
contrast material does not enter the duodenum, then elevate As with the open approach, flushing the CBD with saline
the head of the bed and repeat the sequence after giving through the cholangiogram catheter is the first step in the
nitroglycerin or glucagon intravenously. If the contrast mate- clearance effort. Glucagon (1 mg iv) can be given to relax the
rial still does not enter the duodenum but the radiograph is ampulla and facilitate the passage of a small stone. If on sub-
otherwise negative, discontinue the study. Sphincter spasm sequent cholangiography the stone persists, mechanical
can follow ampullary instrumentation and often cannot be clearance can be attempted.
overcome during completion cholangiography. Remember, Under fluoroscopic vision, a long # 3 Fogarty catheter can be
you will have access to the CBD via your T-tube, and the advanced through the cystic duct into the common bile duct.
duct will be decompressed; also you had passed a catheter Insertion of this flexible tipped catheter can be achieved over a
into the duodenum before closing the choledochotomy over guidewire if necessary. A Franklin forceps can assist in guiding
the t-tube. Remember to have a high suspicion of a distal the catheter (and wire) to the ductotomy and will prevent CO2
CBD stone, stricture, or ampullary neoplasm. leakage from the trocar site. Either an epigastric trocar or a tro-
If the contrast agent does not visualize the bile duct proxi- car in the right midclavicular line will usually provide good
mally, place the patient in extreme Trendelenburg position access to the cystic duct. Once in position, the balloon is insuf-
and repeat the study. If the proximal bile ducts are not seen, flated gently and withdrawn, producing the stone at the cystic
then gently occlude the CBD distal to the T-tube and repeat duct opening. This step is repeated until the duct is clear.
the cholangiogram with a small amount of contrast initially. Alternatively, a choledochoscope can be used to visualize
If a retained stone is seen on this cholangiogram, the the stone(s) and capture them using a 3 or 4 pronged basket
T-tube should be removed and the CBD explored as before (see Fig. 90.4A, B). The laparoscopic choledochoscope is
with a careful completion choledochoscopy. If unsuccessful, smaller in diameter than the open choledochoscope. It is
then place a T-tube and rely on interventional radiology or similar in technical specifications to a flexible ureteroscope.
interventional gastroenterology to help with removal of the Preferably, the choledochoscope will have two ratchets, one
stone 4–6 weeks later. for up/down and one for right/left, to limit the need to torque
lecystectomy. A very large cystic duct may require closure

with an Endoloop if a clip does not cross the entire lumen. A
T-tube is usually not required for a transcystic exploration
unless there is great concern that there are residual stones.
Laparoscopic CBD exploration via a choledochotomy can
also be performed, but should not be used if one can explore
the duct via the cystic duct. Similar to the open exploration,
stay sutures are placed lateral to the site of the planned cho-
ledochotomy. A sharp incision is made and then the choledo-
choscope, catheter, and baskets can be introduced through the
ductotomy. The closure of the ductotomy requires compe-
tence in laparoscopic suturing. Several surgeons who have
become facile at performing an exploration through the CBD
do not consider the placement of a T-tube mandatory; other
Fig. 90.11 surgeons believe that the very thin-walled CBD is at high risk
of leakage of bile, and if there is bacterobilia, a leak can be
the scope through the trocar. The setup of the scope may quite serious. Also a T-tube should be considered strongly if
require some team training. the papilla is very edematous or the distal CBD obstruction is
A laparoscopic camera head and light source can be con- not completely resolved. The fashioning of the T-tube is the
nected to the eye piece of the choledochoscope. The light same as for the open CBD exploration (Fig. 90.5). A trocar
intensity needed will be fairly low (sometimes the setting site may be used to place the tube. Remember to bring the
may be “standby”). Ideally, the image will be displayed T-tube out in as straight a line as possible. Additional sutures
simultaneously with the laparoscopic image on the monitors, may be required to prevent leakage at the skin site.
as “picture in picture,” so the surgical team does not have to
switch positions to visualize the progress being made.
Instead of gas insufflation, a saline flow is established Postoperative Care
through the choledochoscope to allow a clear picture. An infu-
sion bag and tubing is connected to the working port. Attach the T-tube to a sterile plastic bag and permit it to drain
Additionally, a rubber cap with a small flexible opening is posi- freely by gravity until cholangiography is performed through
tioned to allow wires and stone baskets to be passed through the the T-tube on postoperative day 5–7. If the cholangiogram is
instrument. The image of the setup is provided in Fig. 90.11. negative and shows free flow into the duodenum, clamp the
Once the setup is completed, the choledochoscope is T-tube. Unclamp the tube if the patient experiences any
carefully passed through the trocar. If the duct diameter is abdominal pain, nausea, vomiting, shoulder pain, or leakage
too small to admit the scope, a careful, gradual balloon dila- of bile around the T-tube. Although some surgeons have
tion of the cystic duct can be performed. The scope can be removed the T-tube on postoperative days 14 and 21, we pre-
advanced into the cystic duct over a wire if one is present. If fer a more conservative approach and wait a full 4–6 weeks.
the choledochoscope is guided into position with a grasper, If during the 4 to 6 weeks there have been no problems with
care is to be taken when grasping the fragile flexible end of the t-tube clamped, there is no need to again repeat a cholan-
the scope. A protective cover over the grasper arms is useful giogram after the early postop one.
to prevent frequent repairs. Depending on the situation, antibiotics should be discon-
Once the choledochoscope is in place, the mechanism of tinued within 24 h unless there is evidence of bacterobilia,
the exploration is similar to the open exploration. A Dormia- cholangitis, or if there is an obvious bile leak; if cholangitis
like stone basket is advanced through the scope just past the is present, intravenous antibiotics should be focused based
stone, the basket is then opened, and pulled back until the on the intraoperative bile culture and continued until the
stone is captured within the basket. The basket is then gently clinical signs of inflammation are resolved. The closed-suc-
closed and withdrawn through the cystic duct. If visualization drain can be removed by postoperative day 3 unless
tion of the duct wall is difficult, adjusting the rate of saline there has been persistent bilious drainage.
flow or rotating the scope may be helpful. Observe the patient carefully for possible development of
After the retrieval of the stone(s) is completed by visualiza- postoperative acute pancreatitis by determining the serum
tion through the choledochoscope, a completion cholangio- amylase levels if the patient does not progress as expected. In
gram is performed. Once you are convinced that the duct is general, do not feed the patient if there is any suspicion of
clear, the cystic duct is then ligated like during a regular cho- acute pancreatitis.
Complications erative pancreatitis do not complain of an unusual degree of

pain but have abdominal distension and vomiting. The mor-
Bile Leak and Bile Peritonitis tality rate of postoperative acute pancreatitis is reported to be
quite high and can be as greater as 10%.
T-tube displacement The T-tube is fixed at two points: (1)
the CBD and (2) the exit site on the skin where the T-tube is
sutured in position. Enough slack must be left in the T-tube Increasing Jaundice
between the CBD and the site of skin fixation so any increase
in abdominal distension does not pull the tube out of the After choledocholithotomy in the jaundiced patient, it is com-
CBD. When bile leaks at the choledochotomy, bilious drain- mon for the serum bilirubin concentration to decrease slowly
age from the drain track alongside the T-tube or in the closed- during the first postoperative week. If the serum bilirubin
suction drainage catheter is noted. If this leak occurs during increases despite the T-tube draining bile, ask for a direct and
the first few days after the operation, upper abdominal pain indirect serum bilirubin to exclude hepatic dysfunction second-
and tenderness may appear, indicating bile peritonitis. A ary to preoperative jaundice. Rarely a blood clot can obstruct
localized bile leak is fairly well tolerated in the postoperative the biliary tree proximal to the T-tube, but these clots usually
patient who has adequate drainage, whereas when bile dissolve in several days. Any worry about biliary obstruction
spreads diffusely over a large part of the abdominal cavity, it should be excluded with a cholangiogram via the T-tube. The
may produce generalized bile peritonitis, especially if the worry of course is a retained stone proximal to the T-tube.
bile is infected. Diffuse abdominal tenderness generally
demands either immediate laparotomy for replacement of
the T-tube or insertion of an ERC stent into the CBD. Hemorrhage (Hemobilia)
Bleeding through the T-tube indicates hemobilia. Hemobilia

Ductal injury A completion cholangiogram through the usually arises from intrahepatic trauma during attempts to
T-tube should detect a major ductal injury, but an injury to an extract an intrahepatic calculus. This form of hemobilia gen-
accessory duct may not be evident. If the latter manifests by erally resolves with expectant treatment. In case of persistent
continuous drainage of small to moderate amounts of bile hemobilia, hepatic arteriography by an interventional radi-
along the drain tract and the cholangiogram is persistently ologist should be performed to rule out and treat an arterio-
normal, do not remove the T-tube or the drain, and be patient. biliary fistula, because iatrogenic trauma to a branch of the
The most frequently injured anomalous bile duct is the right hepatic artery during the hepatic duct exploration may be the
posterior hepatic duct that drains the posterior segment of the source of bleeding; this is a very rare complication with a
right lobe. Some of these leaks will close spontaneously with reported incidence of less than 0.1%.
the aid of the decompressing T-tube; if the drainage persists,
the patient may need to be reoperated to construct a bilio-
enteric anastomosis to this site of bile leak, especially if the Residual CBD Stone Postoperatively
leaking bile duct is >4 mm in diameter.
Early Postoperative Treatment
Most often a residual CBD stone is seen on the postoperative
Postoperative Acute Pancreatitis T-tube cholangiography. When this study is read as positive
for calculi by the radiologist, carefully review the films.
Acute pancreatitis after choledocholithotomy accounts for Shadows that are odd in shape may not be calculi but may be
about half the postoperative fatalities. This complication due to residual blood clot or debris. There is no need for
may be caused by over-zealous instrumentation of the ampul- early operative intervention aimed at removing a residual
lary region. If an impacted stone cannot be removed with CBD stone so long as the T-tube is draining well and the
ease through the choledochotomy incision, approach it either patient is not septic. Nonoperative interventional radiologic
via a transduodenal papillotomy or via an interventional methods of extracting calculi are extremely effective. Also,
radiologic approach through the T-tube tract or combined some of the radiographic shadows interpreted as calculi may
endoscopic approach 2–3 weeks later. Treatment of this form indeed be artifacts that disappear on subsequent cholangio-
of acute pancreatitis requires antibiotics, because most grams without treatment or may be stones small enough to
patients with choledocholithiasis have bacterobilia. pass spontaneously.
Determination of the serum amylase level should be If the radiographic evidence is convincing and a stone less
obtained in any patient after choledocholithotomy who is not than 1 cm in diameter is seen in the distal CBD, a saline flush
progressing as expected, because some patients with postop- may be indicated if tolerated by the patient. This should not
be performed before the 12th postoperative day for fear of this technique is much more complicated than the radiologic
exacerbating or causing a bile leak at the T-tube choledo- technique.
chotomy site. Similarly, if the calculus completely blocks the
distal CBD, this technique is contraindicated. In the absence
of these contraindications, infuse 1000 ml of normal saline Further Reading
through the T-tube over a 24-h period, provided it does not
produce excessive pain or lead to increased output from the Burhenne HJ. Complications of nonoperative extraction of retained
common duct stones. Am J Surg. 1976;131:260.
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persists and is not obstructing and the patient tolerates chostomy in the surgical treatment of patients with common bile
clamping of the T-tube, keep the tube clamped. Ask the duct stones. World J Surg. 1998;22:1167.
patient to return to the hospital about 6 weeks after the CBD. Franklin M. Laparoscopic common bile duct exploration via cho-
ledochotomy. In: Soper NJ, Scott-Conner C, editors. The SAGES
manual: volume 1, basic laparoscopy and endoscopy. New York:
Subsequent Postoperative Treatment Springer; 2012.
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Heiken TJ, Birkett DH. Postoperative T-tube tract choledochoscopy.
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ual calculi is the Burhenne technique. This method usually tion. Surg Clin North Am. 2008;88:1019.
McAlister VC, Davenport E, Renouf E. Cholecystectomy deferral in
requires at least a 14–16 Fr T-tube. The T-tube is removed patients with endoscopic sphincterotomy. Cochrane Database Syst
and a flexible stone basket is inserted through the track of the Rev. 2007;17:CD006233.
T-tube and into the CBD. Under fluoroscopic control, the Parra-Membrives P, Diaz-Gomez D, Vilegas-Portero R, Molina-
stone is trapped in a stone basket and withdrawn. Experienced Linde M, Gomez-Bujedo L, Lacalle-Romigio JR. Appropriate
management of common bile duct stones: a RAND corporation/
radiologists have reported a success rate >90% with this UCLA appropriateness method statistical analysis. Surg Endosc.
technique. If the stone is quite large, it may not fit into the 2010;24:1187.
T-tube track. Large stones are not commonly left behind by Petelin JB. Laparoscopic common bile duct exploration: transcystic
competent surgeons, so almost all residual stones can be duct. In: Soper NJ, Scott-Conner C, editors. The SAGES manual:
volume 1, basic laparoscopy and endoscopy. New York: Springer;
removed by this technique. If the stone is really quite large, a 2012.
contact lithotripsy can be performed to pulverize the stone. It Thompson JE Jr, Bennion RS. The surgical management of impacted
may also be possible to use percutaneous lithotripsy to break common bile duct stones without sphincter ablation. Arch Surg.
up the stone. It is even possible to cannulate the right and the 1989;124:1216.
Verbesey JE, Birkett DH. Common bile duct exploration for choledo-
left hepatic ducts to remove stones. Another method for cholithiasis. Surg Clin North Am. 2008;88:1315.
accomplishing the same end is to pass a flexible fiberoptic Williams EJ, Green J, Beckinham I, Parks R, Martin D, Lombard M,
choledochoscope into the CBD via the T-tube track, although British Society of Gastroenterology. Gut. 2008;57:1004.
Sphincteroplasty
91
Renganaden Sooppan and Charles J. Yeo
• Failed endoscopic retrieval of impacted distal CBD stones • Pancreatic complications such as postoperative pancreati-
(Cameron and Sandone 2007) tis due to trauma to the pancreatic duct, with subsequent
• Sphincter of Oddi dysfunction (Miccini et al. 2010) pancreatic pseudocyst or abscess (Anderson et al. 1985)
• Pancreas divisum (Madura and Madura 2007) • Postoperative duodenal fistula secondary to a leak from
• Local excision of small to moderate-sized ampullary either the closure of the duodenotomy or the
adenomas sphincteroplasty
• Ampullary or pancreatic duct orifice stenosis with recur- • Postoperative hemorrhage
rent abdominal pain or pancreatitis
• Primary or secondary papillitis (Stefanini et al. 1974)
Operative Strategy
Preoperative Preparation Duodenotomy
Magnetic resonance cholangiopancreatography (MRCP) or After performing a Kocher maneuver, the second part of the
ERCP to map the anatomy of the CBD, main and/or acces- duodenum (descending duodenum) is palpated to identify
sory pancreatic ducts the ampulla or a mass in the case of a duodenal adenoma. If
the ampulla cannot be identified, a biliary Fogarty catheter
• Informed consent for surgery placed via the cystic duct can be used as described below
• Anti-embolism stockings and heparin 5000 unit subcuta- before making a duodenotomy. A longitudinal (vertical) duo-
neous injection denotomy is preferred, in case it has to be extended in either
• Perioperative antibiotics direction.
• Preoperative checklist and “time out”
Preventing Duodenal or CBD Leak
The anterior wall of the bile duct and the posterior wall of the
duodenum merge to share a common wall (Moody et al.
1991). When performing the bile duct sphincteroplasty, one
should pay close attention to the extent of the cephalad inci-
sion at the 12 o’clock position. Leakage from the apex can
R. Sooppan happen if the sphincterotomy is extended beyond that com-
Department of Surgery, Jefferson Pancreas Biliary and Related
Cancer Center, The Sidney Kimmel Medical College, Thomas mon wall, hence leaving an enterotomy in the back wall of
Jefferson University, Philadelphia, PA, USA the duodenum or a choledochotomy in the anterior wall of
C. J. Yeo (*) the CBD. It is also crucial to carefully approximate the CBD
Department of Surgery, Sidney Kimmel Medical College, Thomas and the mucosa of the duodenum at the apex of the vertical
Jefferson University, Philadelphia, PA, USA incision, to prevent leakage.
e-mail: charles.yeo@jefferson.edu

https://doi.org/10.1007/978-3-030-81415-1_91
702 R. Sooppan and C. J. Yeo
Identifying and Protecting the Pancreatic Duct Next, perform a generous Kocher maneuver to elevate the
duodenum away from the flimsy retroperitoneal attachments,
When transecting across the ampulla of Vater in the case elevating the second portion of the duodenum (D2) up almost
of a mucosal resection of a periampullary adenoma, or to the level of the anterior abdominal wall, facilitating expo-
when performing a papillotomy to expose the interior of sure of the ampulla of Vater.
the ampulla, one should be cognizant that there are two
separate ducts that converge at this junction. The orifice
of the pancreatic duct is normally inferior to the bile duct ocation of the Ampulla of Vater
L
(Stefanini et al. 1974). A No. 3 Bakes dilator or a pediat- and Duodenotomy
ric feeding tube can be used to identify, preserve, and
protect the pancreatic duct while performing the bile duct Attempt to palpate the ampulla or the mass through the duo-
sphincteroplasty. Great care should be taken to avoid denum to locate the correct position for the duodenotomy. If
obliterating the orifice of the pancreatic duct by pulling the ampulla cannot be easily identified, create a cystic duc-
the duodenal mucosal over it while approximating the totomy using Metzenbaum scissors or a #15 blade and care-
inferior border of the bile duct to the cut edge of the duo- fully pass a biliary Fogarty catheter through the cystic duct,
denal mucosa. In fact, it is best to place no sutures from down the CBD and out of the ampulla. Once the catheter is
the 4 o’clock to the 8 o’clock positions, to avoid injury to in the duodenum, inflate the balloon to facilitate the location
the pancreatic duct orifice. of the area of the ampulla.
In patients who have had a prior cholecystectomy, per-
form a small choledochotomy and insert a Bakes dilator or
Closure of Duodenotomy biliary Fogarty catheter through the distal CBD, pass it
through the ampulla, and palpate it in the duodenum
The duodenotomy is closed transversely using a two-layer (Cameron and Sandone 2007). Place stay sutures of 3-0 silk
closure technique to prevent narrowing of the duodenal in the duodenum over the ampulla and perform a longitudi-
lumen and stricture. nal duodenotomy using electrocautery (Fig. 91.1).
Operative Technique
Incision and Exploration
Enter the abdomen through a vertical midline incision from

below the xiphoid to above the umbilicus using a skin scalpel
and electrocautery. Perform a thorough exploration of the
liver, gallbladder, stomach, duodenum, small bowel, and
colon to assess for abnormalities or metastatic disease.
Protect the wound edges with moist lap pads and place a self-
retaining retractor for optimum exposure. We favor a Duodenotomy
Bookwalter retractor system.
obilization of the Gallbladder and Kocher

M
Maneuver
If the gallbladder is present, mobilize it from the gallbladder

fossa with electrocautery using a dome down approach.
Identify and tie the cystic artery with 3-0 silk. Dissect the Balloon
advanced
cystic duct free of any adipose or fibrous tissues and prepare
it for access with a biliary Fogarty catheter (if needed to Fig. 91.1 (Reprinted from Cameron and Sandone 2007, p. 33.
identify the ampulla) and subsequent ligation. Copyright © 2008 by PMPH-USA, Ltd. Reprinted with permission)
91 Sphincteroplasty 703
Mucosal Resection of Periampullary Adenoma Bile Duct Sphincteroplasty
Assess the mass for local resectability (i.e., confined to the Identify the orifices of the bile duct and the pancreatic duct.
mucosa), extent, and benign physical features. Place circum- Open the distal common bile duct 1 cm in the vertical direc-
ferential 3-0 silk mucosal stay sutures in the normal duode- tion at the 12 o’clock position using Potts scissors and elec-
nal mucosa at least 5 mm away from the adenomatous lesion trocautery, giving access to the glistening mucosa of the
and hold these with mosquito clamps. We typically place at distal common bile duct (Fig. 91.3). Then, approximate the
least four of these mucosal stay sutures. Elevate the mucosal edges of the duodenal mucosa and the bile duct using inter-
mass off the submucosa by injecting 1% lidocaine with rupted 5-0 or 6-0 absorbable suture such as polydioxanone
1:100,000 epinephrine solution circumferentially at the junc- (PDS). We find it best to commence these sutures inferiorly
tion of the mass and normal mucosa (Fig. 91.2). Use needle- and to advance cephalad to the apex of the sphincteroplasty
tip electrocautery to elevate and resect the mass with a full (Fig. 91.4). Gather the sutures in a hemostat to provide
thickness mucosal resection and a 5-mm circumferential retraction. Once a No. 4 Bakes dilator is passed through the
margin. Identify and transect the distal bile duct and its sur- sphincteroplasty and up the common bile duct with ease,
rounding muscular fibrous tissue, including these with the place the apex suture and tie it. The length of the sphinctero-
specimen. plasty will vary depending on the reason for the procedure
Fig. 91.2
and the length of the muscular sphincter. However, the

sphincteroplasty should not be extended beyond the shared
common wall of the duodenum and bile duct to prevent intra-
peritoneal and retroperitoneal leaks (Cameron and Sandone
2007).
Pancreatic Ductoplasty and Septotomy
Identify the pancreatic duct orifice inferiorly (it may be quite

small and difficult to see; look for a tiny bit of clear pancreatic
juice egressing). If after careful inspection, the pancreatic duct
cannot be properly identified, administer intravenous secretin (1
unit/kg), which causes a brisk flow of clear pancreatic juice
(Kelly and Rowlands 1996). Perform the pancreatic duct septot-
omy by incising the common wall between the anterior surface
of the pancreatic duct and the posterior wall of the bile duct. The
length of the septotomy is usually 4–5 mm in length at which
point the septum thickens as the bile duct and pancreatic duct
diverge (Cameron and Sandone 2007). If the orifice of the pan-
Pancreatic creatic duct is too narrow for the blade of the Potts scissors, insert
duct orifice a metal probe into the pancreatic ductal orifice and incise the
anterior wall of the duct using a scalpel against the metal of the
Fig. 91.3 (Reprinted from Cameron and Sandone 2007, p. 34.
probe (Fig. 91.5). Approximate the edges of the duodenal
Copyright © 2008 by PMPH-USA, Ltd. Reprinted with permission)
mucosa and the pancreatic duct using interrupted 5-0 or 6-0
absorbable sutures such as polydioxanone (PDS). At the comple-
tion of the pancreatic ductoplasty, the orifice should allow pas-
Apex suture sage of at least a No. 2 Bakes dilator. Be careful not to force a
larger dilator through what may be a narrow orifice and duct. If a
mucosal excision has been performed, approximate the mucosal
edges to close the defect as noted above. With large mucosal
Probe in
pancreatic duct
Septotomy
Fig. 91.4 (Reprinted from Cameron and Sandone 2007, p. 34. Fig. 91.5 (Reprinted from Cameron and Sandone 2007, p. 35.
Copyright © 2008 by PMPH-USA, Ltd. Reprinted with permission) Copyright © 2008 by PMPH-USA, Ltd. Reprinted with permission)
91 Sphincteroplasty 705
excisions, the defect cannot be fully closed. In such a case, reepi- 4. Early ambulation at least 3 times per day, with hourly use
thelialization occurs rapidly as part of the healing process. of incentive spirometry.
5. Foley catheter is removed on POD #1 or #2.
6. Diet is advanced to clear liquids on POD #2.
ompleting the Cholecystectomy and Closing
C 7. On POD #3, the patient’s diet is advanced to a regular
the Duodenotomy house diet.
8. The patient is discharged home on POD #3 or #4.
If a biliary Fogarty catheter was used, remove it, tie the cytic
duct with a 2-0 silk ligature below the ductotomy, apply a small
titanium clip to mark the site, and transect the cystic duct, thus Complications
completing the cholecystectomy. Meticulously assess the muco-
sal resection site, sphincteroplasty, and septoplasty for hemosta- Postoperative Acute Pancreatitis
sis. Advance a nasogastric tube (NGT) through the pylorus and
into the duodenum beyond the ampullary area. Close the duode- Postoperative ileus, gastric dilation, surgical site infections,
notomy in a horizontal fashion using a two-layer closure tech- pain, and postoperative pancreatitis are common complica-
nique. First, use 3-0 Vicryl sutures for the inner layer, inverting tions of transduodenal sphincteroplasty. Pancreatitis may be
the mucosa in a continuous Connell fashion. Then carefully due to trauma to the pancreas or pancreatic duct during the
approximate the seromuscular layer with an outer layer of inter- Kocher maneuver, excessive manipulation and instrumenta-
rupted 3-0 silk Lembert sutures. Place a bowel clamp distal to tion of the pancreatic duct while attempting to identity its
the duodenotomy closure site and 200 ml of methylene blue location, or iatrogenic coverage of the pancreatic duct orifice
diluted in normal saline (10 drops of methylene blue in 200 ml with duodenal mucosa during the bile duct sphincteroplasty.
of normal saline) is injected into the NGT to assess for any leak, In the former two instances, the postoperative pancreatitis is
checking both anteriorly and posteriorly. Once the absence of a often self-limited (Stefanini et al. 1974; Moody et al. 1991).
leak is confirmed, pull the NGT back into the stomach and However, occasionally, patients may have an exaggerated
secure it to the nose. Return the duodenum to its normal poste- inflammatory response, leading to a significant increase in
rior position and may be covered with omentum if so desired. fluid requirements and hyperamylasemia in the immediate
postoperative period. The temporary systemic volume over-
load and inflammatory response can lead to cardiovascular
Drainage and Abdominal Closure and pulmonary (such as acute respiratory distress syndrome)
complications, especially in the elderly population (Anderson
Copiously irrigate the abdomen with warm sterile antibiotic et al. 1985).
solution and suction. Closed-suction drain placement is optional.
We typically do not place drains. If one opts to place a drainage
catheter around the duodenotomy site, the closed-suction plastic Duodenal Leak and Fistula
catheter (4–5 mm diameter) is brought out through a puncture
wound in the right flank, lateral to the right rectus muscle. The The posterior surface of the duodenum and the anterior sur-
drain is secured with two 4-0 surgical steel sutures. Close the face of the distal common bile duct share a common wall. If
midline fascia using running No. 2 nylon. Irrigate the subcuta- the distal common bile duct is opened beyond the common
neous tissue with sterile antibiotic solution and approximate it wall, an open posterior duodenotomy remains after comple-
with running 3-0 Vicryl sutures. Close the skin with 4-0 absorb- tion of the sphincteroplasty. The anterior duodenotomy clo-
able monocryl sutures. Apply benzoin and steri-strips to the sure site is also a potential source of duodenal leak and fistula
incision and cover with it a sterile dressing. which is often due to a technical error in closure. In both
instances, bile, pancreatic juice, and enteric contents can
freely spill into the abdominal cavity, causing a duodenal fis-
Postoperative Care tula which should be controlled by image-guided percutane-
ous drain placement. However, a serious duodenal leak can
1. The nasogastric tube placed intraoperatively is removed be life-threatening and may require a reoperative interven-
on the morning of postoperative day (POD) #1 and the tion. In such a case, the tissue surrounding the duodenotomy
patient is started on sips of water and ice chips. is often too friable and inflamed to be closed primarily. The
2. Intravenous proton pump inhibitor such as pantoprazole is duodenal leak can be controlled by performing a pyloric
administered every 12 h to maintain a gastric pH > 5.0. exclusion procedure, to include a gastrojejunostomy and
3. Monitoring of labs (i.e., hepatic function panel, amylase, omental patch repair of the duodenotomy leak site. Another
lipase, complete blood count) at least once option would be to patch the duodenal leak with healthy jeju-
postoperatively. nal serosa, brought up as a Roux-en-Y jejunal limb. Multiple
drains should be placed around the duodenum and in the ret- Cameron JL, Sandone C. In: Cameron JL, Sandone C, editors. Atlas of
roperitoneum for wide drainage and to control the leak. An gastrointestinal surgery. 2nd ed. Hamilton: BC Decker Inc; 2007.
p. 32–6.
optional jejunostomy tube for feeding purposes may also be Furukawa H, Iwata R, Moriyama N, Kosuge T. Blood supply to the
placed at the time of the reoperation. pancreatic head, bile duct, and duodenum: evaluation by computed
tomography during arteriography. Arch Surg. 1999;134:1086–90.
Kelly SB, Rowlands BJ. Transduodenal sphincteroplasty and
transampullary septectomy for papillary stenosis. HPB Surg.
Intraoperative and Postoperative Hemorrhage 1996;9(4):199–207.
Madura JA, Madura JA. Diagnosis and management of sphincter
The posterior branches of the pancreaticoduodenal arcade of Oddi dysfunction and pancreas divisum. Surg Clin North Am.
(i.e., where the posterior superior and the posterior inferior 2007;87(6):1417–29.
Miccini M, Bonapasta SA, Gregori M, Bononi M, Fornasari V, Tocchi
pancreaticoduodenal arteries meet) run in close proximity A. Indications and results for transduodenal sphincteroplasty in the
with the common wall between the anterior surface of the era of endoscopic sphincterotomy. Am J Surg. 2010;200(2):247–51.
pancreatic duct and the posterior wall of the distal common Moody FG, Vecchio R, Calabuig R, Runkel N. Transduodenal sphinc-
bile duct. One should be cognizant of this anatomical rela- teroplasty with transampullary septectomy for stenosing papillitis.
Am J Surg. 1991;161(2):213–8.
tionship and be meticulous and careful when performing a Morgan KA, Romagnuolo J, Adams DB. Transduodenal sphinc-
septotomy, so as not to inadvertently cause uncontrollable teroplasty in the management of sphincter of Oddi dysfunc-
intraoperative hemorrhage by cutting into the posterior arte- tion and pancreas divisum in the modern era. J Am Coll Surg.
rial branches (Furukawa et al. 1999). Delayed postoperative 2008;206(5):908–14.
Stefanini P, Carboni M, Patrassi N, De Bernardinis G, Negro P, Loriga
hemorrhage may be a sequela of intra-abdominal pancreatic P. Transduodenal sphincteroplasty. Its use in the treatment of
or duodenal leaks that lead to erosion into an arterial branch lithiasis and benign obstruction of the common duct. Am J Surg.
(usually the inferior pancreaticoduodenal artery) that can 1974;128(5):672–7.
cause significant and sudden bleeding (Moody et al. 1991).
Acknowledgments The authors thank Jennifer Brumbaugh for her Further Reading
superb original illustration (Fig. 91.2).
Akoglu M, Sahin B, Davidson BR. Extended transduodenal sphinctero-
plasty for bile duct stones associated with a periampullary diverticu-
lum. Postgrad Med J. 1992;68(799):346–9.
References Makary MA, Elariny HA. Laparoscopic transduodenal sphinctero-
plasty. J Laparoendosc Adv Surg Tech A. 2006;16(6):629–32.
Anderson TM, Pitt HA, Longmire WP, et al. Experience with sphincter- Tzovaras G, Rowlands BJ. Transduodenal sphincteroplasty and trans-
oplasty and sphincterotomy in pancreatobiliary surgery. Ann Surg. ampullary septectomy for sphincter of Oddi dysfunction. Ann R
1985;201(4):399–406. Coll Surg Engl. 2002;84(1):14–9.
Choledochoduodenostomy: Surgical
Legacy Technique 92
Indications • Anastomotic leak, duodenal fistula

• Postoperative “sump” syndrome in which debris accumu-
• Common bile duct (CBD) stasis with sludge or primary or lates in the distal common duct
recurrent stones (only if the bile duct is more than 1.5 cm
in diameter)
• Doubt that all CBD stones have been removed (only if Operative Strategy
CBD is >1.5 cm in diameter)
• Constriction of distal CBD because of chronic pancreati- Both end-to-side and side-to-side techniques have been
tis as an alternative to stenting or to Roux-en-Y bypass described. This chapter describes the simplest procedure, in
which a side-to-side anastomosis is created. The procedure
can also be done laparoscopically, but requires a high degree
Contraindications of facility in laparoscopic suturing (see references at the
end).
• CBD diameter <1.5 cm
• Acute inflammation or excessive fibrosis in duodenal wall
• Carcinoma of the pancreatic head when stenting is not suc- Size of Anastomotic Stoma
cessful (hepaticojejunostomy Roux-en-Y is our preferred
bypass procedure for pancreatic carcinoma obstructing the As the anastomotic stoma after side-to-side choledochoduo-
CBD. It is a safer operation, and the anastomosis is not denostomy permits passage of food from the duodenum into
obstructed by the advancing growth of the malignancy.) the CBD, it is important that the anastomosis be large enough
to permit the food to pass back freely into the duodenum.
Otherwise, food particles partially obstruct the anastomotic
Preoperative Preparation stoma, accumulate in the distal duct, and produce recurrent
cholangitis. If the surgeon constructs an anastomosis with a
• Perioperative antibiotics stoma 2.5 cm or more in diameter, postoperative cholangitis
• Vitamin K in jaundiced patients is rare. The size of the stoma may be estimated postopera-
• Nasogastric tube tively by an upper gastrointestinal barium radiographic
study.
Obviously, if the diameter of the CBD is small, a large
Pitfalls and Danger Points anastomotic stoma is difficult to achieve. Transduodenal
sphincteroplasty (see Chap. 80) is thus a better surgical
• Anastomotic stoma too small, resulting in postoperative option for the patient with a small CBD.
recurrent cholangitis
• Diameter of CBD too small
Location of the Anastomosis
Department of Surgery, University of Iowa Carver College There are several alternative locations for incisions in the
of Medicine, Iowa City, IA, USA CBD and duodenum. If postoperative anastomotic leakage is

https://doi.org/10.1007/978-3-030-81415-1_92
to be prevented, it is vitally important that these incisions be Operative Technique

made in tissues of satisfactory quality and that there be no
tension on the anastomosis. Incision
A problem occurs when the surgeon has made one inci-
sion in the CBD in the vicinity of the cystic duct for the CBD A right subcostal or a midline incision from the xiphoid to a
exploration and a second (duodenal) incision opposite the point 5 cm below the umbilicus is suitable for this operation.
ampulla for an impacted ampullary calculus. Under these Divide any adhesions and explore the abdomen. Perform a
conditions, even with an extensive Kocher maneuver, it may complete Kocher maneuver. If the diameter of the CBD is less
not be possible to approximate these two incisions by sutur- than 1.5 cm, do not perform a choledochoduodenostomy.
ing because there is too much tension on the anastomosis. In
this situation, a Roux-en-Y choledochojejunostomy or a
sphincteroplasty is preferable. When the possibility of a cho- Choledochoduodenal Anastomosis
ledochoduodenostomy is anticipated prior to the CBD explo-
ration, make the incision in the CBD near the point where it Free the peritoneum over the distal CBD. Make an incision
enters the sulcus between the pancreas and the duodenum. on the anterior wall of the CBD for a distance of at least
This facilitates constructing the anastomosis described in 2.5 cm. This incision should terminate close to the point
this chapter. where the duodenum crosses the distal CBD. Make another
When the incision in the CBD has been made in a more incision of equal size along the long axis of the duodenum at
proximal location, test the mobility of the duodenum after a point close to the CBD (Fig. 92.1). Insert the index finger
performing a Kocher maneuver. If the duodenum is easily into the duodenum and palpate the ampulla of Vater to be
elevated to the region of the CBD incision, a choledochoduo- certain a carcinoma of the ampulla has not been overlooked.
denostomy by the method illustrated below in “Alternative Place guy sutures at the midpoints of the lateral and medial
Method of Anastomosis” is acceptable. There must be no margins of the CBD incision. Apply traction to these guy
tension on the anastomosis. sutures in opposite directions to open up the choledochotomy
incision (Fig. 92.2). One layer of interrupted 4-0 Vicryl
Preventing the Sump Syndrome
Sporadic reports have appeared describing the accumulation

of food debris or calculi in the terminal portion of the CBD
following choledochoduodenostomy. Such an accumulation
produces intermittent cholangitis and has been called the
“sump syndrome.” Several techniques have been advocated
to prevent it. All are more complex than the technique
described here.
In the simplest variation, the CBD is divided and the dis-
tal portion oversewn. The proximal portion is anastomosed
to the duodenum to create an end-to-side, rather than a side-
to-side, choledochoduodenostomy. Alternatively, the proxi-
mal CBD may be anastomosed to a Roux-en-Y limb of
jejunum. This construction completely prevents food from
entering the CBD and provides the lowest incidence of sump
syndrome.
• Findings
• End-to-side versus side-to-side anastomosis Fig. 92.1
92 Choledochoduodenostomy: Surgical Legacy Technique 709
Fig. 92.2
Fig. 92.3
sutures is used for this anastomosis. Insert the first stitch of
the posterior layer approximating the midpoint of the duode-
nal incision to the distal margin of the choledochotomy. Tie
the stitch with the knot inside the lumen. Insert additional
stitches that go through the full thickness of the duodenum
and the CBD (Fig. 92.3), until the entire posterior layer has
been completed. Cut all of the sutures except the most lateral
and most medial stitches. Approximate the proximal margin
of the choledochotomy with the same suture material to the
midpoint of the anterior layer of the duodenum and tie this
stitch so it inverts the mucosa of the duodenum (Fig. 92.4).
Continue to insert interrupted through-and-through sutures,
until the anterior layer has been completed (Fig. 92.5). This
anastomosis should be completed without tension.
Alternative Method of Anastomosis
In some cases, the surgeon elects to perform a choledocho-

duodenal anastomosis after making a choledochotomy inci-
sion in a location too far proximal on the CBD to accomplish
the anastomosis by the above technique. In this case, enlarge
the choledochotomy so it measures at least 2.5 cm in length.
Next, perform a thorough Kocher maneuver to increase
the mobility of the duodenum. Then move the duodenum Fig. 92.4
Fig. 92.6
Fig. 92.5
toward the choledochotomy incision and determine which

portion of the duodenum is most suitable for a side-to-side
anastomosis without tension. If tension cannot be avoided,
perform a Roux-en-Y anastomosis.
Make an incision in the duodenum parallel to the choled-
ochotomy and approximately equal in length (Fig. 92.6).
Approximate the posterior layer with interrupted sutures and
tie them (Fig. 92.7), with the knots inside the lumen. Leave
the tails of the most cephalad and most distal sutures long,
but cut all other sutures. Bisect the anterior layer of the anas-
tomosis and insert a 4-0 PG Lembert suture to approximate
the midpoint of the CBD incision to the midpoint of the duo-
denal incision. Tie this suture so the duodenal mucosa is
inverted. Insert additional sutures of the same type to com-
plete the approximation. The knots are on the outside surface
of the anastomosis for the anterior layer. Because the CBD is
quite large in these cases and the duodenal wall is free of
pathology, no T-tube or other stent is necessary.
As bile has an extremely low surface tension, there is a tendency

for a small amount of this substance to leak out along the suture Fig. 92.7
92 Choledochoduodenostomy: Surgical Legacy Technique 711
holes during the first day or two following a biliary tract anasto- Degenshein GA. Choledochoduodenostomy: an 18 year study of 175
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Escudero-Fabre A, Escallon A Jr, Sack J, et al. Choledochoduodenostomy:
through a puncture wound in the right upper quadrant and bring analysis of 71 cases followed for 5 to 15 years. Ann Surg.
the catheter to the general vicinity of the anastomosis. 1991;213:635.
Kraus MA, Wilson SD. Choledochoduodenostomy: importance of
common duct size and occurrence of cholangitis. Arch Surg.
1980;115:1212.
Postoperative Care McSherry CK, Fischer MG. Common bile duct stones and biliary-
intestinal anastomoses. Surg Gynecol Obstet. 1981;153:669.
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ledochoduodenostomy: 130 consecutive series. Ann R Coll Surg
• Leave the closed-suction drain in place for 5–7 days.
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Qadan M, Clarke S, Morrow E, Triadafilopoulos G, Visser B. Sump
syndrome as a complication of choledochoduodenostomy. Dig Dis
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Toumi Z, Aljarabah M, Ammori BJ. Role of laparoscopic approach
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• Duodenal fistula review. Surg Endosc. 2011;25:2105–16.
• Subhepatic abscess White TT. Indications for sphincteroplasty as opposed to choledocho-
• Late development of cholangitis, owing to the anasto- duodenostomy. Am J Surg. 1973;126:165.
motic stoma being too small
• Late development of “sump” syndrome
Further Reading
Chander J, Mangla V, Vindal A, Lal P, Ramteke VK. Laparoscopic
choledochoduodenostomy for biliary stone disease: a single
center 10-year experience. J Laparoendosc Adv Surg Tech A.
2012;22:81–4.
Transduodenal Diverticulectomy
93
Indications inverted through an incision in the second portion of the duo-

denum. The diverticulum is excised, and the defect in the
• Perforation duodenal wall is closed from inside the lumen.
• Hemorrhage An alternative technique involves dissecting the duodenal
diverticulum from surrounding pancreas and duodenal wall
down to its neck near the ampulla. The terminal CBD must
Preoperative Preparation be identified as it enters the posterior wall of the duodenum.
Place a catheter in the CBD. Then transect the diverticulum
• Perioperative antibiotics at its neck and repair the defect in the duodenal wall. This
technique may be facilitated by inflating the duodenal diver-
ticulum with air injected through a nasogastric tube. It
Pitfalls and Danger Points requires meticulous dissection of the pancreas away from its
attachments to the posterior duodenal wall. As the pancreas
• Injury to pancreas, resulting in postoperative acute is dissected away from the duodenum, the terminal portion
pancreatitis of the CBD and the diverticulum may be exposed. This dis-
• Injury to distal common bile duct (CBD) section is tedious and sometimes difficult. It carries a greater
risk of causing postoperative acute pancreatitis than does the
transduodenal approach.
Operative Strategy
The strategy of managing patients operated on for perfora- Documentation Basics

tion depends on the degree of surrounding inflammation. If
the neck of the diverticulum is free of inflammation, it may • Findings
be possible to accomplish primary closure of the neck of the • Preservation of ampullary structures (how this was
sac with interrupted sutures. More often, leakage of duode- assured)
nal content through a perforated periampullary diverticulum
produces a violent inflammatory reaction. One cannot expect
primary suture of the duodenal wall to be secure under these Operative Technique
conditions. Consequently, as a lifesaving measure, it may be
necessary to divert both bile and gastric contents and to insert Incision
multiple suction drains to the area of perforation.
In elective cases where the diverticulum is free of inflam- Make a midline incision from the xiphoid to a point about
mation, the technique of transduodenal diverticulectomy 5 cm below the umbilicus or, alternatively, a long subcostal
described here works well. The sac of the diverticulum is incision.
Department of Surgery, University of Iowa Carver
College of Medicine, Iowa City, IA, USA

https://doi.org/10.1007/978-3-030-81415-1_93
Kocher Maneuver
Incise the lateral peritoneal attachments of the descending

duodenum and mobilize the duodenum and the head of the
pancreas, as shown in Chap. 14. Place a gauze pad behind the
head of the pancreas to elevate the duodenum.
Duodenotomy and Diverticulectomy
Make a 4- to 5-cm longitudinal incision near the antimesen-

teric border of the descending duodenum (Fig. 93.1). Identify
the ampulla by palpation or visualization (Fig. 93.2). If there
is any difficulty identifying the ampulla in this fashion, do
not hesitate to make an incision in the CBD and pass a Coude
catheter gently down to the ampulla through the CBD inci-
sion. Identify the orifice of the periampullary diverticulum
and insert forceps into the diverticulum. Grasp the mucosal Fig. 93.2
wall of the diverticulum (Fig. 93.3) and gently draw the
mucosa into the lumen of the duodenum, until the entire
diverticulum has been inverted into the lumen of the duode-
num (Figs. 93.4 and 93.5). Transect the neck of the diverticu-
lum about 2–3 mm from its junction with the duodenal wall.
Inspect the bed of the diverticulum through the orifice in
the duodenum to check for bleeding. Then close the duode-
nal wall by suturing the seromuscular layer with interrupted
Fig. 93.3
4-0 PG and invert this layer into the lumen of the duodenum.
Close the defect in the mucosa with inverting sutures of
interrupted 5-0 PG (Fig. 93.6). This provides a two-layered
closure of the diverticulum, performed from inside the
duodenum.
Close the duodenotomy incision in two layers. Use inter-
rupted or continuous inverting sutures of 5-0 PG for the
mucosal layer and interrupted 4-0 atraumatic silk Lembert
sutures for the seromuscular coat.
Closure and Drainage
Bring a closed-suction drain out from the region of the head

Fig. 93.1 of the pancreas through a puncture wound in the right upper
93 Transduodenal Diverticulectomy 715
Fig. 93.6
quadrant of the abdomen. Close the abdominal wall in rou-

tine fashion.
Postoperative Care
Fig. 93.4 • Continue nasogastric suction for 3–5 days.

• Give the patient perioperative antibiotics.
• Check postoperative levels of serum amylase to detect
postoperative pancreatitis.
Complications
• Acute pancreatitis
• Duodenal leakage
Further Reading
Afridi SA, Fichtenbaum CJ, Taubin H. Review of duodenal diverticula.
Am J Gastroenterol. 1991;86:935.
Androulakis J, Colborn GL, Skandalakis PN, Skandalakis LJ,
Skandalakis JE. Embryology and anatomic basis of duodenal sur-
gery. Surg Clin North Am. 2000;80:171.
Iida F. Transduodenal diverticulectomy for periampullary diverticula.
World J Surg. 1979;3:103.
Lobo DN, Balfour TW, Iftikhar SY, Rowlands BJ. Periampullary diver-
Fig. 93.5 ticula and pancreaticobiliary disease. Br J Surg. 1999;86:588.
Lotveit T, Skar V, Osnes M. Juxtapapillary duodenal diverticula. Thompson NW. Transduodenal diverticulectomy for periampullar
Endoscopy. 1988;20(suppl 1):175. diverticula: invited commentary. World J Surg. 1979;3:135.
Mantas D, Kykalos S, Patsouras D, Kouraklis G. Small intestine Thorson CM, Ruiz PS, Roeder RA, Steeman D, Casillas VJ. The perfo-
diverticula: is there anything new? World J Gastrointest Surg. rated duodenal diverticulum. Arch Surg. 2012;147:81–8.
2011;3:49–53.
Hepatic Resection
94
Wen-Liang Fang and Carlos U. Corvera
• Isolated liver metastases Anatomic Basis for Liver Resection

• Primary hepatic malignancies
• In conjunction with bile duct resection for cases of proxi- There are three major hepatic veins: left, right, and middle.
mal bile duct carcinoma (see also Chap. 90) Each delineates a plane (termed a hepatic scissura) that
• Symptomatic benign liver lesions divides the liver into functional anatomic units (Fig. 94.1).
• Parasitic or bacterial infections, hepaticolithiasis, and The middle hepatic vein defines the main scissura. This
trauma (infrequent indications) anatomic plane divides the liver into two roughly equal units,
• The major contraindications to hepatic resections are the left and right liver. The terms left and right liver are used
hepatic insufficiency and advanced stage of malignancy. to avoid confusion with older terminology in which left and
right hepatic lobes were defined by surface anatomy rather
than deep anatomy. The location of this plane can be approx-
Preoperative Preparation imated by a plane running through the gallbladder fossa
anterior to the left margin of the inferior vena cava (IVC)
• Obtain high-quality arterial and venous phase imaging of posteriorly. This interlobar plane corresponds to the axis of
the liver. the middle hepatic vein. In modern terminology, a right
• Provide adequate blood and blood product support. hepatic lobectomy consists of removing all of the right liver,
• Optimize nutrition. and left hepatic lobectomy removes the entire left liver.
The portal pedicles contain major branches of the hepatic
artery, portal vein, and bile ducts running together. These
Pitfalls and Danger Points pedicles interdigitate with the hepatic veins. The territory
served by the portal pedicles and their major branches define
• Hemorrhage from hepatic or portal veins or hepatic arteries the sectors and segments of the liver (Fig. 94.2).
• Air embolism from hepatic venous injury Segments 1–4 comprise the left liver and segments 5–8
• Injury to the bile ducts, with postoperative obstruction or the right liver. Each segment has an identifiable portal pedi-
fistula cle. Segmental hepatic venous drainage is variable and ana-
• Portal or hepatic vein compromise with subsequent isch- tomically separates from the portal pedicles because of the
emia or postsinusoidal portal hypertension manner in which the hepatic veins interdigitate with and
• Prolonged vascular inflow occlusion leading to refractory cross these portal pedicles inside the liver.
liver ischemia At the hilum, the portal pedicles branch into the right and
• Insufficient residual function of hepatic parenchyma left pedicles (Fig. 94.3). A continuation of peritoneum
termed the cystic plate covers the right pedicle, and the left
W.-L. Fang pedicle is invested by the umbilical plate. This peritoneum
Division of General Surgery, Department of Surgery,
Taipei Veterans General Hospital, Taipei, Taiwan fuses with Glisson’s capsule, and the falciform ligament
C. U. Corvera (*) attaches at the cephalad aspect of the umbilical plate.
Department of Surgery, University of California, San Francisco, Adequate exposure of this area requires upward mobilization
San Francisco, CA, USA of segment 4 and incision of Glisson’s capsule.
e-mail: carlos.corvera@ucsf.edu

https://doi.org/10.1007/978-3-030-81415-1_94
718 W.-L. Fang and C. U. Corvera
Fig. 94.1
R. paramedian L. paramedian
sector sector
R. anteromedial L. anterior pedicle
pedicle
L. lateral
sector
R. lateral
sector L. posterior
pedicle
R. posterolateral
pedicle
R. scissura
R. hepatic v.
Main scissura L. scissura

Mid. hepatic v. L. hepatic v.
Right liver Left liver
7 5
2 Segment 2
8
4
1
6
3 8
3
4
5
Cystic plate Hilar plate Umbilical

plate
Fig. 94.2
Fig. 94.3
Extent of Resection far different when resection is contemplated in the setting of

acute or chronic liver disease. Careful preoperative assess-
There are three simple but important principles that need to ment and judicious treatment of the underlying liver disease
be maintained, prior to proceeding with hepatic resection; are needed. This is especially true in the modern era of more
(1) preservation of inflow structures (and biliary drainage) to effective systemic chemotherapy agents. The hepatotoxic
future liver remnant, (2) preservation of venous outflow, and effects of systemic chemotherapy have changed the land-
(3) preservation of enough liver mass to avoid posthepatec- scape regarding the degree of hepatic resection – nowadays
tomy liver failure. The need to achieve a clean resection with favoring more parenchymal preservation techniques.
an adequate margin must always be kept in balance with the The parenchymal sparing resection strategy (enucleation
need to preserve an adequate functioning liver volume. versus wedge versus formal anatomic resection) depends on
Because the liver has a remarkable capacity for regeneration, the size, location, and relation to the tumor of the major
patients without underlying liver disease can tolerate resec- afferent and efferent vasculature and bile ducts. Enucleation
tion of up to six of the eight liver segments. The situation is is effective for encapsulated or sharply demarcated lesions
94 Hepatic Resection 719
such as neuroendocrine tumors. Wedge resections are typi- tive blood loss. Ligation of the respective bile duct is
cally subsegmental and performed without reference to ana- deferred, until it is unequivocally identified.
tomic boundaries. These nonanatomic resections generally Major lobar resections may be extended anatomically or
are undertaken for peripheral liver masses that are not nonanatomically. Anatomic extensions are performed by
adjacent to the hilus or hepatic veins. Wedge resections are removing the liver segments adjacent to the principal plane.
easiest for small tumors arising within anterior liver seg- For example, a right hepatectomy (polysegmentectomy of
ments. Formal anatomic resection should be considered for 5–8) may be extended anatomically to include segment 4
large or deeply seated lesions or those with indistinct mar- (polysegmentectomy of 4–8), or a left hepatectomy (poly-
gins. This resection may be a standard right or left anatomic segmentectomy of 1–4) can be extended anatomically to
lobectomy, or it may be tailored along segmental boundaries include segments 5 and 8 (polysegmentectomy of 1–5 and
in such a manner as to maximize residual functioning hepatic 8). Anatomic extensions imply formal ligation of the appro-
mass and preserve vital vascular and ductal structures to the priate segmental pedicle and transection of the liver along
liver remnant. intersegmental planes other than the principal plane.
Malignant hepatic tumors, primary or metastatic, require Nonanatomic extensions are self-explanatory.
resection with a margin of normal liver. Ideally, a 1- to 2-cm
margin is preferred to reduce the risk of recurrence. Protect
the afferent and efferent vasculature of the anticipated postre- Principles of Safe Liver Resection
section liver remnant scrupulously to prevent postoperative
liver failure. Intraoperative ultrasonography is a useful Liver resection can be conceptualized as involving three
adjunct. phases: vascular control, parenchymal transection, and iden-
tification and preservation of the bile duct to the liver rem-
nant. The order in which these phases are performed varies.
Anatomic Liver Resections For simple enucleations and wedge resections, only paren-
chymal transection is required. For major anatomic resec-
Resection of a single liver segment or multiple contiguous tions, vascular control is obtained first. The parenchyma is
segments requires identification and ligation of the segmen- then divided, and the bile ducts are divided, only when the
tal vasculobiliary pedicle and parenchymal division through surgeon has ascertained the precise anatomy and ensured
anatomic intersegmental planes. Resection along intraopera- that drainage to the remnant is preserved.
tively defined anatomic boundaries is the major difference
between nonanatomic wedge resections and anatomic seg-
mental resections. In general, anatomic segmental resections Parenchymal Transection
are preferable for primary malignancies because they remove
segmental intraportal metastases. Embedded in the soft liver parenchyma are vascular and duc-
Resection of segments 2 and 3 is commonly termed left tal structures of greater mechanical strength. Most methods
lateral lobectomy because it removes the anatomic left lobe of parenchymal transection use this difference in tissue
of the liver. Current nomenclature refers to this procedure as strength to surgical advantage. Conceptually, the surgeon
a left lateral sectionectomy. It consists of removing the simply disrupts the parenchyma along the planned transec-
hepatic parenchyma to the left of the falciform ligament. tion plane to expose bile ducts and vessels for ligation.
This deceptively easy resection is fraught with hazard, as the Because all branches of the portal pedicle are enveloped by
left hepatic vein (LHV) is large and may be encountered in extensions of the vasculobiliary sheath (Glisson’s fibrous
the plane of dissection. A second danger comes from recur- sheath), the portal veins are less fragile than branches of the
ring or feedback branches of the vasculobiliary pedicle to hepatic vein. Disruption of the small hepatic veins (<l–2 mm)
segment 4, which must be preserved. Maintaining the plane during parenchymal transection is common. Hemorrhage
of dissection 1–2 cm to the left of the falciform ligament is from small hepatic veins is easily controlled by parenchymal
crucial for safe resection. compression, electrocautery, or a suture ligation.
Lobar resections have also been termed right and left Liver parenchyma can be disrupted by compression meth-
hemihepatectomy, lobectomy, or hepatectomy. Lobar resec- ods such as finger fracture, Kelley clamp, contact methods
tions are actually polysegmental resections based on the [Cavitron ultrasonic surgical aspirator (CUSA), water jet], or
main right or left vasculobiliary pedicles. Operative risk of thermal methods (electrocautery, radiofrequency (RF), or
significant blood loss is reduced by ligation of the appropri- microwave). Each method has its advantages and disadvan-
ate lobar hepatic artery and portal vein branch prior to paren- tages and the technique selected is often based on the texture
chymal transection. Subsequent ligation of the corresponding or consistency of the underlying liver. Although the zone of
hepatic vein, if technically possible, further reduces opera- parenchymal damage adjacent to the transection plane varies
among these methods, the clinical significance of these disruptor with suction. It is particularly useful for delicate
microscopic zones of devitalized parenchyma is negligible dissection in the region of the hilum.
unless the transection results in major damage to the vascu- Typically, any structures >2 mm require ligation. Near-
lature of the liver remnant and significant regional ischemia circumferential exposure of intraparenchymal structures opti-
occurs. We prefer a combinational method for parenchymal mizes secure ligation. Intraparenchymal portal pedicle
division that includes the use of bipolar energy, saline link branches and hepatic veins can be ligated between fine silk
radiofrequency sealer (superficial parenchyma), and stapling sutures, metal clips, or a combination of the two. Avulsion of
for intraparenchymal management of the larger hepatic small hepatic vein branches from a major hepatic vein can be
venous structures and to complete the transection. particularly troublesome. Hemorrhage from the orifice of an
After careful intraoperative ultrasound examination and avulsed hepatic vein branch of an exposed major hepatic vein
verification of tumor(s) location, the selected plane of tran- is best controlled by a fine vascular suture material (5–0 or
section is marked on the liver surface using electrocautery at 6–0 Prolene) while carefully maintaining blood flow through
a high setting. In general, the depth of initial division on the the main hepatic vein. If bleeding results from a small hepatic
anterior surface of the liver can be done safely up to ~1 cm vein without exposure of its major hepatic vein, a single fig-
since the hepatic vein branches lie deeper within the liver. ure-of-eight suture ligature is adequate. Conceptualize a tran-
However, on the undersurface of the liver, scoring the cap- section plane during parenchymal transection. Transection
sule should be done cautiously since the vascular inflow along the plane without deviation results in a reduced risk of
structures course more superficially. Parenchymal transec- hemorrhage and elimination of partial devascularization of
tion is most conveniently begun at a free edge, where the the adjacent liver segment at the interface.
liver is relatively thin.
Finger fracture simply involves pinching and compress-
ing about 1 cm of liver parenchyma between thumb and fore- Vascular Control
finger. A pill-rolling back-and-forth motion of thumb and
finger while squeezing the liver disrupts normal liver easily, Safe major hepatic resection primarily depends on avoiding
yet preserving most vascular and ductal structures. As the and controlling hemorrhage. Early during the dissection, obtain
fracture plane develops, the surgeon and first assistant work circumferential access to the hepatoduodenal ligament. This
together to compress the parenchyma on both sides of the permits hepatic vascular inflow occlusion (Pringle maneuver)
developing cleft and to open the cleft to expose the deeper to control hemorrhage from the high-pressure afferent vascula-
portions. The inside part of a pool-tip sucker can be used as ture at any time during resection. Control hemorrhage from the
an adjunct to finger fracture. Alternatively, a Kelley clamp low-pressure hepatic venous system temporarily by digital
can be used to crush the liver tissue to expose the vessels for pressure, parenchymal compression, or packing.
clipping and suture ligation. The CUSA is more precise but Exposure of the hepatic veins at the junction of the infe-
somewhat slower (Fig. 94.4). It should be set to disrupt rather rior vena cava requires complete division of the ligamentous
than cauterize, and in this mode it functions as a mechanical attachments to the liver. In particular, the retrocaval ligament
bridging segments 6 and 7 must be completely divided to
expose the right hepatic vein. Approach the hepatic veins
only after controlling the afferent vessels. If tumor obscures
the hepatic venous anatomy at its junction with the inferior
vena cava, consider total hepatic vascular isolation to permit
safe exposure and control. Circumferentially expose the
inferior vena cava above (infradiaphragmatic) and below
Devascularized (suprarenal) the liver and apply large vascular clamps.
side Ligation of the right adrenal vein combined with infra- and
suprahepatic inferior vena cava clamping and inflow vascu-
lar occlusion of the hepatoduodenal ligament results in total
hepatic vasculature isolation, when necessary. The hepatic
veins can then be exposed in a controlled fashion.
Preservation of Bile Ducts
Bile duct injury is a potential source of major morbidity fol-

Fig. 94.4 lowing hepatic resection. Identify the ductal confluence
unequivocally before ligating any major lobar branches dur-

ing formal or extended lobectomy. If ductal anatomy is in
question, two options exist. First, major lobar branches can
always be clearly identified by deferring ductal ligation until
parenchymal transection exposes the major ducts at the level
of the hilar plate. With the surrounding parenchyma tran-
sected, the major ducts can be traced from the parenchyma to
the confluence and ligated or preserved accordingly.
Parenchyma around the major ducts can be excised by CUSA
if necessary. Division of the ducts within the parenchyma
and probe cannulation distally allows unequivocal confirma-
tion of patency of the ductal confluence. Alternatively, a
transverse cystic duct completion cholangiogram can be
obtained to verify biliary anatomy. If necessary, a choledo-
chotomy permits cannulation of the proximal ducts with
Bakes dilators or other intraluminal devices, which in turn
allows tactile and visual identification of the major ducts for
appropriate management.
Operative Technique
Incision and Exposure

Fig. 94.5
There are several options for abdominal incision to optimize

exposure based on patient body habitus and tumor location. edge (Nonanatomic, Subsegmental, or
W
A bilateral subcostal incision affords wide exposure for most Peripheral) Resection
hepatic resections. For left-sided liver resections (thin
patients), a standard midline incision is preferable. For the For a wedge resection, after mobilizing the liver, place lapa-
majority of right-sided liver resections, we prefer the modi- rotomy pads posteriorly between the liver and diaphragm to
fied Makuuchi incision-reverse L beginning at the upper enhance exposure by anterior displacement. Estimate the
midline extending caudally just above the umbilicus then planned margin of resection by palpation and score the liver
extending transversely or horizontally toward the right flank/ capsule with cautery to outline the margin. Transect the
subcostal area (Fig. 94.5). A partial or complete sternotomy parenchyma with electrocautery, finger/clamp crush tech-
or extension thoracotomy is sometimes necessary for addi- nique, CUSA, and/or energy device of choice. Clip or ligate
tional exposure in difficult situations. bile ducts or vessels >2 mm. After obtaining local bile stasis
The peritoneal cavity should be carefully explored when and hemostasis, close the abdomen. Drainage is generally
treating malignant disease. In particular, the structures not necessary for simple wedge resections within a single
occupying the free edge of the lesser omentum and lymph segment or adjacent segments unless concurrent biliary tract
nodes related to the hepatic artery and the celiac vessels and disease is present.
the supraduodenal nodes should be assessed. Divide any
perihepatic adhesions. Fully mobilize the liver by dividing
the ligamentous attachments (Fig. 94.6A–C). A heavy silk Anatomic Oriented Segmental Resections
ligature should be left on the ligamentum teres, which acts
as a traction stitch during subsequent dissection and manip- For anatomic single or multisegmental resections, define the
ulation of the liver. The lesser omentum should be incised segmental location of the tumor with intraoperative ultraso-
and the caudate lobe should be carefully inspected visually nography. Identify the portal pedicle(s) supplying the
and by finger palpation. The exposed foramen of Winslow segment(s). These structures must be ligated for accurate
allows for facile inflow vascular occlusion. Use an upper anatomic segmental resection. They may be accessed by
hand or Thompson retractor to elevate the rib cage cephalad proximal dissection from the hilar bile ducts and vasculature
and place additional retractors as needed to retract the hol- to the appropriate pedicle or by direct rapid parenchymal
low viscera caudally. transection along an estimated intersegmental plane with
precise, this approach is more technically demanding and

a
requires expertise in operative ultrasonography.
To approach anterior liver segments 3, 4, 5, and 8 for
resection, mobilize the liver and incise the hilar plate.
Identify the appropriate lobar pedicle. Dissection proceeds
proximally, until the segmental pedicle is exposed. Confirm
accurate segmental pedicle identification by ultrasonogra-
phy. Temporarily occlude the pedicle to outline the segmen-
tal boundaries with cautery, ensure that the tumor is included
within the segmental demarcation, and confirm that the ped-
icle provides adequate margins. If appropriate, divide the
segmental pedicle using an Endo GIA vascular stapler or
b
suture ligation. Transect the parenchyma by the preferred
technique of cautery, fracture technique, and/or use of energy
devices. Use temporary inflow vascular occlusion during dis-
section of the pedicle and parenchymal transection as needed.
Few vessels or ducts require ligation if the resection is truly
along intersegmental planes. Hepatic veins do require liga-
tion, and they are individually ligated with silk. We prefer to
gently expose the anterior and posterior surfaces of the cross-
ing veins with a Kelley clamp, which are then divided with
stapler. If the margins are narrow, extend the resection either
nonanatomically into contiguous liver segments or anatomi-
c
cally by adjacent segmentectomy. After securing bile stasis
and hemostasis, place a single suction drain in the resection
bed and close the abdomen.
Multisegmental resection is performed in a manner simi-
lar to single segment except that each segmental pedicle is
ligated sequentially before extending the parenchymal tran-
section. Once all appropriate pedicles are ligated, the con-
tiguous liver segments are removed en bloc.
esection of Segments 2 and 3 (Left

R
Lobectomy/Left Lateral Sectionectomy)
For a left lateral lobectomy, mobilize the left lobe of the

liver by dividing the left triangular ligament. Take care to
Fig. 94.6
avoid injury to the left hepatic vein. Expose the umbilical
fissure completely which often requires the division of a
ultrasound guidance. Dissection from the hilus is most bridge of liver tissue spanning segments 4 and 3 if present.
applicable for anterior segments 3–6. The parenchymal tran- Retract the left lobe toward the right and incise the hepato-
section approach is more appropriate for ligation of the pos- gastric ligament and accessory left hepatic artery if present.
terior segmental pedicles to segments 7 and 8. Both Preserve any recurring or feedback structures that drain and
approaches are greatly facilitated by using temporary vascu- supply segment 4b. Mark the line of transection on the ante-
lar inflow occlusion to reduce hemorrhage and using CUSA rior surface of the liver from starting on the edge of the fis-
for rapid exposure of the pedicle through the intervening sure extending to the lateral edge of the IVC and left hepatic
parenchyma. Alternatively, methylene blue injection of the vein. Split the liver anteroposteriorly just to the left of the
segmental or portal pedicle using ultrasound guidance can ligamentum teres and the falciform ligament. Identify and
provide accurate segmental or sectoral definition. Once the separately ligate or staple the individual portal pedicles to
appropriate portal venous branch is injected, segmental segments 2 and 3. Continue to dividing the parenchyma,
boundaries are defined by parenchymal staining, and resec- taking care to preserve the vertical branch of the left portal
tion proceeds according to the defined boundaries. Although vein by remaining well to the left of the falciform ligament.
The left hepatic vein is encountered posteriorly and divided

with a stapler.
natomic Right Hepatectomy (Right Hepatic

A
Lobectomy)
For right hepatic lobectomy, fully mobilize the liver and per-
form cholecystectomy to enhance exposure of the hilar vas-
culature. First, ligate the right hepatic artery, which generally
Fig. 94.8
traverses the triangle of Calot. Excise the pericholedochal
lymph nodes to further expose the bile duct, portal vein, and
hepatic artery. Incise the right lateral aspect of the hepato- without a common trunk, resulting in a portal vein trifurca-
duodenal ligament (9 o’clock position) longitudinally just tion. Free the right portal vein branch from the surrounding
posterior to the bile duct (Fig. 94.7). The hepatic arteries are lymphoareolar tissue and identify, ligate, and divide the
always found lateral to the common hepatic duct, at the point small portal venous branches extending into the caudate pro-
where they enter the liver parenchyma. The right hepatic cess (often two are present).
artery can be divided before it bifurcates into its anterior and At this point, a caudate hepatotomy is done to help sepa-
posterior branches, or each branch can be individually ligated rate the back of the liver from the inferior vena cava and
and divided. Ligate lymphatic vessels around the hepatic further exposing access to the right portal vein. The perito-
arteries before dividing them to reduce postoperative lymph neal reflection over the inferior vena cava is incised. The IVC
drainage. Temporarily occlude the right hepatic artery while tributaries to the caudate process are isolated, ligated, and
palpating the artery to the opposite lobe to ensure patency of divided. The caudate hepatotomy is started in a plane parallel
the arterial supply to the liver remnant. Having confirmed to the right side of the inferior vena cava and extended
this, double-ligate the right hepatic artery with heavy silk upward and posterior to the right portal vein. The posterior
and divide it (Fig. 94.8). capsule of the liver lying anterior to the IVC is further
Retract the bile duct anteriorly and cephalad with a vein incised, until the posterior liver is partially split for a dis-
retractor to expose the portal vein bifurcation. It is important tance of ~3–4 cm (Fig. 94.8). This caudate hepatotomy facil-
to verify the takeoff of the left main portal vein during this itates isolation of the right main portal vein that can be easily
dissection. Expose the right portal vein from the right of the managed using a single firing of the Endo GIA vascular sta-
hepatoduodenal ligament. The two major branches of the pler (Fig. 94.8). Do not use a simple ligature because dis-
right portal vein (anterior and posterior) may arise separately lodgement risks life-threatening hemorrhage. The bile duct
to the right liver may be managed in a similar manner. With
the hilar plate lowered, the bile duct to the main right liver
can be isolated with a large right angle clamp, encircled with
an umbilical tape, and retracted to the left. Importantly, sta-
pler division of the right bile duct should be as far over into
the right liver as possible to avoid inadvertent injury to the
left bile duct. If tumor involves the inflow structures, an
Gallbladder
bed extrahepatic isolation and division of the right duct is neces-
Hepatic artery sary. (Fig. 94.8) This step may be deferred, until further dis-
Cystic duct section has been completed. A clear line of vascular
Common demarcation along the principal liver plane between lobes
bile duct confirms appropriate and complete lobar ligation
Portal vein (Fig. 94.9A–B).
Duodenum After the inflow vessels are controlled, approach the
hepatic veins. Multiple small short hepatic veins between the
inferior vena cava and segments 1, 6, and 7 must be ligated,
as the liver is retracted anteriorly and to the left (Fig. 94.10).
Ligation starts infrahepatically and proceeds cephalad.
Occasionally, a large, right inferior hepatic vein enters the
inferior vena cava from the posterior aspect of segment 6.
Fig. 94.7 Staple or suture closure for secure ligation is preferred.
a b
Fig. 94.9
Cephalad
Right
hepatic vein
Inf. vena
cava
Retrocaval
lig.
Fig. 94.11
or CUSA are used for division (Fig. 94.13A–B), metal clips

Fig. 94.10 should be placed only on the specimen side to reduce artifact
image distortion on postoperative follow-up computed
To expose the main right hepatic vein, divide the retroca- tomography (CT) scans. As the transection plane is deep-
val ligament bridging segments 1 and 7 (Fig. 94.11). A ened, major hepatic venous branches are encountered and
moderate-sized vein frequently traverses the ligament and managed using direct suture ligation or stapling. Separation
requires ligation. Then dissect the main right hepatic vein of the liver now exposes the hilum and the bile ducts to the
(RHV) from the inferior vena cava and liver. Unless a large lobe being resected and can be divided, if not previously
tumor precludes access, transect the right hepatic vein with a done. Again, ligation is performed only when patency of the
vascular stapler and ligate the parenchymal side with a run- remaining lobar duct can be ensured. Look for the smaller
ning vascular suture before parenchymal transection ducts to segment 1 posterior to the main ductal confluence,
(Fig. 94.12A–C). Large and necrotic tumors distorting the and ligate them if encountered. Transect the remaining
hepatic veins that are at risk for rupture should be managed parenchyma of the caudate process to expose the anterior
by an anterior approach (i.e., hanging maneuver). In this surface of the IVC. Continue parenchymal transection along
approach, the right hepatic vein is divided as the final step of the principal plane, until the main hepatic veins are encoun-
a formal lobectomy after parenchymal transection. tered. Back bleeding from the hepatic veins can be signifi-
Transect the parenchyma along the line of vascular cant and constant awareness of the IVC location is critical to
demarcation in the principal plane from anterior to posterior avoid inadvertent injury. If the major hepatic vein has been
starting on the edge of the liver. If a fracture technique and/ ligated, simply remove the lobe.
a b
R. hepatic v.
Fig. 94.12
a b
Fig. 94.13
If not, clamp or divide the hepatic veins with a vascular sary. We prefer to use inflow occlusion selectively during
stapler. Use inflow vascular occlusion during parenchymal the last phase of parenchymal transection involving expo-
transection to reduce intraoperative hemorrhage if neces- sure and division of the large hepatic vein branches in the
back of the liver. Obtain hemostasis and bile stasis but avoid ligament. The main left portal vein branch always bifur-
large interlocking parenchymal liver sutures. Figure 94.13b cates from the right main branch at approximately 90° and
shows the appearance of the hepatic remnant after right courses anterolaterally. The left portal vein is isolated and
hepatic lobectomy. A suction drain is placed adjacent to the divided above the takeoff of the principal portal venous
transected liver surface and brought out laterally through the branch of the caudate lobe. It is divided using a vascular
abdominal wall. The divided falciform should always be stapler or running suture as previously described. Note the
reattached to prevent torsion of the liver remnant and post- developing line of transection, as the left liver lobe should
operative vascular compromise. A routine omentoplasty now be completely devascularized. If the ductal anatomy
should also be done. The abdomen is closed in standard is clear, double-ligate and divide the left hepatic duct; if
fashion. the anatomy is in doubt, defer this step until later in the
dissection.
The main left hepatic vein (LHV) frequently joins the
natomic Left Hepatectomy (Left Hepatic
A middle hepatic vein (MHV) within the liver parenchyma
Lobectomy) and is referred to as the conjoined hepatic vein. Depending
on tumor location, preservation of the MHV may be desir-
For anatomic left hepatectomy, in a manner analogous to able. If so, postpone ligation of the main LHV until paren-
that used for the anatomic right hepatic lobectomy, first chymal transection is complete because extrahepatic
identify and divide the left hepatic artery and portal vein. exposure is generally difficult. However, if both the middle
After division of the gastrohepatic omentum, approach the and left hepatic veins will be included in the specimen, it is
left hepatic artery through the lesser sac via the left lateral best to isolate and divide the conjoined vein extrahepati-
aspect of the hepatoduodenal ligament. The main left cally prior to beginning parenchymal transection to reduce
hepatic artery is generally found just inferior to the base of venous back bleeding. Isolation of the conjoined venous
the round ligament as it enters the left lobe between seg- trunk is done by mobilizing the left lobe from the dia-
ments 3 and 4 (Fig. 94.14). An accessory left hepatic phragm and turned to the right (Fig. 94.15). Divide the gas-
artery, arising from the left gastric artery, always courses trohepatic ligament and expose the line of the ligamentum
through the gastrohepatic omentum and is often divided venosum. Divide ligamentum venosum at the top, exposing
during division of the gastrohepatic omentum. Confirm the the posterior wall of the conjoined vein and anterior wall of
patency of the arterial supply to the right liver by tempo- the IVC. The liver is now repositioned and retracted inferi-
rarily occluding the left hepatic artery before clamping, orly (Fig. 94.6b). Dissect between the right and middle
ligating, and dividing the vessel (Fig. 94.14a). While hepatic veins posteriorly and toward the left to join the dis-
retracting the bile duct with a vein retractor, identify the section plane previously started. Develop a tunnel in this
left portal vein at the left aspect of the hepatoduodenal space to allow isolation of either the MHV, LHV, or both.
a b
L. hepatic a.
Fig. 94.14
Laparoscopic Liver Surgery
Indications
The indications for hepatectomy are the same whether done
by open or laparoscopic technique. It should be emphasized
that laparoscopic liver surgery is a complex procedure and
requires expertise both in laparoscopic techniques and open
liver surgery. Most importantly, understanding intraoperative
anatomy is critical to avoid biliary or vascular injuries. The
selection for candidate for laparoscopic liver resection is
based on the tumor location, size, and number. With regard
to location, the lesions located in the anterolateral segments
(2–6) are considered safe areas for the laparoscopic
approaches. Lesions located in segments 7, 8, 4A, and 1 or
the caudate lobe remain technically difficult because of the
Fig. 94.15 proximity of the inferior vena cava and the hepatic veins.
With regard to benign tumors, only symptomatic or indeter-
minant masses should be removed. Management of malig-
nant liver tumors should not differ from that of open surgery.
Importantly, laparoscopic liver surgery is merely an adjunct
or tool in hepatic surgery. As such, the guiding principles of
hepatic surgery should always be maintained whether done
openly or laparoscopically. In general, laparoscopic liver
surgery is reserved for patients with small tumors (< than
5 cm) located in favorable anatomic locations within the
liver. The range of resections that can be done laparoscopi-
cally is wide and included single wedge resections, multiple
bilobar resections, anatomic segmental resections, formal
hemihepatectomy, and extended resections. The main deter-
minant for pursuing a laparoscopic approach should be based
on surgeon training, experience, and their comfort level.

Fig. 94.16 Appropriate laparoscopic liver procedures include fenestra-
tion or decapitation of simple hepatic cysts, biopsy of liver
The vein(s) are clamped, divided, and oversewn or divided tumors, ablation of liver tumors, and hepatic resections
with a stapler. including nonanatomic wedge resections, anatomic segmen-
If an en bloc caudate lobectomy is indicated, the left main tal resections, and hemihepatectomies. One important factor
portal vein is divided below takeoff of the principal branch of in patient selection is tumor size. Except for exophytic
the caudate. The peritoneal reflection along the left side of lesions which are located on the edge of the liver, a laparo-
the IVC and caudate is incised. Ligate the short, direct, scopic approach is not recommended for lesions greater than
hepatic veins between the inferior vena cava and segment 1 5 cm. This is especially true when tumors are situated near
(caudate lobe) initially from the right of the hepatoduodenal the in-flow or out-flow vascular structures. Large intrahe-
ligament until segment 1 is mobilized inferiorly (Fig. 94.16). patic tumors are challenging laparoscopically because of the
As the veins are ligated and divided, segment 1 can be difficulty in mobilization, increased risk for hemorrhage, and
retracted anteriorly along with the left hemiliver. Division of a margin positive resection.
the retrocaval ligament from the left side of the inferior vena
cava allows complete mobilization of segment 1. Special Equipment
The remainder of the resection proceeds much as previ- Laparoscopic liver resections require state-of-the-art equip-
ously described. The completed operative field is shown in ment. Two high-volume carbon dioxide insufflators are
Fig. 94.16. needed, since these procedures generate excessive vapor,
a b
Fig. 94.17
smoke, and bleeding that require frequent suctioning.

Operating rooms (ORs) should be equipped with
high-resolution display monitors, camera equipment, laparo-
scopic booms, and specialized beds capable of achieving
extreme position angles (Fig. 94.17A).
These operations tend to be equipment intensive, often
requiring multiple thermal generators, ultrasound and other
bulky machines depending upon the procedure. The setup of
laparoscopic liver procedures uses multiple disposable and
nondisposable instruments. The general surgical instruments
table is maintained away from the patient due to the frequent
table movements and patient repositioning. A Mayo stand is
useful to help organize and secure instruments for ease of
access. Typical instruments used for laparoscopic liver pro-
Fig. 94.18
cedures include a high-power suction irrigator, multiple ther-
mal energy devices, and a flexible tip ultrasound probe
(Fig. 94.17B). cular equipment is available, including laparoscopic Satinsky
In addition to high-resolution monitors, high definition clamps, corrugated flexible and reusable ports, and vascular
flexible tip cameras can improve visualization of the poste- bulldog clamps (Fig. 94.18).
rior liver and dissection of the hepatic veins. We prefer to use
the 45° fixed scope, which provides a stable view and allows Positioning
excellent visualization throughout the abdomen. Strong As with other laparoscopic procedures, proper patient posi-
adjustable atraumatic retractors are needed to support the tioning is important. There are two basic positions used in
large size, weight, and volume of the liver. Specialized vas- laparoscopic liver surgery: left lateral decubitus (i.e., left-
Fig. 94.20
Fig. 94.19
side up, right-side down) and split-legged or “French” posi-

tion. The split-legged position is useful for most Fig. 94.21
resections – allowing access to both right- (anterior/lateral)
and left-sided liver tumors. The left lateral decubitus position
is essential for tumors located in the right posterior liver, aparoscopic Left Lateral Sectionectomy
L
especially segment 7 (Fig. 94.19A-B). Laparoscopic left lateral sectionectomy is ideal for laparo-
Optimal left lateral decubitus position is achieved by scopic approach and is now considered the standard approach
using a beanbag and two kidney rests. The OR table is flexed in many high-volume centers. This is because the anatomic
at the hip to expose the right subcostal and posterior area boundaries are easily identifiable based on surface anatomy.
necessary for port placement. The French position requires a Proper traction on the round ligament allows easy maneuver-
specialized OR table with leg attachments that separate ability of the left lobe of the liver. Traction of the round liga-
(Fig. 94.20). ment to the right produces easy exposure of pedicles to
If not available, a traditional OR table can be equipped segments 3 and 2. Furthermore, the plane of parenchymal
with Allen stirrups to achieve a similar position (Fig. 94.21). transection has few bridging in-flow structures and the left
The split-legged position was popularized in abdominal lap- hepatic vein is encountered at a perpendicular angle for easy
aroscopic surgery because the primary surgeon and assis- control and division.
tant’s positioning is optimized.
This position is especially useful for patients undergoing Position and Port Placement
formal hemihepatectomy, or for resections limited to the Place the patient supine in the French position with exposure
anterolateral segments of the right liver. For patients under- of the left flank. Enter the abdomen at the umbilicus, using a
going procedures involving the left liver, they are placed on Hasson entry technique and place a 12-mm port. Depending
a beanbag in a semi-supine position with both arms out. upon the anticipated size of the tumor/specimen, the umbili-
However, the left side is propped up slightly to allow maxi- cal incision may be enlarged or alternatively, a Pfannenstiel
mal exposure and access to the left flank for dissection of the incision is used for specimen extraction at the end of the
left triangular ligament. operation. Gel ports are available in different sizes and are
useful for specimen retrieval. Place additional working ports pedicles to segments 3 and 2. Divide the parenchyma using a
in alignment with the anticipated line of transection and use bipolar compression cautery device. Begin division on the
of linear staplers. In general, we use two 12-mm and two edge of the liver to the left of the falciform ligament to avoid
5-mm ports. injury to the vertical branch of the left portal vein. This
First, divide the falciform ligament to expose the hepatic exposes the underlying segment 3 and 2 pedicles, respec-
veins. If present, divide the bridge of liver between segments tively. These structures can be managed individually or
3 and 4 to expose the umbilical fissure (Fig. 94.22A–C). together using a linear stapler. The only major vascular struc-
Incise the left triangular ligament off the left hemidiaphragm ture remaining is the left hepatic vein (LHV). Continue to
toward the coronary ligament to join the edges of previous divide the overlying parenchyma along the plane of transec-
dissection. Elevate the left lobe to expose the peritoneal tion until the LHV is exposed. Avoid injuring the middle
reflection on the undersurface of the triangular ligament hepatic vein (MHV) coursing inferiorly and to the right
along left hemidiaphragm. Expose the caudate lobe, the line which can lead to troublesome bleeding. Always be aware of
of the ligamentum venosum, inferior vena cava, and left the axis of the inferior vena cava. The final vascular stapling
hepatic vein origin using sharp and blunt dissection. should be oriented toward the left hemidiaphragm and away
Determine the line of transection using intraoperative ultra- from the IVC, as the left hepatic vein is controlled and
sound and mark it with electrocautery. Use the round liga- divided. Divide the remaining attachments to liberate the
ment as a handle, retracting it to the right to expose the specimen. If the procedure is done for benign disease (i.e.,
cavernous hemangioma), the specimen is removed in a
piecemeal manner to minimize fascial incisions. However, if
a cancer is a concern, the specimen is placed in a robust Endo
Catch bag and removed fully intact for margin evaluation by
pathology. Finally, the cut edge of the liver is treated with
saline-linked bipolar cautery and final hemostasis is obtained.
otally Laparoscopic Right Lobectomy

T
A totally laparoscopic right hemihepatectomy is possible
and safe, but is generally more time consuming. There are
some important differences between an open right hepatec-
tomy compared to a laparoscopic right hepatectomy. One
important difference is control and division of the right
b hepatic vein (RHV). While control and division of the RHV
prior to parenchymal transection is possible laparoscopi-
cally, this is generally technically challenging and can be
hazardous. Instead, an anterior approach is used and the
RHV is divided after parenchymal transection in caudal to
cephalad direction is completed. Hepatic venous back bleed-
ing is surprisingly reduced with the increased pressure from
the carbon dioxide pneumoperitoneum. Lastly, mobilization
of the right liver which is done early in open surgery is done
as the final step in the laparoscopic approach.
c Position and Port Placement

Place the patient in the French position with both flanks
exposed and prepped. Depending upon the patient’s body
habitus, the right liver can be extracted through a limited ver-
tical incision at the umbilicus or a suprapubic Pfannenstiel
incision. Our preferred incision when possible is the
Pfannenstiel incision, given its better postoperative pain pro-
file. The camera port is generally best positioned in the right
midabdomen along the midclavicular line. The 45° scope in
this position allows excellent visualization of the right trian-
gular ligament, RHV, and lateral wall of the IVC. All work-
Fig. 94.22 ing ports are 12 mm in size to optimize instrument versatility
cava. Control and divide short hepatic venous tributaries as

the dissection works from caudal to cephalad direction along
the IVC. This dissection allows the development of a space
to separate the caudate process off the IVC. A formal cau-
date hepatectomy is done, starting on the free edge working
cephalad to the base of the right main portal vein as it enters
the liver (Fig. 94.24).
The goal is to facilitate laparoscopic control of the right
main portal vein. Coagulate and divide the two venous
branches from the right main portal vein to the caudate pro-
cess allowing circumferential dissection of the main right
portal vein. Encircle the right portal vein with a heavy 0 silk
tie and use it for traction. Deploy a vascular bulldog to
occlude the main right portal vein to visualize demarcation
prior to division. Next, divide the right portal vein using a
single firing of a 45-mm linear stapler (Fig. 94.25).
Fig. 94.23
Division of the right hepatic artery and right portal vein
produces an excellent line of demarcation that is then marked
(Fig. 94.23). In obese patients with a low umbilicus, place using hook electrocautery. Use the gallbladder (left attached
the port at approximate 20 cm from xiphoid along the mid- to the liver bed) for traction. Divide the liver using the bipo-
line. In general, operating ports should be placed approxi- lar cautery energy device of choice. In general, as was true
mate 15–20 cm from the operative target, and the angle for open right hepatectomy, management of the right bile
between the axis of the camera and the operating ports should duct is best done after partial transection of the liver allowing
be between 30 and 60 degrees to avoid instrument clashing. accurate identification of the right main bile duct.
A simple rule of thumb is that working ports should be
placed at least a hand’s width apart from each other.
Divide the falciform ligament and ligate and divide the
round ligament. Grasp the round ligament and use it for trac-
tion. Perform intraoperative ultrasonography to assess resect-
ability and tumor margins. Perform a “modified” laparoscopic
cholecystectomy. Separate the gallbladder from the hepato-
duodenal ligament and partially take off the liver leaving it
attached at the fundus to be used as a handle for future
retraction.
Next, pursue the hilar dissection on the right free edge of
the hepatoduodenal ligament. Remove a lateral periductal
lymph node and dissect to expose the main portal vein.
Working on the lateral edge of the hepatoduodenal liga- Fig. 94.24
ment, isolate and dissect the right hepatic artery with a com-
bination of blunt, sharp, and electrocautery dissection.
Manage the main right hepatic artery using plastic locking
clips and divide it using a bipolar cautery sealing and cut-
ting device. Generally, the anterior and posterior branches
of the right hepatic artery can be managed identified,
clipped, and divided. Dissect the lymphovascular tissue in
this area to expose the main right portal vein. As is done in
open surgery, the main portal vein bifurcation needs to be
unequivocally identified. Retract the right bile duct and the
hilum upward and to the left, further exposing the right por-
tal vein.
In order to gain additional exposure to the main right por-
tal vein, perform a formal caudate hepatectomy. Elevate the
transverse process of the caudate off of the inferior vena Fig. 94.25
Deepen the parenchymal transection and manage the

crossing the branches of the middle hepatic vein using bipo-
lar cautery energy devices (Fig. 94.26). The division of the
liver should proceed from caudal to cephalad, with more of
the liver being dissected off of the IVC. This dissection
allows complete visualization of the inferior vena cava. With
partial transection of the anterior liver, the right main bile
duct can now be encircled with a right angle clamp within
the right liver. An umbilical tape can be used to encircle the
main right bile duct to provide traction to the left. Divide the
right main bile duct using a linear stapler (Fig. 94.27).
As the liver is divided, the crossing main trunk of middle
hepatic veins is then exposed and carefully divided using a
Fig. 94.28
linear stapler. Treat the cut edge of the liver using a saline-
linked bipolar cautery device for hemostasis. Ultimately, the
transection will allow the left hemiliver to lie to the left and Hand-Assisted Laparoscopic Right Hepatectomy
the right liver to the right like an open book with the anterior
surface of the IVC exposed. Dissect the right hepatic vein, Position and Port Placement
encircle it, and divide it using a vascular stapler. Final step of When indicated, we prefer a hand-assisted laparoscopic right
the procedure involves dissection of the right liver off the hepatectomy. This approach provides the advantage of the
right hemidiaphragm (Fig. 94.28). The right liver is a large tactile sense (important for tumor margin), tends to be faster,
specimen and should be extracted using a robust Endo Catch provides improved retraction, and adds a sense of safety to
bag. the procedure. Moreover, since a limited incision is neces-
sary for specimen removal, the incision is made early and
used rather than made at the end of the procedure.
We prefer to start with a classic transverse Pfannenstiel
incision above the suprapubic area. A hand-assisted device is
inserted early and a pneumoperitoneum is generated.
Additional working ports are placed, as previously described
above.
Hand-assisted right hepatectomy is done in a similar man-
ner, as described for the totally laparoscopic approach. The
main difference is that the left hand of the primary surgeon is
used throughout the procedure guiding the dissection.
Indeed, introduction of the hand allows for digital blunt dis-
section of avascular planes when appropriate. The advantage
of tactile feedback cannot be overstated. This is especially
true for larger tumors encroaching on major vascular struc-
Fig. 94.26 tures. Understanding the exact areas of concern for margin
positivity is critical. Combining the use of intraoperative
laparoscopic ultrasound with manual palpation assures that
an adequate tumor margin is achieved.
Postoperative Care
Postoperative care for open and laparoscopic procedures

requires appropriate fluid administration, using colloids in
addition to crystalloids to reduce postoperative weight gain
and maintain adequate urine output. Mild acidosis and
coagulation abnormalities are common and need not be
treated unless symptomatic. Nasogastric intubation is
Fig. 94.27 optional. We routinely place an oral gastric tube during sur-
gery which is removed at extubation. Epidural analgesia Cucchetti A, Cescon M, Ercolani G, Bigonzi E, Torzilli G, Pinna AD. A
postoperatively markedly improves pulmonary function comprehensive meta-regression analysis on outcome of anatomic
resection versus nonanatomic resection for hepatocellular carci-
and pain control. noma. Ann Surg Oncol. 2012;19(12):3697–705.
D’Angelica M, Maddineni S, Fong Y, et al. Optimal abdominal inci-
sion for partial hepatectomy: increased late complications with
Mercedes-type incisions compared to extended right subcostal inci-
Complications sions. World J Surg. 2006;30:410–5.
Delattre JP, Avisse C, Flament JB. Anatomic basis of hepatic surgery.
The major complications of hepatic resection are hemor- Surg Clin North Am. 2000;80:345.
rhage, biliary fistula, intra-abdominal infection, and liver Delva E, Nordlinger B, Parc R, et al. Hepatic vascular exclusion (HVE)
for major liver resections. Int Surg. 1987;72(2):78–81.
failure. All complications are best treated by careful intraop- Dirocchi R, Trastulli S, Boselli C, Montedori A, Cavaliere D, Parisi A,
erative prophylaxis. Hemostasis is secured meticulously, as Noya G, Abraha I. Radiofrequency ablation in the treatment of liver
is bile stasis. Hepatic insufficiency is best avoided by careful metastases from colorectal cancer. Cochrane Database Syst Rev.
patient selection, since there are minimal treatment modali- 2012;6:CD006317.
Fong Y. Hepatic colorectal metastasis: current surgical therapy, selec-
ties available once established. tion criteria for hepatectomy, and role for adjuvant therapy. Adv
Surg. 2000;34:351–60.
Fong Y, Brennan MF, Brown K, Heffernan N, Blumgart LH. Drainage
is unnecessary after elective liver resection. Am J Surg.
Further Reading 1996;171:158–62.
Kele PG, de Boer M, van der Jagt EJ, Lisman T, Porte RJ. Early hepatic
Belghiti J, Noun R, Zante E, Ballet T, Sauvanet A. Portal triad clamping regeneration index and completeness of regeneration at 6 months
or hepatic vascular exclusion for major liver resection: a controlled after partial hepatectomy. Br J Surg. 2012;99(8):1113–9.
study. Ann Surg. 1996;224:155–61. McEntee GP, Nagorney DM. Use of vascular staplers in major hepatic
Chang YE, Huang TL, Chen CL, et al. Variations of the middle resections. Br J Surg. 1991;78(1):40–1.
and inferior hepatic vein: applications in hepatectomy. J Clin Starzl TE, Koep LJ, Weil R III, et al. Right trisegmentectomy for hepatic
Ultrasound. 1997;25:175. neoplasms. Surg Gynecol Obstet. 1980;150:208.
Couinaud C. Surgical anatomy of the liver revisited. Paris: C. Couinaud; Starzl TE, Shaw BW Jr, Waterman PNI, et al. Left hepatic trisegmentec-
1989. tomy. Surg Gynecol Obstet. 1982;21:155.
Part VIII
Pancreas
Umut Sarpel
Concepts in Surgery of the Pancreas
95
Divya Sood and Rebekah R. White
Surgical Anatomy Trauma
The pancreas lies in a relatively protected and inaccessible Pancreatic injuries are uncommon because of the relatively
location in the retroperitoneum. It is typically described as sheltered position of the gland. Blunt trauma to the upper
having a head, neck, body, and tail. The head of the pancreas abdomen may result in pancreatic contusion or complete
nestles in the C-loop of the duodenum, with the neck lying transection, most commonly at the point where the pancreas
anterior to the superior mesenteric vein (SMV), and the body drapes over the vertebral column. Penetrating injuries to the
and tail extending laterally toward the hilum of the spleen. pancreas are usually accompanied by injuries to overlying
The pancreas has a rich and somewhat variable arterial viscera and major vascular structures – stomach, duodenum,
blood supply, derived from the celiac trunk and the superior spleen, colon, or small intestine.
mesenteric artery (SMA). The head and neck are supplied by During trauma laparotomy, explore any hematoma in
the anterior and posterior pancreaticoduodenal arches, and Zone I (upper central) of the retroperitoneum (see Chap. 8).
the neck, body, and tail are supplied by branches of the The AAST (American Association for the Surgery of
splenic artery. The venous drainage follows the arterial sup- Trauma) grading system for pancreatic injuries lists five
ply via the SMV and splenic vein. grades, of which the first two (grade I and grade II) do not
Regional lymph nodes include the superior and inferior involve injury to the main pancreatic duct. These are best
pancreaticoduodenal nodes; the celiac, hepatic, and superior treated by drainage. Grade III injuries consist of distal tran-
mesenteric nodes; the superior pancreatic nodes (which drain sections and are generally managed by distal pancreatec-
the body and tail); and the splenic nodes. tomy, and this is probably the commonest resection
The pancreas develops embryologically as dorsal and performed for trauma.
ventral anlages, which fuse during development. The main Grade IV and V injuries are more complex proximal inju-
pattern duct usually receives contributions from both the dor- ries. There may be accompanying duodenal trauma or injury
sal and ventral anlages, but variations abound. In the most to the common duct or liver. Bleeding is often a major prob-
common pattern, the ducts of the pancreas converge into the lem, due to the rich blood supply of the pancreas and numer-
main pancreatic duct (of Wirsung) which drains into the duo- ous arteries in the region. Pancreatoduodenectomy for
denum through the major duodenal papilla (of Vater) in con- trauma carries a high mortality and morbidity rate. Consider
junction with the terminal portion of the bile duct. A second, the principles of damage control laparotomy; obtaining tem-
smaller duct, the duct of Santorini, drains into a minor duo- porary hemostasis, control of bile and gastrointestinal (GI)
denal papilla cephalad to the major papilla. Pancreas divisum leakage, and other temporizing maneuvers may allow resec-
is a common anatomic anomaly in which the ventral and dor- tion to be done more safely at a second procedure when the
sal ducts fail to fuse in utero. It is typically asymptomatic but patient is in better condition.
can cause abdominal pain or pancreatitis.
Acute Pancreatitis
D. Sood · R. R. White (*) Acute pancreatitis is a common problem, and the incidence
Department of Surgery, University of California San Diego, in the United States is increasing. However, only small sub-
La Jolla, CA, USA sets of these cases require surgical management. Acute pan-
e-mail: rewhite@health.ucsd.edu

https://doi.org/10.1007/978-3-030-81415-1_95
738 D. Sood and R. R. White
creatitis can be due to a wide variety of causes; however, tis is necrosis and infected necrosis of the pancreas. If infec-
gallstones and excessive alcohol use account for the majority tion is suspected, through systemic signs, clinical
of cases. Other less common etiologies include iatrogenic deterioration, imaging findings, or culture confirmation,
(endoscopic retrograde cholangiopancreatography, ERCP), intravenous (IV) antibiotics should be started and percutane-
certain drugs (including sulfonamides, metronidazole), rare ous drainage, endoscopic debridement, or surgical debride-
anatomic anomalies (annular pancreas, pancreas divisum), ment should be considered. Surgical debridement typically
and hypertriglyceridemia. involves a necrosectomy with continuous irrigation and
drainage. Although this operation has traditionally been per-
formed via an open approach, minimally invasive techniques
Diagnosis are being used increasingly.
The classic presentation of acute pancreatitis is epigastric

pain that radiates to the back, typically associated with nau- Chronic Pancreatitis
sea or vomiting. The diagnosis can be made with a combina-
tion of these clinical findings and an elevation of serum Diagnosis
pancreatic enzyme levels, including amylase and lipase.
Although imaging is not always necessary for the diagnosis The clinical diagnosis of chronic pancreatitis depends on a
of pancreatitis, contrast-enhanced computed tomography combination of episodic or continuous upper abdominal pain
(CT) scans can be used to evaluate for complications associ- radiating to the back associated with structural or functional
ated with acute pancreatitis. In addition to CT findings, there derangements in the pancreas. Such derangements distin-
are several clinical criteria that can be used to assess the guish this entity from recurring acute pancreatitis or from
severity of disease and predicted mortality. The most com- acute relapsing pancreatitis. The functional derangements
monly used are Ranson’s criteria and the APACHE II (Acute are endocrine (diabetes) or exocrine (malabsorption).
Physiology and Chronic Health Evaluation II) score. Generally, contrast-enhanced CT scan will be performed
as the initial diagnostic modality, followed by targeted stud-
ies designed to elucidate ductal anatomy. If there is a pancre-
Treatment atic duct stricture or a mass, endoscopic ultrasound
(EUS)-directed biopsies or brushings from ERCP can help
The mainstay of treatment for any patient with acute pancre- exclude or confirm the presence of a neoplasm. In addition to
atitis is fluid resuscitation. Additional critical components ductal dilation, other common CT findings of chronic pan-
include pancreatic rest, nutrition, and analgesia. The major- creatitis include parenchymal atrophy and calcifications.
ity of cases of acute pancreatitis will resolve with nonopera- Secondary ductular ectasia, changes seen only in the side
tive management. Although the majority of cases of acute branches of the main pancreatic duct, are earlier signs of
pancreatitis are mild, there is a small subset that will prog- chronic pancreatitis that can be seen on ERCP or magnetic
ress to develop complications. The most common of these is resonance cholangiopancreatography (MRCP). Even earlier,
a peripancreatic fluid collection. Most will resolve without parenchymal changes can be seen by EUS. As the disease
intervention. However, if signs of infection are present, progresses, areas of stricture and dilatation are seen in the
drainage is recommended, by either a percutaneous or trans- main pancreatic duct. The degree of dilatation can vary
gastric endoscopic approach, depending on the location and greatly, and this variation in duct size has implications for
maturity of the collection and the condition of the patient. treatment in the decision between resection and drainage.
Fluid collections can mature into pseudocysts over time, and Secondary narrowing of the terminal common bile duct
those that are large, symptomatic, or causing obstruction may be found in patients with significant head disease,
warrant intervention. When possible, transgastric endoscopic accompanied by proximal biliary ductal dilatation. Typically,
drainage is safe and effective. However, in those that are not the alkaline phosphatase is markedly elevated, but the biliru-
amenable to endoscopic management, surgical cystogastros- bin is normal. True obstructive jaundice is rare, but biliary
tomy or Roux-en-Y cystojejunostomy may be necessary. bypass may help to prevent secondary biliary cirrhosis.
Due to high rates of external fistulas, percutaneous drainage
of pseudocysts is not recommended. Acute pancreatitis can
also be associated with the development of venous thrombo- Treatment of Chronic Pancreatitis
sis, typically in the splenic vein, or pseudoaneurysms, most
commonly seen in the splenic artery. Although the incidence The typical patient with chronic pancreatitis generally
is low, the mortality associated with rupture is very high. requires a trial of medical therapy before any consideration
Another potentially morbid complication of acute pancreati- for surgery. Narcotic dependence is common and may be
95 Concepts in Surgery of the Pancreas 739
complicated by alcohol dependence or abuse which often For this reason, a number of modifications have been pro-
causes the disease. Nutritional depletion is common, owing posed that are intermediary between drainage procedures
to exocrine and/or endocrine failure or to severe postprandial and resections. They include the so-called Frey procedure, in
pain. Supplementing with insulin or pancreatic enzymes is which a limited excavation of the head of the pancreas is
an important first step. combined with longitudinal drainage of the main pancreatic
Although several classes of medications have been uti- duct. No division of the body of the pancreas is performed
lized, there is no effective medical therapy for durable pain during this procedure. Since Frey’s original description,
relief in chronic pancreatitis. Endoscopic stenting appears to many experts have adopted this procedure (or other variants)
provide temporary relief in some patients with focal disease over the Peustow.
and may be predictive of results after operative decompression,
but lack of response to stenting is not a contraindication to
operative decompression. Resection Procedures
The primary indication for surgery is persistent, moderate
to severe abdominal pain. The need for intermittent hospital- Indications for pancreaticoduodenectomy are the symptoms
ization is another important indicator supporting the use of previously described combined with dominant disease in the
surgical therapy. Surgical therapy is not expected to improve head of the pancreas. Less commonly, focal pancreatitis in
exocrine or endocrine function but may slow the deteriora- the tail may indicate a distal pancreatectomy. Resection is
tion of pancreatic function. further indicated in any patient in whom there remains the
suspicion of malignancy based on imaging studies, biopsies,
or the relatively inaccurate CA19-9 tumor marker. Resection
Choice of Operation is also considered reasonable after failure of a previous
drainage procedure and is sometimes advocated in patients
In general terms, the operative procedures for chronic pan- with a so-called small duct variant of chronic pancreatitis. A
creatitis include resection, drainage or decompression, and variation of the classic Whipple resection known as the
nerve ablation. The primary goal of each of these operative duodenum-preserving pancreatic head resection (Beger pro-
procedures is pain relief. No significant difference has been cedure) has been devised. The specific advantages suggested
found between resection and drainage in long-term out- for duodenum preservation include enhanced nutritional sta-
comes, including pain relief, quality of life, and exocrine or tus and better gastric emptying. The body of the pancreas is
endocrine pancreatic function. divided in a manner similar to that for the Whipple resection,
and pancreatic tissue is excavated from the C-loop of the
duodenum, preserving the floor of this dissection plane and
Drainage Procedures leaving a small remnant of pancreas along the edges of the
duodenum. Reconstruction is performed by placing a Roux
When the main pancreatic duct is dilated (normal is 2–3 mm), limb of jejunum over the excavated head of the pancreas and
a drainage procedure should be considered. The classic similarly into the remnant of the body and tail of the pan-
drainage procedure is the Puestow procedure. It was devel- creas after it has been divided.
oped as a modification of the Duval procedure: resection of One important precept of surgery for chronic pancreatitis
the tail of the pancreas and Roux-en-Y jejunal drainage of is that preservation of the pancreatic parenchyma is a goal,
the distal duct. Puestow modified the Duval procedure by and all efforts to preserve function while providing adequate
combining resection of the tail of the pancreas with a longi- pain relief are desirable. Near-total pancreatectomy or total
tudinal incision along the main pancreatic duct. This proce- pancreatectomy with auto-islet cell transplantation has been
dure has been evaluated extensively in clinical series and utilized with some success in delaying or preventing the
achieves improvement of pain in carefully selected patients. onset of diabetes.
The Puestow procedure provides persistent relief of pain
while preserving parenchyma. The mortality and morbidity
associated with this procedure are considerably lower than Nerve Ablation
those associated with major pancreatic resections. Successful
outcomes after a Puestow procedure appear to be limited to Nerve ablation, most commonly performed percutaneously
ducts >6 mm in diameter. The underlying disease will, how- under CT or endoscopically with EUS guidance, may be suc-
ever, continue to progress, and failure often occurs due to an cessful in some patients. However, it has been associated
inadequate drainage of the pancreatic head. with rebound pain after several months, and is therefore
more often selected for patients with terminal malignant a significantly increased risk of infectious complications.
diagnoses with limited life expectancy. However, ERCP and biliary stenting may be necessary if
there is cholangitis, organ dysfunction, or a long expected
interval prior to surgery, as is the case with neoadjuvant
Adenocarcinoma of the Pancreas therapy. In the absence of these indications, many surgeons
will also pursue stenting for severe jaundice (bilirubin
Diagnosis >15 mg/dL), given the association between severe jaundice
and renal dysfunction. The procedure is also of potential
The classic description of a patient with “painless jaundice” value in patients in whom the diagnosis is equivocal or if
belies the significant pain that develops as pancreatic cancer choledocholithiasis is suspected. Percutaneous transhepatic
progresses. The presence or absence of pain should never be cholangiography (PTC) may also establish a diagnosis and
used to eliminate this diagnosis. Early symptoms consist of an access point for biliary decompression but is rarely used
dyspepsia and weight loss, often without jaundice. in current practice, unless ERCP is not technically
Recognition of jaundice frequently triggers an imaging possible.
workup with ultrasound or CT. Finally, it should be stressed that for an experienced pan-
creatic surgeon, tissue documentation of the diagnosis of
pancreatic cancer is not considered mandatory. In major
Imaging centers, many resections are performed without the benefit
of tissue confirmation, and a small minority of patients will
Modern multidetector CT imaging has greatly enhanced our subsequently be determined to have benign disease. This
ability to define the local resectability of tumors. Thus, even should not convey the message that pancreaticoduodenec-
if a patient has had a conventional CT scan before coming to tomy is an operation undertaken lightly, but rather that a
the surgeon, it is advised that a “pancreas protocol” CT scan solid mass in the head of the pancreas, particularly in the
with thin slices taken through the pancreas at specific times absence of pancreatitis history and presence of symptoms, is
after injection of contrast (pancreatic arterial and portal highly suspicious for the diagnosis of pancreatic cancer.
venous phases) be obtained to provide more precise informa-
tion regarding the tumor. Contrast-enhanced magnetic reso-
nance imaging (MRI) is a good alternative if a patient has a Determination of Resectability
contraindication to CT contrast but is not clearly superior to
a high-quality CT for determination of resectability. Many of the same modalities used for diagnosis can also be
Mesenteric arteriography, routinely used in the past to evalu- employed to determine resectability. Factors that determine
ate vascular involvement, has been abandoned by most expe- resectability include local invasion of the tumor into contigu-
rienced pancreatic surgeons in favor of these less invasive ous structures that should be preserved (e.g., vascular struc-
methods. tures) and tumor spread in the abdomen to sites remote from
EUS is more sensitive than CT or MRI for the detection of the primary tumor, including hepatic, peritoneal, and lung
small masses and allows the identification and fine-needle metastases. These features divide tumors into three main cat-
aspiration (FNA) of lymph nodes and pancreatic masses in egories: resectable, borderline resectable, and unresectable.
sufficient proximity to the probe. EUS-guided FNA is con- Alhough clearly resectable and unresectable tumors are eas-
sidered preferable to percutaneous biopsy if tissue diagnosis ily identified, there is no universally accepted definition of
is desired for a localized tumor. Evaluation of invasion into borderline resectability. In general, borderline tumors are
vascular structures, particularly the superior mesenteric vein those in which resection would likely be associated with at
and portal vein, is also excellent with EUS. However, EUS is least a microscopic positive margin, such as tumors with
limited in its ability to evaluate for distant metastatic disease extensive involvement of the superior mesenteric vein (SMV)
and therefore can only provide supplemental information to or portal vein or abutment of the common hepatic artery or
cross-sectional imaging. the superior mesenteric artery (SMA).
ERCP is used selectively in patients with suspected pan-
creatic cancer, as ductal anatomy can be delineated noninva-
sively with MRCP if necessary, and the diagnostic yield of Local Invasion
ERCP brushings is much lower than that of EUS-guided
FNA. There are no data to suggest that routine preoperative Invasion or encasement of the SMA, celiac trunk, or com-
biliary drainage in jaundiced patients is beneficial, and, in mon hepatic artery is generally considered a contraindication
fact, preoperative biliary drainage has been associated with to resection. Arterial resection is associated with poor short-
and long-term outcomes, and is therefore not routinely per- common practice to evaluate the bile duct and pancreatic
formed. In contrast, invasion into the portal vein or the SMV/ margins by frozen section pathologic analysis during the
splenic vein confluence alone does not necessarily make a operative procedure, it is controversial whether further resec-
tumor unresectable, as resection and reconstruction of these tion in the setting of a positive margin improves outcomes.
veins is an established modality. Tangential or segmental Due to the relative absence of symptoms, few tumors of
resection can be accomplished with either primary repair, the tail or body are resectable at the time of presentation. In
patch graft, or interposition grafting. Although these opera- the rare instances of resectability, distal pancreatectomy is
tive procedures are longer in duration and blood loss is the appropriate procedure. Typically, in the setting of malig-
higher than in conventional pancreaticoduodenectomy, most nant disease, this is performed in conjunction with an en bloc
consider these acceptable in the context of improved long- splenectomy.
term outcomes. Arterial invasion can be accurately deter- Total pancreatectomy is rarely used to treat pancreatic
mined by modern cross-sectional imaging and should rarely cancer, as it is uncommon for patients to have tumors that are
be an unexpected finding at laparotomy. Even with the addi- still localized to the pancreas yet require total pancreatec-
tion of EUS, however, venous invasion can be underestimated tomy. Multicentricity of invasive pancreatic cancer is also
by preoperative imaging and is still sometimes established rare. There are no data to suggest that total pancreatectomy
only at laparotomy. enhances survival over partial pancreatectomy for pancreatic
cancer.
All of the operations discussed here can be performed
Distant Metastasis minimally invasively (either laparoscopically or robotic-
assisted). In fact, distal pancreatectomy and splenectomy are
Cross-sectional imaging with contrast-enhanced CT and/or commonly performed via minimally invasive approaches,
MRI is critical for ruling out distant metastatic disease but while pancreaticoduodenecomy is still typically performed
can miss small volume liver and peritoneal disease. Staging via an open approach at most centers. While several studies
laparoscopy is often performed as a means to avoid laparot- have suggested that minimally invasive approaches may
omy in patients with occult metastatic disease, since pallia- improve short-term outcomes, there are no data to suggest
tion of biliary and gastric outlet obstruction – if present – can that these translate to improved long-term outcomes.
usually be accomplished without a laparotomy. The yield of
staging laparoscopy has decreased as the resolution of CT Neoadjuvant Therapy
and MRI imaging has improved, and many surgeons perform Given the high rates of recurrence after surgical resection for
staging laparoscopy only selectively. pancreatic cancer, adjuvant (postoperative) therapy with che-
motherapy with or without radiation therapy has typically
been recommended. However, many patients do not receive
Treatment adjuvant therapy due to postoperative complications or slow
recovery. The use of neoadjuvant (preoperative) treatment
Operative Management ensures that all patients receive multimodality therapy,
Surgical resection provides the only hope for cure of this dis- including those who are unable to receive chemotherapy fol-
ease. Most patients with tumors of the head are treated with lowing resection. It also may allow the provider to judge the
pancreaticoduodenectomy. Although some surgeons advo- tumor biology, since those with disease progression during
cate for either a pylorus-preserving or a standard pancreati- therapy likely have disease that is too aggressive to benefit
coduodenectomy, the two approaches have been found to from resection, and these patients can be spared a futile oper-
produce equivalent oncologic outcomes with no conclusive ation. Neoadjuvant therapy may be employed in an attempt
difference in incidence of delayed gastric emptying (DGE) to improve resectability. Neoadjuvant chemoradiation has
or other short-term outcomes. A number of important mar- been utilized for several years at some centers. However,
gins are considered in this resection. Generally, the bile duct with the development of more effective systemic chemother-
is divided at or above the cystic duct entry, and the common apy regimens, neoadjuvant chemotherapy has become much
hepatic duct is a margin. The pancreas is typically divided at more popular. Although neoadjuvant chemotherapy is now
or slightly to the left of the area that overlies the portal vein used routinely in the setting of local advanced or borderline
and the superior mesentery vein/splenic vein confluence. resectable tumors, its use remains controversial in patients
Perhaps, the most problematic margin is the uncinate process with radiographically resectable disease.
as it abuts the SMV and SMA. This margin is sometimes
found to be unexpectedly involved by tumor, either after
division of the pancreas or at final pathology. Although it is
Islet Cell Tumors fashion, and even patients with metastatic neuroendocrine
tumors can live for several years. It is therefore reasonable to
Islet cell tumors, or pancreatic neuroendocrine tumors, are consider resection of a symptomatic primary tumor, even in
uncommon. However, due to their frequent incidental diag- the setting of metastatic disease, and also to resect metastatic
nosis on CT imaging, they are increasing in incidence, par- disease in selected patients.
ticularly those that are small and benign. As such, there may
now be a role for conservative management of small non-
functional tumors. Cystic Neoplasms of the Pancreas
Functional islet cell tumors may have a subtle clinical pre-
sentation, and localization of the tumor can be challenging. Similar to islet cell tumors, cystic neoplasms seem to be
Once suspected based on symptomatic presentation, the diag- increasing in incidence due to improvements in and increased
nosis can be confirmed with biochemical testing. The tumor utilization of cross-sectional imaging. Cystic neoplasms can
can then be localized, most often using a contrast-enhanced CT be divided into two main categories: mucinous and nonmuci-
scan. However, if unsuccessful, EUS has been shown to have a nous. Mucinous cysts can be further divided into mucinous
high sensitivity for islet cell tumors. A number of adjuvant cystic neoplasms (MCNs), which most often present in
imaging modalities exist. A radioisotope scan using a soma- women as a solitary cyst in the body or tail of the pancreas,
tostatin analog such as octreotide has had some success for and intraductal papillary mucinous neoplasms (IPMNs),
detecting islet cell tumors, particularly gastrinomas. Selective which are more likely to be multifocal and occur equally in
venous sampling (portal and splenic veins and venous tributar- males and females. The most common nonmucinous neo-
ies from the pancreas), sometimes combined with the use of plasm is a serous cystadenoma, which is typically a solitary
secretagogues such as secretin, has been used in the past with lesion in females and has a characteristic “microcystic”
varying success. If a functional tumor cannot be imaged preop- appearance on imaging. Mucinous neoplasms are considered
eratively, operative exploration is generally still indicated, with to be premalignant or may be frankly malignant, whereas
intraoperative ultrasound to help localize the tumor. nonmucinous cystic neoplasms are rarely malignant. The
The most common functional islet cell tumor is an insuli- distinction can sometimes be made based on imaging alone.
noma. They are small and most often occur in the pancreas, When the diagnosis is uncertain, EUS can be used to aspirate
though rarely can be found in the duodenum or splenic fluid to test for the presence of mucin or for measurement of
hilum. The tumors secrete proinsulin, which is subsequently carcinoembryogenic antigen (CEA) levels as a surrogate for
cleaved into insulin and c-peptide. The typical symptomatic mucin. Cytology may also be performed. Although the spec-
presentation includes low blood glucose levels, associated ificity of positive fluid cytology for either mucinous epithe-
with symptoms of hypoglycemia, and symptomatic relief lial or frankly malignant cells is high, the sensitivity of fluid
with glucose administration, or Whipple’s triad. The diagno- cytology is low.
sis can be confirmed with measurement of proinsulin, insu- Lesions with imaging and fluid characteristics consistent
lin, c-peptide, and glucose levels during a supervised period with serous cystadenoma do not require resection unless they
of fasting. are symptomatic. In contrast, suspected mucinous lesions
Gastrinomas are the second most common functional islet require either resection or surveillance. Suspected MCNs
cell tumors. Almost all are located within the gastrinoma tri- should typically be resected in otherwise fit patients. IPMN
angle, which is formed between the junction of the cystic and lesions are further classified by the involvement of the main
common bile ducts, the junction of the head and neck of the pancreatic duct. Those involving only one or multiple side
pancreas, and the junction of the second and third portions of branches are called branch duct (BD) IPMNs, while those
the duodenum. Gastrinomas constitutively produce gastrin, involving the main pancreatic duct are called main duct
without stimulation from amino acids, nor inhibition from (MD) IPMNs. The risk of malignancy in IPMN lesions has
low gastric pH. This leads to Zollinger-Ellison syndrome, been well studied. The Fukuoka Consensus Guidelines
consisting of hypergastrinemia and severe peptic ulcer dis- updated in 2017 suggest that, due to the high risk of malig-
ease. If suspected, the diagnosis can be confirmed by mea- nancy, surgical resection should be considered for all
suring serum gastrin levels and gastric pH. MD-IPMN lesions. BD lesions, however, have a lower risk
Where possible in small, benign tumors, enucleation is of malignancy. For BD lesions associated with “high risk
the preferred approach. If there is any evidence of extension stigmata,” such as obstructive jaundice, an enhancing solid
beyond the capsule or if lymph node involvement is evident, component within the cyst, or a main pancreatic duct dilated
the tumor may be malignant, and formal resection is recom- to 1 cm or greater, resection is still the appropriate treatment.
mended. Most neuroendocrine tumors behave in an indolent In the absence of these high-risk stigmata, a more selective
approach can be utilized based on the presence or absence of severe complications. Pancreatic fistula can lead to mortality
“worrisome features,” including cyst size of 3 cm or greater, via the coexistence of abdominal sepsis. However, another
cyst wall thickening or a mural nodule, or main ductal dila- important potential sequela of POPF is the development of a
tion of 5 mm, cyst location, and the general health of the pseudoaneurysm, potentially leading to life-threatening
patient. Although, historically, resection was recommended hemorrhage. This often presents with a “sentinel bleed”
for all IPMN lesions, it is now becoming apparent that many demonstrated by either blood in the surgical drain, acute GI
IPMN lesions can be safely observed. bleed, or an unexpected drop in hematocrit. If a leak is sus-
pected, the patient should undergo embolization by interven-
tional radiology to prevent subsequent life-threatening
Complications of Pancreatic Surgery hemorrhage. Pancreaticoduodenectomy also adds the risk of
biliary and gastrojejunal anastomotic leakage. Similar to
The most common complication after pancreaticoduodenec- pancreatic fistula, biliary fistula, if controlled, should be a
tomy is delayed gastric emptying (DGE). Some surgeons fairly benign event when managed with closed-suction drain-
routinely employ a prokinetic agent during the immediate age, and spontaneous closure again should be anticipated.
postoperative period after this procedure, and patients with Leakage from the gastrojejunal anastomotic leakage is much
severe DGE may require artificial nutrition (either total par- less common than from the other anastomoses.
enteral nutrition or enteral tube feeds) or even drainage gas- Despite a high morbidity and mortality historically, out-
trostomy tube placement. Fortunately, long-term severe comes for pancreatic resections have significantly improved,
DGE is uncommon. Initially, there was concern that pylorus- particularly at high volume institutions. Furthermore, while
preserving pancreaticoduodenectomy, which was originally the overall morbidity remains significant, mortality has
developed in order to prevent dumping and bile reflux, would dropped to less than 5%, largely in part due to a better ability
lead to even higher rates of DGE. However, as discussed ear- to recognize and manage complications.
lier, there has been no significant difference found between a
standard Whipple and a pylorus-preserving pancreaticoduo-
denectomy with respect to the rates of DGE. Furthermore, Further Reading
there has been no difference in any short- or long-term out-
comes, including operative time, blood loss, mortality, length Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM,
et al. Pancreatic ductal adenocarcinoma radiology reporting tem-
of stay, and survival. plate: consensus statement of the Society of Abdominal Radiology
Although DGE is the most common complication of pan- and the American pancreatic association. Gastroenterology.
creatic surgery, pancreatic fistula carries the highest associ- 2014;146(1):291–304.
ated morbidity. In the past, this complication was considered Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, et al. Postoperative
pancreatic fistula: an international study group (ISGPF) definition.
to be the cause of the high mortality rate associated with Surgery. 2005;138(1):8–13.
these resections. In 2005, the International Study Group of Bockhorn M, Uzunoglu FG, Adham M, Imrie C, Milicevic M, et al.
Pancreatic Fistula (ISGPF) established a definition and grad- Borderline resectable pancreatic cancer: a consensus statement
ing system in order to classify postoperative pancreatic fis- by the international study Group of Pancreatic Surgery (ISGPS).
Surgery. 2014;155(6):977–88.
tula (POPF). They established three grades based on the Conroy T, Hammel P, Hebbar M, Ben Abdelghani M, Wei AC, et al.;
patient’s overall clinical condition, presence of infection or Canadian Cancer Trials Group and the Unicancer-GI–PRODIGE
sepsis, duration of drainage, and whether readmission, reop- Group. FOLFIRINOX or gemcitabine as adjuvant therapy for pan-
eration, or other specific treatment was required. Pancreatic creatic cancer. N Engl J Med. 2018;379(25):2395–406.
Diener MK, Knaebel HP, Heukaufer C, Antes G, Buchler MW,
fistulas are far more common when the texture of the pan- Seiler CM. A systematic review and meta-analysis of pylorus-
creas is essentially normal and soft and poorly prepared to preserving versus classical pancreaticoduodenectomy for surgical
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Partial Pancreatoduodenectomy
96
Joseph J. Kim, Umut Sarpel, and Daniel M. Labow
Indications –– Hospitals or surgical teams that lack experience in

pancreatoduodenectomy: studies have shown improved
• Tumors of the head of pancreas, duodenum, ampulla, or patient outcomes when this operation and resultant
distal bile duct that have been determined to be resectable postoperative care are performed at high-volume
based on imaging and endoscopy centers.
• Pancreatic cystic neoplasms (i.e., intraductal papillary
mucinous neoplasms [IPMNs]) that are high-risk for
malignant degeneration Preoperative Preparation
• Select patients with chronic pancreatitis and intractable
pain who have failed medical management and whose • High resolution imaging with computed tomography
disease is limited to the head of the pancreas (CT) or magnetic resonance imaging (MRI) to obtain
• Rare cases of pancreatic head involvement and/or signifi- accurate staging and resectability.
cant duodenal involvement by adjacent tumor • Routine preoperative biliary decompression has not been
shown to be beneficial and is usually only required if the
bilirubin is extremely high (>20 mg/dL).
Contraindications • Neoadjuvant chemotherapy (with/without radiation ther-
apy) should be considered for pancreatic adenocarci-
• Absolute contraindications: noma; for patients with borderline resectable disease,
–– Patients with metastatic disease who will obtain no neoadjuvant treatment can lead to an increased resectabil-
survival benefit from resection ity rate and an improved oncologic resection.
–– Extensive tumor involvement of superior mesenteric • Vitamin K should also be considered in all jaundiced
artery (SMA) patients, as many have occult vitamin K deficiency even
with normal coagulation panels.
• Relative contraindications: • Perioperative antibiotics.
–– Extensive involvement of portal vein (PV), superior • Epidural catheter for post-operative analgesia.
mesenteric vein (SMV), and hepatic artery (HA): • Nasogastric tube (NGT) for decompression of the stom-
resectability of a pancreatic head mass is often deter- ach during the procedure.
mined by the involvement of these critical vessels.
While vascular resections can be performed, these
cases must be approached with caution and under- Pitfalls and Danger Points
standing of the increased risk of postoperative compli-
cations, morbidity, and mortality. • Intraoperative hemorrhage
• Injury or inadvertent ligation of superior mesenteric
artery or vein, an anomalous hepatic artery or the portal
vein
J. J. Kim · U. Sarpel (*) · D. M. Labow • Failure of pancreaticojejunal anastomosis with leakage
Division of Surgical Oncology, Department of Surgery, Icahn • Failure of hepaticojejunal anastomosis with leakage
School of Medicine at Mount Sinai, New York, NY, USA (unusual)

https://doi.org/10.1007/978-3-030-81415-1_96
746 J. J. Kim et al.
• Failure of gastrojejunal anastomosis with leakage (rare) neck of the pancreas. If the vein is lacerated while making
• Postoperative hemorrhage (typically gastroduodenal the tunnel, controlling the hemorrhage is extremely difficult
artery blowout secondary to pancreatic leak) due to poor exposure caused by the overlying pancreas gland.
• Postoperative sepsis Temporary control of hemorrhage is generally possible in
this situation if the surgeon compresses the vein against the
tumor by passing the left hand behind the head of the pan-
Operative Strategy creas. An experienced assistant then divides the neck of the
pancreas anterior and just to the left of the SMV. In some
The operation may be conceptualized as consisting of three cases, it is necessary to isolate and temporarily occlude the
stages: assessment of resectability, resection of the speci- splenic, inferior mesenteric, superior mesenteric, coronary,
men, and reconstruction for enteric continuity. The operative and portal veins to achieve proximal and distal control.
technique will describe a standard pancreatoduodenectomy,
with resection of the gastric antrum and pylorus, and a
gastrojejunostomy. Modifications of technique for a pylorus- Vascular Resections
preserving pancreatoduodenectomy will be outlined after-
wards. Diagnostic laparoscopy is usually performed as a first The need for a vascular resection during pancreatoduodenec-
step, to exclude small metastatic deposits not seen on preop- tomy can lead to significant complications both intraopera-
erative imaging studies. tively and postoperatively. Pre-operative imaging can often
identify patients who have a higher chance of requiring a
vascular resection. While vascular resection and reconstruc-
ssessment of Pathology to Determine
A tion may be technically possible in many cases, these patients
Resectability should be selected carefully, and the operation should be
done with a team that has significant experience with these
Before any major, irreversible resections of bowel and/or types of resections. Prior to any planned vascular resection,
vessels are done, an evaluation of resectability of the lesion proximal and distal control must be obtained in order to
should be completed. The liver should be palpated, as well as safely complete the resection and reconstruction.
the mass itself. The root of the small bowel mesentery and If tumor has indeed invaded the portal vein, a patch or a
celiac axis nodes should be evaluated. A complete kocheriza- segment of vein may have to be excised. Partial resection of
tion of the duodenum, palpation and visualization of the pan- the vein should ideally be closed perpendicular to the course
creas, and assessment of the SMV, SMA, and PV should be of the vein as to avoid narrowing of the vessel. Alternatively,
included in the evaluation for resectability. Of note, lymph a vein patch can be used. If a short segment of vein is
node involvement along the gastrohepatic or gastroduodenal resected, an end-to-end anastomosis of the PV to the SMV is
artery adjacent to the malignancy is not a contraindication to usually possible. Ligation of the splenic vein can often pro-
resection. Patients with preoperative biliary stent placement vide enough laxity to create a tension-free anastomosis. To
may have enlarged lymph nodes due to inflammatory reac- replace longer segments of resected PV/SMV, an interposi-
tion. Any decision to abort the procedure should be con- tion vein graft may be needed. Sources of conduit include
firmed with definitive intraoperative frozen section. saphenous vein, left renal vein, internal jugular vein, or com-
Most patients will go to the operating room with a patho- mon femoral vein. The choice of conduit is dependent on
logic diagnosis. If there is some doubt in the diagnosis or need size of PV and SMV, as a close match in diameter is pre-
of proof of malignancy, then intraoperative biopsy can be per- ferred. Acute ligation of the PV is often fatal and should be
formed prior to resection. In general though, the decision to avoided at all costs.
operate is made preoperatively. The lesion in the head of the
pancreas can be exposed by dividing the omentum and entering
the lesser sac. Typically, a fine-needle aspiration cytology will voiding and Managing Postoperative
A
be sufficient for confirmation, but a transduodenal core biopsy Hemorrhage
may be necessary if more tissue is needed. Occasionally, it is
necessary to proceed without confirmation of malignancy. A possible disastrous complication is exsanguination from a
gastroduodenal (GDA) stump blowout. When this happens,
it typically occurs around postoperative day (POD) 5–14 in
voiding and Managing Intraoperative
A the setting of a pancreatic leak. Classic presentation begins
Hemorrhage with a sentinel bleed that in the drain or hematemesis and
then progresses to uncontrolled and rapid exsanguination. A
The greatest risk of major intraoperative hemorrhage occurs CT angiogram should be performed immediately and any
when the surgeon is dissecting the PV/SMV tunnel under the suspicion of a pseudoaneurysm of the GDA treated with
96 Partial Pancreatoduodenectomy 747
increased use of neoadjuvant chemotherapy and repeat imag-

ing prior to surgery, there appear to be fewer cases of patients
with grossly metastatic disease undergoing surgery. Not all
patients need a diagnostic laparoscopy, but it is a simple,
inexpensive procedure that could spare a patient undergoing
a non-therapeutic laparotomy. The peritoneum, liver, and
omentum should be inspected for any gross metastatic dis-
ease. Any suspicious nodules should be biopsied and con-
firmed to be benign prior to proceeding.
Incision and Exposure
A midline incision from the xiphoid to or just below the

umbilicus will usually provide adequate exposure. The
Fig. 96.1
extension of the incision will be based on body habitus with
a longer incision required for patients with higher body mass
embolization. Operative intervention is reserved only for indexes (BMIs). Some surgeons prefer a bilateral subcostal
cases where embolization is not possible or fails. Ideally, a incision, with or without an upper midline incision to create
short stump should be left on the common hepatic artery at a chevron incision. This will provide excellent exposure, but
the origin of the GDA so an interventional radiologist can patients may experience more postoperative pain, respiratory
place their coils without risking occlusion of the common splinting, and a diminished cosmetic result.
hepatic artery (Fig. 96.1). Transect the round ligament, either with an energy device
or ligate it with 0-silk ties. Some surgeons choose to use the
tied ligament for retraction of the liver, or to wrap around the
voiding Leakage from the Pancreatojejunal
A pancreatic anastomosis at the completion of the case. A
Anastomosis wound protector may be placed in an attempt to decrease the
risk of a surgical site infection (SSI). Then place a self-
Leakage from the pancreatojejunal anastomosis is the retaining retractor to allow for exposure of the operative
Achilles heel of the Whipple procedure, and is documented field, which will include access to the hepatic flexure on the
to occur in approximately 15% of cases, even at high-volume right, the porta hepatis superiorly, the stomach on the left,
centers. Failure of the pancreatic anastomosis is more com- and the ligament of Treitz inferiorly (Fig. 96.2).
mon in patients with a soft gland and small pancreatic duct,
such as seen in patients with carcinoma of the distal portion
of the common bile duct (CBD) or the duodenum because
these patients do not typically develop obstruction of the
pancreatic duct, which is frequently associated with low-
grade pancreatitis and a firm pancreas. Both obstruction and
pancreatitis produce thickening of the pancreatic duct and
the pancreatic parenchyma. Anastomosis to a soft pancreas
can be technically challenging.
Operative Technique
Diagnostic Laparoscopy
The first step of the operation is a diagnostic laparoscopy

(with the exception of pre-malignant cysts) to ensure there is
no gross metastatic disease to the peritoneum or liver which
was not detected on pre-operative imaging. With the Fig. 96.2
Fig. 96.3
Kocherization of the Duodenum Fig. 96.4
Perform an extensive Kocher maneuver to separate the duo-

denum and the head of the pancreas from the underlying
inferior vena cava. It may be necessary to mobilize the
hepatic flexure to gain sufficient exposure of the second por-
tion of the duodenum. Retract the colon and small bowel
inferiorly with a self-retaining or Deaver retractor.
Pull the second portion of the duodenum medially and
anteriorly to allow division of the peritoneal attachments
along the duodenum (Fig. 96.3). There is an avascular plane
between the duodenum/head of the pancreas and the vena
cava. Much of the dissection can be done bluntly or sharply
with the occasional use of electrocautery to ensure meticu-
lous hemostasis. If the mass is bulky, there may be signifi-
cant inflammation, making the kocherization more
challenging. Continue this kocherization medially until the
left renal vein is visualized (Fig. 96.4). This extensive dissec-
tion may take effort before reaching exposure of the left
renal vein, but is worth the investment in time as excellent
mobilization will ease subsequent resection. Avoid excessive
upward traction on the duodenum and pancreas, as it may
tear the right gastroepiploic vein or the SMV. Fig. 96.5
orly. This will facilitate opening the potential space of the

issection of Portal Vein and Superior
D lesser sac (Fig. 96.6). The colonic mesentery can be adher-
Mesenteric Vein ent to the omentum and care must be taken not to injure the
mesocolonic vessels while developing this space. Separate
In order to gain exposure of the pancreas and SMV, enter the omentum from the transverse colon all the way to the
the lesser sac by incising the greater omentum proximal to splenic flexure to gain full exposure of the pancreas
the transverse colon (Fig. 96.5). In order to provide the cor- (Fig. 96.7).
rect exposure, retract the omentum and stomach anteriorly Identify the SMV by dissecting the peritoneum at the
and superiorly while retracting the transverse colon inferi- inferior aspect of the pancreas, near the neck and body. If it
creas. There are usually no branches to the pancreas along

the immediate anterior surface of the SMV/PV, allowing a
clear path for dissection. Despite this, take extra care and
time to ensure that there is no injury to the vessel during this
dissection, as control can be difficult prior to transection of
the pancreatic neck. The dissection can be done by passing a
blunt tip Tonsil or Peon clamp into the plane and gently
spreading. However, as this is often a blind maneuver, take
extreme care not to push against any resistance encountered
(Fig. 96.9). A vein retractor can be used to lift the inferior
edge of the pancreas and Metzenbaum scissors can be used
to gently develop the plane under direct vision as much as
possible (Fig. 96.10). Note that at this point in the case, the
tunnel beneath the pancreas is started, but is typically not
fully completed until the superior portion of the dissection
along the portal vein.
Creation of this tunnel between the SMV/PV and the pan-
creatic neck is the most critical part of the operation and may
Fig. 96.6 be challenging if there is venous invasion of the tumor. Note
that the direction of the PV (and therefore the direction of the
tunnel) is to the patient’s right shoulder, and not directly
upwards toward the head.
Cholecystectomy
Perform a cholecystectomy in the usual manner via a top-

down approach as for any open cholecystectomy. Tie the cys-
tic artery with permanent suture (4-0 silk) proximally and
clip it on the specimen prior to being divided. Similarly, tie
the proximal cystic duct with a 2-0 silk prior to transection.
Some surgeons prefer to keep the gall bladder in continuity
with the Whipple specimen while others prefer to remove it
from the field; either is acceptable.
Performing the cholecystectomy early can help with
exposure of the porta hepatis and the duodenum, especially
in those patients with obstruction causing gallbladder disten-
sion and those with an unfavorable body habitus.
Cholecystectomy does not commit to pancreatoduodenec-
Fig. 96.7 tomy and the primary procedure can still be aborted without
major sequelae if the tumor is determined to be
is difficult to identify the SMV, trace the middle colic vein to unresectable.
its junction with the SMV (Fig. 96.8). Then follow the SMV
as it courses under the pancreas. Dissect the SMV from the
pancreas to begin the inferior part of the tunnel between the Dissection of the Porta Hepatis
pancreas and the PV. During the dissection of the inferior
pancreas, the gastroepiploic vessels will be encountered Prior to dissecting the porta hepatis, palpate for a replaced
toward the duodenum. Dissect, tie, and ligate these early in right hepatic artery running on the posterolateral aspect of
this part of the procedure. Failure to identify these vessels the common bile duct (CBD). Understanding the patient’s
and ligating them appropriately can lead to avulsion of the vascular anatomy prior to surgery is critical. A replaced right
vessels and significant bleeding. hepatic or an aberrant common hepatic artery originating
The tunnel is created between the anterior surface of the from the SMA may be encountered at variable locations in
SMV/PV and the posterior aspect of the neck of the pan- the dissection and must be preserved.
Fig. 96.8 Common

hepatic a. L. gastric a. Coronary v.
Splenic
a. and v.
Common bile duct
R. gastic a.
Portal v.
Gastroduodenal a.
Sup. mesenteric v.
Inf.
Sup. mesenteric a. mesenteric v.
R. gastroepoploic
a. and v.
Mid. colic v. and a.
Fig. 96.10
two ligatures of 2-0 silk. Dissect the GDA free for about
Fig. 96.9 1–2 cm to allow for a stump to be left in situ after ligation,
should coil embolization be required for control of post-
The hepatic artery can be identified medial to the lesser operative hemorrhage.
curvature of the stomach after incising the filmy avascular After the right gastric artery and GDA are divided, the
portion of the gastrohepatic omentum. Continue to dissect HA can be rolled medially allowing further dissection in the
the common hepatic artery to identify origins of the right porta hepatis. Incise the peritoneum over the CBD and the
gastric artery and gastroduodenal (GDA). Dissect the right CBD encircled just upstream from the cystic duct insertion.
gastric artery and ligate and divide it between two ligatures For oncologic purposes, sweep any lymph nodes encoun-
of 4-0 silk, allowing exposure of the GDA. Occlude the GDA tered in the porta hepatis toward the specimen so that they
and palpate the distal hepatic artery to confirm anatomy and are removed with it.
that the GDA is not the primary arterial inflow to the liver Next, the anterior aspect of the portal vein is exposed
(Fig. 96.11). Once this is confirmed, divide the GDA between (Fig. 96.12). This is usually immediately deep to where the
Fig. 96.11
Fig. 96.13
When the tunnel is completed, pass a blunt-tip Tonsil clamp

from below and use it to pull a vessel loop through the tunnel
with the clamp. Use a clamp or clip to secure the vessel loop.
Retract the pancreas using the vessel loop and widen the tun-
nel under direct vision. Once the tunnel along the PV/SMV
is complete, the tumor is probably resectable, and one may
now proceed with the resection (Fig. 96.14).
Transect the CBD with a fresh #15 blade, using a right-
angle clamp to ensure the PV is not injured during the divi-
sion of the duct. If a preoperative stent was placed, remove it
and take a culture of the bile. If the patient develops a SSI or
sepsis, the source is almost always from the colonized biliary
system and this culture can help direct antibiotic therapy.
Fig. 96.12 There can be bleeding from the vessels that run along the
duct in the 3′ and 9′ o’clock positions. This bleeding may be
GDA is divided, although this anatomy can be distorted with self-limiting or controlled with precise electrocautery.
a large tumor. The presence of a large carcinoma in or near Alternatively, control it with 5-0 prolene sutures. Do not
the head of the pancreas can often lead to numerous small skeletonize the duct, as this may compromise its blood sup-
veins superficial to the porta hepatis. Individually ligate ply and increase the risk of a hepaticojejunal anastomotic
these vessels with 4-0 silk sutures as clips in this area can be leak or late stricture. If the tumor is a distal cholangiocarci-
inadvertently displaced during the subsequent dissection and noma, consider a frozen section of the duct margin to ensure
manipulation. a sufficient margin has been obtained.
Gently free the portal vein from the overlying pancreas
using a combination of blunt and sharp dissection. A blunt-
tip right-angle clamp can be used to slowly and carefully Antrectomy
develop this plane by inserting the tip between the PV and
pancreas and using small gentle spreads (Fig. 96.13). Any Proceed with antrectomy or pylorus preservation as appro-
resistance could mean there is inflammation due to, or pos- priate. Prior to stapling, make certain the nasogastric tube
sible invasion of, the lesion. (NGT) has been pulled back and will not be caught in the
Complete the tunnel between the PV and the pancreas by staple line. Once divided, tuck the remnant stomach into the
alternately developing the plane from above and below. left upper quadrant to expose the body of the pancreas fully.
Portal v.
a b
Sup.
mesenteric v.
Fig. 96.14
Dissection and Division of Proximal Jejunum
Retract the transverse colon superiorly to expose the ligament

of Treitz. Inspect the proximal jejunal mesenteric arcades.
Select a point for jejunal transection that will allow the distal
loop to reach up to the right upper quadrant without tension.
This point is typically about 10 cm from the ligament of
Treitz. Divide the jejunum using a 60/3.5 mm linear stapling
device (GIA). Then divide the proximal jejunal mesentery
using a Ligasure device. It is possible to injure the SMA dur-
ing this dissection, therefore ligate the mesentery of the
remaining proximal jejunum and distal duodenum as close to
the bowel wall as possible. If the kocherization was sufficient,
the transected proximal jejunum/distal duodenum can be
passed underneath the mesenteric vessels to the right side of
the patient without difficulty. Any remaining mesentery of the
duodenum can now be visualized and divided (Fig. 96.15).
Division of Pancreas
There are many described techniques for the transection of Fig. 96.15
the pancreas. Our preferred method is passing a Satinsky
clamp under the pancreas and dividing the pancreas sharply
with a fresh #15 blade in one or two definite strokes to mini- When transecting the pancreas, it is helpful to cut directly
mize trauma to the gland. Regardless of the method chosen, perpendicular to the gland or slightly from the patient left to
the most important factor is protection of the portal vein pos- right to create a slight oblique edge. This will facilitate the
teriorly. Take care to cut down onto the clamp and not slip off creation of the pancreaticojejunostomy because the cut sur-
the clamp (Fig. 96.16). Alternatively, electrocautery can be face of the gland will be facing slightly more anteriorly than
used to divide the pancreas or a 30/3.5 mm linear stapler posteriorly (Fig. 96.16).
(TA) can be fired across the pancreas and the pancreas Typically, there is minor bleeding from the inferior and
divided to the left of the stapling device. superior pancreaticoduodenal arteries. Some choose to place
prolene sutures to help control these vessels prior to transec-
Line of
a b Bile duct Portal vein transection
Angle of
Pancreas transaction
SMV Satinsky
PV
Fig. 96.16
Fig. 96.17
tion of the pancreas. These small bleeders can be controlled Fig. 96.18
with precise electrocautery or prolene sutures, being careful
not to injure or occlude the duct. At this time, a margin can and retracted to the patient’s right. This will expose the ante-
be sent if there is concern regarding tumor involvement. If rior surface of the superior mesenteric and portal veins
the margin is positive, then further pancreatic resection can (Fig. 96.18). Gently dissect the specimen dissected free of
be done to a negative margin (Fig. 96.17). the vein, ligating small branches along the way.
Once the specimen is dissected off the SMV, the dissec-
tion continues along the SMA. There are usually two or three
Dissection of Uncinate Process branches from the SMA into the head of the pancreas. While
retracting the specimen, identify these branches, and dissect
At this point, the specimen should be attached only by the and ligate them with 4-0 silk ties on the in situ side (and clips
head and uncinate process of the pancreas. The specimen, on the specimen to save time) (Fig. 96.19). It is important to
including the cut end of pancreas, divided stomach, and the note that in patients with a replaced right hepatic artery, it is
cut limb of jejunum, should be held in the surgeon’s left hand critical to identify and protect it at its origin from the
Fig. 96.19
Portal vein
Pancreatic veins
Head of pancreas
and duodenum
SMA. Once the SMA is dissected away, divide any remain-

ing tissue with the Ligasure. Prior to transecting any tissue, it
is important to confirm with either direct vision or palpation,
that the SMA is not compromised. Of note, this is the margin
most often compromised during pancreaticoduodenectomy.
Skeletonization of the SMA border is important for an opti-
mal oncologic resection in patients with pancreatic cancer. In
patients having a Whipple for duodenal cancer or other
etiologies, an option for this dissection is to use a linear sta-
pling device to transect the uncinate process. Upon comple-
tion of this dissection, the specimen should now be
completely free and passed off the field (Figs. 96.20 and
96.21).
Reconstruction Techniques
Typically, the anastomoses are completed in the following Fig. 96.20

order: (1) Hepaticojejunostomy, (2) pancreaticojejunostomy,
and (3) gastrojejunostomy (or duodenojejunostomy). Prior There is a natural thin avascular area near the root of the
to beginning the anastomoses, inspect the surgical field and colonic mesentery to the patient’s right of the middle colic
obtain good hemostasis. This is the best time to address any vessels. Incise this area and pass the cut end of the jejunum
bleeding as once the anastomoses are completed, unnecessary through. The jejunum should reach the cut bile duct and pan-
manipulation and pulling on the anastomoses should be creatic duct and be oriented so the staple line is toward the
avoided. pancreas (Fig. 96.22).
Mucosa Serosa
Fig. 96.21
Fig. 96.23
Pancreaticojejunal Anastomosis
Elevate the cut edge of the pancreas off the underlying

splenic vein. A few small branches from the pancreas to the
splenic vein may require division. Free up approximately
1–2 cm of the cut end of the pancreas to facilitate the cre-
ation of the anastomosis.
Next, carefully estimate where the pancreatic duct will
line up with the jejunum in order to create a tension-free
anastomosis. Use Bovie electrocautery to make an incision
on the antimesenteric border of the jejunum for the pancre-
aticojejunostomy. The size of the enterotomy should be
Fig. 96.22 made slightly smaller than the pancreatic duct as the enter-
otomy will tend to be stretched during the anastomosis.
Hepaticojejunal Anastomosis Again, use a 7-0 PDS stitch to secure the mucosa to the
serosa of the enterotomy in four quadrants. This will help
Use Bovie electrocautery to make an incision on the antimes- ensure fill thickness bites of the bowel and also help guide
enteric border of the jejunum for the hepaticojejunostomy. the anastomosis (Fig. 96.23).
The enterotomy should be slightly smaller than the diameter There are multiple techniques described to create the pan-
of the hepatic duct, as the enterotomy will stretch during the creatic anastomosis; we describe our two preferred options.
anastomosis. If the duct is small in size, use a 7-0 PDS stitch For the Blumgart technique, use 2-0 Vicryl sutures on an
to secure the mucosa to the serosa of the enterotomy in four MH1 needle to take a full thickness bite through the pancre-
quadrants (Fig. 96.23). This will help ensure full-thickness atic parenchyma about 1 cm from the cut edge (Fig. 96.25).
bites of the bowel and also help align the duct and the bowel Take a seromuscular bite of the jejunum about 1 cm posterior
during the anastomosis. Use a double-armed 5-0 PDS to from the antimesenteric aspect using the same stitch and then
stitch the left side of the duct to the left corner of the enter- go back up through the pancreatic parenchyma (dorsal to
otomy so that the knot is outside of the anastomosis (3 ventral) right next to the original stitch. Place a clamp on the
o’clock position). Complete the posterior layer of the anasta- two ends of the suture, leaving the needle on the suture.
mosis first using a running stitch. Then complete the anterior Repeat this same technique to place two to three more trans-
layer in a running fashion and the tie the two arms in the far pancreatic stitches about 5–10 mm apart so the dorsal pan-
right corner (Fig. 96.24). For ducts <5 mm in diameter, use creas is lined up with the posterior aspect of the jejunum and
interrupted sutures instead, starting at the 6 o’clock position pancreatic duct and the enterotomy are lined up for the
and working up toward 12 o’clock. anastomosis.
Bile duct
5-0 PDS
double-armed
Jejunum
Fig. 96.24
For the duct to mucosa anastomosis, use interrupted 6-0 in the immediate postoperative period. The tip will eventu-
PDS sutures to sew the pancreatic duct to the full thickness ally migrate and be passed out through the bowel.
of the jejunal wall at the enterotomy (Fig. 96.25). When Then complete the duct-to-jejunum anastomosis with
completing the pancreatic duct-to-mucosa anastomosis, it interrupted 6-0 PDS sutures, but leave these untied and place
can be helpful to keep the sutures double-armed, as this will rubber-shods on these sutures. This will facilitate continued
provide flexibility in how to approach each individual stitch. visualization of the duct and help ensure a patent anastomo-
Begin in the middle of posterior half of the anastomosis, and sis (Fig. 96.25). These sutures are tied after all the sutures
then work toward both corners, tying each suture as they are have been placed to complete the anterior of the anastomo-
placed. Cut off about 4 cm of the tip of a 5-Fr pediatric feed- sis. The previously placed 2-0 MH1 Vicryl sutures are then
ing tube. After the posterior half of this anastomosis has been used to take a seromuscular stitch of the anterior jejunum
completed, place the feeding tube across the anastomosis mirroring the posterior stitch. These are tied carefully on the
(into the pancreatic duct and enterotomy). This will help anterior wall of the jejunum, allowing the entire cut end of
ensure that the posterior wall is not caught while suturing the the pancreatic parenchyma to be covered by jejunal wall.
anterior aspect of the anastomosis. The “stent” is left in place Alternatively, a modified Cattell-Warren pancreaticojeju-
to aid in the anastomosis but also serves to help keep it open nostomy can be used for the outer layer. Using a double-
Fig. 96.25
a
e
Fig. 96.27
Fig. 96.26
creaticojejunostomy. Rarely, a second drain is placed anteri-
orly as well; usually if there is increased concern for a
armed 3-0 PDS or prolene, the dorsal capsule of the pancreas pancreatic leak, such as when the pancreas is soft or the duct
is sutured to the posterior aspect of the jejunum in a running is small in size. The drain can be placed to self-suction, to
fashion, making sure to align the duct with the enterotomy gravity, or not placed at all, based on the preference of the
(Fig. 96.26). The duct-to-mucosa anastomosis is then com- surgeon.
pleted using the same method described previously. The
anterior aspect of the pancreas capsule-to-jejunal wall layer
is completed and the two arms are tied in the corner. Gastrojejunostomy
Wrapping the pancreaticojejunostomy with the Falciform
ligament or a tongue of omentum has been reported to The gastrojejunostomy is a two-layer anastomosis usually
decrease the leak rate. hand-sewn, though an anastomosis using staplers is equally
as effective. Identify the proximal jejunum as it passes retro-
colic and bring a loop up to the gastric remnant in an antecolic
Pancreaticojejunal Anastomosis by fashion. Make sure this anastomosis will be tension-free.
Invagination Leave 10–20 cm between the hepaticojejunostomy and the
gastric anastomosis.
An alternative method for anastomosing pancreas to jejunum The antimesenteric border of the jejunum is lined up in
is to invaginate 2–3 cm of the pancreatic stump fully into the apposition with the staple line on the distal stomach. The
lumen. This anastomotic method is more historical and is entire length of the staple line can be used for the anasto-
infrequently used, however, we have included some figures mosis. However, if this is very long, there may be a concern
(Fig. 96.27) for a basic representation of the anastomosis. for dumping, so use of only part of the staple line is prefer-
The only indication for invagination rather than a duct-to- able. Place two silk 4-0 stay stitches to approximate the
mucosa anastomosis would be if the pancreatic duct cannot antimesenteric wall of the jejunum to the staple line on the
be identified at the cut end of the pancreas. Even the smallest stomach about 2 cm from the future anastomosis. Using 4-0
of ducts can usually be anastomosed successfully to the PDS or silk, run the back wall of the outer layer of the anas-
mucosa of the jejunum with four to six stitches with a stent tomosis, about 1 cm from the antimesenteric aspect of the
left in place. jejunum and 2 cm from the staple line of the stomach.
Using electrocautery, remove the staple line (or part of it)
and create an enterotomy on the antimesenteric border of
Insertion of Drains the jejunum that is approximately the same length as the
gastrotomy. Use 4-0 PDS or 3-0 Vicryl in a running fashion
Our preference is to position the drain prior to the gastrojeju- to create the inner layer of the anastomosis, starting in the
nostomy, since this anastomosis will obscure access to the middle and running the stitches in each direction, ensuring
site. If a diagnostic laparoscopy was performed, the trocar full thickness bites on both the stomach and jejunum. After
site can be used for the drain. A 10-Fr Jackson-Pratt (JP) the posterior layer is completed, the same stitches are used
drain is placed posterior to the hepaticojejunostomy and pan- to run the anterior layer from each end and tied in the mid-
Fig. 96.28
Gastrojejunostomy
Transverse colon
dle. Invert the mucosa with a Connell stitch. The anterior linear stapling device (GIA) to divide the duodenum about
outer layer is then completed with a 4-0 PDS or silk in a 2 cm distal to the pylorus. Be careful not to devascularize
running fashion. The silk stay sutures can now be removed. the duodenum with overly aggressive mobilization.
The anesthesiologist can now advance the nasogastric tube Anastomose the end of the duodenum to the antimesenteric
and the tip should be positioned just proximal to the anas- side of the jejunum to form an end-to-side duodenojejunal
tomosis and the tube secured carefully to the nose. anastomosis in an antecolic manner as you would the gas-
Figure 96.28 shows the anatomy after completion of all the trojejunostomy. The staple line should be removed from the
anastomoses. duodenum, leaving the duodenum wide open. Observe the
cut duodenum for adequacy of bleeding. Place a layer of 4-0
interrupted silk Lembert sutures to approximate the poste-
Pylorus Preservation rior seromuscular duodenum to the jejunum just off the
antimesenteric border. Make an incision in the antimesen-
The important steps of the pylorus-preserving partial pancre- teric border of the jejunum approximating the length of the
atoduodenectomy are identical with the standard Whipple cut end of the duodenum (Fig. 96.29). Use two 4-0 PDS or
pancreatoduodenectomy except that the pylorus and 1–2 cm 3-0 Vicryl sutures, starting in the mid-point, to run a con-
of duodenum are preserved. tinuous stitch in both directions to form the posterior layer
(Fig. 96.30). Then use these same sutures to complete the
anterior layer and tie the stitches in the middle. The anterior
Operative Technique outer layer is completed using 4-0 interrupted silk Lembert
sutures (Fig. 96.31). Do not place the anastomosis too close
Follow the procedure as described for a standard Whipple to the pylorus because the close proximity of the suture line
with the following exceptions. Dissect the posterior wall of to the pylorus interferes with pyloric function and results in
the duodenum off the head of the pancreas. Use a cutting gastric retention.
Fig. 96.31
Fig. 96.29
postoperatively, the intraoperative bile culture can help direct

antibiotic therapy.
Hemodynamic monitoring in an intensive care unit or
step-down unit can be helpful, especially in older patients or
those with significant co-morbidities. Intravenous fluids
should be administered in sufficient quantities to ensure nor-
mal urine output. By the third postoperative day, there is fre-
quently a brisk diuresis, at which time intravenous fluids
should be limited in volume.
The patient should remain nothing-per-oral (NPO) for the
first postoperative day (POD) and the nasogastric tube (NGT)
can be removed unless the output is high or the patient is
distended. Typically, clear liquids can be initiated on POD2
and their diet advanced as they have return of bowel
function.
The Jackson-Pratt drain can typically be removed on
POD7 unless there are signs of pancreatic or bilious output.
If output remains high after POD5, consider sending the
fluid for amylase, even if the output appears serosanguinous,
Fig. 96.30 as this can be a sign of a pancreatic leak.
Closure
Complications
Close the abdominal wall using #1 PDS sutures in the usual
continuous fashion. The wound should be irrigated and • Leakage from pancreatic anastomosis Most pancreatic
closed with skin staples. leaks are self-limited if the fluid is adequately evacuated
by the drains placed during the procedure. A CT scan can
demonstrate whether there are undrained collections that
Postoperative Care may require the placement of additional drains by inter-
ventional radiology. While some advocate for the use of
Perioperative antibiotics should be re-dosed based on opera- total parenteral nutrition (TPN) while the anastomosis
tive room protocol. If the patient shows signs of infection heals, most will heal while continuing to take normal oral
intake. Operative intervention is rarely, if ever, needed for Further Reading

a pancreatic leak and should only be done when non-
operative management fails. Re-laparotomy can lead to Allen PJ, Gönen M, Brennan MF, et al. Pasireotide for postoperative
pancreatic fistula. N Engl J Med. 2014;370(21):2014–22.
further disruption of the pancreatic and biliary anastomo- Baron TH, Kozarek RA. Preoperative biliary stents in pancreatic can-
ses and cause more harm than good. If initial attempts to cer – proceed with caution. N Engl J Med. 2010;362:170.
control the leak fail and the patient is doing poorly, a last Cameron JL. Whipple or pylorus preservation? A critical reappraisal
resort can be to remove the remaining pancreas. and some new insights into pancreatoduodenectomy. Ann Surg.
2000;231:301.
• Postoperative Sepsis Sepsis and hemorrhage are evi- Hidalgo M. Pancreatic cancer. N Engl J Med. 2010;362:1605.
dence of leakage from the pancreaticojejunal anastomosis Jimenez RE, Warshaw AL, Rattner DW, et al. Impact of laparo-
unless proven otherwise. Use of broad-spectrum antibiot- scopic staging in the treatment of pancreatic cancer. Arch Surg.
ics and fluid resuscitation are mainstays of therapy. All 2000;135:414.
Lin PW, Lin YJ. Prospective randomized comparison between pylorus-
undrained collections should be drained by percutaneous preserving and standard pancreatoduodenectomy. Br J Surg.
radiological guided drainage. 1999;86:603.
• Postoperative Hemorrhage A GDA blowout, classically Rossi RL, Braasch JW. Techniques of pancreaticojejunostomy in pan-
heralded by a sentinel bleed seen in the Jackson-Pratt (JP) creatoduodenectomy. Probl Gen Surg. 1985;2:306.
Schnelldorfer T, Ware AL, Sarr MG, et al. Long-term survival after pan-
drain or hematemesis is pathognomonic of a pancreatic creatoduodenectomy for pancreatic adenocarcinoma: is cure pos-
leak. This complication must be recognized at the time of sible? Ann Surg. 2008;247:456.
the first bleed and should prompt angiography and embo- Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative
lization by interventional radiology. Failure to recognize biliary stents increase postpancreatoduodenectomy complications?
J Gastrointest Surg. 2000;4:267.
this event and initiate early intervention often leads to Tyler DS, Evans DB. Reoperative pancreatoduodenectomy. Ann Surg.
catastrophic outcomes. 1994;219:211–21.
• Delayed Gastric Emptying This complication can be Yekebas EF, Bogoevski D, Cataldegirmen G, et al. En bloc vascular
unpredictable in onset, though many feel that it is the resection for locally advanced pancreatic malignancies infiltrating
major blood vessels: perioperative outcome and long-term survival
sequelae of an unrecognized pancreatic leak. Duration in 136 patients. Ann Surg. 2008;247:300–9.
may be a few days, which may necessitate placement of Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pan-
an NGT for decompression. Prolonged delayed gastric creaticoduodenectomies in the 1990’s: pathology, complications,
emptying will necessitate continued feeding through and outcomes. Ann Surg. 1997;226:248.
Yeo CJ, Cameron JL, Sohn TA, et al. Pancreatoduodenectomy with or
the jejunostomy tube, if placed, or TPN. Although there without extended retroperitoneal lymphadenectomy for periampul-
are few effective therapies, fortunately the course is lary adenocarcinoma: comparison of morbidity and mortality and
usually self-limited. short-term outcome. Ann Surg. 1999;229:613–22.
Total Pancreatoduodenectomy
97
Yael Feferman and Umut Sarpel
Benign Conditions Given the physiologic changes in the apancreatic state, any
patient scheduled for an elective total pancreatectomy should
• Chronic pancreatitis (performed in conjunction with meet with endocrinology in the preoperative setting. This
autologous islet cell transplantation) allows for both assessment of the patient’s ability to manage
the resulting diabetes, to set expectations, and to begin edu-
cation on the subject.
Premalignant Conditions Total pancreatectomy is performed under general endo-
tracheal anesthesia. In the absence of contraindications, epi-
• Main branch intraductal papillary mucinous neoplasm dural anesthesia can be used to help with perioperative pain
(IPMN) control (See also Chap. 96). Prophylactic antibiotics should
• Multifocal side branch IPMN be administered prior to incision based upon hospital proto-
• Hereditary pancreatic cancer cols. Patients should receive both pharmacologic and
mechanical venous thromboembolism prophylaxis.
Malignant Conditions
Operative Strategy
• Pancreatic adenocarcinoma of the neck/body
• Large pancreatic neuroendocrine tumors (pNET) Over the recent decades, there has been an increase in the
• Completion pancreatectomy (for malignant pancreatic indications for total pancreatectomy, primarily due to recog-
margin, pancreatic fistula, or in select patients who are of nition of the malignant potential of intraductal papillary
high risk for pancreatic fistula) mucinous neoplasms (IPMN). Main duct IPMNs have high
incidence of malignant transformation, thus surgical resec-
tion is strongly recommended in fit patients. If the entire pan-
Contraindications creatic duct is involved, many centers advocate for a total
pancreatectomy – the only option which can remove all at-
• Extensive venous or arterial invasion risk tissue. In cases of limited duct involvement, intraopera-
• Distant metastases tive frozen section of the pancreatic duct is necessary to
• Patient who lacks ability to manage diabetes ensure negative margins. If there is evidence of severe dys-
plasia or invasive cancer at the margin, the resection should
be extended up to and including total pancreatectomy. With
branch duct IPMN, the incidence of malignant degeneration
is lower, and clear indications for resection are still evolving.
However, in the case of diffuse multifocal branch duct dis-
Y. Feferman · U. Sarpel (*) ease, total pancreatectomy should be considered in select
Division of Surgical Oncology, Department of Surgery, Icahn cases, such as young patients, if the aim is to prevent any
School of Medicine at Mount Sinai, New York, NY, USA chance of future malignancy.

https://doi.org/10.1007/978-3-030-81415-1_97
764 Y. Feferman and U. Sarpel
The role of chronic pancreatitis as an indicator for total the superior mesenteric vein (SMV) is necessary to deter-
pancreatectomy is in decline. However, pain control and mine resectability, we advise beginning the operation similar
intraductal obstruction not amenable to a drainage procedure to a pancreaticoduodenectomy, with creation of a tunnel
are the remaining indications for this operation. A thorough under the neck of the pancreas before proceeding to the
evaluation for compliance with postoperative medical care mobilization of the tail. This approach will be familiar to
should be made especially in those abusing alcohol. most surgeons and is described below.
In patients who develop a pancreatic fistula following
pancreaticoduodenectomy, some surgeons advocate for
prompt completion pancreatectomy as the most expeditious Laparoscopic Exploration
way to resolve the leak. Total pancreatectomy at the time of
the index operation has been described in select patients with In cases of pancreatic malignancy, first perform a staging
very high probability of developing a fistula after surgery, laparoscopy to rule out metastatic disease. After obtaining
although we do not recommend this approach. access into the peritoneal cavity, carefully explore the perito-
Total resection of the pancreas necessarily results in endo- neal surfaces and liver parenchyma. Biopsies and frozen sec-
crine and exocrine insufficiency which may lead to severe tion analysis should be performed on any suspicious lesions.
metabolic consequences, such as difficult glycemic control,
malabsorption, steatohepatitis, and liver failure. Treatment
must include interdisciplinary management. Except in emer- Incision
gency situations (trauma or completion total pancreatec-
tomy), patients should be prepared for the metabolic Use an upper midline incision from the xiphoid to below the
consequences of this procedure. Historically, the term “brit- umbilicus, which can be extended further as needed for
tle diabetic” was used to describe the apancreatic state. This exposure. In extremely stocky patients, a bilateral chevron
term well demonstrates the hesitancy to perform total pan- incision can be employed.
createctomy, however, major improvements in the control of
diabetes mellitus (DM) including long-acting insulin prod-
ucts, blood glucose monitoring, and automated insulin deliv- obilization of Pancreatic Head,
M
ery devices, allow for better control of pancreatic insufficiency Determination of Resectability
and provide options for overcoming the morbidity that fol-
lows this procedure (see postoperative care). Mobilize the hepatic flexure of the colon as necessary to
We prefer pylorus preservation when possible, however, expose the duodenal sweep. Perform a wide Kocher maneu-
this technique is not appropriate in the case of tumor involve- ver and elevate the duodenum and pancreatic head off the
ment of the duodenum or if there is concern for duodenal inferior vena cava to the level of the left renal vein. Extend
blood supply. the Kocher maneuver and continue mobilizing the third por-
En bloc splenectomy is typically indicated in resections tion of the duodenum (see Chap. 14).
for malignancy due to involvement of the splenic vein or Next, enter the lesser sac between the greater omentum
encroachment upon the splenic hilum. Spleen preserving and the transverse colon to expose the body of the pancreas
total pancreatectomy should be considered in cases of benign (Fig. 97.1). Using electrocautery, score the retroperitoneum
or premalignant disease. In cases when accompanying sple- along the lower aspect of the pancreas. Identify the SMV as
nectomy is planned or may be required, the patient should be it dives under the neck of the pancreas. In thin patients, the
vaccinated 2 weeks preoperatively against pneumococcus, course of the middle colic vein can be used as a guide to the
Hemophilus influenzae group B, and meningiococcus to location of the SMV. Begin the creation of a tunnel under the
minimize the likelihood of developing potentially lethal neck of the pancreas by gently dissecting along the anterior
post-splenectomy sepsis. aspect of the SMV. Evaluate for tumor extent and vessel
infiltration. In cases of portal or SMV involvement, vascular
resection should be considered if it allows for complete
Operative Technique tumor excision.
Total pancreatectomy is classically performed by beginning

at the pancreatic tail and progressing proximally toward the Cholecystectomy and Hilar Dissection
head. This approach is well-suited to patients with benign or
premalignant disease, or if the left aspect of the superior Next, move to the upper aspect of the dissection. Dissect the
mesenteric artery (SMA) is of concern for vascular involve- gallbladder from the fundus down. Obtain complete hemosta-
ment. However, in cases of malignancy where assessment of sis in the liver bed with electrocautery. At this time, identify,
97 Total Pancreatoduodenectomy 765
Portal v.
Sup.
mesenteric v.
Fig. 97.1 Opening the lesser sac and retruction of the stomach to
expose the body of the pancreas Fig. 97.2 Dissection along SMV/PV
ligate, and divide the cystic artery and the cystic duct and Ligate enough short gastric vessels until full exposure of the
remove the gallbladder. Perform a hilar dissection to identify splenic hilum is achieved. Make an incision in the avascular
the common hepatic artery. Ligate and divide the right gastric lienophrenic fold of the peritoneum (Fig. 97.3A, B). Divide
artery which allows exposure of the gastroduodenal artery the attachments between the lower pole of the spleen and the
(GDA). Next, ligate and divide the GDA and allow the proper colon. Elevate the tail of the pancreas together with the
hepatic artery to roll medially, thus exposing the portal vein spleen. Expose the posterior surface of the spleen and iden-
(PV) beneath. While carefully protecting the PV, encircle the tify the splenic artery and veins at this point.
hepatic duct and transect it, ideally at a point just proximal to
its junction with the cystic duct. However, if this is techni-
cally difficult, division below the cystic duct insertion is Mobilizing the Distal Pancreas
acceptable and preferable if it allows for a better anastomosis.
Send biliary fluid cultures, which will allow for tailored anti- Now direct the attention to the tail and body of the pancreas,
biotic selection in the case of post-operative intra-abdominal which is covered by a layer of posterior parietal peritoneum.
abscess. Sweep all nodal and soft tissue down with the speci- Incise this avascular layer first along the superior border of
men. Dissect along the anterior aspect of the portal vein under the pancreas and then again along the inferior border of the
the pancreatic neck. At this point, return to the site of SMV pancreas, joining the area of earlier dissection. As the pan-
dissection below the pancreas. Create a tunnel along the creas and spleen are elevated from the retroperitoneum, fol-
SMV/PV using gentle dissection (Fig. 97.2). Once this tunnel low the posterior surface of the splenic vein to the point
is complete and resectability has been confirmed, proceed to where the inferior mesenteric vein enters; then divide this
the distal pancreatic mobilization. vessel between 2-0 silk ligatures (Fig. 97.4). Identify the
splenic artery, ligate it at its origin with 2-0 silk sutures
(Fig. 97.5), divide between these ties, and place a suture liga-
Splenectomy ture through proximal stump. Carefully dissect the junction
of the splenic and portal veins away from the posterior wall
Adjust the retractor on the left costal margin to improve the of the pancreas. After the terminal portion of the splenic vein
exposure of the left upper quadrant. Continue dissection of has been cleared (Fig. 97.6), divide it between 2-0 silk liga-
the omentum to the level of short gastric vessels and ligate tures. At this point, the prior area of dissection under the
them with a bipolar vessel sealing system (e.g., Ligasure). neck of the pancreas has been reached.
a b
Fig. 97.3 (a) Incision of the lienophrenic peritoneum later to the spleen (b) Division of the splenocolic ligaments
Fig. 97.4 Division of the

inferior mesenteric vein
Splenic vein
Inf.
mesenteric v.
Spleen
Antrectomy/Pylorus-Preserving Procedure Mobilizing the Duodenojejunal Junction
Employ pylorus preserving resection in eligible patients. Expose the ligament of Treitz by elevating the transverse
Divide the duodenum with a linear stapling device, approxi- colon. Divide the jejunum as previously described approxi-
mately 2 cm beyond the pylorus. If the pylorus is not to be mately 10–15 cm distal to the ligament of Treitz. Use elec-
preserved, then divide the stomach across the antrum as pre- trocautery to divide the avascular lateral attachments, and
viously described. Preservation of the coronary vein (left use a vessel sealer device to ligate the mesentery of the prox-
gastric vein) is important because it allows sufficient venous imal bowel. Once sufficient mobilization has been achieved,
drainage of the stomach following resection of the splenic pass this segment of bowel under the root of the mesentery to
vein. the patient’s right side.
97 Total Pancreatoduodenectomy 767
Portal v.
Uncinate Stumps of ligated

process splenic and inf.
mesenteric v.
Sup.
mesenteric a.
Sup.
mesenteric v.
Fig. 97.7 Ligation of small venous branches from SMV to uncinate

process
Fig. 97.5 Ligation of the splenic artery
Hepatic a. Sup. mesenteric a.

Portal v. Inf. mesenteric v.
Splenic a.
Duodenojejunal
Splenic v. Sup. Stump of ligated junction
mesenteric v. inf. mesenteric v.
Fig. 97.8 Ligation of arterial branches from SMA to the pancreas
Fig. 97.6 Division of the splenic vein
SMA in order to identify arterial branches to the pancreas;
dissect, ligate, and divide each of these (Fig. 97.8). Divide
Freeing the Uncinate Process the uncinate process at the level of the SMA as previously
described (see Chap. 96). The specimen should now be free.
Now the specimen is only attached to the patient by the unci-
nated process. Roll the entire pancreas over to the patient’s
right, thereby exposing the full course of the SMV/PV and Reconstruction
the uncinate process. Gentle dissection will reveal small
venous branches from the SMV (Fig. 97.7). Ligate these Reconstruction is simpler than for a Whipple procedure
veins to the uncinate with clips or 4-0 silk and divide them. because no pancreatic anastomosis is needed. The hepatico-
It is now possible gently to retract the SMV to the patient’s jejunostomy is performed first, as described in Chap. 96. Our
left, thus exposing the SMA. Dissect along the plane of the preference is an end to side, retrocolic anastomosis, using a
a b
Fig. 97.9 (a) Resection (b) Reconstruction
running 5-0 PDS suture for large bile ducts, or 6-0 inter- Complications
rupted sutures for small ducts.
Downstream from the biliary anastomosis, construct an • Hypoglycemia or hyperglycemia
antecolic gastrojejunostomy or duodenojejunostomy as • Postoperative gastric bleeding due to stress ulceration or a
applicable. We prefer to perform a hand-sewn anastomoses, marginal ulcer
although staplers are also acceptable (Fig. 97.9). Drainage of • Postoperative hemorrhage
the operative field is at discretion of the surgeon. Close the • Postoperative sepsis
midline incision and skin in the routine fashion. • Leakage from biliary anastomosis
• Mesenteric venous thrombosis
Postoperative Care
Further Reading
The principles of postoperative care described in Chap. 96
apply to total pancreatectomy, except there is no possibility Almond M, Roberts KJ, Hodson J, et al. Changing indications for total
of a pancreatic fistula. The most important element of postpancreatectomy: perspectives over a quarter of a century. HPB
operative care following total pancreatectomy is regulation (Oxford). 2015;17(5):416–21.
Dresler CM, Fortner JG, McDermott K, et al. Metabolic consequences
of the resulting diabetes, thus it is critical to coordinate care of (regional) total pancreatectomy. Ann Surg. 1991;214(2):131–40.
with the endocrinology team. Perform blood glucose deter- Hartwig W, Gluth A, Hinz U, et al. Total pancreatectomy for primary
minations every 4 h for the first few days. After patients pancreatic neoplasms: renaissance of an unpopular operation. Ann
begin to eat, they may be switched to one of the longer-acting Surg. 2015;261(3):537–46.
Heidt DG, Burant C, Simeone DM. Total pancreatectomy: indications,
insulin products. Patients and their relatives should be care- operative technique, and postoperative sequelae. J Gastrointest
fully instructed about the symptoms of hypoglycemia. A suf- Surg. 2007;11(2):209–16.
ficient dose of pancreatic enzymes must also be given to Kulu Y, Schmied BM, Werner J, et al. Total pancreatectomy for pan-
prevent steatorrhea. In addition, patients should receive sup- creatic cancer: indications and operative technique. HPB (Oxford).
2009;11(6):469–75.
plementation of fat-soluble vitamins (i.e., A, D, E, K). Müller MW, Friess H, Kleeff J, et al. Is there still a role for total pancre-
atectomy? Ann Surg. 2007;246(6):966–74; discussion 974–5
Distal (Left) Pancreatectomy
98
Brendan P. Lovasik and David A. Kooby
Indications runs directly posterior to the gland. This anatomy carries

substantial variability.
• Solid tumors. Primary pancreatic tumors include adeno- Distal (left) pancreatectomy (DP) will typically include
carcinoma and neuroendocrine tumors. Rare metastatic removal of the gland area to the left of the superior mesen-
tumors, such as renal cell carcinoma, and direct invasion teric artery (SMA)/ superior mesenteric vein (SMV) axis,
from gastric or colon tumors may be considered on a though the transection line may be extended to the right if
case-by-case basis. dictated by the pathology and per discretion of the operating
• Chronic pancreatitis. The most common indications for surgeon (Fig. 98.1). Owing to the shared vascular supply,
pancreatectomy following pancreatitis are chronic pain splenectomy is often included with DP, but spleen preserving
and gland necrosis. techniques [minimally invasive DP (MIDP)] may be consid-
• Cystic tumors, such as intraductal papillary mucinous ered for select patients with benign pancreatic pathology. It
neoplasm and mucinous cystic neoplasms, should be con- may be inappropriate to attempt splenic vascular preserva-
sidered for resection if high-risk features are present. tion if there is sufficient concern regarding adequacy of sur-
• Trauma. Most commonly penetrating trauma (gunshot gical margins in cases of malignancy.
wounds), but can also include sequelae of blunt trauma Spleen preservation can be achieved through several
with crushing injuries to abdomen (including motor vehi- approaches; the two most-described are the Kimura and
cle collisions) causing duct disruption. Warshaw procedures. The Kimura approach preserves the
splenic artery, vein, and short gastric vessels. Conversely, the
Warshaw approach preserves only the short gastric arteries
Operative Strategy and resects the splenic vessels away from the hilum
(Fig. 98.2). The spleen should be thoroughly inspected fol-
The pancreas is a retroperitoneal organ with both and endo- lowing the Warshaw procedure, as the short gastric blood
crine and exocrine glandular functions. The gland is divided supply may be tenuous. If concern for ischemia develops, the
anatomically by regions, which include head, neck, body, spleen should be removed to prevent postoperative splenic
and tail. The uncinate process is the portion of the head that necrosis or severe infarction with associated chronic pain.
wraps around posterior to the portal vein. The pancreatic The open, laparoscopic, and robotic approaches to distal
body lies posterior to the gastric antrum and pylorus, while pancreatectomy each have their advantages and disadvan-
the tail extends to the edge of the spleen. It is bordered supe- tages, as listed in Table 98.1.
riorly by the celiac axis and inferiorly by the superior mesen-
teric vessels. The splenic artery courses longitudinally along
the cephalad border of the pancreas, while the splenic vein Operative Technique
Laparoscopic Distal Pancreatectomy

B. P. Lovasik
Department of Surgery, Emory University School of Medicine, Two common laparoscopic setups are pictured in Fig. 98.3A,
Atlanta, GA, USA B. The choice of patient position is at the discretion of the
D. A. Kooby (*) surgeon. However, the authors prefer supine position for
Emory Saint Joseph’s Hospital, Atlanta, GA, USA tumors closer to the portal/SMV axis, and the right lateral
e-mail: dkooby@emory.edu

https://doi.org/10.1007/978-3-030-81415-1_98
770 B. P. Lovasik and D. A. Kooby
Fig. 98.1 (a) Anatomic

landmarks for pancreatic a
exposure (b) Pancreatic gland
Greater
anatomy including
omentum
surrounding vessels with Stomach
SMV axis as traditional reflected cephalad
demarcation for distal
pancreatectomy
Spleen
Celiac trunk
Head and body

of pancreas Splenic artery
(retroperitoneal)
Tail of pancreas
Second part retroperitoneal
of duodenum
Jejunum
Superior
Attachment of mesenteric artery
transverse colon Superior
(removed) mesenteric vein
Root of mesentery
b
Proper hepatic Aorta
artery Spenic
Celiac artery
trunk
Gastroduodenal Tail
artery Neck Body
Pancreaticoduodenal Head
arcade
Sup. mesenteric
vein and artery
decubitus approach for tumors closer to the spleen, as the lat- Camera access is typically best to the left of the umbili-
ter allows for better gravity retraction of the stomach and cus. Due to improved optics, 5 mm scopes can now be used
colon and easier access to the pancreatic tail and spleen. Both in place of the more traditional 10 mm scopes.
positions are enhanced by making sure the patient is secured Begin with a thorough diagnostic laparoscopy to evaluate
to the operating table to allow for right rotation and signifi- for peritoneal spread of disease or other factors which may
cant reverse Trendelenberg positioning. The supine position influence surgical approach. Reverse Trendelenburg may be
may require an additional trocar for gastric retraction. used to better expose the lesser sac for dissection.
98 Distal (Left) Pancreatectomy 771
Stomach
Splenic gastric
Left arteries
gastro-epiploic
artery
Spleen
Portal vien
Splenic artery
Splenic vein
Pancreas
Inferior
mesenteric
Aorta
vein
Superior
mesenteric
vein
a. Kimura b. Warshaw
Fig. 98.2 Spleen-preserving approaches to distal pancreatectomy
Table 98.1 Advantages of open laparoscopic and robotic approaches gastrocolic ligament. Next, divide the gastrocolic ligament,
to distal pancreatectomy ensuring adequate control of the short gastric vessels with
Open Laparoscopic Robotic clips or Harmonic scalpel.
Advantages If the spleen is to be removed with the pancreas, first tran-
1. Direct access to 1. Smaller incision, 1. Benefits of sect the short gastric vessels to allow the stomach to fall
surrounding decreased pain minimally away (lateral position) or to be retracted superiorly (supine
structures 2. Fewer wound invasive surgery
2. Dissection of complications 2. Ability to repair
position). The stomach may also be temporarily secured to
borderline (infection and hemorrhage the anterior abdominal wall with one or two sutures to assist
resectable lesions hernia) 3. Binocular with exposure. If the spleen is to be preserved, then do not
3. Ability to palpate 3. Shorter length of vision and divide the short gastric vessels.
structures directly stay endowrist
for neoplasms and 4. Improved technology
Next, grasp the transverse colon and reflect it caudally.
repair bleeding cosmesis 4. Platform Divide the splenocolic ligament at the splenic flexure to facil-
5. Faster recovery stability itate wide mobilization. The anterior and inferior aspects of
Disadvantages the pancreas are now fully visualized. If the spleen is to be
1. Poor visibility 1. More 1. Large removed with the pancreas, dissect the gastrosplenic ligament
behind the pancreas challenging investment to
2. Greatly impacted approach, start a program –
cranially to the Angle of His, followed by the splenorenal and
by obesity requires different surgeon and splenophrenic ligaments to free the lateral margin of the en
3. Wound skill set financial bloc specimen.
complications 2. More 2. Greater The posterior dissection of the pancreas is best approached
challenging to emphasis on
repair setting up team
from the inferior aspect of the gland to avoid damage to the
intraoperative 3. Equipment splenic artery coursing along the gland’s cephalad margin.
hemorrhage failure Use a closed atraumatic grasper to gently elevate and retract
3. Greater risk of 4. Limited ability the distal end of the pancreas, moving it anteriorly and medi-
equipment to manipulate
failure table for
ally. It is generally not safe to actually grasp the pancreas as
4. Cancer concerns: benefits of it has a tendency to fracture and bleed, so blunt retraction is
adequacy of gravity preferred. If a bit of omentum remains adherent to the pan-
approach creas, it may be possible to grasp this and use it as a handle.
The gland can either be dissected from lateral to medial or
from medial to lateral as it is freed from its posterior attach-
To enter the lesser sac and expose the pancreas, grasp the ments to the retroperitoneal fat and underlying structures
inferior border of the stomach along the lesser curvature. using a combination of blunt dissection and an energy device,
Then elevate the stomach to expose the gastrocolic ligament. such as bipolar dissector or ultrasonic shears as needed
Dissect the avascular omental gastrocolic plane to expose the (Fig. 98.4). An early focus on the planned area of transection
a b
0.5 0.5
0.5
1.2 0.5 1.2 0.5
0.5 0.5
Fig. 98.3 Two common laparoscopic port arrangements for laparoscopic distal pancreatectomy
tion and anatomy. The splenic vein is directly posterior to the

pancreas and comes into view before the artery as the gland
is dissected posteriorly. The authors prefer the following
order: artery, then vein, followed by gland (Fig. 98.5A–C).
Keep the stumps of the splenic artery and vein as short as
possible, since long vascular stumps increase the risk of
thrombosis or rupture. Before ligating the artery, test-clamp
it to confirm flow in the common hepatic artery; after confir-
mation, transect it with a vascular stapler, or with ties and
locking clips in concert. Clips alone on these vessels may not
be sufficient. The inferior mesenteric vein (IMV) may also
be visualized on the posterior aspect of the gland as it inserts
into the splenic vein or into the superior mesenteric vein; this
can be divided as needed to facilitate exposure. Finally, the
pancreatic gland itself is transected using a stapler (some
surgeons use reinforcing strips) or an energy device, with or
without oversewing the stump. The dissection of the speci-
men from the remaining retroperitoneal attachments can
Fig. 98.4 Lateral-to-medial retroperitoneal dissection during mini-
then be completed.
mally-invasive distal pancreatectomy, with cephalic retraction of gland
Next, inspect the stump of the gland to check adequacy of
is critical if urgent vessel ligation is required in the event of closure, particularly at the duct. The staple line can be
hemorrhage during dissection. secured with overlapping clips or oversewn with interrupted
The splenic artery, vein, and pancreas may be ligated/ imbricating sutures. The stump can be further fortified using
transected in any order as dictated by the flow of the opera- an omental pedicle flap overlying the transected edge.
a b
Fig. 98.5 Intraoperative photographs showing stapled division of splenic vessels and pancreatic gland during minimally-invasive distal
pancreatectomy
Place the specimen in an endoscopic retrieval bag. geon and the team are not prepared for a laparoscopic
Pancreas and spleen may be placed in the same retrieval bag approach, and/or the tumor is directly invading other struc-
or in separate bags. The umbilical incision can be extended tures, such as a major vascular structure, the stomach and/or
inferiorly to allow for specimen delivery or a small pfannen- the colon, which may not be amenable to en bloc surgical
stiel incision can be used, to minimize pain and hernia risk resection.
postoperatively. Once the specimen is delivered, close this The patient is placed in a supine position. An upper mid-
incision to allow for reinsufflation and inspection, leaving line incision is typically used, although a left or bilateral sub-
the original trocar port space open. costal incision can be employed if significant midline
Inspect the surgical bed for adequacy of hemostasis and adhesions are expected or better exposure is needed.
retained objects. Typically an operative drain is used in these Nasogastric tube and foley catheter are typically indicated.
cases, although recent randomized data suggest that this may Two large-bore intravenous lines are reasonable as the poten-
be performed at the experience and discretion of the operat- tial for hemorrhage exists.
ing surgeon.
• Explore the abdomen for deposits of metastatic disease.
Expose the pancreas by first incising the gastrocolic
Open Distal Pancreatectomy omentum with electrocautery and exposing the gastro-
colic ligament. Divide the gastrocolic ligament with elec-
The open approach typically follows the similar steps as the trocautery and clips on the short gastric vessels. Similarly
laparoscopic approach. The open approach is favored when divide the splenocolic ligament at the splenic flexure to
the patient has significant adhesions which may prohibit a facilitate wide mobilization. Retract the stomach superi-
minimally invasive approach, the patient has a large cystic orly and the transverse colon caudally. The anterior sur-
tumors that may rupture with inadequate experience, the surface of the pancreas is then exposed. If the spleen is to be
removed with the pancreas, dissect the gastrosplenic liga- Anterior

ment cranially to the Angle of His, followed by the sple- pararenal
Pancreas space
norenal and splenophrenic ligaments to free the lateral
margin of the en-bloc specimen. Parietal
peritoneum
The pancreatic dissection can again proceed in a left-to- Duodenum
right (lateral to medial) fashion. Separate the gland from its
posterior attachments to the retroperitoneal fat using blunt Anterior
finger or Kitner peanut dissection and electrocautery renal fascia
(Fig. 98.6). The IMV is the first named vessel encountered,
and it may be ligated. Palpate the splenic artery on the poste-
rior aspect of the gland to avoid arterial injury, and suture- Aorta
SF
ligate the splenic artery and vein. The gland can then be Adernal gland
transected with a vascular stapler, and the en-bloc pancreas-
spleen specimen is passed off the field. Perirenal
space
Imbricate the transected pancreatic edge over the staple
line with interrupted sutures with or without an omental flap. Kidney
Again, the authors advocate for operative drainage by placing
Standard distal
a fluted surgical drain placed at the distal end of the stump. pancreatectomy
Anterior RAMPS
Borderline Resectable Neoplasms

Posterior RAMPS
adical Antegrade Pantreatico-Splenectomy

R Fig. 98.7 Axial projection of standard distal pancreatectomy (green
A radical antegrade modular pantreatico-splenectomy line), anterior RAMPS (purple line) including Gerota’s fascia, and pos-
(RAMPS) procedure is indicated for neoplasms with inva- terior RAMPS (red line) including left adrenal gland
sion into the retroperitoneal fat (Fig. 98.7). Here, the poste-
rior margin of dissection includes the anterior renal fascia of lateral (right to left, antegrade) direction. The neck of the
Gerota’s capsule. In contrast to the standard distal pancre- pancreas is divided as the primary step. Next, a celiac lymph-
atectomy approach, the dissection proceeds in a medial-to- adenectomy is performed to obtain N1 nodes. The dissection
is carried laterally and includes the anterior left renal fascia.
Careful consideration of the close relationships between the
pancreas, left renal vein, and adrenal vein much be consid-
ered in this approach. In the anterior RAMPS procedure, the
left renal vein becomes the posterior margin of dissection at
the medial edge. In the posterior RAMPS procedure, the pos-
terior margin includes the left adrenal gland. Studies examin-
ing RAMPS show higher rates of R0 resection, particularly
at the posterior margin.
istal Pancreatectomy with Celiac Axis Resection

D
(DP-CAR, Appleby)
A distal pancreatectomy with celiac axis resection (DP-CAR
or Appleby procedure) is indicated for borderline resectable
tumors with tumor invasion into the celiac axis. In this pro-
cedure, the hepatic artery is ligated, but hepatic perfusion is
maintained through collateral flow through the gastroduode-
nal artery (GDA) from pancreatico-duodenal artery collater-
als. Here, the celiac axis and its branches are carefully
dissected and isolated, with particular attention to the GDA.
(Fig. 98.8) The common hepatic artery is ligated proximal to
Fig. 98.6 Lateral-to-medial retroperitoneal dissection during open dis- the GDA take-off, and the celiac artery is ligated at its aortic
tal pancreatectomy, with ligature shown on splenic artery take-off. Collateral flow is preserved to the liver and stomach
Fig. 98.8 Resection

Common hepatic
landmarks for Appleby artery
(DP-CAR) procedure To liver
including resection of celiac Celiac artery
axis and retrograde perfusion Proper hepatic
of proper hepatic artery from artery
superior mesenteric artery
through pancreaticoduodenal
arcade Gastroduodenal Splenic artery
artery
Tumor
Pancreaticoduodenal Inferior pacreatoduodenal artery

arcades providing
retrograde arterial Superior mesenteric artery
flow to the hepatic
artery
(through the right gastric artery) from GDA collateralization.

A medial-to-lateral distal pancreatectomy is then performed.
A mild postoperative transaminitis is expected, which typi-
cally normalizes within days to weeks.
Robotic Distal Pancreatectomy
The use of robotic surgical technology allows for the benefits

of minimally invasive surgical approach combined with
improved dexterity, stability, and 3-dimensional visualization.
The robotic approach follows a similar operative sequence
as the laparoscopic method previously described. The robotic
approach uses five ports in a concave arc (Fig. 98.9). The
robot is then docked.
0.8 Grasp the stomach and elevate it cranially and anteriorly
0.8
0.8 1.2 with the grasper in the far right port; maintain this position
1.2
throughout the operation. Dissection is then carried out with
the bipolar forceps and hook electrocautery as previously
described in the laparoscopic section (Fig. 98.10). When the
distal pancreas and vessels are isolated and prepared, the assis-
tant introduces a laparoscopic stapler for the transection. The
specimen is then removed through the periumbilical port site.
Postoperative Care
Fig. 98.9 Common robotic tracer arrangements for robotic-assisted
distal pancreatectomy Prior to an operation that may involve splenectomy, patients
should receive vaccination against encapsulated organisms
Table 98.2 Fistulae classification

No Grade
fistula A Grade B Grade C
Drain amylase level (vs. < 3x > 3x > 3x > 3x
normal serum amylase
level)
Clinical condition Well Well Often Ill
well appearing/
bad
Persistent drainage No No Usually Yes
(>3 weeks) yes
Signs of infection No No Yes Yes
Sepsis No No No Yes
Reoperation No No No Yes
Death related to fistula No No No Yes
three, with amylase content greater than three times the

Fig. 98.10 Intraoperative photographs showing retroperitoneal dissec- serum amylase level. Fistulae are classified into three groups
tion during robotic-assisted minimally-invasive distal pancreatectomy (A, B, and C) depending on the patient’s clinical status
(Table 98.2).
to prevent post-splenectomy sepsis. Vaccines are typically

given 2–3 weeks prior to the procedure, or within 1–2 weeks Further Reading
following the procedure.
de Rooij T, Klompmaker S, Abu Hilal M, Kendrick ML, Busch
OR, Besselink MG. Laparoscopic pancreatic surgery for
benign and malignant disease. Nat Rev Gastroenterol Hepatol.
Complications 2016;13(4):227–38.
Fernández-Cruz L. Distal pancreatic resection: technical differ-
One of the most common complications following distal ences between open and laparoscopic approaches. HPB (Oxford).
2006;8(1):49–56.
pancreatectomy is development of a pancreatic fistula at the Kooby DA. Tips and tricks of laparoscopic distal pancreatec-
distal transection margin, which occurs in up to one third of tomy for ductal adenocarcinoma. J Hepatobiliary Pancreat Sci.
patients. As such, placement of an operative drain at the sta- 2016;23(6):E10–3.
ple line is recommended. Fistulae are diagnosed using the Magge D, Zureikat A, Hogg M, Zeh HJ 3rd. Minimally inva-
sive approaches to pancreatic surgery. Surg Oncol Clin N Am.
International Study Group on Pancreatic Fistula definition of 2016;25(2):273–86.
any measurable volume of fluid on or after postoperative day
Operations for Pancreatic Pseudocyst
99
Nicholas J. Zyromski
Operative Strategy
Background/Natural History
Pancreatic pseudocyst represents a heterogeneous disease pro-

cess that may arise as a consequence of either acute or chronic
pancreatitis. Pseudocysts are seen less frequently in the setting
of acute pancreatitis (AP). Many AP patients develop intraab-
dominal fluid early in the disease process, but these fluid col-
lections commonly resolve. When fluid collections persist
beyond 4 weeks and develop a fibrous wall, they may be accu-
rately termed pseudocyst. In the setting of AP, differentiation
must be made between a true pseudocyst and walled-off necro-
sis (WON), the latter of which is far more common in this dis-
ease. The presence of solid necrosis in a peripancreatic
collection changes treatment approach dramatically.
Chronic pancreatitis (CP) patients develop pseudocysts that
are often different morphologically compared to AP patients –
pseudocysts in CP may be simple; however, are just as often
multiple, small, and densely involving pancreatic parenchyma Fig. 99.1 Multiple small, loculated pseudocysts in the pancreatic head
caused abdominal pain and recurrent acute pancreatitis. Treatment was
(Fig. 99.1). It is critically important for treating physicians to by pancreatoduodenectomy
understand the anatomy of both the pancreatic parenchyma as
well as the pancreatic duct prior to initiating therapy. Pancreatic
pseudocysts may be solitary and large – these cysts are durably techniques such as endoscopic retrograde cholangiopancrea-
treated by drainage procedures. On the other hand, pancreatic tography (ERCP) and endoscopic ultrasound (EUS) has per-
pseudocysts may be small or multiple; in this case, resection mitted many pseudocyst patients to be treated durably by
may be the most appropriate therapy. More thorough under- these minimally invasive procedures (Fig. 99.2A–C).
standing of pseudocyst natural history has shown that asymp- Indications for surgical intervention in contemporary prac-
tomatic pseudocysts do not require treatment. tice are often reserved for patients with recurrent pseudocyst,
Pseudocyst patients should be evaluated by a multidisci- more challenging anatomy, or associated problems such as
plinary treatment team including both gastroenterologists biliary or duodenal stricture.
with experience in advanced endoscopic technique as well as
surgeons with experience treating patients with pancreatic
inflammatory disease. Development of advanced endoscopic Operative Indications
The predominant indication for treatment of a pancreatic

N. J. Zyromski (*)
Department of Surgery, Indiana University School of Medicine, pseudocyst is abdominal pain. The clinician should strive to
Indianapolis, IN, USA differentiate abdominal pain caused by mass effect of the
e-mail: nzyromsk@iupui.edu

https://doi.org/10.1007/978-3-030-81415-1_99
778 N. J. Zyromski
a b
Fig. 99.2 Endoscopic management of pancreatic pseudocyst. (a) Computed tomography showing retrogastric pseudocyst (note thickened wall).
(b) Endoscopic visualization after placing 3 10 French pigtail catheters. (c) Postprocedure radiograph documenting position of pigtail catheters
pseudocyst from pain of recurrent acute pancreatitis. tract (most often the duodenum) or bile duct and hemorrhage
Symptoms from mass effect are often described as a constant (Table 99.1). Patients who experience sudden increase of
fullness, with dull pain that may worsen in the postprandial pain should be evaluated for the presence of a visceral arte-
state. Nausea and vomiting are common. Pain related to rial pseudoaneurysm (Fig. 99.3A–C).
acute pancreatitis is typically sharp (“knife-like”), and may
be more episodic than pain related to mass effect. This dis- Table 99.1 Operative indications
tinction is important as draining a pseudocyst will usually Pain (must distinguish between pain from mass effect and that of
relieve discomfort from mass effect, but will not address recurrent acute pancreatitis)
Gastrointestinal obstruction
symptoms caused by recurrent acute pancreatitis (e.g., in
Biliary obstruction
patients with a “disconnected” pancreatic tail). Additional
Bleeding (visceral arterial pseudoaneurysm)
indications for treatment include obstruction of the intestinal
99 Operations for Pancreatic Pseudocyst 779
a b
Fig. 99.3 Pseudoaneurysm arising from the splenic artery in a pancre- coursing through pseudocyst. (b) visceral angiogram demonstrating
atic tail pseudocyst caused by chronic pancreatitis. (a) Axial computed splenic artery pseudoaneurysm before and (c) after treatment by coil
tomography image documenting splenic artery with pseudoaneurysm embolization
reoperative Preparation and Perioperative

P mal situation is important as well. When considering a
Considerations drainage procedure, the remnant gland must produce a suf-
ficient volume of pancreatic digestive juice in order to keep
Selecting the proper intervention for pseudocyst depends a cyst enterostomy patent. In the case of a small pancreatic
critically on understanding the pancreatic ductal and paren- remnant (i.e., tail), resection is preferable, as recurrence of
chymal anatomy. Ideally, pseudocyst patients should undergo a pseudocyst will be high if drainage is attempted. The
multidisciplinary evaluation by a team that includes experi- quality of the pancreatic parenchymal remnant should be
enced ERCP endoscopists and surgeons with experience in considered as well. If the pancreatic remnant has signs of
managing patients with pancreatic inflammatory disease. severe chronic pancreatitis, that is, stricture or irregularity
The first branch point in treatment algorithm is endoscopic of the main pancreatic duct, dilation of the side branches,
versus surgical therapy. A pseudocyst forming simply from atrophy of the gland, etc., the patient may best be served by
disruption of a branch duct or incomplete disruption of the resection. As mentioned above, it is important to take a
main pancreatic duct may be treated effectively with endo- detailed history with respect to symptoms – often times
scopic techniques (Fig. 99.4A, B). On the other hand, if the with careful questioning the clinician can distinguish
main pancreatic duct is completely disrupted or severely between symptoms of recurrent left-sided pancreatitis
strictured, endoscopic treatment is far less likely to provide (often left-sided pain radiant to the left shoulder; episodic
durable therapy and therefore surgical treatment should be nature of “attacks”) as opposed to constant discomfort and
considered. gastrointestinal (GI) symptoms such as nausea and vomit-
The next branch point relates to drainage versus resec- ing that are associated with pseudocyst impinging on the
tion: at this point, understanding the pancreatic parenchy- gastrointestinal tract.
780 N. J. Zyromski
a b
Fig. 99.4 Endoscopic treatment of pancreatic duct disruption. (a) Endoscopic retrograde cholangiopancreatography demonstrating stricture and
leak in main pancreatic duct at pancreatic neck. (b) after stent placement bridging leak in main pancreatic duct
Cross-sectional imaging is an important step in the preop-

erative work-up. Both computed tomography (CT) and mag-
netic resonance imaging (MRI) are useful to evaluate
pseudocyst size, location, pancreatic parenchyma volume
and quality, duodenal stricture, biliary stricture, and vascular
anatomy. The presence of splanchnic venous thrombosis
often results in collateral venous transformation, which com-
plicates operative conduct particularly if the operation is
necessary in the area of the pancreatic head. The presence of
bile duct stricture and duodenal stricture should also be con-
sidered – careful history and physical exam may suggest
both duodenal and biliary stricture, findings that may be con-
firmed by thorough review of cross-sectional imaging.
Cross-sectional imaging documents the volume of paren-
chyma and provides clues as to the quality of the parenchyma
feeding the pseudocyst. Secretin-enhanced MRI can provide
objective data regarding parenchymal function. A small or atro-
phic pancreatic tail may not provide enough pancreatic digestive
juice to maintain patency of a cyst-enterostomy. The cyst location
should be noted with thoughts toward drainage. An ideal drainage
procedure provides dependent drainage (many pancreatic sur- Fig. 99.5 Mucinous cystic neoplasm mistaken for pancreatic pseudo-
geons favor Roux-en-Y cyst jejunostomy over cyst gastrostomy cyst (no preoperative fluid analysis was performed). Operative cyst-
gastrostomy was performed. Remedial operation included distal
for just this reason). Finally, it is critical to differentiate an inflam- pancreatectomy, splenectomy, and partial gastrectomy
matory pseudocyst from a neoplastic cyst (Fig. 99.5). Neoplastic
cysts (mucinous cystic neoplasm, symptomatic serous cystade- Magnetic resonance cholangiopancreatography (MRCP)
noma, intraductal pancreatic mucinous neoplasm, etc.) should be also provides useful information about the biliary tree – the
resected and biopsy of the cyst wall should be routine during pro- presence of stricture, biliary dilation, and stones in the gall-
cedures, draining the presumed inflammatory pancreatic pseudo- bladder or bile ducts. It is worth noting that MRCP is not as
cysts to exclude the presence of neoplastic epithelium. If any helpful delineating pancreatic ductal anatomy in the pres-
suspicion exists for diagnosis of neoplastic cyst, preoperative ence of a large cysts or fluid collections. In select patients,
EUS with sampling of cyst fluid should be mandatory. endoscopic retrograde cholangiopancreatography is helpful
to delineate pancreatic ductal anatomy. Indeed, ERCP is still exploration should also seek to identify occult metastatic dis-
considered the gold standard for imaging the pancreatic duct. ease; chronic pancreatitis patients have significantly elevated
If necessary, ERCP should be performed close to the time of incidence of pancreatic ductal adenocarcinoma, and though
surgery to minimize any consequence of contaminating the rare, necrotizing pancreatitis is occasionally caused by
pseudocyst with endoscopic manipulation. adenocarcinoma.
Preoperative laboratory evaluation should include objec-
tive nutritional metrics such as serum albumin, prealbumin,
and transferrin concentration. Liver chemistry values should Cyst-Enterostomy
be evaluated as well – elevation in the serum alkaline phos-
phatase concentration may be the first, subtle hint of biliary Large cysts are suitable for drainage procedure if they have
obstruction. enough pancreatic volume to support long-term patency of
“Prehabilitation” is routine; this plan includes nutritional the cyst enterostomy. In general, the rule of thumb regarding
supplementation, smoking cessation, and aggressive focus drainage of pancreatic pseudocyst is to “play it as it lies.”
on increasing physical activity. That is to say, cysts lying immediately behind the stomach
Vascular consequences of pancreatitis include visceral maybe suitable for cyst-gastrostomy, cysts abutting the duo-
arterial pseudoaneurysm (Fig. 99.3), portal hypertension, denum may be suitable for cyst-duodenostomy, and cysts
and venous thromboembolism. Clinicians must be alert to discreet from the stomach and duodenum maybe best
the presence of visceral pseudoaneurysm, which may occur approached with Roux-en-Y cyst-jejunostomy. Some pan-
at virtually any branch of the splanchnic arterial tree. Portal creatic surgeons favor Roux-en-Y cyst-jejunostomy for all
hypertension in pancreatitis typically arises after mesenteric pseudocysts. Those in this camp suggest that the Roux limb
venous thrombosis. Collateral vascular development around provides more dependent drainage particularly relative to
the porta hepatis (cavernous transformation) or through the cyst-gastrostomy, and that this dependent drainage may be
short gastric/gastroepiploic system (left-sided or “sinistral” more durable. In actuality, the volume of pancreatic digestive
portal hypertension) may complicate operative conduct sub- juice flowing across the cyst-entreric anastomosis is likely a
stantially; these anatomic problems should always be on the more important factor than anatomic dependency when con-
surgeon’s radar screen. Finally, pancreatitis patients have a sidering long-term expected patency. Always biopsy the cyst
remarkably high incidence of venous thromboembolism; wall for frozen section during the course of operation to
aggressive perioperative chemical prophylaxis should be the exclude the diagnosis of neoplastic cyst.
norm.
Cystogastrostomy
Operative Strategy and Technique
Make a midline incision from the xiphoid to the umbilicus.
A laparoscopic approach is favored if possible, particularly Explore the abdomen. Use intraoperative ultrasound to eval-
for patients undergoing drainage procedures. Operative uate the liver, biliary tree, pancreatic parenchyma, and pseu-
resection of pseudocyst is usually quite challenging due to docyst – with particular focus on vascular relationships to the
the dense inflammatory response surrounding the cyst and pseudocyst. If the gallbladder contains stones, perform cho-
pancreas; patients who require resection are often approached lecystectomy and cholangiography. Explore the lesser sac by
with open surgery. For open operation, upper midline and exposing the posterior wall of the stomach from its lesser
low subcostal incisions both provide adequate exposure of curvature aspect. If the cyst is densely adherent to the poste-
the upper abdomen. Intraoperative ultrasound provides a tre- rior wall of the stomach, cystogastrostomy is the operation of
mendous amount of information, and should be considered choice. Make a 6- to 8-cm incision in the anterior wall of the
standard of care in pancreatic surgical practice. stomach (Fig. 99.6) opposite to the most prominent portion
A thorough abdominal examination includes evaluation of the retrogastric cyst. Obtain hemostasis with electrocau-
of the liver for presence fibrosis/cirrhosis and portal hyper- tery or ligatures. Then insert an 18-gauge needle through the
tension. The small bowel is evaluated from ligament of Treitz back wall of the stomach into the cyst and aspirate. Make an
to the ileocecal valve; this maneuver is particularly impor- incision about 3–6 cm in length through the posterior wall of
tant in patients who may require Roux-en-Y drainage. the stomach and carry it through the anterior wall of the cyst.
Intraoperative ultrasound documents location of the pseudo- Excise an adequate ellipse of tissue from the anterior wall of
cyst relative to surrounding enteric and vascular structures, the cyst for frozen-section histopathology to rule out the
presence of any mesenteric venous thrombosis, presence and presence of a neoplastic cyst or adenocarcinoma.
volume (if any) of solid necrotic debris, and presence of bili- Approximate the cut edges of the stomach and cyst by
ary strictures or common bile duct stones. The abdominal means of continuous or interrupted 3-0 prolene sutures
782 N. J. Zyromski
Fig. 99.6 Anterior gastrotomy site illustrated
Fig. 99.8 Site of small bowel and mesentery division
the cyst by carefully clearing adherent omentum and small

bowel. The cyst’s relationship with vascular structures
should be assessed, particularly the splenic artery in pan-
creas body and tail cysts. Prepare a segment of jejunum at a
point about 30–40 cm beyond the ligament of Treitz. Divide
the jejunal mesentery as illustrated in Fig. 99.8. Then divide
the jejunum with a GIA stapler. Liberate enough of the mes-
entery of the distal jejunal segment to permit the jejunum to
reach the cyst without tension. Often times the small bowel
mesentery is foreshortened; in this situation dividing the first
mesenteric arcade helps to achieve satisfactory length of the
Roux limb.
Make a small window in an avascular portion of the trans-
verse mesocolon to the left of the middle colic vessels for
body/tail cysts, and deliver the distal jejunal segment into the
supramesocolic space. Cyst-enterostomy should include a
long cystotomy. Excise a window of anterior cyst wall and
send it for frozen-section histopathologic examination.
Perform a two-layer anastomosis between the open end of
Fig. 99.7 Construction of cyst-gastrostomy jejunum and the window in the anterior cyst wall. Insert
interrupted 3-0 or 4-0 PG Lembert sutures. Then use 3-0 silk
(Fig. 99.7). Close the defect in the anterior wall of the stom- sutures to attach the mesocolon to the jejunum at the point
ach in two layers of suture – running 3-0 vicryl and inter- where it passes through the mesocolon.
rupted 2-0 silk. Anastomose the divided proximal end of the jejunum to
the antimesenteric border of the descending limb of the jeju-
num at a point 60 cm beyond the cystojejunal anastomosis.
Roux-en-Y Cystojejunostomy Align the open proximal end of jejunum so that its opening
points to the cephalad direction. Make a 1.5 cm incision in
Make a long midline incision and explore the abdomen. the antimesenteric border of the descending jejunum using
Check the gallbladder for stones. The first step of the Roux- electrocautery and complete the jejunojejunostomy. Close
en-Y cyst-jejunostomy is to prepare the dependent portion of the mesenteric defect.
Resection docyst in communication with the pancreatic duct results in

a controlled external pancreatic fistula; however, recurrent
Small cysts, multiple cysts, or cysts arising in a very small pseudocyst is to be expected when the percutaneous drain is
remnant pancreatic tail may be considered for resection. removed.
These morphologies are typically found in the setting of
chronic pancreatitis. Cysts localized to the pancreatic tail
should be approached by distal pancreatectomy. Occasionally, Postoperative Care
the spleen maybe preserved – usually spleen preservation is
accomplished in the fashion of Warshaw by dividing the Follow-Up
splenic artery and splenic vein proximally and in the splenic
hilum. More commonly in the setting of chronic pancreatitis, Long-term follow-up is important for any patient having
the splenic vein has thrombosed and left-sided (sinistral) pseudocyst treatment. Despite excellent selection, anywhere
portal hypertension has developed – established sinistral from 5% to 15% of patients will experience cyst recurrence.
hypertension generally makes splenic salvage impossible In addition, the natural history of inflammatory pancreatic
from a technical standpoint. In general, ligating the splenic disease is such that disease progression may present prob-
artery as a first step in distal pancreatectomy decreases the lems such as recurrent acute pancreatitis, biliary or duodenal
risk of hemorrhage. This maneuver is not always possible obstruction, and exocrine or endocrine insufficiency. After
because of the dense retroperitoneal inflammatory response satisfactory recuperation from operation, the surgeon may
associated with chronic pancreatitis. Distal pancreatectomy pass care of the pseudocyst patient to a gastroenterologist or
in the setting of sinistral portal hypertension is often quite primary physician. Excellent communication at this point
challenging. It is worth noting that if the operative conduct highlights the need for aggressive medical screening (i.e., for
progresses to medial mobilization of the spleen and pancre- exocrine/endocrine insufficiency, periodic evaluation of liver
atic tail (as in the approach to splenectomy in a trauma situ- chemistry function to identify biliary stricture, etc.) as well
ation), oozing type hemorrhage may be quite brisk. Once the as supports a low threshold for cross-sectional imaging and
surgeon initiates this maneuver (medial mobilization), it is return consultation with the pancreatic specialist if recurrent
important to continue with some alacrity until the splenic symptoms develop.
artery has been ligated and splenic venous collaterals have
been controlled.
Pearls
Pancreatic Head Resection • Pseudocyst patients are best evaluated in a multidisci-

plinary setting including experienced clinicians – pancre-
Small/multiple pseudocysts in the pancreatic head or those atic surgeons and gastroenterologists who possess
causing biliary obstruction should be approached by pancre- advanced endoscopic skills.
atic head resection. In general, many pancreatic surgeons • Pseudocyst may be treated endoscopically or operatively
treating inflammatory pancreatic disease favor parenchymal depending on individual characteristics of the cyst and
sparing approaches such as duodenal preserving pancreatic pancreatic duct and parenchyma.
head resection. The caveat to this approach is that the duo- • It is critical to understand underlying pancreatic ductal and
denal sweep must not be heavily involved with the inflam- parenchymal anatomy prior to undertaking treatment.
matory response. It is possible to perform duodenal • Percutaneous drainage will not provide durable therapy
preserving pancreatic head resection (such as Frey, Beger, for true pancreatic pseudocysts (those with pancreatic
Izbicki type of operation) with choledochoenterostomy in duct disruption).
patients with biliary obstruction. Choledochoduodenostomy • Beware of vascular consequences of pseudocyst (and the
is a reasonable choice for biliary bypass if necessary. causative pancreatic inflammatory disease) such as vis-
Dividing the bile duct completely and performing end-to- ceral arterial pseudoaneurysm and splanchnic venous
side choledochoduodenostomy minimizes the hazard of thrombosis with portal hypertension/collateral vein
sump syndrome. development.
External Drainage Further Reading
External drainage is mentioned only to be discouraged in Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr
MG, et al. Classification of acute pancreatitis – 2012: revision of
patients with true pseudocysts (which by definition include the Atlanta classification and definitions by international consensus.
pancreatic duct disruption). Percutaneous drainage of pseu- Gut. 2013;62(1):102–11. PubMed PMID: 23100216
784 N. J. Zyromski
Behrns KE, Ben-David K. Surgical therapy of pancreatic pseudocysts. J lowing acute or chronic pancreatitis. Surgery. 2010;148(4):847–56;
Gastrointest Surg. 2008;12(12):2231–9. PubMed PMID: 18461418 discussion 56-7. PubMed PMID: 20797747
Butler JR, Eckert GJ, Zyromski NJ, Leonardi MJ, Lillemoe KD, Howard Nealon WH, Walser E. Main pancreatic ductal anatomy can direct
TJ. Natural history of pancreatitis-induced splenic vein thrombo- choice of modality for treating pancreatic pseudocysts (surgery ver-
sis: a systematic review and meta-analysis of its incidence and rate sus percutaneous drainage). Ann Surg. 2002;235(6):751–8. PubMed
of gastrointestinal bleeding. HPB (Oxford). 2011;13(12):839–45. PMID: 12035030. Pubmed Central PMCID: 1422503
PubMed PMID: 22081918. Pubmed Central PMCID: 3244622 Teixeira J, Gibbs KE, Vaimakis S, Rezayat C. Laparoscopic Roux-en-Y
Easler J, Muddana V, Furlan A, Dasyam A, Vipperla K, Slivka A, et al. pancreatic cyst-jejunostomy. Surg Endosc. 2003;17(12):1910–3.
Portosplenomesenteric venous thrombosis in patients with acute PubMed PMID: 14569449
pancreatitis is associated with pancreatic necrosis and usually has Warshaw AL. Conservation of the spleen with distal pancreatectomy.
a benign course. Clin Gastroenterol Hepatol. 2014;12(5):854–62. Arch Surg. 1988;123(5):550–3. PubMed PMID: 3358679
PubMed PMID: 24161350 Zyromski NJ, Haidenberg J, Sarr MG. Necrotizing pancreatitis caused
Lowenfels AB, Maisonneuve P, Cavallini G, Ammann RW, Lankisch by pancreatic ductal adenocarcinoma. Pancreas. 2001;22(4):431–2.
PG, Andersen JR, et al. Pancreatitis and the risk of pancreatic PubMed PMID: 11345146
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1993;328(20):1433–7. PubMed PMID: 8479461 et al. Improved outcomes in postoperative and pancreatitis-related
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Sandrasegaran K, et al. Clinical framework to guide operative deci- PubMed PMID: 17390186
sion making in disconnected left pancreatic remnant (DLPR) fol-
Pancreaticojejunostomy for Chronic
Pancreatitis 100
Faik G. Uzunoglu and Jakob R. Izbicki
Indications chronic pain, missing evidence of alcohol abuse or elevated

CA 19-9 levels are indicators for a potential pancreatic car-
• Disabling recurrent or continuous abdominal pain caus- cinoma. In such cases, endoscopic ultrasound-guided biop-
ing periodic sick leaves, frequent hospitalization and sies may be performed but if a pancreatic carcinoma cannot
impairment be ruled out, biopsy proof is not required before proceeding
• Persistent pain after conservative treatment with adequate with an oncological resection rather than a lesser
analgesic medication procedure.
• Failed endoscopic interventions
• Local anatomic complications such as biliary, duodenal
or venous obstruction due to an inflammatory mass in the Operative Strategy
head of the pancreas
• Dilatation and hypertension of the main duct caused by Chronic pancreatitis is characterized by distinctive recurrent
fibrotic strictures, calculi or debris or continuous abdominal pain. These disabling attacks cause
• Pseudocysts, fistulas or chronic calcification of the periodic sick leaves, frequent hospitalization and impairment
pancreas in the quality of life. The initial treatment of patients is con-
servative with adequate analgesic medication and endo-
scopic interventions as needed. Surgery has been shown to
Preoperative Preparation be superior to repeated endoscopic treatments in multiple
randomized trials and is strongly recommended in cases of
A successful outcome depends on an adequate preoperative persistent pain or failed endoscopic interventions.
diagnostic work-up which includes imaging of the biliary The exact operative strategy should be determined prior
and pancreatic duct system, preferably by magnetic reso- to surgery based on the preoperative findings. A variety of
nance cholangiopancreaticography (MRCP). Patient comor- options for decompression of the pancreatic duct are avail-
bidities, especially hepatic function, portal hypertension and able, such as the longitudinal incision of the pancreatic duct
nutritional status need to be evaluated and if necessary followed by a pancreaticojejunostomy (Partington-Rochelle
treated prior to surgery. Procedure, Fig. 100.1), the duodenum-preserving subtotal
pancreatic head resection with complete transection of the
pancreas above the portal vein (Beger Procedure), the
Pitfalls and Danger Points duodenum-preserving local resection of the pancreatic head
with a complete longitudinal incision of the pancreatic duct
The primary pitfall is failure to diagnose pancreatic adeno- (Frey Procedure, Fig. 100.2) and the subtotal pancreatic head
carcinoma. A precise assessment of patients’ medical his- and uncinate resection with a V-shaped resection of the pan-
tory can avoid mistreatment. A pancreatic mass without creatic duct (Hamburg Procedure, Fig. 100.3).
Each procedure has its assets and drawbacks. Whereas
isolated incision of the pancreatic duct does preserve pancre-
F. G. Uzunoglu · J. R. Izbicki (*)
Department of General-, Visceral- and Thoracic Surgery, atic parenchyma to the greatest extent, it does not include the
University Medical Center Hamburg-Eppendorf, resection of the pancreatic head, which is often the pace-
Hamburg, Germany maker of chronic pancreatitis. The term ‘pacemaker’ is used
e-mail: izbicki@uke.de

https://doi.org/10.1007/978-3-030-81415-1_100
786 F. G. Uzunoglu and J. R. Izbicki
a b
Fig. 100.1 Partington and Rochelle procedure: longitudinal pancreaticojejunostomy preserving spleen and pancreatic tail
a b
Fig. 100.2 Frey procedure: longitudinal pancreaticojejunostomy combined with local excision of the pancreatic head but without transection
above the portal vein
internationally for the function of the pancreatic head in tion of the pacemaker at little expense of pancreatic paren-
chronic pancreatitis. Failure to address an inflammatory chyma but is not the optimal treatment for small-duct disease
mass in the head of the pancreas will cause inadequate drain- or extensive inflammation in the head of the pancreas. Such
age of the organ, even if the main duct has been incised com- findings can be treated by an additional V-shape resection to
pletely, which might lead to an ongoing pancreatitis and drain second- and third-grade pancreatic branches (Hamburg
chronic pain. The Frey Procedure includes a limited resec- Procedure).
100 Pancreaticojejunostomy for Chronic Pancreatitis 787
a b
Fig. 100.3 Hamburg procedure: V-shaped longitudinal incision of the pancreatic duct combined with a subtotal pancreatic head and uncinate
resection
Fig. 100.4 Separation of the greater omentum from the transverse

colon for exposing the lesser sac and the pancreas to the full extent
Operative Technique (Fig. 100.4). If the exploration or resection of the pancreatic

head is intended, an extended Kocher maneuver and the
Exposure exposure of the superior mesenteric vein is necessary. The
Kocher maneuver allows a manual dorsal and ventral palpa-
Separate the greater omentum from the transverse colon tion and assessment of the pancreatic head and control of
between the hepatic and splenic flexures to expose the lesser potential bleeding during the resection (Fig. 100.5a, b). The
sac and pancreas. Divide remaining peritoneal attachments exposure of the superior mesenteric vein adjacent to the pan-
between the pancreas and the posterior wall of the stomach. creas is necessary for subtotal resection of the head and unci-
Ligate and divide the right gastroepiploic artery and vein to nate with preservation of an adequate rim of pancreatic tissue
expose the head and neck of the pancreas to the full extent for the anastomosis.
a b
Fig. 100.5 (a) Dorsal and ventral palpation and assessment of the pancreatic head after Kocher maneuver. (b) Dorsal palpation of the duodenum
and pancreatic head; the superior mesenteric vein is looped and secured
a b
Fig. 100.6 (a) Puncturing the pancreatic duct top the left of the superior mesenteric vein with a 22-gauge needle. (b) Visible pancreatic secretion
after successful puncturing of the pancreatic duct
Incising the Pancreatic Duct main duct and side branches. It is crucial to open the entire
duct from the head to the tail of the pancreas; in the end, the
A dilated main pancreatic duct is usually palpable to the left of clamp should pass through the ampulla into the duodenum
the superior mesenteric artery and vein. Localize a small, non- against a finger placed at the duodenum. The last part of the
palpable duct confidently by puncturing the duct with a incision to within the 0.5 to 1 cm of the ampulla is necessary
22-gauge needle (Fig. 100.6a, b). After successful a spiration to achieve complete drainage of the duct. If the operative strat-
of pancreatic juice, incise the pancreas along the duct with egy is limited to the Partington-Rochelle procedure, the next
electrocautery, using the needle as guidance. Next, extend the step would be the construction of the Roux-en-Y pancreatico-
incision of the anterior wall using a right-angle clamp to define jejunostomy. In the presence of an inflammatory mass in the
the direction of the duct towards the head and tail of the pan- head of the pancreas, many surgeons prefer to continue with
creas (Fig. 100.7a–c). Remove any calculi or debris in the the duodenum preserving resection of the pancreatic head
a b
Fig. 100.7 (a, b) Incision of the anterior wall using a right-angle clamp following the direction of the duct toward the head and tail of the pan-
creas. (c) Entire duct is opened; in the end the clamp passes through the ampulla into the duodenum against a finger placed at the duodenum
(e.g. Beger, Frey, Hamburg Procedure) to treat or to avoid artery and vein needs to be spared for preservation of duode-
local anatomic complications in the future. nal blood supply and to facilitate the pancreaticojejunos-
tomy. Preoperative findings of common bile duct obstruction
indicate the need for identification and decompression of the
Pancreatic Head Resection intrapancreatic segment of the common bile duct.
Local resection of the pancreatic head/uncinate is achieved

by careful excision of disc-shaped slices of parenchyma, V-Shape Resection of the Body and Tail
beginning anteriorly and working posteriorly towards the
retroperitoneum, using a scalpel or electrocautery Coring out the pancreatic head and uncinate might be
(Fig. 100.8a, b). Hemostasis during resection using fine insufficient in the presence of small duct disease or exten-
suture ligatures is crucial to avoid postoperative anastomotic sive calcification of the pancreatic tissue. In such cases,
leakage and bleeding. Avoid excision beyond the posterior the anterior V-shaped excision of the main duct and sec-
wall of the main duct to preserve the posterior capsule of the ond- and third-grade pancreatic branches achieves suffi-
pancreas. A small rim of pancreatic tissue (5–10 mm) at the cient drainage and prevents relapse (Hamburg-Procedure)
duodenal curve and to the right of the superior mesenteric (Fig. 100.9a, b).
a ab
Fig. 100.8 (a) Local resection of the pancreatic head: careful excision stent was placed before surgery. During the decompression, the bile
of disc-shaped slices of parenchyma, beginning anteriorly and working duct could not be preserved. In such cases, a biliodigestive anastomosis
posteriorly toward the retroperitoneum. (b) Completed local resection should be given preference instead of reinsertion of the bile duct into
of the pancreatic head. In this case, a pancreatic as well as a bile duct the pancreatic parenchyma
a b
Fig. 100.9 (a) Diagram and (b) Operative view of the Hamburg- third grade pancreatic branches was done, the dorsal aspect of the pan-
Procedure: the entire pancreatic duct is opened; in addition, an anterior creatic duct is preserved
V-shaped parenchyma excision for sufficient drainage of second- and
Roux-en-Y Reconstruction The posterior layer of the pancreaticojejunostomy should

begin at the pancreatic tail using a double-armed 3-0 mono-
The reconstruction phase begins with the localization of the filament suture. Insert the needle through both the mucosal
first jejunal loop and transection 10–15 cm beyond the liga- and seromuscular portions of the jejunal wall. Then pass the
ment of Treitz using a linear stapler. The division of the mes- needle through the fibrotic parenchyma of pancreas. The
entery is done with careful preservation of the vascular arc suture is tied with the knot inside the lumen of the anastomo-
using clamps and ligatures. The alimentary limb is now sis. After stitching out one arm of the suture, the remaining
passed through an avascular area of the transverse mesoco- intraluminal arm is used for a running suture attaching the
lon and placed side-to-side against the pancreas. This should full thickness of the jejunum to the cut surface of the pan-
be possible without any tension, if necessary the division of creas along the capsule. Depending on the length of the anas-
the jejunal mesentery can be extended for laxity. Now, incise tomosis, a second monofilament suture can be used for
the antimesenteric aspect of the jejunum over a length continuing along the cored-out head of pancreas and towards
approximately equal to the incision in the pancreatic duct the anterior layer of the anastomosis (Fig. 100.10). The ante-
using electrocautery. rior layer is performed using running seromuscular stitches,
Complications
The most common complications are pancreatic fistulas and

the formation of intra-abdominal abscesses. Computed
tomography (CT)-guided percutaneous drainage might be
necessary and avoids reoperation in most cases. Intra-
abdominal or intraluminal bleeding, especially late onset
bleeding, is a rare but serious adverse event which needs
prompt intervention. These patients should undergo early
diagnostic angiography followed by embolization. If this
does not control the bleeding, an emergency laparotomy
should be performed.
Further Reading
Fig. 100.10 Pancreaticojejunostomy beginning at the pancreatic tail. Attasarany S, Abdel Aziz AM, Lehman GA. Endoscopic management of
The anterior layer is performed using running seromuscular stitches acute and chronic pancreatitis. Surg Clin North Am. 2007;87:1379.
Bachmann K, et al. Surgical treatment in chronic pancreatitis tim-
at the pancreatic tail using the remaining arm of the double- ing and type of procedure. Best Pract Res Clin Gastroenterol.
2010;24(3):299–310. https://doi.org/10.1016/j.bpg.2010.03.003.
armed suture. The tying of the anterior and posterior suture Review.
at the pancreatic head completes the pancreaticojejunos- Beger HG, et al. Experiences with duodenum-sparing pancreas head
tomy. At a point at least 30 cm distal to the pancreaticojeju- resection in chronic pancreatitis. Der Chirurg. 1980;51(5):303–7.
nostomy, construct an end-to-side jejunojejunostomy to Frey CF, et al. Description and rationale of a new operation for chronic
pancreatitis. Pancreas. 1987;2:701–7.
complete the Roux-en-Y anastomosis. If desired, a silicone Izbicki JR, et al. Longitudinal V-shaped excision of the ventral
drain may be left in the region of the pancreaticojejunal anas- pancreas for small duct disease in severe chronic pancreatitis:
tomosis. Close the abdomen in routine fashion. prospective evaluation of a new surgical procedure. Ann Surg.
1998;227:213–9.
Kutup A, et al. For which type of chronic pancreatitis is the Hamburg
procedure indicated? J Hepatobiliary Pancreat Sci. 2010;17:758–62.
Postoperative Care Negi S, Singh A, Chaudhary A. Pain relief after Frey’s procedure for
chronic pancreatitis. Br J Surg. 2010;97:1087.
The procedure itself does not necessitate postoperative inten- Schneider C, et al. Longitudinal V-shaped excision of the ventral
pancreas for small duct disease in severe chronic pancreatitis:
sive care monitoring, but this might be indicated due to the prospective evaluation of a new surgical procedure. Der Chirurg.
frequently existing comorbidities. The nasogastric tube 2009;80(1):28–33.
should be removed as soon as possible along with the imme- Yekebas EF, et al. Postpancreatectomy hemorrhage: diagnosis and
diate enteral nutrition and mobilization whenever possible treatment: an analysis in 1669 consecutive pancreatic resections.
Ann Surg. 2007;246:269.
(fast-track surgery). Close monitoring of vital signs, fluid
balance and serum glucose concentrations is advised.
Part IX
Spleen
Umut Sarpel
Concepts in Splenic Surgery
101
Prashant Sinha and H. Leon Pachter
Splenectomy for Disease appropriately treatable with splenectomy, (2) has been pre-
operatively immunized with pneumococcal, meningococcal,
Indications for splenectomy have evolved with changes in and Haemophilus vaccine (when not previously immunized),
hematologic management. Staging laparotomy and splenec- and (3) is hematologically optimized for surgery.
tomy for lymphoma has been supplanted by increasingly
accurate imaging techniques. Lymphoma, while the most
common malignancy to affect the spleen, is now rarely an Perioperative Evaluation
indication for splenectomy. Splenic marginal zone lym-
phoma, long treated with splenectomy, has shown a signifi- Hematologic evaluation is focused on accurate diagnosis,
cant response to rituximab and may no longer benefit from a ruling out secondary causes of thrombocytopenia and ane-
first-line surgical approach. However, splenectomy for early- mia, assessing thrombotic risk, initiating and completing
stage primary splenic diffuse large B-cell lymphoma has first-line pharmacologic therapy, and outlining reasonable
recently demonstrated a significant survival benefit (Bairey goals of care within whose framework surgical therapy can
et al. 2015; Kalpadakis et al. 2014). Outside of these specific be safely offered.
entities, splenectomy for immunologic or hematologic con- Immunologic assessment must take into account prior
ditions is best done in partnership with a treating hematolo- history of vaccination and timing of vaccination, which is
gist. As splenectomy is not a curative procedure in many optimally more than 2 weeks prior to or more than 2 weeks
hematolgic conditions, careful patient selection and thera- following surgery. An important caveat is that rituximab
peutic or palliative goals are important to establish with an treatment prevents antibody response for 6 months; thus,
appropriate risk-benefit discussion. vaccination should be offered prior to rituximab therapy. The
Common hematologic indications for splenectomy out- standard regimen of pneumococcal, meningococcal, and
side of trauma are autoimmune (formerly termed idiopathic) Haemophilus influenzae vaccines has not changed; however,
thrombocytopenic purpura (ITP), hereditary spherocytosis, evidence of haemophilus vaccination may be substituted for
and other forms of hemolytic anemia. Additionally, elective perioperative vaccination.
splenectomy is used to palliate anemia or thrombocytopenia Preoperative radiologic imaging (computed tomography
of myelofibrosis and other hematologic malignancies, to [CT], ultrasonography) do not reliably detect accessory
offer symptomatic relief of splenomegaly, to obtain a patho- splenic tissue and are rarely indicated during the first opera-
logic diagnosis, or to allow continuation of chemotherapy tion. When a hematologic disorder recurs because of a
(Bickenbach et al. 2013). missed accessory spleen, the combined use of damaged red
The surgeon must be conversant with these hematologic blood cell scintigraphy and CT scanning can be helpful for
entities to ensure that the patient (1) has a disorder which is localizing accessory splenic tissue. Although radiologic
embolization has been employed immediately prior to sple-
nectomy to reduce the size and vascularity of the spleen in
P. Sinha
Department of Surgery, NYU Langone Brooklyn Surgery the case of extreme splenomegaly, this approach is used as an
Associates, Brooklyn, NY, USA adjunct in larger spleens to reduce risk of blood loss and
H. L. Pachter (*) increase the safety of a laparoscopic approach in both chil-
Department of Surgery, New York University School of Medicine, dren and adults (Van Der Veken et al. 2016; Wu et al. 2012a).
New York, NY, USA
e-mail: leon.pachter@nyumc.org

https://doi.org/10.1007/978-3-030-81415-1_101
796 P. Sinha and H. L. Pachter
In addition to postsplenectomy sepsis, postoperative con- majority; however, overlooked accessory splenic tissue may
cerns unique to splenectomy include pancreatic tail injury demonstrate hypertrophy, subsequently causing recurrence
and portal-splenic vein thrombosis. Both complications are of the hematologic symptoms for which the splenectomy
low frequency, but may carry high morbidity if missed. was initially performed. Some have questioned whether
Thrombocytosis postoperatively exceeding 600 × 109/L accessory spleens are more likely to be overlooked during
should prompt antiplatelet therapy with aspirin and exceed- laparoscopic splenectomy than open splenectomy (Gigot
ing 1000 × 109/L should prompt reimaging and hematology et al. 1998). Park et al. reported a 12.3% incidence of acces-
specialists. Delayed onset abdominal pain may be the only sory splenic tissue in their series of 203 laparoscopic sple-
presenting complaint for important postoperative conditions: nectomies, with one patient requiring reexploration for a
subdiaphragmatic abscess, pancreatic tail collection, or missed accessory spleen (Park et al. 2000). They attributed
portal-
splenic vein thrombosis. Cross-sectional imaging this to their ability to visualize the perisplenic tissues better
should be requested and timed appropriately to assess for laparoscopically than at open splenectomy. In our experi-
each of these specific conditions. ence, the incidence of accessory spleens seen at laparoscopy
is 20%, equivalent to the rate generally cited in the litera-
ture. Autopsy and radiological studies demonstrate the
Autoimmune Thrombocytopenic Purpura majority of accessory spleens are up to 10 mm in size and
found in the splenic hilum, followed by the greater omen-
In ITP, the spleen produces antibodies directed against plate- tum, in the tail of the pancreas, and rarely in the pelvis
let antigens and also is the main site of platelet destruction. (Romer and Wiesner 2012; Unver Dogan et al. 2011). A
Characteristic findings of thrombocytopenia and presence of small subset of patients with ITP may ultimately require a
megakaryocytes (in the absence of splenomegaly) make the subsequent open or laparoscopic procedure to remove an
diagnosis. In children, ITP is generally a self-limited pro- accessory spleen that has caused recurrence of the ITP
cess, and surgical intervention is rarely needed. Adults are (Velanovich and Shurafa 2000). Fortunately, most accessory
treated with glucocorticoids as first-line therapy or with spleens should be close by or captured within the splenec-
cytotoxic agents and immunoglobulin as alternate options. tomy specimen, particularly if any attached omentum is left
Splenectomy is reserved for chronic or refractory ITP gener- on the spleen.
ally after 12 months from diagnosis. While some have used Splenic implantation is another cause of recurrence. Care
rituximab and newer thrombopoietic agents as second line, must be taken not to fracture the spleen during dissection or
the role of splenectomy as second line remains strong, show- to spill splenic tissue during the “morcellation” process. The
ing immediate and more durable effect and with limited mor- surgical team must be prepared for an accurate, bloodless
bidity (Chater et al. 2016). There are still no reliable splenectomy. All steps should be taken to protect the abdom-
predictors of response to splenectomy; however, the vast inal cavity from contamination by splenic tissue. This means
majority of patients experience a complete or partial gentle handling of the spleen and its attachments and use of
response. Failure to respond postoperatively should prompt a strong, impervious extraction bag.
evaluation for possible accessory splenic tissue or splenic
implants from trauma during surgery.
Although these patients are thrombocytopenic, the plate- hoice of Surgical Approach: Open Versus
C
lets circulating in the peripheral blood are large immature Laparoscopic Procedure
platelets with excellent hemostatic potential. Studies indi-
cate safety of surgery with preoperative platelet counts lower The ideal surgical approach for splenectomy would have the
than 10 × 109/L to 20 × 109/L with variable but acceptable following features:
risk for perioperative transfusion. Since the response to sple-
nectomy is prompt, with rapid rise in platelet count, platelet • Provide excellent surgical exposure of the splenic hilum,
transfusions are no longer routinely used. They are reserved ligaments, and perisplenic tissues.
for situations in which bleeding and persistent thrombocyto- • Cause minimal disturbance of the abdominal wall
penia complicate the postoperative phase (Aleem 2011; muscles.
Chen et al. 2011; Hollander et al. 2011; Wu et al. 2012b). • Permit precise dissection of the splenic vessels and avoid
splenic parenchymal injury.
• Avoid injury to the pancreas, stomach, and adjacent
ecurrent Symptoms After Splenectomy
R structures.
for Hematologic Disease • Laparoscopic splenectomy fulfills these criteria in many
instances and has become the method of choice for all
In palliative splenectomy, durable symptom relief of cyto- forms of splenic pathology when the spleen is mildly to
penias and pressure symptoms is achievable in the vast moderately enlarged.
101 Concepts in Splenic Surgery 797
Massive splenectomy with myelofibrosis in which the

spleen is hard, tethered, and supplied by large collateral ves-
sels may not be appropriate for minimal access surgery, how-
ever. The surgeon’s experience determines the point at which
the enlarged spleen is “too large” to remove laparoscopically.
echnical Considerations for Safe Laparoscopic

T
Splenectomy
The spleen develops from buds in the dorsal mesogastrium

that subsequently coalesce. This provides the conceptual
framework for understanding the layers and contents of the
splenic ligaments. The configuration of these ligaments and
blood vessels is used to the surgeon’s advantage during the
laparoscopic approach. Until the surgeon is familiar with
mobilizing and handling the organ, it is best that the liga- Fig. 101.1 Large superior pole splenic cyst without septations. This
ments of the spleen be left undisturbed until the vessels in the cross section demonstrates compression of adjacent stomach. A laparo-
scopic approach is appropriate
hilum have been divided. Dissection should occur about
10 mm away from the hilum where the vessels are less well
vation, however, has undergone a remarkable evolution from
fixed and safer to dissect (see Chap. 98). If the splenic artery
operative splenorrhaphy to nonoperative management
is accessible above the pancreas, it can be clipped or tied in
(Pachter et al. 1998) and selective angioembolization.
continuity. If a stapler is to be used to divide hilar vessels,
Advances in CT scan speed and resolution, along with
any clips should be positioned further proximally or distally
increasingly advanced interventional catheters, have estab-
to avoid the anticipated location of the stapler in order to
lished the primacy of the nonoperative approach to splenic
avoid stapler misfires.
trauma. Nonetheless, instances arise where operative inter-
vention is required – hence the need for familiarity with
techniques such as safe splenectomy, splenorrhaphy, and
Laparoscopic Management of Splenic Cysts
splenic autotransplantation (Pisters and Pachter 1994).
When operative intervention has been dictated by a
Splenic cysts can develop as the result of prior trauma, infec-
patient’s inability to maintain hemodynamic stability
tion, or may be idiopathic in nature. Surgical intervention is
despite adequate fluid resuscitation or having sustained
only necessary in the presence of symptoms such as pain or
multiple organ injuries, splenectomy should be undertaken
mass effect (e.g., compression of the stomach causing early
without hesitation. When splenectomy is necessary and
satiety) (Fig. 101.1). Most splenic cysts can be unroofed
conditions permit, it seems prudent to use the removed
laparoscopically and the cyst wall removed in a retrieval bag.
spleen as a source for heterotopic splenic autotransplanta-
Care must be taken to excise a sufficient portion of the cyst
tion. The benefits derived from heterotopic splenic auto-
wall to prevent recurrence.
transplantation seem to be, theoretically at least, associated
with its ability to restore partially the host’s reticuloendo-
thelial function. Whether such partial restoration of reticu-
Splenic Trauma
loendothelial function is sufficiently protective against
specific antigenic challenges is presently unknown. As
Splenectomy renders patients susceptible to the lifelong risk
splenic autotransplantation can be performed with relative
of infectious complications. Overwhelming postsplenec-
ease and has not to date been associated with significant
tomy infection (OPSI) is rare (occurring in only 0.25–5.0%
complications, it seems reasonable to continue employing
of adult splenectomized patients), but it can occur rapidly
this technique.
and result in more than 50% mortality rate (Lynch and Kapila
In patients with splenic injuries who remain hemodynam-
1996). Recognition of this syndrome has led to the develop-
ically stable but require operative intervention, a variety of
ment and, now universal, acceptance of splenic preservation
techniques can be used to achieve splenic salvage. Included
as the treatment modality of choice whenever it is safe and
in these techniques are splenorrhaphy, partial splenectomy,
feasible.
mesh splenorrhaphy, topical hemostatic agents, and energy-
The importance of splenic preservation has been recog-
based coagulation techniques (see Chap. 94).
nized for more than 20 years. The method of splenic preser-
Nonoperative Splenic Salvage ultrasonography), patients with pathologically diseased

spleens (human immunodeficiency virus, leukemia, mono-
In the past, splenic salvage was most often achieved (70– nucleosis), selected patients with isolated stab wounds to the
75%) by operative splenorrhaphy, partial splenectomy, elec- spleen, and neurologically impaired patients.
trocautery, and the use of adjunctive hemostatic agents.
Nonoperative management was, at best, applicable to only
15–20% of patients with blunt injuries. Current data suggest rognostic Indicators of Failure
P
an almost mirror-image reversal, with at least 50–65% of of Nonoperative Management
patients with blunt injuries and a small group of select
patients with penetrating injuries being managed nonopera- There are certain instances where more active intervention is
tively with success rates exceeding 90%; only 17–20% indicated despite the patient meeting all “conventional” cri-
undergo splenorrhaphy. Splenorrhaphy techniques are teria for nonoperative management. Irrespective of the
detailed in Chap. 103. patient’s hemodynamic stability, a shattered spleen envel-
oped by a significant perisplenic hematoma (Fig. 101.3) in
our experience eventually bleeds. It must be remembered
Nonoperative Management of Splenic Trauma that nonoperative management of hepatic and splenic inju-
ries differs greatly. Hepatic injuries rarely rebleed. In con-
An algorithm for nonoperative splenic preservation is given trast, even when bleeding has initially stopped, splenic
in Fig. 101.2. The following criteria for nonoperative man- injuries have a propensity to bleed late. Shattered spleens are
agement have proven safe and effective in our hands: particularly vulnerable to this complication. Prompt surgical
intervention and expeditious splenectomy, preferably with
• Hemodynamic stability splenic autotransplantation, are warranted.
• CT scan documentation of the injury Another instance where there is a higher degree of failure
• No other intraperitoneal or retroperitoneal injuries requir- of nonoperative management is when the initial CT scan
ing operative intervention (documented by CT scan) reveals contrast blushes, pseudoaneurysms, or arteriovenous
• Limited need for spleen-related transfusions fistulae. Multiple vascular anomalies increase the risk of fail-
ure. Any vascular anomaly, and especially a blush, should
The almost exponential rise in the number of patients prompt rapid angiographic embolization. Figure 101.4 shows
managed nonoperatively since the early 1990s has been a a CT scan from a patient who was injured in a motor vehicle
direct result of including the following patients who in the collision, demonstrating a contrast “blush” and a large peri-
past would have been excluded from nonoperative manage- splenic hematoma. Failure rates of nonoperative manage-
ment: all hemodynamically stable patients regardless of CT ment may well be related in part to underestimation of the
grade of splenic injury, patients with intraperitoneal blood significance of this finding. The hemodynamically stable
accumulation exceeding 250 ml (delineated by CT scan or patient with CT-demonstrated “contrast blush” should
undergo immediate angiographic embolization of the bleed-
ing vessel. Figure 101.5 shows selective subtraction splenic
angiography revealing free extravasation of contrast from the
lower pole of the spleen (same patient as in Fig. 101.4). The
patient underwent successful angioembolization with a com-
bination of autologous clot and gelfoam (Fig. 101.6).
Angioembolization has become one of the cornerstones in
the successful multidisciplinary approach to the nonopera-
tive management of splenic injuries (Pachter and Grau 2000).
Follow-Up Imaging
Most follow-up imaging studies with CT in patients with

stable postobservation courses remain controversial. The
role of repeat CT scanning either inpatient or outpatient
should be limited to specific circumstances. Higher injury
Fig. 101.2 Algorithmic Approch To Nonoperative Management of severity or splenic grade can be used to select patients for a
Blunt Splenic Injury. (From Pachter et al. 1998, with permission) repeat CT scan at 48 h to assess for evolving vascular injury;
Fig. 101.3 Axial cut of CT

scan demonstrating large Algorithmic Approach to Nonoperative
perisplenic hematoma Management of Blunt Splenic Injury
Hemodynamic Stability
CT Scan
No intra-abdominal injuries “Contrast Blush”

requiring operative interventaion within the spleen
Observe Angioembolization
Success Failure
Hematocrit Injury
falls worse
Celiotomy
Repaeat CT Scan
Continued
observation
No
change
Fig. 101.4 Axial cut of CT scan showing contrast blush with large Fig. 101.5 (From Pachter and Grau 2000, with permission)
perisplenic hematoma
The role of diagnostic laparoscopy in the assessment of

patients with penetrating thoracoabdominal trauma is well
established. Concerns about potentially missed intraperito-
neal injuries or the ability to treat discovered injuries has
limited the application of diagnostic and therapeutic laparo-
scopic techniques in this setting. However, multiple case
reports have described successful laparoscopic splenic repair
and salvage utilizing techniques of intracorporeal suture
placement, application of fibrin glue, and absorbable mesh
splenorrhaphy, and this role may continue to expand.
References
Aleem A. Durability and factors associated with long term response after
splenectomy for primary immune thrombocytopenia (ITP) and out-
come of relapsed or refractory patients. Platelets. 2011;22(1):1–7.
Fig. 101.6 (From Pachter and Grau 2000, with permission) Bairey O, Shvidel L, Perry C, Dann EJ, Ruchlemer R, Tadmor T,
et al. Characteristics of primary splenic diffuse large B-cell lym-
phoma and role of splenectomy in improving survival. Cancer.
2015;121(17):2909–16.
those with vascular anomaly may undergo angioemboliza- Bickenbach KA, Gonen M, Labow DM, Strong V, Heaney ML, Zelenetz
tion (Weinberg et al. 2007). Outpatient imaging may also be AD, et al. Indications for and efficacy of splenectomy for haemato-
helpful for determining which patients may return to contact logical disorders. Br J Surg. 2013;100(6):794–800.
Chater C, Terriou L, Duhamel A, Launay D, Chambon JP, Pruvot FR,
sports, particularly those who initially sustained an American et al. Reemergence of splenectomy for ITP second-line treatment?
Association for the Surgery of Trauma (AAST) grade III or Ann Surg. 2016;264(5):772–7.
greater injury. There would be understandable reluctance to Chen X, Peng B, Cai Y, Zhou J, Wang Y, Wu Z, et al. Laparoscopic
allow a patient with a large intrasplenic hematoma to play splenectomy for patients with immune thrombocytopenia and very
low platelet count: is platelet transfusion necessary? J Surg Res.
tackle football without documenting complete resolution of 2011;170(2):e225–32.
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In summary, recognition of the pivotal role of the spleen Inadequate detection of accessory spleens and splenosis with lapa-
in the immune response has resulted in almost universal pol- roscopic splenectomy. A shortcoming of the laparoscopic approach
in hematologic diseases. Surg Endosc. 1998;12(2):101–6.
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continues to be associated with an increased need for trans- of response to steroid therapy on response to splenectomy in
fusion and excessive perioperative sepsis. Splenic preserva- children with immune thrombocytopenic purpura. Surgery.
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Kalpadakis C, Pangalis GA, Vassilakopoulos TP, Sachanas S,
become the accepted treatment protocol of choice. Angelopoulou MK. Treatment of splenic marginal zone lym-
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rarely performed today, having been replaced for the most 2014;55(7):1463–70.
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phy, partial splenectomy, and heterotopic splenic autotrans- Surg. 2000;34:137–74.
plantation must be in the trauma surgeon’s armamentarium. Pachter HL, Guth AA, Hofstetter SR, Spencer FC. Changing patterns
in the management of splenic trauma: the impact of nonoperative
management. Ann Surg. 1998;227(5):708–17; discussion 17–9.
Park AE, Birgisson G, Mastrangelo MJ, Marcaccio MJ, Witzke
aparoscopy for the Management of Splenic
L DB. Laparoscopic splenectomy: outcomes and lessons learned from
Trauma over 200 cases. Surgery. 2000;128(4):660–7.
Pisters PW, Pachter HL. Autologous splenic transplantation for splenic
trauma. Ann Surg. 1994;219(3):225–35.
Laparoscopy is another tool available to the trauma surgeon Romer T, Wiesner W. The accessory spleen: prevalence and imaging
dealing with the diagnosis and management of splenic findings in 1,735 consecutive patients examined by multidetector
trauma. Its role in elective splenic surgery is described ear- computed tomography. JBR-BTR. 2012;95(2):61–5.
lier, and there is interest in applying the lessons learned to Unver Dogan N, Uysal II, Demirci S, Dogan KH, Kolcu G. Accessory
spleens at autopsy. Clin Anat. 2011;24(6):757–62.
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while obviating the need for open laparotomy. spleen embolization as a useful tool in laparoscopic splenectomy for
simple and massive splenomegaly in children: a prospective study. Wu Z, Zhou J, Pankaj P, Peng B. Comparative treatment and lit-
Surg Endosc. 2016;30(11):4962–7. erature review for laparoscopic splenectomy alone versus preop-
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discussion 7–8.
Open Splenectomy for Disease
102
Carl Winkler and Umut Sarpel
Indications • Postoperative hemorrhage

• Injury to the greater curvature of the stomach
• Hematologic disorders, for example, immune thrombocy- Injury to the pancreas
topenia (ITP) and hemolytic anemia (Splenectomy is ben- • Failure to identify and remove an accessory spleen (lead-
eficial in a variety of other hematologic conditions. In these ing to persistent ITP)
cases, the surgical indication and timing should be reviewed • Splenic rupture (leading to the formation of splenules
in close consultation with the patient’s hematologist.) with recurrent ITP)
• Splenic tumor (e.g., primary splenic lymphoma or iso-
lated metastatic disease)
• Splenic abscess Operative Strategy
• Splenic cyst
• Gastric varices due to splenic vein thrombosis Choice of Approach: Open or Laparoscopic?
Laparoscopic or robotic splenectomy has become the stan-

Preoperative Preparation dard approach for most patients. A minimally invasive
approach is easiest in patients with small spleens, such as
• Immunize the patient against Streptococcus pneumoniae, those with ITP. Although technically more challenging,
Neisseria meningitidis, and Haemophilus influenzae at patients with massive spleens benefit especially from this
least 2 weeks prior to surgery. approach, since the specimen can usually be morcellated,
• Stress dosing of steroids may be necessary in some cases. thus dramatically reducing the size of the incision.
• Administer perioperative antibiotics.
• Preoperative transcatheter embolization of the splenic
artery is a rarely used option in select patients. Avoiding Intraoperative Hemorrhage
Splenectomy should be performed immediately following
completion of the splenic artery occlusion, otherwise pain Rupturing the splenic capsule or avulsing the short gastric
and necrosis of the spleen are likely to occur. vessels are the usual causes of intraoperative hemorrhage.
These injuries can be best avoided with proper exposure,
which allows for gentle traction and better visualization.
Pitfalls and Danger Points Ensure that exposure is adequate for each step of the opera-
tion. Removing a large spleen requires a long incision.
• Intraoperative hemorrhage Elevating the left costal margin with a table-mounted retrac-
tor greatly improves exposure.
When performing splenectomy for hematologic disor-
C. Winkler ders, we prefer to isolate and ligate the splenic artery as the
Department of Surgery, The Valley Hospital, Ridgewood, NJ, USA first step. This frequently allows a large spleen to shrink con-
U. Sarpel (*) siderably in size, and thus, makes the remaining dissection
Division of Surgical Oncology, Department of Surgery, Icahn safer.
School of Medicine at Mount Sinai, New York, NY, USA

https://doi.org/10.1007/978-3-030-81415-1_102
804 C. Winkler and U. Sarpel
Patients with portal hypertension, such as those with tion. Routine drainage of the splenic bed is not necessary, but
myelofibrosis, may have collateral veins in the normally the selective use of closed suction drainage in patients with
avascular splenophrenic and splenorenal ligaments. Patients concern for pancreatic injury is appropriate.
with sinistral portal hypertension as a result of splenic vein
thrombosis will often have large gastric varices. These frag-
ile vessels have the potential for significant hemorrhage and Accessory Spleen
must be ligated carefully.
Accessory spleens are common; if overlooked, they may
impair the therapeutic effect of the splenectomy. Special
Preventing Postoperative Hemorrhage attention should be paid to identify accessory spleens on pre-
operative cross-sectional imaging. A dedicated intraopera-
At the conclusion of the splenectomy, it is important to tive exploration is also warranted. The most common location
achieve complete hemostasis of the splenic bed, especially to find an accessory spleen is within the splenic hilum. The
along the tail of the pancreas, the left adrenal gland, and the gastrosplenic, splenocolic, and splenorenal ligaments are
retroperitoneum. If there is diffuse oozing due to thrombocy- other possible sites.
topenia, administer platelets as needed only after ligating the
splenic artery, to prevent their immediate consumption by
the spleen. Operative Technique
Incision
Avoiding Pancreatic Injury
In the patient who has a small spleen, as is often the case
The greatest risk of injuring the tail of the pancreas occurs with ITP, a left subcostal incision reaching at least to the
when the splenic blood supply is being ligated and divided at anterior axillary line provides excellent exposure. In some
the hilum of the spleen. Avoid this by clearly identifying the cases, the subcostal incision may be improved by a vertical
tip of the pancreatic tail and individually ligating vessels (Kehr) extension to the xiphoid (Fig. 102.1). A midline inci-
rather than masses of tissue. If visualization is limited or sion is preferable in patients with marked splenomegaly,
there is urgency to complete the procedure, we recommend since the hilum will be shifted to the midline. Apply a retrac-
using a vascular stapler to transect the splenic hilum. This tor to elevate the left costal margin and to draw it in a cepha-
approach ensures secure ligation of the pancreatic duct if the lad and lateral direction.
tail is inadvertently included.
Ligating the Splenic Artery

Avoiding Trauma to the Stomach
In straightforward cases, the splenic artery may be simply
It is easy to injure the greater curvature of the stomach ligated in the hilum along with the splenic vein. However, in
with an energy device in the course of ligating the short cases where there is the potential for hemorrhage, such as
gastric vessels, especially when a large spleen is being with massive splenomegaly, or in patients with severe throm-
removed. This injury may result in a gastric leak, which bocytopenia, there is an advantage to early ligation of the
can be a life-threatening complication. In high-risk cases, splenic artery, before any hilar dissection is performed.
a secure closure should be obtained by imbricating the In these cases, ligate the splenic artery where it is most
greater curvature of the stomach with a continuous layer of directly accessible, close to its take-off from the celiac trunk.
Lembert sutures. Incise the avascular portion of the gastrohepatic ligament
midway along the lesser curvature of the stomach, exposing
the upper border of the pancreas. Palpate the splenic artery as
Preventing Postoperative Sepsis it courses along the upper border of the pancreas. Incise the
peritoneum over the splenic artery as distally as is easily
Subphrenic abscess is preventable with meticulous hemosta- visualized. Carefully pass a blunt-tipped right-angle clamp
sis and by avoiding injury to adjacent structures. The use of around the splenic artery. Temporarily occlude this artery
prophylactic antibiotics administered intravenously at the with a vascular clamp or by double encircling it with a vessel
induction of anesthesia may reduce the rate of this complica- loop and ensure that the occluded vessel is not the hepatic
tion. This is especially true if there is any danger that the artery by confirming a pulse in the porta hepatis. Then, ligate
stomach or colon may be entered during a difficult dissec- the splenic artery with a 2-0 silk ligature (Fig. 102.2). Once
102 Open Splenectomy for Disease 805
quadrant. Release the colon and its attached omentum from

the lower pole of the spleen. The short gastric vessels are
encountered between the greater curvature of the stomach
and the spleen. Take care not to place excessive traction on
the stomach because this can lead to avulsion of these vessels
and significant hemorrhage. Continue dividing the short gas-
tric vessels until the stomach can be reflected cephalad and
the exposure is satisfactory.
Mobilizing the Spleen
With the left hand, retract the spleen medially to expose the
Kehr subcostal
incision avascular splenophrenic and splenorenal ligaments. Divide
these ligaments sharply or with electrocautery. Only in the
presence of portal hypertension is it necessary to formally
Midline incision
ligate vessels within these ligaments. Insert the index finger
behind the incised splenorenal ligament and continue the dis-
section until the spleen has been freed from the capsule of
Gerota and the diaphragm (Figs. 102.3 and 102.4).
Ligating the Splenic Vessels
Once the ligamentous splenic attachments are divided, care-

fully mobilize the spleen to the midline. Handling the spleen
too roughly during this maneuver can tear the splenic cap-
Fig. 102.1 Alternative incisions for open splenectom sule, causing unnecessary bleeding and potentially postop-
erative peritoneal splenosis. Medializing the spleen allows
for direct visualization of the pancreatic tail and its intimate
relationship with the splenic hilum. Gently dissect the tail of
the pancreas away from the splenic artery and vein. Identify
the splenic artery which, depending on technique, may have
Splenic a.
been previously ligated. Ligate the artery again near the
Pancreas
Divided
L. gastroepiploic a. gastrosplenic lig. Spleen
Stomach
Fig. 102.2 Isolating the splenic artery in the lesser sac
inflow control has been obtained, proceed with the operation Splenic
as usual. a. and v.
Pancreas
Exposing the Spleen Divided splenorenal lig.

Kidney
Expose the tail of the pancreas and the spleen by opening the
gastrocolic omentum and entering the lesser sac. Use an
energy device to continue the dissection toward the left upper Fig. 102.3 Points of division of gastrosplenic ligament and splenore-
nal ligament
806 C. Winkler and U. Sarpel
chieving Hemostasis and Searching

A
for Accessory Spleens
Splenic a.
Pack the splenic bed to stop any remaining minor bleed-
ing. Use this time to explore the abdomen for accessory
Splenic v. spleens. Investigate the pancreatic tail, left kidney, gastro-
splenic ligament, omentum, small and large bowel mesen-
tery, and the pelvis. Remove the gauze pads from the
Pancreas splenic bed and achieve final hemostasis utilizing electro-
cautery as needed.
Colon
Imbricating the Greater Curvature of Stomach
Fig. 102.4 Fully mobilized spleen with splenic artery and splenic vein Carefully inspect the greater curvature of the stomach. If
exposed there is a suspicion of thermal injury or any serosal tears are
Divided short Divided seen, invert the tissue of the greater curvature together with
gastric vessels splenic a. Splenic v.
the ligated stumps of the short gastric vessels. Use a running
Lembert stitch with 4-0 absorbable suture material to accom-
plish this step (Figs. 102.6 and 102.7).
Abdominal Closure
Irrigate the upper abdomen and close the fascia in routine

fashion. Drainage of the splenic bed is not necessary unless
there is suspicion for pancreatic tail injury.
Fig. 102.5 Division of splenic vein close to spleen
splenic hilum and divide it. Next, isolate the splenic vein,
which may be a single vessel or multiple branches at this
level. Carefully encircle either the main splenic vein or each
of its branches with 2-0 silk ligatures (Fig. 102.5). Ligate and
divide the vein(s) between ligatures. An alternative approach
is to use a vascular stapler to ligate the hilum en masse, how-
ever, this maneuver risks incorporating pancreatic tissue into
the staple line. If technically feasible, a meticulous dissec-
tion of the vasculature is preferred. At this point, the spleen
should be free from all attachments and can be removed from
the body. Fig. 102.6 Imbrication of region of short gastric vessels with Lembert
sutures
102 Open Splenectomy for Disease 807
Ideally, the patient should wear a medical alert bracelet

stating that they have undergone splenectomy.
• If the patient was not immunized preoperatively, vacci-
nate them against S. pneumoniae, N. meningitidis, and
H. influenzae 2 weeks postoperatively. This can be done
prior to hospital discharge if there is concern for poor
follow-up.
• Young children should receive prophylactic penicillin
until they are old enough to reliably communicate symp-
toms of illness, typically at least 2 years of age.
Complications
• Hemorrhage
• Subphrenic abscess
• Pancreatic fistula
• Gastric leak
• Splenosis
Fig. 102.7 Stomach at completion of operation
Further Reading
Postoperative Care
Brunt LM, Lander GJ, Quasebarth MA, Whitman ED. Comparative
analysis of laparoscopic versus open splenectomy. Am J Surg.
• In patients on steroid therapy prior to splenectomy, post- 1996;172:596.
operative dosing should be coordinated with the patient’s Cameron JL, Cameron AM. Splenectomy for hematologic diseases,
hematologist. Current surgical therapy. Philadelphia: Elsevier Saunders; 2016.
• The platelet count typically rises postoperatively but only Crary SE, Buchanan GR. Vascular complications after splenectomy for
hematologic disorders. Blood. 2009;114:2861.
requires aspirin administration when the count exceeds Farid H, O’Connell TX. Surgical management of massive splenomeg-
one million platelets per microliter. aly. Am Surg. 1996;62:803.
• The leukocyte count also rises markedly following sple- Feldman LS. Laparoscopic splenectomy: standardized approach. World
nectomy, but this does not indicate infection and no treat- J Surg. 2011;35:1487.
Irving M. Postoperative complications after splenectomy for hemato-
ment is necessary. Correlate with the presence of a fever logical malignancies. Ann Surg. 1997;225:131.
and other systemic signs to determine if an infection is Katkhouda N. Chapter 26. Laparoscopic splenectomy. In: Nguyen N,
present. CEH S-C, editors. SAGES volume II. Advanced laparoscopy and
• The patient and their family should be educated regarding endoscopy. New York: Springer; 2012.
the risk of overwhelming postsplenectomy infection.
Operations for Splenic Trauma
103
Carina Biggs
• Splenic injury not amendable to nonoperative Decision for Splenectomy or Repair of Spleen
management
• Failed nonoperative management of splenic injury Before making a decision about splenectomy or splenic sal-
• Splenic injury concurrent with other intra-abdominal vage, the spleen must be completely mobilized into view in
injuries requiring laparotomy order to assess whether the injury is amenable to repair.
Several factors must be taken into consideration in the
decision to repair or remove the spleen. The patient with
Preparation ongoing shock, multiple injuries, particularly traumatic brain
injury, should undergo immediate splenectomy. Splenic sal-
• Assure adequate intravenous access vage is more important is children for immune function and
• Have blood products available in the operating room is more successful in children because the pediatric splenic
• Administer perioperative antibiotics capsule is thick and holds sutures well. The injury should be
• Place a nasogastric tube amenable to a good, safe repair which the surgeon is experi-
enced in performing. Finally, the experience of the surgeon
in splenic repair should also be kept in mind.
Pitfalls Much has been written about intricate procedures to save
the spleen. Splenic repair should be simple and performed
• Prolonged attempts at splenic repair only in a stable patient. Basic suture techniques and/or cau-
• Performing splenorrhaphy rather than splenectomy in the tery work well. Patients with multiorgan injury will not toler-
multi-injured or hemodynamically unstable patient ate lengthy splenic repairs or rebleeding.
• Injury to pancreatic tail
Operative Technique
Every trauma laparotomy for splenic injury follows the fol-

lowing sequence: exposure, mobilization, temporary control
of hemorrhage, identification of injury, and decision for
damage control or definitive repair. Proper positioning of the
patient is critical; both arms should be abducted to allow the
anesthesiologists full access.
C. Biggs (*)
Trauma Medical Director, St. Mary’s Hospital, Waterbury,
CT, USA

https://doi.org/10.1007/978-3-030-81415-1_103
810 C. Biggs
Exposure for Splenectomy of fixed abdominal wall retractors is optimal if time permits.
A midline incision will provide optimal exposure for splenec-

tomy and allow evaluation of other intra-abdominal injuries. Use Mobilization of the Spleen
The first step is to mobilize the spleen into the midline. This
allows the surgeon to determine whether the spleen may be
repaired or whether splenectomy should be performed.
For the spleen to be easily mobilized out of the left upper
quadrant, pass your nondominant hand over the splenic
convexity, hook the fingers around the deepest part of the
spleen, and bring it to the middle of the operative field
(Fig. 103.1). The splenorenal ligament which is posterior to
the spleen will be in view and easily divided. The key
maneuver is to incise the splenorenal ligament and enter the
correct plane between the spleen and kidney. If the spleen
is not easily mobilized due to adhesions between the spleen
and a bdominal wall and/or an inflexible splenorenal liga-
ment, mobilization may be difficult. The first step here is to
free the splenic capsule from the abdominal wall. This may
be done with electrocautery or sharply with a scissor. If the
operative field is full of blood and the dissection cannot be
visualized, a combination of finger dissection and scissor
dissection will free the spleen from the anterior abdominal
wall.
If the splenorenal ligament is unyielding or short, gain
Fig. 103.1
access by sliding the nondominant hand over the splenic con-
vexity and gently pulling the spleen forward, away from the
lateral abdominal wall. The splenorenal ligament will be
stretched and become palpable along the fingertips and can
then be divided. At this point, palpate the left kidney and
develop the plane between the spleen and left kidney. Take
care not to mobilize the left kidney with the spleen.
Once the spleen is adequately mobilized, control bleeding
by squeezing the spleen with the nondominant hand or by
pinching or placing a vascular clamp across the splenic vas-
Splenic v. cular pedicle.
Splenic a. If the injured spleen is enlarged from disease, mobiliza-
tion may be particularly challenging. Consider rapid early
control of the splenic artery. Enter the lesser sac through the
gastrocolic ligament and control the splenic artery along its
path on the upper boarder of the pancreas. By dividing the
gastrosplenic ligament, the splenic hilar vessels come into
view. Place a vascular clamp on the splenic hilum and mobi-
lize the devascularized spleen.
Temporary Control of Hemorrhage
Control bleeding by squeezing the spleen once it has been

mobilized or by controlling the splenic hilum with fingers or
with a vascular clamp (Fig. 103.2).
Fig. 103.2
103 Operations for Splenic Trauma 811
Removal of the Spleen
The three basic steps of the operation are exposure, vascular

ligation, and removal.
Perform splenectomy by clamping and dividing the
splenic vessels at the hilum. It is imperative to stay close to
the spleen so as not to injure the tail of the pancreas or the
stomach. Serially clamp and tie vessels in the gastrosplenic
ligament away from the curve of the stomach. Clamp and tie
the splenocolic ligament.
It is prudent to doubly ligate or suture ligate hilar ves-
sels. Ligate any other bleeding vessels. Take care to inspect
the greater curvature of the stomach for bleeding or iatro-
genic injury. If there is a concern for an iatrogenic injury to
the tail of the pancreas, place a closed suction drain. After
the spleen has been removed, check hemostasis by placing
a rolled laparotomy pad into the furthest portion of the
splenectomy bed and rolling it back medially over the area
of dissection. Any bleeding can be controlled by electro-
cautery or suture.
Fig. 103.3
Techniques for Splenic Preservation
If a decision is made to repair the spleen, the organ must first

be completely yet atraumatically mobilized. Take care not to
make the situation worse by stripping capsule off spleen dur-
ing mobilization. All peritoneal attachments between the
spleen and other organs should be divided. If bleeding is
encountered during mobilization of the spleen, it can be con-
trolled by compressing the splenic artery and vein between
the thumb and index finger.
A simple repair is the best technique to preserve the
spleen. Most surgeons do not have experience with a large
number of techniques and it is best to use what has worked
well in prior operations. The first step is to hold finger pres-
sure on the injury as a technique is being chosen. A variety of
hemostatic agents work well on slow bleeding. Avitene pow-
der is easy to apply to an irregular surface and pressure is
Fig. 103.4
held with a laparotomy pad. Cautery or argon beam laser are
excellent options for small injuries.
Suture repair is a safe, quick, and effective method to
Identification of the Splenic Injury repair a splenic laceration (Fig. 103.3). A monofilament
suture which easily glides through tissue is optimal in the
The splenic artery and vein divide into two to four trunks adult spleen because its capsule is thin and does not hold
prior to entering the spleen. The intrasplenic branches travel suture well. Strips of Teflon can be used as a bolster
horizontally. Since most splenic fractures also travel in a (Fig. 103.4).
transverse direction, often only one or two small blood ves- Omentum can be placed into a deep laceration and secured
sels have been torn. Control of bleeding can be gained by for hemostasis. If an edge of the spleen is badly injured, it
clips, a hemostatic agent, or suture. can be simply amputated with a linear stapler. The stapler
If a portion of the spleen has been separated from its should be closed slowly before firing so that it does not break
blood supply that portion of the spleen should be removed. the capsule. After replacing the repaired spleen into its natu-
The spleen is then examined in its entirety. ral bed, always wait 10–15 min and reinspect the spleen to be
812 C. Biggs
Fig. 103.6
Fig. 103.5 with a gauze pad. Electrocautery and argon beam coagula-
tion can be used.
sure the bleeding has indeed been completely controlled. In

some cases, a narrow pedicle of viable omentum is placed in Abdominal Closure
a fracture and sutured in place with chromic catgut
(Fig. 103.5). Close the abdomen in standard fashion. A closed suction
Absorbable Mesh Wrap may be used if the spleen has drain is generally placed due to the risk of possible injury to
been fractured into several pieces and the hilum is intact. the pancreatic tail.
Fashion a piece of absorbable mesh large enough to enfold
the entire spleen, allowing the hilar vessels to enter and exit.
Wrap the spleen in this mesh and close it circumferentially Postoperative Care
around the hilum (Fig. 103.6). If necessary, plicate the mesh
to snug it up, forming a sort of “pressure dressing” around • Perioperative antibiotics should be given for 24 h.
the entire spleen. Hemoglobin and hematocrit should be followed
postoperatively.
Iatrogenic Injuries • Patients who have had a splenic repair or partial splenec-
Most spleens injured during dissection (e.g., during colon tomy should avoid sports and strenuous activity for
resection) may be salvaged without fully mobilizing the 6 weeks.
spleen. Commonly, the splenic capsule is torn when the • Patients who have undergone splenectomy are at increased
stomach or the transverse colon is retracted away from the risk for overwhelming postsplenectomy sepsis as a result
spleen. These injuries can be controlled by a variety of meth- of infection from encapsulated organisms, particularly
ods including topical hemostatic agents followed by pressure Streptococcus pneumoniae, Neisseria meningitidis, and
103 Operations for Splenic Trauma 813
Haemophilus influenzae. Vaccines should ideally be Further Reading

administered 2 weeks postoperatively for maximum
effect. Young children should receive prophylactic peni- Fingerhut A, Oberlin P, Cotte JL, et al. Splenic salvage using an absorb-
able mesh: feasibility, reliability and safety. Br J Surg. 1992;79:325.
cillin throughout childhood. Rubin LG, Schaffer W. Clinic practice. Care of the asplenic patient. N
• Asplenic patients should be informed of the risk of infec- Engl J Med. 2014;371(4):349–56.
tion and should be advised to seek medical attention Uranus S, Kronberger L, Kraft-Kine J. Partial splenic resection using
immediately when flu-like symptoms or fever occurs. the TA-stapler. Am J Surg. 1994;168:49.
Laparoscopic Splenectomy
104
Manish Parikh and H. Leon Pachter
Laparoscopic splenectomy is the preferred method of elec- Preoperative Evaluation and Preparation
tive splenectomy for the vast majority of patients. The most
common indication for elective splenectomy is autoimmune The preoperative abdominal exam and computed tomogra-
(idiopathic) thrombocytopenic purpura (ITP). Splenectomy phy (CT) can estimate spleen size, which facilitates opera-
typically leads to long-term normalization of platelet count tive planning. Moderate splenomegaly (>11 cm) or massive
in 65–85% of patients. Other hematologic indications include splenomegaly (>25 cm) may change the operative approach
hereditary spherocytosis, myeloproliferative disorder to either an anterior split-leg approach with up to 45-degree
(chronic and acute myeloid leukemia), and autoimmune tilt, or hand-assist, or open laparotomy, depending on the
hemolytic anemia. Occasionally elective splenectomy is per- experience of the surgeon. CT scan does not reliably detect
formed to palliate myelofibrosis or for resection of a primary accessory splenic tissue, and therefore it is important to rou-
splenic lymphoma. Laparoscopic splenectomy may also be tinely explore for accessory spleen(s) during the surgery.
safely performed in select situations of splenic trauma, Pneumococcal, meningococcal, and Haemophilus influenza
depending on the experience of the surgeon. type B vaccines should be administered at least 2 weeks pre-
operatively. In cases of unexpected splenectomy, the vac-
cines can be administered 2 weeks following surgery.
Indications Close communication with the hematologist is important.
In select ITP patients (particularly if the platelet count is
Laparoscopic splenectomy has been used in essentially all below a certain threshold), immune globulin (2 g/kg body
situations for which splenectomy is indicated. The most weight intravenous divided into two doses) may be given
common indications include the following: 48 h preoperatively. Intravenous antibiotics (first-generation
cephalosporin) are frequently used for prophylaxis. In ITP
• Autoimmune thrombocytopenic purpura (formerly patients with platelet count under 50,000, platelet transfu-
termed idiopathic thrombocytopenic purpura, ITP) sion is on standby and may be administered, if needed, once
• Hemolytic anemias (hereditary spherocytosis, autoim- the splenic artery is ligated.
mune hemolytic anemia)
• Felty’s syndrome
• Hematologic malignancies Pitfalls and Danger Points
• Hemoglobinopathies
• Splenic abscess As with open splenectomy, bleeding is a major concern with
the laparoscopic approach. The capsule of the spleen may
crack during the surgery which can obscure the operative
field. It is also important to dissect the tail of the pancreas
from the splenic hilum to avoid injuring the pancreas.
If the spleen is inadvertently ruptured, splenic tissue may
implant on peritoneal surfaces, and the resulting splenosis
M. Parikh · H. L. Pachter (*) may cause a recurrence of hematologic problems; therefore,
Department of Surgery, New York University School of Medicine, gentle handling is essential. Careful search for accessory
New York, NY, USA spleens is important to avoid recurrence and should be
e-mail: leon.pachter@nyumc.org

https://doi.org/10.1007/978-3-030-81415-1_104
816 M. Parikh and H. L. Pachter
p erformed at the outset of the case. The most common sites men 2 cm below and parallel to the costal margin, just medial
for splenules are in the splenic hilum, the tail of the pancreas, to the left anterior axillary line (Fig. 104.2). Once the perito-
or the greater omentum. neal cavity has been entered under direct vision, place a
10-mm trocar and insufflate to 15 mmHg.
Introduce a 10-mm 30° laparoscope and perform a diag-
Operative Strategy nostic laparoscopy. Place a second 10-mm trocar under the
eleventh rib at the mid-axillary line, also parallel to the costal
For most laparoscopic splenectomies (especially normal- margin. Place the third 5-mm trocar medial and anterior to
sized spleens), the patient is positioned in the lateral decubi- the first trocar, along the midclavicular line and lateral to the
tus position. The spleen is exposed but allowed to hang from rectus muscle. Ideally, all trocars should be at least 5 cm
its posterior peritoneal attachments—“the hanging spleen apart to avoid crossing of instruments. The fourth 5-mm tro-
maneuver.” A careful search for accessory spleens is made, car at the costovertebral angle may be inserted after the
and then the splenocolic ligaments and gastrosplenic liga- splenic flexure has been mobilized.
ments (including the short gastric vessels) are divided with Using a laparoscopic peanut in the surgeon’s left hand for
the harmonic scalpel. The main advantage of this technique retraction and the ultrasonic scalpel in the surgeon’s right
is that minimal retraction of the spleen is required. The stom- hand, mobilize the splenic flexure inferomedially.
ach, colon, and small bowel naturally fall out of the field of Next, enter the lesser sac and divide the gastrosplenic
view after division of these ligaments. The spleen is mobi- ligament (including all the short gastric vessels) with an
lized to the level of the left crus. The hilar vessels are then energy device such as the ultrasonic scalpel (Fig. 104.3a).
divided. The spleen is placed in a retrieval bag and We prefer to keep the thermal blade anterior to avoid inad-
morcellated. vertent thermal injury to posterior structures.
In cases of larger spleens, some surgeons prefer to suture Next, incise the splenorenal and splenophrenic ligaments
ligate the splenic artery first, which may help shrink the until the left crus of the diaphragm is visualized (Fig. 104.3b).
spleen intraoperatively. This is performed by entering the Take care to avoid inadvertent injury to the stomach in this
lesser sac and identifying the splenic artery in its proximal area.
course, and ligating it with a suture or vascular stapler. In Now, attention can be turned to the splenic hilum. The
cases of extensive hilar adenopathy (splenectomy for malig- spleen can be gently elevated to identify the hilar structures
nancy), one strategy is to dissect the tail of the pancreas with as shown in Fig. 104.3c. The shaft of a grasper may be used
the splenic hilum and then transect the distal tail of the as an atraumatic retractor. Avoid grasping the spleen to avoid
pancreas. splenic capsule tears (with bleeding and potential to seed the
peritoneal cavity with splenic tissue). Many patients have a
pancreas that abuts the hilum, and care must be taken to dis-
perative Technique
O sect the tail of the pancreas from the hilum.
Once the hilum is separated from the tail of the pancreas,
The lateral approach is the most widely used patient’s posi- a 10-mm right-angle dissector is a good instrument to dissect
tion for laparoscopic splenectomy. Position the patient in the the splenic vein and artery individually. We prefer to avoid
lateral decubitus position with the left side up. Place a bean- clips in this area, because clips can interfere later with stapler
bag under the right flank and a protective role under the right transection. Our preference is to divide the vessels individu-
axilla. The left arm is extended. Flex the table so as to hyper- ally, if feasible, with a vascular load stapler. Some surgeons
extend the left side, in order to maximize the space between prefer pre-ligation of the splenic artery with 0-silk suture;
the left costal margin and iliac crest (the flank muscles should this permits platelet administration in ITP patients before
appear taut). Secure the patient’s torso and legs to the table hilar dissection has started. Alternatively, the hilum can be
with 2-in. cloth tape. divided en masse with the vascular stapler (Fig. 104.3c).
The surgical prep extends from the nipple to the anterior The spleen is then removed with an Endo-Catch bag.
superior iliac spine and from the umbilicus to the spine pos- Often a 15-mm Endo-Catch bag will be needed depending
teriorly. The surgeon and assistant stand on the right side of on the size of the spleen. Pull the opening of the bag out
the patient and the second assistant stands on the left through the trocar site. Morcellate the spleen with ring for-
(Fig. 104.1). An orogastric tube is placed to decompress the ceps (Fig. 104.3d).
stomach. We utilize the open technique to access the abdo-
104 Laparoscopic Splenectomy 817
Fig. 104.1 (© Lianne

Krueger Sullivan)
Spleen
Working port: Posterior axillary

grasper/peanut: line retraction port:
5 mm. 5 mm.
Anterior axillary line

for optical trocar
(30 Øscope
10 mm.
Mid-axillary line working port.

ultrasonic scalpel/linear
stapler: 10−12 mm.
Check the field for hemostasis. Close all trocar sites over Another challenge may be specimen extraction since the
5 mm in the usual fashion. Usually, Jackson-Pratt drains are 15-mm Endo-Catch bag is not large enough. The LapSac®
unnecessary unless there is a concern for pancreatic injury. (Cook Medical, Bloomington, IN, USA) or any sterile surgi-
cal bag may be useful in these scenarios.
Preoperative splenic artery embolization has been
Special Consideration: Splenomegaly (>11 cm) described in cases of massive splenomegaly to facilitate lap-
aroscopic splenectomy or hand-assist laparoscopic splenec-
Depending on the degree of splenomegaly (Fig. 104.4), the tomy. However, we do not routinely practice this; our
hilum of the spleen will be shifted toward the midline. For preference in these cases is to pre-ligate the splenic artery in
these cases, we prefer the anterior approach with the patient the lesser sac (and prior to hilar dissection).
in split-leg position, with a bump placed under the left side to For splenomegaly due to lymphoma, the hilar dissec-
facilitate 45° rotation to the right (Fig. 104.5). The primary tion may be difficult due to bulky lymphadenopathy. In
challenge in splenomegaly is adequate retraction of the these cases, one surgical strategy is to incise the perito-
spleen to expose the hilum. This can be addressed by placing neum along the inferior border of the pancreas and create
an additional 10-mm trocar in the left lower quadrant for a a posterior plane behind the pancreas. Then clear this avas-
10-mm fan-type liver retractor to retract the spleen cular plane to the level of the hilum, transecting the most
(Fig. 104.6). We prefer large (10–12 mm) trocars in these distal tail of the pancreas including the splenic vein with
cases, and generally, the trocar placement needs to be several an Endo-GIA (Covidien Medtronic, MN) 60 purple-load
cm inferior to the usual trocar placement for standard buttressed with Bioabsorbable Seamguard (Gore, AZ). In
splenectomies. these cases, we may leave a 10-Fr JP in the splenic bed.
Fig. 104.2 (© Lianne

Krueger Sullivan)
Anaesthesia
table
itor
Mon
Mo
n
itor
Assistant 1 Assistant 2
Surgeon
Divide gastrosplenic Divide

a ligament and short b splenorenal
gastric vessels ligament
Stomach
Spleen
Stomach Spleen
Outline of
pancreas
Splenocolic
Outline of ligament
pancreas (divided)
Colon Colon
c Spleen d
Morcellate
and remove
spleen
Stomach
Divide
splenic
vessels
Tail of
pancreas
Colon
Fig. 104.3 (a–d) (© Jennifer Gentry)
Laparoscopic Management of Splenic Cysts
Indications for surgery for splenic cyst are usually deter-

mined by patient’s symptoms and cyst size. Typically,
asymptomatic nonparasitic cysts <5 cm resolve spontane-
ously. For symptomatic cysts, percutaneous drainage
should be avoided because of the high recurrence rate.
Surgical options include complete or partial splenectomy,
unroofing of the cyst, and fenestration. Generally, these
cysts can be unroofed laparoscopically. The patient posi-
tion and trocar placement are similar to laparoscopic sple-
nectomy described above. The key surgical maneuver is to
excise a sufficient portion of the cyst wall to prevent
recurrence.
Fig. 104.4
Fig. 104.5
Anaesthesia
table
M
r
ito
on
on
ito
M
r
Surgeon Assistant 2
Assistant 1
Postoperative Care Complications
Clear liquids can be started the same evening or the next • Bleeding
morning, depending on the clinical scenario. Patients are • Subphrenic abscess
usually discharged home by the first or second postoperative • Injury to pancreas
day. Ketorolac (nonsteroidal anti-inflammatory) is an effec- • Injury to stomach or colon
tive pain medication especially for pain at the specimen • Missed accessory spleen
extraction site. • Venous thrombosis
Further Reading
Feldman LS. Laparoscopic splenectomy: a standardized approach.
World J Surg. 2011;35:1487–95.
Habermalz B, Sauerland S, Decker G, et al. Laparoscopic sple-
nectomy: the clinical practice guidelines of the European
Association of Endoscopic Surgery (EAES). Surg Endosc.
2008;33:821–48.
Katkhouda N. Chapter 26. Laparoscopic splenectomy. In: Nguyen
NT, Scott-Conner CEH, editors. The SAGES manual volume 2:
advanced laparoscopy and endoscopy. 3rd ed. New York: Springer;
2012. p. 385–400.
Spleen Musallam K, Khalife M, Sfeir P, Faraj W, et al. Postoperative outcomes
Stomach
after laparoscopic splenectomy compared with open splenectomy.
Ann Surg. 2013;257:1116–23.
Park A, Gagner M, Pomp A. The lateral approach to laparoscopic sple-
nectomy. Am J Surg. 1998;173:126–30.
Reso A, Brar M, Church N, et al. Outcome of laparoscopic splenectomy
5 mm. with preoperative splenic artery embolization for massive spleno-
megaly. Surg Endosc. 2010;24:2008–12.
Sharma D, Shukla V. Laparoscopic splenectomy: 16 years since
Delaitre with review of current literature. Surg Laparosc Endosc
Percutan Tech. 2009;19:190–4.
Targarona E, Balaque C, Cerdan G, et al. Hand-assisted laparoscopic
splenectomy (HALS) in cases of splenomegaly: a comparison
12 mm. analysis with conventional laparoscopic splenectomy. Surg Endosc.
12 mm. 2002;16:426–30.
12 mm. Winslow E, Brunt L. Perioperative outcomes of laparoscopic versus
open splenectomy: a meta-analysis with emphasis on complica-
Fig. 104.6 tions. Surgery. 2003;134:647–55.
Part X
Hernia Repairs, Operations for Necrotizing Faciitis,
Drainage of Subphrenic Abscess
Concepts in Hernia Repair, Surgery
for Necrotizing Fasciitis, and Drainage 105
of Subphrenic Abscess
Mark C. Horattas and Ileana K. Horattas
From a historical perspective, the repair of inguinal hernia in Patient Selection

adults is one of surgery’s most ancient and vexing problems.
According to the Society of American Gastrointestinal and Management of abdominal wall defects and patient selection
Endoscopic Surgeons (SAGES) in 2015, over one million for surgery is dependent on a number of factors, most nota-
hernia repair operations are performed annually in the United ble being the type of hernia. As about 71% of all hernias are
States with 600,000 inguinal repairs and 350,000–500,000 inguinal, patient selection for this group is particularly
ventral hernia repairs. The associated medical and socioeco- important (Dabbas et al. 2011). In this concept chapter, we
nomic costs continue to fuel interest in this mechanical prob- raise a challenge to one of the most fundamental questions
lem which, most likely, will not abate as population regarding treatment of inguinal hernia: Should all patients
demographics and general surgery workforce issues move in with groin hernia undergo elective repair? For generations,
opposition (Rutkow 2003; Valentine et al. 2011). According the answer to this question had been an emphatic yes with
to the most recent 10-year update on surgical workloads by the exception of patients with significant medical morbidi-
the American Board of Surgery, general surgeons perform ties. The intuitive thought behind this dictum was that elec-
approximately 87% of “hernia” operations, while surpris- tive repair under controlled circumstances was far safer than
ingly those surgeons with additional board certification in the alternative, that is, to wait and operate urgently in the
surgical subspecialties perform the balance. As fellowship face of potentially serious complications of bowel incarcera-
training becomes integrated into a shortened general surgical tion or strangulation. With surgery performed on an ambula-
residency education, it is unclear if these subspecialists will tory basis and, in many parts of the country, by freestanding
possess the necessary skills to continue this practice (Etzioni high volume hernia centers, the elective operation is associ-
et al. 2003). More recently, surgical training fellowships in ated with low morbidity, making elective repair even more
both complex hernia surgery and minimally invasive surgery advisable. Randomized prospective trials have been con-
have become more available and may impact the workforce ducted and now can offer our patients a specific answer to
accordingly. The gap between patient needs and supply of this question. Such studies commonly focus on male popula-
surgeons who can address these problems may widen. Issues tions as greater than 96% of inguinal hernias occur in this
such as patient selection, operative technique, choice of group (Dabbas et al. 2011). The American College of
prosthetic material, disability, and cost will only become Surgeons study of inguinal hernia management—watchful
magnified. waiting versus operation—was completed over a 2-year
period. Men with asymptomatic or minimally symptomatic
inguinal hernias were randomized to watchful waiting or
elective surgery. For men with minimally symptomatic her-
nias, watchful waiting was found to be an acceptable option,
M. C. Horattas (*)
Department of Surgery, Northeast Ohio Medical University, contradicting the commonly held belief that nonoperative
Rootstown, OH, USA approaches to inguinal hernias result in higher risk of bowel
Department of Surgery, Cleveland Clinic Akron General, incarceration. The frequency of acute hernia problems was
Akron, OH, USA rare: 1.8/1000 patient years (Fitzgibbons et al. 2006).
e-mail: mark.horattas@akreongeneral.org However, after 2 years the crossover rate to surgery was
I. K. Horattas 23%, with 17% conversely opting out of operative repair in
Department of Surgery, Northeast Ohio Medical University, favor of watchful waiting. At 7 years of additional follow-up,
Rootstown, OH, USA

https://doi.org/10.1007/978-3-030-81415-1_105
826 M. C. Horattas and I. K. Horattas
68% had crossed over to surgery for chief complaint of pain, patient comfort. An endotracheal tube is preferred when
with persistently low incidence of hernia-related emergency faced with an emergent operation such as incarceration or
and no increased mortality in this group (Fitzgibbons et al. strangulation when the bowel may be obstructed and require
2013). Given this high crossover rate, specific patient charac- manipulation so risks of aspiration can be minimized.
teristics have been identified which may portend an end to Additionally, a general anesthetic is necessary when the
watchful waiting. These include severe pain accompanying repair is performed laparoscopically because of the pneumo-
strenuous activity, the presence of constipation, and the pres- peritoneum. After using all three anesthetic techniques
ence of prostatism (Sarosi et al. 2011). Additionally, it is extensively, our surgeons now prefer general anesthesia
appropriate to counsel patients opting for watchful waiting administered via a laryngeal mask airway because of patient
that surgery may eventually be necessary for progressive comfort and quick recovery, facilitating surgical intervention
symptoms. In our practice, the majority of patients who elect and ease of administration with an excellent safety profile.
to proceed with surgery or fail a nonoperative approach do so
because of ongoing or increased discomfort or pain that lim-
its their daily activities. Perioperative Antibiotics
Guidelines for the surgical treatment of ventral hernias,
including incisional hernias, have been set forth by the Recent meta-analysis and Cochrane analysis of wound
International Endohernia Society (Bittner et al. 2014). infection and the use of prophylactic antibiotics for elective
Surgery is appropriate for relief of symptoms, prevention of inguinal hernia repair report conflicting results, an issue
complications, and resolution of acute complications includ- further confused by differences in recommendations for
ing incarceration and strangulation. The authors were unable open versus laparoscopic repair (Sanchez-Manual et al.
to make a recommendation for treatment of asymptomatic 2012; Köckerling et al. 2015). Guidelines published jointly
ventral hernias, but noted expert opinion in favor of surgery by the Infectious Diseases Society of America (IDSA) and
for such cases to avoid future complications. The AWARE Surgical Infection Society (SIS) among others recommend
trial is progressing as a multicenter study investigating the a single dose of first-generation cephalosporin to be admin-
effectiveness of watchful waiting for incisional hernias to istered within 60 minutes prior to incisional hernia repair
provide an evidence-based answer to this question once the with a prosthetic (Earle et al. 2014). We tailor the periop-
trial has reached its completion (Lauscher et al. 2016). erative use of antibiotics to the specific patient situation.
In marked contrast to the cases heretofore discussed, even Antibiotics are given for those at high risk for wound infec-
asymptomatic patients presenting with femoral hernias are tions such as diabetics or those on immunosuppressive
considered surgical candidates because of their risks of agents. With the use of an alcohol-based skin preparation,
hernia-related complications. Since the risks and benefits of universal administration of antibiotics is probably not ben-
surgery vary among patients, it is important to approach her- eficial for the prevention of wound infection. At our institu-
nia management by taking into account the individual’s pre- tion, the practice of using prophylactic cefazolin
sentation, comorbidities, occupation, and daily routine. preoperatively with mesh placement has become routine,
but the literature supporting this practice has not been nec-
essarily supportive or conclusive.
Selection of Anesthesia
Elective operation in men or women may be performed Groin Hernia Repair

under local, regional or epidural, or general anesthesia. Each
has its distinct advantages or disadvantages and should be Inguinal hernias are broadly classified as direct (i.e., a weak-
tailored to the comfort of the patient and surgeon. In practice, ness in the transversalis fascia within Hesselbach’s triangle)
the choice tends to be based on community experience. Local or indirect (a weakness in the internal inguinal ring associ-
anesthetics consisting of lidocaine and/or bupivacaine are ated with a patent processus vaginalis). Usually, this distinc-
readily available, easy to use, and well tolerated; they may tion is not readily or accurately accomplished preoperatively
also have a reduced incidence of some of the regional or gen- and is finalized during the operation itself. Always inspect all
eral anesthetic side effects seen on occasions such as postop- three potential hernia sites (including femoral) when operat-
erative headache, nausea, and vomiting. ing for a groin hernia, as a common cause of recurrence is
If general anesthesia is chosen, it may be administered failure to repair all defects. A femoral hernia occurs through
using a laryngeal mask airway (which does not require ven- a defect in the femoral canal, lateral to the lacunar ligament
tilatory support or muscle paralysis), thus maximizing and medial to the femoral vein.
105 Concepts in Hernia Repair, Surgery for Necrotizing Fasciitis, and Drainage of Subphrenic Abscess 827
In adults, the operative repair selected is based on the sur- incision created in the anterior rectus sheath. The purpose
geon’s experience and training and should be individualized was to reduce excessive tension, diverting it away from the
as much as is feasible. Additionally, hernia repair represents actual repair. This concept of tension and its avoidance has
a prime opportunity for each surgeon to analyze his or her become central to all repairs now using prosthetic mesh.
individual rates of recurrence, postoperative complications,
and resultant disability—key factors consistent with the pro-
vision of excellent professional advice. As implied earlier, Prosthetic Mesh Repair
the range of operative choices available for groin hernia
repair is broad and is described in the chapters which follow. Currently, in the United States, polypropylene mesh repair,
This chapter reviews pros and cons of primary repair, mesh by either the Lichtenstein technique using a precut piece of
or tension-free repair, and repair using laparoscopic Marlex mesh or Rutkow’s mesh “plug,” is increasingly
techniques. becoming the most popular method. Repair of groin hernias
utilizing any type of prosthetic mesh relies on the mesh to
bridge the inguinal defect in a tension-free manner with suf-
Primary Repair ficient overlap of the mesh with the surrounding tissue for a
secure repair, either as an onlay or preperitoneally, respec-
Primary repair remains the preferred technique in the pres- tively. Both are straightforward technically and associated
ence of contamination from incarcerated or strangulated with low postoperative disability and a low (reportedly less
intestine when avoidance of prosthetic mesh is desired. In than 1–2%) incidence of recurrence. The common strategy
women, when the round ligament is removed and the resid- with either method is the concept of minimal tissue dissec-
ual defect is small, primary repair with interrupted sutures tion, anchoring the mesh with sufficient sutures in a tension-
can be readily accomplished without mesh and without a free fashion, and often encouraging early ambulation and
great deal of tension. For an adolescent boy, high ligation of return to activity. The Lichtenstein repair is remarkably free
the hernia sac and primary suture repair for a weakened of postoperative complications. There have been a few
internal ring are also appropriate. Primary repair may be reports of “plug” migration into the abdominal cavity lead-
accomplished using the Bassini, McVay, or Shouldice tech- ing to a small bowel obstruction, so accordingly it is impor-
nique. The Bassini method is mentioned only for its histori- tant to secure it with sutures in a preperitoneal location. Note
cal context and relative simplicity. It was the first technique that Gore-Tex mesh minimizes the foreign body reaction.
that led to a marked reduction in both operation mortality Although that may be useful elsewhere in the body, it has not
and recurrence. The basic technique involves recreating the been found by many to be useful for inguinal hernia repair.
floor of the inguinal canal. Bassini accomplished this with Generally, absorbable mesh has no role in the repair of ingui-
interrupted sutures sewing Poupart’s ligament to the lateral nal hernias because of increased risks of recurrence.
border of the transversus arch or conjoined tendon. Any peri-
toneal sac underwent high ligation after opening to ensure
the reduction of its contents and to check for a femoral com- Laparoscopic Technique
ponent. The Shouldice technique, developed in the Shouldice
Clinic in Toronto, incorporates complete dissection and Inguinal hernias may be repaired laparoscopically. However,
reconstruction of the inguinal floor. It is tension free as the of all laparoscopic techniques, repair of groin hernia has the
repair utilizes the opened and healthy transversalis fascia steepest learning curve. The anatomy is new (and often con-
imbricated in layers over one another. Four layers of suture fusing), requiring participation in over 50 operations before
are placed to incorporate the transversalis, iliopubic tract, a surgeon becomes experienced by some published reports.
femoral sheath, and inguinal ligament. Data from the Reported series consistently note a high (approaching 10%)
Shouldice clinic attests to the excellent long-term results incidence of recurrence during the surgeon’s initial operative
coupled with minimal postoperative disability. McVay’s experience. Two methods are in wide use: the totally extra-
repair is predicated on a detailed study of the anatomy of the peritoneal approach and the transabdominal preperitoneal
inguinal region he performed as a surgical resident. He pos- approach. They are based on laparoscopic reconstruction of
tulated that the central factor accompanying groin hernia was the weakened posterior abdominal wall utilizing mesh. This
a weakened posterior floor. To remedy this problem, his is the one method of repair where complications can be cata-
method incorporates suturing the transversus abdominis to strophic. Yet in the hands of experienced laparoscopic sur-
Cooper’s ligament. A transition stitch is placed in the femo- geons, excellent results are achieved. Comparisons between
ral sheath. McVay also popularized the concept of a relaxing laparoscopic and open inguinal repairs consistently report
less postoperative pain and earlier return to work and return ally rigid surrounding tissues. The laparoscopic approach
to normal activities following laparoscopic repair with avoids this occasionally difficult exposure.
equivalent recurrence rates between the two approaches
(Langeveld et al. 2010; Myers et al. 2010). Laparoscopic
repair has also been shown to result in a lower surgical site Repair of Large Ventral Hernias
infection rate than open repair when used in ventral hernias,
and SAGES strongly recommends that these advantages be Repair of non-inguinal abdominal hernias is performed more
considered by surgeons and disclosed to patients during than 200,000 times in the United States annually. Although
discussion of surgical options (Earle et al. 2014; Rogmark ventral hernia disease is a common problem, there is no con-
et al. 2013; Sauerland et al. 2011). As the definition of post- sensus on the best approach. Factors such as hernia location,
operative disability is expanded, laparoscopic repair may be size, etiology, and patient characteristics all are important in
more widely utilized. This approach has evolved into the pre- management. Standard concepts in any hernia surgery are
ferred technique for bilateral hernias and may be a superior particularly worth reemphasis including utilization of mesh
option for a difficult recurrence (Waschkuhn et al. 2010). reinforcement for larger hernias, selecting the appropriate
Issues of increased resource expenditure remain unresolved procedure, minimizing tension of the repair, and patient
with a Cochrane review showing significantly higher in- selection. Non-prosthetic hernia repairs are associated with
hospital expenses associated with laparoscopic surgery high recurrence rates, and mesh reinforcement is generally
(Earle et al. 2014). utilized uniformly.
Prosthetic material can be classified into several subtypes
with unique attributes and applications. Nonabsorbable
Repair of Femoral Hernia meshes include polypropylene (i.e., Marlex) and polyester
(i.e., Parietex). These permanent meshes cause significant
In contrast to inguinal hernias, surgical repair is always indi- fibroblastic reaction, and intra-abdominal contact with bowel
cated for femoral hernia, even in asymptomatic cases. The should be avoided to prevent fistulization.
anatomic defect is narrow, and there is a higher incidence of Polytetrafluoroethylene (i.e., Gore-Tex) or dual-layer-type
incarceration. When a femoral hernia is diagnosed preopera- meshes have the benefit of minimizing adhesion formation
tively, the surgeon has three operative approaches: low ingui- with intestines and can be utilized for intraperitoneal onlay
nal, high inguinal, or preperitoneal via a low midline incision. hernia repair as done with a laparoscopic approach. Many
We favor a preperitoneal exposure if strangulation is sus- different commercially available coated synthetic materials
pected. Conversion to a midline laparotomy can be relatively for hernia repair are available and work in a similar fashion
easily accomplished. For elective repair of femoral hernia, to keep the fibroblastic reaction only on the fascial side of the
use of a modified piece of 2 × 10 cm polypropylene mesh hernia repair and minimize intra-abdominal adhesion forma-
rolled into a tubular shape, sized and secured by suture into tion on the opposite intraperitoneal side. When the risk of
the femoral defect externally from below the inguinal liga- infection is significant, biological prosthetics may be appro-
ment, has allowed excellent results with minimal disability priate. These grafts are derived from human, porcine, or
(Shulman et al. 1992). bovine sources. Many different types are commercially mar-
keted and generally are much more expensive than standard
meshes. They are designed to provide an extracellular matrix
Repair of Recurrent Inguinal Hernia for neovascularization and promote vessel ingrowth. In
selection of the repair, the placement of the mesh can be con-
When operating for a recurrent inguinal hernia in male sidered to be an overlay (onlay), underlay (preperitoneal,
patients, the surgeon must avoid inadvertent transection of intermuscular, retrorectus), or inlay. Securing the mesh to the
the vas deferens and devascularization of the testis. These edges as an inlay has higher rates of recurrence presumably
problems are best avoided using careful slow dissection in a related to inadequate overlap to the tissue laterally and insuf-
bloodless field. Both the internal inguinal ring and the pubic ficient fixation. Onlay repairs are commonly done but associ-
tubercle should be inspected as recurrence is common in ated with higher wound complications due to the need for
these regions. Often the recurrence is a direct inguinal hernia wide undermining of the skin and subcutaneous tissue.
as the cord has been previously evaluated for a congenital Sublay or retromuscular placement of the mesh requires
indirect sac at the original surgery. Additionally, the “recur- additional effort in placement but has the advantage of poten-
rence” may be a femoral hernia missed at time of initial tially being more successful.
operation in up to 10% of cases (Itani et al. 2009). Once A number of fascial relaxation techniques have been
identified, the recurrence may be easily repaired using the described. The most common involves an anterior compo-
mesh “plug” that is carefully sized and anchored to the usu- nent separation of the abdominal musculature, allowing
105 Concepts in Hernia Repair, Surgery for Necrotizing Fasciitis, and Drainage of Subphrenic Abscess 829
medialization of the rectus muscle. A longitudinal incision is Subphrenic Abscess

made along the medial aponeurosis of the external oblique
approximately 2 cm lateral to the rectus muscle. After sepa- Most subphrenic abscesses are amendable to image-guided
rating the external oblique muscle from the internal oblique, percutaneous drainage. If this technique is technically not
significant reduction in the tension can result. Additional feasible or is unsuccessful, an operative approach becomes
relaxation can be achieved by adding a longitudinal incision necessary. The key points emphasized in Chap. 114 (a surgi-
along the posterior rectus fascia as well (Shulman et al. cal legacy technique chapter) remain salient.
1992). Increasingly popular has been the development of a
posterior component separation utilizing a relaxing incision
within and along the lateral rectus sheath (retrorectus) sepa- References
rating the internal oblique muscle from the transverse mus-
cle. This transversus abdominis release can allow similar Bittner R, Bingener-Casey J, Dietz U, et al. Guidelines for laparo-
scopic treatment of ventral and incisional abdominal wall hernias
tissue advancement for a tension-free repair and can be done (International Endohernia Society (IEHS))-part 1. Surg Endosc.
with retrorectus mesh placement for the concomitant hernia 2014;28(1):2–29.
repair (Paul and Rosen 2013). Dabbas N, Adams K, Pearson K, Royle GT. Frequency of abdominal
Laparoscopic ventral herniorrhaphy with mesh is another wall hernias: is classical teaching out of date? JRSM Short Rep.
2011;2(1):5.
effective tension-free approach that may be particularly Earle D, Roth S, Saber A, et al. Guidelines for laparoscopic
helpful in certain situations as well. Decreased wound prob- ventral hernia repair. Approved by the Board of Governors
lems especially in obese patients may be noted with this of the Society of American Gastrointestinal and Endoscopic
approach. Patient selection is also important for successful Surgeons (SAGES). 2014. http://www.sages.org/publica-
tions/guidelines/guidelines-f or-l aparoscopic-v entral-h ernia-
ventral hernia surgery. Patients who smoke are at increased repair/#_ENREF_6.
risk of postoperative complications. The assessment of coti- Etzioni DA, Liu JH, Maggard MA, et al. The aging popula-
nine levels can be measured on the morning of surgery to tion and its impact on the surgery workforce. Ann Surg.
ensure compliance with instructions for smoking cessation. 2003;238(2):170–7.
Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting
Other risk factors include obesity, pulmonary disease, wound vs. repair of inguinal hernia in minimally symptomatic men – a ran-
healing problems, immunocompromised status, and being domized clinical trial. JAMA. 2006;295(3):285–92.
malnourished. Patients who have massive hernias with loss Fitzgibbons RJ, Ramanan B, Arya S, et al. Long-term results of a ran-
of abdominal domain may not physiologically tolerate repair domized controlled trial of a nonoperative strategy (watchful wait-
ing) for men with minimally symptomatic inguinal hernias. Ann
of their hernia. Patients with ascites or potential bacterial Surg. 2013;258(3):508–15.
contamination with fistulas or a stoma can be particularly Itani KM, Fitzgibbons R, Awad SS, et al. Management of recurrent
difficult to repair as well. Appropriate informed consent in inguinal hernias. J Am Coll Surg. 2009;209(5):653–8.
patients with increased risk factors should also highlight Köckerling F, Bittner R, Jacob D, et al. Do we need antibiotic prophy-
laxis in endoscopic inguinal hernia repair? Results of the Herniamed
their increased risks of recurrence and associated potential Registry. Surg Endosc. 2015;29(12):3741–9.
wound problems. Langeveld HR, van’t Riet M, Weidema WF, et al. Total extra-
peritoneal inguinal hernia repair compared with Lichtenstein
(the LEVEL- Trial): a randomized controlled trial. Ann Surg.
2010;251(5):819–24.
Necrotizing Fasciitis Lauscher JC, Leonhardt M, Martus P, et al. Watchful waiting vs. surgi-
cal repair of oligosymptomatic incisional hernias: current status of
An unusual but potentially serious and life-threatening the AWARE study. Chirurg. 2016;87(1):47–55.
complication, necrotizing fasciitis, requires early detec- Myers E, Browne KM, Kavanaugh DO, Hurley M. Laparoscopic (TEP)
versus Lichtenstein inguinal hernia repair: a comparison of quality-
tion, urgent operation, and often aggressive debridement of-life outcomes. World J Surg. 2010;34(12):3059–64.
of any suspected involved tissue. Intraoperative gram Paul EM, Rosen MJ. Open ventral hernia repair with component sepa-
stain and cultures are imperative along with the adminis- ration. Surg Clin North Am. 2013;93(5):1111–33.
tration of broad-spectrum antibiotics. Re-exploration at Rogmark P, Petersson U, Bringman S, et al. Short-term outcomes
for open and laparoscopic midline incisional hernia repair: a ran-
24 and 48 h is often necessary. Wound management can domized multicenter controlled trial: the ProLOVE (prospective
be complex and on occasion fecal diversion with a colos- randomized trial on open versus laparoscopic operation of ventral
tomy can be necessary, depending on the location and eventrations) trial. Ann Surg. 2013;258(1):37–45.
extent of the infection and debridement. Temporary clo- Rutkow IM. Demographic and socioeconomic aspects of hernia repair
in the United States in 2003. Surg Clin North Am. 2003;83:1045–
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Often the application of a wound VAC after the acute prophylaxis for hernia repair. Cochrane Database Syst Rev.
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3769.pub4.
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Sarosi GA, Wei Y, Gibbs JO, et al. A clinician’s guide to patient selec- Valentine RJ, Jones A, Biester TW, et al. General surgery work-
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Cochrane Database Syst Rev. 2011;3:CD007781. https://doi. hernia repair: gold standard in bilateral hernia repair? Results of
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Shouldice Repair of Inguinal Hernia
106
Evgeny V. Arshava and Michael Alexander
Indications pressure implies stress on the repair. While BMI >30 is a

relative contraindication for elective repair per Shouldice
The majority of inguinal hernias can be safely observed. clinic guidelines, regrettably in some countries these criteria
However, any symptomatic direct and indirect hernia in fit may be impractical.
patient should be repaired to relieve symptoms and avoid In the Shouldice clinic, patients are admitted the day
risk of incarceration. The Shouldice repair remains the best before surgery. On the first postoperative day, patients are
autologous tissue (non-mesh) repair for direct inguinal her- fully ambulatory and are discharged the following day. In
nias. Since its introduction into clinical practice in 1945, most other settings, a 3-day hospital stay is not possible due
over 382,000 hernias have been repaired in Shouldice clinic to logistics of healthcare systems. The author, practicing in
with excellent long-term results and a long-term recurrence the United States, performs operations on an outpatient basis.
rate of 1.17%. The operation is usually performed under In the Shouldice clinic, the average time off work after repair
local anesthesia and is well tolerated by most patients. is 8 days, and 4 weeks is the maximum time patients are
Success and outcomes of the hernia repair are closely tied authorized to return to heavy labor.
to the reproducibility and mastery of the technique. While
the Shouldice method may be difficult to teach and master in
the current era, it undoubtedly has its benefits. Potential Pitfalls and Danger Points
adverse outcomes related to implantation of prosthetics are
avoided, and the cost of the procedure is less than that of the • Infection
laparoscopic approach. Implantation of mesh can be reserved • Hemorrhage
to recurrent cases where prior operations resulted in deficit • Injury to bladder and bowel
of native tissues for adequate reconstruction (4% of cases). • Postoperative testicular atrophy and hydrocele
• Chronic postoperative pain
• Ejaculatory dysfunction
Preoperative Preparation • Hernia recurrence
• Urinary retention
Weight loss in obese patients is of paramount importance not • Known or suspected femoral hernia
only for hernia repair itself but also for a long-term control of
comorbidities and overall health. Excessive fat, just like in
any other operation, contributes to difficulties of dissection Documentation
and repair of an inguinal hernia. Increased intraabdominal
In addition to routine description of the procedure, the
patient’s specific anatomical characteristics need to be docu-
E. V. Arshava (*) mented. Describe the quality of tissues, the way nerves were
handled (preservation versus neurectomy), size of the indi-
e-mail: evgeny-arshava@uiowa.edu rect/direct hernia, and results of exploration of the preperito-
neal space for the presence of the femoral hernia.
M. Alexander
Department of Surgery, Shouldice Hospital, Suggested definitions of hernia sizes that may be used for
Thornhill, ON, Canada operative notes are as follows:

https://doi.org/10.1007/978-3-030-81415-1_106
832 E. V. Arshava and M. Alexander
• Direct and femoral hernias: small <2 cm, medium

2–5 cm, large >5 cm.
• Indirect hernias: small <5 cm, medium 5–15 cm, large
>15 cm.
• Giant hernia extends below the midpoint of inner thigh in
standing position.
• Peritoneal protrusion is an empty small gossamer-thin sac
(that may appear obliterated).
Operative Strategy
Anesthesia
Repair is usually performed under local field block with a

monitored anesthesia care and conscious sedation. Local
Fig. 106.1 Diagram of a myopectineal orifice with locations of poten-
anesthesia alters muscle tone less than general anesthesia.
tial hernias: I - indirect inguinal hernia (through the internal inguinal
This allows one to judge the muscle tension more appropri- ring); D - direct inguinal hernia (Hesselbach’s triangle); F – femoral
ately and facilitates the performance of tension-free repair. hernia (in the femoral canal); O – obturator hernia, in the obturator
Preoperative sedation in the Shouldice clinic is no longer canal (outside the myopectineal orifice)
used. Instead, midazolam, fentanyl, and occasionally propo-
fol are injected intravenously, immediately preoperatively,
and topped up as necessary during the procedure. The medi- Division of the cremasteric muscle and its components is
cation regimen can certainly be adjusted according to the performed in all patients without any harmful sequelae.
usual practice of an individual institution. General anesthesia Division of the cremasteric muscle prevents the repetitive
may be preferred for certain operations on recurrent or incar- traction on the newly reconstructed internal inguinal ring and
cerated hernias. reduces the chance of its being damaged and allowing an
Ropivacaine 0.23% is now being used in the Shouldice indirect hernia to recur. It also allows better visualization of
clinic for local infiltration and nerve blocks with amounts up the floor during subsequent reconstruction. Prior to the divi-
to 150 ml proving to be quite safe and effective in massive sion of the cremasterics, the recurrence for an inguinal hernia
and multi-recurrent hernias. One of the authors uses 0.25% at the Shouldice hospital was 4.2%. Simply adding this pro-
lidocaine (up to 200 cc) buffered with 20 ml of 8.4% sodium cedure led to a reduction of the recurrence rate to below 1%.
bicarbonate to decrease burning during infiltration. It is very uncommon in males not to find at least a small
portion of peritoneum protruding down the anteromedial
aspect of the cord. If small and empty, it may be called a “peri-
Dissection toneal protrusion” to be distinguished from an indirect hernia
sac, which from the Shouldice clinic experience has to mea-
The Shouldice technique mandates meticulous and complete sure >25 mm to merit any surgical repair because below this
dissection of the groin. Observers of the Shouldice repair are size it has proven to be virtually undetectable clinically and
awarded with perhaps the best lesson of the groin anatomy highly unlikely to be responsible for any symptoms a patient is
that by far surpasses any other open technique that they may having in that groin. If mostly obliterated, it may be hard to
have witnessed or performed. identify. This protrusion may be the precursor of an indirect
Thorough dissection allows a complete and lasting repair hernia and potentially a hernia recurrence if an operation is
and decreases the risk of missing coexisting defects. done for a direct or femoral hernia as a primary pathology.
Preoperative physical examination for the presence of second- Routine high ligation of all indirect sacs is not mandatory.
ary hernias is unreliable even for the experienced surgeon. The An indirect sac, if broad-necked or sliding, or a peritoneal
frequency of secondary hernias found at the time of surgery is protrusion, can be simply dissected free and reduced into the
13% according to Shouldice clinic data. These secondary her- preperitoneal space deep to the level of the internal ring.
nias (either indirect, direct inguinal, femoral, or interstitial) Only long narrow sacs may need to be divided and excised,
may account for a widely quoted figure of at least 10% 10-year to avoid later incarceration. Some indirect sacs may need to
recurrence rate following all inguinal hernia repairs. Thus, the be opened to examine or reduce the contents.
importance of a complete dissection cannot be overempha- Wide incision of the transversalis fascia is the key step of
sized. The entire myopectineal orifice is explored and recon- the Shouldice technique (like in classic Bassini operation).
structed during the Shouldice repair (Fig. 106.1). This allows exploration of preperitoneal space, full assess-
106 Shouldice Repair of Inguinal Hernia 833
ment of the femoral canal, identification, and mobilization tis- comfortable with using it. The author practicing in the United
sues for subsequent repair. Care should be taken to avoid States is using 0-prolene on a CT-2 needle for repair.
injury to inferior epigastric and femoral vessels. Additionally, Regardless of the suture material used, the suture lines are
the preperitoneal space of Bogros (which is the lateral exten- not to be pulled on tension to avoid cutting through tissues
sion of the space of Retzius) contains a circle of 1–3 mm and inflicting more postoperative pain.
branches of the inferior epigastric vein and also the Iliopubic If a femoral hernia is found during exploration, it is
(marginal) vein consistently crossing the Cooper’s ligament. reduced and two to three additional interrupted sutures are
The incidence of chronic postoperative pain, inguino- placed to close the defect and these are incorporated into the
dynia, has been reported in some series to be over 30%. inguinal repair to perform a Complete Groin Repair (CGR).
Ilioinguinal (IIN) and iliohypogastric (IHN) nerves should
be visualized and handled appropriately. It is well estab-
lished that the risk of developing chronic postoperative groin Operative Technique
pain is directly related to the number of nerves not identified
during surgery. Less than half of patients have “textbook” Local Anesthesia and Incision
nerve anatomy. Any nerve or its branches that prevent ade-
quate dissection should be sharply divided. In cases where A skin incision along the line joining the pubic tubercle and
the main trunk is to be sacrificed, it should be divided very anterior superior iliac spine provides best exposure for groin
laterally (to allow its stump to retract deep inside the oblique dissection. Start the incision medial to the pubic tubercle and
muscles that the nerves come through) and the distal part extend it laterally just past the projection of the deep inguinal
widely excised. Sharp division and retraction under muscle ring, which is located approximately in the midpoint of this
may prevent stump neuroma formation. line.
The genital branch of the genitofemoral nerve (GBGFN) The incision, typically 6–10 cm, should be large enough to
is located on the lateral aspect of the cord and is routinely provide adequate exposure and avoid excessive retraction. The
divided en block with cremasteric muscle and vessels in all sensation of traction is not well abolished by local anesthesia
Shouldice operations. and may also be associated with increased postoperative pain.
One of us is highly liberal with neurectomies and observes First, inject local anesthetic of choice intradermally to
very few cases of postoperative inguinodynia (E.A.). raise a wheal along the site, but longer than the planned inci-
Additionally, even in cases where triple neurectomy was per- sion. Next, perform a generous field block of the subcutane-
formed, patients are not bothered by sensory disturbances, ous tissues using several diverging needle passes (Fig. 106.2).
likely due to small area affected due to cross innervation Usually, 50–100 cc of solution are sufficient. Once the skin
from surrounding dermatomes. incision is made, the incision is deepened through the subcu-
taneous layer until the external oblique aponeurosis (EOA) is
seen. Superficial fascia (frequently referred to in groin as
Reconstruction Scarpa’s fascia) is a distinct membrane separating the thicker
and more globular superficial adipose fat and less prominent
Following the complete dissection described above, the and smoother deep adipose layer. Ligate or cauterize subcu-
4-layer repair is performed using native tissues to correct
both indirect and direct defects and any areas of weaknesses,
regardless of the size, identified intraoperatively.
Key to repair is a solid understanding of groin anatomy
and adequate mobilization of layers to perform repair with-
out any undue tension. Bites of the tissues should be precise
but not excessively wide. Fine-gauge stainless steel wire was Anterior superior
selected for operation in the Shouldice clinic before the iliac spine
development of modern synthetic monofilament suture mate- Deep inguinal ring
rial for its properties of bacterial resistance and excellent
strength compared to braided suture. The wire used is 34- or Superficial inguinal
32-gauge monofilament stainless steel for all four layers of ring
the repair with excellent results. An in-house trial at the
Pubic tubercle
Shouldice clinic comparing the wire with monofilament
polypropylene suture showed the wire to be superior in all
respects including recurrence rates. One drawback is the dif-
ficulty in handling the wire because it is so thin but after their
first few hundred cases, the Shouldice surgeons get quite Fig. 106.2
taneous vessels as needed. Inject another 10–20 cc of anes- Widely dissect the flaps of the EOA from the internal
thetic solution under the EOA in several location (Fig. 106.3). oblique muscle (IOM) and rectus muscle medially and later-
Incise the EOA along the direction of its fibers, 2–3 cm ally. The shelving edge of the inguinal ligament, spermatic
above its junction with the thigh fascia, and open it from cord, covered by external spermatic fascia, and the cremas-
about 2 cm above the internal ring and down through the teric muscle are now exposed (Fig. 106.4).
external ring. If the incision is placed lower than 2–3 cm, the At this point, identify the ilioinguinal and iliohypogastric
lateral flap of EOA will be narrow and hard to use for third nerve and frequently their large branches. Handle nerves as
and fourth suture lines. Conversely, a higher incision of the atraumatically as possible. Alternatively, perform neurec-
EOA will interfere with the exposure of the cord and the tomy or excision of individual branches if they would pre-
floor of the inguinal canal. vent subsequent dissection or become overstretched or
otherwise traumatized. In patients with longstanding hernias
and significant preoperative pain, it is not uncommon to find
a thickened portion of a nerve in the area of the external ring,
suggestive of neuritis that may be prudent to manage with
wide neurectomy as well.
Next, several 1–2 cc injections of anesthetic solution are
then performed along the edge of the IOM, and proximally
into cremasteric muscle to block the areas where the IIN, IHN,
External oblique and GBGFN originate. Injections are later performed under
aponeurosis the transversalis fascia as well. Little if any more local anes-
thesia will need to be administered during the rest of the case.
Pubic tubercle
If a decision is made to perform neurectomies, after local
anesthetic infiltration is done to block the origin of the IIN or
IHN, dissect the nerves free and divide them with a sharp blade
under gentle tension as lateral as possible to allow the stumps
Ilioinguinal to retract into the IOM. Excise the distal part of the nerve.
nerve
At this time or sometimes even before opening the exter-
Fig. 106.3 nal oblique aponeurosis, incise and explore the thigh fascia
Iliohypogastric Ilioinguinal
nerve nerve
Shelving edge
of the inguinal
Conjoined ligament
tendon
Cremaster
muscle
Fig. 106.4
just inferolateral to the inguinal ligament (Fig. 106.5). This to dissect the cord structures away from the cremasteric mus-
maneuver allows the discovery of a covert femoral defect cles (Fig. 106.6). Once the cremasteric muscle and internal
and also releases some tension at the inguinal ligament. spermatic fascia are incised to expose the contents of the cord,
divide the cremasteric muscle at the level of the internal ring.
If the cremasteric muscle is well developed, it may be easier to
Dissection divide it into two portions. The medial portion contains only
muscle fibers and is thinner. The lateral portion, containing the
Placing the patient in the Trendelenburg position allows the cremasteric vessels and the genital branch of the genitofemo-
abdominal contents to fall away from the groin and facili- ral nerve, may be a cause of postoperative bleeding. Securely
tates the dissection and subsequent repair. ligate both stumps with an absorbable sutures. The proximal
Now, circumferentially dissect the cord away from the floor stump will be incorporated in the second suture line. The distal
of the inguinal canal. Divide the cord coverings longitudinally stump may be incorporated into the closure of the external
oblique aponeurosis at the medial end.
Excise and ligate any bulging preperitoneal fat (com-
monly called a “cord lipoma”) or if broad based, reduce it
through the internal inguinal ring, into the preperitoneal
plane. Identify the testicular vessels and vas deferens. Handle
these with care and protect them throughout the operation.
At this time, the floor of the inguinal canal should be com-
pletely exposed. Occasional anastomosing vessels passing
through the canal floor near the pubis must be divided to
completely mobilize the cord and assure adequate exposure
of the floor near the pubic tubercle, where a large number of
Ilioinguinal
nerve recurrences occur.
The indirect sac or peritoneal protrusion must be searched
for and dissected free. If an indirect hernia sac is obvious,
dissect it away from the cord structures before dissecting the
internal ring. In some cases, it may be easier to dissect the
internal ring free first. Some fibers of the IOM extend onto
the cord forming the cremasteric muscle. The cuff of trans-
Cribriform fascia versalis fascia (TF) is continuous with the internal spermatic
fascia and must be freed circumferentially to permit full
Fig. 106.5 mobilization of the cord (Fig. 106.6).
Fig. 106.6 Cuff of transversalis

fascia
Superior flap of the

external oblique
aponeurosis
Internal oblique
muscle Ilioinguinal
Iliohypogastric nerve
nerve Indirect hernia sac
Transversalis
fascia Inferior flap of the
external oblique
aponeurosis (reflected
Shelving edge of back)
the inguinal
ligament Spermatic cord
Cremastric
muscle dissected off the
cord structures
If the sac is empty and has a wide neck, dissect it free Leave the inferior flap of the TF wide enough to be used for
from the cord structures under gentle traction to allow its the subsequent first suture line. A simple way to approach this is
retraction into the abdomen. As indicated earlier in the chap- to start the incision along the edge of the oblique muscles once
ter, not all indirect sacs and peritoneal protrusions have to be the dissection of the transversalis fascia at the internal ring is
excised and high ligation performed. If there is a visible con- completed and extend it carefully above the inferior epigastric
tent in the indirect hernia, the sac may need to be opened to vessels. Now the excess of attenuated superior flap of the TF
reduce bowel or omentum and divide adhesions as needed. may be judiciously trimmed. While the inferior flap needs to be
Narrow sacs should be opened and high ligation performed. free for subsequent repair, the superior one may be left attached
Assure hemostasis before allowing a peritoneal stump to dis- to undersurface of the transversus abdominis muscle. Mobilizing
appear into the preperitoneal space. A sac may be hard to flaps of TF from the preperitoneal fat is of paramount impor-
dissect free without violating the peritoneum. If this occurs, tance. Expose the edge and undersurface of the transversus
try to close the defect using an absorbable stitch. If a tear abdominis and its aponeurosis superior-laterally and the edge of
extends very proximally, closure or complete high ligation rectus medially. Bluntly dissect any fat away and expose
may not be feasible. Small openings in the peritoneum are Cooper’s ligament and the inguinal ligament blending into the
unlikely to cause problems of hernia recurrence assuming iliopubic tract inferiorly. Visualize and protect the femoral vein.
that the sac had been completely dissected away from the Most direct sacs are wide and can be reduced without the need
internal ring and reduced into the preperitoneal space, since to open them. Sliding hernias with bladder at the medial wall
the peritoneum regenerate promptly. may be typically found here. With careful dissection, small
In longstanding hernias, an indirect sac may be very venous branches in the preperitoneal space are easy to handle.
adherent to the testicular vessels or extend along the cord At this point, inspect the femoral area to assure the
into scrotum. In such cases, divide and perform high ligation absence of a femoral hernia, palpating with a finger under a
of the sac and leave the distal part of the sac attached to the well-defined inferolateral flap of the transversalis fascia
vessels. This avoids unnecessary trauma and devasculariza- above the Cooper’s ligament. Simultaneously, inspect the
tion to the cord structures, something that may lead to post- femoral area from the outside if the thigh fascia was incised
operative edema and later testicular atrophy. If the distal sac during an earlier stage of the operation. If a femoral hernia
is left widely open, the development of hydrocele is highly (either with a true peritoneal sac or merely containing pre-
uncommon. peritoneal fat) is found, reduce it. Occasionally, in women
Sliding hernias, containing colon or bladder, may be rec- chronically incarcerated sizable preperitoneal fat bulges out-
ognized by the presence of fat accompanying the hernia sac. side of the femoral canal and cannot be reduced. It can then
These sacs need to be dissected free like any other and simply be amputated and removed from the outside.
reduced. If a sliding hernia is recognized upon opening the Always remember that if no groin hernia is found during
sac, the peritoneum should be closed prior to reduction to exploration, then that would correlate with a preoperative
preserve the organ and its blood supply. bulge, think about femoral hernia, and explore the femoral
In women, the cremasteric muscle and internal spermatic canal again. Uncommon abdominal wall hernias such as spi-
fascia equivalents are similarly divided and ligated. Once an gelian, interstitial, and prevascular femoral hernias should
indirect sac has been appropriately dealt with or excluded, also be kept in mind.
divide the round ligament as well, completely emptying the Prior to beginning the repair, check the condition, posi-
internal ring. Subsequently during the repair, the inguinal tion, and mobility of the IIN and IHN to plan placing sutures,
floor is completely closed. and avoid nerve entrapment. If necessary perform neurec-
Once the cord structures are fully dissected and the indi- tomy at this time.
rect hernia sac has been dealt with, assess the internal ring
for deficiency visually and by digital palpation. Any weak-
nesses if missed may result in an early recurrence. If weak- Inguinal Repair
ness is present superior-laterally (not uncommon with large
hernias), extend the ring laterally splitting the muscle if he First Line of the Repair
T
needed and include this area into the repair, simply displac- The first pass of the needle is from inferolaterally, through
ing the cord laterally. the flap of transversalis fascia right next to the pubic crest
At this stage, the floor of the inguinal canal and femoral (but avoiding periosteum) to superiorly and medially without
ring must be examined. Even in the absence of an obvious tension past the edge of the rectus muscle, right where it
direct hernia, visual and digital examination may be mislead- inserts into the bone and as far as possible toward the mid-
ing. The most reliable way of exploring the floor and prepar- line, 9 mm or more, from the lateral edge of the RAM
ing tissue flaps for the repair is to split the transversalis fascia, (Fig. 106.8). Direct hernia recurrences occur often just lat-
starting at the internal ring, to the pubic tubercle or until the eral to the pubic tubercle, and this assures a well-anchored
lateral edge of the rectus abdominis muscle (RAM) can be beginning of the first suture line. The suture is tied with the
reached where it inserts into the pubic tubercle (Fig. 106.7). tail left long and tagged with a hemostat.
Fig. 106.7 Iliohypogastric Internal

nerve oblique muscle
External oblique
aponeurosis
Ilionguinal nerve
Spermatic cord
Inferior epigastric
vessels
Stump of cremasteric
muscle
Shelving border
of inguinal ligament
Spermatic Veins in space Flap of external

cord of bogros (under oblique
transversalis fascia) aponeurosis
Fig. 106.8
Internal oblique muscle

external oblique
aponeurosis
Iliohypogastric
nerve
Flap of internal Ilioinguinal nerve
oblique, transversus
abdominis muscle, Inferior epigastric vessels
transversalis fascia Spermatic cord
Veins in the Stamp of cremastric
space of Bogros muscle
Inferior flap of the
Spermatic cord external oblique
aponeurosis
(reflected back)
Marginal Transversalis Shelving

(iliopubic) fascia border of
vein inguinal ligament
Fig. 106.9
a

external oblique
aponeurosis
Iliohypogastric
nerve
Ilioinguinal nerve
Flap of internal oblique,
transversus abdominus, Stump of cremastric
transversalis fascia muscle
Spermatic cord
Flap of external
oblique (reflected
black)
Shelving edge
of inguinal ligament
Spermatic cord
Transversalis
fascia
Transversalis fascia
b with overlying aponeurosis
of transversus m.
Superior Inferior flap of the

flap EOA external oblique
aponeurosis
IOM
TM
Shelving edge
of Poupart’s ligament
Iliopubic tract
Then run this suture continuously, taking bites of the behind the abdominal wall muscles, reconstructing the
free inferolateral flap of transversalis fascia and anchoring floor. Essentially, the free mobile inferolateral flap of TF is
it to the lateral edge of the RAM, 9 mm or more, medial to tucked behind the arch consisting of the rectus, transversus
the lateral edge of the muscle. As the suture moves laterally aponeurosis, and IOM as far back as possible to leave a free
and when the lateral rectus edge gets out of easy reach, edge of the oblique muscles for the suture of the second
carry it to the undersurface of the transversus abdominis line (Fig. 106.9a and b).
muscle (TAM) until the internal inguinal ring is reached. Pass the last stitch of the first line full thickness through
Thus, the suture line brings the flap of TF without tension the inferolateral TF flap deep to superficial, through both
oblique muscles to exit on the superficial surface of the IOM, repair. When the first line tucked the inferior lateral flap of
where it becomes the second suture. It also incorporates the TF behind the oblique muscles, it created the triple-layered
proximal stump of cremasteric muscle medially the cord flap (TLF), consisting of the edge of the IOM, transversus
(Fig. 106.9a). aponeurotic arch with an underlying superomedial TF mar-
The first line of repair is strong medially but may be quite gin. Take full-thickness bites to suture this TLF flap to the
week laterally as the quality of TF usually deteriorates as the shelving edge of the inguinal ligament (Fig. 106.10a and
suture line approaches the internal ring. However, it is an b). These are the same layers that are sutured (although
essential part of the entire repair, as it provides strength to with interrupted suture) in the original Bassini repair.
the medial part of the floor, where recurrences most com- Medial to the femoral vein, a couple of deeper bites may
monly occur. The first layer also reduces the preperitoneal fat be taken through the shelving edge into the Cooper’s liga-
facilitating subsequent repair. ment (like in McVay repair). Because the Cooper’s ligament
is covered by the TF after the completion of the first suture
he Second Line of the Repair
T line and is not directly visible, this maneuver needs to be
After the last stitch of the first line takes the full thickness done most carefully. The line is then carried medially and
of oblique muscles, reverse the suture and continue it medi- beyond the initial bite of the first line and tied to the free end
ally back toward the pubic tubercle as a second line of of the suture.
Fig. 106.10
a Iliohypogastric
nerve

external oblique
aponeurosis
Ilioinguinal nerve
Spermatic cord
Flap of internal oblique, 2nd line of repair

transverse, abdominus,
transversalis fascia Inferior flap of the
external oblique
aponeurosis
Spermatic cord (reflected back)
1st line of Shelving border

repair of Inguinal ligament
Internal oblique
Transversalis
muscle
fasica
Transversus
muscle
he Third and Fourth Lines of Repair

T Then, reverse the suture and run it back between the
These two suture lines are very similar and incorporate same bites of the third line toward the internal ring bringing
layers to complete the repair. They are less strong than the the same flap of EOA to the IOM as a fourth layer
first two lines but provide additional coverage and complete (Fig. 106.12a and b). Once the internal ring is reached,
the reconstruction. Place the initial stitch into IOM at the the tails are tied, avoiding excessive tension. Insert the
internal ring, just medial to the cord. Take small “through tip of a curved hemostat through the new internal ring
and through” bites of the external oblique next to the ingui- into the preperitoneal space to make sure there is no
nal ligament to suture it to the IOM. Pay attention to the loca- bleeding and that the new internal ring is not too tight.
tion of the IHN and IIN. To assure adequate width of the After the third and fourth lines are completed, they look
lateral flap for adequate third and fourth lines, the initial like a continuous line of “X’s” on the outer surface of
incision of the EOA should have been placed 2–3 cm above EOA.
its junction with the thigh fascia. Some surgeons omit the fourth line and perform what
Run the third line medially to the pubic crest past the may be called “modified Shouldice repair.” We discourage
knot of the first and second lines (Fig. 106.11a and b). this.
Fig. 106.11
a

external oblique
aponeurosis
Internal Ilioinguinal
oblique muscle nerve
Iliohypogastric
3rd line of repair
nerve
2nd line of repair Spermatic cord
Inferior flap of the

external oblique
Spermatic cord
aponeurosis
(reflected back)
Shelving edge of the

inguinal ligament
3rd layer
2nd layer
1st layer
Superior flap of
the external oblique
aponeurosis
Internal oblique Ilioinguinal nerve
muscle
3rd line of repair
Iliohypogastric
nerve
Spermatic cord
4th line of
repair
Spermatic
cord
Superior flap of the external

oblique aponeurosis
b 3rd and 4th layers
2nd layer
1st layer
Fig. 106.12
omplete Groin Repair Technique for Femoral

C below the inguinal ligament and reduce its contents. The sac
Hernia needs to be excised and ligated because its neck is frequently
narrow. The herniated fat may either be reduced or excised.
If the primary pathology is a femoral hernia or a femoral Place two or three Prolene sutures medial to the femoral
hernia is found during an operation as a coexisting hernia, vein just under 1 cm apart to help to obliterate the femoral
complete reconstruction should be performed. Dissection is orifice. They are passed through the defect from below, then
performed identically to the description above. A femoral through the Cooper’s ligament and then returned back out-
hernia may have a sac or be comprised of only preperitoneal side through the iliopubic tract of the transversalis fascia and
fat. Clear the femoral ring of any herniated tissue. Either inguinal ligament as wide loops. Stitches are left untied and
reduce a hernia sac back through the femoral canal or open it clamped with hemostats (Fig. 106.13).
Internal oblique
External oblique
Iliohyppogastric
nerve
Flap of internal oblique, Ilioinguinal nerve
transversus, abdominus,
transversalis fascia Spermatic cord
Epigastric vessels
Stump of cremasteric
Copper’s ligament Inferior flap of the

transversalis,
fascia
Spermatic cord (reflected black)
Shelving border Flap of external oblique

of inguinal ligament (reflected black)
Fig. 106.13
The inguinal reconstruction is then completed as usual. removed on the first postoperative day and the remainder on
The loops of the free femoral stitches are incorporated into the second postoperative day. This assures that a patient is
the stronger second line of repair. After the fourth line is examined and reviewed at least once daily before discharge.
completed, these femoral stitches are tied, without any slack Serious complications after a Shouldice repair are rare.
and without any attempt to bring the entire inguinal repair to When catastrophic ones such as massive retroperitoneal
the Cooper’s ligament. This creates a three-dimensional lat- bleeding (0.6%) or severe infection (0.3%) do occur, 99%
ticework of permanent sutures across the upper entrance of show up within 72 hours postoperatively, when the patient is
the femoral canal. Collagen then forms in this latticework to still under medical observation and supervision. Since the
create a reinforced diaphragm that prevents future entry to Shouldice clinic performs >140 procedures per week, this
the femoral canal from above. This is analogous to making a observation period becomes significant but also allows the
reinforced concrete cover for an opening using re-bar. clinic to get each patient immediately started on a supervised
Such a CGR effectively deals with femoral defects. In rehabilitation program.
cases where the femoral space is simply enlarged and there is
a concern about its future integrity, it may be closed with a
couple of deeper bites of the second line of the repair into the Postoperative Care
Cooper’s ligament medial to the femoral vein as described
earlier. Patients are encouraged to ambulate the afternoon of opera-
tion and are able to resume a normal diet the same evening.
losure of Superficial Layers
C The day after the operation patients start gentle stretching
Once four lines of repair are completed, place the spermatic exercises. Patients usually take 1–2 weeks off work, but the
cord on the newly reconstructed floor. Close the EOA over it repair is immediately able to withstand all forms of lifting
with absorbable suture. In the Shouldice clinic, the distal and strenuous activities. Passing urine puts the same force on
cremasteric stump is incorporated into formation of the new the fresh repair as lifting 50 lbs to shoulder height, so the
external ring to decrease sagging of the testicle. The superfi- return to unrestricted activities is limited only by patient dis-
cial fasciae (Scarpa’s fascia and Camper’s fascia) are then comfort. At the Shouldice clinic, return-to-work certificates
closed with absorbable sutures. are issued for a maximum of 28 days unless one of the rare
Close the skin with subcuticular running stitches if sur- complications occurs. A patient requesting a longer period is
gery is an outpatient procedure. In the Shouldice clinic, the asked to return to the clinic or see their own physician for a
skin is closed with Michel clips. Alternate Michel clips are review in case a complication might be developing.
Avoiding Postoperative Complications Sliding hernias, which are more common with direct her-
nias, should be recognized and reduced. When a larger indi-
Infection rect hernia has a thicker non-translucent sac, the surgeon
Infections are very uncommon less than 0.5% and are usu- should think about a sliding hernia. Aggressive dissection of
ally superficial. Deep surgical site infections, requiring take- the medial aspect of a hernia sac or bold ligation of a non-
down of the inguinal repair, are seen extremely rarely. translucent sac may result in injury to the bladder or bowel.
Preoperative antibiotics are not routinely given in the Questionable hernia sacs should be carefully opened and
Shouldice clinic. Hair clipping is performed in the operating explored. If a sliding component is found, the sac should be
room. The duration of the operation is usually less than an closed with a purse-string stitch avoiding colon or bladder. If
hour. Gentle handling of tissues and meticulous hemostasis an injury occurs, it should be recognized and dealt with
are also paramount in decreasing the frequency of appropriately. The bladder should be repaired with running
postoperative infection. The wound should be irrigated, and absorbable suture in two layers. After repair, decompress the
all debris removed prior to closure. bladder with a urinary catheter for 7 days.
Serosal tears of the bowel are repaired with interrupted
Hemorrhage seromuscular sutures, while the enterotomies can be closed
While major bleeding is highly uncommon, hematomas may with one or two layers. If an incarcerated or strangulated her-
occasionally occur. The bleeding can originate from cremas- nia containing bowel cannot be safely inspected and reduced,
teric vessels if the cremasteric muscle stumps are inade- the hernia ring needs to be extended as needed. For indirect
quately controlled. With precise dissection and knowledge of hernias, this is usually done at the superior lateral position
anatomy, other sources are very uncommon, but other poten- through the oblique muscles. A femoral hernia can be freed
tial sites of bleeding are the femoral vessel, deep inferior epi- up by dividing the overlying inguinal ligament. If the incar-
gastric vessels and veins in the preperitoneal space of cerated bowel cannot be safely dealt with through the groin
Bogros. The common femoral vein may be injured by insert- incision, a midline laparotomy should be performed. It is
ing a suture too deeply through the transversalis fascia and wise therefore to put the patient under general anesthesia for
iliopubic tract during repair. If this occurs, cut the needle off the operation for an acutely incarcerated hernia.
and gently pull the suture out. Usually, direct exposure of the
vein and suture repair of the vein is not needed, as needle hronic Postoperative Pain
C
stick bleeding will resolve with precise point pressure within The incidence of chronic postoperative pain (inguinodynia),
5–10 min. depending on the definition, has been quoted as high as over
50%, particularly when mesh had been used for the repair.
esticular Atrophy and Hydrocele
T This has led to the term “meshodynia.” Results of the
The incidence of testicular atrophy and hydrocele is below Shouldice repair are lower with reports from Shouldice
1%. Arterial ischemia of the testicle is very uncommon as Clinic reporting an incidence of inguinodynia of 0.3% by
even division of the testicular artery may be compensated by 3 years postoperatively.
epididymal and scrotal collaterals. Postoperative venous Neuropathic and nociceptive (somatic) are two distinct
congestion and thrombosis may lead to bothersome testicu- types of inguinodynia. Certainly, both types of pain can
lar swelling and subsequent atrophy. Newly reconstructed coexist and may be hard to differentiate even with a careful
deep and superficial inguinal rings should not be too tight. interview and examination of the patient and differential
Venous hypertension can be also avoided with careful pres- blocks with local anesthetic.
ervation of the pampiniform plexus branches during dissec- Neurogenic pain is caused by nerve injury or entrapment
tion. The distal end of an indirect inguinal sac densely with a stitch or mesh. It is usually episodic, described as
adherent to the cord should be left in place to preserve cord burning, stabbing, or aching. It is aggravated with walking
vessels. The sac, however, should be left wide open to avoid and sitting and usually has a trigger point. A positive Tinel’s
hydrocele formation. sign, “arch and twist” maneuver, and presence of allodynia
are typical for neuropathic pain. Visualization and gentle
I njury to Bladder and Bowel handling of the ilioinguinal and iliohypogastric nerves are
Injury to visceral organs should be non-existent. The key the keys to avoiding this problem. When there is any concern
principles are meticulous dissection and careful placement that a nerve has been stretched or any other injury has hap-
of stitches during reconstruction. Complete dissection of an pened or may have happened during the operation, neurec-
indirect sac, freeing and reduction it into the preperitoneal tomy should be performed according to the principles
space are more important in the prevention of hernia recur- described above. GBGFN is not easily visualized but runs
rence than ligation and excision of the sac. consistently within the cremasteric muscle on the posterior
lateral aspect of the cord. It can be trapped by a suture or below 5%. In “the real world,” despite the wide use of this
mesh at the internal ring. It is routinely divided along with synthetic “silver bullet,” the long-term recurrence rate
cremasteric muscle during a Shouldice repair. remains around 15–20% in 20 years. Use of mesh is not a
Somatic pain is related to tissue damage from rough tis- substitute for knowing the anatomy, meticulous dissection,
sue handling, overtightened sutures, and fibrosis around the and correct placement of stitches.
mesh. It is usually constant, localized to the groin area with- As described in this chapter, the most common causes of
out any particular trigger point and exacerbated by strenuous recurrence are as follows:
exercise.
• Inadequate dissection of the indirect component
jaculatory Dysfunction (Dysejaculation)
E • Missing femoral hernia
Dysejaculation is a highly rare complication that is mediated • Inadequate placement of sutures for repair
through the autonomic nervous system and associated with a
burning or searing sensation occurring before, during, or
after ejaculation. It is thought to be related to obstruction of Further Reading
the vas deferens secondary to fibrosis and likely related to
distention of the hollow structure. Usually, it resolves with Anson BJ, Morgan EH, McVay CB. Surgical anatomy of the ingui-
nal region based upon a study of 500 body-halves. Surg Gynecol
time without intervention but may last for several years. Obstet. 1960;111:707–25.
Bendavid R. The space of Bogros and the deep inguinal venous circula-
Urinary Retention tion. Surg Gynecol Obstet. 1992;174:355–8.
General anesthesia, excessive intravenous fluid administra- Bendavid R. Sliding hernias. Hernia. 2002;6:137–40.
Halverson K, McVay CB. Inguinal and femoral hernioplasty. Arch
tion, and duration of the operation are modifiable risk factors Surg. 1970;101(2):127–35.
for postoperative urinary retention. Increased rate of urinary Koot VC, de Jong JR, Perre CI. The interparietal hernia: a rare variant
retention in laparoscopic repairs compared to open repairs of an inguinal hernia. Eur J Surg. 1997;163(2):153–5.
may be attributed to need for bladder cauterization and Ryan EA. An analysis of 313 consecutive cases of indirect sliding
inguinal hernias. Surg Gynecol Obstet. 1956;102:45–58.
resulting urethral trauma and bladder irritation. Shouldice EB. The Shouldice repair for groin hernias. Surg Clin N Am.
2003;83:1163–87.
Hernia Recurrence Welsh DJ, Alexander MAJ. The Shouldice repair. Surg Clin N Am.
With the introduction of a wide variety of meshes and devices 1993;73(3):451–69.
Welsh DR. Repair of indirect sliding inguinal hernias. J Abdom Surg.
during the last two decades, fewer than 10% of all hernia 1969;11:204–9.
repairs are performed without the use of prosthetic material Glassow F. High ligation of the sac in indirect inguinal hernia. Am J
in North America. Some of it is undoubtedly driven by the Surg. 1965;100:460–3.
industry and is driving up healthcare costs. In a classic series Wijsmuller AR, Lange JF, Kleinrensink GJ, van Geldere D, Simons MP,
Huygen FJ, Jeekel J, Lange JF. Nerve-identifying inguinal hernia
regarding Shouldice, McVay, Lichtenstein and totally extra- repair: a surgical anatomical study. World J Surg. 2007;31:414–20.
peritoneal mesh repairs, long-term recurrence is quoted well
Cooper’s Ligament (McVay) Repair
of Inguinal Hernia 107
Indications Mobilize the spermatic cord. Excise the entire cremaster

muscle from the area of the inguinal canal and remove any
• Symptomatic direct or indirect inguinal hernia when use lipomas of the cord. Explore the cord carefully for the pres-
of prosthetic mesh is not desired ence of the indirect sac. If a sac is present, dissect it from the
• Femoral hernia cord. Open the sac, explore it, close it at its neck with a
suture ligature, amputate it, and permit the stump to retract
into the abdominal cavity. Identify the external spermatic
Operative Strategy vessels at the point where they emerge from the transversalis
fascia. Divide and ligate them at this point and remove about
The McVay repair uses autogenous tissue to close the floor 4–5 cm of the vessels; ligate them again at the pubic
of the canal. Because the femoral canal is also closed, this is tubercle.
a good repair to use when an associated femoral hernia is In patients with an indirect inguinal hernia, identify the
found at repair of an inguinal hernia. This repair can succeed margins of the transversalis fascia around the internal ingui-
only if the fascia is strong. If exploration of the groin reveals nal ring. If the internal inguinal ring is only slightly enlarged,
tenuous fascia, a prosthetic mesh repair is required (see close it with several sutures between the healthy transversalis
Chap. 102). fascia along its cephalad margin and the anterior femoral
sheath at its caudal margin. If the hernia has eroded more
than 2 cm of posterior inguinal wall, complete reconstruction
Documentation Basics is necessary. In this case, incise the transversalis fascia with
a scalpel beginning at a point just medial to the pubic tuber-
• Findings cle. Carry the incision laterally with a scalpel or Metzenbaum
• Presence or absence of incarceration scissors, taking care not to injure the underlying deep infe-
• Primary or recurrent rior epigastric vessels. Continue the incision all the way to
the internal inguinal ring. Sweep the preperitoneal fat away
from the undersurface of the transversalis fascia. Free the
Operative Technique deep inferior epigastric vessels so they may be retracted pos-
teriorly together with the preperitoneal fat. A few small
Incision and Exposure branches may have to be divided and ligated.
Excise the iliopubic tract adjacent to Cooper’s ligament.
Make a skin incision over the region of the external inguinal Apply two identifying hemostats to the cephalad cut edge of
ring and continue laterally to a point about 2 cm medial to the transversalis fascia and elevate to expose the aponeurosis
the anterosuperior iliac spine. Open the external oblique apo- of the transverses muscle. Excise the fleshy portion of the
neurosis with an incision along the line of its fibers from the internal oblique muscle overlying the fibrous transverse arch
external inguinal ring laterally for a distance of about 5–7 cm. to improve the exposure (Fig. 107.1).
Identify the anterior femoral sheath by gently inserting
C. E. H. Scott-Conner (*) the back of a scalpel handle between the shelving edge of
Department of Surgery, University of Iowa Carver College Poupart’s ligament and the femoral sheath overlying the
of Medicine, Iowa City, IA, USA external iliac artery and vein. Then identify the anterior

https://doi.org/10.1007/978-3-030-81415-1_107
Fig. 107.1
about 1.5 cm above the pubic tubercle and continue the inci-
sion in a cephalad fashion just medial to the point where the
external oblique aponeurosis fuses with the anterior rectus
sheath. This constitutes a vertical line that curves as it contin-
ues in a superior direction. The anterior belly of the rectus
muscle is exposed as downward traction is applied to the
transverse arch (Fig. 107.2).
Inserting Cooper’s Ligament Sutures
Suture the transverse arch to Cooper’s ligament using atrau-

matic 2-0 silk or other nonabsorbable suture materials
Fig. 107.2 (Fig. 107.3). Take substantial bites of both the transverse
arch and Cooper’s ligament and place the sutures no more
than 5 mm apart. Do not tie the sutures until all are in place.
s urface of the external iliac vein and artery and retract them As the suture line progresses laterally, the external iliac
gently in a posterior direction with a peanut sponge dissec- vein is approached (Fig. 107.4). At this point insert a “transi-
tor. This maneuver separates these vessels from the femoral tion suture” (Fig. 107.5) that penetrates the transverse arch,
sheath. To see the femoral sheath clearly, be certain to excise Cooper’s ligament, and the anterior femoral sheath. Lateral
100% of the overlying cremaster muscle fibers. to this suture, sew the transverse arch to the femoral sheath.
In his description of Cooper’s ligament repair, Rutledge
advocated including a bite of the shelving edge of the ingui-
Making the Relaxing Incision nal ligament together with the anterior femoral sheath.
Continue to insert sutures until the internal ring is sufficiently
A relaxing incision is essential to prevent tension on the narrowed to admit only a Kelly hemostat alongside the sper-
suture line. Elevate the medial portion of the external oblique matic cord (Fig. 107.6). Do not insert any sutures lateral to
aponeurosis and dissect it bluntly away from the internal the cord. After all the sutures have been inserted, tie each
oblique muscle and from the anterior rectus sheath. Make a suture proceeding from medial to lateral. Suture the incised
7- to 8-cm incision in the anterior rectus sheath beginning anterior rectus sheath down to underlying muscle along the
107 Cooper’s Ligament (McVay) Repair of Inguinal Hernia 847
Fig. 107.3
Fig. 107.5
superficial to the cord and complete the wound closure as

Fig. 107.4 described in Chap. 106.
lateral aspect of the relaxing incision with a few 3-0 inter- Postoperative Care
rupted silk sutures.
• See Chap. 106.
Closing the External Oblique Aponeurosis

Complications
Replace the cord in the inguinal canal. Check to ensure com-
plete hemostasis. Close the external oblique aponeurosis • See Chap. 106.
Further Reading
Chan G, Chan CK. Longterm results of a prospective study of 225 fem-
oral hernia repairs: indications for tissue and mesh repair. J Am Coll
Surg. 2008;207:360.
McVay CB, Halverson K. Inguinal and femoral hernias. In: Beahrs
OH, Beart RW, editors. General surgery. Boston: Houghton Mifflin;
1980.
Panos RG, Beck DE, Maresh JE, Harford FJ. Preliminary results
of a prospective randomized study of Cooper’s ligament ver-
sus Shouldice herniorrhaphy technique. Surg Gynecol Obstet.
1992;175:315.
Rosenberg J, Bisgaard T, Kehlet H, Wara P, Asmussen T, et al. Danish
hernia database recommendations for the management of inguinal
and femoral hernia in adults. Dan Med Bull. 2011;58:C4243.
Rutledge RH. Cooper’s ligament repair: a 25 year experience with a
single technique for all groin hernias in adults. Surgery. 1998;103:1.
Fig. 107.6
Mesh Repair of Inguinal Hernia
108
• Inadequate fascia for autogenous tissue repair of direct This repair is performed through a short incision with mini-
inguinal hernia. mal dissection. Direct and indirect sacs must be identified
• Recurrent inguinal hernia repair. Mesh is frequently used and reduced. A piece of mesh is then sutured in place in an
when a recurrent inguinal hernia is approached through onlay fashion, reinforcing the floor and creating a new inter-
the groin. nal ring. Several kinds of mesh are available.
• Prosthetic mesh repairs are used by some surgeons for The procedure may be done under local or regional
virtually all inguinal hernias. Advocates of the repair anesthesia.
shown here in a modified form cite speed, simplicity, and
minimal dissection as major advantages to the surgeon;
decreased pain and immediate return to normal activities Documentation Basics
are advantages to the patient. Current data support the use
of a mesh repair for virtually all elective primary • Findings
herniorrhaphies. • Presence of incarceration
• Presence of strangulation
• Type of mesh used and exact details of placement and
Preoperative Preparation fixation
• Perioperative antibiotics.
Operative Technique
Pitfalls and Danger Points Incision
• Failure to identify, reduce, and repair all hernias. A missed Center a small skin line or nearly transverse incision over the
indirect hernia sac is a common cause of recurrence. medial third of the inguinal ligament and external inguinal
• Failure to secure the mesh adequately. Mesh can curl or ring (see Fig. 109.1).
migrate. When this happens, it may fail to produce the
desired effect or may be palpable in the subcutaneous tis-
sues of a slender patient. issection and Identification of Direct
D
• Infection. and Indirect Sacs
The groin structures are exposed, and the external oblique

aponeurosis is identified as described in earlier chapters.
Incise the external oblique aponeurosis in the direction of its
C. E. H. Scott-Conner (*) fibers, preserving the ilioinguinal nerve. Encircle the cord
Department of Surgery, University of Iowa Carver College and its posterior mesentery (which contains the genitofemo-
of Medicine, Iowa City, IA, USA ral nerve). Perform just enough dissection to encircle the

https://doi.org/10.1007/978-3-030-81415-1_108
Fig. 108.1
cord. Do not divide the cremaster muscle. Simply incise it in

the direction of its fibers to allow careful inspection of the
cord structures.
An indirect sac, if present, is found anteromedial to the
cord structures. Trace the cord structures back to the internal
ring, with the cord on traction to ensure that the leading edge
of any indirect sac is seen. Visualization of the peritoneal
lappet, a crescentic thickening of normal peritoneum created
by traction on the cord, is positive proof that adequate dis-
section had been performed.
If an indirect hernia sac is found, separate it from the cord
structures all the way to the internal ring. This high dissection
allows the sac to be simply inverted into the peritoneum.
Assess the strength of the floor of the inguinal canal by
palpation. If a direct hernial defect is present, circumferen-
tially incise the fascial defect with electrocautery and reduce
the hernia with the attached portion of sac into the preperito-
neal space.
Fig. 108.2
Placement of Patch
Insert the precut patch so it covers the floor of the canal with 3-0 Prolene. Carefully place sutures medial to the pubic
the cord coming through the hole and the incision and tails of tubercle, and laterally to secure the two tails together. Then,
the mesh extending laterally to the internal ring (Figs. 108.1 tack the lateral part to the aponeurosis of the internal oblique
and 108.2). Tuck it carefully into place. It should lie in a flat, muscle, inferiorly to the inguinal ligament, and superiorly to
stable position covering the floor of the inguinal canal the conjoint tendon.
(Fig. 108.3). Secure it in position with interrupted sutures of
108 Mesh Repair of Inguinal Hernia 851
Postoperative Care
• Patients are allowed to lift up to 25 lb immediately. They

may resume heavy manual labor after 2 weeks.
Complications
• Infection has been rare in most series.

• Mesh migration into adjacent structures (femoral vein,
spermatic cord), a theoretic concern, has not proven to be
a significant problem. Rutkow and Robbins, in a 1998
review, were unable to find any documented cases.
• Pain.
Further Reading
Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, Moschetti
I. Shouldice technique versus other open techniques for inguinal
hernia repair. Cochrane Database Syst Rev. 2009;7:CD001543.
Lichtenstein IL, Shulman AG, Amid PK, et al. The tension-free hernio-
Fig. 108.3 plasty. Am J Surg. 1989;157:188.
Reinpold WM, Nehls J, Eggert A. Nerve management and chronic pain
after open inguinal hernia repair: a prospective two phase study.
Ann Surg. 2011;254:163.
Closure Rosenberg J, Bisgaard T, Kehlet H, Wara P, Asmussen T, Juul P,
Strand L, et al. Danish hernia database recommendations for the
Close the external oblique and remaining layers in the usual management of inguinal and femoral hernia in adults. Dan Med
Bull. 2011;58:C4243.
fashion.
Laparoscopic Inguinal Hernia Repair:
Transabdominal Preperitoneal (TAPP) 109
and Totally Extraperitoneal (TEP)
Repairs
Muhammed Ashraf Memon and Robert J. Fitzgibbons Jr
The role of this procedure is now well established in the • Missed hernia or inadequate mesh fixation resulting in
management of uncomplicated inguinal hernia based on a hernia recurrence
number of meta-analyses. It offers its most significant advan- • Injury to bladder during the totally extraperitoneal
tage in these special situations: approach
• Nerve or major vessel injury
• Recurrent hernia following previous open repair (see
Chap. 113). Laparoscopic repair is a logical choice
because it avoids the previous surgical field and allows Operative Strategy
repair to be performed through healthy tissues with poten-
tially better results. There are two general approaches: transabdominal preperito-
• Bilateral hernias. They can be repaired simultaneously neal (TAPP) and totally extraperitoneal (TEP). TAPP is the
without additional incisions or trocar sites. logical choice when inguinal herniorrhaphy is performed
after another laparoscopic procedure or when previous pre-
Although incidental TAPP herniorrhaphy is technically peritoneal dissection limits access to the extraperitoneal
feasible in the appropriately consented patient during the space. It offers the additional advantage that the approach
performance of another laparoscopic surgery, we prefer to and anatomy are familiar to most surgeons, and hernias are
avoid doing this. readily identified as peritoneal outpouchings. The major dis-
advantage is penetration of the peritoneal cavity with associ-
ated potential for visceral injury or adhesion formation.
Preoperative Preparation The TEP approach avoids entry into the peritoneal cavity
and hence minimizes these potential problems, but it requires
• See Chaps. 8 and 106. dissection in the extraperitoneal plane and an excellent
• Encourage the patient to urinate before arriving in the understanding of regional anatomy. The TEP approach is
anesthetic bay. Otherwise, it may be necessary to decom- contraindicated when previous surgery, for example, laparo-
press the bladder preoperatively with a straight or Foley scopic prostate surgery or radiation therapy, may have oblit-
catheter. erated the retroperitoneal plane.
• Prescribe perioperative antibiotics. Crucial to the success of either approach is accurate iden-
tification of anatomy and hernias, accurate placement of
mesh, and avoiding injury to adjacent structures. Figure 109.1
shows the laparoscopic anatomy of the inguinal region.
M. A. Memon (*)
Figure 109.2 shows two danger areas—the triangle of pain
Department of Surgery, South East Queensland Surgery and
Sunnybank Obesity Centre, Sunnybank, QLD, Australia and the triangle of doom—where staple fixation must be
avoided. The single most important landmark is the iliopubic
R. J. Fitzgibbons Jr
Division of General Surgery, Department of Surgery, Creighton tract. If no fixation devices are placed below this structure,
University School of Medicine, Omaha, NE, USA major nerves and vessels can be avoided.

https://doi.org/10.1007/978-3-030-81415-1_109
854 M. A. Memon and R. J. Fitzgibbons Jr
assistants. The surgeon stands on the side opposite to the her-

nia (Fig. 109.3). A Foley catheter is placed to establish blad-
der decompression only if the patient does not void
immediately prior to entering the operating room.
Although a 30°-angled laparoscope is preferred by most
surgeons, it is not a necessity. A 0° laparoscope can provide
adequate exposure.
TAPP Approach
Place the first laparoscopic cannula (10–12 mm) at the umbili-

cus. Place two additional 5-mm cannulas lateral to the rectus
sheath on either side at the level of the umbilicus under direct
Fig. 109.1 It would be worth asking Prof Fitzgibbons Jr if he has any
updated and better picture of TAPP repair as this is quite an old picture vision. Inspect both inguinal regions. Identify the median
and not very clear. He still practices TAPP repair umbilical ligament (remnant of the urachus), the medial umbil-
ical ligament (remnant of the umbilical artery), and the lateral
umbilical fold (peritoneal reflection over the inferior epigastric
artery). Commonly, the internal spermatic vessels and the vas
deferens can be seen through the peritoneum. If the median
umbilical ligament appears to compromise exposure, divide it.
A hernia is visible as an outpouching of the peritoneum.
Incise the peritoneum along a line approximately 2 cm
above the superior edge of the hernial defect, extending from
the median umbilical ligament toward the anterosuperior iliac
spine. The space between the peritoneum and the transversalis
fascia (spaces of Retzius and Bogros) is entered allowing
mobilization of the peritoneal flap inferiorly using blunt and
sharp dissection (Fig. 109.4). Some surgeons routinely inject
local anesthetic (0.5% bupivacaine with epinephrine mixed in
an equal amount of normal saline) under the peritoneum
Fig. 109.2 before opening it. This makes mobilization of the superior and
inferior flaps of peritoneum much easier and provides excel-
lent postoperative pain relief for at least 6 hours.
When laparoscopic herniorrhaphy follows an unrelated Expose the inferior epigastric vessels to the ipsilateral and
laparoscopic operation on the same patient under the same contralateral pubic tubercles, Cooper’s ligament, and the
anesthesia, take the time to optimize the working environment iliopubic tract. Dissect Cooper’s ligament to its junction with
for the second procedure. Additional trocars may be required, the femoral vein. Continue the dissection inferiorly, with
monitors moved, equipment procured, and other adjustments care to avoid an injury to the femoral branch of the genito-
made. This is time well spent. femoral nerve and the lateral femoral cutaneous nerve, which
enter the lower extremity just below the iliopubic tract
(Fig. 109.2). Complete the dissection by skeletonizing the
Operative Technique cord structures. A small indirect hernial sac is easily mobi-
lized from the cord and reduced back into the peritoneal cav-
Patient Position and Room Setup: TAPP or TEP ity. A large sac may be difficult to mobilize because of dense
adhesions between the sac and the cord structures due to the
Position the patient supine with arms tucked at the side. chronicity of the hernia. Undue trauma to the cord may result
Extending the arms on arm boards will not allow enough if an attempt is made to remove the sac in its entirety. In this
room for the surgeon to operate comfortably in the lower situation, divide the sac just distal to the internal ring, leav-
abdomen. The Trendelenburg position allows the bowel to ing the distal sac in situ. This is most easily accomplished by
fall away from the pelvis, providing excellent access. A sin- opening the sac on the side opposite to the cord structures
gle video monitor at the foot of the operating table adjusted and completing the division from the inside. Dissect the
to a comfortable viewing height serves both surgeons and proximal sac away from the cord structures. A direct hernia
109 Laparoscopic Inguinal Hernia Repair: Transabdominal Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) Repairs 855
Fig. 109.3
Anesthesiologist
and
Machine
1st Surgeon
Assistant
2nd
Assistant
Monitor
Nurse
Monitor
Mayo Table
Fig. 109.5
Fig. 109.4
is easily managed by reducing the sac and preperitoneal fat ensuring proper placement. If the prosthesis is large enough,
from the hernial orifice by gentle traction (Fig. 109.5) no fixation is necessary.
separating the peritoneal sac from the thinned out transversa-
lis fascia which lines the abdominal wall portion of the Peritoneal Closure
hernia defect and is easily visualized as a white tongue of Perhaps the biggest advantage of the TEP procedure over the
tissue (pseudosac) which can be teased back into the defect TAPP is the fact that the peritoneum does not need to be
in the abdominal wall. closed with the former. This step adds a significant amount
It is important to complete the dissection by mobilizing of time to the procedure. The goal when closing the perito-
the inferior flap for a significant distance past the bifurca- neum is to completely isolate the prosthesis from the intraab-
tion of the vas deferens and the internal spermatic vessels. dominal viscera and not necessarily to re-approximate the
This step is considered essential to prevent rollup of the edges although this almost always can be accomplished.
prosthesis. By gently elevating the internal spermatic ves- Occasionally, it is necessary to simply cover the mesh with
sels, the peritoneum can be stripped off by counter traction. the inferior flap, leaving exposed transversalis fascia. The
A similar maneuver can be accomplished with the vas preferred technique is suture because there is evidence that
deferens. there is less pain when compared to tacks (Fig. 109.6). The
use of a barbed suture which does not require intracorporeal
lacement of Mesh
P knot tying facilitates this. It may be helpful to decrease the
For a unilateral inguinal hernia, a flat mesh of at least pneumoperitoneum before flap closure. Avoid excess gaps,
11 × 6 cm should be used with the goal of covering the as bowel can herniate or adhere to the mesh through these
entire myopectineal orifice to include the direct, indirect, defects. Inject a long-acting local anesthetic such as bupiva-
and femoral spaces. Alternatively, one can use one of the caine into the preperitoneal space before closure to decrease
preformed prostheses which comes in various sizes and postoperative pain.
conform to the preperitoneal space. We do not cut a slit for
the cord. We prefer to lay the mesh over the cord structures, Bilateral Hernias
rather than cutting a slit and wrapping the mesh around the For bilateral inguinal hernias, the same peritoneal incision
cord structures. Recurrences have been reported through and preperitoneal dissections are used. One can then either
the orifice created around the new internal ring, even when use individual prosthesis on either side or completely expose
the mesh has been closed around the cord. However, this is the symphysis pubis so that both preperitoneal dissections
left to the personal preference of the surgeon. A large pros- communicate with each other. This exposure allows the
thesis allows intraabdominal pressure to act uniformly over placement of one large prosthesis (at least 25 × 8 cm) that
a large area, thereby preventing the mesh from protruding essentially covers the entire lower pelvis. A long transverse
through the hernia defect. The prosthesis is introduced peritoneal incision extending from one anterosuperior iliac
through the larger umbilical cannula and then deployed spine to the other is unnecessary and risks potential damage
intraabdominally into the preperitoneal space to cover the to a patent urachus if one exists.
entire myopectineal orifice. Take time to lay the mesh care-
fully over all hernia defects with good overlap. Fixation of
the mesh is controversial. Sutures, tacks, glue, or no fixa-
tion at all have proponents. If fixation is chosen, the medial
edge is secured to the soft tissue around the contralateral
pubic tubercle and the symphysis pubis. Do not place tacks
directly into either pubic tubercle because chronic postop-
erative pain (osteitis pubis) can result. The medial, inferior
border is fastened just above Cooper’s ligament. Next, the
prosthesis is secured along the superior border to the poste-
rior rectus sheath and transversalis fascia, at least 2 cm
above the hernia defect. Always respect the triangles of
doom and pain by not placing any tacks or sutures below
the iliopubic tract. Tacks are never placed below the iliopu-
bic tract when lateral to the internal spermatic vessel
because of the danger of damage to the important nerves in
this area (Fig. 109.2). It is useful to palpate the head of the
tacking device through the abdominal wall with the non-
dominant hand. This allows counter-pressure to be applied, Fig. 109.6
Fig. 109.9
Fig. 109.7
Fig. 109.8
Fig. 109.10
TEP Approach Complications
Make the skin incision for the first trocar (10–12 mm) infra- Vascular Injuries
umbilically. Open the anterior rectus sheath on the ipsilateral
side and retract the muscle laterally to expose the posterior Injury to the inferior epigastric and spermatic vessels are the
rectus sheath. Following the incision of the anterior rectus most common vascular complications. Other vessels at risk
sheath and retraction of the muscle laterally, insert a include the external iliac, circumflex iliac profunda, and
transparent balloon-tipped trocar into this space directed
obturator vessels. Use of the open laparoscopic technique for
toward the pubic symphysis. Place the laparoscope in the tro- inserting the initial cannula, meticulous dissection, and abso-
car. Under direct vision, inflate the balloon to create an extra- lute identification of important landmarks is essential for
peritoneal tunnel or space (Figs. 109.7 and 109.8). Note that preventing these injuries.
dissection in the correct plane mobilizes the bladder down-
ward. This is followed by the insertion of a structural trocar
which keeps the peritoneum pushed cranially. rinary Retention, Urinary Infection,
U
Place two additional trocars in the midline under direct Hematuria
vision: one (5 mm) at the pubic symphysis and the other
(either 5 mm or 10–12 mm) midway between the first and These are usually secondary to urinary catheterization, exten-
second (Fig. 109.8). Place these trocars by incising the skin sive preperitoneal dissection, general anesthesia, and adminis-
with a scalpel. tration of large volumes of intravenous fluids. These problems
Complete the dissection of the preperitoneal space, mesh generally respond promptly to the usual treatments.
placement, and tacking in a manner similar to that described
for the TAPP procedure (Fig. 109.9). Bilateral hernias are
usually repaired with two pieces of mesh as previously dis-
cussed (Fig. 109.10).
Bladder Injury and testicular atrophy is seen in about the same incidence as
during conventional surgery. The risk of these complications
This is one of the more common complications of laparo- may be significantly decreased if the surgeon avoids exces-
scopic herniorrhaphy. It is seen most commonly in patients sive tightening of the deep inguinal ring, gently dissects
with previous “space of Retzius” surgery. Previous surgery around the cord structures, and does not attempt complete
in this space (e.g., a prostate operation) should be considered removal of large indirect hernial sacs. Minor cord and tes-
a relative contraindication to laparoscopic hernia repair. If a ticular complications are treated by supportive care, such as
bladder injury is recognized during hernia repair, it should be testicular support, limitation of activities, and analgesics. If
repaired immediately laparoscopically or via laparotomy if the vas deferens is transected, the cut ends should be repaired
necessary. Repair the hernia by a conventional anterior with fine, interrupted sutures unless fertility is not a consid-
approach to avoid placing a foreign body next to the bladder eration. There is no treatment for unilateral testicular atro-
repair. A high index of suspicion is the key to the diagnosis phy. The hypogonadism produced by bilateral testicular
of a missed urinary tract injury. Lower abdominal pain, a atrophy is treated by supplemental testosterone.
distended bladder, dysuria, and hematuria should be promptly
investigated. Other signs may include azotemia, electrolyte
abnormalities, and ascites. Indwelling catheter drainage Complications Related to the Mesh
alone may suffice for retroperitoneal bladder injuries, but
intraperitoneal perforations are best closed laparoscopically Migration, infection, mass lesions representing palpable
or by laparotomy. mesh, adhesion formation, and erosion of the mesh into
intraabdominal organs have been reported following laparo-
scopic herniorrhaphy. Fixation of the mesh prevents migra-
Nerve Injury tion. Perioperative prophylactic antibiotics are recommended
to prevent mesh infection. Adhesion formation is least likely
The femoral branch of the genitofemoral nerve, the lateral to occur after the TEP procedure, as the mesh is never in
cutaneous nerve of the thigh, and the intermediate cutaneous contact with intraabdominal organs unless there are unrecog-
branch of the anterior branch of the femoral nerve are at risk nized peritoneal perforations. Following the TAPP proce-
of damage during laparoscopic herniorrhaphy because of (1) dure, adequate closure of the peritoneum over the mesh is the
failure to appreciate the anatomy from the posterior aspect; most important factor in preventing complications such as
(2) difficulty visualizing the nerves preperitoneally; (3) the bowel herniating through large gaps or becoming adherent to
variable course of the nerves in this region; (4) improper exposed mesh. Minimizing trauma, avoiding infection, spar-
staple placement; or (5) extensive preperitoneal dissection. ing the blood supply, and avoiding exposed mesh decrease
Symptoms of burning pain and numbness usually develop the incidence of adhesion formation. Mesh complications
after a variable interval during the postoperative period. If usually manifest weeks to years after the repair in the form of
neuralgia is present in the recovery room, immediate re- small bowel obstruction, abscess, or fistula. They may
exploration is the best course of action. When the onset of respond to conservative management or may require formal
the symptoms is delayed, the condition is usually self- laparotomy.
limiting. In most cases non-steroidal anti-inflammatory
drugs (NSAIDs) are sufficient. Re-exploration and removal
of the offending staple are occasionally required. Recurrence of the Hernia
Potential mechanisms for recurrence include missed hernias

Vas Deferens and Testicular Complications or failure of the mesh to cover all hernial defects adequately.
The latter may occur when the mesh rolls, migrates, is too
Testicular pain may be the result of trauma to the genito- small, or is improperly secured. We believe that thorough
femoral nerve or to the sympathetic innervation of the testis dissection of the preperitoneal space with identification of all
during dissection around the cord structures or during sepa- the landmarks followed by fixation of a large piece of mesh
ration of the peritoneum from the cord structures. Testicular that adequately covers and overlaps the entire myopectineal
swelling may be secondary to narrowing of the deep inguinal orifice without slitting or folding is the best way to avoid
ring, ischemia, or interruption of lymphatic or venous ves- recurrence. A repeat laparoscopic repair or a conventional
sels resulting from attempts at complete removal of a large repair (see Chap. 106) is needed to correct the recurrence.
indirect inguinal hernial sac. Pain and swelling are usually However, a repeat laparoscopic repair may be extremely dif-
transient and self-limiting. Transection of the vas deferens ficult and dangerous.
Osteitis ISBN: 0-7817-1962-3, NLM: WI 950, LC: RD621. p. 650, hard

cover, $179.00.
Fitzgibbons RJ Jr, Camps J, Cornet DA, et al. Laparoscopic inguinal
Pelvic or pubis osteitis results from staples placed directly herniorrhaphy: results of a multicenter trial. Ann Surg. 1995;1:3.
into bone. Placing staples on the anterior and superior por- Katkhouda N. Avoiding complications of laparoscopic hernia repair:
tion of Cooper’s ligament or avoiding fixing mesh altogether laparoscopic inguinal herniorrhaphy: current techniques. In:
Arregui ME, Fitzgibbons Jr RJ, Katkhouda N, McKernan JB, Reich
prevents these complications. The diagnosis is essentially H, editors. Principles of laparoscopic surgery: basic and advanced
one of exclusion. NSAIDs may help. techniques. New York: Springer-Verlag; 1995. p. 435–8.
Lowham AS, Filipi CJ, Fitzgibbons RJ Jr, et al. Mechanisms of hernia
recurrence after preperitoneal mesh repair: traditional and laparo-
scopic. Ann Surg. 1997;225:422.
Wound Infection Memon MA, Fitzgibbons RJ Jr. Assessing risks, costs and benefits of
laparoscopic hernia repair. Annu Rev Med. 1998;49:63.
This may be prevented by using meticulous sterile Memon MA, Fitzgibbons RJ Jr. Laparoscopic inguinal hernia repair:
technique. transabdominal preperitoneal (TAPP) and totally extraperitoneal
(TEP). In: Scott-Conner CEH, editor. The SAGES manual: fun-
damentals of laparoscopy and GI endoscopy. New York: Springer-
Verlag; 1999. p. 364–78.
Memon MA, Feliu X, Salient F, Camps J, Fitzgibbons RJ Jr.
Further Reading Laparoscopic repair of recurrent hernias. Surg Endosc. 1999;13:807.
Memon MA, Rice D, Donohue JH. Laparoscopic herniorrhaphy. J Am
Coll Sug. 1997;184:325.
Arregui ME, Navarrete J, Davis CJ, Castro D, Nagan RF. Laparoscopic
Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. A meta-
inguinal herniorrhaphy: techniques and controversies. Surg Clin
analysis of randomized controlled trials comparing open and lapa-
North Am. 1993;73:513.
roscopic inguinal herniorrhaphy. Br J Surg. 2003;90(12):1479–92.
Camps J, Nguyen N, Annibali R, Filipi CJ, Fitzgibbons RJ Jr.
Rosser JB Jr. Laparoscopic inguinal hernia repair: transabdominal and
Laparoscopic inguinal herniorrhaphy: current techniques. In:
balloon-assisted extraperitoneal approaches [CD-ROM]. New York:
Arregui ME, Fitzgibbons Jr RJ, Katkhouda N, McKernan JB,
Springer-Verlag; 1999.
Reich H, editors. Principles of laparoscopic surgery: basic
Simons MP, Aufenacker T, Bay- Nielsen M, et al. European Hernia
and advanced techniques. New York: Springer-Verlag; 1995.
Society guidelines on the treatment of inguinal hernia in adult
p. 400–8.
patients. Hernia. 2009;13:343–403.
Colborn GL, Brick WG. Inguinal region. In: Scott-Conner CEH,
Tetik C, Arregui ME. Prevention of complications of open and lapa-
Cuschieri A, Carter FJ, editors. Minimal access surgical
roscopic repair of groin hernias. In: Arregui ME, Fitzgibbons Jr
anatomy. Philadelphia: Lippincott Williams & Wilkins; 2000.
RJ, Katkhouda N, McKernan JB, Reich H, editors. Principles of
p. 239–66.
laparoscopic surgery: basic and advanced techniques. New York:
Crawford DL, Phillips EH. Laparoscopic repair and groin hernia sur-
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Treadwell J, Tipton K, Oyesanmi O, Sun F, Schoelles K. Surgical
Filipi CJ, Fitzgibbons RJ Jr, Salerno GM. Laparoscopic herniorrhaphy.
options for inguinal hernia: comparative effectiveness review.
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gov/books/NBK100633).
Bibliographic data. 5th ed. Lippincott Williams & Wilkins; 2002.
Operations for Recurrent Inguinal
Hernia 110
Kent C. Choi and Carol E. H. Scott-Conner
• Strangulation of recurrent hernia • Failing to identify all defects and to tailor the repair to the
• Incarceration or recent history of incarceration of recur- problem
rent hernia • Injuring internal spermatic artery and vein or iliac artery
• Symptomatic recurrent hernia in good-risk patients or vein
• Injuring vas deferens
• Injuring colon (rare)
Preoperative Preparation • Injuring bladder (rare), especially in case with giant
hernia
• Standard preoperative assessment regarding potential sur- • Incomplete reduction of hernia sac, especially in preperi-
gical risks. Additional focus shall be placed on cardiac toneal repair
and pulmonary risks. If the patient suffers from chronic • Inadequate repair
pulmonary disease, make every effort to achieve optimal
improvement and eliminate factors contributing to chronic
cough. Encourage all patients to stop smoking for at least Documentation
a month before the operation.
• Evaluate potential coagulation issues. Consider the need • Type and estimated size of the defect
of bridging chronic anticoagulation with heparin. Balance • Nature of the hernia, incarcerated or strangulated
the risk and benefits of continuing or discontinuing anti- • Any anatomical alternation from previous repair
platelet therapy. • Type of repair, with or without mesh
• Encourage the obese patient to lose weight. • Never and vessel identification and management
• Evaluate nutritional status, and other medications might
interfere with wound healing, such as chronic steroid usage.
• Evaluate elderly male patients for potential prostatic Operative (Management) Strategy
obstruction.
• Administer perioperative antibiotics if the use of mesh is The management of a recurrent groin hernia depends upon
anticipated. the underlying etiology. Groin hernia recurrence can be clas-
• Obtain consent for possible orchiectomy in elderly sified as early and late. Early recurrence typically is associ-
patients. ated with technical issues, while late recurrence is likely
secondary to underlying pathophysiology. There is no uni-
form agreement on how early is “early” or how late is “late.”
K. C. Choi In general, any hernia repaired that lasted for a year should
Department of Surgery, Roy J. and Lucille A. Carver College of
be considered technically sound. We note here the common
causes of recurrence and their prevention. Thorough under-
standing of this material is essential for anatomic repair of
of Medicine, Iowa City, IA, USA recurrent hernias and helps the surgeon keep the primary
e-mail: carol-scott-conner@uiowa.edu recurrence rate low.

https://doi.org/10.1007/978-3-030-81415-1_110
862 K. C. Choi and C. E. H. Scott-Conner
Internal Ring Left Too Wide Failure to Excise Sac
At the conclusion of the repair, the internal ring should admit Failure to identify and remove the entire indirect sac is an
only the spermatic cord plus 2–3 mm (the tip of a Kelly important cause of recurrent hernia. Obviously, if the sur-
hemostat). If closure is not adequate, the risk of recurrence is geon fails to remove the sac, an underlying patent passage is
increased. Generally, this requires removing both cremaster maintained. Hernia recurrence is expected. Even when an
muscle and any lipomas from the spermatic cord as it passes obvious direct hernia is found, always explore the cord and
through the internal ring. remove any indirect sac.
Inadequate closure of the internal ring often follows repair
of a large indirect hernia in adults. Simply removing the sac
and performing a Bassini-type repair by suturing internal Use of Absorbable Sutures
oblique muscle to the inguinal ligament often fail to produce
adequate closure of the internal ring. It was demonstrated long ago that the use of catgut for repair-
ing an inguinal hernia is followed by an excessive rate of
recurrence. Nevertheless, a few surgeons persist in using
I nadequate Reconstruction of the Inguinal absorbable suture material, which loses most of its tensile
Floor strength within several weeks, a length of time inadequate
for solid healing of an inguinal hernia repair.
This typically occurs with a large inguinal hernia which
might have destroyed the inguinal floor structure. Inadequate
reconstruction may result in early recurrence with the hernia Subcutaneous Transplantation of Cord
content and the mesh material herniating down the tract
together. Proper prevention relies on adequate repair with Recurrent inguinal hernia may follow a Halsted repair, in
sufficient mesh and tissue overlap. which the spermatic cord is transplanted into the subcuta-
neous plane by fashioning a new external ring directly
superficial to the internal ring. Fortunately, this repair is no
Defect at Pubic Tubercle longer used and thus this mechanism of recurrence is rarely
seen. The superimposition of one ring over the other results
The second most common location of the hernial defect in a in a repair that is weaker than those that preserve the obliq-
recurrent inguinal hernia is the most medial portion of uity of the inguinal canal. Following the Halsted repair, a
Hesselbach’s triangle adjacent to the pubic tubercle. This is recurrent hernia presents at the point where the spermatic
often a localized defect measuring no more than 1–2 cm in cord exits from the internal–external ring. Generally, the
diameter. The exact cause of this defect is not clear. It may two rings appear to have fused, and the hernia protrudes
result if the surgeon does not continue the suture line up to from this common orifice alongside the cord. It is important
and including the pubic periosteum. Tying interrupted to recognize this before repairing the recurrence, as the
sutures (e.g., during a McVay repair) with excessive tension cord is encountered early during the dissection and may be
may play a part in the etiology of this type of defect. When injured.
doing a mesh repair, it maybe secondary to mesh being
folded or not positioned adequately to cover the area.
emoral Recurrence Following Inguinal Hernia
F
Repair
ailure to Suture Transversalis Fascia or
F
Transversus Arch Several authors have emphasized that following repair of an
inguinal hernia, 1–3% of patients later develop a femoral
A Bassini repair is apt to fail if performed by suturing inter- hernia on the same side. When operating to repair an ingui-
nal oblique muscle to the shelving edge of the inguinal liga- nal hernia, the surgeon should inspect and palpate the cepha-
ment. Often these sutures fail to catch transversalis fascia or lad opening of the femoral canal in search of a small femoral
the aponeurosis of the transversus muscle (transversus arch), hernia. The normal femoral canal does not admit the sur-
which is a stronger structure in the region. This structure, the geon’s fingertip. The only circumstance in which this step
transversus arch, can sometimes degenerate in cases with might be omitted is when a young patient presents with a
very large chronic hernia. In those cases, mesh repair is simple indirect hernia and no weakness of the floor of the
essential. inguinal canal.
110 Operations for Recurrent Inguinal Hernia 863
If a femoral hernia is detected, it should be repaired with excessive scarring from the previous open approach.
simultaneously with the inguinal hernia repair. McVay’s The laparoscopic approach is detailed in separate chapter.
technique sutures the transversus arch to Cooper’s ligament We will discuss the traditional open repair technique in this
(McVay and Halverson 1980). Glassow recommended chapter.
exposing the inferior opening of the femoral canal in the
groin and repairing it with a few sutures from the lower
approach (Glassow 1970). He then completed the inguinal Anesthesia
repair by the Shouldice technique. Mesh repair can be done
to cover the entire inguinal floor, including the femoral canal Many groin operations for a recurrent inguinal hernia can be
opening. performed under local anesthesia with regional nerve block
or spinal anesthesia without undue difficulty. The transverse
abdominal plane block is a commonly employed regional
Infection anesthesia technique for hernia repair procedure with added
post-op pain control. Patients who have had previous opera-
Infection is rare in modern practice. When it occurs, the risk tions for a recurrent hernia and have accumulated a great
of subsequent recurrence may be as high as 40%. deal of scar tissue are preferably operated on with general
anesthesia. General anesthesia is also needed for the preperi-
toneal (open or laparoscopic) approach.
Recurrent Indirect and Direct Inguinal Hernia
For every repair of an inguinal hernia, adequate and com- electing the Optimal Technique for Repair
S
plete reduction of the sac is essential. Carefully identify the of Recurrent Inguinal Hernia
margins of the internal ring. It is also important to differenti-
ate weak from strong transversalis fascia. After identifying There is no single best approach to all recurrent hernias. The
the lateral edge of the transversalis fascia as it joins the inter- surgeon’s ability and skill level with certain techniques play
nal ring, one can insert the index finger behind the transver- an important role in this decision. Obtain the previous opera-
salis layer and evaluate the strength of the inguinal canal’s tive record and determine what type of repair was done origi-
floor. It is not uncommon that the internal ring has signifi- nally; then make an educated guess as to the probable
cantly enlarged and requires suture approximation to recon- mechanism and location of the recurrence. The occasional
struct the floor. Primary tissue repair will only be as strong as missed indirect inguinal hernia or the direct hernia with a
the tissue being pulled together. Excellent results have been virgin floor may be repaired in a manner similar to that used
reported following appropriate use of the Shouldice and for primary repair. However, most recurrent hernias are more
McVay repairs and for the various techniques utilizing pros- complex, with scarring and lack of good fascia to approxi-
thetic mesh. mate without tension. The simplest, most secure way to
During both indirect and direct hernia repairs in the adult repair these recurrent hernias is to bridge the gap with pros-
patient, remove all of the cremaster muscle and adipose tis- thetic mesh tailored to overlap good fascia by at least 3 cm
sue surrounding the spermatic cord. If the diameter of the and sutured in place. The repair must be individualized, and
spermatic cord is narrowed, the aperture of the internal frequently the decision is made only after the anatomic
inguinal ring can also be narrowed, leaving an insignificant defect has been exposed and identified.
defect in the floor of the inguinal canal for a possible recur- A preperitoneal approach, whether open (as described by
rent hernia. Nyhus (Nyhus 1995; Nyhus 1989)) or laparoscopic, allows
dissection in virgin planes. The defect is closed, again, after
placing a large sheet of prosthetic mesh. This may be the best
Choice of Approach approach if mesh was placed at the primary operation.
A major decision required before surgery is whether to use

an anterior (groin) approach or a preperitoneal (usually lapa- Technique of Dissection
roscopic) approach. This choice determines the instruments,
room setup, and choice of anesthesia. The preperitoneal When the anterior inguinal approach has been selected,
approach has gain popularity in recent years. The clinical remember that the patient may have undergone the previous
outcome has been viewed as similar to that of the traditional repair by the Halsted technique. Anticipate the possibility of
open repair. There is some advantage in doing preperitoneal encountering the spermatic cord in the subcutaneous layer of
approach if dealing with bilateral hernia or recurrent hernia the dissection. Therefore, soon after the skin incision is
made, elevate the cephalad skin flap and direct the dissection dissect the skin flap in a cephalad direction. Be aware of the
so the anterior surface of the external oblique aponeurosis is possibility that at the previous operation the surgeon may
exposed at a point 3–5 cm above the inguinal canal. This is have transplanted the spermatic cord into a subcutaneous
virgin territory that has not been involved in the previous sur- location. Be careful not to injure the cord during this dissec-
gery. Carefully direct the dissection in a manner that does not tion. After the skin flap has been dissected for a distance of
expose the external oblique aponeurosis inferiorly until the about 2–3 cm, carry the dissection down to the aponeurosis
subcutaneous spermatic cord or the reconstructed external of the external oblique muscle. Accomplish this in an area
ring has been exposed. In the absence of a previous Halsted that is superior to the region of the previous surgery. Now
repair, continue the dissection beyond the previous suture dissect all subcutaneous fat off the anterior surface of the
line of the external oblique aponeurosis until the junction of aponeurosis, proceeding in an inferolateral direction until the
the inguinal ligament and the upper thigh has been exposed. inguinal ligament and the subcutaneous inguinal ring have
If one does encounter the spermatic cord in a subcutaneous been cleared.
location, meticulous dissection is necessary to preserve the
fragile spermatic veins. In the absence of a previous Halsted
repair, incise the external oblique aponeurosis with caution epairing Recurrent Hernia Following Previous
R
to avoid traumatizing the cord. Halsted Operation Without Opening
the Inguinal Canal
Avoiding Testicular Complications If the spermatic cord was transplanted into the subcutaneous
plane at the previous operation, the subcutaneous and deep
In the elderly patient with a large recurrent hernia, the repair inguinal rings are now superimposed, one directly on the
can be simplified if the patient is willing preoperatively to other. In this case, the inguinal region is generally quite
accept a simultaneous orchiectomy. In most series of recur- strong except for a single defect that represents an enlarged
rent hernia repairs, 10–15% of patients undergo simultane- common external–internal ring through which the spermatic
ous orchiectomy. In younger patients and in those in whom cord passes together with the hernial sac. In these patients, it
the surgeon wishes to minimize the risk of having a testicular is often difficult to separate the external oblique aponeurosis
complication, the preperitoneal approach offers a sound from the deeper structures, a step that is necessary before
alternative to dissection in a previous operative field. accomplishing either a Shouldice or a McVay repair. Instead
Otherwise, take the time to perform meticulous dissection of of incising the external oblique aponeurosis in the region
the spermatic vessels and vas deferens. Sometimes the sper- between the hernial defect and the pubic tubercle in these
matic veins have been spread apart by a large hernia, increas- patients, it may be more prudent to remove the hernial sac
ing their vulnerability to operative trauma. and then narrow the enlarged common ring with several
When the anterior inguinal approach through the previ- heavy sutures.
ous incision has been selected for repair of a recurrent her- To accomplish this, carefully identify and dissect the
nia in a young man, occasionally preserving the spermatic spermatic cord free from surrounding structures and isolate
cord seems impossible. In this situation, it is advisable to the hernial sac. Open it and insert the index finger to verify
abandon the anterior approach and extend the skin incision that the floor of the inguinal canal is indeed strong. Dissect
so the medial skin flap can be elevated for a distance of the sac away from any attachments at its neck. Close the sac
3–5 cm. Continue the operation by an incision through the with a single suture ligature of 2-0 PG. Alternatively, use a
abdominal wall using the preperitoneal approach of Nyhus. purse-string suture. Amputate the sac and permit the stump
After dissecting the peritoneum and the sac away from the to retract into the abdominal cavity. Dissect areolar tissue,
posterior abdominal wall in the inguinal region, insert a fat, and cremaster from the margins of the hernial defect.
prosthetic mesh. This approach helps avoid testicular Close the defect medial to the point of exit of the spermatic
complications. cord using 2-0 Tevdek or Prolene on an atraumatic needle. In
effect, the needle penetrates (at the medial margin of the
ring) 5–6 mm of the external oblique aponeurosis, the under-
Operative Technique lying internal oblique, and the transversalis fascia. At the lat-
eral margin of the repair, the needle pierces the external
Inguinal Approach oblique aponeurosis and the shelving edge of the inguinal
ligament. Narrow the ring to the extent that a Kelly hemostat
Incision and Exposure can be passed into the revised inguinal ring alongside the
Enter the operative site through the old incision. It may be spermatic cord. Making the ring any smaller increases the
cosmetically advantageous to excise the previous scar. Then risk of testicular complications.
Inevitably, these sutures must be tied with some tension, material provides durable repair in this setting without the
which threatens the success of any hernia repair. Therefore, undue tension.
it is preferable when possible to insert an appropriately sized
plug of Marlex mesh into the ring. Stabilize the plug with
sutures as described in Fig. 111.7. This method obliterates Prosthetic Mesh Repair
the defect with no tension on the tissues. If the hernial defect
is large (>3 cm in diameter), apply a patch consisting of a In most cases of recurrent hernia, after dissection of the
layer of Marlex or Prolene mesh to cover the defect. Suture inguinal canal, the remaining tissues are simply not strong
the mesh to the edge of the hernial defect using large bites of enough to ensure successful suturing of the hernial defect.
interrupted or continuous 2-0 atraumatic Prolene. Leave an By far the most common error made by surgeons repairing a
opening for exit of the spermatic cord along the medial mar- recurrent hernia is to misjudge the strength of the tissues
gin of the repair. being sutured. Attenuated scar tissue sutured under tension
does not allow a successful long-term repair. Inserting pros-
thetic mesh to replace the defect will allow a tension-free
Dissecting the Inguinal Canal repair. The weakened tissue can be used to provide coverage
over the mesh materials.
Most patients presenting with a recurrent inguinal hernia Complete the dissection of the inguinal canal through the
have had their previous repair performed with some variety layer of the transversalis fascia (see Figs. 112.3, 112.4,
of the Bassini or McVay technique; the spermatic cord thus 112.5, 112.6, 112.7, 112.8, 112.9, 112.10, 112.11, and
remains in its normal location deep to the external oblique 112.12), so the peritoneum, Cooper’s ligament, and the apo-
aponeurosis. In these cases, make an incision in the external neurosis of the transversus muscle have all been exposed.
oblique aponeurosis along the lines of its fibers aimed at the Separate the peritoneum from the transversalis fascia for a
cephalad margin of the external inguinal ring, as described distance of at least 5–8 cm around the perimeter of the ingui-
above. Perform a patient and meticulous dissection of the nal defect. Now take a layer of Marlex or Prolene mesh and
spermatic cord to avoid traumatizing the delicate spermatic cut a patch in the shape of an ellipse whose diameter is
veins. After mobilizing the spermatic cord, identify the her- 3–5 cm larger than that of the defect. Place the mesh behind
nial sac. In our experience, the most common location of a the abdominal wall between the peritoneum and the transver-
recurrence is in the floor of Hesselbach’s triangle medial to salis fascia. Fully deployed the mesh to cover the entire
the deep inferior epigastric vessels. The previous surgeon inguinal floor, including the Hesselbach triangle and the
probably did not identify the transversalis fascia and the apo- femoral canal, will help prevent future recurrence. It is not
neurosis of the transversus muscle. If this area is virgin terri- necessary to suture the entire circumference of the mesh.
tory, repair the recurrent hernia by the classic Shouldice However, it is wised securing the mesh onto selected ana-
technique described in Chap. 106. This repair is also suitable tomical points, such as pubic tubercle, Cooper’s ligament,
in patients who have a recurrence of an indirect nature, as and anterior and lateral abdominal wall to prevent mesh
these patients almost always have considerable weakness of migration. It is certainly wise to avoid placing suture onto
the inguinal canal. Of course, an indirect sac must be sought area rich with nerve elements and blood vessels, such as the
and, if found, excised. posterior aspect of the inguinal floor. Approximating the
weakened or scarred tissue over the mesh will help to hold
the mesh in place. Close the aponeurosis of external oblique
epairing a Localized Defect in the Inguinal
R muscle over the spermatic cord. After confirming hemosta-
Floor sis, approximate Scarpa’s fascia using interrupted suture and
close the skin in a subcuticular fashion with absorbable
A number of patients with recurrent hernias suffer from a suture.
relatively small (≤2 cm) defect in the inguinal canal floor
just medial to the pubic tubercle. Simple suturing of this
defect produces excessive tension and is doomed to failure. Abandoning the Anterior Approach
Standard repair calls for an incision through the floor of the
inguinal canal followed by a definitive Shouldice or McVay With rare recurrent inguinal hernias, it may be apparent dur-
reconstruction. Mesh repair is an excellent alternative that ing dissection of the spermatic cord that there is such dense
avoids an extensive dissection. A plug of Marlex mesh is fibrosis as to endanger preservation of the cord. When these
placed in the defect and sutured in place with one or two conditions are encountered, especially in young patients,
stitches of 2-0 Prolene as described for repair of a femoral simply abandon the anterior approach. Elevate the cephalad
hernia (see Fig. 111.7). Preperitoneal positioning of mesh skin flap and make an incision through the abdominal wall
down to the peritoneum, as described below for the preperi- Suturing the Mesh
toneal approach to the repair of a recurrent hernia (below).
Dissecting peritoneum away from the posterior wall of the Select an oval of Marlex or Prolene mesh sufficiently large to
inguinal canal via the preperitoneal approach does not provide complete coverage of the entire inguinal floor, a
endanger the spermatic cord because this dissection is car- layer of prosthesis that reaches at least from the abdominal
ried out in territory free of scar tissue. incision (cephalad) to Cooper’s ligament and to the iliopsoas
fascia (caudad) and from the mid-rectus region medially to
the anterosuperior iliac spine laterally.
reperitoneal Approach Using Mesh Prosthesis
P For recurrent hernias repaired by this approach, do not
(Surgical Legacy Technique) attempt to close the hernial defect by suturing it because the
tension would be excessive. Use nonabsorbable sutures with
The technique described below is derived in many aspects substantial bites of strong tissue to ensure that the mesh
from the contributions of Nyhus (Nyhus 1995; Nyhus 1989). remains permanently in place. Do not expect that the
It is described as used for a large right recurrent inguinal ingrowth of fibrous tissue into the mesh will ensure fixation,
hernia. as the polypropylene is relatively inert and substantial fibrous
ingrowth does not always take place. Place the first suture in
the ligamentous tissue adjacent to the pubic symphysis. It is
Incision and Exposure not necessary to suture the entire circumference of the mesh.
It may result in undesired post pain from trapping never ele-
Enter the abdominal cavity by making a transverse incision ments or undue vascular compromised. Additional suture
in the lower quadrant at a level at least 3 cm above the upper can be placed to suture the mesh onto Cooper’s ligament
margin of the hernial defect. Start the skin incision near the along the pubic ramus, lateral and anterior abdominal walls.
abdominal midline approximately two fingerbreadths above It is a good practice to cut the mesh bigger to allow extension
the pubic symphysis and proceed laterally for a distance of posterior to provide sufficient coverage of the femoral canal
about 10 cm, aiming at a point just above the anterosuperior opening, as well as the obturator space. Allow the perito-
spine of the ilium. Expose the external oblique aponeurosis neum to roll onto the mesh to avoid mesh folding.
and the artery. Figure 110.1 illustrates the anatomy of struc- Because of the irregular nature of the surface that has
tures encountered during this preperitoneal dissection on the been covered by the flat patch of mesh, there may be surplus
right side of the patient. of mesh material at the periphery of the mesh covering area.
One shall simply stretch the edges to minimized mesh fold-
Fig. 110.1
Rectus muscle
Inguinal hernia defect

Deep inferior
epigastric
artery Location of femoral nerve
deep to iliopsoas fascia
Femoral canal
External iliac
Pubis atery
Femoral vein External iliac

vein
Vas deferens
Bladder
Spermatic
vein
Ureter
Iliopsoas
muscle
Fig. 110.2
Rectus muscle
Cooper’s
ligament
Pubic tubercle
Abdominal wall
Bladder Illiopsoas muscle

coverd by
Vas deferens iliopsoas fascia
Spermatic vien
External iliac
artery and vein
ing back on itself. Due to the nature of all the dissection, • Wound hematoma or seroma
meticulous attention is needed to ensure hemostasis. • Wound sepsis
When infection develops in patients who have undergone

Closing the Abdominal Incision insertion of a mesh prosthesis, it is not always necessary to
remove this foreign body to remedy the infection, as the mesh
Close the abdominal wall in layers. Close the anterior rectus is made up of monofilament fibers. In most patients, wide
sheath with interrupted nonabsorbable sutures. Lateral to the drainage of the skin incision accompanied by parenteral anti-
rectus muscle, close the abdominal incision using interrupted biotics with perhaps local antibiotic irrigation may prove
0 Prolene sutures that grasp a width of at least 1.5 cm of the effective. If effective drainage is not achievable, mesh explant
abdominal wall including the internal oblique and transver- is indicated in addition to continuing parenteral antibiotics.
sus muscles, the transversalis fascia, and the Poupart liga-
ment. This layer will be closed over the mesh. Then close the
external oblique aponeurosis over the spermatic cord. References
Approximate Scarpa’s fascia, and the subcutaneous tissue is
also line up with absorbable sutures. Close the skin with a Glassow F. Femoral hernia following inguinal herniorrhaphy. Can J
Surg. 1970;13:27.
continuous 4–0 PG subcuticular stitch. Figure 110.2 illus- McVay CB, Halverson K. Inguinal and femoral hernias. In: Beahrs
trates the completed incision suture line. OH, Beart RW, editors. General surgery. Boston: Houghton Mifflin;
1980.
Nyhus LM. The recurrent groin hernia: therapeutic solutions. World J
Surg. 1989;13:54l.
Postoperative Care Nyhus LM. The preperitoneal approach and iliopubic tract repair of
inguinal hernias. In: Nyhus LM, Condon RE, editors. Hernia. 4th
• Incentive spirometry if general anesthesia was used. ed. Philadelphia: Lippincott; 1995. p. 153–77.
• Ambulate the patient the day of the operation.
Further Reading
Complications
Abrahamson J. Etiology and pathophysiology of primary and recurrent
groin hernia formation. Surg Clin North Am. 1998;78:953.
• Testicular swelling and/or atrophy Berliner S, Burson L, Katz P, et al. An anterior transversalis fascia
• Urinary retention in males repair for adult inguinal hernias. Am J Surg. 1978;135:633.
• Recurrence of hernia
Heifetz CJ. Resection of the spermatic cord in selected inguinal hernias. Rehman S, Khan S, Pervaiz A, Perry EP. Recurrence of inguinal herniae
Arch Surg. 1971;102:36. following removal of infected prosthetic meshes: a review of the
Lichtenstein IL. A two-stitch repair of femoral and recurrent inguinal literature. Hernia. 2012;16(2):123–6.
hernias by a “plug” technique. Contemp Surg. 1982;20:35. Shulman AG, Amid PK, Lichtenstein IL. The “plug” repair of 1,402
Lichtenstein IL, Shulman AG, Amid PK. The cause, prevention, recurrent inguinal hernias. Arch Surg. 1990;125:265.
and treatment of recurrent groin hernia. Surg Clin North Am.
1993;73:529.
Femoral Hernia Repair
111
Patrick W. McGonagill, Kent C. Choi,
Indications best access for bowel resection if strangulation has occurred.

An inguinal approach allows any associated inguinal hernia
The majority of femoral hernias present with incarceration, to be repaired and gives adequate access for bowel resection,
and strangulation is common. Repair should be performed but it creates a defect in an otherwise intact inguinal floor.
on all such patients unless significant underlying comorbidi- Elective femoral hernia repair with mesh has a lower recur-
ties prohibit intervention even under local anesthetic. rence rate than tissue repair in retrospective large database
studies. Laparoscopic preperitoneal hernia repair with mesh
has lower recurrence rates than open repair in the elective
Preoperative Preparation setting. The low groin and open preperitoneal approaches are
described here.
Signs of intestinal obstruction warrant nasogastric suction
and IV rehydration prior to operation.
When a patient has symptoms suggestive of a femoral Inguinal Approach
hernia but lacks definitive physical findings, obtain further
imaging. Ultrasonography accurately detects occult femoral The inguinal approach is essentially identical to the McVay
hernia but can be operator dependent. Computed tomogra- repair described in Chap. 107.
phy can also detect a small femoral hernia.
Low Groin Approach

For the low groin approach, after opening the sac and reduc-
• Injuring or constricting femoral vein ing its contents, amputate it. It is not necessary to close the
• Transecting an aberrant obturator artery neck of the sac with sutures (Ferguson). It is important, how-
ever, to clear the femoral canal of any fat or areolar tissue so
the sutures can bring the inguinal ligament into direct contact
Operative Strategy with Cooper’s ligament and the pectineus fascia. This
maneuver obliterates the femoral canal but leaves an opening
Choose the operative approach (low groin, high inguinal, or of 4–6 mm adjacent to the femoral vein. Equally good results
open/laparoscopic preperitoneal) that best fits the situation. can be obtained if the femoral canal is obliterated by insert-
A low groin approach under local anesthesia is an excellent ing a plug of polyethylene or polypropylene mesh. The tech-
choice for the frail elderly patient (unless strangulated bowel nique avoids all tension on the suture line.
is suspected). The open preperitoneal approach offers the To reduce an incarcerated femoral hernia, an incision may
be made to divide the constricting neck of the hernial sac. It
P. W. McGonagill · K. C. Choi should be done on the medial aspect of the hernial ring.
Department of Surgery, Roy J. and Lucille A. Carver College of Although we have never observed the phenomenon, a num-
ber of texts warn that an anomalous obturator artery may fol-
C. E. H. Scott-Conner (*) low a course that brings it into contiguity with the neck of the
of Medicine, Iowa City, IA, USA hernial sac, making it vulnerable to injury when the con-
e-mail: carol-scott-conner@uiowa.edu stricted neck is incised. This accident rarely occurs if the
https://doi.org/10.1007/978-3-030-81415-1_111
870 P. W. McGonagill et al.
neck of the sac is incised on its medial aspect. If hemorrhage • Primary or recurrent
is indeed encountered during this maneuver and the artery • Type of repair
cannot be ligated from below, control the bleeding by finger • Type of mesh used (if applicable)
pressure, and rapidly expose the inner aspect of the pelvis by
the Henry approach, which involves a midline incision from
the umbilicus to the pubis, after which the peritoneum is Operative Technique
swept in a cephalad direction to expose the femoral canal
from above. With this exposure, a bleeding obturator artery Low Groin Approach for Left Femoral Hernia
can be easily ligated. It should be emphasized that this com-
plication is so rare that it does not constitute a significant Make an oblique incision about 6 cm in length along the
disadvantage of the low approach to femoral herniorrhaphy. groin skin crease curving down over the femoral hernia
If the sutures drawing the inguinal ligament down to (Fig. 111.1). Carry the incision down to the external oblique
Cooper’s ligament must be tied under excessive tension, aponeurosis and the inferior aspect of the inguinal ligament.
abandon this technique. Then insert a plug of nonabsorbable Identify the hernial sac as it emerges deep to the inguinal
mesh to obliterate the femoral canal, as described below. ligament in the space between the lacunar ligament and the
common femoral vein (Fig. 111.2). Dissect the sac down to
its neck using Metzenbaum scissors.
Preperitoneal Approach Grasp the sac with two hemostats and incise sharply.
Often the peritoneum is covered by two or more layers of
The posterior approach to femoral hernias utilizes the pre- tissue, each of which may resemble a sac. They consist of
peritoneal space. Open and laparoscopic exposures of the preperitoneal tissues and fat. This situation is seen especially
preperitoneal space provide access to the interior of the pel- when intestine is incarcerated in the sac.
vic floor with visualization of the femoral canal as well as the When the bowel or the omentum remains incarcerated
direct and indirect inguinal hernia spaces. Open preperito- after opening the sac, incise the hernial ring on its medial
neal repair mobilizes the pelvic peritoneum circumferen- aspect by inserting a scalpel between the sac and the lacunar
tially away from the hernia defect. If the hernia remains ligament (Figs. 111.3 and 111.4). After returning the bowel
incarcerated despite gentle mobilization, the femoral ring and the omentum to the abdominal cavity, amputate the sac
may be incised medially. Injury to an aberrant obturator at its neck. Although it is not necessary to ligate or suture the
artery is rare but more readily controllable from this neck of the sac, this step may be performed if desired
approach. Bowel is examined through the hernia sac. Bowel (Fig. 111.5). Using a peanut sponge, push any remaining
resection and anastomosis are performed as necessary.
In the elective setting, repair with mesh reinforcement
reduces the risk of recurrence. This is achieved with either a
mesh plug sewn into the hernia defect or a mesh sheet secured
overlying the femoral hernia and inguinal floor. A tissue repair
is performed with permanent suture between the femoral ring
and Cooper’s ligament in cases of minimal tension.
Laparoscopic preperitoneal femoral hernia repair is per-
formed through the transabdominal preperitoneal (TAPP) or
total extraperitoneal (TEP) approaches detailed in Chap.
109. The laparoscopic approach is associated with lower
rates of recurrence for elective repairs. Typically, a mesh
sheet is used to cover the femoral and inguinal spaces. TAPP
laparoscopic repair allows for examination of the intestines
in cases of incarceration where the TEP exposure does not.
Bowel resection requires a separate incision with either lapa-
roscopic approach.
• Findings
• Presence of incarceration or strangulation Fig. 111.1
111 Femoral Hernia Repair 871
Fig. 111.2 Fig. 111.4
Femoral vein,
artery, nerve
Inguinal
ligament
Lacunar Femoral
ligament canal
Fig. 111.3
preperitoneal fat into the abdominal cavity, thereby clearing

the femoral canal of all extraneous tissues.
Fig. 111.5
Repair the hernial defect by suturing the inguinal liga-
ment down to Cooper’s ligament using interrupted 2-0
sutures of Prolene on a heavy tapered needle. Often this can ral canal to take a bite of Cooper’s ligament and pectineus
be accomplished if the inguinal ligament is pressed down fascia. No more than two or three sutures are generally nec-
and cephalad toward Cooper’s ligament with the index fin- essary. Identify the common femoral vein where it emerges
ger. The needle is then passed through the inguinal ligament from underneath the inguinal ligament, and leave a gap of
and through Cooper’s ligament in one simultaneous motion. 4–6 mm between the femoral vein and the most lateral suture
Cooper’s ligament is indistinguishable from the periosteum (Fig. 111.6). Close the skin of the groin incision with either
overlying the cephalad aspect of the pubic ramus. An alterna- continuous 4–0 PG subcuticular sutures or interrupted 4–0
tive method involves placing the stitch through the inguinal nylon sutures.
ligament and then positioning a narrow retractor in the femo-
Plug of marlex
mesh
Right femoral
vein
Fig. 111.7
may also be used. When the properly sized plug is snug in

the femoral canal with about 0.3 cm of the plug protruding
into the groin, fix it in place by inserting two sutures of 2-0
Fig. 111.6 atraumatic Prolene (Fig. 111.7). Insert the needle first
through the inguinal ligament, then through the Marlex plug,
If strangulated bowel requiring resection is encountered and finally into the pectineal fascia or Cooper’s ligament.
after opening the hernial sac, make a second incision in the After the two sutures have been tied, the plug should fit
midline between the umbilicus and the pubis. You may enter securely in the canal. After irrigating the wound, with a
the peritoneal cavity to perform a bowel resection or utilize dilute antibiotic solution, check for complete hemostasis,
the Henry approach as follows. Separate the two rectus mus- and then close the skin incision without drainage. If a seroma
cles and identify the peritoneum. Do not incise the accumulates postoperatively, aspirate the fluid with a
peritoneum. Elevate the peritoneum from the pelvis by blunt needle.
dissection until the iliac vessels and the femoral hernial sac
are identified. At this point, open the peritoneum just above
the sac. Incise the constricting neck of the femoral canal on reperitoneal Approach for Right Femoral
P
its medial aspect and reduce the strangulated bowel. After Hernia (Nyhus)
resecting the bowel, irrigate the femoral region with a dilute
antibiotic solution, and repair the femoral ring from below as Anesthesia
already described. Irrigate the abdomen and close the General or regional anesthesia with good muscle relaxation
abdominal incision in routine fashion. is required.
Incision
ow Groin Approach Using Prosthetic Mesh
L Start the skin incision at a point two fingerbreadths above the
“Plug” symphysis pubis (Fig. 111.8) and about 1.5 cm lateral to the
abdominal midline. Carry the incision laterally for a distance
Approximating the inguinal ligament to Cooper’s ligament of 8–10 cm, and expose the anterior rectus sheath and the
by sutures frequently requires excessive tension. external oblique aponeurosis. Elevate the caudal skin flap
Tension-free closure of the defect can be achieved by sufficiently to expose the external inguinal ring.
inserting a rolled-up plug of polyester or polypropylene Make a transverse incision in the anterior rectus sheath
mesh as advocated by Lichtenstein and Shore. We believe about 1.5 cm cephalad to the upper margin of the external
this is the best method for repairing a femoral hernia. Cut a inguinal ring for a distance of about 5 cm in a direction paral-
strip of mesh about 2 × 10–12 cm. Roll this mesh strip into a lel to the inguinal canal (Fig. 111.9). Retract the rectus mus-
tight coil, 2 cm in length. After the hernial sac has been elim- cle medially, and deepen the incision through the full
inated and all the fat has been cleared from the femoral canal, thickness of the internal oblique and transversus abdominis
insert this mesh plug into the femoral canal. The diameter of muscles, exposing the transversalis fascia. Carefully make a
the plug may be adjusted by using a greater or lesser length transverse incision in this layer but do not incise the
of mesh, as required. Commercially available mesh plugs peritoneum.
111 Femoral Hernia Repair 873
Hernia
sac
Spermatic
cord
Fig. 111.10
against the sac in the groin. Although the presence of an

Fig. 111.8 aberrant obturator artery along the medial margin of the fem-
oral ring is a rarity, there may be one or two small venous
branches that require suture ligation prior to incising the
medial margin of the ring.
Open the sac. Evaluate the condition of the bowel. If stran-
gulation mandates bowel resection, enlarge the incision
enough so adequate exposure for a careful intestinal anasto-
mosis may be guaranteed. If bowel has been resected, change
gloves and instruments before initiating the repair. Irrigate the
incision with a dilute antibiotic solution. Excise the peritoneal
sac and close the peritoneal defect with continuous 3–0 PG.
Cephalad uturing the Hernial Ring

S
The superficial margin of the femoral ring consists of the
iliopubic tract and the femoral sheath. These structures are
just deep to the inguinal ligament. The deep margin of the
femoral ring is Cooper’s ligament, which represents the rein-
forced periosteum of the superior ramus of the pubis. When
repairing the hernial defect, suture the strong tissue situated
in the superficial margin of the femoral ring to Cooper’s liga-
Fig. 111.9 ment with several interrupted sutures of 2-0 Ethibond or
Prolene (Figs. 111.11 and 111.12). Whether the suture catch-
ing the superficial margin of the femoral ring contains only
Apply a Richardson retractor against the lateral margin of the iliopubic tract or it also catches a bite of inguinal liga-
the incised abdominal wall. Use blunt dissection to elevate ment is immaterial so long as the tension is not excessive
the peritoneum out of the pelvis. when the knot is tied. If closing the ring by approximating
strong tissues would result in tension, a mesh repair is prefer-
obilizing the Hernial Sac
M able. There are two options for prosthetic mesh repair. The
If the femoral hernia is incarcerated, it is possible to mobilize first is suturing a small coil or plug of mesh into the femoral
the entire pelvic peritoneum except for that portion incarcer- ring from the cephalad approach. The second is reinforcing
ated in the femoral canal (Fig. 111.10). If the hernia cannot the pelvic floor with a sheet of synthetic mesh. The mesh is
be extracted by gentle blunt dissection around the femoral oriented to cover the femoral, indirect, and direct spaces. It is
ring, incise the medial margin of the femoral ring, and extract secured in a similar fashion to laparoscopic mesh placement
the hernial sac by combining traction plus external pressure using 2-0 Prolene or Ethibond rather than tacks.
Fig. 111.11
Iliopubic tract and

inguinal ligament
Cooper’s
ligament
Spermatic cord
(right)
Stump of deep inferior
epigastric artery
External iliac artery

and vein
Complications
• Deep vein thrombosis has been reported secondary to

constriction of the femoral vein by suturing.
• Wound infections occur but are rare.
• Ventral hernia may follow the preperitoneal approach to
femoral hernia repair.
• Recurrence is uncommon, although in some series it has
ranged from 2% to 7%.
Further Reading
Andresen K, Bisgaard T, Kehlet H, Wara P, Rosenberg J. Reoperation
rates for laparoscopic vs open repair of femoral hernias in Denmark:
a nationwide analysis. JAMA Surg. 2014;149:853–7.
Dahlstrand U, Wollert S, Nordin P, Sandblom G, Gunnarsson
Fig. 111.12 U. Emergency femoral hernia repair: a study based on a national
register. Ann Surg. 2009;249:672–6.
Dahlstrand U, Sandblom G, Nordin P, Wollert S, Gunnarsson U. Chronic
pain after femoral hernia repair: a cross-sectional study. Ann Surg.
Glassow F. Femoral hernias: review of 1143 consecutive repairs. Ann
• Early ambulation. Surg. 1966;163:227.
Lichtenstein IL, Shore JM. Simplified repair of femoral and recurrent
• Perioperative antibiotics are employed in patients with inguinal hernia by a “plug” technique. Am J Surg. 1974;128:439.
intestinal obstruction or those who have had bowel Nyhus LM. Iliopubic tract repair of inguinal and femoral hernia: the pos-
resection for strangulation. Use nasogastric suction terior (preperitoneal) approach. Surg Clin North Am. 1993;73:487.
selectively in patients with intestinal obstruction or Nyhus LM. The preperitoneal approach and iliopubic tract repair of
femoral hernias. In: Nyhus LM, Condon RE, editors. Hernia. 4th ed.
bowel resection. Philadelphia: Lippincott; 1995. p. 178–87.
Operations for Large Ventral Hernia
112
Ariel P. Santos
Indications • Review previous operative notes: operations, prior mesh

use, and operative technique used in prior repair of recur-
• Good-risk patients should undergo elective repair of a rent hernias.
ventral hernia for any defect greater than 1–2 cm. • Bowel preparation if there is a concomitant ostomy
Nonoperative therapy is almost always followed by grad- reversal.
ual enlargement of the hernial ring over time. Not only • Consultation with a plastic surgeon if use of expanders,
does this make the repair more difficult, but there is a sig- implants, flaps, or graft is necessary.
nificant incidence of incarceration. • Review mesh available in your institution depending on
• Symptomatic incarcerated hernia. surgeon’s preference. A mesh cart (Fig. 112.1) that can be
• Strangulated hernia. rolled near the operating room is helpful.
• Insertion of nasogastric tube prior to operation for large
hernias.
Preoperative Preparation • Placement of Foley catheter in most cases.
• Administer appropriate prophylactic antibiotics and re-

dose if needed. Inquire for previous infection, especially Pitfalls and Danger Points
MRSA infection and consider decolonization if needed.
Pre-existing infection must be treated prior to repair. • Misdiagnosis in differentiating hernia from diastasis recti
• Look for modifiable factors such as follows: and eventration
1. Obesity. Weight loss in the obese is an admirable goal • Excessive tension on the suture line
but difficult to achieve in practice. Manage obesity • Inadequate dissection of hernia sac
prior to ventral hernia repair but if refractory consider • Sewing tissues that are too weak to hold sutures
laparoscopic bariatric surgery followed by elective • Seroma formation
hernia repair once appropriate weight has been • Postoperative infection
achieved to decrease recurrence. Repairing the ventral • Failure to achieve complete hemostasis
hernia first will not only increase the risk of hernia • Unrecognized or missed enterotomy or thermal injury to
recurrence but may make laparoscopic bariatric sur- the bowel
gery more difficult.
2. Smoking cessation.
3. Evaluate and treat prostatism since this will poten- Operative Strategy
tially increase hernia recurrence.
• Recommend CT scan to prevent misdiagnosis as well as The multitude of repair techniques available for ventral
for better operative planning. (incisional) hernia repair attests to lack of satisfaction with
any one method. One of the key factors associated with
decreased recurrence is the use of mesh. Numerous pros-
A. P. Santos (*) thetics and biologic (biomesh) mesh are commercially
Department of Surgery, Texas Tech University Health Sciences available for use. Prosthetic materials differ in weight,
Center, Covenant Medical Center, Lubbock, TX, USA resistance to infection, amount of tissue ingrowth, pore
e-mail: ariel.santos@ttuhsc.edu

https://doi.org/10.1007/978-3-030-81415-1_112
876 A. P. Santos
Infection
Infection of the postoperative abdominal wound will com-
monly lead to an incisional hernia, especially if the infection
was not detected and widely drained early during the course
of its development. Presence of infection in previous pros-
thetic mesh repairs usually requires complete explantation of
the mesh (Fig. 112.2a–c). Strategies to minimize the inci-
dence of wound infection during a contaminated abdominal
operation are discussed in a separate chapter.
Occult Wound Dehiscence

When a large ventral hernia appears within the first few
months after an abdominal operation, a likely cause of the
hernia is contained dehiscence of the fascial and muscular
layers of the abdominal wall during the early postoperative
course in a patient whose skin incision has remained intact.
arge Drain Exit Site at the Fascia

L
Postoperative hernias may occur at drain exit sites, particu-
larly the large stab wounds used for Penrose and sump drains.
Generally, if the stab wound admits only one finger, a post-
operative hernia is unlikely. When drainage of necrotic tissue
(e.g., necrotizing pancreatitis) is required, large drains like
Abramson Triple Lumen Sump drains are appropriate, and
the risk of subsequent hernia formation is accepted. Closed
suction drains require smaller incisions and rarely become
sites of hernia formation.
Fig. 112.1
ailure to Close Laparoscopic Trocar Sites

F
Adequately
size, and elasticity, among other properties. Most surgeons In general, fascial defect must be closed after inserting any
will settle on one or two types of each. Problems associated trocar larger than 5 mm in diameter. Radially dilating trocars
with mesh repairs as well as potential contraindication for are designed to spread rather than cut fibers of the abdominal
its use have led to a resurgence of interest in autologous wall muscle and fascia. Larger radially dilating trocar sites
tissue repairs. The most common type of autologous repair may not require closure, therefore, because the spread fibers
is component separation. It involves wide mobilization of simply close. This is particularly true for lateral sites where
the musculoaponeurotic layers of the abdominal wall with overlapping muscle layers have fibers that cross at right angles
appropriate relaxing incisions designed to preserve the neu- providing a gridiron type of closure that may be more secure.
rovascular supply to the muscles. Component separation is
particularly useful in contaminated fields. It may be com- ransverse Versus Vertical Incision
T
bined with mesh placement. The choice of open or laparo- Despite theoretical concerns, there is no detected increased
scopic repair is based upon several factors including the incidence of hernia or dehiscence in vertical midline incision
size of the defect and the experience of the operating team. when compared to transverse or oblique subcostal incisions,
In general, laparoscopic repairs work well for smaller provided the midline incision has been carefully closed.
defects, but large ventral hernias (≥10 cm2) associated with Long subcostal incisions may be associated with denervation
open abdomen management (damage control laparotomy) of part of the abdominal wall. The resulting bulge must be
require open approach. differentiated from a true hernia via CT or ultrasound.
Avoiding Postoperative Complications Suturing Technique
A thorough understanding of the factors that lead to inci- ype of Suture Material
T
sional hernia formation is crucial. These same factors con- Closure with catgut, polyglycolic acid (Dexon), or polyglac-
tribute to recurrence after repair. tin (Vicryl) has resulted in a large number of dehiscence and
112 Operations for Large Ventral Hernia 877
a b c
Fig. 112.2
hernia, and for this reason it is no longer recommended. It is easy to tie monofilament sutures too tightly because
Nonabsorbable monofilament sutures (nylon, Prolene) do the knot tends to slip. Resist the temptation to snug the knot
not dissolve but often result in suture sinus formation or down successively tighter with each throw because this may
painful bumps at sites of knots. As a compromise, polydioxa- potentially cause ischemia and necrosis of the underlying tis-
none (PDS) has been adopted by many surgeons for closure sue. Request that the anesthesiologist provides adequate
material. It maintains strength sufficiently long enough to muscle relaxation at the time of closure, as it makes it easier
allow secure healing but eventually dissolves, thus minimiz- to apply the proper tension to each suture. Use of botulinum
ing the tendency to form suture sinuses. toxin A has been described to help facilitate fascial closure
and may be an option.
ize of Tissue Bites
S
The width of tissue included in each stitch is an important
determinant of the incidence of wound dehiscence or inci- Intercurrent Disease
sional hernia, regardless of whether a continuous or inter-
rupted technique is used. Based on current evidence in • Cirrhosis and ascites
midline closure, small bite techniques are recommended to • Chronic obstructive pulmonary disease
reduce significantly the buttonholes and rate of incisional • Chronic high-dose steroid treatment
hernia. • Marked obesity
• Severe malnutrition
Suture Tension • Abdominal aortic aneurysm
When a stitch in an abdominal incision is tied with strangulat- • Abdominal wall defects secondary to tumor resection
ing force, even if large bite was obtained, this may cause the
stitch to cut through the abdominal wall. This error manifests Defects in the abdominal wall secondary to resection
as a small hernia located 1–2 cm lateral to the scar several for tumor may be managed by inserting a prosthetic or bio-
months following the operation. This phenomenon is some- logic mesh provided adequate coverage of the mesh with
what less likely to occur with synthetic monofilament sutures viable skin and subcutaneous fat is possible. Otherwise, a
than with wire sutures because these sutures have a larger full-thickness pedicle flap must be designed to cover the
diameter than the equivalent-strength stainless steel suture. mesh.
878 A. P. Santos
Tissue Integrity simply approximated with the Smead-Jones technique. It is

important to excise all the attenuated tissues, but it is not
In the hope of facilitating approximation of the edges of the necessary to remove the condensation of fibrous tissue that
defect, the surgeon is often tempted to preserve, and insert often forms a firm ring and separates the hernial defect from
sutures into, weak scar tissue instead of carrying the dissec- the normal tissues of the abdominal wall. Using the Smead-
tion beyond the edge of the hernial ring to expose the normal Jones stitch, simply insert the sutures 2–3 cm beyond the
musculoaponeurotic tissue of the abdominal wall. Depending hernial ring through all layers of the abdominal wall includ-
on scar tissue to hold sutures for repair of a hernia leads to a ing peritoneum. It may be preferable to close a circular
high recurrence rate. It is best to carry the dissection 2–3 cm defect in a transverse (rather than vertical) direction, but the
beyond the perimeter of the hernial ring on all sides and main consideration is to select the direction that produces
clearly expose the anterior surface of the muscle fascia. the least tension.
Often an obvious incisional hernia is accompanied by
additional smaller hernias 3–5 cm away from the major
defect (Swiss cheese effect). These secondary hernias occur Role of Prosthetic Mesh
because more than one suture, inserted at the previous clo-
sure, has cut through the tissue, leaving additional small If there is tension on the proposed suture line, do not close
defects. If the additional defects are close to the large hernial the defect at all. Rather, bridge the defect with one or two
ring, incise the tissue bridges and convert the several defects layers of a prosthetic mesh. No attempt is made to close the
into one large hernial ring. defect with this technique. The defect is thus replaced by the
Some surgeons advocate separating the abdominal wall mesh, which is sutured in place by means of 2-0 or 0 Prolene/
into its component layers—peritoneum, muscle, and fas- PDS mattress sutures that penetrate the full thickness of the
cia—and then suturing each individual layer. We believe that abdominal wall.
in most cases, it is preferable to insert the suture by taking a The most serious complication following the use of pros-
large bite of the entire abdominal wall in each stitch, follow- thetic mesh arises when dense adhesions form between the
ing the principle of the Smead-Jones technique, rather than small intestine and the fabric of the mesh. If intestinal
splitting the abdominal wall and closing each layer sepa- obstruction in this situation requires subsequent laparotomy,
rately. By the same token, we have not used relaxing inci- it may prove impossible to separate the mesh from the bowel
sions through the aponeurosis of the external oblique layer to without extensive intestinal damage. Although this compli-
expedite hernial closure because we have observed subse- cation is uncommon, it is important to take the precaution of
quent herniation through the area of the relaxing incision. interposing omentum between the mesh and the intestines
Other surgeons have advocated creating a flap from the ante- whenever possible. When omentum is not available for this
rior rectus sheath on each side and then bridging the hernial purpose, preserve the hernial sac and interpose this tissue
defect by suturing one fascial flap to the other. Our experi- between the intestines and the mesh, which is then sutured as
ence suggests that this technique does not successfully repair an onlay patch over the defect (as shown later in this chap-
an incisional hernia larger than a few centimeters in ter). Although using an onlay patch mechanically does not
diameter. result in as strong a repair as inserting stitches through the
entire abdominal wall to fasten the mesh, it may be prefera-
ble to the risk of producing excessive intestinal adhesions.
Tension During Repair In contrast to the onlay patch technique, a sublay patch is
placed deep into the fascia. The fascia may or may not be
By far the most dangerous threat to long-term success with closed over the sublay patch. The major theoretical advan-
hernial repair is excessive tension on the suture line. Although tage of the sublay patch is that increased intra-abdominal
all surgeons agree with this principle, there is a wide varia- pressure should push the patch against the abdominal wall.
tion in each surgeon’s perception of what comprises “exces- The disadvantage is that the prosthetic material may be in
sive” tension. We believe that any degree of tension is contact with viscera, but this can be potentially prevented by
“excessive” because this judgment is always made with the placing a tongue of omentum between them.
patient under anesthesia. Even local anesthesia produces
muscle relaxation in the anesthesized area, so any degree of
tension is magnified when the effects of anesthesia have Types of Synthetic Prosthetic Material
disappeared.
In the case of small ventral hernias (<3 cm in diameter), There are three general types of synthetic prosthetic material
success may be anticipated if the weakened tissues are in common use: absorbable mesh, monofilament polypropyl-
excised and the remaining defect in the abdominal wall is ene (or other nonabsorbable) mesh, and expanded polytetra-
fluoroethylene (ePTFE) sheets. True long-term follow-up has recovered from the initial problem and enough time
data are not available for many of these prosthetic (about 6 months or more) has elapsed for the skin and hernia
materials. sac to “pinch” easily off underlying bowel. This technique
Absorbable polyglycolic mesh is suitable for temporary has largely been superseded by the use of bioprostheses or by
closure of abdominal wall defects, particularly in the infected component separation. Absorbable mesh is not suitable for
abdomen. After granulation tissue forms, this can heal by permanent repair of ventral hernias as described in this chap-
secondary intention (Fig. 112.3a–c) or earlier closure can be ter and will not be discussed further.
achieved by skin grafting (Fig. 112.3d and e). Because the Monofilament nonabsorbable meshes from different man-
mesh absorbs, subsequent incisional hernia formation is ufacturers vary in chemical composition, stiffness (resistance
inevitable, and a delayed repair is needed when the patient to bending), and degree of stretch. As mentioned earlier, ero-
a b c
d e
Fig. 112.3
880 A. P. Santos
sion into bowel, fistula formation, and dense adhesions have vascular supply to the muscles. Techniques have been further
been problems with these prosthetic materials. A major developed that facilitate closure of even large defects by this
advantage of this mesh is its tolerance to infection. Because method. The key elements are elevation of extensive flaps of
the mesh is composed of monofilament fibers, the patient skin and subcutaneous tissue to expose the external oblique
often tolerates a wound infection without the need to remove aponeurosis above and below the hernia sac. Create flaps at
the mesh. Opening the skin widely for drainage generally the level between subcutaneous fat and musculoaponeurotic
proves sufficient and, in many cases, avoids the need to layers as far laterally as possible (Fig. 112.5). A longitudinal
remove the mesh. incision in the external oblique aponeurosis, just lateral to
Expanded PTFE sheets are soft and pliable. Adhesion to the lateral edge of the rectus muscle (Fig. 112.6a and b),
bowel is much less of a problem than with the previously allows the muscles to slide medially. This slide is enhanced
described meshes. This material feels smooth to the touch by separation of the external oblique from the underlying
and does not encourage tissue ingrowth. Currently available internal oblique muscle as far laterally as can be achieved.
ePTFE mesh does not tolerate infection well and is Note that the neurovascular structures pass deep to the inter-
recommended for use only during clean procedures. If the nal oblique muscle and should be preserved if this dissection
operative field becomes contaminated during dissection progresses in the correct plane. This allows the rectus and
(e.g., by inadvertent enterotomy or exposure of a buried internal oblique muscles to slide medially and be closed
chronic suture abscess), this material is not a good choice. without tension in the midline (Fig. 112.7). Pull the midline
Combination prostheses are also available. These use a together and assess tension, keeping in mind that muscle
material such as ePTFE on one side (to be put next to the relaxation under general anesthesia makes it easy to underes-
bowel) bonded to a material which enhances tissue ingrowth timate the tension on the repair under normal physiologic
on the other side (to be put next to the fascia). conditions. Some surgeons will add a sublay prosthetic or
biologic mesh to provide further reinforcement.
Biologic Mesh (Biomesh)

Use of Drains
The theoretical advantages of these materials are as follows:
they are resistant to infection, encourage tissue ingrowth, Because most all repairs result in elevation of large subcuta-
and in time can be incorporated into the abdominal wall. For neous flaps, many surgeons place closed suction drains in the
this reason, many surgeons prefer these materials in repair of space between the subcutaneous tissue and the fascia to
the contaminated abdomen (Fig. 112.4a–e). There is insuffi- decrease seroma formation. Meta-analysis (Gurusamy)
cient evidence of the clinical efficacy of biological mesh failed to demonstrate any difference in outcome associated
materials for the repair of abdominal wall hernia, and ran- with drain placement.
domized control study is recommended.
Operative Technique
Myocutaneous Flap
lective Ventral Hernia Repair
E
Increased interest in the myocutaneous flap has resulted in 1. Patient preparation
the development of techniques that facilitate rotation of large 2. Excision of the old scar and non-viable skin
flaps of muscle covered by skin and subcutaneous fat into 3. Dissection and excision of the hernia sac
full-thickness defects of the abdominal wall with retention of 4. Identification of fascial edges and dissection of the sub-
an excellent blood supply to the flap. The tensor fasciae latae cutaneous flaps
muscle is one example of such a myocutaneous flap that can 5. Reduction of the hernial contents to the abdomen and
be used to bridge defects in the abdomen. The exact role of adhesiolysis if indicated
this modality is still being evaluated, but it is an important 6. Mesh placement ± component separation
option to remember in complex situation. 7. Fascial closure
8. Drain placement
9. Skin closure
Separation of Components
Dissecting the Hernial Sac
Separation of components was originally described by Make an elliptical incision in the skin along the axis of the
Ramirez to obtain autologous tissue closure of moderate- hernial ring and carry the incision down to the sac. Dissect
sized abdominal wall defects with preservation of the neuro- the skin away from the sac on each side until the area of the
a b
c d e
Fig. 112.4
hernial ring itself has been exposed in its entire circumfer- taneous fat attached to the area where the sac meets the her-
ence (Fig. 112.8). Retract the skin flap away from the sac and nial ring. Using scissors, remove this collar of fat from the
make a scalpel incision down to the anterior muscle fascia. base of the hernia. For small defects, the hernia sac is usually
Continue to dissect normal muscle fascia using a scalpel or removed. For large ventral hernias, it may be possible to
Metzenbaum scissors until at least a 2 cm width of fascia has keep the dissection superficial to the hernia sac, preserving it
been exposed around the entire circumference of the hernial as a protective layer between the bowel and any prosthetic
defect. This dissection generally leaves some residual subcu- material used.
882 A. P. Santos
esecting the Hernial Sac

R
Make an incision along the apex of the hernial sac and divide
all of the adhesions between the intestine and the sac, reduc-
ing the intestines into the abdominal cavity after inspecting
them for viability (Fig. 112.9). Expose the circumference of
the hernial defect, so the neck of the sac and a 2- to 3-cm
width of peritoneum are freed of all adhesions around the
entire circumference of the hernia.
Fig. 112.5
Fig. 112.7
Fig. 112.8
esh Repair of Ventral Hernia

M
There are different technical approaches to mesh placement,
and this can be divided into underlay (intra-abdominal),
Fig. 112.6
interlay (interfascial), and overlay (suprafascial).
Fig. 112.10
Fig. 112.9
the entire abdominal wall, and then the deep layer of mesh.
Sandwich Repair When returning the suture, the width of the bite of mesh
The “sandwich repair” was first described by Usher. It com- must be less than the width of the bite in the abdominal wall;
bines what would now be called a sublay patch (deep to the otherwise, the mesh tends to bunch together when the stitch
fascia) and an onlay patch. Two identical sheets of mesh are is tied rather than lying flat. Therefore, when returning the
cut from a large sheet. Each piece of mesh should be 2 cm stitch through the deep layer of mesh, select a spot that
larger than the hernial defect. One sheet is placed inside the encompasses only 7 mm of mesh while including a 1 cm
abdominal cavity, and the other contacts the fascia around width of abdominal wall. After penetrating the anterior rec-
the hernial ring. The two sheets are held by sutures that go tus fascia, pass the needle through the anterior layer of mesh
through the top sheet, then through the full thickness of the again at a point 7 mm away from the tail of the stitch. Tie the
abdominal wall, and finally through the deep sheet of mesh. suture. We use the 3–1–2 knot, supplemented by a few addi-
The stitch then returns as a mattress stitch penetrating the tional throws. The suture material used is 2-0 Prolene on an
deep sheet of mesh, the full thickness of the abdominal wall, atraumatic needle. Insert additional mattress sutures of the
and finally the superficial sheet of mesh before being tied same material at intervals of about 1.0–1.5 cm until half of
with a knot located in the subcutaneous layer. The deep layer the sutures have been inserted and tied. Then insert the
of mesh should be separated from the bowel by the omen- remaining sutures, but do not tie any of them until all have
tum. In the absence of a satisfactory layer of omentum, it been properly inserted. After tying all the sutures, check for
may be preferable to omit the intraperitoneal layer of mesh any possible defects in the repair. When a hernial defect bor-
and to preserve enough hernial sac which after being trimmed ders on the pubis, include the periosteum of the pubis in the
and sutured closed, can be retained as a protective layer to sutures attaching the mesh to the margins of the defect.
separate the intestines from the mesh, which is now used as Be certain to achieve complete hemostasis with electroco-
an onlay patch, as described in the next section. After the agulation or ligatures. If a drain is desired, insert a multiper-
skin flaps have been elevated, which exposes healthy fascia forated closed suction catheter through a small puncture
around the entire circumference of the hernial defect, make wound in the skin. Lead the catheter across the superficial
certain there are no additional hernial defects above or below layer of the mesh and attach it to a closed suction device
the major hernia. If there are additional hernias, combine (Fig. 112.11). Approximate the skin either by subcuticular
them into one large defect by incising the bridge of tissue Monocryl stitch (Fig. 112.12), interrupted nylon sutures, or
between them. skin staples. A closed suction dressing is currently being
Excise the sac down to its point of attachment to the her- used to decrease seroma and wound infection after an open
nial ring and excise subcutaneous fat around the hernial ring. ventral hernia repair (Fig. 112.13a and b).
Then insert one sheet of mesh inside the abdominal cavity
and the other over the rectus fascia. Place the mattress sutures nlay Patch Mesh Repair
O
through the mesh at a point about 2–3 cm away from the As mentioned above, the onlay patch mesh repair is suitable
hernial ring to be certain the sutures engage normal abdomi- when there is no layer of omentum available to be interposed
nal muscle and aponeurosis (Fig. 112.10). A horizontal mat- between the intestines and the mesh. Here, the hernial sac is
tress suture penetrates first the superficial layer of mesh, next preserved. Trim away the excess sac, leaving enough tissue
884 A. P. Santos
Fig. 112.12
Fig. 112.11
using atraumatic 2-0 Prolene. Insert a closed suction catheter

so it can be closed without tension by a continuous 2-0 atrau- through a puncture wound and close the skin in a routine
matic PG suture. This serves as a viable layer that hopefully fashion.
will avoid the development of adhesions between the bowel
and the mesh. The drawback to this technique is that its
sutures, compared with those of the sandwich technique, are Postoperative Care
weaker because the bites of tissue are not equivalent to those
of large mattress sutures, which penetrate the entire abdomi- • Remove the suction drains (if used) 5–7 days following
nal wall. Only the peritoneum of the hernial sac is sutured to operation and if the output is less than 20 cc/day.
cover the defect with this method. • Give perioperative antibiotics.
A piece of Prolene mesh is cut 2–3 cm larger on all sides • Institute early ambulation promptly on recovery from
than the diameter of the hernial defect. The first stitch of 0 anesthesia.
Prolene starts at the caudal margin of the defect and catches • Enhanced recovery after surgery protocol.
the edge of the hernial ring. Tie the stitch and then proceed
with a continuous stitch that fixes the mesh to the dense
fibrous tissue at the margin of the hernial defect. When the Complications
cephalad edge of the hernial defect is reached, insert a sec-
ond stitch and tie it. Anchor the first stitch by tying it to the • Wound Infection. With proper precautions, wound infec-
tail of the second one. The second stitch runs in a continuous tion should be rare following elective repair of a ventral
fashion along the opposite margin of the hernia and is termi- hernia. If an infection of the subcutaneous wound does
nated at the caudal edge of the hernial defect. occur, it is not generally necessary to remove the mesh
Using a similar technique, stitch the edge of the mesh to especially the large pore mesh. Because of its monofila-
the anterior layer of muscle fascia in a continuous fashion ment nature, polypropylene mesh with monofilament
a b
Fig. 112.13
Fortelny RH. Abdominal wall closure in elective midline laparotomy:

Prolene sutures resists infection if the skin incision is the current recommendations. Front Surg. 2018;5:34.
Gurusamy KS, Allen VB, Samraj K. Wound drains after incisional her-
promptly opened widely for drainage. Change the moist nia repair. Cochrane Database Syst Rev. 2012;2:CD005570.
gauze packing daily until clean granulation tissue had Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ven-
formed over the mesh. Then, permit the skin to heal by tral and incisional hernia repair in 407 patients. J Am Coll Surg.
secondary intention. 2000;190:645.
Houston GC, Drew GS, Vazquez R, Given KS. The extended latissi-
• Hematoma. Most hematomas, unless large, can be treated mus dorsi flap in repair of anterior abdominal wall defects. Plast
expectantly. Reconstr Surg. 1988;81:917.
• Seroma formation. Small seroma can be managed expec- Huerta S, Varshney A, Patel PM, Mayo HG, Livingston EH. Biological
tantly. Larger seroma may need to be aspirated but care mesh implants for abdominal hernia repair: US Food and Drug
Administration approval process and systematic review of its effi-
must be done to prevent secondary infection. It is also cacy. JAMA Surg. 2016;151(4):374–81.
recommended to place abdominal binder to prevent Lima HVG, Rasslan R, Novo FCF, Lima TMA, et al. Prevention
re-accumulation. of fascial dehiscence with onlay prophylactic mesh in emer-
gency laparotomy: a randomized clinical trial. J Am Coll Surg.
2020;230(1):76–87.
Ramirez O, Ruas E, Dellon A. “Components separation” method for
closure of abdominal-wall defects: an anatomic and clinical study.
Further Reading Plast Reconstr Surg. 1990;86:519.
Senoz O, Arifoglu K, Kocer U, et al. A new approach for the treat-
Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, et al. Small ment of recurrent large abdominal hernias: the overlap flap. Plast
bites versus large bites for closure of abdominal midline incisions Reconstr Surg. 1997;99:2074.
(STITCH): a double-blind, multicenter, randomised controlled trial. Weissler JM, Lanni MA, Tecce MG, Carney MJ, et al. Chemical
Lancet. 2015;386(10000):1254–60. component separation: a systematic review and meta-analysis of
DiBello JN Jr, Moore JH Jr. Sliding myofascial flap of the rectus botulinum toxin for management of ventral hernia. J Plast Surg
abdominis muscles for the closure of recurrent ventral hernias. Plast Hand Surg. 2017;51(5):366–74. https://doi.org/10.1080/20006
Reconstr Surg. 1996;98:464. 56X.2017.1285783. Epub 2017 Feb 20.
Laparoscopic Ventral Hernia Repair
113
Peter Nau
The indications for laparoscopic ventral hernia repair mirror • Smoking cessation is critical prior to an elective repair.
those of an open repair. The procedure is done electively for Exposure to tobacco increases the risk for both respira-
symptomatic hernias and those that limit activities of daily tory and infectious complications in populations undergo-
living. When there is ambiguity as to the impact of the hering ventral hernia repairs. It also decreases oxygen tension
nia, the HerQLes survey provides a reliable and valid instru- and impairs collagen formation in healing wounds.
ment to evaluate its impact on the patient’s health-related Patients should be abstinent from tobacco for 4 weeks to
quality of life (Krpata et al. 2012). It can accurately define minimize the risk of postoperative complications.
the effect of the hernia and may be used as a tool to docu- References at the end of the chapter give additional infor-
ment improvement in abdominal wall function mation on smoking and hernia repair.
postoperatively. • Weight loss in an obese cohort is also important to
Laparoscopic repair is best undertaken by an experienced improve the durability of a hernia repair. Obese patients
laparoscopic team. It is an approach which is particularly are over-represented in a population with abdominal wall
useful for smaller defects. It is also applicable to multiple defects. They are also more likely to experience postop-
“Swiss cheese defects” that would otherwise necessitate a erative complications when undergoing ventral hernia
large incision when approached with an open technique. As repairs. Currently, a target body mass index (BMI) less
minimally invasive skills have improved and techniques than 40 kg/m2 is preferred as this decreases the likelihood
evolved, it is increasingly common to address large and of both complications and recurrence (Pernar et al. 2017).
recurrent incisional hernias from a laparoscopic approach. It may be appropriate to consider a staged approach start-
While the literature remains equivocal for the general popu- ing with bariatric surgery in those with very high BMIs or
lation, a laparoscopic procedure is likely better in an obese who are refractory to non-operative attempts at weight
individual due to the decreased risk of wound complications. loss.
Conversely, the presence of dense adhesions, particularly • Diabetes is associated with a decrease in collagen synthe-
adhesions to previous mesh placement, renders the mini- sis and deposition in a healing wound. It is also a signifi-
mally invasive approach more difficult, and an open approach cant predictor of morbidity in patients undergoing elective
may be preferred by those who are less proficient laparo- ventral hernia repair. Strict blood sugar control should be
scopically and are not comfortable with complex elective achieved prior to intervention. A target of an HbA1C less
laparoscopic bowel manipulation. Emergency repair of than or equal to 7.3% is a reasonable preoperative goal
incarcerated ventral hernias is generally performed by an (Novitsky and Orenstein 2013).
open, rather than laparoscopic, approach. • The stomach will often be distended during the preoxy-
genation stages of anesthetic induction and can result in
gastric injury. Orogastric tubes should be placed prior to
establishing access to the abdomen.
• Perioperative antibiotics should be administered accord-
P. Nau (*) ing to Surgical Care Improvement Program (SCIP) guide-
Department of Surgery, Roy J. and Lucille A. Carver College of
Medicine, University of Iowa, Iowa City, IA, USA lines. Re-dosing of antibiotics should be completed based
e-mail: peter-nau@uiowa.edu on operative time.

https://doi.org/10.1007/978-3-030-81415-1_113
888 P. Nau
• In particularly complex patients or those reticent to com-

ply with preoperative recommendations, the Carolinas
Equation for Determining Associated Risks (CeDAR) app
produced by the Carolinas HealthCare system is available
for use on all devices running iOS. This program is able
to risk stratify patients for wound complications and the
associated financial impact following ventral hernia
repairs.
• Accessing the abdomen in a multiply operated abdomen

• Injury to bowel, either unnoticed or identified during
surgery
• Inadequate mesh fixation leading to recurrent hernia
formation
• Failure to achieve adequate mesh overlap
• Chronic pain associated with mesh fixation
Operative Technique
atient Positioning and Preparation

P
of the Defect
Position the patient supine on the operative table. Place a

footboard on the operating table in any case where reverse
Trendelenburg positioning will be utilized. When feasible, Fig. 113.1
tuck both arms in order to facilitate working in all quadrants
of the abdomen. An Ioban dressing may be utilized to ade-
quately anchor the drapes to the patient and to isolate the (Fig. 113.1). Conversely, if the hernia is in the lower abdo-
mesh from skin flora. A Foley catheter is used at the sur- men, position the trocars as shown in Fig. 113.2.
geon’s discretion based on expected difficulty and duration First, inspect the abdomen. Sometimes the contents of the
of the case. In the event that mesh placement in the pelvis is hernia sac will reduce as the abdominal wall expands with
anticipated, place a Foley catheter to prevent injury of the pneumoperitoneum. Often adhesions between omentum or
bladder during mesh fixation. bowel and the hernia defect persist, particularly around the
Choose an entry site remote from incisions and away edges of the defect. Gently reduce these adhesions into the
from the hernia. Initial entry into the abdomen is usually abdomen. Use energy modalities sparingly; usually, the
made with a Veress needle placed through a stab incision in adhesions are avascular, and simple blunt or sharp dissection
the left upper quadrant. Entrance is then established using a suffices. Bleeding is usually minimal. It is crucial to perform
5-mm optical trocar in the left upper quadrant. Additional this dissection with care, as inadvertent enterotomy produces
port placement is dictated by the hernia location and pres- a contaminated field not favorable to mesh placement.
ence and severity of adhesions. In the event of dense adhe- If an enterotomy occurs, carefully repair the bowel
sions, it is best to place initial trocars on the left lateral according to your individual skill set. A conversion to open
abdominal wall to facilitate safe and efficient adhesiolysis should not be considered outside the standard of care. In this
without working “against the camera.” It is critical to stay scenario, consider performing the hernia repair at a later date
lateral with port positioning so that trocars span the perime- (staged repair). With that said, there is increasing support in
ter of the defect and are sufficiently far apart and distant from the literature that synthetic mesh is a reasonable option in a
the hernia defect to allow a comfortable working distance. If clean-contaminated field from both an outcome and cost
the hernia is in the upper abdomen, position instruments and consideration. There are no good randomized data. It is pru-
laparoscope along an arc in the lower and lateral abdomen dent to address this topic with the patient prior to surgery in
order to assess the patient’s degree of risk aversion. See ref-
113 Laparoscopic Ventral Hernia Repair 889
Fig. 113.3
Fig. 113.2
erences at the end of chapter for further information on this

topic.
Once all adhesions are lysed, identify all defects. A
missed defect is a common cause of recurrence, and it is only
when the entire abdominal wall can be visualized laparo-
Fig. 113.4
scopically that you can be certain no defects remain.
Figure 113.3 shows the kind of Swiss cheese defects that
laparoscopic incisional ventral hernia repair is well-suited or tacked back up to the mesh to prevent bowel herniating
for. into this pocket.
If the hernia is in the lower abdomen (as is seen with a
Pfannenstiel incision), it may be necessary to create a pre-
peritoneal plane. This allows the bladder to be gently dis- Sizing the Mesh
placed posteriorly to avoid inadvertent injury during tack
placement. Furthermore, dissection can be carried posterior Map the extent of the area that must be covered with a
to Cooper’s ligament to allow for sufficient caudal overlap to 22-gauge spinal needle. Pass the needle directly into the
decrease the risk for recurrence. This is typically accom- abdomen under laparoscopic visualization at the upper
plished with a hot scissors to create a preperitoneal flap simi- aspect of the most cephalad defect. Pass a second needle
lar to that used for a transabdominal preperitoneal inguinal directly into the abdomen at the lower aspect of the most
hernia. The majority of the dissection can be accomplished caudal defect. Pass a measuring tape into the abdomen and
bluntly after entering this space. Having successfully com- measure the distance between the two spinal needles
pleted mesh fixation, the peritoneum can then be handsewn (Fig. 113.4). Add 10 cm to this distance, to allow a 5 cm
890 P. Nau
overlap at each end. This measurement tells you the long axis
of the patch. Mark the skin at the entry site of these needles.
Repeat this maneuver with the farthest lateral aspects of the
defect or defects on each side. This distance (with an addi-
tional 10 cm for overlap) gives you the width of the patch.
Remove the measuring tape from the abdomen.
There are numerous mesh options available to the hernia
surgeon. Laparoscopic-specific products typically feature a
collagen barrier on one side to limit visceral attachments
prior to mesh incorporation. Choice of mesh is often dictated
by hospital contracts. To date, no synthetic mesh has been
absolutely proven to be superior to others. Cut the patch to
size. Mark the side that is to face the viscera. The mesh will
be anchored with four to six transfascial sutures depending
on the size of the mesh being used. Place these sutures in
predetermined spots such that the long tails are on the
“uncovered” side of the mesh and leave the tails long. If the
skin is covered by an adhesive drape, simply place it on the
abdominal wall and outline the desired shape, and identify Fig. 113.5
the transfascial suture sites directly. Roll the mesh up into a
tight cylinder and pass it into the abdomen. Unfurl it so that
the marked side is made to face the viscera and separate the
sutures so that they can be easily manipulated into the suture
passer.
It is crucial that the mesh be centered over the defect with
adequate overlap and proper orientation. The mesh must also
be placed with sufficient tautness to encourage tissue
ingrowth and mesh incorporation. It is easiest to use the
mesh tracing on the anterior abdominal wall to dictate trans-
fascial suture placement. Pass each suture 1–2 cm lateral to
the mesh edges to accommodate for the thickness of the
abdominal wall and avoid gathering of the mesh. For each
suture, make a small incision in the skin. Pass a suture passer
into the abdomen, grasp one end of the preplaced suture, and
pull it out through the fascia. Take care not to pull the other
end out of the mesh, anchoring it as needed with a grasper.
Then replace the suture passer through a slightly different
point in the fascia and grasp and retrieve the other end. Place
a hemostat on this suture (Fig. 113.5). Pull all of the sutures Fig. 113.6
tight before tying in order to ascertain that the mesh becomes
taut and accurately spans the defect. Some surgeons will par-
tially desufflate the abdomen at this point to more nearly where. Figure 113.8 shows completed intraperitoneal only
approximate normal anatomy and verify that the mesh does mesh placement with a caudal bladder flap to allow for low
not gape. If the mesh spans the defect nicely, tie these deep mesh placement.
to the subcutaneous tissues (Fig. 113.6). Take care not to Check hemostasis. If omentum is available, bring it down
catch any subcutaneous tissue in the tie, as this may cause to lie under the mesh. Inject trocar sites with local anesthe-
unsightly dimpling. sia. Remove the trocars and close sites as usual.
It is now relatively simple to secure the perimeter of the
mesh circumferentially with a hernia tacker (Fig. 113.7).
Depending on the size of the mesh, it may be advisable to Management of the Fascial Defect
place additional transfascial sutures to anchor the mesh to
the abdominal wall. Again, check by partially desufflating There is increasing emphasis placed on the compromised
the abdomen to ensure that the mesh does not gape any- quality of life associated with an incisional hernia as well as
113 Laparoscopic Ventral Hernia Repair 891
Fig. 113.9
Increasingly, laparoscopic surgeons are attempting to

reapproximate the fascial edges prior to mesh placement,
effectively obliterating the hernia defect. This can be done
with stab incisions made in the midline every 1–2 cm along
Fig. 113.7 the length of the hernia prior to mesh fixation. Using a suture
passer, a nonabsorbable suture is passed through the fascial
edges on either side of the defect to bring together the mid-
line. Using this technique, the abdominal pressure should be
decreased prior to tying all of the sutures so as to avoid unde-
sirable tension. Alternatively, there are numerous knotless
sutures with “barbs” that prevent suture from backing out of
the tissue. This suture is an ideal adjunct to close the fascia
using intracorporeal skills. Similar to the transfascial
approach, decreasing the abdominal pressure will facilitate
reapproximation. In either case, given the fact that is not a
true tension-free repair, a piece of mesh tailored closer to the
original hernia size is indicated to achieve adequate overlap
in the event that the primary repair fails.
More recently, advanced laparoscopic techniques have
been described which reproduce the classic Rives Stoppa
operation utilizing a laparoscopic approach. This is begun by
Fig. 113.8 entering the retrorectus space similar to the approach used for
a totally extraperitoneal inguinal hernia repair. The surgeon
the resultant improvement accompanying a surgical repair. then creates bilateral myofascial flaps using a combination of
Fundamental to this equation is the patient’s abdominal wall blunt and cautery dissection. Figure 113.9 shows re-approxi-
function. While current research is not definitive, it has been mated posterior sheath at the bottom of the picture with an
suggested that reapproximation of the midline may yield appropriate-sized piece of mesh lying on top. Following clo-
improved abdominal wall strength (Den Hartog et al. 2010). sure of the posterior sheath, the mesh can be placed in the
Additionally, seroma formation has historically been the retrorectus space. Finally, the anterior fascia is closed most
Achilles heel of the laparoscopic repair. A hernia sac is ubiq- often with a running, barbed suture. Figure 113.10 shows the
uitous. Collapsing this potential space postoperatively can be completed repair after reapproximation of fascial edges using
problematic laparoscopically. There is increasing evidence fascial suture. This technique has the benefits of allowing for a
that closure of the fascial defect may yield decreased seroma tension-free reapproximation of the rectus muscles while also
rates and overall adverse hernia-site events postoperatively isolating the mesh from the intra-abdominal contents and the
(Tandon et al. 2016). associated risk of unwanted postoperative adhesions.
892 P. Nau
lematic postoperatively. Referral to a pain management

clinic for chronic analgesics such as gabapentin and/or inter-
ventional procedures to ablate the offending nerve are rea-
sonable adjuncts to reliance on opiates alone.
References
Den Hartog D, Eker HH, Tuinebreijer WE, Kleinrensink GL, Stam HJ,
Lange JF. Isokinetic strength of the trunk flexor muscles after surgi-
cal repair for incisional hernia. Hernia. 2010;14(3):243–7.
Krpata DM, Schmotzer BJ, Flocke S, Jin J, Blatnik JA, Ermlich B,
Novitsky YW, Rosen MJ. Design and initial implementation of
HerQLes: a hernia-related quality-of- life survey to assess abdomi-
Fig. 113.10 nal wall function. J Am Coll Surg. 2012;215(5):635–42.
Novitsky YW, Orenstein SB. Effect of patient and hospital character-
istics on outcomes of elective ventral hernia repair in the United
Postoperative Care States. Hernia. 2013;17(5):639–45.
Pernar LIM, Pernar CH, Dieffenbach BV, Brooks DC, Smink DS,
Tavakkoli A. What is the BMI threshold for open ventral hernia
Postoperative care is routine. These procedures are typically repair? Surg Endosc. 2017;31(3):1311–7.
done on an outpatient basis. Seroma formation is virtually Tandon A, Pathak S, Lyons NJ, Nunes QM, Daniels IR, Smart NJ. Meta-
universal, and the patient must understand that this is a nor- analysis of closure of the fascial defect during laparoscopic inci-
mal finding and not a recurrence of the hernia. Many sur- sional and ventral hernia repair. Br J Surg. 2016;103(12):1598–607.
geons advise wearing an abdominal binder to minimize
seroma formation during the first few weeks.
Further Reading
Complications Bansal VK, Misra MC, Babu D, Singhal P, Rao K, et al. Comparison
of long-term outcome and quality of life after laparoscopic repair of
incisional and ventral hernias with suture fixation with and without
Missed enterotomy is the most feared complication of this tacks: a prospective, randomized, controlled study. Surg Endosc.
procedure. Take extreme care during adhesiolysis, and care- 2012;26(12):3476–85.
fully inspect the bowel several times. If an enterotomy Bondre IL, Holihan JL, Askenasy EP, Greenberg JA, et al. Suture, syn-
thetic, or biologic in contaminated ventral hernia repair. J Surg Res.
occurs, repair it either laparoscopically or through an open 2016;200(2):288–94.
incision. In this case, safety is of primary importance and Colavita PD, Tsirline VB, Walters AL, Lincourt AE, Belyansky I,
should override any concerns of improved cosmesis or dis- Heniford BT. Laparoscopic versus open hernia repair: outcomes and
charge timing. As stated earlier, mesh placement in this situ- sociodemographic utilization results from the nationwide inpatient
sample. Surg Endosc. 2013;27(1):109–17.
ation is a controversial subject. The use of a synthetic mesh Fischer JP, Basta MN, Krishnan NM, Wink JD, Kovach SJ. A cost-
in an intraperitoneal onlay position in this setting may be utility assessment of mesh selection in clean-contaminated ventral
inadvisable at this point in time. hernia repair. Plast Reconstr Surg. 2016;137(2):647–59.
Recurrent hernia can occur. Minimize the risk of this by Kubasiak JC, Landin M, Schimpke S, Poirier J, Myers JA, Millikan
KW, Luu MB. The effect of tobacco use on outcomes of laparo-
carefully identifying all defects and by sizing the mesh scopic and open ventral hernia repairs: a review of the NSQIP data-
appropriately (sufficient overlap). It has been advocated that set. Surg Endosc. 2017;31(6):2661–6.
the entire incision should be covered by mesh notwithstand- Majumder A, Winder JS, Wen Y, Pauli EM, Belyansky I, Novitsky
ing the extent of the fascial defect as there is a risk for further YW. Comparative analysis of biologic versus synthetic mesh out-
comes in contaminated hernia repairs. Surgery. 2016;160(4):828–38.
disruption of the incision uninvolved in the hernia. Finally, Pluvy I, Garrido I, Pauchot J, Saboye J, Chavoin JP, Tropet Y, Grolleau JL,
the obese patient has consistently been shown to have Chaput B. Smoking and plastic surgery, part I. Pathophysiological
increased risk of recurrences. Maximizing preoperative aspects: update and proposed recommendations. Ann Chir Plast
weight loss is critical to success of the repair. Esthet. 2015;60(1):e3–e13. (Epub 2014).
Thomsen T, Tonnesen H, Moller AM. Effect of preoperative smoking
Pain due to sutures traversing the richly innervated pari- cessation interventions on postoperative complications and smoking
etal peritoneum can also occur. Management can be prob- cessation. Br J Surg. 2009;96(5):451–61.
Operations for Infected Abdominal
Wound Dehiscence, Necrotizing 114
Fasciitis, and Intraabdominal Abscesses
Ariel P. Santos
Indications noninvasive cardiac monitoring, lactic acid, and blood gas

determinations.
• Necrotizing soft tissue infections (NSTI) • Intensive care unit admission if necessary.
• Surgical site infections: classified as superficial inci- • Nutritional support preferably enteral if possible.
sional, deep incisional, and organ or space surgical site • Glycemic control.
infection.
• Infected dehiscence, with or without evisceration
• Intraabdominal abscess Pitfalls and Danger Points
• Inadequate debridement of devitalized tissue

Preoperative Preparation • Bleeding and significant blood loss from overzealous
debridement
• Obtain adequate blood and wound culture with sensitivity • Obtain high-quality specimen for gram stain and culture
testing. to identify the causative pathogens and its antimicrobial
• Administer therapeutic doses of systemic broad-spectrum susceptibility
intravenous antibiotics effective against gram-positive, • Deescalate antibiotic as needed
gram-negative, enterococci, and anaerobic organisms • Failure to identify and drain intraabdominal abscesses,
guided by the local antibiogram. including loculations and multiple abscesses
• Radiographic imaging: computed tomography is the most • Failure to identify the source of the infection like a vis-
commonly favored modality for imaging in necrotizing ceral injury, perforation, or fistula
soft tissue infection as well as localization of the source of • Serosal or intestinal tear and injury to the spleen, liver, or
abdominal sepsis. urinary bladder
• Use of scoring system, the Laboratory Risk Indicator for
Necrotizing fasciitis (LRINEC) scoring system, has
shown to be useful in differentiating NSTI from other perative Strategy: Infected Abdominal Wall
O
infections, though disproving may need either imaging or and Dehiscence
surgical exploration.
• Establish nasogastric suction if indicated. The treatment strategies for abdominal infection (Fig. 114.1)
• Insert a Foley catheter in selected cases, especially if include appropriate resuscitation with immediate adminis-
exploratory laparotomy is required. tration of empiric antibiotics guided by the institutional anti-
• In the elderly and critically ill patients, monitor fluid biogram. Expedient source control is imperative; depending
requirements and cardiorespiratory function by means of on the situation this can be done percutaneously under radio-
graphic guidance, laparoscopically, and open or gross
debridement. It is also paramount to obtain high-quality
specimen for gram stain and culture to identify the causative
A. P. Santos (*)
Department of Surgery, Texas Tech University Health Sciences pathogen. This will also guide timely antibiotic deescalation.
Center, Covenant Medical Center, Lubbock, TX, USA Once infection is controlled, follow-up wound care and
e-mail: ariel.santos@ttuhsc.edu eventual reconstruction maybe necessary.

https://doi.org/10.1007/978-3-030-81415-1_114
894 A. P. Santos
Fig. 114.1 Treatment Strategies for Abdominal Infections
Source Control:
Immediate
Surgery or
Resucitation antibiotic
percutaneous
coverage
drainage
Pathogen
Local wound
Timely antibiotic Identification &
care and
de-escalation Microbial
Reconstruction
sensitivity
release of loculations, secure specimens for microbiologic

examination followed by wet-to-dry dressing of the open
wound. This can be done at the bedside with just IV or oral
analgesics.
Wide Debridement
There is a trend for skin sparing debridement but this should

not compromise adequate debridement of devitalized tissue.
Use scissors or scalpel to remove all nonviable tissue
(Fig. 114.3a and b). The push test described above can be
used to further delineate extent of debridement. Bleeding in
itself is not an indication of tissue viability since active infec-
tion will render some area hyperemic. Also, the surgical
Fig. 114.2 team must pay attention to significant blood loss. Maintain
meticulous hemostasis and prepare for possible blood trans-
Local Exploration fusion if deemed appropriate. Inadequate debridement can
lead to leaving devitalized tissue, which can be a nidus for
Delay in the diagnosis of NSTI leads to delay in definitive further infection. Wide debridement of right chest area for
treatment. Surgical exploration is reasonable in case of severe surgical site infection following local excision of
doubt. This will require full-thickness elliptical excision of basal cell carcinoma in Fig. 114.3a. Another example of
all tissue down to the fascia and muscle to rule out necrotiz- wide debridement, this time of a perineal wound extending
ing fasciitis or myositis (Fig. 114.2). This local wound explo- to the abdominal wall, is shown in Fig. 114.3b. Note that in
ration can be performed bedside under local anesthesia if each case, the debridement extends well beyond the initial
tolerated. The wound is inspected for necrosis, purulence, visible area of concern and clean, viable tissue (with excel-
dishwater fluid, or discoloration of tissue. Use the “Push lent hemostasis).
Test” or blunt finger pressure to differentiate viable and non-
viable tissue. Normal viable tissue is firm and resists pres-
sure from the pushing finger, whereas necrotic tissue does Managing the Abdominal Wall Defect
not. If the surgeon is able to dissect using blunt finger pres-
sure, this is considered a positive finding and warrants for- Closure of even small abdominal wall defects in the setting
mal wide debridement. Obtain at least a 1 cm3 of skin and of necrotizing infection is doomed to failure. The strategy
subcutaneous tissue and samples from fascia and muscle if that has evolved accepts the trade-off of a possible inci-
warranted for microbiologic examination. Viable muscle sional hernia for a better chance of patient survival. Small
reacts with application of electrocautery in the absence of defects (<4–6 cm in diameter) may be managed by Adaptic
paralytics. gauze covered with moist gauze packing. Larger defects
Superficial and deep surgical site infection can be man- may be managed by application of a vacuum dressing
aged by removing the staples, drainage of the abscess with (Fig. 114.4) or closure with absorbable mesh like Vicryl or
114 Operations for Infected Abdominal Wound Dehiscence, Necrotizing Fasciitis, and Intraabdominal Abscesses 895
Fig. 114.3
biologic mesh (Fig. 114.5a and b). Dressing changes and epeat Laparotomy for Recurrence
R
subsequent granulation tissue formation ultimately result in of Abdominal Sepsis
a surface that can be covered with a split-thickness skin
graft (Fig. 114.6). Generally, the large resulting incisional Always anticipate the potential need for repeat exploration.
hernia is managed by healing by secondary intention, If reexploration is likely, use a vacuum dressing. Sometimes,
delayed repair, possibly involving component separation, after successfully debriding an infected abdominal incision
or musculocutaneous flap once recovered from the acute and repairing the defect with mesh, subsequent clinical
affliction. observation may disclose the need to reexplore the abdomen
896 A. P. Santos
colostomy (C), and negative pressure dressing is placed if

the area is deemed adequately debrided.
It is challenging to manage an open abdomen with entero-
atmospheric fistula typically seen after mesh closure of open
abdomen. Isolation of the fistula using small red rubber tube
will provide accurate measurement of the output and protec-
tion of the wound and the surrounding skin (Fig. 114.10a).
Baby bottle nipple or teat is used to further secure the area.
This effectively separates the enteric drainage from the
wound. The open wound is then managed by negative pres-
sure dressing (Fig. 114.10b). Lay a white sponge or Adaptic
gauze before placing the black sponge. Once granulation tis-
sue is formed, this can be managed by split-thickness skin
grafting.
arsupialization and Open Abdomen

M
Management
When complex collections with multiple loculations and

necrotic tissue are encountered, the probability of recurrence
is high. In the critically ill patient, consider leaving the abdo-
men open (and applying a vacuum dressing) so that daily
explorations, debridements, irrigation, and packing can be
done in the intensive care unit. Closure (generally using
mesh) is performed once sepsis has been controlled.
Fig. 114.4
Intraabdominal Abscesses
for recurrent sepsis between the loops of small bowel, the
pelvis, the subhepatic or subphrenic spaces, or elsewhere. Source control is important. Percutaneous drainage is pre-
Temporary abdominal closure using dynamic traction ferred for walled-off abscesses and should be done as soon as
devices like ABRA™ (Fig. 114.7) or Wittmann patch possible. Operative drainage is reserved for failure of percu-
(Fig. 114.8) used with negative pressure dressing allows taneous drainage, multiple abscesses, and absence of safe
dynamic traction closure of an open abdomen. percutaneous route.
Management of Intestinal Stomas and Fistulas Approaches to Abscess Drainage
When a patient who is taken to the operating room for Percutaneous Drainage
debridement of an infected abdominal incision also requires Percutaneous drainage under radiographic guidance (ultra-
exteriorization of an intestinal fistula or requires a colos- sound or CT scan) is appropriate for unilocular or sometimes
tomy, avoid loop colostomy or enterostomy creation. This multiple abscesses that are accessible. Figure 114.11 shows
type of stoma is difficult to control, and secretions continu- percutaneous drainage of suprahepatic and intrahepatic
ously contaminate the open abdominal wound. If possible, abscesses. It is relatively less invasive and associated with
create matured end stomas of the small bowel or colon and lower morbidity. Small abscesses less than 5 cm may be
bring them out at sites well away from the open abdominal managed to full resolution by antibiotics and percutaneous
wound. If the surgical site infection involves the ostomy, aspiration without leaving a drain. Larger abscess requires a
resite the ostomy to the other side away from the infected drain until the abscess cavity is collapsed or resolved.
area. As shown in Fig. 114.9, it is important to contain the Removal of the drain is based on the drain output, but in
ostomy output by securing it with a catheter (A) or suturing certain instances drain study or contrast imaging is ordered
it close. It is important to identify and mend the source of to ensure proper timing of drain removal. Occasionally, a
infection and debride all nonviable tissue (B). Resite the safe route is not available and operative drainage is required
Fig. 114.5
898 A. P. Santos
Fig. 114.6
Fig. 114.7
either laparoscopic or open. Operative drainage is also as the tip of the eleventh rib. The layers of the abdominal
needed when there are multiple abscesses, unavailability of wall are divided down to the peritoneum. The surgeon
percutaneous intervention resources, presence of diffuse then dissects the peritoneum away from the diaphragm
peritonitis, intestinal loop abscesses, or associated intraab- until the abscess is reached. The lateral extraperitoneal
dominal pathology that requires correction or when repeated approach may also be used to treat a right posterior intra-
percutaneous drainage fails to eradicate the infection. hepatic abscess. DeCosse and associates were successful
in draining left subphrenic and left posterior infrahepatic
abscesses in the lesser sac through the subcostal or lateral
ateral and Subcostal Extraperitoneal
L extraperitoneal approach. The lesser sac abscesses were
Approach reached by dissecting the peritoneum away from the upper
pole of the kidney. The right suprahepatic subphrenic
DeCosse and associates modified the subcostal extraperi- abscess is easily approached through an anterior (subcos-
toneal approach by extending it in a lateral direction as far tal) extraperitoneal approach. An abscess in the left ante-
Fig. 114.8
a b c d
Fig. 114.9
rior infrahepatic space is best approached by performing a Percutaneous drainage is an important nonoperative inter-
laparotomy. ventional procedure but surgery is still the cornerstone in the
management of intraabdominal infection. Only surgical
intervention, laparoscopic or open, can do appropriate source
Laparoscopy control like resection of diseased viscera, repair of perfora-
tion, debridement of pancreatic necrosis, and removal of
There is an increasing utility of laparoscopy in diagnosing infected organ like gallbladder or appendix. Minimally inva-
and treating intraabdominal infections (Fig. 114.12a–d). sive approach has the advantage of shorter hospitalization,
900 A. P. Santos
Fig. 114.10
Fig. 114.11
a b
c d
Fig. 114.12
lesser pain, fewer postoperative complications, and faster which limit mobilization and exposure and may need open
recovery and return to work. Laparoscopy is ideal in easily approach.
accessible abscess of the peritoneal cavity, pelvic, sub-
phrenic, and solid organ abscess. The use of laparoscopy will
depend on the surgeon’s experience, the disease pathology, Laparotomy
patient’s condition, and tolerance of abdominal insufflation.
Intermesenteric abscess and retroperitoneal abscess can be Laparotomy is still the main stay in the management of
challenging due to adherence of surrounding structures, intraabdominal infection, especially in the absence of percu-
902 A. P. Santos
taneous resources, failure of multiple percutaneous treat- preferred. Cut the mesh so it is only 1 cm larger than the
ment, complex and multiple abscess without safe abdominal defect. Be certain that all intraabdominal
percutaneous window, intermesenteric and interloop abscesses have been evacuated. Attempt to place a layer of
abscesses, and failure of laparoscopic approach. omentum between the mesh and the underlying bowel. In no
When the transperitoneal approach has been elected, we case should a bowel anastomosis ever be left in contact with
prefer a midline incision, especially if there is suspicion of synthetic mesh. Then, use atraumatic sutures of 1-0 PDS or
an anastomotic leak or an abscess located within the folds or prolene to attach the cut end of the mesh to the undersurface
the small bowel mesentery. If exploration of the subphrenic, of the abdominal wall. In most cases, continuous sutures are
subhepatic, and lesser sac spaces does not reveal the source employed. For both techniques, take a larger bite of the
of the patient’s sepsis, it may be necessary to free the entire abdominal wall than of the mesh; otherwise, the mesh wrin-
small bowel and the pelvis to rule out an abdominal abscess. kles. Apply slight tension to the mesh when inserting these
Previous recent laparotomy or suspicion of hostile abdomen, sutures so it lies as flat as possible. It is helpful to insert the
may require subcostal approach to drain the abscess. suture through the entire thickness of the rectus muscle
including the anterior rectus fascia; otherwise, the muscle
and peritoneum may have inadequate holding power. After
Extraserous Approach the mesh has been sutured in place, apply gauze packing
moistened with isotonic saline.
Dissection in the extraserous preperitoneal or retroperitoneal
plane is generally simple if the surgeon enters the proper
plane by incising the transversalis fascia but not the perito- xtraserous Subcostal Drainage of Right
E
neum. The incision should be made long enough to admit the Subphrenic Abscess (Surgical Legacy
surgeon’s hand. Blunt dissection then separates the perito- Technique)
neum from the undersurface of the diaphragm until an area
of induration is reached. This represents the abscess. Incision and Exposure
Generally, blunt dissection with a finger permits entry into Make a 10- to 12-cm incision, beginning near the tip of the
the abscess. Intraoperative ultrasonography or aspiration right eleventh rib and continue medially parallel to the costal
with a long spinal needle helps establish the location with margin. Carry the incision through the external oblique mus-
certainty in difficult cases. Although it is possible to drain cle and aponeurosis. Generally, the internal oblique muscle
abscesses in the posterior right subhepatic space and in the can be separated along the line of its fibers. It is usually nec-
lesser sac by the extraserous approach, we usually prefer a essary to divide the ninth intercostal nerve. Then, transect the
laparotomy to drain these two spaces. transversus muscle with electrocautery. Identify the transver-
When an extraserous approach has failed to reveal an salis fascia and carefully divide it with scissors, revealing the
abscess, it is generally simple to lengthen the incision in the underlying peritoneal membrane. Use a gauze sponge on a
abdominal wall transversely, converting it to a subcostal inci- sponge holder to dissect the peritoneum away from the trans-
sion. Then, incise the peritoneum and continue the explora- versalis fascia. Continue the dissection upward by inserting
tion for the abscess transperitoneally. Alternatively, make a the hand to separate the peritoneum further from the under-
second vertical midline incision for further exploration. surface of the diaphragm until the dome of the liver is reached.

Operative Technique After exposing an area of induration in one of the subphrenic
spaces, enter the abscess by inserting a fingertip or the tip of
During surgery for large abdominal defects that remain after a blunt Kelly hemostat. Open the abscess cavity widely and
wide debridement of infected abdominal incisions, we rec- irrigate out the purulent material after obtaining a sample for
ommend using the simplest possible closure technique in cultures followed by placement of a large closed suction
critically ill patients. For most, this will be a simple vacuum drain.
dressing. This is fast, controls leakage, and allows easy reex-
ploration in the operating room or intensive care unit. It has
the disadvantage of allowing the fascia and muscles to aparotomy for Subphrenic and Abdominal
L
retract, making subsequent closure more difficult. Retraction Abscesses
of fascia can be prevented by using dynamic traction devices
like Wittmann patch described earlier. Incision and Exposure
If the patient is sufficiently stable and reoperation is not When draining an accurately localized right infrahepatic
likely, simple closure of the fascia with absorbable mesh is abscess, a right lateral subcostal incision is suitable. Left
anterior infrahepatic and lesser sac abscesses, suprahepatic sump drains are suitable for subphrenic abscesses, there is
abscesses, and most other abdominal abscesses are better considerable risk of creating a fistula if a large and rigid plas-
drained through midline incisions. If the patient has had a tic drain remains in contact with a segment of bowel for
recent operation through a midline incision, try to enter the more than 2 weeks.
abdomen by extending the previous midline incision into a
virgin area of the abdominal wall to minimize the chance of
injuring densely adherent bowel. After the abdomen is Postoperative Care
opened, identify the falciform ligament and peritoneum.
Dissect these two structures away from all the underlying • Continue therapeutic dosages of appropriate antibiotics.
bowel and omentum, first on the right side and then on the • Change the gauze packing over the mesh every 8–12 h
left. Then pass a hand over the liver to explore the suprahe- until it is ascertained that there has been no extension of
patic and then the infrahepatic spaces (Fig. 114.13a–c). the necrotizing infection. Thereafter, inspect the wound
Divide the avascular portion of the gastrohepatic ligament and change the dressing daily.
and enter the lesser sac behind the lesser curvature of the • If a vacuum dressing has been applied, change as per
stomach. If this approach has been obliterated by previous protocol.
surgery or adhesions, enter the lesser sac by dividing the • Observe the patient carefully for recurrent abdominal sep-
omentum along the greater curvature and expose the poste- sis and take appropriate diagnostic, therapeutic, and sur-
rior wall of the stomach and the anterior surface of the pan- gical measures to correct this sepsis.
creas. Identify the right and left paracolic spaces and expose • After the wound is cleaned and granulation has formed,
the pelvic cavity, as both are likely abscess sites, especially if the defect is small, it is possible that epithelialization
in patients suffering ruptured appendicitis or diverticulitis. may proceed spontaneously. In most cases, as abdomi-
Finally, if it is necessary to rule out the possibility of an internal distension disappears, wrinkling of the mesh pre-
loop abscess, the surgeon must patiently free the entire length cludes spontaneous healing. In these cases, remove the
of small intestine and its mesentery. Perform a needle cath- mesh when the wound is clean and the patient’s condi-
eter jejunostomy in all patients not likely to resume oral tion has stabilized, preferably around the 20th postop-
nutrition early in the postoperative course. erative day. Then, apply a split-thickness graft over the
granulations covering the intestinal viscera. Delay
Drainage and Closure definitive repair of a large abdominal hernia until a later
When a long midline incision has been used, bring drains out date.
through suitable stab wounds. Although large soft silastic
a b c
Fig. 114.13
904 A. P. Santos
Postoperative Care After Abscess Drainage Fernando SM, Tran A, Cheng W, Rochwerg B, Kyeremanteng K, Seely
AJE, et al. Necrotizing soft tissue infection: diagnostic accuracy of
physical examination, imaging, and LRINEC score: a systematic
• If the abscess cavity was not rigid and its walls collapsed review and meta-analysis. Ann Surg. 2018;269(1):58–65. https://
after the pus was evacuated, remove the drains after doi.org/10.1097/SLA.0000000000002774.
10–14 days. If there is any question about a residual cav- Kohl A, Rosenberg J, Bock D, et al. Two-year results of the random-
ized clinical trial DILALA comparing laparoscopic lavage with
ity, inject sterile Hypaque or other iodinated aqueous resection as treatment for perforated diverticulitis. Br J Surg.
contrast medium through the sump drain to obtain a
2018;105(9):1128–34. https://doi.org/10.1002/bjs.10839.
radiographic sinogram or CT scan. Leave at least one of Martinez M, Peponis T, Hage A, Yeh DD, Kaafarani HMA, Fagenholz
the drains in place until the cavity has been eliminated. PJ, et al. The role of computed tomography in the diagnosis of nec-
rotizing soft tissue infections. World J Surg. 2018;42(1):82–7.
• If the patient has a large abscess cavity with rigid walls Mazuski JE, Tessier JM, May AK, et al. The surgical infection society
and thick pus, consider the advantages of irrigating the revised guidelines on the management of intra-abdominal infection.
abscess daily through one of the sump catheters with a Surg Infect. 2017;18(1):1–76. https://doi.org/10.1089/sur.2016.261.
dilute antibiotic or sterile saline solution. Puckett Y, Caballero B, Tran V, Estrada M, McReynolds S, Richmond
RE, Ronaghan CA. A case series of successful abdominal closure
utilizing a novel technique combining a mechanical closure system
with a biologic xenograft that accelerates wound healing. J Vis Exp.
2019;(149):e57154. https://doi.org/10.3791/57154.
Further Reading Sartelli M, Chichom-Mefire A, Labricciosa FM, Hardcastle T, Abu-
Zidan FM, Adesunkanmi AK, et al. The management of intra-
abdominal infections from a global perspective: 2017 WSES
Boyd DP. The subphrenic spaces and the emperor’s new robes. N Engl
guidelines for management of intra-abdominal infections. World J
J Med. 1966;275:911.
Emerg Surg. 2017;12:29.
Coccolini F, Tranà C, Sartelli M, et al. Laparoscopic management
Zielinski MD, Kuntz M, Zhang X, Zagar AE, et al. Botulinum toxin
of intra-abdominal infections: systematic review of the litera-
A induced paralysis of lateral abdominal wall after damage
ture. World J Gastrointest Surg. 2015;7(8):160–9. https://doi.
control laparotomy: multi-institutional, prospective, random-
org/10.4240/wjgs.v7.i8.160.
ized, placebo-controlled pilot study. J Trauma Acute Care Surg.
Dellinger EP. Severe necrotizing soft-tissue infections: multiple disease
2016;80(2):237–42.
entities requiring a common approach. JAMA. 1981;246:1717.
Part XI
Breast and Melanoma
Sonia L. Sugg
Concepts in Breast Surgery
115
Sonia L. Sugg, Sophia L. Fu, and Carol E. H. Scott-Conner
Introduction Breast Cancer Risk
The multidisciplinary management of breast cancer is best Breast cancer risk assessment should be part of the initial
led by a surgeon. In order to fulfill this role, the surgeon must history and physical of any woman with a breast problem.
keep current with the literature and new consensus state- Hormonal exposure, a known risk factor for breast cancer,
ments. Most surgeons who treat patients with breast cancer should be assessed by querying for age at menarche, first
also take care of women with benign breast problems. This parity, menopause, and use of hormonal contraceptives or
chapter provides a brief overview of both. replacement. Alcohol intake is associated with breast cancer
risk in a dose-dependent fashion and needs to be docu-
mented. A detailed family history of breast, ovarian, and
Breast Cancer other cancers should be obtained. Known genetic mutations
(BRCA, Li-Fraumeni, Cowden syndrome, NF1, and others),
Epidemiology history of chest radiation, or previous biopsies showing atyp-
ical hyperplasia or lobular carcinoma in situ should be noted.
Breast cancer is the most common type of cancer in women, Risk assessment models such as the Gail or the Tyrer-Cuszk
with an estimated 266,120 new cases in 2018 (National models can be used to calculate breast cancer risk. This
Cancer Institute SEER Program 2019). It represents 15.0% patient-specific risk information assists in tailoring screening
of all cancer cases in women and is the fourth leading cause regimens, threshold for biopsy, and prophylactic surgery.
of cancer death in the United States, with 126 new cancers
and 20.9 deaths per 100,000 women per year, based on
2011–2015 SEER data (National Cancer Institute SEER Breast Cancer Screening
Program 2019). The survival rate has been improving by
1.8% each year. Because the rates of new female breast can- Breast cancer screening consists primarily of screening
cer cases are now stable, we are making progress in this once mammography. Self-breast exam and clinical breast exam
deadly disease. Breast cancer can also occur in men but is are no longer recommended for screening modalities in
much less common (see section “Breast Problems in Men,” breast cancer screening due to lack of survival benefit
which concludes this chapter). (Oeffinger et al. 2015). Screening mammography has been
shown to decrease mortality from breast cancer. Despite this,
there is controversy as to the recommended age to begin
screening mammography. Younger women have higher
breast density, reducing the sensitivity of screening mam-
mography (Melnikow et al. 2016). Their prevalence of breast
cancer is also lower, which increases the chance of false-
S. L. Sugg · C. E. H. Scott-Conner (*)
Department of Surgery, University of Iowa Carver College positive results. The risks of screening such as false positives
of Medicine, Iowa City, IA, USA requiring additional testing, anxiety, and overdiagnosis are
e-mail: carol-scott-conner@uiowa.edu being weighed against the benefits of screening in the devel-
S. L. Fu opment of these guidelines. The American Cancer Society
Department of Oncology, Good Samaritan Hospital Medical now recommends that women at average risk have their first
Center, West Islip, NY, USA

https://doi.org/10.1007/978-3-030-81415-1_115
908 S. L. Sugg et al.
screening mammogram at age 45. Radiology and breast sur- situ disease versus invasive disease, and biomarker assess-
gery guidelines recommend starting at age 40, while the ment is difficult. A core needle biopsy (CNB) provides infor-
U.S. Preventative Task Force and many European countries mation on the histologic subtype, grade, and accurate tumor
recommend starting at age 50. Patients at increased risk biomarker status for estrogen receptor (ER), progesterone
based on genetics, family and medical history, or breast receptor (PR), and HER2/neu (HER2).
biopsy results should begin screening earlier. There is also If the lesion is not palpable, the needle biopsy can be per-
controversy as to how frequently women should have screen- formed percutaneously guided by the imaging modality
ing mammograms. The American Cancer Society recom- which detected the lesion. Commonly, the biopsy is per-
mends that women 55 years or older may have mammograms formed via ultrasound guidance or stereotactically via mam-
every 1 or 2 years, and that screening should continue as long mography. Occasionally, if the lesion is only seen on MRI,
as there is a 10-year life expectancy (American Cancer then an MRI-guided biopsy can, and generally should, be
Society 2019a). Most guidelines recommend risk assessment performed.
and shared decision-making to help guide screening regi- Core needle biopsy is performed with spring-loaded (12-
mens. Risk-stratified screening protocols are currently 14G) or vacuum-assisted (7-10G) devices. Multiple samples
undergoing clinical trials. are taken to ensure adequate biopsy of the target lesion. A
clip is then placed at the biopsy site to allow subsequent
excision or follow-up. Markers that incorporate hydrophilic
Imaging Modalities markers are particularly useful if ultrasound-guided lumpec-
tomy is planned.
Mammography: Screening mammography is used for detec- If a lesion is palpable, then a CNB can be performed with-
tion of breast cancer, and diagnostic mammography is used out imaging, although it may be prudent to use ultrasound
to further characterize abnormal findings. Screening mam- assistance. Ultrasound allows the targeting of the most high-
mography fails to detect breast cancers in 20–30% of cases yield part of a tumor, which may be heterogeneous. A clip
(Hoff et al. 2012). Digital breast tomosynthesis (DBT) or 3D should be placed in case subsequent neoadjuvant therapy is
mammography has significantly better sensitivity and speci- used; such treatment may shrink the tumor so well that it is
ficity, especially in women with dense breast tissue. There is no longer palpable or even detectable by imaging
a slightly higher radiation dose with current techniques modalities.
(Gilbert et al. 2016). The pathology report must be examined for concordance.
Ultrasound: Ultrasound (US) is useful for characterizing Was a lesion such as a fibroadenoma identified (may be con-
mass lesions, and is particularly helpful in guiding proce- cordant with imaging findings) or was it “normal breast”
dures such as needle biopsies and lumpectomies. All breast (which suggests that the target was missed)? If a percutane-
surgeons should be facile in this modality. It can also be used ous biopsy result is not concordant with radiologic imaging,
in screening, particularly with the whole breast ultrasound then the next step is generally an open excisional biopsy in
machines, which renders the procedure less operator depen- the operating room. A weekly mammography/biopsy confer-
dent. The role of whole breast ultrasound as a supplemental ence, in which all biopsies are reviewed by a multidisci-
screening test remains to be defined. plinary team including the radiologist, helps ensure that all
MRI: Magnetic resonance imaging (MRI) may be used biopsy findings are either concordant or, if discordant, man-
for screening in some cases, such as those with a lifetime risk aged appropriately.
of cancer >20–25% (Saslow 2007). The false-positive rate of
MRI is high and, therefore, its use is restricted to high-risk
patient populations for screening purposes. In selected anagement of Common Benign Breast
M
patients with DCIS or breast cancer, It is used to define the Lesions
extent of disease, and it can be used to evaluate the results of
neoadjuvant chemotherapy. Use of MRI is associated with an Nipple Discharge
increased rate of mastectomy and, therefore, must be used Nipple discharge is common and occurs in 2–5% of women
judiciously (Houssami et al. 2017). (Ashfaq et al. 2014). Physiologic nipple discharge related to
lactation, medications, or conditions such as prolactinoma is
not treated with surgery. Pathologic nipple discharge is
Breast Biopsy: Obtaining a Tissue Diagnosis defined as being unilateral, spontaneous, and arising from a
single duct. It does not have to be bloody. It is most often
Any lesion that is deemed suspicious should be biopsied by caused by a papilloma or benign duct ectasia, but can also be
needle rather than surgically excised. Although a fine-needle caused by DCIS or invasive ductal carcinoma in 5–10% of
aspiration (FNA) may be performed, it cannot distinguish in cases (Ashfaq et al. 2014; Morrogh et al. 2007). The workup
115 Concepts in Breast Surgery 909
includes mammography and ultrasound, which may identify nents to rule out malignancy. Fibroadenomas and phyllodes
associated malignancy. US is highly sensitive and predictive tumors are classified as fibroepithelial lesions and are stro-
of lesions in the setting of pathologic discharge (Ballesio mal tumors of the breast. A fibroadenoma is a solid benign
et al. 2007). If negative, galactography may identify lesions tumor that does not need excision unless symptomatic.
within the ductal system; however, it is not a widely avail- Pseudoangiomatous stromal hyperplasia (PASH) is a benign
able test. Contrast-enhanced breast MRI is less operator proliferative lesion affecting women in the reproductive
dependent, highly sensitive, and specific for detecting lesions years. It does not require excision if diagnosed on image-
and may be preferred over galactography (Berger et al. guided core needle biopsy of a nonpalpable mass (Protos
2017). A duct exploration and excision should be undertaken et al. 2016). Large palpable masses may require excision on
in persistent pathologic nipple discharge, even if a lesion is a case-by-case basis.
not identified on imaging. This resolves the nipple discharge Phyllodes tumors can mimic fibroadenomas on imaging
and will often excise the papilloma or less commonly the and histopathology, but will often grow more rapidly. They
DCIS or invasive cancer causing the discharge. If a lesion is are graded as benign, borderline, and malignant based on
seen on imaging, it should undergo image-directed core nee- WHO-defined histologic features (Krings et al. 2017). Local
dle biopsy prior to surgical excision. recurrence varies with grade. Malignant phyllodes tumors
will rarely metastasize. Uniformly poor pathologic features
Breast Abscess of marked stromal cellularity, stromal overgrowth, infiltra-
Breast abscesses can be divided into two categories: lacta- tive borders, and 10 or more mitoses per 10 high-power
tional (puerperal) or nonlactational (nonpuerperal). The most fields are associated with distant metastases (Spanheimer
common organism in lactational abscesses is Staphylococcus et al. 2019). When the pathologist is unable to distinguish a
aureus (including MRSA), followed by streptococci and fibroadenoma from a phyllodes tumor on core biopsy, exci-
Staphylococcus epidermidis. The treatment plan for these sion is then indicated (see below). A recent metaanalysis
abscess include: (1) appropriate antibiotic coverage early on, found an overall 11% recurrence rate after excision of benign
(2) promoting milk drainage, and (3) ultrasound-guided aspi- phyllodes tumors, with no difference in recurrence between
ration with a large-bore needle. Patients may need serial 1 mm and 10 mm margins. Positive margins had a recurrence
aspirations every 2–3 days. If the overlying skin is thinned rate of 12% (Shaaban & Barthelmes 2017). Therefore,
out or necrotic or the abscess appears too complex with mul- benign phyllodes tumors that have been enucleated with no
tiple loculations, then an incision and drainage may need to margins may be observed. With borderline and malignant
be performed (Dixon & Khan 2011). Nonlactational phyllodes tumors, a positive margin should be reexcised as
abscesses are typically located in the central subareolar or the local recurrence rates are higher at around 30%. An ideal
peripheral regions. Central subareolar abscesses develop margin width has not been established (Tan et al. 2016).
because of periductal mastitis. They are usually attributed to Larger tumors may require a mastectomy.
anaerobic bacteria in the context of damaged subareolar
ducts. A very typical location would be centered under the
areolar margin. Subareolar abscesses appear to be more reast Lesions on CNB That May Require
B
common in smokers and are associated with nipple piercing Excision
(Gollapalli et al. 2010). Nonlactational peripheral abscesses
may be associated with diabetes, rheumatoid arthritis, or Although many lesions found on CNB are benign and require
granulomatous lobular mastitis. These are treated with serial no further surgery, there are certain “benign” findings that do
aspirations with antibiotic coverage, reserving incision, and require a surgical excision either to treat the condition or to
drainage for refractory cases. Granulomatous mastitis may exclude associated malignancy. The “upgrade rate” is the
require medical comanagement with rheumatology and rate of discovering associated malignancy (DCIS and inva-
infectious disease specialists, and surgery should be used sive ductal and lobular cancer) upon surgical excision. This
sparingly. When the infection has resolved, breast imaging used to determine whether or not a “high risk lesion” seen on
should be performed to rule out a malignancy that may rarely core needle biopsy needs surgical excision. Some of these
present with infection or abscess. lesions are also associated with an increased risk of develop-
ing breast cancer, making the nomenclature somewhat con-
enign Breast Mass or Cyst
B fusing. As core needle biopsy specimens have become larger,
Ultrasound can be used to distinguish between a solid mass the ability to adequately sample the lesion has improved and
and cyst. A benign cyst is typically simple in nature as seen more specific criteria are being developed to decrease the
on ultrasound. It can be aspirated if symptomatic. A complex number of surgical excisions without missing malignancy. A
cyst may have septations or solid components and may general observation is that atypia seen in the core biopsy is
require aspiration for cytology and/or biopsy of solid compo- associated with a higher upgrade rate and also increases the
risk for developing breast cancer. The need for a surgical Atypical lobular hyperplasia (ALH) or lobular carcinoma
excision for various lesions continues to evolve and is an in situ (LCIS) is commonly identified on CNB and has been
area of controversy. Not surgically excising a lesion requires increasingly found to have lower upgrade rates in the setting
meticulous follow-up. of imaging-pathologic concordance (Muller et al. 2018). If
As noted above, benign phyllodes tumors generally there are no other pathologic findings, such as ADH, papil-
deserve excision; and often the pathologist is unable to dis- loma, or radial scar, upgrade rates are less than 5% (Morrow
tinguish a fibroadenoma from a benign phyllodes tumor and et al. 2015; Middleton et al. 2014). In this setting, the
may give the diagnosis of fibroepithelial lesion on CNB. In American Society of Breast Surgeons no longer recommends
this case, excision is warranted after clarification with the routine excision of ALH or LCIS (Pesce et al. 2014).
pathologist. However, excision is warranted if there is pleomorphic LCIS,
A radial scar has a stellate appearance very similar to LCIS with necrosis, other nonclassical variants, discordant
carcinoma on imaging. Lesions smaller than 1 cm may be findings, or other high-risk lesions (Nakhlis et al. 2019).
called complex sclerosing lesions. They are proliferative Flat epithelial atypia (FEA) may be found incidentally on
lesions but are not thought to be premalignant, or increase biopsies performed for calcifications seen on screening
breast cancer risk. The upgrade rates vary from 0% to 28% mammogram. There is a low upgrade rate (1–7.5%) mostly
and depend upon whether atypia is present and whether the to DCIS, but FEA can be associated with ADH (18%) and
lesion was sampled extensively or not. Contemporary series lobular neoplasia in a significant proportion of subsequent
have 0–2% rates in lesions without atypia. Small, adequately excisions (Hugar et al. 2019), especially if there is a genetic
sampled lesions, with radiologic and pathologic concor- mutation or personal history of breast cancer (Lamb et al.
dance, may not need to be excised (Cohen & Newell 2017). 2017). These findings could alter patient management and
Intraductal papillomas may present in association with underlies the rationale to surgically excise FEA despite its
nipple discharge, as a palpation or image detected mass, or as low upgrade rate to malignancy (Rudin et al. 2017).
an incidental finding on core biopsy. They can be solitary or Recommendation to excise FEA is, therefore, dependent on
multiple, and are more commonly located near the nipple patient factors, how diagnosing a high-risk lesion may affect
rather than at the periphery of the breast. Intraductal papil- management, and shared decision-making.
lomas are not thought to be premalignant, but may increase
the risk of developing breast cancer very slightly, especially
if multiple. In the past, intraductal papillomas were excised Breast Malignant Diseases
surgically as a standard (Wen & Cheng 2013) because of the
high upgrade rates. Studies show that papillomas with atypia Ductal Carcinoma In Situ (DCIS)
need surgical excision due to an upgrade rate of up to 25%
(Arora et al. 2007), but solitary papillomas without atypia DCIS is considered to be a potential precursor of invasive
diagnosed on image-guided core biopsy have an upgrade rate ductal carcinoma in which the malignant cells, though shar-
of 5% or less, and may be observed (Lewis et al. 2006; ing molecular changes with invasive cancer cells, are still
Ahmadiyeh et al. 2009). Surgical excision should be consid- contained within the basement membrane. Thus, DCIS is
ered for larger (>1 cm) size, age greater than 50, a location generally not thought to have metastatic potential. As a pre-
more than 3 cm from the nipple, and the presence of micro- cursor lesion, it will progress to invasive cancer some of the
calcifications, as these are features associated with higher time. It most often presents with microcalcifications on
upgrade rates (Agoumi et al. 2016). screening mammography, but may also present with nipple
Atypical ductal hyperplasia (ADH) found on CNB is discharge or a mass. The incidence of DCIS increased greatly
associated with a 20–50% upgrade rate to ductal carcinoma after screening mammography, and currently it is postulated
in situ (DCIS) or to invasive breast cancer (Sutton et al. 2019; that many cases of DCIS represent overdiagnosis.
Salagean et al. 2019). Therefore, a surgical excision of the Overdiagnosis is the discovery of DCIS or breast cancer
area is recommended. The risk for upgrade is related to the through screening that would never have become clinically
sampling and severity of ADH, the lesion size on imaging, apparent during the patient’s lifetime. Estimates of breast
and patient age that can be calculated using a risk prediction cancer overdiagnosis vary with statistical modeling method-
model (Salagean et al. 2019). In select patients with no mass ology, ranging from 5% to 30%, and are highly controversial
and small-volume low-grade ADH that was completely (Etzioni et al. 2013). DCIS is treated much like cancer, yet
excised on CNB (especially if a vacuum-assisted device was the treatment has virtually no impact on mortality. Because
used to remove >90% of the target calcifications), follow-up of the likely overdiagnosis and subsequent overtreatment of
with serial mammograms and risk assessment and manage- DCIS, there are currently several randomized clinical trials
ment (without surgical excision) may be safe (Racz & (COMET in the United States and LORIS in the United
Degnim 2018). Kingdom) investigating if low-risk DCIS may safely be
observed under active surveillance protocols instead of stan- tamoxifen acting as a prevention drug. Currently, tamoxifen
dard treatment (see below). AJCC staging of DCIS is Tis and is recommended for 5 years (Early Breast Cancer Trialists'
stage 0. Collaborative, G 2011a). The NRG Oncology/NSABP B-35
trial showed that the aromatase inhibitor anastrozole was
Surgical treatment of DCIS The goal of surgery in DCIS superior to tamoxifen in preventing recurrence, mainly in
is to remove the lesion(s) from the breast, and this can be women younger than 60, with fewer episodes of thrombosis
done with either removing part of the breast (lumpectomy, (Margolese et al. 2016).
partial mastectomy) or the entire breast (mastectomy). In a
recent review of patients with DCIS in the Surveillance,
Epidemiology, and End Results (SEER) database, 10-year Paget’s Disease of the Breast
disease-specific survival showed no clinically meaningful
difference between those treated with lumpectomy with radi- Paget’s disease of the breast is rare (3% of all breast cancers)
ation (98.9%), mastectomy (98.5%), or lumpectomy alone (Ashikari et al. 1970) and presents with a refractory pruritic,
(98.4%) (Worni et al. 2015). In general, lymph node staging eczematous rash involving the nipple-areolar complex
is not required in DCIS because it does not metastasize. (NAC). Recognition of the disease may be delayed, and the
However, invasive cancer will be found on the final surgical diagnosis can be made with a simple core needle biopsy
specimen of 10–20% of DCIS diagnosed on CNB. The pres- (2 mm) of the affected nipple, which will demonstrate epi-
ence of a palpable mass, younger age, large size on imaging, dermal invasion by malignant cells. Most (90%) patients
and high-grade DCIS increases the risk of invasive cancer have an associated breast neoplasm, and up to 50% present
(Yen et al. 2005). With a lumpectomy, SLN biopsy may be with an associated breast mass (Ashikari et al. 1970).
performed at a second operation, and therefore, SLN biopsy Multifocal disease is common. However, mammogram and
is only done concurrently with the lumpectomy when there is US may not identify the associated neoplasm in some cases,
a high risk of invasive cancer based on clinical features but MRI is highly sensitive and should be routinely used to
(mass, pathology suspicious for microinvasion, and large determine the extent of disease (Morrogh et al. 2008).
area). After a mastectomy, the feasibility and accuracy of Although mastectomy was the recommended therapy in the
SLN biopsy are not known, therefore, a SLN biopsy is rec- past, breast-conserving therapy with a central lumpectomy
ommended in patients with DCIS diagnosed on CNB under- and radiation appears to be safe in patients with limited dis-
going mastectomy (Chin-Lenn et al. 2014). ease (Trebska-McGowan et al. 2013). SLN biopsy is driven
by the underlying disease of DCIS or invasive cancer, and
the role of SLN biopsy for isolated noninvasive Paget’s dis-
Radiation therapy in DCIS The role of radiation in DCIS ease is unclear.
has been controversial. Adjuvant radiation therapy decreases
the local recurrence rate by 50% when used with lumpec- I nvasive Breast Cancer
tomy (Wapnir et al. 2011) but there is no improvement in Invasive cancer has acquired the ability to spread beyond the
overall survival (Krings et al. 2017). Fifty percent of recur- breast to the lymph nodes and distant organs. Invasive ductal
rences in DCIS will be invasive cancer, and this is associated carcinoma is the most common type (70–80%), followed by
with a slight increase in breast cancer-specific mortality invasive lobular carcinoma (7%). Other types include tubu-
(Wapnir et al. 2011). Lumpectomy without radiation therapy lar, mucinous, papillary, and metaplastic, which altogether
may be appropriate for some patients, including those with account for less than 5% of invasive cancers. These histo-
advanced age, extensive comorbidities, or small foci of low- logic subtypes have well-characterized clinical features,
grade disease with negative margins. The oncotype Dx DCIS which include prognosis; however, significant advances have
recurrence score calculated from a multigene assay was been made in characterizing tumors and individualizing
developed to identify a low-risk subgroup in whom RT may treatment based on receptor expression and mRNA expres-
be omitted (Solin et al. 2013). The test has not yet been sion in breast cancer. Breast cancer was initially character-
widely adopted and its clinical utility is still under investiga- ized by the presence of estrogen (ER) and progesterone (PR)
tion (Lin et al. 2018; Manders et al. 2017). receptors, which was associated with response to hormonal
treatment. HER2/neu receptor amplification was identified
as a predictor of breast cancer relapse (Slamon et al. 1987),
Adjuvant therapy in DCIS For hormone receptor-positive and the anti-HER2 monoclonal antibody showed efficacy
DCIS, adjuvant endocrine therapy in the form of tamoxifen (Pegram et al. 1998), ushering the era of molecular targeting
was shown to decrease local recurrence but not survival in in cancer treatment. These three receptors, ER, PR, and
women with breast-conserving therapy (Staley et al. 2012). HER2, are the only receptors routinely analyzed on invasive
Contralateral new breast cancers were also reduced, with breast cancer pathology because they are useful in treatment
planning with antiestrogen therapy and anti-HER2 therapy rates but with no difference in survival. Sentinel lymph node
and prognosis (Waks & Winer 2019). All three are analyzed biopsy is now performed for staging to direct the adjuvant
by immunohistochemistry, and fluorescent in situ hybridiza- radiation and systemic therapy, reserving axillary lymph
tion (FISH) is used in cases where HER2 staining is equivo- node dissection as therapy for node-positive patients. The
cal. The classification of breast tumors via transcriptome continued improvement in breast cancer survival results
analysis (Sorlie et al. 2001) has led to identification of from this evidence-based, multidisciplinary approach to
molecular subtypes that correlate clinical behavior, response treatment. Breast Tumor Board facilitates collaboration
to treatment, and prognosis. Luminal A and Luminal B sub- among specialists, the optimal sequencing of treatment,
types are ER-positive, HER2-enriched subtype has high enrollment in clinical trials, and is a feature of breast cancer
expression of HER2, and basal subtypes which are ER, PR, specialty care. With increasing numbers of breast cancer
and HER2 negative, or triple negative. Genomic assays such patients living many years after treatment, survivorship
as Oncotype DX and MammaPrint are used to characterize issues such as surveillance, physical and psychological
the primary tumor according to risk of recurrence, and this health, and quality of life are under scrutiny for
information is used to guide recommendations for chemo- improvements.
therapy (Varga et al. 2019). The assays vary in terms of the
tumor type and patient population studied and, therefore,
multidisciplinary input may be required to use the assays Considerations Prior to Surgery
appropriately.
I s the Patient a Surgical Candidate?
It is rare that a patient is unable to undergo surgery due to
Inflammatory Breast Cancer comorbid conditions. A lumpectomy under local anesthesia
can be performed safely in most cases where the risk of gen-
Inflammatory breast cancer (IBC) is a distinct clinical entity, eral anesthesia is prohibitive. In women who have metastatic
presenting with a rapid (≤3 months) onset of skin changes disease at time of diagnosis, surgery does not play a major
with erythema and edema (peau d’orange), encompassing role and is reserved for palliation, although recent studies
more than a third of the breast, with or without an underlying suggest that there may be a benefit in selected patients (Xiao
mass. Its pathologic hallmark is dermal lymphatic invasion, et al. 2018).
but a biopsy is not required to make this clinical diagnosis. A
delay in diagnosis is common, the disease may be mistaken I s the Patient a Candidate for Breast
for mastitis and treated with antibiotics. It is staged as T4d. It Conservation?
is the most lethal of breast cancer types, associated with a The aim of breast conservation is to remove the area of DCIS
5-year survival of 30% (Yamauchi et al. 2012). At presenta- or invasive cancer with negative margins and a cosmetically
tion, 85% of patients have regional lymph node involvement, acceptable result. Therefore, the primary consideration for
and 30% have distant metastases (Masuda et al. 2014). At breast conservation suitability is the extent of disease in the
diagnosis, IBC is considered surgically unresectable and the breast compared with the breast size and ability to undergo
initial treatment is neoadjuvant chemotherapy, followed by radiation therapy (see below for details).
modified radical mastectomy and radiation therapy.
urgery First or Neoadjuvant Treatment
S
Followed by Surgery?
Surgical Treatment of Breast Cancer In early stages, surgery (BCT or mastectomy) is the primary
treatment, followed, if appropriate, by adjuvant systemic
The radical mastectomy as described by Halstead in 1894 therapy. There is a general tendency to offer some kind of
(Halsted 1894–1895) and others (Sakorafas 2008) was the adjuvant systemic therapy (whether chemotherapy, HER2/
preferred operation for breast cancer until the 1970s. neu-directed therapy, or hormonal therapy) to all patients
Landmark clinical trials by the National Surgical Adjuvant with invasive breast cancer who are physically able to take it.
Breast and Bowel Project (NSABP) and others (Julian et al. In more advanced stages, neoadjuvant chemo- or hor-
2015) paved the way to modern treatment plans, reducing monal therapies are used prior to surgery to decrease the
surgery in the breast and axillary lymph nodes, and incorpo- extent of surgery in both the breast and axilla. Neoadjuvant
rating the adjuvant therapies of radiation, combination che- chemotherapy is the initial treatment for inflammatory breast
motherapy, anti-HER2 therapy, and antiestrogens. Breast cancer, as previously discussed. In the breast, neoadjuvant
conservation surgery with radiation was found to be compa- therapy can convert women needing mastectomy to candi-
rable to mastectomy with slightly higher local recurrence dates for BCT (Mieog et al. 2007; Spanheimer et al. 2013).
In addition, resection of less breast tissue or skin may result ill the Patient Require Postmastectomy
W
in improved cosmetic outcomes in both BCT and mastecto- Radiation?
mies with reconstruction. In the axilla, pCR in node-positive Knowing if a patient will require postmastectomy radiation
patients could convert an ALND into SLN biopsy (Caudle is important in preoperative planning, even after neoadjuvant
et al. 2017) with a decrease in lymphedema risk. If clinically treatment and/or a mastectomy (see below for details). With
evident lymph node metastases are present at initial diagno- radiation, reconstruction options are more limited and favor
sis, neoadjuvant chemotherapy is often recommended to delayed autologous over implant reconstruction. Therefore,
facilitate subsequent ALND, even if a pCR is not anticipated. if BCT is possible, it should be strongly recommended.
The rate of complete pathologic response (pCR) is depen-
dent on the receptor subtype (Table 115.1). Neoadjuvant re There Indications for Genetic Counseling?
A
therapy also provides important prognostic information by Genetic testing should be offered to patients with a personal
allowing the team to determine response to therapy: pCR is or family history suggestive of/or known to have a hereditary
generally associated with better survival (Boughey et al. cancer syndrome involving breast cancer. Genetic counsel-
2017). Conversely, patients with residual disease could ben- ing, if available, is an essential part of this evaluation.
efit from additional therapy such as capecitabine in TN Identification of a high-risk mutation is important informa-
tumors (Masuda et al. 2017), or ado-trastuzumab emtansine tion that should be available to a woman if it will change her
(TDM1) in HER2+ disease (von Minckwitz et al. 2019), or choice of surgery (BCT vs. bilateral mastectomy), especially
enroll in clinical trials evaluating novel agents. for early-stage disease. If BRCA 1 or 2 is confirmed, ovarian
Prior to commencing neoadjuvant treatment, it is impera- cancer screening or risk-reducing oophorectomy is per-
tive that the extent of disease in the breast and axilla is fully formed. The additional information obtained by testing may
evaluated with imaging and marked (usually with clips) so be of value not only to the woman but to her children or
that pCR can be confirmed if no disease is found on surgical siblings.
pathology. MRI is most commonly used, but US is less
expensive and useful in well-circumscribed tumors. The
extent of disease in the breast should be reevaluated by imag- The Role of Shared Decision-Making
ing at the conclusion of neoadjuvant treatment.
It is the responsibility of the surgeon to educate the patient,
I s the Patient a Candidate for Omitting SLN help identify goals of treatment, and thoroughly discuss the
Biopsy? risks and benefits of the treatment options. Colleagues in
In patients where axillary staging would not impact adju- genetic counseling, radiation and medical oncology, and
vant treatment decisions, SLNB may be omitted. This could plastic surgery should be appropriately consulted to ensure
be considered in older women (over age 70) with early- the patient has adequate information to make an informed
stage cancers that are clinically node negative and estrogen decision prior to surgery. The surgeon should not hesitate to
receptor positive and HER2 negative as per the Society for offer an opinion including recommending against options
Surgical Oncology (SSO) Choosing Wisely guidelines. that have significant potential for harm, but must also respect
This guideline was based on the CALGB 9343 results, the patient’s autonomy and values.
where patients meeting those criteria were treated with
lumpectomy plus tamoxifen with or without breast irradia-
tion and had no difference in overall survival or distant Surgical Treatment of the Breast
disease-free survival (Hughes et al. 2013). The decision to
deescalate surgical therapy should be made in conjunction The surgical choices for management of the breast are the
with radiation and medical oncologists in a multidisci- same for invasive cancer as for DCIS: BCT versus mastec-
plinary setting. Some healthy elderly patients who have a tomy. Since there is a risk of distant spread, the axilla is usu-
longer life expectancy may want to have the same treatment ally staged with a sentinel lymph node biopsy, followed by a
as younger patients. complete axillary lymph node dissection (ALND) if neces-
sary (see Lymph Node Staging, below).
Table 115.1 Response to neoadjuvant chemotherapy

Breast cancer type Pathologic complete response (pCR) rate Breast Conservation Therapy (BCT)
Triple negative Up to 60%
HER2+ (ER−) Up to 80% BCT is removal of part of the breast and generally includes
HER2+ (ER+) Up to 45% radiation therapy. Resection of part of the breast is most
From Pusztai et al. 2019, with permission commonly known as lumpectomy, but can also be referred to
as partial or segmental mastectomy or quadrantectomy. breast conservation are reduced significantly with radiation
Survival rates for BCT were equivalent to mastectomy in therapy (Early Breast Cancer Trialists' Collaborative, G
multiple randomized controlled trials (Julian et al. 2015). 2011b). For patients with a low risk of recurrence, or with
Contraindications to BCT include factors related to extent of sufficient competing causes for mortality, radiation may not
disease such as multicentric disease (synchronous foci of be beneficial. For example, in women over age 65 with
cancer more than 5 cm apart), inflammatory breast cancer, hormone-positive tumors and taking antiestrogen therapy,
large tumor-to-breast ratio, diffuse malignant-appearing cal- radiation therapy reduced a 5-year recurrence rate from 6.5%
cifications seen on imaging, persistently positive margins to 2.2%, with no change in survival (van de Water et al.
despite reexcision, and factors related to radiation delivery 2014). Conventional whole breast radiation (WBRT) deliv-
such as early pregnancy, or prior chest wall radiation ers 1.8–1 Gy daily fractions over a 4.5- to 5-week period to a
(Morrow et al. 2002). Technical factors such as inability to total dose of 45–50 Gy. A boost dose of 10–14 Gy in 2–2.5 Gy
deliver radiation due to patient positioning, weight limits, fractions to the tumor bed is given in most cases. It is gener-
pacemaker, or other large implanted metal devices on the ally well tolerated, with the most common acute toxicities
side of the radiation could also preclude it. Patients with col- being fatigue and skin burn, although long-term complica-
lagen vascular disease, especially scleroderma and systemic tions such as cardiotoxicity, lung injury, and secondary
lupus erythematous, are at higher risk for developing late malignancies can occur (Taylor et al. 2017). Access for rural
toxicity (Lin et al. 2008). and elderly patients may preclude the use of radiotherapy.
The goal of the breast resection is to remove the tumor Additional breast radiation options include (1) hypofraction-
with negative margins with an acceptable cosmetic result ated whole breast radiation (delivering 40–42.5 Gy over a
and, therefore, a certain degree of precision is required. The shorter time (3–5 weeks)), and (2) partial breast radiation
extent of disease, including suspicious microcalcification, (delivering radiation to the tumor bed via a catheter, external
needs to be determined prior to surgery. This may require beam, or intraoperative radiation therapy). These alternate
additional breast imaging and biopsies. Well-circumscribed, methods require careful patient selection and have shorter
palpable lesions can be excised without imaging; however, follow-up time compared to conventional whole breast radia-
we have found intraoperative US to be useful even in these tion therapy.
lesions. Nonpalpable lesions require a localization method.
These methods include wire localization, hematoma
ultrasound- guided (HUG) lumpectomy (Larrieux et al. Mastectomy
2012), or the use of implanted, detectable tags such as radio-
active or magnetic seeds, radiofrequency emitters, etc., Mastectomy is removal of the entire breast. The nomencla-
which are also gaining popularity. Large areas of resectionture of mastectomy has evolved with changes in surgical
may require several wires or “tags” to delineate the area of
treatment. A simple mastectomy is defined as removal of the
removal. Specimen radiographs are performed to ensure breast and nipple, whereas a total mastectomy does not
removal of the clip or “tag” and associated mass and/or include removal of the nipple (American Medical Association
microcalcifications. The specimen must be oriented so that a
2019); therefore, a nipple-sparing mastectomy (NSM) would
positive margin can be identified for reexcision. An adequate
be classified as a total mastectomy for billing purposes. A
margin for DCIS is ≥2 mm (Morrow et al. 2016), whereas modified radical mastectomy is a mastectomy with an axil-
for invasive carcinoma it is “no tumor on ink” (Moran et al.
lary lymph node dissection (ALND), whereas a radical mas-
2014). In patients with DCIS and invasive cancer, “no tumortectomy is a mastectomy, ALND, and removal of the
on ink” applies to both the DCIS and the invasive componentpectoralis major and minor muscles. As noted above, a mas-
(Morrow et al. 2002). tectomy is equivalent to BCT in terms of survival. The local
With recent increasing interest in oncoplastic techniques,
recurrence after a mastectomy is dependent on tumor biol-
larger lumpectomies may be performed with good cosmetic ogy and is around 4% overall (Glorioso et al. 2017). After a
and oncologic outcomes (De La Cruz et al. 2016), particu- long period of decline, mastectomy rates have increased, and
larly in large-breasted women. These techniques involve tis-
in particular, contralateral prophylactic mastectomies (CPM)
sue rearrangement and sometimes contralateral mastopexies (Marmor et al. 2019). The ASBrS has issued a consensus
for symmetry. Oncoplastic techniques may be performed by statement discouraging the use of CPM for women of aver-
the trained breast surgeon and/or with a plastic surgeon, age risk due to increased complications with no survival ben-
especially when a contralateral symmetry procedure is efit (Boughey et al. 2016).
needed. If a mastectomy is required or chosen as a treatment
option, the skin-sparing and nipple-sparing techniques can
Radiation with breast conservation Local recurrence (10- be used with immediate reconstruction with excellent cos-
year risk by 50%) and mortality (15-year risk by 4%) after metic outcomes. Reconstruction may be performed by autol-
ogous or implant-based techniques by a plastic surgeon. It is result of excellent systemic and radiation therapy. Similar
important to preoperatively discuss with the patient that the results were seen in the IBCSG 23-01 trial (Galimberti et al.
reconstructed breast will not have normal sensation. Sexual 2013). In women with positive sentinel lymph nodes who do
and arm function may be impaired (Anderson et al. 2017; not fit the Z-11 criteria, such as those having mastectomy,
Chrischilles et al. 2019), and additional surgeries are often data are insufficient to advocate omitting ALND.
required. Delayed reconstruction is usually recommended if Sentinel lymph node biopsy after neoadjuvant chemother-
radiation is indicated, although many plastic surgeons will apy was investigated in the ACOSOG Z-1071 trial. This trial
insert a tissue expander to preserve skin and maintain a space showed that the ability of the SLN to predict the status of the
for the future reconstructed breast. axillary lymph nodes approaches that of conventional SLN
biopsy. Retrieval of three or more nodes, using dual dye for
Postmastectomy radiation (PMRT) Most patients undergo- SLN identification, and retrieving the clipped node (if previ-
ing mastectomy will not require radiation. However, chest ous biopsy had demonstrated nodal disease), all contributed
wall and nodal radiation after mastectomy is usually recom- to lowering the false-negative rate (Boughey et al. 2013).
mended in those with locally advanced disease (T3-4, N2-3): Subsequent work by Caudle et al. showed that targeted axil-
tumors ≥5 cm, positive margins, and extranodal extension, lary dissection (TAD), in which the clipped node is removed
in addition to those with residual nodal disease after neoad- along with any sentinel node(s) decreased the FNR to 1.4%
juvant chemotherapy (Liu et al. 2016). Patients with 1–3 (Caudle et al. 2016).
positive lymph nodes may have not only a survival benefit Because of the significant harm of ALND, with a 20% rate
with PMRT but also a slightly higher rate of complications of lymphedema and associated arm dysfunction, it was rap-
(Ragaz et al. 2005). Therefore, PMRT in this group of idly replaced by SLN biopsy in the 1990s for axillary stag-
patients require careful weighing of risks and benefits and ing. However, there continues to be a role for ALND in the
consideration of the patient’s treatment goals. removal of axillary disease in (1) patients with positive
lymph nodes who do not meet Z-11 criteria, including
patients with positive lymph nodes undergoing a mastec-
Lymph Node Surgery tomy, (2) those with residual lymph node disease after neo-
adjuvant therapy, and (3) those with inflammatory breast
Lymph node surgery in breast cancer is performed for either cancer regardless of response. Left untreated, axillary lymph
staging or therapeutic purposes. The majority of lymph node node disease can sometimes progress to encase the axillary
metastases occur in the axillary lymph nodes, though inter- vessels and brachial plexus, producing a painful situation
nal mammary, supraclavicular, and cervical lymph nodes can that is very difficult to palliate.
be involved, especially with advanced disease. In early-stage Axillary reverse mapping (ARM) is a procedure described
disease, sentinel lymph node biopsy has replaced routine by Klimberg (Klimberg 2008), which identifies the arm lym-
axillary lymph node dissection for staging, leading to a phatics within the axilla. Blue dye or indocyanine green is
reduction in lymphedema and arm dysfunction. injected in the ipsilateral upper arm to identify the arm lym-
Sentinel lymph node biopsy was initially only done in phatics, which are then avoided where possible. In a prospec-
women with early-stage disease and a clinically negative tive study of 654 patients, who underwent ARM procedures
axilla. The procedure identifies the lymph node(s) that drain with SLNB versus ALND, lymphedema rates were 0.8% and
the breast by injecting a tracer, most commonly blue dye 6.5% and recurrence rates were 0.2% and 1.4%, demonstrat-
and/or radioactive technetium sulfur colloid, and identifying ing significantly reduced rates compared with published
and removing the axillary lymph nodes that have taken up results (Tummel et al. 2017). A multi institutional prospec-
the substance. It is highly accurate in predicting the status of tive clinical trial is now underway to confirm the findings.
the axillary lymph nodes, with a false-negative rate of 7.3%
(Kim et al. 2006). If it is negative, no further axillary surgery Lymph node radiation considerations WBRT radiation
is done. SLN has lower lymphedema rates, and improved fields cover a portion of the axilla in most patients. Therefore,
quality-of-life measures than ALND (Fleissig et al. 2006). In WBRT may have contributed to the low axillary recurrence
the case of a positive sentinel lymph node, the ACOSOG rates in the IBCSG 23-01 (Galimberti et al. 2013) and
Z-11 randomized clinical trial in clinically node-negative ACOSOG Z11 (Giuliano et al. 2010) trials, which enrolled
women undergoing BCT for early-stage tumors indicated women with micrometastatic or up to two positive lymph
that it was safe to omit ALND if there were fewer than three nodes. In the AMAROS trial, axillary recurrence was shown
positive lymph nodes, no extranodal extension, or lympho- to be equivalent for axillary radiation and ALND in patients
vascular invasion. Although 30% of patients had additional with a positive sentinel lymph node, but with fewer compli-
positive lymph nodes, there was no difference in survival and cations (Donker et al. 2014). In patients with high-risk dis-
excellent regional control (Giuliano et al. 2010), and the ease (greater than 3 positive lymph nodes, T3/T4 primary,
etc.), regional nodal radiation is recommended. Regional Trialists' Collaborative, G 2012). Iterations that incremen-
nodal radiation includes the infra-, supraclavicular, and tally improved survival include the addition of anthracy-
internal mammary nodes. It reduces the risk of locoregional clines, taxanes in node-positive patients, and administration
recurrence but has added toxicity. Axillary nodes may be of chemotherapy in a dose-dense fashion. The side effects of
included if there was no ALND and/or if high-risk disease in chemotherapy include acute toxicities of nausea, vomiting,
the axilla was present. The combination of ALND + axillary hair loss, myelosuppression, and neuropathy, and there can
radiation has a higher lymphedema rate than either treatment be long-term cardiotoxicity, leukemia, permanent neuropa-
alone. thy, and cognitive impairment. Patients with triple negative
breast cancer (TNBC) benefit from chemotherapy unless
their Stage is T1aN0, as they have no other systemic therapy
Adjuvant Systemic Therapy option. Patients with hormone-positive disease derive a sig-
nificant survival benefit from hormone therapy alone, and the
The goal of adjuvant systemic therapy is to reduce the risk of addition of chemotherapy may not have a clinically signifi-
distant metastatic disease; however, local recurrence is also cant benefit. Therefore, assays based on tumor gene expres-
significantly reduced. The risks and benefits of systemic sion (Table 115.2) were developed to categorize patients into
therapy are tailored to the recurrence risk and to the patient risk categories for recurrence, allowing patients at low risk to
characteristics, including comorbid conditions and life avoid chemotherapy. Clinical trials evaluating these molecu-
expectancy. Systemic therapy includes antiestrogen therapy lar tests have recently come to fruition, allowing many
for hormone-positive tumors, combination chemotherapy for patients to forego chemotherapy.
triple-negative and high-risk hormone-positive breast cancer, Adjuvant anti-HER2 therapy, one of the first biologic
and anti-HER2 therapy in combination with chemotherapy therapies for cancer, was a major advance in the treatment of
for HER2-positive tumors. Significant progress is being breast cancer. Patients whose tumors express HER2 have
made in deescalation of chemotherapy when there is no ben- poor prognosis, and the addition of anti-HER2 therapy
efit, especially with molecular testing. showed a 30% improvement in survival (Moja et al. 2012).
Antiestrogen therapy alone reduces the risk of systemic Anti-HER therapy is given together with chemotherapy and
recurrence of hormone-positive (ER and/or PR positive) is continued for a total of 1 year after the chemotherapy is
tumors and mortality (Early Breast Cancer Trialists' completed. Toxicity is primarily cardiac. Additional targeted
Collaborative, G 2011a). Aromatase inhibitors are more therapies such as CDK 4/6 inhibitors and PARP inhibitors
effective than the selective estrogen receptor modulator are used primarily in the metastatic setting or in clinical
(SERM) tamoxifen (Early Breast Cancer Trialists’ trials.
Collaborative, G 2015), and is preferred in postmenopausal
women. Premenopausal women can only take tamoxifen,
unless ovarian function is suppressed. Antiestrogen therapy Treatment of Local Recurrence
is given for 5 years. An extended course of up to 10 years
may decrease recurrence and contralateral breast cancer but In-breast recurrences after BCT are typically treated by com-
does not improve survival (Burstein et al. 2019). Antiestrogen pletion mastectomy. SLN may be repeated in selected
therapy is generally well tolerated. patients, even if the technical success rate is lower than de
Adjuvant multiagent chemotherapy was shown to improve novo SLN biopsy. Systemic therapy is added as indicated.
survival in multiple clinical trials (Early Breast Cancer The rare patient who has not undergone radiation therapy
Table 115.2 Genomic assays for invasive breast cancer patient risk classification
No. of Prognostic validation
Multigene test genes Testing indication Categories (yeara) Prediction validation
MammaPrint 70 pT1-2, pN0-1, age < 55 High/Low 2002 Mindact 2016
Oncotype Dx 21 pT1-2, ER+/HER2-, pN0-1 2004 NSABP B20, SWOG8814,
TailorX 2018
Breast Cancer 7 pT1-3, ER+/HER2-, pN0, adjuvant High/Low 2009 NA
Index ET
Prosigna 58 pT1-2/pN0 or pT2pN1, ER+, High/Int/ 2009 NA
adjuvant ET, PM Low
Endopredict 12 pT1-2, ER+/HER2, pN0/pN1, PM High/Low 2011 NA
From Varga et al. (2019), with permission
ET endocrine therapy, PM post menopausal
a
Year of first validation study
may be treated by re-resection and radiation. Occasionally, a benign breast conditions such as fibroadenomas and cysts are
second course of radiation can be done, but the toxicity is rare in men (Fentiman 2018).
significant. Recurrences after mastectomy are treated by
local excision (if possible) and chest wall radiation including
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Excision of Benign Palpable Breast Mass
116
Indications often termed “enucleation,” allows clean excision but will

invariable leave some cells behind. Thus, if there is concern
See Chap. 115. about a potential phyllodes tumor, excision should include a
rim of normal breast tissue.
• Fibroadenoma. Operation is indicated when a fibroade- If the pathology report says, “cannot exclude phyllodes,”
noma enlarges or when the diagnosis is in doubt. Most the surgeon must decide how wide a margin to take. We gen-
fibroadenomas are small, round, freely movable, and erally take a narrow margin of normal breast tissue and avoid
well-encapsulated nodules that are easily diagnosed on enucleation in these cases.
physical examination. It is sometimes difficult to differen- Sometimes, the plane is not well defined between the
tiate a fibroadenoma from a low-grade phyllodes tumor fibroadenoma and surrounding breast. Whenever this is the
on imaging studies, core biopsy, or fine-needle aspiration. case, include a narrow rim of normal adjacent breast in the
Occasionally, carcinoma masquerades as a fibroadenoma, specimen being excised. Always be wary of small additional
but generally this should be easily differentiated by core “lobes” or extensions of the fibroadenoma. These must be
needle biopsy or fine-needle aspiration. excised as well; otherwise, local recurrence of the tumor is
• Hamartoma. These benign lesions may require excision possible. A similar technique may be employed for excision
when they are large and deform the breast. of hamartomas.
• Other well-circumscribed benign palpable lesions. The strategy for biopsy or excision (lumpectomy) of a
presumed malignant lesion is different (see Chap. 118).
Therefore, current guidelines emphasize the use of needle
Preoperative Preparation biopsy (rather than surgical biopsy) for initial diagnosis of
breast masses. This allows surgery to be tailored to the par-
Preoperative evaluation may include ultrasonography, core ticular circumstances, either a simple excision in the case of
biopsy, fine-needle aspiration cytology, or mammography as benign masses or a lumpectomy with sentinel node biopsy
individually appropriate. Although several techniques have (or even neoadjuvant systemic therapy) in the case of breast
been described for percutaneous management of these cancer.
lesions (see references at the end), most are treated either by Among the errors encountered during surgery for a pal-
observation or surgical removal. pable mass is failure to locate the lesion. This can occur
when a deep-seated tumor is being excised under local anes-
thesia. Infiltration of a large volume of local anesthesia in
Operative Strategy close proximity to the mass may render it nonpalpable. Even
when the tumor is easily palpable and superficial, it may not
Most fibroadenomas are completely surrounded by a smooth be easy to palpate, especially when the operation is being
fibrous pseudocapsule surrounded by a thin areolar rim and performed through a cosmetic circumareolar incision at a
it is easy to dissect in this plane. Dissection in this plane, distance from the lesion. Be particularly wary of lesions that
are easy to palpate with the patient sitting upright, but diffi-
C. E. H. Scott-Conner (*) cult to feel with the patient supine. Marking the location of
Department of Surgery, University of Iowa Carver College the mass with the patient’s input preoperatively is also help-
of Medicine, Iowa City, IA, USA ful. Intraoperative use of ultrasound is a really useful adjunct

https://doi.org/10.1007/978-3-030-81415-1_116
that can help in difficult circumstances. Always palpate the noma via one of these incisions. For tumors more than a few
inside of the cavity after removing the lesion. centimeters away from the areola, make an incision in the
A more important consideration, especially with large line of Langer directly over the tumor (Fig. 116.2). These
fibroadenomas, is the possibility of a phyllodes tumor, which lines are essentially circular in nature in the skin overlying
resembles a large fibroadenoma on physical examination. the breast, each circle being concentric with the areola.
The most important characteristic of both benign and malig-
nant phyllodes tumors is a strong predilection for local recur-
rence. It is not always possible to confirm or exclude Local Anesthesia
phyllodes tumor on needle biopsy. Therefore, always include
a 1 cm rim of normal breast tissue when excising a large Raise a skin wheal along the line of the proposed incision
fibroadenoma (>4–5 cm in diameter) or one that has grown using 1% Xylocaine without epinephrine. (Epinephrine causes
rapidly. vasoconstriction, and delayed bleeding may result when the
Consider an oncoplastic approach, incorporating breast vasospasm relaxes.) Infiltrate laterally in a fanlike pattern on
reduction techniques, whenever a large fibroadenoma or all sides of the skin incision to anesthetize the skin and subcu-
hamartoma has enlarged and distorted the breast. These tech- taneous regions of the breast thoroughly. Do not inject directly
niques are referenced at the end of Chap. 118. into the area containing the mass; rather, inject in a circumfer-
ential manner around it, creating a field block. It may be nec-
essary to inject underneath the mass as dissection progresses.
Operative Technique Allow sufficient time for the anesthetic to work and use gentle
technique. Sharp dissection is frequently better tolerated than
Choice of Incision electrocautery. Mild sedation may be beneficial.
Superior cosmetic results follow the use of a circumareolar

incision (Fig. 116.1) or an incision made in the inframam- Dissection
mary crease. However, it is not advisable to dissect through
a large distance of breast when trying to extract a fibroade- After opening the skin, use a scalpel to carry the incision
through the subcutaneous fat down to breast tissue; then,
incise the breast tissue down to the lesion. Push the lesion
down toward your field as you work. Palpate to verify the
location of the lesion as the dissection progresses. If in doubt,
Fig. 116.2 Incision in natural skin line for lesion at distance from
Fig. 116.1 Incision in periareolar skin line for lesion near areola areola
116 Excision of Benign Palpable Breast Mass 923
use intraoperative ultrasound to confirm the location of the Repair

lesion. Electrocoagulate each bleeding point so the field
remains bloodless. Self-retaining retractors are helpful. We Make no attempt to resuture the defect in the breast, as these
prefer Gelpi retractors (placed as a pair at right angles to sutures often create a mass at the site of the repair. During the
each other) because they have a very low profile. months and years following surgery, evaluation of the patient’s
If you are approaching the mass from a circumareolar breast on physical examination can be made extremely diffi-
incision, it may be helpful to maintain gentle pressure behind cult by the presence of a firm mass at the site of the previous
the mass in such a fashion as to push it down into the inci- excision. The defect in the breast will fill with fluid and serum
sion. With practice, this can be done with the fully extended and gradually be replaced by normal tissue. Because these
little finger of the nondominant hand. masses tend to displace rather than replace surrounding breast
Unless the lesion is quite superficial and the dissection is tissue, even large benign fibroadenomas or hamartomas may
easy, a traction stitch facilitates subsequent dissection. Use be removed without creating a defect in the breast.
2-0 silk on a curved cutting needle to transfix the lesion or Place several interrupted 3-0 PG sutures to approximate
deep breast tissue just superficial to the mass (Fig. 116.3). the subcutaneous layer just under the skin. Then, close the
Place a figure-of-eight suture for security and use it to ele- skin with interrupted sutures of 5-0 nylon or a running sub-
vate and manipulate the lesion (Fig. 116.4). Take care not to cuticular suture of 5-0 PDS. No drain is used.
tear the lesion.
Enter the pseudocapsule of the fibroadenoma (or the dis-
section plane, if normal breast tissue will be included) with a Postoperative Care
scalpel. If the fibroadenoma then shells out with no further
attachment, the adjacent tissue may be left behind. Check for To apply even pressure on the operative site, request that the
small lobules or “ears” that protrude from the main mass and patient wear a supportive brassiere over a bulky gauze dress-
ensure that these are removed in toto. If left behind, one of ing continuously for the first postoperative week.
these small nodules may contribute to later recurrence for
even these benign lesions. Excise the remaining attachments
with a small rim of breast tissue, using cautery to attain
hemostasis.
Fig. 116.3 Suture used to provide traction on benign lesion

(fibroadenoma) Fig. 116.4 Dissection around benign lesion using suture for traction
Complications Belkacemi Y, Bousquet G, Marsiglia H, Ray-Coquard I, et al. Phyllodes

tumor of the breast. Int J Radiat Oncol Biol Phys. 2008;70:492.
Biggers BD, Lamont JP, Etufugh CN, Knox SK. Inframammary
• Hematoma approach for removal of giant juvenile fibroadenomas. J Am Coll
• Infection Surg. 2009;208:e1–4.
• Inadequate excision (missed lesion) Grady I, Gorsuch H, Wilburn-Bailey S. Long-term outcome of benign
fibroadenomas treated by ultrasound-guided percutaneous excision.
• Incomplete excision leading to recurrence Breast J. 2008;14:275.
Kaufman CS, Littrup PJ, Freeman-Gibb LA, et al. Office-based cryo-
ablation of breast fibroadenomas with long-term follow-up. Breast
Further Reading J. 2005;11:344.
Nurko J, Mabry CD, Whitworth P, et al. Interim results from the fibro-
adenoma cryoablation treatment registry. Am J Surg. 2005;190:647.
Barth RJ Jr. Histologic features predict local recurrence after breast
conserving therapy of phyllodes tumors. Breast Cancer Res Treat.
1999;57:291.
Excision of Ducts, Operations for Breast
Abscess 117
Emily L. Albright
Excision of Ducts the patient can be instructed to coat the nipple in clear nail
polish.
Indications
Ductography
• Single duct discharge with or without palpable mass Ductography may be performed by inserting a tiny catheter
• Abnormal duct on ultrasound evaluation of nipple into the duct orifice and injecting a small amount of aqueous
discharge radiopaque medium. The key point is to accurately identify
• Recurrent subareolar abscesses with or without associ- the specific draining duct orifice.
ated mammary fistula
Ductal Endoscopy
This technique allows direct visualization of the ductal sys-
Preoperative Preparation tem as well as the potential to sample the epithelium and in
selected cases to remove small intraductal papillomas but is
Always perform complete imaging workup, including mam- not widely available. If available, it may prove useful in
mography and ultrasound as appropriate identifying the site of underlying pathology.
If single (rather than total) ductal excision is planned,
localize the involved duct by one of the following methods:
Operations for Breast Abscess
Physical Examination
Apply finger pressure at varying points along the outer Indications
margin of the areola to determine which segment of the
breast contains the offending duct (the finger pressure Breast abscess not responding to antibiotics and aspiration.
induces discharge from the duct). If this is not accom-
plished at initial examination, apply collodion or skin glue
to the surface of the nipple to occlude all the ducts tempo- Preoperative Preparation
rarily and prevent any discharge. At subsequent examina-
tion a week later, remove the collodion and repeat the Targeted ultrasound of the area can confirm the presence of
attempt to localize the offending duct. Also, collodion may an abscess and may help to differentiate between a simple
be applied to the surface of the nipple 1 week prior to oper- abscess versus a complicated one (e.g., a multiloculated
ation to cause distension of the diseased duct. Alternatively, collection).
E. L. Albright (*)
Documentation
Department of Surgical Oncology, University of Iowa,
Iowa City, IA, USA • Findings
e-mail: emily-albright@uiowa.edu • Selective or complete duct excision

https://doi.org/10.1007/978-3-030-81415-1_117
926 E. L. Albright
Operative Strategy tant not to include more than 40–50% of the circumference
of the areola in order to avoid skin necrosis. Handle the skin
Single Duct Excision Versus Total Duct Excision flap delicately to avoid unnecessary trauma. A radially ori-
ented incision confined to the skin of the areola is an excel-
When the indication for surgery is bloody nipple discharge, lent alternative, particularly in women with large areolae.
the diagnosis is generally an intraductal papilloma. In rare
cases, carcinoma or DCIS may be the cause. Careful local-
ization to a single duct allows precise excision, which is Operative Technique
diagnostic in the case of carcinoma and therapeutic in the
case of an intraductal papilloma. Single duct excision pro- Single Duct Excision
vides better preservation of sensation to the nipple-areolar
complex and may permit breast feeding once healing has Incision
occurred. Multiple papillomas or ductal ectasia with recurrent A single duct may be excised through a radial incision or an
subareolar abscesses generally require complete ductal incision around the circumference of the areola. Use a sharp
excision. scalpel and obtain hemostasis with accurate electrocoagula-
tion. Develop flaps under the smooth muscle layer.
Strategic Approach to Breast Abscesses Identification and Excision

If discharge is visible, cannulate the duct with a lacrimal duct
Many breast abscesses respond to aspiration and antibiotics probe and use it to guide dissection. If lacrimal probes are
and do not require incision and drainage. When an abscess not readily available a stiff suture such as a 2-0 or 3-0 Nylon
requires incision and drainage, first consider the location in may be used. An alternative is to cannulate the duct with a
the breast. Abscesses that are located close to the nipple- small caliber venous catheter and inject methylene blue to
areolar complex are often associated with pathology in the dye the duct and surrounding tissue.
terminal ducts. It is important to warn the patient that recur- If collodion has been used to occlude the surface of the
rence of the abscess and/or formation of a chronically drain- nipple for a week prior to surgery, the diseased duct should
ing fistula are common sequela. Drain abscesses in this be distended. A duct containing bloody or serosanguinous
location through a radial incision close to the areolar margin discharge will generally appear bluish. Gently dissect the
to facilitate excision of any resulting fistula at the time of duct from surrounding tissue. Divide it between hemostats at
secondary ductal excision. its junction with the nipple and dissect it out to a point about
Abscesses that are located peripherally away from the 1–2 cm beyond the circumareolar incision. Submit it for his-
nipple-areolar complex are not as prone to recurrence and tological examination.
fistula formation. Adequate incision and drainage, biopsy If the duct cannot be clearly identified, excise an area of
of the wall of the abscess, and packing or application of a the ductal system beginning at the nipple and proceeding in
vacuum dressing to facilitate closure generally suffice. An a peripheral direction. Here, it is important to have accurate
alternative is closure over a drain to allow for easier information from the initial physical examination so that if,
wound care. In these cases, the location and direction of for example, the discharge was observed to come from a duct
the incision used for drainage may be tailored to the indi- at 10 o’clock, the ducts appropriate to that quadrant can be
vidual situation and particular anatomic cosmetic consid- excised. Have the pathologist examine the specimen to ascer-
erations. Galactoceles and lactational breast abscesses tain that the pathology has indeed been excised. Be alert dur-
may be managed by aspiration and (if infected) antibiotics ing dissection as the offending duct may be visible as a
without interrupting breast-feeding. These rarely require dilated, bluish structure, facilitating excision. If the woman
surgery. is past childbearing, conversion to a total ductal excision
may be the best course of action.
Avoiding Postoperative Complications Closure

In many cases, it is necessary only to close the skin incision.
revention of Skin Necrosis with Ductal Excision
P In some cases, a few deep sutures may be placed if there is a
Total excision of the mammary ducts requires elevation of significant defect in the underlying breast. This will provide
the entire areola. Most surgeons use a circumareolar inci- support to the nipple areolar complex and improve the cos-
sion, which is almost invisible when fully healed. It is impor- metic result.
117 Excision of Ducts, Operations for Breast Abscess 927
a b
Fig. 117.1
Use sharp dissection (scalpel or scissors) to elevate the are-

ola deep to the smooth muscle layer, with a thin layer of fat
and contained vessels (Fig. 117.1b). Continue this dissection
beyond the nipple so the entire skin of the areola has been
elevated. Do not detach the nipple from its ducts at this stage
of the operation.
xcising the Ductal System

E
After the skin has been elevated, note that the approximately
12 terminal ducts constitute the only attachment between the
nipple and the underlying breast. Apply a ligature to these
ducts and excise them flush with the nipple (Fig. 117.2).
Dissect the ducts for a distance of 3–5 cm. Using electro-
cautery, excise the circle of ducts and breast tissue
(Fig. 117.3a and b). The circular mass of tissue has a radius
of 3–5 cm and a thickness of 1–2 cm. If any of the diseased
ducts is dilated and extends beyond 5 cm, follow this duct
and remove a further section until it disappears into the
breast tissue. Occasionally, a disease duct involves a section
Fig. 117.2 of the nipple, which then appears inverted. In this case, a tiny
segment of the nipple may be removed. This may be facili-
tated with a punch biopsy instrument. Obtain complete
Total Duct Excision hemostasis with electrocautery.
Incision
Make an incision along the circumference of the areola at the Reconstruction
exact margin between the areola and skin. The length of the
incision should encompass no more than 50% of the areolar In the patient with a large breast, the resulting defect may be
circumference. Insert sutures in the edge of the incised are- relatively shallow so the reconstructed areola rests on a solid
ola temporarily and apply a hemostat to each suture. These base of tissue. In this case, no further reconstruction is neces-
are used to apply traction while the areola is being dissected sary. In many cases, however, there is a significant defect
off the breast (Fig. 117.1a). Skin hooks are an alternative. underneath the areola. Because the blood supply of the are-
928 E. L. Albright
a b
Fig. 117.3
Fig. 117.4 Fig. 117.5
ola is somewhat tenuous, it requires a firm base of breast the skin incision, insert an absorbable purse-string suture in
tissue for optimal healing. In this case, close the defect in the the subcuticular tissues at the base of the nipple to maintain
breast in layers with interrupted absorbable sutures. it in the erect position (Fig. 117.4). Then close the skin inci-
If detaching the areola results in a tendency for the nipple sion with interrupted 5-0 nylon sutures (Fig. 117.5) or a sub-
to invert, corrective measures must be taken. Before closing cuticular absorbable monofilament suture.
117 Excision of Ducts, Operations for Breast Abscess 929
a b
Fig. 117.6
Simple Breast Abscess
Breast abscesses are most often seen in nursing mothers.

They are generally the result of bacteria being introduced via
a break in the skin of the nipple. Often these lactational
abscesses respond to antibiotics and aspiration.
In the non-lactating woman, an abscess may appear with
little surrounding inflammation and induration. In some of
these cases, aspiration of pus under local anesthesia and
treatment with antibiotics lead to rapid resolution. If pus is
not obtained on aspiration or the abscess does not respond
promptly, perform operative drainage with biopsy of the
abscess wall. Evacuate the pus, obtain cultures, and loosely
insert a gauze pack. Conversion to a vacuum wound dressing
may speed closure of the resulting cavity.
ecurring Subareolar Abscess/Lactiferous Duct

R
Fistula
Fig. 117.7
An abscess in the region of the areola or just adjacent to the
areola often originates in an obstructed mammary duct. formed when the infection has subsided. Similarly, chronic
Pathogenesis is believed to be due to squamous metaplasia draining fistulae may require surgery. In either case, proper
of the terminal ducts leading with duct obstruction. There is treatment requires a radial elliptical incision overlying the
a strong association with smoking and the development of duct, which can usually be palpated as a thickened cord run-
squamous metaplasia. Nipple piercing can cause a similar ning from the nipple toward the periphery of the breast.
kind of abscess. A cleft-type nipple inversion may also play Include the sinus tract or scar from previous drainage. This
a role in the pathogenesis. The underlying pathology may may require extending the incision beyond the areolar mar-
result in a recurring abscess at the same location or in a gin. Remove a small ellipse of skin and surrounding breast
chronically draining fistula. Drain an abscess in this loca- tissue (Fig. 117.6a and b). Identify the duct (Fig. 117.7) and
tion through a radial incision close to the areolar margin, to excise it together with any diseased tissue back to normal
facilitate any secondary procedure that may be required. tissue (Fig. 117.8).
Recurrent abscesses should be rendered quiescent by anti- If the incision has not been greatly contaminated, close
biotics and drainage or aspiration and elective surgery per- primarily or alternatively close the skin loosely around a
930 E. L. Albright
• Pain is typically minimal, and many patients do not

require narcotic pain control.
• Monitor for signs of bleeding or infection.
Complications
• Hematomas may appear.

• Occasionally, following total duct excision, elevation of
the entire areola in a plane too close to the subcutaneous
tissue results in an area of skin necrosis. Generally, this
will resolve with local wound care but may result in scar-
ring and distortion of the nipple-areolar complex with a
suboptimal cosmetic result.
Further Reading
Cardenosa G, Doudna C, Eklund GW. Ductography of the breast: tech-
Fig. 117.8 nique and findings. AJR Am J Roentgenol. 1994;162:1081.
Dixon JM, Hardy RG. Chapter 16. Breast infection. In: Dirbas FM,
CEH S-C, editors. Breast surgical techniques and interdisciplinary
management. New York: Springer; 2011. p. 161–78.
Dixon JM, Thompson AM. Effective surgical treatment for mammary
duct fistula. Br J Surg. 1991;78:1185.
Gollapalli V, Liao J, Dudakovic A, Sugg SL, Scott-Conner CE, Weigel
RJ. Risk factors for development and recurrence of primary breast
abscesses. J Am Coll Surg. 2010;211:41.
Hadfield GJ. Further experience of the operation for excision of the
major duct system of the breast. Br J Surg. 1968;55:530–5.
Hughes LE. The duct ectasia/periductal mastitis complex. In: Hughes
LE, Mansel RE, Webster DJT, editors. Benign disorders and dis-
eases of the breast. Concepts and clinical management. 2nd ed.
London: Saunders; 2000. p. 143–70.
Kato M, Simmons RM. Chapter 17. The evaluation and treatment of
nipple discharge. In: Dirbas FM, Scott-Conner CEH, editors. Breast
surgical techniques and interdisciplinary management. New York:
Springer; 2011. p. 179–86.
Lannin DR. Twenty-two year experience with recurring subareolar
abscess and lactiferous duct fistula treated by a single breast sur-
Fig. 117.9 geon. Am J Surg. 2004;188:407–10.
Meguid MM, Oler A, Numann PJ, Khan S. Pathogenesis-based
drain. If the area is grossly contaminated, it may be wiser to treatment of recurring subareolar breast abscesses. Surgery.
insert skin sutures for delayed primary closure. An alterna- 1995;118:775–82.
Sabel MS, Helvie MA, Breslin T, Curry A, Diehl KM, Cimmino VM,
tive is to close around a Penrose drain to allow drainage and Chang AE, Newman LA. Is duct excision still necessary for all
slow advancement of the drain from the cavity (Fig. 117.9). cases of suspicious nipple discharge? Breast J. 2011;10:1524.
If the diseased duct is not removed, the abscess or fistula will Seow JH, Metcalf C, Wylie E. Nipple discharge in a screening pro-
recur. Recurrence may occur even with adequate ductal exci- gramme: imaging findings with pathological correlation. J Med
Imaging Radiat Oncol. 2011;55:577.
sion, particularly in smokers, and it is important to warn Urban JA. Excision of the major duct system of the breast. Cancer.
patients of this possibility. 1963;16:516–20.
Webster DJT. Nipple discharge. In: Hughes LE, Mansel RE, Webster
DJT, editors. Benign disorders and diseases of the breast. Concepts
and clinical management. 2nd ed. London: Saunders; 2000.
Postoperative Care p. 171–86.
• Instruct the patient to wear a supportive brassiere over a

moderately bulky dressing to apply even pressure for the
first 7 days and nights after surgery.
Lumpectomy for Breast Cancer
118
Ingrid Lizarraga
Indications • Failure to communicate with the pathologist about the

presence of multiple lesions or need to assess response to
• Definitive treatment of breast cancer (as part of breast- neoadjuvant chemotherapy
conserving therapy) in suitable patients
• Excise lesion with clear margins and preserve adequate
breast parenchyma Documentation
• Indication for procedure

Preoperative Preparation • Laterality and location of lesion
• Method of localization
• Use imaging studies to clearly delineate extent of target • Intraoperative findings
lesion. Ensure you are aware of the extent of any suspi- • Extent of lumpectomy (to pectoralis fascia or not, removal
cious calcifications associated with a mass. Confirm with of overlying skin)
imaging and examination that there are no other abnor- • Method of orientation of specimen
malities in either breast that require excision. • Source of any additional margins taken, and reason for
• Determine the best modality to localize the lesion intraop- doing so
eratively (e.g., palpation, ultrasound, wire, seed). • Specimen imaging obtained, and confirmation of clip
• If patient is having standard breast conservation therapy retrieval
(as in most cases of ductal carcinoma in situ (DCIS) and • Closure of cavity and any oncoplastic techniques used
invasive cancer), ensure there are no contraindications to
radiation therapy.
• Determine need for concomitant intraoperative axillary Operative Strategy
staging and plan method of localization (injection of
radioactive-labeled colloid with or without vital blue Localization
dye).
Review the imaging studies to determine the best form of
intraoperative localization. Intraoperative ultrasound is the
Pitfalls and Danger Points most convenient tool for localization of non-palpable lesions
but is dependent on the surgeon’s familiarity with the tech-
• Failure to include the target lesion in the specimen or to nique (Fig. 118.1a and b). It can be used to localize masses
retrieve the clip marking the lesion as well as mammographically biopsied lesions in which the
• Failure to obtain clear margins residual hematoma and clip are visible on ultrasound (hema-
• Inadequate cosmetic result (volume deformity or size dis- toma ultrasound guided (HUG) lumpectomy). Lesions which
crepancy with other breast) are not seen on ultrasound, or which are associated with
adjacent suspicious calcifications, are best localized using
I. Lizarraga (*) mammography with placement of seeds or hookwires. MRI
Department of General Surgery, University of Iowa Hospitals and can be used to localize lesions which are only well visualized
Clinics, Iowa City, IA, USA with that modality. Extensive calcifications or multiple small
e-mail: ingrid-lizarraga@uiowa.edu

https://doi.org/10.1007/978-3-030-81415-1_118
932 I. Lizarraga
a b
Fig. 118.1
lesions may require localization of two or more areas and

this is best planned beforehand with the team performing
localization.
There are a variety of devices used for localization, the
oldest of which is a hookwire placed in or near the target
lesion using any of the imaging modalities described above.
Radioactive and magnetic seeds are increasingly used.
Incision
Incisions do not have to be made directly over the target

lesion and should be planned with the final cosmetic result in
mind. Most central lesions can be readily accessed through a
periareolar incision. Oncoplastic techniques can be used to
Fig. 118.2
excise more remote lesions through this incision as well. For
procedures requiring wire localization, it is usually not nec-
essary or favorable to make the incision at the wire entry the pectoralis fascia. Tumors that are less than 5 mm from
point. Incisions placed along Langer’s lines provide the most the skin or that involve the skin require excision of overlying
cosmetically aesthetic scars, although radial incisions work skin to achieve negative margins. This is best achieved
well if skin is excised or in the inferior aspect of the breast. through an elliptical incision with a 3:1 ratio of length:width.
Specimen orientation should be clearly marked by the
surgeon to facilitate pathologic examination and accurate
xtent of Excision, Orienting the Specimen
E reporting of margins. A variety of techniques are available,
and Additional Margins including suture (long suture marks lateral margin, short
marks the superior), radio-opaque metallic margin markers
Current guidelines recommend that invasive cancer treated sewn or clipped to individual margins, and intraoperative
with lumpectomy and radiation requires a margin no larger inking (Fig. 118.2). Specimen imaging should be performed
than no tumor seen at the inked margin, while a 2 mm margin to confirm removal of the clip and the entire target lesion and
is preferred for ductal carcinoma in situ. The extent of sur- help to evaluate adequacy of margins at the time of surgery.
gery should balance the need for complete excision with the Other specialized techniques for margin assessment are
need for an acceptable cosmetic result. Adequate margins available, including frozen section examination of margins
may be achievable without extending the resection down to and use of intraoperative devices that can detect cancer cells
118 Lumpectomy for Breast Cancer 933
at the borders of the specimen. Additional margins can be Avoiding Postoperative Complications
excised from the cavity walls to ensure that all the disease is
removed. This can be done routinely for all lumpectomies or • Bleeding—Scrupulous hemostasis is essential, as a rela-
selectively based on the intraoperative findings. tively small hematoma can be symptomatic and increase
the likelihood of infection.
• Infection—Attention to careful tissue handling, use of
Closure preoperative intravenous antibiotic that covers skin flora.
• Poor cosmesis—Thoughtful incision placement, closure
Clips or another marking device is usually placed in the of the cavity, and consideration of oncoplastic surgery
lumpectomy cavity to mark the space and facilitate the plan- with contralateral procedure for symmetry if lumpectomy
ning of radiation delivery. The lumpectomy cavity should be results in a large volume deficit.
closed using absorbable sutures. This usually requires mobi- • Failure to remove the lesion or clip—Carefully review
lization of local flaps of adjacent breast tissue off the chest preoperative imaging, including any studies performed
wall and skin. This reduces likelihood of seroma and during localization. Obtain specimen imaging to confirm
improves cosmetic outcome. tumor removal. Depending on the type of clip used, intra-
operative fluoroscopy can be used to find and remove an
errant clip.
Special Techniques • Positive margin—While often unavoidable, careful adher-
ence to the strategy detailed above and the judicious use
Intraoperative Radiation Therapy of shave margins will help avoid this complication.
Radiation can be delivered at the time of lumpectomy utiliz-
ing either a low energy x-ray or electron beam device. Patient
selection for this procedure should be based on published Operative Technique
guidelines. Eligibility is also limited by lumpectomy size
and proximity to skin. Both techniques require introduction Basic Lumpectomy
of an applicator into the lumpectomy cavity that must be in
contact with the surface of the cavity to be effective. A Place the incision based on the imaging studies and cosmetic
lumpectomy cavity that is symmetrical, less that 5x5x5 cm in considerations. Create a curvilinear incision along Langer’s
size, and located close to the incision is ideal for intraopera- lines, or use a straight (radial) one. The length of the incision
tive radiation. Routine shave margins can reduce the likeli- is determined by the size of the target lesion. Most lesions
hood of positive margins and need for additional radiation. can be excised through a 3–4 cm incision. Infiltrate local
An adequate distance from the applicator to the overlying anesthetic into the subcutaneous tissue prior to making the
skin is confirmed with ultrasound to prevent radiation injury. skin incision.
Excision of skin may be necessary to achieve this for very Next, use serrated skin retractors to help elevate skin flaps
superficial tumors. in all directions beyond the extent of the lesion. Tailor the
thickness of the skin flaps to the anticipated depth of the
Oncoplastic Lumpectomy lesion (Fig. 118.3).
Oncoplastic techniques for incision placement and closure of
the cavity should be considered for all lumpectomies to
ensure the best cosmetic results. However, for tumors that
are large relative to breast size or those in unfavorable loca-
tions, such as the upper inner quadrant of the breast, more
specialized techniques are required to achieve a good out-
come. Oncoplastic lumpectomy involves wide local excision
of the lesion with reshaping of the breast and usually a con-
tralateral procedure to achieve symmetry. It may require
excision of skin to reduce the size of the breast envelope as
well as repositioning of the nipple areolar complex.
Oncoplastic lumpectomy is most commonly utilized in
patients with macromastia but can also be used in women
with small or moderate sized breasts. Intraoperative radia-
tion therapy can be performed in the setting of oncoplastic
lumpectomy. Fig. 118.3
934 I. Lizarraga
Fig. 118.4 Fig. 118.5
Use a right-angled retractor to provide visualization and Close the incision in layers with interrupted absorbable
counter traction. Place a finger or two of your nondominant suture. Close the skin with a running subcuticular suture.
hand, wrapped in gauze, on the tissue to be excised. Use this
to retract and guide the plane of tissue division. Divide the
tissue using electrocautery or scissors (Fig. 118.4). The Techniques for Localization
extent of excision is guided by the method of localization as
described below. Palpation-Guided Lumpectomy
To facilitate marking, examination, and reporting of mar- Even in a lesion that is palpable, consider using ultrasound
gins by the pathologist, it is best to strive for a cube-shaped intraoperatively to make the extent of the lumpectomy more
specimen with smooth edges, with the target lesion centered precise. Once the flaps are elevated, place two fingers of your
in the excised tissue (Fig. 118.2). It is usually easiest to nondominant hand on the palpable lesion and use these to
define and mark the medial, lateral, cranial, and caudal bor- retract and guide the extent of resection. A 5 mm margin
ders of the specimen before detaching it at the deep aspect. grossly is desirable to ensure histologically negative
Use specimen mammography or ultrasound to confirm margins.
and document retrieval of the entire target lesion and clip (if
one was placed). This can be used to determine the need for Wire-Localized Lumpectomy
additional margins if routine sampling of all margins is not Use the mammographic images taken after wire placement
performed. to assess the trajectory of the wire and the relation of the
If additional margins will be taken, grasp the relevant bor- target lesion to the end of the wire. It can be helpful to know
der of the cavity with one or two Allis clamps and excise a the length of the wire used and measure the part that is out-
new margin excised as a thin sheet from the entirety of the side of the breast. Keep in mind that a mammographically
surface. Orient this margin if desired. This is best done by placed wire may take a longer trajectory to reach the lesion,
placing the new margin surface on a card and suturing it in and the length of the wire in the breast may change signifi-
place. cantly when the patient returns to the supine position. In con-
Irrigate the cavity and obtain scrupulous hemostasis. trast, a wire placed under ultrasound guidance will typically
Place clips or specialized devices to mark the borders of the have a shorter, more direct, trajectory to the lesion. Gentle
cavity. Alternatively, specialized devices are made for this palpation of the breast in the area where the end of wire is
purpose. anticipated to be should cause the top of the wire to move.
Close the defect with interrupted absorbable sutures. This Divide the wire about 3 cm from the skin. The placement of
usually requires that the adjacent breast tissue be mobilized the incision should be based upon the anticipated location of
from the fascia (Fig. 118.5). Take care to avoid distortion of the end of the wire and the target lesion. Raise flaps as
the nipple and breast skin during closure by also mobilizing described in “basic lumpectomy,” and identify the wire.
the breast tissue from the overlying skin. For larger defects, Grasp the exposed wire under the flap with a hemostat to
more advanced oncoplastic techniques can be used for clo- stabilize it, and use a second hemostat to bring it into the cav-
sure. These are beyond the scope of this chapter. ity by pulling it back through the skin (Fig. 118.6). Once it is
118 Lumpectomy for Breast Cancer 935
Fig. 118.7
Fig. 118.6
in the lumpectomy cavity, use the observed trajectory of the

wire and the imaging studies to estimate where you would
anticipate the targeted segment of the wire to be, and excise
the tissue around this area as described above. Ensure a mar-
gin of normal tissue around the area where the lesion/clip is
anticipated to be. If the wire is well positioned in relation to
the lesion on imaging, it is generally preferred to have the
entirety of the distal wire contained within your specimen to Fig. 118.8
avoid missing the lesion/clip. As you create the margins of
lumpectomy, observe and palpate carefully for the wire, as
the trajectory may change within the breast. It is often easiest men before dividing the deep tissue to ensure the entire
to develop the margin on either side of the wire first and lesion is contained within the specimen. Orient the specimen
leave the distal margin closest to the end of the wire for last. as previously described. The ultrasound probe can also be
Take care that the entire wire is retrieved, as it can be inad- used to examine the specimen once it is detached to confirm
vertently divided with electrocautery. This is particularly apt removal of the lesion and adequacy of margins.
to happen with MRI-compatible wires. Orient the specimen
as previously described. umpectomy Using Implanted Localization
L
Marker
Ultrasound-Guided Lumpectomy The device is placed preoperatively and mammographic
Use an 8 Mhz probe to localize the lesion and guide skin images are obtained to document the relationship of the
incision (Fig. 118.1). Place the probe in a sterile cover with marker to the target lesion. The localizing probe is used to
ample jelly so that it can be used to guide excision during the identify the area of maximum signal on the skin and guide
procedure. A hockey stick–shaped probe is ideal for use with incision placement (Fig. 118.9). Incise the skin and develop
a small incision as it can be inserted under the skin flaps for flaps in the usual fashion. Then use the probe to guide exci-
excellent visualization of the target area (Fig. 118.7). Perform sion of the tissue surrounding the area of maximal signal in
the lumpectomy as described in #1 above, using the ultra- the fashion described above. This technique can also be used
sound probe to identify the borders of the lesion and guide to define the necessary depth of the lumpectomy. It is impor-
the extent of the excision (Fig. 118.8). If a hockey stick– tant to be familiar with the properties of the particular device
shaped probe is used, it can also be used to gauge the appro- and probe used as they all differ in their directionality and
priate depth of the lumpectomy as the probe surface can be sensitivity. Once the specimen is removed, use the probe to
placed perpendicular to the borders of lumpectomy speci- confirm removal of the marker.
936 I. Lizarraga
• Poor cosmetic outcome

• Chronic pain
Further Reading
Arentz C, Baxter K, Boneti C, Henry-Tillman R, Westbrook K,
Korourian S, Klimberg VS. Ten-year experience with hematoma-
directed ultrasound-guided (HUG) breast lumpectomy. Ann
Surg Oncol. 2010;17(Suppl 3):378–83. https://doi.org/10.1245/
s10434-010-1230-x.
Chagpar AB, Killelea BK, Tsangaris TN, et al. A randomized, con-
trolled trial of cavity shave margins in breast cancer. NEMJ.
2015;373(6):503–10.
Landercasper J, Attai D, Atisha D, Beitsch P, Bosserman L, et al. Toolbox
to reduce lumpectomy reoperations and improve cosmetic outcome
in breast cancer patients: the American Society of Breast Surgeons
consensus conference. Ann Surg Oncol. 2015;22(10):3174–83.
https://doi.org/10.1245/s10434-015-4759-x.
Langhans L, Tvedskov TF, Klausen TL, et al. Radioactive seed local-
ization or wire-guided localization of nonpalpable invasive and
in situ breast cancer: a randomized, multicenter. Open-label
Trial Ann Surg. 2017;266(1):29–35. https://doi.org/10.1097/
SLA.0000000000002101.
Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, et al. SSO
margin guidelines Society of Surgical Oncology-American Society
Fig. 118.9 for Radiation Oncology consensus guideline on margins for breast-
conserving surgery with whole-breast irradiation in stages I and II
invasive breast cancer. J Clin Oncol. 2014;32(14):1507–15. https://
doi.org/10.1200/JCO.2013.53.3935.
Postoperative Care Morrow M, Van Zee KJ, Solin LJ, Houssami N, Chavez-MacGregor
M, et al. Society of Surgical Oncology-American Society for
Radiation Oncology-American Society of Clinical Oncology con-
Place a gauze dressing over the wound. This can be held in sensus guideline on margins for breast-conserving surgery with
place by a supportive surgical bra to avoid placing tape all whole-breast irradiation in ductal carcinoma in situ. J Clin Oncol.
over the breast. The patient should resume regular activity 2016;34(33):4040–6. https://doi.org/10.1200/JCO.2016.68.3573.
after observing a1 week 10 lb weight lifting restriction. Rezai M, Knispel S, Kellersmann S, Lax H, Kimmig R, Kern
P. Systematization of oncoplastic surgery: selection of surgical tech-
Exercises for arm range of motion should be instituted after niques and patient-reported outcome in a cohort of 1035 patients.
surgery once the patient can tolerate, especially if there is Ann Surg Oncol. 2015; https://doi.org/10.1245/s10434-0154396-4.
concomitant axillary surgery. Shah C, Vicini F, Shaitelman SF, et al. The American Brachytherapy
Lumpectomy is usually an outpatient procedure. It is gen- Society consensus statement for accelerated partial-breast irradia-
tion. Brachytherapy. 2018;17(1):154–70. https://doi.org/10.1016/j.
erally not associated with significant postoperative pain and brachy.2017.09.004.
use of outpatient narcotic analgesia should be limited or Silverstein MJ, Mai T, Savalia N, Vaince F, Guerra L. Oncoplastic
avoided. breast conservation surgery: the new paradigm. J Surg Oncol.
2014;110:82–9.
Vaidya JS, Wenz F, Bulsara M, et al. Risk-adapted targeted intraop-
erative radiotherapy versus whole-breast radiotherapy for breast
Complications cancer: 5-year results for local control and overall survival from
the TARGIT-A randomised trial. Lancet. 2014;383(9917):603–13.
• Bleeding/hematoma https://doi.org/10.1016/S0140-6736(13)61950-9.
Veronesi U, Orecchia R, Maisonneuve P. Intraoperative radio-
• Infection therapy versus external radiotherapy for early breast can-
• Failure to remove clip or lesion cer (ELIOT): a randomised controlled equivalence trial.
• Positive margins Lancet Oncol. 2013;14(13):1269–77. https://doi.org/10.1016/
• Chronic seroma S1470-2045(13)70497-2.
Mastectomy: Simple (Total), Modified,
and Classical Radical 119
Indications skin/nipple-
sparing mastectomy. It may be performed
after primary (neoadjuvant) chemotherapy.
• These procedures are indicated when mastectomy is • Modified radical mastectomy remains the operation of
required, but skin-sparing or nipple-sparing mastectomy choice for patients who present with inflammatory carci-
is not feasible due to extent of disease. In this chapter, noma of the breast. In this situation, primary (neoadju-
they will be presented as a continuum of options that may vant) chemotherapy is administered before surgery, and
be used when anatomic distribution of disease within the surgery is generally followed by radiation therapy.
breast requires wide excision of the skin envelope, the • Classical radical mastectomy may rarely be of use in
underlying pectoral muscle, or lymph nodes. highly selected patients for local control of advanced
• Simple (total) mastectomy is used for patients with ductal disease.
carcinoma in situ or clinically node-negative invasive
breast cancer who are not candidates for breast conserva-
tion or skin/nipple-sparing mastectomy. In this setting, Preoperative Preparation
sentinel lymph node biopsy is performed.
• Simple mastectomy is occasionally performed as a sal- Patients in whom these procedures are contemplated should
vage procedure when breast conservation fails. undergo multidisciplinary evaluation before surgery.
• Simple mastectomy may be appropriate for treatment of The extent of preoperative workup is dictated by the clini-
rare tumors of the breast such as leiomyosarcoma. Wide cal situation but will generally include these required
excision of overlying skin may be required. studies:
• By virtue of nipple involvement, Paget’s disease of the • Bilateral mammograms.
breast will generally preclude nipple-sparing mastectomy • Core needle biopsy.
and typically skin-sparing mastectomy (or, in some cases, • Ultrasound is done to stage the axilla. If suspicious nodes
one of these procedures will be required). are found, perform core needle biopsy of the most acces-
• Women who opt for mastectomy and do not desire recon- sible/most suspicious node and have a marker (clip or
struction may request or expect flaps that nicely conform seed) placed.
to the contours of the chest wall. The flap techniques • Many patients will also undergo MRI scans to evaluate the
described here may be useful in this circumstance. extent of disease in the breast. If primary (neoadjuvant)
• Modified radical mastectomy (simple mastectomy with chemotherapy has been used, MRI scans are typically
axillary node dissection) is the operation of choice in obtained before and after the course of chemotherapy to
patients with lymph node-positive invasive carcinoma of evaluate the response. Use of PET-CT scans and other stag-
the breast who are not eligible for breast conservation or ing studies depends upon clinical situation. Genetic testing
may be appropriate, and gene-expression panels may be
used to more accurately determine tumor genotype.
Department of Surgery, University of Iowa Carver College • If extensive excision of skin is anticipated, consider how
of Medicine, Iowa City, IA, USA you will close the resulting defect. Arrange plastic sur-
e-mail: carol-scott-conner@uiowa.edu gery consultation for flap closure if necessary.

https://doi.org/10.1007/978-3-030-81415-1_119
Pitfalls and Danger Points uncommon for one or two axillary lymph nodes to be
included in the adipose tissue surrounding the axillary tail,
• Ischemia of skin flaps. and it is prudent to explain this to the patient preoperatively.
• Inadequate resection of skin, resulting in positive skin Frequently, sentinel lymph node biopsy is performed as the
margin. first phase of this procedure, and the procedure is converted
• Injury to long thoracic or thoracodorsal nerve. to a modified radical mastectomy if a positive sentinel node
• Injury to lateral pectoral nerve resulting in atrophy of the is encountered.
major pectoral muscle.
• Injury to axillary vein or artery.
• Injury to brachial plexus. Modified Radical Mastectomy
• Pneumothorax may be produced by perforation into the
chest cavity during attempts to control bleeding from Modified radical mastectomy is used currently as synony-
branches of the internal mammary artery. mous with total mastectomy and axillary node dissection. As
originally described, modified radical mastectomy removed
all of the breast tissue together with the underlying fascia of
the major pectoral muscle in continuity with a total axillary
Operative Strategy lymphadenectomy. The minor pectoral muscle was also
excised. Most surgeons simply retract (or possibly divide)
Sequencing the Operation the minor pectoral muscle. The muscle can be divided if
access to the higher axillary nodes is desired; it is not neces-
The operation can be broken down into sequential, logical sary to remove it.
steps. Take time to conceptualize how the procedure can flow It is not considered necessary to remove breast and axil-
most efficiently. Here are the general steps that are required. lary tissue together en bloc, but resection in continuity con-
First, outline the skin incision and, if necessary (e.g., in cases siderably facilitates the dissection for several reasons. First
of inflammatory breast cancer after primary chemotherapy), and most importantly, the weight of the breast falling later-
biopsy the margins for frozen section confirmation that the ally provides helpful traction on the axillary contents.
planned skin incision is adequate. If possible, arrange the Second, because axillary nodes are sometimes found in the
skin incision in such a way that it is not only oncologically fat surrounding the axillary tail of the breast, removing all of
sound but will facilitate wound closure without tension, sub- the adipose tissue in continuity may facilitate the patholo-
sequent reconstruction, or concealment (low medially). gist’s evaluation of extent of nodal involvement.
Develop flaps to the clavicle superiorly, the sternum medi- Handle the skin flaps with care. Place warm moist packs
ally, the inframammary crease inferiorly, and the latissimus under the flaps and do not allow the fat to dessicate. Avoid
dorsi laterally. Take care to perform this dissection in the folding the flaps back on themselves as this may temporarily
natural fusion plane between breast and subcutaneous fat to compromise blood flow.
minimize bleeding and maximize flap viability. If sentinel Close the defect. If excess tension causes blanching of the
node biopsy with touch prep or frozen section is planned, skin, consider a split thickness skin graft. Ideally, obtain
concentrate on developing the lateral aspect of the field first, plastic surgery assistance with flap closure.
so that a result on the lymph nodes will be available by the
time you would naturally perform axillary node dissection (if
required). After the flaps have been completely developed, Radical Mastectomy
remove the breast from the underlying major pectoral mus-
cle, taking the pectoral fascia. If the tumor is deep and Radical mastectomy involves all of the steps described for
removal of part or all of the major pectoral muscle is required, modified radical mastectomy, but also includes excision of
do so in continuity with the breast. Swing the breast and part or all of the major pectoral muscle. When possible, the
attached tissues laterally and, if necessary, perform axillary clavicular head of the major pectoral muscle is preserved to
node dissection. create a more natural contour of the upper chest wall. The
sternal head of the major pectoral muscle is most efficiently
removed by dividing it from its attachment on the humerus,
Simple Versus Modified Radical Mastectomy then shaving it off the chest wall (ligating perforating
branches of the internal mammary artery). When the tumor is
Simple mastectomy is used when axillary lymphadenec- adherent to or has invaded a limited part of the major pecto-
tomy is not required. The dissection is simply terminated ral muscle, simply remove a generous disc of underlying
when the lateral border of the breast is reached. It is not muscle.
119 Mastectomy: Simple (Total), Modified, and Classical Radical 939
Incision and Skin Flaps
hickness of Skin Flap

T
The extremely thin skin flaps advocated as an integral part of
the classic Halsted radical mastectomy were necessitated by
the advanced stage of cancer common at that time. Even
these thin flaps have been shown to harbor islands of glandu-
lar breast tissue, negating the argument in favor of their use.
How thin to make the skin flap depends on how much sub-
cutaneous fat exists between the skin and the breast. There is
frequently a relatively avascular cleavage plane between this
fat and the fat of the breast. Obese patients may have 1–2 cm
of subcutaneous fat, whereas thin patients may have only a
few millimeters of fat in this location. The important concept
is to remove all grossly obvious breast tissue. Leaving behind
a layer of subcutaneous fat on the skin flap helps ensure the
viability of the flap. Subcutaneous veins should be visible
(and intact) on the underside of the flap. Bleeding should be
minimal. If excess bleeding is encountered, reassess the plane
of dissection. When a wide skin excision is made around the
primary tumor site, local recurrence should be minimized.
Frequently the natural plane becomes thicker as the dissec- Fig. 119.1
tion progresses away from the nipple-areolar complex.
Cooper’s ligaments extend from the breast to the subcutis
and form a discontinuous layer of thin white fibrous tissue,
visible against the background of yellow fat. Incising this
fibrous layer where it joins the subcutaneous fat is a good
method for ensuring complete removal of the breast tissue
while at the same time preserving an even layer of subcuta-
neous fat. This technique is described below.
Alternative Incisions for Mastectomy
If immediate or delayed reconstruction is planned, allow the

reconstructive surgeon to have input into the location, direc-
tion, and size of the scar—always prioritizing the complete
excision of any tumor. Large-breasted women, or women
with inferior quadrant lesions, may benefit from breast-
reduction pattern incisions which allow the reconstructive
surgeon to reshape the skin envelope. References at the end
of this chapter give guidance for this incision. Skin and
nipple-sparing mastectomy incisions and dissection tech-
niques are described in Chap. 120.
In general, placing the incision in a transverse or gently Fig. 119.2
oblique (low medial to high lateral) or horizontal direction
gives the best cosmetic result because the scar is not visible
when the patient wears clothing with a low-cut neckline. remainder of the incision so that the entire areola is included
Although this incision is easy to apply to tumors in the three in the specimen. If possible, accomplish this in an oblique or
and nine o’clock positions, some modifications are necessary horizontal direction. After having drawn the circle around
for tumors in the upper or lower portions of the breast. the tumor, preserve as much of the remaining skin as possi-
A good basic approach is to draw a circle around the ble so as to avoid tension on the skin suture line (Figs. 119.1
tumor and full extent of skin resection required. Plan the and 119.2). Remember that flaps can be designed so as to
Fig. 119.3
slide both horizontally and vertically to close the defect. mammary group, the subscapular group, and the axillary
Extensive undermining may help. vein group. The lateral border of the minor pectoral muscle
There are a number of alternative incisions for tumors in forms the upper border of this node group. Level II nodes lie
various locations of the breast (Fig. 119.3) and ways of mini- directly underneath (deep to) the minor pectoral muscle.
mizing Dog-ear deformities. The old vertical incision Level III nodes are superomedial to the minor pectoral mus-
occasionally performed as part of a Halsted radical mastec- cle. Thus, the minor pectoral muscle, crossing the axillary
tomy should not be necessary. neurovascular bundle, must be retracted, divided, or removed
If difficulty in flap closure is anticipated, arrange plastic to perform a complete lymphadenectomy. Additional nodes,
surgery assistance. In this case, simply incise around tumor termed Rotter’s nodes, are found between the major and
and nipple-areolar complex and develop flaps. Do not attempt minor pectoral muscles. It is thus prudent to tease away any
to tailor the flaps; allow plastic surgery to excise as much or adipose tissue found in this region, submitting it separately
as little as needed before performing their closure. for pathological examination. Although most surgeons no
longer divide or excise the minor pectoral muscle, there
should be no hesitancy in doing so if exposure is poor.
Avoiding Dog Ears
The dog-ear deformity can result at either end of a mastec- Documentation Basics
tomy incision. It is particularly apt to occur when a “fat” (as
opposed to a long, slender) skin ellipse is closed. This bunch- • Findings.
ing together of skin is interpreted by many women as a resid- • Any biopsy/frozen section examinations? Results?
ual tumor and may occasion great anxiety. It is easily • Sentinel lymph node biopsy? Results?
prevented by excising a small additional triangle of skin, so • Axillary lymph node dissection?
that the redundancy is eliminated and the skin lies flat to the • Closure – flap, reconstruction, skin graft?
chest wall. Note that such excision may impair viability of
this part of the flap and use it with caution. See references at
the end of the chapter for additional guidance. Operative Technique
Position the patient so that the arm is abducted 90 degrees on

xillary Lymph Node Anatomy for Breast
A an armboard and place a folded sheet, about 5 cm thick,
Surgeons underneath the patient’s scapula and posterior hemithorax.
Avoid hyperextending the shoulder. Prepare the area of the
Breast cancer surgeons conventionally divide the axillary breast, upper abdomen, shoulder, and upper arm with solu-
lymph nodes into three levels. The minor pectoral muscle is tion of choice. Enclose the entire arm in a double layer of
the anatomic landmark that delimits the three levels. Level I sterile orthopedic stockinette to maintain sterility of the
nodes lie along the chest wall and under the lateral portion of entire extremity in case the arm must be flexed to facilitate
the axillary neurovascular bundle. They include the external dissection of the upper axilla. A sterile Mayo instrument
stand may be placed over the patient’s head. It may be used tant elevate the skin flap by drawing these in an anterior and
for extra hemostats and gauze pads for the assistant, and it upward direction. Apply countertraction by depressing the
supports the patient’s arm during the period of the operation breast posteriorly and pulling it toward you. Then use elec-
that requires it to be flexed. trocautery to incise Cooper’s ligaments which attach the sub-
Using a sterile marking pen, draw a circle 3 cm away cutaneous tissues to the surface of the breast. Incise the
from the perimeter of the primary tumor. In addition to the pectoral fascia at the cephalad aspect of the dissection
area of skin outlined by the circle drawn around the tumor, (Fig. 119.4). Leave no visible breast tissue on the skin flap.
include the entire nipple-areolar complex in the patch of skin When significant bleeding is encountered, which should be
left on the specimen. Depending on the location and ease of rare, use a hemostat to grasp and elevate the bleeding vessel
closure, mark the medial and lateral extensions of the inci- away from the underside of the flap before coagulating it
sion as discussed above. Use a scalpel to make the incision with electrocautery. This minimizes the chance that the cau-
through all layers of the skin. Attain hemostasis by applying tery will “burn through” the skin flap. Bleeding should be
electrocautery to each bleeding point. minimal and the network of subcutaneous veins should go up
If the patient has (or has had) skin involvement (e.g., with the skin flap. Continue elevating the inferior skin flap
inflammatory breast cancer), it is prudent to biopsy at least until the dissection is beyond the breast. The medial margin
four spots along the incision close to the upper and lower for the dissection is the sternum. At the medial aspect, perfo-
extent of the tumor, even if the skin involvement has regressed rating vessels from the internal mammary (internal thoracic)
with chemotherapy. Place an Allis clamp on the skin edge artery will be encountered. Preserve these, if possible, to pro-
and shave a piece off. Label each piece by location (e.g., tect viability of the skin flaps.
“Upper medial,” “upper lateral,” “lower medial,” and “lower The lateral margin is the anterior border of the latissimus
lateral”) and submit for frozen section examination. dorsi muscle, which is exposed for the first time during this
Stand facing the flap which is to be elevated first. Some phase of the operation. Apply a moist gauze pad to the opera-
surgeons begin with the lower flap, others will start with the tive site, carefully placing the flap back down without allow-
upper flap. If sentinel node biopsy is planned and will affect ing it to fold over upon itself (which may impede the blood
the course of the operation, concentrate on developing both supply). Remove the Adair clamps from the lower skin flap
flaps at the lateral extent first. and apply them now to the upper skin flap. Use the same
Use Adair clamps, skin hooks, or sharp rake retractors to technique to elevate the upper skin flap to a point about
elevate the cut edge of skin on the lower flap. Have an assis- where the breast appears to dissolve into the filmy tissue of
Triangle of
redundant
skin
Fig. 119.4
the pectoral fascia, usually about 3 cm below the clavicle. If

axillary node dissection is planned, whichever skin incision
has been selected, it should permit wide exposure of the axil-
lary contents. The final step in achieving exposure consists
of clearing the fat from the anterior border of the latissimus
muscle with a scalpel so the entire lateral margin of the dis-
section has been identified.
Clearing the Pectoral Fascia
Unless a radical mastectomy (with resection of part or all of

the major pectoral muscle) is planned, next shave the breast
off the pectoral muscle with a scalpel or electrocautery and
strong upward traction. Please see the section at the end for
the technique of radical mastectomy.
Begin removing the breast near the upper medial margin
of the muscle and proceed with scalpel or electrocautery to
dissect the fascia off the anterior surface of the major pecto- Fig. 119.5
ral muscle from the sternum to the lateral margin (Fig. 119.5).
Hemostasis is achieved if the first assistant electrocoagulates
each of the branches of the mammary vessels as they are
exposed or divided by the dissection. Whether using electro-
cautery or hemostasis, exercise caution when pursuing a ves-
sel that has retracted into the chest wall after being divided.
A simple pneumothorax may (rarely) occur, especially in a
thin patient, when the point of a hemostat is jealously poked
into the tissues of the chest wall. When the vessel is not eas-
ily controlled by electrocautery or a hemostat, simply apply
a suture-ligature to control it. Retract the specimen laterally
and allow gravity to assist as the lateral margin of the dissec-
tion is approached.
If the tissue feels abnormal, consider the possibility of
tumor adherence to or involvement of the pectoral fascia. If
in doubt, excise a disc of major pectoral muscle with the
specimen. This can be full or partial thickness, depending
upon the bulk of the muscle.
When the lateral margin of the major pectoral muscle has
been reached, use a combination of blunt and sharp dissec-
tion to elevate the edge of the pectoral muscle from its invest-
ing fascia. This maneuver maintains continuity between the
Fig. 119.6
breast, the pectoral fascia, and the lymph nodes of the axilla.
If simple mastectomy is planned, terminate the dissection
after removing the axillary tail of Spence. lateral to the origin of the minor pectoral muscle and may be
divided, if necessary, without serious consequence. Be sure
to identify and preserve the major branch of the lateral pec-
Axillary Dissection: Unroofing the Axillary Vein toral nerve that emerges just medial to the origin of the minor
pectoral muscle and travels along the undersurface of the
Avoid the sentinel lymph node dissection space, if one exists. major pectoral muscle. Division of this nerve may result in
Work in clean tissue planes deep, cephalad, and medial to atrophy and contraction of the major pectoral muscle. Dissect
this area. Use a Richardson retractor to elevate the major the fat and fascia off the anteroinferior edge of the coraco-
pectoral muscle. Identify the minor pectoral muscle brachialis muscle using a scalpel. Directly inferior to the
(Fig. 119.6). Branches of the medial pectoral nerve are seen muscle is the brachial plexus and the axillary vessels.
Continuing the dissection of the inferior border of the cora- Identify all of the branches entering the axillary vein from
cobrachialis in a medial direction leads to the coracoid pro- below. Clear each of the branches of adventitia and divide
cess, upon which the minor pectoral muscle inserts. Elevate each between hemoclips or ties (Fig. 119.9). Do not divide
this muscle with a Richardson retractor and continue dissec- the subscapular vein, which enters the axillary vein from
tion underneath it. If it is necessary to divide the muscle, use behind.
coagulating current to divide it near its insertion (Fig. 119.7) At this point, label the apex and the lateral margin of the
and then free up enough of the divided muscle to provide axillary specimen (or follow the preferences of your
complete exposure of the axillary vein (Fig. 119.8). This is pathologist).
rarely if ever needed in modern practice. Deep to the minor The medial upper boundary of the axillary dissection is
pectoral muscle is a well-defined fat pad overlying the junc- the crossing of the clavicle over the axillary vein. Detach the
tion of the cephalic and axillary veins. Gentle blunt dissec- lymphatic and areolar tissue at this point with the electrocau-
tion general succeeds in elevating this fat pad and drawing it tery. Now incise the clavipectoral fascia along a line parallel
in a caudal direction to expose the anterior surface of the
axillary vein.
Next, incise the adventitial sheath of the axillary vein with
Metzenbaum scissors. A few branches of the lateral anterior
thoracic artery, vein, and nerve cross over the anterior wall of
the axillary vein. Divide these branches between hemostatic
clips. To complete division of the sheath of the axillary vein
from the region of the latissimus muscle to the clavicle, it is
necessary to flex the upper arm. This relaxes the major pec-
toral muscle, which is then elevated with a Richardson
retractor.
Axillary Vein Dissection
Axillary lymphadenectomy aims at removing all of the

lymph nodes inferior to the axillary vein (levels I–III). If
positive nodes are encountered above the axillary vein, it is
unwise to attempt to remove these. Simply document the
extent of disease. Stripping fat from the brachial plexus may
Fig. 119.8
produce lifelong painful neuritis in some patients.
Pectoralis
major m.
Pectoralis minor m.
Fig. 119.7 Fig. 119.9

to and 1 cm inferior to the axillary vein. Do not retract the

axillary vein cephalad, as this may expose the underlying
axillary artery to injury. If suspicious nodal tissue is identified
cephalad to the axillary vascular bundle, biopsy it to docu-
ment the extent of disease.
Dissect the areolar and lymphatic tissues off the intercos-
tal muscles and ribs going from medial to lateral. Restore the
arm to its previous position, flat on the arm board. As the
Thoracodorsal n.
chest wall is cleared laterally, one or two intercostobrachial
nerves are seen emerging from the intercostal muscle on
their way to innervate the skin of the upper inner arm. These
nerves penetrate the specimen; however, some surgeons will Long thoracic n.
attempt to preserve these rather than dividing them to avoid
a sensory deficit (and sometimes painful paresthesia) of the
upper inner arm (Fig. 119.10).
Intercostobrachial n.
Use a sterile gauze pad to wipe the loose fat out of the
subscapular space going from above downward. This maneu- Fig. 119.10
ver exposes the long thoracic nerve that runs along the rib
cage in the anterior axillary line in vertical direction from Pectoralis major m.
above downward to innervate the anterior serratus muscle.
Identify the thoracodorsal nerve as it leaves the area of the
subscapular vein and runs both laterally and downward
together with the thoracodorsal artery and vein to innervate
the latissimus dorsi muscle. Because these two nerves run
close to the peripheral boundary of the dissection and
because substantial disability can result from division of the
long thoracic nerve, preserve both unless directly involved
by metastatic nodes.
Detach the lymphatic tissue inferior to the portion of the
axillary vein that crosses over the latissimus muscle.
Intercostal m.
Preserving the long thoracic nerve is complicated by the fact
Latissimus
that a number of small veins cross over the nerve in its distal dorsi m.
Serratus
portion. Circumvent this difficulty by moving the partially ant. m.
detached breast in a medial direction so it rests on the
patient’s chest after freeing the specimen from the anterior Fig. 119.11
border of the latissimus muscle. Then make an incision in the
fascia of the serratus muscle 1 cm medial to the long thoracic major pectoral muscle where they attach laterally. Dissection
nerve. Dissecting this fascia a few centimeters in a medial will proceed after dividing the muscle, in a plane between
direction detaches the entire specimen from the chest wall the muscle and the chest wall.
(Fig. 119.11). Usually it is possible to preserve the clavicular head, thus
It is not necessary to maintain an en bloc specimen of maintaining the contour of the upper chest. Consequently,
mastectomy and axillary nodes; it is simpler more conve- develop a line of separation by blunt dissection between the
nient to do so. If the mastectomy detaches from the axillary sternal and clavicular heads of the pectoral muscle. Continue
nodes during dissection, simply place orienting sutures and this separation to the point where the major pectoral muscle
submit the specimens separately with appropriate labels. inserts on the humerus. Place the left index finger underneath
the sternal head of the muscle near its insertion and divide
the muscle from the insertion using coagulating current
Radical Mastectomy (Fig. 119.12). Complete the line of division between the two
heads of the muscle proceeding in a medial direction until
If resection of part or all of the major pectoral muscle is the sternum is reached. A number of lateral anterior thoracic
anticipated, then this is best done immediately after develop- arteries, veins, and nerves are divided between hemoclips
ing the flaps. Do not dissect the breast off the pectoral mus- during this dissection. Also detach the upper 2–3 cm of the
cle, rather expose the sternal and clavicular heads of the major pectoral muscle from the upper sternum. Continue the
Fig. 119.12
dissection until the sternal portion of the major pectoral mus-

cle, adherent to the breast, has been completely detached
from the chest wall. Then swing the breast and muscle tissue
laterally and proceed as noted above.
Irrigation and Closure

Fig. 119.13
Thoroughly irrigate the operative field. Sterile water will
lyse not only clot and blood, making it easier to spot small • Encourage early ambulation and use of the arm but have the
bleeders, but may also lyse any spilled tumor cells that may patients avoid abducting the arm on the side of the operation
have been dispersed into the operative field. Check the entire for 5–7 days. This gives the flaps time to adhere securely to
field to make sure complete hemostasis has been achieved. the underlying chest wall and may help prevent seroma for-
Insert two large closed suction drains through puncture mation. Note that this is a problem only with mastectomies
wounds into the lower axilla. Bring one catheter along the that involve extensive skin resection and the creation of
cephalad aspect of the field, and the second one along the flaps that may lie flat and adhere nicely with the arm at the
caudal aspect of the field. Suture each one to the skin and side, but tend to “tent up” when the arm is abducted.
attach to closed suction drainage (Fig. 119.13). • Refer the patient to a physical therapist who is experi-
Close the skin with subcuticular PDS or closure of your enced in the care of post-mastectomy patients.
choice. Be certain there is no significant tension on the inci- • Arrange for emotional as well as physical rehabilitation,
sion; otherwise, postoperative necrosis of the skin flap may as needed.
be anticipated. Often shifting the skin flaps in a medial or • Aspirate any significant collections of serum underneath the
lateral direction (or undermining the inferior flap more skin flaps with a sterile syringe and needle as necessary.
extensively) relieves tension. Do not permit either of the skin • If skin sutures or staples were used, leave these in place
flaps at the medial or lateral aspects of the incision to bunch for 2 weeks to allow full healing of incision.
up forming a “dog ear.” If necessary, excise a triangular • Seek input from multidisciplinary tumor board or, failing
wedge of skin as noted previously. Apply a comfortable that, medical and radiation oncology, to assure appropri-
dressing, but avoid compression. This is not necessary with ate additional therapy. Consider eligibility for clinical
closed suction drains. trials.
• Follow the patient for development of lymphedema and
refer to lymphedema clinic/therapist if it develops.
Postoperative Care Instruct patient in lymphedema precautions.
• We follow these patients for local recurrence or the devel-
• Leave the two closed suction drainage catheters in place opment of carcinoma in the contralateral breast. Follow-up
until the daily drainage diminishes to 30–40 ml/day or intervals are initially short, but lengthen to 6–12 months
about 7 days. as the years pass. We follow these patients for life.
Postoperative Complications when the skin flaps have failed to adhere to the chest wall.
Treatment consists of aspirating the seroma every 3–5 days.
Ischemia of Skin Flap Sometimes a gentle pressure dressing, created by cutting
sterile foam rubber to shape and wrapping the chest with
This is a serious, only partially preventable complication. gauze followed by compression bandages, can be fashioned
Avoid excessively devascularizing the skin flaps and tension and may help.
on the suture line. Look at the final suture line, and if there Seromas may, in rare cases, persist for months. Placement
are significant areas where tension and ischemia have caused of a small closed suction drain is an alternative to continued
blanching of the skin, consider revising your closure. aspiration. The variety of possible approaches (ranging from
The area of involvement is typically a band adjacent to the instillation of sclerosing agents to reoperation and use of
suture line, in the midportion of the incision. This area is “quilting stitches” to hold flaps against the chest wall)
farthest from the base of the flaps (and hence has the worst reflects the sense of frustration and lack of a perfect solution
blood supply). It is also the region where tension on the for this problem.
suture line is typically greatest, subjecting an area of tenuous
vascularity to additional stress. With a classical transverse or
oblique incision, the upper flap is more susceptible than the Lymphedema
lower, presumably reflecting the greater extent of
dissection. Lymphedema remains an unpredictable and feared compli-
Partial thickness ischemia, often termed “epidermolysis,” cation of axillary surgery. Although it can occur after senti-
is characterized by the formation of discoloration and blis- nel node biopsy, it is more common after formal axillary
ters and is usually limited to a small area adjacent to the node dissection. Additional contributing factors include obe-
suture line. Because the deep layers of the skin remain via- sity, radiation to the axilla, and postoperative wound compli-
ble, such areas will heal with simple wound care. cations including infection. Early identification and referral
Full-thickness ischemia and necrosis typically first mani- to a lymphedema clinic may limit progression and give the
fests as non-blanching purple discoloration. Full-thickness best chance for a good outcome.
necrosis, left untreated, will progress to eschar formation
with underlying purulence. Small narrow bands may be
managed with office debridement and local wound care. In Further Reading
rare circumstances, large areas of necrosis require surgical
(operative) debridement and closure. Ching-Wei DT, Howard H, Bland KI. Chapter 35. Mastectomy. In:
Dirbas FM, Scott-Conner CE, Breast surgical techniques and inter-
disciplinary management. New York: Springer; 2011. p 409–422.
Cutress RI, Simoes T, Gill J, et al. Modification of the wise pattern
Wound Infection breast reduction for oncological mammoplasty of upper outer and
upper inner quadrant breast tumours: a technical note and case
series. J Plast Reconstr Aesthet Surg. 2013;66:e31–6.
Wound infection is rare in the absence of skin necrosis. Malata CM, Hodgson EL, Chikwe J, et al. An application of the LeJour
vertical mammaplasty pattern for skin-sparing mastectomy: a pre-
liminary report. Ann Plast Surg. 2003;51:345–50.
Seromas Weisberg NK, Nehal KS, Zide BM. Dog-ears: a review. Dermatol Surg.
2000;26:363–70.
Seromas are collections of serum underneath the skin flaps.

These occur during the first few weeks after mastectomy,
Skin and Nipple Sparing Mastectomy
120
Sonia L. Sugg, Cynthia Lee, and Iryna Chesnokova
Indications • Consult plastic surgery to discuss method of reconstruc-

tion, feasibility, and consideration of incision placement.
• Skin sparing and nipple sparing mastectomies are done in • Review and discuss patient expectations and goals to
conjunction with immediate reconstruction. The recon- ensure that these can be achieved. Discuss thoroughly the
struction can be performed with tissue expanders or expected benefit or lack of benefit with regard to mortality,
implants, or with autologous tissue. The aesthetic results local recurrence, prevention of future breast cancer, taking
are superior due to the natural contour and preserved skin into account risk factors for the individual patient. If post-
envelope of the breast. mastectomy radiation therapy may be required, discuss the
• Skin sparing mastectomy removes the nipple and preserves possible adverse effects on cosmetic outcome. Inform the
as much skin as possible (Fig. 120.1a). Nipple sparing mas- patient about the lack of sensation in the reconstructive
tectomy preserves the nipple skin while removing most of breast(s) and nipple(s) post-mastectomy, expected cos-
the underlying ducts and associated breast tissue of the metic outcome, and the increased likelihood of requiring
nipple-areolar complex (Fig. 120.1b). Fig. 120.1 additional reconstructive procedures in the future.
• Both operations were initially developed for risk-reducing
(prophylactic) mastectomies. However, these are now
also performed in patients with DCIS and invasive cancer, Pitfalls and Danger Points
with careful patient selection.
• Ischemia of skin flaps, nipple
• Retained breast tissue at the periphery of the breast, or on
Preoperative Preparation the flaps
• Review breast imaging: consider distance of disease from

the nipple and skin for choice of operation. Operative Strategy
• Obtain an MRI if indicated, to determine extent of disease
including proximity to the nipple for nipple sparing mas- kin Sparing Versus Nipple Sparing
S
tectomy, proximity to the skin for skin sparing mastec- Mastectomy
tomy, and presence of disease in the breast undergoing
prophylactic mastectomy in women with dense breasts, a In addition to a patient preference, two factors are important
large area of DCIS, or unclear findings on mammography. when deciding between skin sparing versus nipple sparing
Understand that MRI has been shown to increase contra- mastectomy. The first is oncologic safety.
lateral mastectomies. As with any mastectomy, clean margins are important and
every effort must be made to avoid positive margins. It can
be extremely difficult to deal with a positive anterior (under
S. L. Sugg (*) · C. Lee
Department of Surgery, University of Iowa Healthcare, the skin flap) margin, because it is often not possible to
Iowa City, IA, USA determine exactly where the margin was positive, and there-
e-mail: sonia-sugg@uiowa.edu fore an accurate re-excision is not possible. This could result
I. Chesnokova in a recommendation for postmastectomy radiation. When a
Department of Surgery, RWJPE Steeplechase Breast Specialists, tumor closely approaches the skin, the overlying skin may be
Somerville, NJ, USA

https://doi.org/10.1007/978-3-030-81415-1_120
a b
Fig. 120.1
excised, or if feasible, the overlying skin can be marked Single short suture 12:00
(ultrasound prior to incision may be useful), and an addi-
tional oriented margin could be taken at this site to ensure it
pathologically negative margin. In addition, we orient the Right
Mastectomy
breast by clock face (Fig. 120.2), and label our additional
anterior margins also by clock face, so that a more specific Double long Single long
pathological examination of the margins can be done. suture 9:00 suture 3:00
Sufficient retrospective data exists to confirm the onco-
logic safety of sparing the nipple in appropriate patients.
There does not appear to be an increased risk of recurrence at
the nipple. Patients with disease involving the nipple should
not undergo nipple sparing mastectomy. A positive nipple
Double short suture 6:00
margin may require its excision.
The second factor relates to reconstructive considerations. Fig. 120.2
Patients with very large breasts or significant ptosis are not
great candidates for nipple sparing mastectomy. Staged pro-
cedures for such patients, performing a breast reduction sur-
gery followed by nipple sparing mastectomy, have been
performed in some centers with good results. This strategy
could be utilized for patients undergoing prophylactic
mastectomy.
Axillary Lymph Nodes
The management of the axillary lymph nodes is dictated by

current recommendations. A sentinel lymph node procedure
may be performed through the breast incision; however,
making a small, separate incision in the axilla is easier in
most cases. Axillary lymph node dissection is best performed Fig. 120.3
through a separate incision.
the breast should be marked with the patient upright, prefer-

Extent of Mastectomy ably in the preop holding area (Fig. 120.3). After the patient
is anesthetized and in the supine position, the sternal border,
Pre-incision marking of the “footprint” of the breast is 2 cm below the clavicle, lateral aspect of the breast while
important. The inframammary crease and lateral aspect of supine, and inframammary crease should be connected to
120 Skin and Nipple Sparing Mastectomy 949
mark the outline of the breast tissue to be removed entirely on the subdermal plexus, preservation of adequate
(Fig. 120.4). Stopping the mastectomy at the inframammary thickness at the base of the skin flaps is especially important.
crease likely removes slightly less breast tissue then with a Careful handling of the flaps, by avoiding prolonged retrac-
standard simple mastectomy; however, preservation of the tion in a single area, is also vital to success.
crease is important for optimal cosmetic outcome. The lat- There are two basic ways to raise skin flaps. One is using
eral aspect of the breast is the latissimus dorsi. This usually scissors, and the other is using some form of cautery. The
corresponds to the lateral aspect of breast while the patient is scissors technique uses curved, serrated flap-raising scissors
supine. In patients with thick chest wall subcutaneous tissue, also known as Gorney scissors (Fig. 120.5a–b), and once the
this lateral aspect may not be quite so obvious, and palpation correct plane is identified, the scissors are used to push and
of the latissimus may be helpful to aid in identification. separate the plane between the subcutaneous fat and breast
tissue. This technique takes advantage of a natural fusion
plane that is typically quite avascular. Observing the scissors
Incision and Skin Flaps from the skin side as you push allows for determination of
the skin flap depth. It is important to resist the temptation to
Skin Flap Techniques push far into the skin flap without adequate exposure as
The thickness of skin flaps for skin and nipple sparing mas- hemostasis would be difficult. The main advantages of this
tectomy are no different from that of a simple mastectomy as method are (1) the lack of thermal damage to the skin and (2)
described in Chap. 119. Skin flaps are considerably longer, the ability to reach areas distant to the incision without direct
and techniques to preserve blood supply are paramount to visualization. Its main disadvantages are reduced hemostasis
avoid complications. Since the skin blood supply relies and a steep learning curve. This technique can also be quite
speedy in experienced hands.
Alternatively, some form of cautery such as Bovie, or
energy devices such as the PlasmaBlade, is used to separate
the subcutaneous fat from breast tissue. With this technique,
the distinction between subcutaneous and breast tissue can
be done under direct visualization, and there is good hemo-
stasis; however, thermal damage needs to be guarded against.
Using the cutting setting minimizes tissue damage but
reduces hemostasis. A combination of both techniques is
sometimes required.
Visualization
With both these techniques, the operative site is distant from
incision throughout a significant portion of the operation.
This poses technical challenges in terms of visualization of
the operative field and hemostasis. The use of lighted retrac-
Fig. 120.4 tors (Fig. 120.6) and often a headlight is key for good visual-
a b
Fig. 120.5
Fig. 120.6 Fig. 120.8
B
Fig. 120.7
A
C
ization. A seated position is required for the inframammary
approach for optimal surgical ergonomics (Fig. 120.7).
Incisions
For the skin sparing mastectomy, most breasts can be Fig. 120.9
removed through a circumareolar incision (Fig. 120.8),
developing a cone of continuous skin flaps as you work. This as the incision is hidden when viewed from the front. The
allows for the greatest flexibility for reconstruction. However, length of the incision ranges from 10 to 15 cm. Start the inci-
reconstructive surgeons may need to remove additional skin sion at the medial edge of the areolar border extending along
for contouring of the breast, and advance communication the inframammary crease, following the lateral edge of the
and planning could result in a larger incision through which breast that was marked with the patient sitting upright. This
to work. Paradoxically, it is sometimes easier to work through more medial incision typically matches the lateral border of
a smaller incision initially for better skin tension, then to the implant better than the lateral aspect of the breast while
enlarge the incision later when it is necessary to reach more the patient is lying supine. This incision is also the most
distant locations. challenging, because it is the farthest from the superior
Several incisions are most commonly used for nipple aspect of the breast, and away from the central portion of the
sparing mastectomy (Fig. 120.9). Avoid incisions at the areo- breast requiring going up and over the breast mound to reach
lar border, as these have been shown to increase rates of the superior aspect. When the breast is large, and no reduc-
nipple necrosis. The inframammary incision (Fig. 120.9, line tion of the skin envelope as planned, a better incision might
A) with lateral extension is the most cosmetically pleasing, be one extending from the lateral edge of the areola radially
for around 10 cm or longer if necessary (Fig. 120.9, line B).

The more central location of this incision allows for easier
access to the periphery of the breast. A third alternative is a
similar incision extending radially at six o’clock to the infra-
mammary fold (Fig. 120.9, line C). This incision is also
mostly hidden.
• Findings including areas of concerns regarding margins.

• Sentinel lymph node biopsy?
• Axillary lymph node dissection?
• Reconstruction?
Fig. 120.10
Operative Technique
Position the patient so the arms are abducted 80–90° on an

arm board and secure the arms circumferentially with rolled
gauze if the plastic surgeon will be flexing the patient during
the reconstruction. Since the combined surgery usually lasts
longer than 4 hours, a Foley catheter should be placed, and
all pressure points carefully padded. Even in the case of a
unilateral operation, the other side is exposed so that sym-
metry can be evaluated. Prepare the area of the breast, lateral
chest wall to the operating table, upper abdomen, shoulder,
and upper arms bilaterally with chlorhexidine solution.
Sentinel lymph node biopsy (see Chap. 121) is usually
done prior to mastectomy to facilitate earlier return of frozen
Fig. 120.11
section results. Axillary lymph node dissection, if needed,
may be performed after the mastectomy is completed. A
separate short transverse or curvilinear axillary incision is this first step (Fig. 120.11). Try not to make the flap too thin
typically required. at this point, where it is the most vulnerable, subject to the
most retraction injury, as well as being furthest away from its
tangential blood supply.
Develop the Skin Flaps (Anterior)
kin Sparing Mastectomy
S
Using a sterile marking pen, mark the footprint of the breast Develop the skin flaps as described above using your method
as described above (Fig. 120.10). This marking will guide of choice, scissors or cautery. A circumferential approach is
the extent of mastectomy. Next, mark the incision. If a bilat- helpful for better exposure, moving gradually toward the
eral operation as planned, ensure that both the extent of mas- periphery of the breast that you have marked. Once 4–5 cm
tectomy, and the incisions are as symmetrical as possible. of flap length is developed, insert lighted retractors with
Use a scalpel to make a skin incision through all layers of the increasing lengths for better visualization (Fig. 120.12), if
skin. Attain hemostasis by applying electrocoagulation to the cautery method is being used. Consider approaching the
each bleeding point. lateral aspect from the contralateral side of the table, if there
Apply skin hooks or Freeman facelift retractors is not another team operating on the contralateral breast. At
(Fig. 120.11) to the cut edge of the skin. Have an assistant the medial border, perforating vessels from the internal tho-
elevate the skin flap by drawing the retractors in an anterior racic artery will be encountered. Preserve these, if possible,
direction. Grasping the breast tissue with Allis clamps and to protect viability of the skin flaps. Protect the integrity of
applying countertraction perpendicular to the skin flap will the sternal border to ensure separation of the breasts at the
identify the plane between breast and subcutaneous tissue at sternum.
ipple Sparing Mastectomy

N cle fibers under the areola rather than skeletonizing the
If using the inframammary incision, continue dividing the areola.
breast tissue straight down to the chest wall muscles at the At the nipple-areolar complex, dissect around the termi-
inframammary crease. A seated position may be required, nal ducts much as you would for a complete ductal excision
with the assistant retracting from cephalad to the patients (see Chap. 117). Divide the ducts close to their termination
arm. Then, for all types of incisions, develop the skin flaps on the underside of the nipple and mark the specimen at this
using your method of choice, scissors or cautery. Once point with a stitch. If concerned about margin, send a frozen
4–5 cm of flap length is developed, insert lighted retractors section from the terminal ducts.
with increasing lengths for better visualization, if the cau- Once the nipple has been divided, find the correct (some-
tery method is being used. Recall that the breast tissue what thicker) plane beyond the nipple and continue to
draws closer to the skin as it approaches the nipple areolar develop the flaps to the periphery of the breast that you have
complex (Fig. 120.13) and that the angle of attack will need marked. If the superior aspect is difficult to access, consider
to change at the nipple. Try to preserve the cremaster mus- releasing the posterior aspect of the breast inferiorly at this
point (as described below), which will lend more mobility to
the superior and superior-medial edge of the breast. Consider
approaching the lateral aspect from the contralateral side of
the table, if there is not another team operating on the contra-
lateral breast. At the medial border, perforating vessels from
the internal thoracic artery will be encountered. Preserve
these, if possible, to protect viability of the skin flaps. Protect
the integrity of the sternal border to ensure separation of the
reconstructed breasts at the sternum.
elease the Breast from the Chest Wall

R
(Posterior)
With the inframammary incision, the chest wall muscle was

previously exposed. The pectoralis muscle is most easily
Fig. 120.12 defined medially (Fig. 120.14), and starting there, lift the
breast off the pectoralis muscle including its fascia using
electrocautery in an inferior to superior direction. Develop
this posterior plane until it meets with the anterior plane at
Chest wall
Anterior margin the periphery of the breast medially and superiorly, where
of mastectomy Pectoralis the breast is then detached. Develop the posterior plane later-
muscle
Posterior margin
of mastectomy
Lobules
Areola
Duct
Fatty tissue
Skin
Fig. 120.13 Fig. 120.14

Fig. 120.16
Fig. 120.15
ally, where the serratus anterior and latissimus muscles will Postoperative Care
be encountered. Retract the breast anteriorly, divide the tis-
sue between the anterior and posterior planes to release the Consult and collaborate with plastic surgery colleagues
breast in an inferior to superior direction, including the axil- regarding postoperative care of drains and exercise restric-
lary tail at the most superior extent. tions. We encourage early mobilization of the arm with a
With other incisions, expose the chest wall musculature standardized series of graded physical exercises to ensure
using electrocautery at the closest edge of the breast superi- that the patient regains full mobility without affecting her
orly or inferiorly, and proceed as described above. reconstruction. Physical therapy is encouraged early if mobi-
When using electrocautery to develop the posterior plane, lization is problematic.
proceed parallel to the fibers of the pectoralis muscle where After mastectomy, breast imaging is not needed. Follow
possible to obtain a smoother pectoralis surface, transecting existing protocols for additional treatment and surveillance.
the muscle fibers can lead to small areas of bleeding requir-
ing additional time to cauterize. Prior to detaching the breast,
place orienting sutures including at the nipple for a nipple Postoperative Complications
sparing mastectomy for the most accurate orientation.
I schemia of Skin Flap
This results from inadequate blood supply to the skin due to
Finishing the Mastectomy flaps that are injured by surgical removal or retraction dam-
age to the subdermal plexus or vessels feeding the skin flaps
Inspect the skin flaps and trim the flap tangentially to an even located on the periphery. The reconstructive surgeon gener-
thickness with curved Mayo scissors (Fig. 120.15). Identify ally manages this complication. Areas of ischemia can be
the additional anterior margins by location and send sepa- identified intraoperatively using fluorescent dye (isocyanine
rately for pathologic examination. Large excisions could be green) and imaging. Ischemic areas are excised prior to
oriented on a card. For nipple sparing mastectomy, excise reconstruction. Compromised areas can be observed, and tis-
any residual duct and breast tissue behind the nipple using sue expanders placed but not filled until the skin recovers.
sharp dissection with scissors and orient the margin. There Bruising of viable skin flaps can occur and does not portend
should be minimal tissue and ducts left behind the nipple ischemia.
(Fig. 120.16). Perform frozen section of the nipple margin
only if the results would alter the surgical plan. Obtain Ischemia of Nipple
meticulous hemostasis. Call on your reconstructive surgeon Removal of most of the ductal tissue behind the nipple rarely
to complete the reconstruction. results in ischemia, provided a peri-areolar incision is absent.
a b
Fig. 120.17
Peled AW, et al. Expanding the indications for Total skin-sparing mas-
Ischemia presents with a purple discoloration of part or all of
tectomy: is it safe for patients with locally advanced disease? Ann
the nipple (Fig. 120.17a–b). Observe carefully and excise if Surg Oncol. 2016;23(1):87–91.
the skin has full thickness necrosis. Again, this complication Jakub JW, et al. Oncologic safety of prophylactic nipple-sparing mas-
is usually managed by the reconstructive surgeon. tectomy in a population with BRCA mutations: a multi-institutional
study. JAMA Surg. 2018;153(2):123–9.
Albright EL, et al. Nipple-sparing mastectomy is not associated with a
Wound Infection delay of adjuvant treatment. Ann Surg Oncol. 2018;25(7):1928–35.
With or without skin or nipple necrosis, early or late infec- Grobmyer SR, et al. Evolving indications and long-term oncological
tions can occur. With the presence of an implant or tissue outcomes of risk-reducing bilateral nipple-sparing mastectomy. BJS
Open. 2019;3(2):169–73.
expander, surgical removal or exchange is sometimes
Wang M, Huang J, Chagpar AB. Is nipple sparing mastectomy associ-
required to clear the infection. ated with increased complications, readmission and length of stay
compared to skin sparing mastectomy? Am J Surg. 2019;
Wong SM, et al. National Patterns of breast reconstruction and nipple-
sparing mastectomy for breast cancer, 2005–2015. Ann Surg Oncol.
Further Reading 2019;26(10):3194–203.
Valero MG, et al. Increase in utilization of nipple-sparing mastectomy
Piper M, et al. Total skin-sparing mastectomy: a systematic review of for breast cancer: indications, complications, and oncologic out-
oncologic outcomes and postoperative complications. Ann Plast comes. Ann Surg Oncol. 2020;27(2):344–51.
Surg. 2013;70(4):435–7.
Sentinel Lymph Node Biopsy
and Axillary Staging for Breast Cancer 121
Lillian Erdahl and Carol E. H. Scott-Conner
Indications • Blue dye is contraindicated in pregnancy; however, uter-

ine exposure to radiotracer is not significant and SLN
• Sentinel lymph node (SLN) biopsy is used to detect axil- biopsy with radiotracer is safe in pregnancy.
lary metastases in clinically node-negative patients with
invasive breast cancer and in patients who present with
non-matted axillary metastases to evaluate the pathologic Preoperative Preparation
response to neoadjuvant chemotherapy.
• SLN biopsy is used when mastectomy is performed for • If marker localization with a needle, radioactive seed, or
ductal carcinoma in situ (DCIS) because of the possibility other marker is required for lumpectomy, schedule this
of an occult invasive cancer and the technical difficulty of first.
performing sentinel lymph node biopsy after • Allow sufficient time for injection of radioisotope and
mastectomy. migration to sentinel node (generally around 1 hour). This
• Axillary node dissection is used for many but not all may be done the afternoon before surgery.
node-positive women. In selected women with otherwise • If blue dye is to be used, inject this after induction of
early stage disease or node-positive women at diagnosis anesthesia in the breast for SLN biopsy or in the upper
with axillary pathologic, complete response to neoadju- inner arm for axillary reverse mapping (ARM).
vant chemotherapy completion axillary node dissection
may be omitted.
Operative Strategy
Contraindications Sentinel Lymph Node Biopsy
• Axillary staging should not be performed for DCIS unless Sentinel lymph node biopsy relies upon a tracer (or, more
total mastectomy is planned. commonly, two tracers)—substances that will accurately
• Sentinel node biopsy is not routinely used in patients travel to the first node or nodes to which tumor cells would
undergoing surgery prior to systemic therapy when the localize, thus identifying the node(s) at highest risk for
axilla has been proven positive by ultrasound-guided metastasis. Conceptually, then, examination of that node or
biopsy. In these cases, axillary node dissection is gener- nodes will accurately predict the involvement of the nodal
ally performed. basin and can be used to guide subsequent treatment deci-
• Allergy to any of the dyes used for SLN contraindicates sions. References at the end of this chapter detail the evi-
the use of that specific tracer. dence behind this approach and the learning curve. SLN
biopsy has essentially replaced axillary node dissection for
clinically node-negative patients with breast cancer. In addi-
L. Erdahl
Department of Surgery, Roy J. and Lucille A. Carver College of tion, recent evidence is expanding the role of SLN biopsy to
Medicine, University of Iowa, Iowa City, IA, USA include patients with known axillary metastases who undergo
C. E. H. Scott-Conner (*) neoadjuvant chemotherapy and have clinical evidence of a
Department of Surgery, University of Iowa Carver College good response in the axilla.

https://doi.org/10.1007/978-3-030-81415-1_121
956 L. Erdahl and C. E. H. Scott-Conner
breast cancer. Methylene blue dye is much cheaper and less

likely to cause allergic reactions but can cause local tissue
necrosis. To minimize this possibility, dilute the methylene
blue dye 1:8 with sterile normal saline before injection.
Always inform the patient that the breast can be stained blue
(and in some cases, this is permanent) and the patient may
pass green urine for a few days after the procedure. Always
tell the anesthesia team that you are injecting a substance
into the patient, and inform them of the possibility of an ana-
phylactic reaction if you are using Lymphazurin blue dye,
and serotonin syndrome if you are injecting methylene blue
dye. These reactions may be minimized by premedication or
holding antidepressants when possible (see references).
Although sentinel node biopsy may be performed as an
isolated procedure, it is most commonly combined with
Fig. 121.1 (Courtesy of Michael Graham, Professor, Department of lumpectomy or mastectomy. Sometimes it is possible to do
Radiology, Nuclear Medicine, University of Iowa Carver College of the sentinel lymph node biopsy through a lumpectomy or
Medicine, Iowa City, IA) mastectomy incision, but for most situations, a separate inci-
sion is required.
Most surgeons use both a colloidal suspension of radio- The gamma probe, set for the appropriate energy window
isotope (technetium-99 m) and a blue dye. Some experienced (technetium-99 m), is draped into the sterile field and used to
surgeons may choose to omit the blue dye. Dual dye map- locate the incision and then to identify the node. Test the
ping is strongly recommended in patients with previously probe by interrogating the injection site and axilla before
documented axillary metastases undergoing sentinel lymph prepping and draping the field. If you do not obtain a strong
node biopsy after neoadjuvant chemotherapy in order to signal, verify that the probe is set for the correct isotope. In
achieve an acceptable false negative rate. In addition, other obese patients, the best incision will almost always lie in the
dyes are being explored including indocyanine green. The natural skin line between the axillary fat pad and the breast
radioisotope may be injected the morning of surgery or the (Fig. 121.2). Plan your incision so that it can be extended to
day before. The physicochemical characteristics of the
colloid are such that the tracer will go to the SLN and not
continue to travel up the chain.
Some institutions use lymphoscintigraphy to document
progression to an axillary node or nodes, many do not. The
benefits of imaging with lymphoscintigraphy are to confirm
good localization and demonstrate drainage which occasion-
ally occurs through two separate lymphatic pathways to two
separate SLNs (Fig. 121.1). If lymphoscintigraphy is not
routinely performed, it should be considered in cases of
patient with prior axillary lymph node surgery. Even when
localization is not identified on preoperative lymphoscintig-
raphy, it may be possible to identify the SLN in the operating
room utilizing the gamma probe.
The isotope will very rarely localize to only the internal
mammary location with modern injection techniques.
Currently, most surgeons do not pursue these nodes.
In the operating room, after the patient is positioned and
asleep, blue dye is injected. Two kinds of blue dye are in
common use. Lymphazurin blue dye is nontoxic to the tis-
sues but can occasionally cause anaphylactic reactions. It
rarely causes serotonin syndrome in patients taking sero-
tonin reuptake inhibitors although it has not been reported in
the low doses used for sentinel lymph node mapping for Fig. 121.2
121 Sentinel Lymph Node Biopsy and Axillary Staging for Breast Cancer 957
perform a full axillary node dissection if necessary. In some node dissection cavity by initiating dissection along the lat-
slender patients, an oblique incision just behind the lateral eral border of the pectoralis major muscle. Continue the
border of the pectoralis major muscle may give better access dissection along the underside of the pectoralis major mus-
to the hot node. cle, sweeping the fascia and node-bearing tissue down.
Always palpate the axillary space before and after dis- Often this will allow dissection to progress in plane free
secting nodes so as not to miss a node full of tumor (which from scar tissue, facilitating the identification of important
might not take up the tracer substances). Use both the gamma landmarks.
probe (now draped into the sterile field) and any blue lym- The crucial landmarks for axillary node dissection are the
phatics to find the sentinel node or nodes. neurovascular bundle to the pectoralis major muscle (which
Take a 10-second ex vivo count on the node after you should be preserved by gently sweeping it medial and cepha-
remove it. Take time to obtain the strongest signal possible lad), the long thoracic nerve, the thoracodorsal nerve, the
from the node before taking this count, so as to maximize axillary vein, and the intercostobrachial nerve. Neuropathic
signal-to-noise ratio. The background count should be less pain syndromes after axillary surgery are almost always
than 10% of the hottest node. Obtain careful hemostasis and related to injuries of the intercostobrachial nerves and other
lymph stasis before closing the incision. smaller sensory nerves in the region. It is unclear whether it
is better to divide these nerves cleanly or to preserve them.
Some advocate preserving the first intercostobrachial nerve,
Axillary Node Dissection but most surgeons routinely sacrifice it (see references at the
end of the chapter).
Axillary node dissection for breast cancer is generally con-
fined to the level I and II lymph nodes (Fig. 121.3). Either
a transverse skin crease incision below the axillary hair line Targeted Axillary Dissection
(and usually in the crease between the axillary fat pad and
the fat of the breast in the patient with obesity, as noted As previously mentioned, sentinel lymph node biopsy is now
above) or an oblique incision just posterior and parallel to utilized for patients who have limited axillary metastases
the lateral border of the pectoralis major muscle will work identified at presentation and undergo neoadjuvant chemo-
well. therapy. In preparation for SLN biopsy, these patient should
When performing axillary node dissection in the patient undergo imaging following chemotherapy to evaluate for
who has had prior axillary surgery, try to avoid the sentinel clinical response. If no response is seen, SLN biopsy should
Fig. 121.3
not be performed. If a partial or complete response is seen on Operative Technique

imaging, SLN biopsy may be considered.
In order to improve identification of the node biopsied Sentinel Lymph Node Biopsy
prior to chemotherapy, targeted axillary dissection (TAD)
includes identifying the lymph node containing a biopsy Position the patient supine, with the ipsilateral arm out on an
clip. This can be done with preoperative imaging localization arm board. It is not necessary to drape the arm free or place
using a localizing device such as a wire or radioactive seed. a roll under the ipsilateral shoulder. Interrogate the injection
In addition, specimen x-ray should be used to confirm the site and the axilla with the gamma probe. Confirm that the
removal of the clipped node. gamma probe is working properly. If no signal is obtained,
check the battery pack and verify that the isotope is correctly
set to technetium-99 m. Familiarize yourself with the various
Axillary Reverse Mapping settings on the gamma probe device that is in use in your
operating room and know how to optimize it for your
One of the complications of both SLN biopsy and axillary purpose.
node dissection is upper extremity lymphedema. Although If blue dye is to be used, have it ready to inject as soon as
SLN biopsy has a lower risk of this complication than the patient is stable under anesthesia. Always tell the anes-
axillary node dissection, the risk of morbidity is still sig- thesiologist what you are about to do. Use 3–5 ml of
nificant. Axillary reverse mapping (ARM) was developed Lymphazurin blue dye. An equivalent amount of diluted
as a technique to reduce the risk of lymphedema by iden- methylene blue dye can also be used (always dilute the meth-
tifying and, when possible, preserving the lymphatics ylene blue 1:8 with normal saline to avoid local tissue toxic-
draining the arm when dividing the lymphatics draining ity). Inject the subareolar region through a single stick and
the breast. fan out to inject the entire amount in the subcutaneous plane
The technique involves injecting blue dye into the upper to access the subareolar lymphatic plexus.
inner arm instead of the breast. At least 4% of the time when If there is a previous lumpectomy site, consider whether
they are identified, the blue arm lymphatics will drain to an or not this excision may have disrupted the lymphatic chan-
SLN. If the ARM identifies a lymphatic that has to be divided nels between this subareolar plexus and the axilla. Simply
in order to remove a SLN, some surgeons will reapproximate visualize a line from nipple to axilla—if the excision site is
the lymphatic with suture. in the upper outer quadrant, it falls on this line and the lym-
phatics may be disrupted. In this situation, inject all or half
of the blue dye at the axillary end of the lumpectomy site.
Pitfalls and Danger Points Verify that the dye is actually going into the breast (rather
than into the seroma cavity) by aspirating before injection.
• Failure to identify a positive SLN due to technical failure Massage the dye gently into the tissues for a few minutes.
of the procedure or poor localization. Injecting the dye before prepping and draping the breast will
• Reaction to blue dye. maximize the amount of time for the dye to migrate to the
• Injury to intercostobrachial nerves causing numbness nodes.
and/or neuropathic pain syndromes. Clip, prep, and drape the breast and axilla in the usual
• Injury to median pectoral nerve causing atrophy of pecto- fashion. Secure the drapes laterally so that, if necessary, the
ralis major muscle. breast can be retracted medially without losing adhesion of
• Injury to long thoracic or thoracodorsal nerves. the drape to the skin. If the breast tends to fall laterally and
• Failure to remove the clipped node during SLN biopsy obscure the field, have the anesthesiologist “airplane” the
after neoadjuvant chemotherapy. table to the contralateral side. Additional retraction may be
obtained by placing a sterile adhesive plastic drape over the
breast in such a manner as to provide medial and caudad
Documentation Basics retraction. This drape can then be released after the axillary
procedure is completed, if further surgery (e.g., lumpec-
• Sentinel node biopsy. tomy) is to be performed.
–– Blue dye injected? How much? Where? Drape the gamma probe into the sterile field. Some
–– Findings (number of nodes, counts, appearance). gamma probe devices have foot pedals that allow you to con-
• Axillary node dissection. trol the various functions, but most require some assistance
–– Nerves and axillary vein identified and preserved. from a person who is not gowned and gloved. Spend a few
Fig. 121.4
moments instructing this person in exactly what you will

need them to do to assist you.
Use the gamma probe to identify the hot spot in the axilla.
If the injection site is in the upper outer quadrant, make sure Fig. 121.5
you can separate the high activity in the injection site from
the fainter but nearby signal from the axillary node. retractors to hold the incision open. Watch for blue lymphat-
Retracting the breast medially, as described above, increases ics. Carefully preserve these by dissecting along their super-
the distance between these two points and will make this ficial aspect and working laterally. Most commonly, the blue
separation more apparent. Always take advantage of the col- lymphatic trunk will eventually dive deep and medially, lead-
limation afforded by the probe tip construction (Fig. 121.4). ing you to a blue node. If it is necessary to divide a lymphatic
Basically, the probe “looks” preferentially in the direction in trunk, use clips or ties to avoid subsequent seroma formation.
which it is pointed. Pointing the probe toward the axilla and If ARM is performed, avoid dividing the blue lymphatics
away from the injection site, then accessing the axilla by unless they are draining into an SLN.
pressing down with the probe (maintaining the orientation) Always palpate and inspect for abnormal nodes first,
as shown help considerably. before dissection distorts the anatomy. Remove any palpably
Plan an incision that can be extended for a completion abnormal nodes and submit them for pathologic analysis;
axillary node dissection, if necessary. There are two excel- always remember that a node may be too full of tumor cells
lent incisions for axillary dissection—the skin crease inci- to take up either of the tracer substances.
sion shown in Fig. 121.5 and an oblique incision along and If no abnormal nodes are palpated, next use the sterile
just posterior to the lateral border of the pectoralis major gamma probe to identify the area of greatest radioactivity.
muscle. This oblique incision sometimes works better in Gently grasp this fat and elevate it into the field. Confirm that
slender muscular women but may produce a more obvious the hot spot is contained within this fat. Next, dissect through
scar. In either case, always keep the incision lateral to the the fat seeking a node. The node will be either blue (if dye
pectoralis major muscle so that it will be hidden behind this was used and if it localized) or shiny and pinkish (Fig. 121.5).
muscle. In a slender woman, a 1-cm incision may suffice to It will be slightly firmer than surrounding fat. Confirm that it
extract a single SLN. In an obese woman, do not hesitate to is radioactive with the gamma probe.
make a 2–3 cm incision or larger to provide sufficient Carefully dissect the node from surrounding fat, clipping
exposure. or ligating any lymphatics, until it is hanging from its hilar
Continue the incision through the subcutaneous fat and vessels. These vessels typically enter deep and medial. Place
into the axillary fascia. Generally, the axillary fat can be a clamp across the hilum and remove the node. Some sur-
identified because it is smoother, more like visceral fat, than geons will leave this clamp in situ rather than immediately
the lumpy-bumpy subcutaneous fat. The axillary fascia is tying the pedicle, because if there is residual radioactivity, it
often palpable as a smooth barrier. Once this fascia is opened, is most likely in the fat contained in this pedicle. The clamp
it becomes possible to palpate the structures in the axilla and provides a handy way to rapidly return to the region of
to pass the palpating finger without difficulty. Place fixed interest.
Cup the node in your nondominant hand, turn away from reversed) so that motor nerves can be identified and tested, if
the field (to avoid stray counts from the injection site), and necessary, with a nerve stimulator. Position, prep, and drape
face the display panel of the gamma counter. Probe the node the patient as described above. As with sentinel node biopsy,
with the gamma counter until you find the hottest region. two incisions are in common use. For most patients, a trans-
Identify this by the highest counts-per-second number as verse skin crease incision in the line between breast and axil-
well as the louder audio signal. You will need to hold the lary fat pad provides excellent exposure and an optimal
probe solidly against this hot spot for 10 seconds to get an cosmetic result. Keep this incision below the hair-bearing
accurate count; therefore, it is important that you stand compart of the axilla. Curve the two ends of the incision upward,
fortably and well braced. Take a 10-second count. It should if necessary, to create a sufficiently long incision while keep-
be about 10× the counts-per-second number. If it is low, ing it within the axilla. Raise flaps in the subcutaneous plane
count again. Use the higher count. and identify the lateral border of the pectoralis major
Next, check the bed from which the node was removed. If muscle.
no major hot spots are found, do a 10-second count to The alternate incision parallels the lateral border of the
evaluate for any residual radioactivity. This count should be pectoralis major muscle. This incision is particularly useful
less than 10% of your hottest node. in lean, muscular women. Take care to make the incision
On rare occasions, it may seem difficult if not impossible behind the border of the pectoralis major muscle so that the
to obtain a sufficiently low background count. If you are con- resulting scar will disappear behind the muscle. Only a lat-
fident that you have obtained the nodes with the strongest eral (posterior) flap needs to be developed with this
signals, it is acceptable to terminate the dissection after 4 or incision.
5 nodes (or, at most, 6) have been harvested given the litera- Identify the fascia along the lateral border of the pectora-
ture showing the very low false-negative rate when 4–5 lis major muscle. Place retractors to provide exposure.
nodes are removed. Be wary, however, because occasionally Develop flaps circumferentially in the plane between the fas-
the true sentinel (hottest) node has not yet been found empha- cia and the subcutaneous fat to ensure adequate exposure.
sizing the importance of searching carefully for the hottest Incise the axillary fascia and dissect along the underside of
node prior to starting to remove lymph nodes. the pectoralis major muscle, sweeping all fatty node-bearing
If the lymphoscintigram showed two channels leading to tissue laterally and down off the muscle. Be alert to the neu-
two nodes as shown in Fig. 121.1, always seek the second rovascular bundle supplying the pectoral muscles. This con-
node. If the lymphoscintigram demonstrated progression to tains the medial pectoral nerve. If this nerve is divided, the
an internal mammary node or a supraclavicular node, these lateral portion of the pectoral muscle will atrophy and
are generally not biopsied. become a fibrous cord, producing significant cosmetic defor-
In addition, remove any blue nodes in the case of blue dye mity and some functional disability. Sweep this neurovascu-
injection in the breast. There is generally excellent concor- lar bundle medially and cephalad and continue to pull the fat
dance between the two tracers. Keep in mind that nodes will down out of the axilla (Fig. 121.6).
absorb tattoo ink. If your patient has a tattoo on the arm or Identify the lateral border of the pectoralis minor muscle.
breast, consider whether any colored (but not clearly blue) Incise the fascia lateral to this muscle. Elevate the muscle
node might be due to the tattoo and thus not in need of
removal.
Irrigate the wound and obtain hemostasis and lymph sta-
sis. If an immediate examination of the nodes (touch prep or
frozen section) is being performed, it is efficient to proceed
to any other part of the surgery (lumpectomy, mastectomy)
once hemostasis is achieved as it may take 20–30 min or
more to obtain the results. If this is the case, simply pack the
wound and proceed with additional surgery.
If no further axillary surgery is planned, close this small
incision in layers including the axillary fascia without any
drains.
Axillary Node Dissection
Ensure that any neuromuscular blockade used during induc-

tion of anesthesia has been allowed to wear off (or has been Fig. 121.6
Fig. 121.8
the nerve where it can be surprisingly difficult to gain con-

trol. Next, clear the fatty tissue off the lateral chest wall and
seek the long thoracic nerve. It may be necessary to carefully
Fig. 121.7 incise the fascia to free the nerve. Gently push it back along
the chest wall where it belongs. It is generally at the same
with a retractor and continue to dissect under it. Generally, depth as the thoracodorsal nerve and can be palpated along
only a small amount of fatty tissue will remain, and this can the serratus anterior before it is visualized.
be swept laterally. The intercostobrachial nerve and other smaller sensory
The next structure to identify is the axillary vein. In a nerves pass from the chest wall directly lateral into the speci-
morbidly obese patient, it may be helpful to palpate the arm men. We divide these cleanly as needed to extract the
under the drapes and mentally visualize the level at which specimen.
this structure is likely to be found. Then bluntly dissect down Now, all major structures have been identified (Fig. 121.8).
through the fat until the bluish structure is located. Often the All that remains is to sweep the fatty node-bearing tissue out
fat will “cleave” (with some lobules of fat easily being of the axillary space, securing any small vessels with clips or
pushed cephalad and some caudad) right over the vein. If ligatures. Irrigate the space and obtain careful hemostasis
your dissection brings you down over a firm whitish struc- and lymph stasis. Place one or two closed suction drains in
ture, you are too far cephalad, over the brachial plexus. the space, bring these out through separate stab wounds infe-
Minimize trauma to the brachial plexus by abandoning this rior to the incision, and secure them in place. We prefer chan-
plane of dissection and working 1–2 cm inferior to the nel or Blake-type drains, which slide out easily and
plexus. Palpating for the pulse of the axillary artery may atraumatically. Close the incision in layers with interrupted
help. The vein will be found inferior and superficial to the 3–0 Vicryl and a running subcuticular stitch. Place fluffs over
artery. the axilla and apply firm but gentle pressure to smoothly
Once the axillary vein is found, continue dissection medi- reapproximate the skin to the deeper structures.
ally and laterally in the anterior adventitial plane of the vein
over its superficial aspect (Fig. 121.7). Any structure that
crosses over the vein can be divided (all motor nerves lie Postoperative Care
deep to the vein). Use clips or ligatures liberally to avoid
bleeding. Small branches entering the inferior aspect of the Remove the drains when output is less than 30 ml/24 hours
axillary vein can be clipped or ligated and divided. Sweep for 2 days or after a specified period of time if drainage per-
the fatty tissue downward and seek the thoracodorsal vein, a sists for several weeks. The earlier the drains are removed,
sizeable tributary that heads deep and inferior several centi- the more likely a postoperative seroma will form. Conversely,
meters lateral to the chest wall. The thoracodorsal artery and the longer the drains stay in situ, the less likely a seroma will
nerve lie about 1 cm deep to the vein. Generally, there is a occur, but the risk of drain tract infection (particularly in
small tributary to the specimen from the thoracodorsal ves- obese women) may be increased.
sels—it is best to find and secure this little twig with clips Encourage early mobilization. Gentle exercises designed
before it is avulsed. If it is avulsed, it tends to retract along to preserve mobility help avoid a “frozen shoulder” and may
decrease the risk of lymphedema. If the patient has limited of preservation of the intercostobrachial nerve. Eur J Surg Oncol.
mobility at first postoperative visit (in about 2 weeks), pre- 2003;29:213–5.
Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Witworth PW, et al.
scribe physical therapy. Many surgeons will prescribe physi- Axillary dissection vs no axillary dissection in women with invasive
cal therapy routinely to all patients undergo axillary breast cancer and sentinel node metastasis: a randomized clinical
dissection to optimize upper extremity mobility. trial. JAMA. 2011;305:569–75.
Guo J, Yang H, Wang S, et al. Comparison of sentinel lymph node
biopsy guided by indocyanine green, blue dye, and their combina-
tion in breast cancer patients: a prospective cohort study. World J
Complications Surg Oncol. 2017;15(1):196.
Han JW, Seo YJ, Choi JE, Kang SH, Bae YK, Lee SJ. The efficacy of
arm node preserving surgery using axillary reserve mapping for pre-
• Bleeding, seroma, and infection are all possible compli- venting lymphedema in patients with breast cancer. J Breast Cancer.
cations. Seromas are managed by serial aspiration. 2012;15:91–7.
Persistent seromas may require placement of a small Johnson MT, Guidroz JA, Smith BJ, et al. A single institutional experi-
ence of factors affecting successful identification of sentinel lymph
closed suction drain and even sclerotherapy with agents node in breast cancer patients. Surgery. 2009;146(4):671–6; discus-
such as alcohol. sion 676-677.
• Lymphedema may occur after either procedure but is Khan A, Chakravorty A, Gui GP. In vivo study of the surgical anatomy
more common after axillary node dissection especially of the axilla. Br J Surg. 2012;99:871–7.
Kong AL, Hwang RF. Chap. 39. Sentinel lymph node biopsy: an over-
when combined with postoperative radiation. Early treat- view. In: Dirbas FM, Scott-Conner CEH, editors. Breast surgical
ment helps limit progression. Referral to a lymphedema techniques and interdisciplinary management. New York: Springer;
therapist is essential. 2011. p. 471–80.
• Injury to one of the motor nerves results in decreased Lopchinsky RA. Locating the axillary vein and preserving the medial
pectoral nerve. Am J Surg. 2004;188:193–4.
mobility of the shoulder. Ochoa D, Korourian S, Boneti C, Adkins L, Badgwell B, Klimberg
• Trauma to the intercostobrachial nerve or one of the other VS. Axillary reverse mapping: five-year experience. Surgery.
sensory nerves commonly results in a patch of insensate 2014;156(5):1261–8.
skin on the medial aspect of the upper arm. Some women Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro
R. Surgical anatomy of the pectoral nerves and the pectoral muscu-
will develop a neuropathic pain syndrome. lature. Clin Anat. 2012;25(5):559–75.
• Axillary web syndrome is characterized by a palpable Shah-Khan MG, Lovely J, Degnim AC. Safety of methylene blue dye
cord-like structure right under the axillary skin. It is more for lymphatic mapping in patients taking selective serotonin reup-
noticeable in slender women. This rarely limits mobility take inhibitors. Am J Surg. 2012;204(5):798–9.
Shin K, Caudle AS, Kuerer HM, et al. Radiologic mapping for tar-
but may be of cosmetic concern. Physical therapy can geted axillary dissection: needle biopsy to excision. AJR Am J
help with release of axillary web. Roentgenol. 2016;207(6):1372–9.
Spanheimer PM, Graham MM, Sugg SL, Scott-Conner CE, Weigel
RJ. Measurement of uterine radiation exposure from lymphoscin-
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Throckmorton AD, Askegard-Giesmann J, Hoskin TL, et al.
Bergmann A, Mendes VV, de Almeida DR, Do Amaral ESB, Da Costa Sclerotherapy for the treatment of postmastectomy seroma. Am J
Leite Ferreira MG, Fabro EA. Incidence and risk factors for axillary Surg. 2008;196(4):541–4.
web syndrome after breast cancer surgery. Breast Cancer Res Treat. Tokmak H, Kaban K, Muslumanoglu M, Demirel M, Aktan
2012;131:987–92. S. Management of sentinel node re-mapping in patients who have
Clough KB, Nasr R, Nos C, Vieira M, Inquenault C, Poulet B. New second or recurrent breast cancer and had previous axillary proce-
anatomical classification of the axilla with implications for sentinel dures. World J Surg Oncol. 2014;12:205.
node biopsy. Br J Surg. 2010;97:1659–65. Torresan RZ, Cabello C, Conde DM, Brenelli HB. Impact of the preser-
Flynn LW, Park J, Patil SM, Cody HS 3rd, Port ER. Sentinel lymph vation of the intercostobrachial nerve in axillary lymphadenectomy
node biopsy is successful and accurate in male breast carcinoma. J due to breast cancer. Breast J. 2003;9:389–92.
Am Coll Surg. 2008;206(4):616–21. Van Zee KL, Manasseh DM, Bevilacqua JL, et al. A nomogram for pre-
Foster D, Choy N, Porter C, Ahmed S, Wapnir I. Axillary reverse map- dicting the likelihood of additional nodal metastases in breast can-
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Concepts in Melanoma
122
Leah Kathryn Winer and Jeffrey J. Sussman
Introduction and male sex (Azoury and Lange 2014). The traditional algo-
rithm for screening patients for melanoma is ABCDE, which
In 2020, an estimated 100,350 new cases of melanoma will stands for asymmetry, border irregularity, color variation,
be diagnosed in the United States, making it the fifth and diameter > 6 mm, and evolution of lesion appearance over
sixth most common cancer among men and women, respec- time. If a patient has numerous nevi, a lesion that appears
tively (Siegel et al. 2020). With growing emphasis on early distinct from the others may raise concern. If a changing skin
diagnosis and frequent skin examination, the incidence of lesion is not clearly benign, especially in the setting of the
cutaneous melanoma is expected to rise, especially with pop- aforementioned risk factors, a biopsy is indicated.
ulation growth and aging (Karimkhani et al. 2017; Whiteman
et al. 2016). Despite being the deadliest skin cancer, public
health efforts focused on early detection and improvements Biopsy
in therapy give cutaneous melanoma a generally favorable
prognosis relative to other common cancers, with an esti- Because lesion thickness is critical for pathologic staging,
mated 5-year survival rate of 92% (Siegel et al. 2018; prognosis, and the guidance of surgical management, com-
National Cancer Institute Surveillance 2008–2014). Surgery plete excisional biopsy is usually the best initial approach. If
remains the most effective treatment for early-stage mela- the lesion in question is large or located on the face or acral
noma, and recent advances in targeted and immune therapies region (fingers and toes) where excisional biopsy is not
have dramatically improved outcomes in advanced disease. straightforward, an incisional, punch, or deep saucerization
This chapter reviews the principles of primary cutaneous (not shave) biopsy centered over the most suspicious-looking
melanoma diagnosis and excision, approach to the draining and thickest portion of the lesion is an alternative. In either
nodal basins, adjunct therapies, and management of recur- case, the biopsy should be of adequate depth for pathologic
rences and distant metastases. examination and accurate determination of lesion thickness.
For this reason, superficial shave biopsies are not recom-
mended if a lesion is truly suspicious for melanoma. When
Diagnosis performing the excisional biopsy, the margins should be nar-
row. In anticipation of a later wide local excision (WLE),
Risk Factors clinicians should orient the biopsy such that the site can be
easily incorporated into the formal re-excision procedure.
Melanoma arises from melanocytes in the basal layer of the After biopsy, the pathologist determines whether the
epidermis. Risk factors include a personal history of prior lesion is melanoma, and if possible, the histologic subtype.
melanoma, ultraviolet light exposure and sunburn (including The pathology report also includes the Clark level (anatomic
that from tanning beds), fair complexion with light-colored depth), the Breslow depth (vertical thickness from the top of
eyes and/or red hair, multiple atypical nevi, family history the granular layer to the lowest tumor cell measured in mil-
and genetic predisposition, immunosuppression, older age, limeters), the presence or absence of ulceration, margin sta-
tus, mitotic rate, as well as several other features according
L. K. Winer · J. J. Sussman (*) to College of American Pathologists recommendations
Department of Surgery, University of Cincinnati College of (Smoller et al. 2017). This pathologic information is used to
Medicine, Cincinnati, OH, USA begin clinical and pathologic staging, and thus accuracy is
e-mail: SUSSMAJ@ucmail.uc.edu

https://doi.org/10.1007/978-3-030-81415-1_122
964 L. K. Winer and J. J. Sussman
crucial. If any questions remain regarding the diagnosis, the gins status, complex reconstruction should await final
slides should be reviewed at a referral center. pathology.
Staging Management of the Regional Lymph Nodes
The American Joint Committee on Cancer TNM staging Sentinel Lymph Node Biopsy
guidelines provide the framework for stratifying and treating
patients with melanoma. The primary tumor (T) classifica- In patients without clinically evident nodal disease, there is a
tion is based on Breslow thickness and ulceration (see AJCC risk of occult metastatic nodal disease that increases with the
Cancer Staging Manual). The nodal (N) classification is thickness of the primary lesion. Before WLE is performed,
based on the extent of both regional lymph nodes and the surgeon must review this risk and determine if sentinel
non-
nodal regional disease (see AJCC Cancer Staging lymph node biopsy (SLNB) is warranted. In most circum-
Manual). Finally, distant metastasis (M) classification is stances, SLNB is recommended for patients with melanomas
determined by the presence of at least one metastatic lesion, that are T1b or greater (non-ulcerated primaries ≥0.8 mm or
its specific anatomic location, and serum lactic acid dehydro- any thickness if ulcerated) (Gershenwald and Scolyer 2018).
genase assessment(see AJCC Cancer Staging Manual) Patients with thin melanomas and selected risk factors may
(Gershenwald and Scolyer 2018; Amin 2017). The patho- also be candidates for SLNB.
logic stage integrates the aforementioned components after Introduced in 1992 by Morton et al., SLNB is a minimally
pathologic information about the primary melanoma and invasive technique performed at the time of WLE and is
lymph node basins is complete (see tables in American Joint based on the concept that melanoma often spreads first via
Committee on Cancer’s Cancer Staging Manual for the draining lymphatics from the primary site to one or a few
reference). lymph nodes within the nearest nodal basin (Morton et al.
1992). The tumor status of these sentinel lymph nodes not
only stages the draining nodal basin, but is also a prognostic
Primary Lesion: Wide Local Excision (WLE) factor for other nodal and distant metastatic disease. If the
SLNB is negative, there is high likelihood that the other
The first step in surgically treating melanoma is nodes will also be negative and the patient will be at decreased
WLE. Because many melanomas spread radially as well as risk for distant disease.
invade vertically, and thicker melanomas confer a worse Identification and removal of the sentinel lymph node is
prognosis, the principle of WLE is that increasing Breslow facilitated by two complementary methods: lymphscintigra-
depth necessitates wider circumferential margins. Commonly phy and vital blue dye. Preoperative lymphscintigraphy
accepted margin guidelines are as follows: 0.5 to 1 cm for traces the flow of lymph from the primary lesion to the drain-
melanoma in situ; 1 cm for melanomas <1.0 mm thick; 1 to ing nodal basins and nodes. This technique is especially use-
2 cm margins for melanomas 1.0 to 2.0 mm thick; and 2 cm ful for head, neck, and trunk melanomas, which may drain in
margins for melanomas >2.0 mm thick (see AJCC Cancer unpredictable patterns to multiple basins, interval nodes, or
Staging Manual) (Lens et al. 2002). It is acceptable to mod- contralateral basins particularly if near the midline. Usually
ify the margins for individual anatomic or functional on the day of WLE, a small amount of technetium-99 m
considerations. radiolabeled colloid or another radiolabeled lymph node
Primary repair can usually be achieved by extending the binding agent is injected into the dermis in a circumferential
circular margins about the biopsy site into an ellipse with a manner adjacent to the primary lesion. This is followed by
1:2 to 3 ratio oriented along the longitudinal axis of the scintigraphy scanning to identify the lymphatic draining
extremity or tension/lymphatic drainage lines of the trunk. basin and the approximate number of first echelon sentinel
After a skin incision is made, excision is performed to the nodes. Once in the operating room, a handheld gamma probe
level of the fascia covering the underlying muscle. Perform is used to confirm the location of the sentinel node, help
the excision with care to avoid transfer of any malignant guide the dissection, and verify removal of the sentinel
melanocytes into the open wound. The specimen should be node(s).
sent to pathology for permanent histologic sectioning intact Vital blue dye is often also used to assist in locating the
and correctly oriented. sentinel lymph node. Approximately 5 to 10 minutes before
In most instances, WLE defects can be closed primarily. SLNB, a blue dye—isosulfan blue, methylene blue, or patent
However, if a primary repair cannot be achieved, local flaps blue V—is injected intradermally around the primary lesion
and/or a skin graft may be needed. Rarely more complex within the scope of the planned excision (Figs. 122.1 and
reconstruction is required. If there is concern regarding mar- 122.2). The purpose of the blue dye is to facilitate visualiza-
122 Concepts in Melanoma 965
Fig. 122.1
Fig. 122.3
Fig. 122.2
tion of the sentinel node during dissection (Figs. 122.3 and
122.4), and, in combination with lymphscintigraphy, it
allows for the detection of sentinel lymph nodes in 99% of
patients (Morton et al. 2014). Upon removal, the sentinel
lymph node is sent to pathology for permanent step section-
ing and immunohistochemistry to look for evidence of mela-
noma. SLNB has replaced elective complete lymph node
dissection because it more accurately identifies small vol-
ume of disease within the nodes due to focused pathology
and has less morbidity as it avoids more extensive surgery in
node-negative patients (Morton et al. 2014).
Fig. 122.4
Until recently, patients with a positive SLNB would sub-
sequently undergo a formal completion lymphadenectomy. assigned to undergo WLE followed by either clinical obser-
The efficacy of the SLNB technique and its ability to accu- vation with subsequent surgery for nodal failure or SLNB
rately predict nodal basin status were evaluated prospec- and immediate completion lymph node dissection (CLND)
tively through the first Multicenter Selective only if positive. The authors found that nodal metastasis
Lymphadenectomy Trial (MSLT I) (Morton et al. 2014). In occurred in 21% of all enrolled patients, and that sentinel
this clinical trial, melanoma patients were randomly node status was the strongest predictor of recurrence and
death for patients with intermediate-thickness melanoma. For many years, high-dose interferon-α2b was used for
Moreover, this study demonstrated a survival benefit in advanced stage II and stage III patients with limited efficacy
node-positive patients diagnosed by SLNB compared with and significant morbidity (Sullivan et al. 2018). This has
the WLE-only patients whose nodal disease was detected been largely abandoned in favor of more efficacious and less
during follow-up. The authors concluded that SLNB pro- toxic therapies. Combined use of targeted adjuvant BRAF/
vided accurate staging information and regional control, as MEK inhibitors has resulted in a 53% lower relapse risk in
well as enhanced melanoma-specific survival in the node- stage III patients with tumors characterized by V600e/k BRAF
positive patient subgroup (Morton et al. 2014). mutations, which drive approximately 40% of melanomas
MSLT II evaluated whether CLND improved melanoma- (Long et al. 2017). Immune therapies represent another ther-
specific survival compared with SLNB followed by clinical apeutic option for stage III melanoma. Ipilimumab, a human
observation. The authors found that over a median follow-up monoclonal antibody against cytotoxic T-lymphocyte anti-
of 43 months, CLND after positive SLNB increased morbid- gen 4 (CTLA-4) was shown to improve recurrence-free sur-
ity without improving survival, suggesting that the survival vival in select, high-risk stage III melanoma patients
benefit of nodal surgery seen in MSLT I resulted from remov- (Eggermont et al. 2016), but this has now been replaced by
ing the sentinel lymph node itself. Although the average programmed death receptor-1 (PD-1) inhibitors, which have
tumor burden within the sentinel node was small, patients in better safety profiles and outcomes (Weber et al. 2017).
the observation group required close follow-up because Patients with extensive nodal disease and/or extranodal
approximately 30% eventually had a nodal recurrence. extension have a higher risk of regional failure with surgery
Patients with early detection of isolated nodal recurrences alone. Adjuvant radiation treatment can improve regional
should be able to be salvaged with a delayed therapeutic control in these high-risk patients but does not benefit overall
node dissection (Faries et al. 2017). These data, along with survival (Henderson et al. 2015). Due to the additive morbid-
similar findings from another prospective trial (Leiter et al. ity, adjuvant radiation is therefore only used very selectively.
2016), have led to the routine abandonment of CLND for Finally, for patients with borderline resectable lymphade-
patients with a positive sentinel node. Some surgeons may nopathy or those at high-risk for distant recurrence after
still consider up-front CLND in patients with high sentinel CLND, a trial of neoadjuvant therapy may be an effective
node tumor burden because they are at increased risk for approach and is being actively explored in clinical trials
non-sentinel involvement and eventual nodal basin failure. (National Comprehensive Cancer Network. Cutaneous
However, this will not likely improve overall survival as pos- Melanoma (Version 1.2019) n.d.).
itive non-sentinel nodes reflect a greater probability of occult
distant disease that regional surgery would not preempt.
In-Transit Melanoma
Adjuvant Therapy In-transit melanoma is defined as locoregional disease recur-

rence characterized by cutaneous or subcutaneous metasta-
As the molecular, immunologic, and genetic profile of mela- ses found between the primary lesion and draining lymph
noma becomes better understood, the role of targeted and node basin that result from tumor deposits in the intradermal
immunologic therapies has surged forward. In less than a lymphatic vessels (Pawlik et al. 2005). In-transit recurrence
decade, nearly a dozen new drugs and therapeutic combina- has an incidence of approximately 5%, and the 5-year overall
tions have been approved for advanced melanoma, offering survival rates are relatively poor at 46% and 69% for positive
patients and providers a multitude of treatment options. and negative SLNB patients, respectively (Byers et al. 2014;
Some of these therapies have now been tested in the adjuvant Testori et al. 2011). Patients with locoregional recurrences
setting to prevent progression to clinically evident, distant require whole-body imaging to evaluate for distant metasta-
disease. The decision to pursue adjuvant therapy is based on ses and BRAF mutation testing. For limited in-transit dis-
the estimated risk of melanoma recurrence balanced by the ease, excision of the lesion to negative margins is advised.
therapeutic benefit and risk profile. Most pathologic stage I Unlike the approach to primary melanoma, wide excision is
and IIA melanoma patients can be safely observed postop- not recommended for in-transit lesions because they indicate
eratively. Although individually at low risk, because this rep- progression of regional and possibly distant disease, not
resents a very large population of patients, a significant local failure. Several intralesional therapies have been stud-
number of these patients will still progress to advanced dis- ied for lesions not amenable to resection. A recent prospec-
ease (Sullivan et al. 2018). Genetic expression profiles of tive, randomized control trial demonstrated that in patients
these patients’ tumors may reveal subgroups at higher risk with unresectable stage IIIB/C disease, injections of talimo-
that could benefit from adjuvant treatments or closer gene laherparepvec (T-VEC), an oncolytic immunotherapy,
observation. improved durable response rate but had no significant effect
122 Concepts in Melanoma 967
on overall survival (Andtbacka et al. 2015). However, the remains to be achieved. Prevention and early detection con-
results suggested that a systemic response was occurring; tinue to be of utmost importance.
therefore, potential combination with other immunothera-
pies is being studied, which may achieve better survival
outcomes. References
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administration of high-dose chemotherapy—typically mel- noma: results from the global burden of disease study 2015. Br J
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methods rely on selective cannulation and tourniquet used to Whiteman DC, Green AC, Olsen CM. The growing burden of invasive
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HILP uses an extracorporeal bypass circuit with membrane 2016;136(6):1161–71.
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(Speicher et al. 2015). Complete response rates are 30–40% Azoury SC, Lange JR. Epidemiology, risk factors, prevention, and early
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toxicity, compartment syndrome, and rarely, limb loss. mittee on cancer (AJCC) 8th edition and beyond. Ann Surg Oncol.
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Wide Local Excision and Sentinel Lymph
Node Biopsy for Melanoma 123
Carlos H. F. Chan and Hisakazu Hoshi
Table 123.1 Excision margin by Breslow thickness

Indications
Breslow thickness Excisional margin
Melanoma in situ 0.5 cm
Wide Local Excision Melanoma <1.0 mm 1 cm
Melanoma 1.0–2.0 mm 1–2 cm
The diagnosis of melanoma is usually made by a punch or Melanoma ≥2 mm 2 cm
excisional biopsy. Occasionally, a shave biopsy has been per-
formed; however, due to the possibility of underestimating
true thickness of the primary lesion by transecting the bot- Table 123.2 Sentinel lymph node biopsy based on melanoma
tom, shave biopsy is not a recommended biopsy method. characteristics
Wide local excision is indicated for local control. The width Breslow Ulceration or Clinically positive Sentinel lymph
of the gross (not microscopic) margin required is determined thickness mitosis lymph node node biopsy
by the Breslow thickness of the lesion (Table 123.1). ≤ 0.80 mm +/− − No
0.81– − − Yes/noa
1.0 mm
Sentinel Lymph Node Biopsy 0.81 – + − Yes
1.0 mm
1.0–4.0 mm +/− − Yes
Sentinel node biopsy provides prognostic information and is > 4.0 mm +/− − Yes if patient is
used to stage the clinically node-negative patients according a candidate for
to the characteristics of primary lesion. In intermediate thick- adjuvant
ness melanoma (Breslow thickness 1.20–3.50 mm), expected treatmentb
positivity of the sentinel node is 20–30% and sentinel lymph Any +/− + Nob
thickness
node biopsy will provide regional disease control. Thick a
Risks/benefits discussion
melanoma (Breslow thickness more than 4.0 mm) has higher b
The presence of clinically positive lymph node precludes SLNB
sentinel node positivity rate and positive sentinel node diag-
nosis makes them candidates for adjuvant immunotherapy
(Table 123.2). trolled trials comparing completion dissection versus obser-
Traditionally, a positive sentinel lymph node is consid- vation, there is no melanoma-specific survival benefit
ered an indication for complete nodal dissection (see Chap. demonstrated in dissection arm.
124). Only 20–30% of those positive sentinel node patients
have additional positive non-sentinel nodes in the nodal
basin. Based on most recent published randomized con- Contraindications
• Widespread metastatic disease may be a

C. H. F. Chan · H. Hoshi (*) contraindication.
Department of Surgery, Surgical Oncology and Endocrine Surgery,
University of Iowa, Iowa City, IA, USA • Sentinel node biopsy is rarely indicated in patients with
e-mail: hisakazu-hoshi@uiowa.edu known node-positive or metastatic disease.

https://doi.org/10.1007/978-3-030-81415-1_123
970 C. H. F. Chan and H. Hoshi
• Systemic condition prohibits general anesthesia (sentinel • Inadequate excision due to underestimation of Breslow
node biopsy generally requires general anesthesia). thickness: Avoid shave biopsy for pigmented suspicious
skin lesion.
• Failure to identify a positive sentinel lymph node due to
Preoperative Preparation technical problems or poor localization: Intradermal
injection of radionucleotide, use of preoperative lympho-
1. Determining the width of excisional margin: The margin scitigraphy with low threshold to use SPECT scan.
width is based on the Breslow thickness of the primary
lesion (Table 123.1), which should be determined by a
punch biopsy or narrow margin excisional biopsy preop- Operative Strategy
eratively. However, in certain situations, the melanomas
may have been removed completely or partially by shave Wide local excision may be performed alone or with sentinel
biopsy. In this case, the Breslow thickness reported lymph node biopsy. Often the diagnosis of melanoma has
should be interpreted with caution. been made before the patient is first seen by the surgeon.
2. Exploring reconstructing options after wide local exci-
sion: In certain anatomical locations, such as face, scalp,
neck, distal 1/3 of the limb and joints, simple skin closure Biopsy
may not be feasible after wide local excision. Preoperative
evaluation by a plastic and reconstructive surgeon may be The manner in which that diagnostic biopsy was done can
essential for considering skin grafts and flaps. These tech- make the subsequent excision easier or harder. Therefore,
niques will not be discussed here as they are beyond the special attention should be made in doing a biopsy for pos-
scope of this chapter. sible melanoma. First, the thickness of the melanoma is a
3. Considering sentinel lymph node biopsy: The necessity crucial prognostic factor. It can only be determined by a full-
of a sentinel lymph node biopsy is based on the character- thickness biopsy that goes down into the underlying fat. For
istics of the primary lesion, including Breslow thickness this reason, conservative very narrow margin excisional
and the presence or absence of ulceration, mitosis, and biopsy, incisional biopsy of the thickest portion of a large
clinically positive lymph node (Table 123.2). lesion, or punch biopsy is strongly preferred over shave
4. Localizing lymph node basins for sentinel lymph node biopsy.
biopsy: For melanoma located in extremities, the senti- Align the long axis of the biopsy wound with the long
nel lymph node is often located in the respective axillary axis of any subsequent wide excision site to minimize the
or inguinal lymph node basin of that particular extrem- amount of tissue that must be removed at wide excision. For
ity. Occasionally, in-transit sentinel node between the the extremities, this requires placing the incision parallel to
primary and nodal basin can be identified, and if this is the long axis of the limb (rather than in a natural skin crease).
the case, this node needs to be biopsied. For melanoma For the torso, incisions parallel to the likely lymphatic drain-
of the trunk and head and neck, accurate preoperative age pattern are often preferred; however, the skin is usually
localization is the key of successful identification and loose enough that a skin crease incision can be made. If the
retrieval of the sentinel lymph nodes in the operating lesion is large, take a representative biopsy from the thickest
room since sentinel lymph nodes can be in more than (non-ulcerated) part of the lesion either by making a small
one lymph node basin. Low threshold to use SPECT incision or performing a punch biopsy.
scan is particularly recommended for head/neck pri-
mary melanoma to assure the accuracy of the results.
Preoperative lymphoscintigraphy involves an intrader- Wide Local Excision
mal (not a subdermal injection) single injection of
radionuclide Technetium-99 m at the site of melanoma. The margin is defined from the edge of the lesion or edge of
It can be performed on the same day or the day prior to the biopsy site if the lesion has been completely removed.
surgery. The size of margin ranges between 0.5 and 2 cm (Table 123.1).
These recommended margins are gross in vivo margin and
not microscopic margin.
Pitfalls and Danger Points First draw a circle of the appropriate size around the
lesion. Then plan the long axis of your excision site and draw
• Primary lesion not identifiable at the time of surgery: triangles at both ends to convert your circle into a lens-
Photo documentation or leaving biopsy suture can be use- shaped excision. Usually a ratio of length to width of 3.5:1 is
ful to assure the correct identification.
123 Wide Local Excision and Sentinel Lymph Node Biopsy for Melanoma 971
advocated to allow closure without “dog ears” at the ends, lymph node.” Thus, even for extremity melanoma, preopera-
but fatter excisions can be used if necessary. tive lymphoscintigraphy should be performed. Truncal mela-
When planning the long axis of the excision site, take the nomas exhibit somewhat less predictable patterns. The trunk
following general guidelines into consideration. For the can be divided into four quadrants by a vertical line down the
extremities, use an incision parallel to the long axis of the middle and a transverse line at the level of the umbilicus
extremity. If possible, put your long axis parallel to likely anteriorly and L2 posteriorly (the “belt line” or line of
lymphatic drainage pathways. Plan your excision first and Sappey). Generally, the lymphatics drain to the regional
worry about closure later. lymph node basin in their respective quadrant; thus, the skin
Take your wide excision down to fascia. The purpose of of the left upper quadrant of the trunk will usually drain to
the excision is to remove lymphatic channels located in the
soft tissue where the microscopic deposits exist. It is not nec-
essary to take the fascia with the excision. Generally, pri-
mary closure is possible. Sometimes a local rotation or
tissue-transfer flap technique may allow closure (see refer-
ences at the end). Split-thickness or full-thickness skin graft
is an alternative when primary or transposed local tissue clo-
sure is not feasible.
Sentinel Lymph Node Biopsy
The general strategy and considerations for successfully sen-

tinel lymph node biopsy are discussed in detail in Chap. 121
and will not be repeated here.
Melanomas of the extremities typically drain in a predict-
able fashion to regional nodes, most commonly the axillary
or inguinal lymph nodes. Distal extremity melanomas or
even truncal melanomas sometimes drain to intermediate
node basins such as the popliteal or epitrochlear nodes
(Fig. 123.1) or in-transit node located between primary and Fig. 123.1
nodal basin (Fig. 123.2). If so, that would be the “sentinel
Fig. 123.2
the left axilla and so on. The line of Sappey is a watershed Inject the blue dye intradermally for sentinel node biopsy
area and varies from person to person, so lymphatic drainage in four quadrants around the lesion or biopsy site, generally
in this region is particularly prone to variation. Hence, the within the field that will be excised during wide excision
use of radioisotope and lymphoscintigraphy to localize the (Fig. 123.3). Avoid direct injection into the lesion to prevent
sentinel lymph node is of crucial importance. Figure 123.2 dissemination of the melanoma cells. Massage the dye into
shows an atypical drainage pattern that would not have been the tissues. If this step is performed immediately after induc-
predicted based upon anatomic location. tion of anesthesia, usually sufficient time will have passed
Lymphazurin blue dye is used in addition to radiocolloid for the dye to migrate out of the local site by the time inci-
to enhance accuracy. Do not use methylene blue for injection sion is made.
because it can create necrosis of the skin with intradermal
injection. Blue dye injection also makes it easy to see and
clip or ligate lymphatics and thus may minimize subsequent Wide Local Excision
lymphocele formation. Because blue dye travels through the
lymphatic system rapidly, it is injected just before surgery. If Draw a circle around the melanoma or the biopsy site. The
the primary site needs to be excised first, then blue dye will radius of the circle depends upon the thickness of the mela-
not likely seen in the sentinel lymph node. noma, with 1 cm being adequate for thin melanomas
Use the gamma probe to identify the region of greatest (<1.0 mm) and 2 cm required for thick melanomas
radioactivity and make an incision over this spot (see Chap. (≥2.0 mm). As noted previously (see Table 123.1),
121). Always make this incision in such a way that you can intermediate-thickness melanomas generally are excised
easily incorporate it into a subsequent completion nodal dis- with 1–2 cm margins.
section incision, should this be required. If the primary site Convert the circle to an elliptical or lens-shaped incision
locates in upper back for axilla and gluteal/lower back for by outlining two triangles at apposing ends (Fig. 123.4).
groin, then consider resection of the primary site prior to the Align the long access of the resulting incision with the
sentinel node biopsy to avoid shine-through effect of the pri- regional lymphatics or the long axis of the limb (if arm or
mary site to obscure the sentinel nodes. leg). Melanomas of the head and neck present particular
Enter the nodal basin and palpate and inspect for abnor- challenges (see references at the end).
mal nodes before proceeding. Remove any abnormal, radio- Incise the skin sharply and deepen the incision straight
active, or blue node. The background count should be less down to the deep fascia. Grasp one end of the specimen with
than 10% of the hottest node at the completion. an allis clamp and remove it by following the generally avas-
cular plane just superficial to the deep fascia (Figs. 123.5 and
123.6). It is not necessary to remove the fascia. Orient the
Documentation Basics specimen with two sutures (e.g., long stitch = lateral, short
stitch = superior) and submit it for pathological
• Lymphoscintigraphy findings. examination.
• Counts and appearance (Blue dye? Abnormal to inspec-
tion or palpation?), number of nodes, background count at
the completion.
• Margin taken.
• Complex layered closure (if used).
• Flap closure (if used).
• If split-thickness skin graft, document area grafted in
square centimeters.
Operative Technique
Frequently, wide excision and sentinel node biopsy are done

under the same anesthesia. It may be possible to position the
patient to allow both procedures to be done under the same
prep, for example, a melanoma of the anterior trunk which
drains to the axillary region. However, in many cases, it will be
necessary to reposition the patient and re-prep and redrape to
provide optimum exposure for both portions of the operation. Fig. 123.3
123 Wide Local Excision and Sentinel Lymph Node Biopsy for Melanoma 973
Undermine the incision in all directions by further dis-

section in the avascular plane superficial to the deep fascia.
Close it in layers with running 2–0 Vicryl for the superficial
fascial layer, and interrupted inverted deep dermal sutures
of 3–0 or 4–0 Vicryl. Subcuticular closure with 4–0
Monocryl can be used unless the incision is under signifi-
cant tension; in this case, 3–0 or 4–0 nylon suture can be
used.
If the wound will not come together without undue ten-
sion, consider using a local flap (see references at the end).
This decision is best made at the initial part of the procedure
and the incision outlined accordingly. Alternatively, use a
split-thickness or full-thickness skin graft to secure
coverage.
Fig. 123.4 Sentinel Lymph Node Biopsy
Reposition and drape the patient, if necessary, to provide

optimal exposure of the appropriate nodal basin as deter-
mined by the lymphoscintigram. Use the sterile gamma
probe to identify the region of greatest radioactivity and
make an incision directly over this spot. The incision can
be as short as 1–2 cm in slender patients. Obese patients
will require longer incisions, sometimes up to 3–4 cm.
Plan the incision so that it could be excised easily during a
subsequent completion nodal dissection, should this be
required.
Be alert for blue lymphatics and, if you see one, gently
dissect superficial to this and in a direction away from the
primary site until you see the lymphatic dive deep to the
appropriate draining node. If it is necessary to divide a lym-
phatic trunk, secure it with clips or ties to minimize seroma
formation.
Fig. 123.5 As with sentinel node biopsy for breast cancer (see Chap.
121), it is generally necessary to go through the superficial
fascia to enter the space in which lymph nodes are found.
Carefully inspect and palpate the fatty areolar tissue in this
space. Any palpably or visibly abnormal nodes should be
removed. Also remove any node that has taken up the blue
dye (Fig. 123.7) or that is radioactive. Number the nodes as
they are removed.
Perform a 10-second count on each node. Take time to
find the hottest spot on the node. Continue to seek nodes
until the background (post-excision) count is less than 10%
of the hottest node.
Obtain hemostasis and lymph stasis. Close the incision in
layers (without drainage) with interrupted 3–0 Vicryl and
running 4–0 Monocryl.
Fig. 123.6
Complications
• Wound separation or infection.

• Seroma formation.
• Lymphedema (see above).
Further Reading
Boland GM, Gershenwald JE. Sentinel lymph node biopsy in mela-
noma. Cancer J. 2012;18:185–91.
Egnatios GL, Dueck AC, Macdonald JB, Laman SD, Warshaw KE,
DiCaudo DJ, Nemeth SA, et al. The impact of biopsy technique on
upstaging, residual disease, and outcome in cutaneous melanoma.
Am J Surg. 2011;202:771–7.
National Comprehensive Cancer Network (NCCN) guidelines.
Available from: http://www.nccn.org/professionals/physician_
gls/f_guidelines.asp.
Fig. 123.7 Ott PA, Berman RS. Surgical approach to primary cutaneous mela-
noma. Surg Oncol Clin N Am. 2011;20:39–56.
Ross MI, Thompson JF, Gershenwald JE. Sentinel lymph node biopsy
for melanoma: critical assessment at its twentieth anniversary. Surg
Postoperative Care Oncol Clin N Am. 2011;20:57–78.
Steen ST, Kargozaran H, Moran CJ, Shin-Sim M, Morton DL, Faries
Although the incidence of lymphedema is lower after senti- MB. Management of popliteal sentinel nodes in melanoma. J Am
Coll Surg. 2011;213:180–7.
nel node biopsy (about 6–7%) than after complete lymphad-
Uren RF, Howman-Giles R, Thompson JF. Patterns of lymphatic
enectomy, patients should be informed of the signs and drainage from the skin in patients with melanoma. J Nucl Med.
symptoms. Any indication of lymphedema requires prompt 2003;44:570–82.
treatment.
Axillary Lymphadenectomy
for Melanoma 124
J. E. Maxwell and Sonia L. Sugg
Indications Documentation
• Melanoma metastatic to axillary nodes. • Description of operative findings—palpable nodes

• Positive sentinel lymph node biopsy. • Level III lymph nodes removed
• Pectoralis minor muscle divided
• Nerves identified and preserved
Preoperative Preparation • Axillary vein skeletonized
Axillary lymphadenectomy is indicated for patients with pal-

pable axillary lymph node metastases or those with a positive Operative Strategy
sentinel lymph node biopsy. In the case of palpable disease,
a diagnosis of metastatic melanoma should be obtained pre- Fundamentally, axillary lymphadenectomy for melanoma
operatively with fine needle aspiration cytology. Basic labo- employs the same strategy as that used for modified radical
ratories and a chest X-ray will suffice for the preoperative mastectomy. Adipose and lymphatic tissues inferior to the
workup unless the patient’s symptoms or clinical exam raise axillary vein are excised en bloc from the clavicle to the ante-
suspicion for distant metastases, in which case more exten- rior border of the latissimus muscle. Adequate exposure
sive imaging such as a CT of the head or chest or 18FDG- requires that the arm be extended to relax the pectoralis
PET/CT may be indicated. major muscle during the medial portion of the dissection.
The levels of the axilla from level I (the lowest) to level III
(the highest) are discussed in Chap. 119. Optimal access to
Pitfalls and Danger Points level III lymph nodes requires division, and sometimes
removal, of the pectoralis minor muscle as described here.
• Nerve injury: lateral pectoral, long thoracic, thoracodor- The long thoracic and thoracodorsal nerves may be pre-
sal nerve, brachial plexus. served if they are not involved with tumor.
• Bleeding: axillary vein.
• Missed lymph nodes are usually located at the periphery
of the dissection along the posterior axillary line, lower Operative Technique
chest wall, or along the long thoracic nerve.
Incision
Position the patient supine with the ipsilateral arm abducted

to 90 degrees on an arm board. Place the skin incision just
inferior to the hair-bearing area of the axilla (Fig. 124.1).
J. E. Maxwell
Department of Surgery, Roy J. and Lucille A. Carver College of Keep this incision between the anterior and posterior axil-
Medicine, University of Iowa, Iowa City, IA, USA lary lines. Excise any scar left from previous a sentinel
S. L. Sugg (*) lymph node biopsy. Elevate both the superior and inferior
Department of Surgery, University of Iowa Carver College of Medicine, skin flaps, leaving no more than 8 mm of fat on the skin over
Iowa City, IA, USA the area indicated by the dotted line in Fig. 124.1. The supe-
e-mail: sonia-sugg@uiowa.edu

https://doi.org/10.1007/978-3-030-81415-1_124
976 J. E. Maxwell and S. L. Sugg
Incision
Fig. 124.3
Exposing the Axillary Contents

Fig. 124.1
Incise the fascia overlying the lateral border of the pectoralis

major muscle near its insertion onto the humerus and dissect it
Major pectoral m. away from the undersurface of the muscle. Insert a Richardson
Coracobrachial m.
retractor beneath the pectoralis major muscle and expose the
coracobrachialis muscle. Dissect the fat and fascia off of the
inferior surface of the coracobrachialis and carry this dissec-
tion toward the coracoid process, where the coracobrachialis
meets the pectoralis minor muscle. Free the pectoralis minor
Brachial plexus
muscle circumferentially with blunt dissection and divide it
Latissimus dorsi
m. near its insertion with electrocautery to facilitate removal of
the level III lymph nodes (Fig. 124.3). Branches of the medial
pectoral nerve are seen entering the pectoralis minor muscle
near its lateral border. Divide these small branches, but take
care to protect the medial pectoral nerve trunk, which emerges
through or along the medial margin of the pectoralis minor
muscle, as this nerve largely constitutes the innervation of the
pectoralis major muscle. Free the pectoralis minor muscle
from the chest wall with blunt dissection. Incise the fat along
Fig. 124.2 the anterior border of the latissimus muscle to identify the lat-
eral boundary of the lymphadenectomy.
rior dissection exposes the anterior surface of pectoralis Open the thin layer of costocoracoid ligament just cepha-
major in its medial aspect, the fat overlying the axillary vein lad to the course of the axillary vein. Do not skeletonize the
and brachial plexus in the middle, and the coracobrachialis nerves of the brachial plexus as it may produce a painful,
and latissimus muscles laterally (Fig. 124.2). The lower permanent neuritis. After dividing this ligament, sweep the
extent of the dissection is the level at which the latissimus loose fat in a caudal direction. This maneuver exposes the
meets the chest wall. axillary vein.
124 Axillary Lymphadenectomy for Melanoma 977
Thoracodorsal n.
Long thoracic n.
Latissimus dorsi m.
Fig. 124.5
and lymphatic tissue away, leaving its proximal attachment

Fig. 124.4
to the thorax. Divide the intercostobrachial nerve that
emerges from the second intercostal space and enters the
Clearing the Axillary Vein specimen. At this point in the dissection, the anterior and
inferior portions of the axillary vein have been cleared along
Identify the axillary vein in the lateral portion of the axilla. the upper 6–10 cm of the anterior chest wall.
Elevate its adventitia and incise it with Metzenbaum scis-
sors. Carry this dissection medially until the clavicle is
reached. Several branches of the lateral anterior thoracic and Subscapular Space
thoracoacromial nerves and blood vessels are encountered
crossing over the axillary vein. Divide each between hemo- In the subscapular space, use a Kittner dissector or gauze pad
static clips. In general, nerves crossing over and small to dissect the nodal packet downward. This will clear the
branches draining into the axillary vein are safe to divide as space between the scapula and lateral chest wall. This step
motor nerves run deep to the vein. exposes the long thoracic nerve, which tends to hug the chest
Regrasp the adventitia of the axillary vein and divide it in wall. Identify the thoracodorsal nerve, which crosses the
a caudal direction, which exposes the various venous subscapular vein and moves laterally together with the ves-
branches entering the main vein from below. Ligate each of sels supplying the latissimus muscle (Fig. 124.5).
these branches as they enter the vein on its inferior surface If the anterior border of latissimus muscle was not dissected
(Fig. 124.4) taking care not to narrow the axillary vein. free during the first step of this operation, liberate this muscle
Preserve the subscapular vein, which enters the posterior now, preserving the thoracodorsal nerve. Dissect the specimen
wall of the axillary vein. Once the axillary vein has been free of the chest wall, after dissecting out and preserving the
skeletonized, sweep the nodal packet away from the vessel. long thoracic nerve. Orient the specimen for pathology.
Dissecting the Chest Wall Drainage and Closure
Incise the clavipectoral fascia on a line parallel and just cau- Make a puncture wound in the anterior axillary line about
dal to the axillary vein beginning at the level of the clavicle 10 cm below the axilla and pass a closed suction drain into
and continuing to the subscapular space. Make a vertical the apex of the axillary dissection near the point where the
incision in the fascia from the apex of the dissection down- axillary vein goes under the clavicle. Secure the drain to skin
ward for 4–6 cm parallel to the sternum. This is the anterior with 3–0 Nylon suture. Close the skin with running 4–0
border of the dissection. Sweep the nodal packet of adipose Monocryl suture.
978 J. E. Maxwell and S. L. Sugg
Postoperative Care Further Reading
• Maintain bulb suction on the drain until the output is less Davis PG, Serpell JW, Kelly JW, Paul E. Axillary lymph node dissec-
than 30 cc/d, then remove. tion for malignant melanoma. ANZ J Surg. 2011;81:462.
McNeil C. Endoscopy removal of axillary nodes gains ground abroad,
• Limit abduction of the arm during the first postoperative toehold in US. J Natl Cancer Inst. 1999;91:582.
week, but thereafter encourage the patient to exercise the Moore MM, Nguyen DH, Spotnitz WD. Fibrin sealant reduces serous
shoulder joint through its entire range of motion. drainage and allows earlier drain removal after axillary dissection: a
• The patient should ambulate the day of the operation. randomized prospective trial. Am Surg. 1997;63:97.
Namm JP, Chang AE, Cimmino VM, Rees RS, Johnson TM, Sabel
• A seroma may accumulate under the skin flap in a delayed MS. Is a level III dissection necessary for a positive sentinel lymph
fashion after the drain has been removed. If it becomes node in melanoma? J Surg Oncol. 2012;105:225.
symptomatic, aspirate the fluid as necessary. Reassure the Spillane AJ, Cheung BL, Winstanley J, Thompson JF. Lymph node
patient; this usually resolves without intervention. ratio provides prognostic information in addition to American joint
committee on cancer N stage in patients with melanoma, even if
quality of surgery is standardized. Ann Surg. 2011;253:109.
Complications
• Hematoma or seroma
• Wound infection
• Lymphedema
Superficial and Deep Groin
(Femoroinguinal and Pelvic) Dissection 125
Hisakazu Hoshi
Indications Documentation
• Superficial groin dissection: Inguinofemoral nodal metas- • Pre- and postoperative stage
tasis from skin cancer (melanoma and squamous cell car- • Findings (gross positive node)
cinoma) of the lower extremity, lower trunk, or external • Preservation of saphenous vein
genitalia and anal cancer. • Anatomical boundary of the dissection
• Deep groin dissection: Palpable nodal metastasis and/or • Deep groin dissection (if performed)
multiple positive nodes in the superficial (femoroingui- • Sartorius muscular flap (if performed)
nal) compartment, positive sentinel node, or imaging
study showing a positive node localized in the pelvis.
Operative Strategy
Preoperative Evaluation reventing Wound Infection and Wound

P
Dehiscence
• Perform complete staging with proper imaging technique
to evaluate absence of distant metastatic disease and Wound complications are observed relatively commonly
locoregional extent of the disease. with groin dissection due to the location of the incision.
• Prescribe preoperative prophylactic antibiotics covering Classically, a “lazy S incision” is made across the groin
Gram-positive organisms. crease (Fig. 125.1), however, some prefer to make two sepa-
rate incisions (lower abdomen and upper thigh within femo-
ral triangle, Fig. 125.2) to avoid incision across the crease to
Pitfalls and Danger Points reduce the risk of infection. The impact of this approach on
reducing wound infection and subsequent wound dehiscence
• Making skin flaps too thin or too thick is unknown at best. If your preferred incision is two inci-
• Injuring the iliofemoral vessels sions, plan the location of the sentinel node incision well so
• Injuring the femoral nerve and its branches that it will be included in the specimen at the time of dissec-
• Injuring the obturator nerve tion without making incision across the groin crease. If inci-
• Injuring ureter, urinary bladder, and intraabdominal sion across the groin crease is utilized, resection of the
contents medial and lateral skin/soft tissue flap over the femoral tri-
• Inadequate extent of dissection angle to shorten the distance of the flap will reduce risk of
flap necrosis. The skin/soft tissue flap should be developed
just deep to the superficial femoral/Scarpa’s fascia to avoid
flap ischemia since no lymph nodes are found superficial to
this level.
H. Hoshi (*) If risk factors like high BMI for wound infection/dehis-
Department of Surgery, Surgical Oncology and Endocrine Surgery,
cence exist, consider a sartorius flap to protect femoral
e-mail: hisakazu-hoshi@uiowa.edu vessels.

https://doi.org/10.1007/978-3-030-81415-1_125
980 H. Hoshi
Fig. 125.2
Fig. 125.1
an important predictor for negative deep nodal metastatic
disease. Currently, the validity of this concept has been
Reducing Incidence of Lymphedema debated since we now see a large number of cases of
mapped iliac sentinel node with absence of radiotracer
Preserving the greater saphenous vein might have some the- uptake in Cloquet’s node. Deep groin dissection is now
oretical advantage in preventing short- and long-term lymph- considered/performed if preoperative imaging shows sus-
edema. The evidence to support this approach is limited to picious metastatic nodes in pelvis without distant meta-
case series and no randomized trial is available. Preservation static disease, histologically positive iliac sentinel nodal
of the vein can be attempted if the gross nodal disease/previ- metastasis, large macrometastatic node in superficial
ous sentinel node biopsy scar do not involve the vein. groin, multiple positive nodes in superficial groin, and
It is important to prevent infection/cellulitis of the groin positive Cloquet’s node.
incision since this might precipitate the development of
lymphedema.
Limit the extent of the dissection to the femoral triangle Adequacy of Nodal Dissection
and lower abdominal wall 5 cm above the inguinal ligament.
Overly aggressive dissection will increase the incidence of The extent and thoroughness of nodal dissection has been
lymphedema. defined by the anatomical boundaries. Recent years as is
often the case with other nodal dissections, the number of
the harvested node has been advocated as a surrogate of
I ndications for Deep Groin Dissection quality of the procedure. For superficial groin dissection,
and Exposure the number advocated is more than 5–7 lymph nodes; how-
ever, the procedure should be always performed based on
In the past, the status of highest superficial node located at anatomical boundary and not by the number of the lymph
the femoral canal (Cloquet’s node) was emphasized to be nodes.
125 Superficial and Deep Groin (Femoroinguinal and Pelvic) Dissection 981
Operative Technique Supra Inguinal Ligament Dissection
Incision and Exposure Divide the soft tissue toward the external oblique fascia 5 cm
cephalad and parallel to the inguinal ligament. Identify pubic
Position the lower extremity with thigh mildly abducted and tubercle medially and anterior superior iliac spine laterally,
knee flexed. Support the knee with a pillow or small roll. and mobilize soft tissue from abdominal wall in between
Protect the lateral malleolus and heel with padding. If neces- toward inguinal ligament. Find spermatic cord in male and
sary, retract the scrotum to the other side with towel or an preserve. Detach the whole specimen from the inguinal liga-
adhesive barrier drape. Prep lower abdomen, groin, and ante- ment (Figs. 125.3, 125.4, and 125.5).
rior thigh down to the knee level.
Start the “Lazy S” incision 2–3 cm medial to the
anterior-superior iliac spine down to the apex of the femo- Deep Groin (Pelvic) Dissection
ral triangle (Fig. 125.1). Alternatively, make one incision
in lower abdomen parallel to the inguinal ligament and If a deep groin dissection is planned, divide external oblique
longitudinally in femoral triangle (Fig. 125.2). Include the aponeurosis about 3–4 cm cephalad of the inguinal ligament
sentinel node biopsy incision, if present, to excise entire along the direction of the fibers. Then, divide internal oblique
scar tissue. Create skin flap just deep to the Scarpa’s/ and transversalis muscles and fascia. Once in the preperitoneal
superficial femoral fascia encompassing entire dissection space, identify the inferior epigastric artery and vein at their
area (5 cm above the inguinal ligament cephalad, anterior junction with the external iliac artery and vein, and ligate and
superior iliac spine and sartorius muscle laterally, pubic divide them. Dissect the preperitoneal space, expose iliac
tubercle and adductor longus muscle medially and apex of fossa, and sweep the intraabdominal contents medially to
the femoral triangle caudally). expose entire length of external iliac vessels. Note that the ure-
ter can be seen on the surface of the reflected intraperitoneal
Dissection in the Femoral Triangle
Divide the soft tissue along the adductor longus muscle.

Divide the muscular fascia if planning to resect fascia
together. Find the great saphenous vein, and ligate and
divide (or dissect entire length to preserve by ligating all
the other tributaries from saphenofemoral junction if pres-
ervation is planned). Similarly divide the soft tissue along
the sartorius muscle. Divide the muscular fascia if planning
to resect fascia together. Divide the soft tissue caudal direc-
tion until the sartorius and adductor muscle meet in the
apex of the femoral triangle. Find the femoral artery at the
apex of the femoral triangle. If the muscular fascia is taken,
then divide the fascia again closer to the vessels to gain
access to the surface of the vessels. Find the femoral vein
posteromedial to the artery. Dissect off all the soft tissue
anterior to the muscles and vessels toward the inguinal liga-
ment. Ligate a few small arterial branches from the femoral
artery to the specimen. Identify the saphenofemoral junc-
tion and divide the vein between vascular clamps, and
suture-ligate or oversew the stump on the femoral vein (or,
alternatively, dissect all the soft tissue from the sapheno-
femoral junction and preserve the greater saphenous vein).
Identify the femoral nerve and its branches lateral to the
femoral artery. Dissect soft tissue off of the nerve. Medially
dissect soft tissue off of femoral canal and mark the highest
node (Cloquet’s node) with a suture.
Fig. 125.3
982 H. Hoshi
nal ligament to the bifurcation of internal and external iliac

vessels (Fig. 125.6). Starting at the bifurcation, dissect the
tissue medial to the external iliac vein. Identify the obturator
neurovascular bundle in this tissue and preserve it. Remove
all the soft tissue along the obturator neurovascular bundle to
the obturator foramen and surface of the internal obturator
muscle (Fig. 125.7). Be particularly careful in dissecting
Fig. 125.4
Fig. 125.6
Fig. 125.5
contents. Mobilize the bladder from pubic bone and apply a

mechanical retractor to retract entire abdominal and pelvic
contents from lateral wall of the pelvis.
Start dissection lateral to the external iliac artery. Preserve
lateral femoral cutaneous nerve seen lateral to the external
iliac artery. Make sure to remove all the soft tissue covering
entire length of external iliac artery and vein from the ingui-
Fig. 125.7
125 Superficial and Deep Groin (Femoroinguinal and Pelvic) Dissection 983
around and near the internal iliac vein. Bleeding can be mas-
sive and difficult to control.
Once the specimen is removed, obtain careful hemostasis.
No drain is necessary in pelvis. Allow intraabdominal con-
tents return to the original position and close transversalis
fascia, transverse muscle, and internal oblique muscle with
running 2–0 absorbable suture. Then, close external oblique
muscle with running 2–0 PDS suture. Close the defect in
femoral canal approximating inguinal ligament to Cooper’s
ligament with 2–0 proline.
Sartorius Muscular Flap
Due to the relatively high incidence of the wound complica-

tion of the groin dissection, we routinely create a sartorius
muscle flap to cover the femoral vessels to prevent exposure
of the vessels and subsequent blow out. This step is optional.
Divide the investing fascia over the sartorius muscle. In the
proximal portion, superficial circumflex iliac artery crosses
the anterior surface of the sartorius fascia. Ligate and divide
this prior to division of the fascia. Encircle the proximal por-
tion of the muscle and divide the origin of the muscle from
anterior superior iliac spine. Free the proximal portion of the
muscle from the lateral and posterior attachment just enough
to transpose the muscle to cover the femoral vessels. Due to
the segmental blood supply to the sartorius muscle, more
Fig. 125.8
than necessary mobilization creates ischemia in the muscular
flap. Suture the proximal end to the inguinal ligament with
3–0 PDS horizontal mattress sutures. Approximate medial • Keep the patient at bed rest with bathroom privilege only,
border of the muscle to the pectineus muscle with a couple of with the leg elevated for the first day. Thereafter allow
simple sutures (Fig. 125.8). ambulation 30 minutes at a time for 1 week. After each
30-minute ambulation session, the patient should go back
to couch to elevate the leg for at least 30 minutes.
Skin Closure and Drainage
Ensure hemostasis in the dissection field. Place two closed Complications

suction drains through separate stab wound in distal thigh,
one along the lateral and the other along the medial portion • Wound infection and dehiscence
of the dissection field. Close the superficial femoral fascia/ • Fluid collection under the flap
Scarpa’s fascia, if available, with running 2–0 absorbable • Femoral nerve injury
suture. Close deep dermal layer with 3–0 Vicryl interrupted • Deep vein thrombosis
buried sutures and epidermis with 4–0 Monocryl running • Lymphedema
intracuticular suture. Apply skin glue to seal the incision. • Femoral arterial exposure and blowout
Postoperative Care
Further Reading
• Discontinue IV antibiotics within 24 hours.
• Maintain drains until output is less than 30 cc per day. Chu CK, Delman KA, Carlson GW, Hestley AC, Murray
DR. Inguinopelvic lymphadenectomy following positive inguinal
• Apply an elastic bandage, tighter in lower leg and lighter sentinel lymph node biopsy in melanoma: true frequency of syn-
in thigh, starting in the operating room, and maintain this chronous pelvic metastases. Ann Surg Oncol. 2011;18(12):3309–15.
until 1 week after the operation.
984 H. Hoshi
Chu CK, Zager JS, Marzban SS, Gimbel MI, Murray DR, Hestley AC, in melanoma patients - a historical cohort study and risk factor anal-
Messina JL, Sondak VK, Carlson GW, Delman KA. Routine biopsy ysis. Eur J Surg Oncol. 2014;40(10):1284–90.
of Cloquet's node is of limited value in sentinel node positive mela- Zdzienicki M, Rutkowski P, Nowecki ZI, et al. The analysis of the
noma patients. J Surg Oncol. 2010;102(4):315–20. outcomes and factors related to iliac-obturator involvement in
Rossi CR, Mozzillo N, Maurichi A, et al. Number of excised lymph cutaneous melanoma patients after lymph node dissection due to
nodes as a quality assurance measure for lymphadenectomy in mel- positive sentinel lymph node biopsy or clinically detected inguinal
anoma. JAMA Surg. 2014;149(7):700–6. metastases. Eur J Surg Oncol. 2013;39(3):304–10.
Stuiver MM, Westerduin E, ter Meulen S, Vincent AD, Nieweg OE,
Wouters MW. Surgical wound complications after groin dissection
Part XII
Thyroid, Parathyroid, and Adrenal, Parotidectomy,
and Tracheal Procedures
Sonia L. Sugg
Concepts in Thyroid, Parathyroid,
and Adrenal Surgery 126
Janice L. Pasieka
Thyroid more than a 3% risk of neck hematoma. The extent of surgi-

cal resection is dependent on the disease. The minimal oper-
Thyroid surgery was rarely performed in the mid-1800s, in ation for thyroid disease should be a lobectomy including the
part because the mortality rate exceeded 50%. In 1866, Samuel pyramidal lobe and the isthmus as there is no role for enucle-
Gross a well-respected American surgeon wrote: “if a surgeon ating a thyroid nodule.
should be so adventurous, or foolhardy, just to undertake thy-
roidectomy, I shall not envy him… Every step he takes will be
in environed with difficulty, every stroke of his knife will be full Benign Thyroid Disease
by a torrent of blood, and lucky will it be for him if his victim
lives long enough to enable him to finish his horrid butchery… Hyperthyroidism
No honest and sensible surgeon it seems to me, would ever Overproduction of thyroid hormone results in thyrotoxicosis.
engage in it.” It took pioneer surgeons like Theodor Kocher to Depending on the severity of the thyrotoxicosis, symptoms
significantly decrease the operative mortality from this opera- include nervousness, palpitations, fatigue, weight lost, heat
tion utilizing meticulous dissection, minimizing blood lost and intolerance, and sleep disruption. The most common causes of
protecting the parathyroid glands and the recurrent laryngeal endogenous hyperthyroidism are Graves’ disease, toxic multi-
nerve (RLN) by leaving some thyroid tissue behind. By the nodular goiter (TMG), toxic follicular adenoma, and thyroid-
time Kocher retired in 1912, he had decreased the operative itis. Endogenous hyperthyroidism can be treated medically,
mortality from a thyroidectomy to <2%, teaching others to with radioactive iodine, or surgically, depending on the cause.
safely perform this operation worldwide. Graves’ disease is the most common cause of endogenous
Thyroid surgery is performed for both benign and malig- hyperthyroidism, accounting for 75% of thyrotoxic patients.
nant diseases. The major risk of this operation includes Immunoglobulin G autoantibodies (thyroid-stimulating
injury to the parathyroid glands and the recurrent laryngeal immunoglobulin (TSI)) produced by B lymphocytes bind
nerve (RLN), and a life-threatening postoperative neck and activate the TSH receptor on the follicular cell causing a
hematoma. Although the standard “Kocher” cervical incision release of T3 and T4. Approximately 50% of Graves’ patients
is the most common approach, endoscopic, robotic, and will develop ophthalmopathy characterized by proptosis and
remote access techniques are increasingly performed world- periorbital edema. The diagnosis of Grave’s disease is con-
wide. Adjuncts such as RLN monitoring, energy devices for firmed by the demonstration of a suppressed TSH, elevated
vessel ligation, and hemostatic agents for hemostasis are serum T3 and T4 levels, and the presence of TSI. The thyroid
commonly utilized. Regardless of the approach, thyroid sur- gland is diffusely enlarged, and on I123 uptake, scan will dem-
gery should carry a risk of RLN injury no greater than 2%, onstrate diffuse uptake as high as 80% in 24 hours.
and permanent hypoparathyroidism less than 2% and no The initial treatment of Graves’ disease is directed at con-
trolling the symptoms of hyperthyroidism and blocking the
production of thyroid hormone. This is achieved with the
J. L. Pasieka (*)
antithyroid medication such as methimazole or propylthio-
Department of Surgery, Sections General Surgery and Surgical
Oncology, Faculty of Medicine, Cumming School of Medicine, uracil. Biochemical euthyroidism is usually achieved within
University of Calgary, Calgary, AB, Canada 6–8 weeks. In addition, the utilization of beta-blocking
Foothills Medical Center, Calgary, AB, Canada agents on initial presentation can quickly reduce the beta-
e-mail: hisakazu-hoshi@uiowa.edu adrenergic symptoms. Complete long-lasting remission fol-

https://doi.org/10.1007/978-3-030-81415-1_126
988 J. L. Pasieka
lowing the administration of antithyroid medication can RAI. Medical management of AAT involves the discontinua-
occur in up to 30% of patients. However, 70% of patients tion of amiodarone (if possible) and the utilization of anti-
will require a more permeant solution to their hyperthyroid- thyroid medication. Unfortunately, because of the long
ism. Radioiodine therapy (RAI) is the most frequently uti- half-life of amiodarone (107 days), it can take several months
lized treatment in North America. RAI will take several before a clinical effect is achieved. Steroids have been shown
months to have an effect and may require multiple treat- to be beneficial in AAT type 2. Many of these patients cannot
ments. Contraindications to RAI include pregnancy, nursing tolerate the stoppage of the amiodarone, and also require a
mothers, significant ophthalmopathy, and large goitres. prompt resolution of their thyrotoxic state. Total thyroidec-
Surgical management of Graves’ disease is becoming tomy has been shown to be an effective treatment of AAT,
more common not just for medical and RAI refractory despite the significant perioperative comorbidities these
patients. The advantages of a thyroidectomy include rapid patients have.
onset of effect and a low recurrence rate. Preoperatively, the A toxic follicular adenoma is benign discrete nodule that
patient should be rendered clinically and biochemically secretes thyroid hormone independent of TSH control. A
euthyroid (normalization of T3 and T4) with antithyroid suppressed TSH and a thyroid scan demonstrating a hot
medication. The addition of Lugol’s solution 5 days before autonomous nodule with suppression of the reminding thy-
the operation helps decrease the vascularity of the gland and roid gland confirm the diagnosis. These lesions are rarely
the risk of developing thyroid storm perioperatively. The malignant (<1%), and fine-needle aspiration (FNA) is not
operation of choice is a near-total thyroidectomy. Some sur- recommended as it may be misleading (often demonstrating
geons have advocated for a bilateral subtotal thyroidectomy cellular atypia). The natural history of these lesions follows
to avoid the need for thyroid hormone replacement. This the “rule of thirds.” One-third of these nodules will involute,
operation, however, has a greater risk of surgical failure and one-third will demonstrate no change in size or hormone
a higher incidence of recurrence than a total thyroidectomy. production and one-third will progress. Although RAI can be
A Dunhill procedure (total lobectomy and contralateral sub- utilized in these patients, thyroid lobectomy results in com-
total thyroidectomy) is a reasonable alternative to avoid per- plete cure and rarely do these patients require thyroid hor-
meant hypoparathyroidism while minimizing the risk of mone supplementation postoperatively.
recurrence.
Toxic multinodular goiter (TMG) is most prevalent in
areas of endemic goiter and iodine deficiency. Iodine defi- Multinodular Goiter
ciency results in low thyroid hormone production leading to
an increase in TSH. This chronic TSH stimulus leads to nod- Multinodular goiter (MNG) is an enlarged thyroid gland
ular formation and eventually, the development of autono- containing multiple colloid and hyperplastic nodules. MNG
mously secreting nodules. These patients tend to be older, is one of the most common endocrine disorders worldwide
and many patients present insidiously with cardiac manifes- affecting up to 600 million people. The etiology appears to
tations such as heart failure, atrial fibrillation, tachycardia, be multifactorial. Causes include iodine deficiency, goitro-
and insomnia. In contrast to Graves’ disease, the I123 uptake gens (substances that induce thyroid enlargement), and
scan will demonstrate patchy uptake in a background of a genetic predisposition. Surgical indications for multinodu-
multinodular goiter. RAI can be utilized in elderly, poor sur- lar goiter are as follows: 1) suspicious or confirmed thyroid
gical candidates; however, unlike Graves’s disease, TMG is cancer, 2) toxic multinodular goiter (as discussed above),
relatively RAI refractory and as such, commonly requires 3) compressive symptoms, 4) documented growth, and 5) a
surgical intervention. Ideally, the patient should be blocked significant retrosternal component. Signs and symptoms of
and rendered euthyroid preoperatively. compression of the trachea, esophagus, the vascular struc-
With the increased use of amiodarone for refractory ven- tures, or the RLN may occur; and these should all be
tricular and supraventricular arrhythmias, amiodarone- included in the initial assessment. A history looking for dif-
associated thyrotoxicosis (AAT) has become more prevalent ficulty in lying flat, disrupted sleep, and an audible stridor
worldwide. The incidence of AAT has been reported between all suggest tracheal compression. The physical finding of a
2 and 18% of patients on this drug. There are two proposed positive Pemberton sign (venous congestion of the face
mechanisms for AAT. Type 1 is an iodine-induced phenom- when both arms are raised over the head) is used to detect
enon caused by the excess iodine load from amiodarone in compression at the thoracic inlet by the goiter. Although
patients with a preexisting goiter. Type 2 AAT is due to the exceedingly rare, a direct laryngoscopy should be done to
direct toxic effects of the drug on the thyroid, causing fol- assess function of the RLN. Cross-sectional imaging has
licular destruction and a chemically induced thyroiditis. facilitated the assessment of tracheal compression,
Patients with AAT demonstrate very poor uptake on radioac- retrosternal extension not adequately assessed with physi-
tive iodine scans, thereby precluding treatment with cal exam, and the documentation of significant growth.
126 Concepts in Thyroid, Parathyroid, and Adrenal Surgery 989
When indicated, total thyroidectomy has become the opera- respectively. As such, surgical intervention is recommended.
tion of choice for MNG. Benign lesions, Bethesda 2, have only a 0–3% chance of malig-
nancy and, therefore, can be safely observed.
It is the Bethesda 3, atypia or follicular lesion of undeter-
Thyroid Carcinoma mined significance (AUS or FLUS), and Bethesda 4, the fol-
licular neoplasm, that continue to be a challenge for both the
Thyroid cancer is the ninth most commonly diagnosed can- surgeon and the patient. The estimated risk of cancer for an
cer and comprised of approximately 4% of all new cancers in AUS/FLUS lesion is 5–15% and 15–30% for a Bethesda 4
North America. The majority (90%) are well-differentiated lesion. As a general rule, a repeat FNA is recommended for
thyroid cancer (WDTC) derived from the follicular epithelial AUS/FLUS lesions as a more definite diagnosis occurs >70%
cells. The histological subtypes of WDTC include papillary of the time. For the Bethesda 4 lesion, a diagnostic lobec-
(80%), follicular (5–8%), and Hurthle or oncocytic tomy is recommended.
carcinomas (5%). Exposure to ionizing radiation, particu- More recently, the development of molecular testing has
larly in the pediatric population, and high iodine intake have focused on these two indeterminate groups in the hopes of
each been associated with an increased risk of developing avoiding unnecessary surgery and decreasing the need for
WDTC. Although most WDTC are sporadic, familial forms completion thyroidectomy. Molecular testing on thyroid
associated with familial adenomatous polyposis, Carney’s lesions can be categorized into two groups, a “rule out” test
complex, and Cowden’s syndrome are well recognized. and a “rule in” test. The ideal “rule out” test would have a
Medullary thyroid cancer (MTC) (5%) arises from the negative predictive value (NPV) similar to the Bethesda 2 cat-
parafollicular C cells and is both clinically and genetically egory (3%) and a “rule in” test would carry a positive predic-
distinct from WDTC. Most MTC are caused by an activating tive value similar to Bethesda 6 (98%). A 167 gene expression
mutation in the RET protooncogene, and 25% carry a germ- classifier has been proposed as a “rule out” test due to its rela-
line mutation. tively high NPV of 93%. It, therefore, can be utilized in those
Anaplastic thyroid cancer is exceedingly rare and com- patients with AUS/FLUS lesions in whom non-surgical man-
prises of <1% of all thyroid cancers. agement or active surveillance is considered. Mutations in
BRAF, RET/PTC, or RAS have been seen in over 70% of papil-
lary thyroid cancer, and PAX8/PPAR gamma mutations are
Ultrasound, Fine-Needle Aspiration, found in 80% of follicular cancers. Identifying point muta-
and Molecular Testing tions, deletions, and gene re-arrangements of these genes with
a next- generation sequencing panel is now commercially
Over the last two decades, the incidence of WDTC has been available. Proponents of this molecular test have illustrated its
increasing at a rate of 6% per year. This increase is in part related utilization as a “rule in” test with a sensitivity of 90% in pre-
to the increase in detection of small subclinical thyroid cancers dicting cancer in the cytological follicular neoplasm Bethesda
by widespread use of neck ultrasounds (US) and fine-needle 4. The Pittsburg group utilizes this test to rule in malignancy in
aspirations (FNA). Since most thyroid nodules are benign, strat- a follicular neoplasm, allowing the surgeon to go directly to a
ification with ultrasound and, ultimately, FNA has significantly total thyroidectomy instead of a diagnostic lobectomy at the
reduced the need for thyroid surgery. Standardized thyroid ultra- initial procedure. However, with the current ATA guidelines
sound reporting, developed in 2015, by the American College of suggesting that some low-risk WDTC no longer require a total
Radiology (ACR) has become the expectation of clinicians in thyroidectomy, it is unclear how gene panel molecular testing
their diagnostic workup. The American Thyroid Association will be utilized in the future. The use of molecular testing on
(ATA) recently stratified these sonographic patterns of thyroid indeterminate FNA specimens is involving. Currently molecu-
nodules and their potential risk of malignancy, developing an lar testing of FNAs is utilized to help stratify treatment options
algorithm for ultrasound-directed FNA. Solid, hypoechoic nod- for the patient, either surgical intervention or active surveil-
ules with irregular borders, microcalcifications, taller than lance At the present time, these tests should not replace clini-
wider, and with evidence of extrathyroid extension are highly cal judgment or the clinical findings on physical exam and/or
suspicious features of malignancy and require FNA. In contrast sonographic evaluation.
smooth cystic or spongiform lesions rarely require FNA.
Thyroid FNA cytology should be reported using the diagnostic
categories outlined by the Bethesda reporting system in 2007. Surgical Treatment of Thyroid Cancer
Each of the six diagnostic categories have a calculated risk of
malignancy, allowing for a more informed and educated discus- Well-Differentiated Thyroid Cancer
sion with the patient regarding the need for thyroid surgery. The extent of surgery for WDTC is currently under consider-
Bethesda 5 (suspicious for malignancy) or Bethesda 6 (malig- able debate with the publication of the 2015 ATA guidelines.
nant) have an estimated cancer risk of 60–75% and 97–99% In the past, most centers performed a total thyroidectomy for
990 J. L. Pasieka
WDTC ≥1 cm, as it allowed for the ease of postoperative cessfully following MicroPTC with only 8% demonstrating
surveillance with thyroglobulin and the administration of progression at long-term follow-up. Although MicroPTC can
RAI when deemed necessary. Recently, retrospective evi- metastasize, most have an indolent biological behavior and
dence from large institutional databases have demonstrated most surgeons agree that a unilateral lobectomy, if undertaken,
that, in low-risk WDTC (solitary lesions <4 cm with no is all that is required when confined to the thyroid.
extrathyroidal extension or lymph node involvement), the
extent of the initial operation had little effect on disease- Medullary Thyroid Cancer
specific survival. In addition, it appears that salvage surgery Most MTC are sporadic (75%) presenting with a solitary
is effective in the few patients who do reoccur following thy- lesion, while hereditary MTC are usually bilateral and multi-
roid lobectomy alone. For these reasons, the 2015 ATA centric. Involvement of both the central and lateral nodal
guidelines have recommended a thyroid lobectomy in compartments is common in both sporadic and hereditary
low-
risk WDTC. Completion thyroidectomy is recom- MTC (50–80%). Cytopathology can usually distinguish
mended in those patients who on final pathology are upstaged MTC from WDTC. Most of these cancers secrete calcitonin
to an intermediate- or high-risk category. For all WDTC and CEA, although they can also secrete vasoactive peptide
≥4 cm, total thyroidectomy remains the treatment of choice. and ACTH. All patients diagnosed with MTC should undergo
It is however, too early to evaluate what the impact of per- genetic testing. Multiple endocrine neoplasia (MEN) types
forming a lesser operation will have on the long-term sur- IIa and IIb have other associated tumors that need to be
vival of these patients. assessed prior to surgical intervention on the thyroid.
The extent of lymph node dissection in the clinical nega- Screening for a pheochromocytoma and hyperparathyroid-
tive patient has also undergone considerable debate. Regional ism is essential as the adrenal disease should always be
microscopic lymph node disease is found in approximately treated prior to the MTC. Familial MTC (FMTC) is a heredi-
50% of PTC patients. The ability to assess level VI disease tary form of MTC that is not associated with the other endo-
with US or by inspection had proven to be inaccurate. This crine neoplasms of MEN II. Specific codon mutations of the
led many surgeons to perform prophylactic central lymph RET gene have identified the particular phenotype of FMTC
node dissections (pCND) without evidence that it changed versus MEN IIa and MEN IIb. The ATA has developed a
survival. Prophylactic CND did, however, upstage 30–50% stratification system correlating genotype with the risk of
of patients, likely resulting in a greater utilization of RAI aggressiveness of the MTC. This has helped define when to
therapy. The jury is still out as to the benefit of pCND in low- initiate screening of the at-risk patients and when to perform
risk patients. It may be beneficial in T3 or T4 tumors to help prophylactic thyroidectomy to avoid the development of
guide postoperative management. However, there is an MTC.
increased risk of injury to the RLN and parathyroids with Serum calcitonin and CEA levels should be done preop-
CND. Therapeutic compartmental neck dissections should eratively. Lymph node mapping with neck US and/or cross-
be done in patients with clinically proven metastatic disease sectional imaging of the neck and mediastinum is required.
for local/regional control. Lateral lymph node mapping with Additional metastatic workup for distant disease should be
US should be done to aid in the preoperative planning. included in patients with lymph node disease or calcitonin
Follicular WDTC rarely spreads via the lymphatics and as levels >400 pg/ml. The appropriate surgical management of
such regional nodal disease is found in only 5% of patients. MTC includes a total thyroidectomy and bilateral central
Small, encapsulated follicular carcinomas can be adequately neck dissection. Lateral neck dissection should be included
treated with a lobectomy. However, total thyroidectomy when clinically concerning lateral nodal disease is detected
allows for the assessment of occult distant metastatic disease or in patients with calcitonin levels >400 pg/ml.
with RAI and is advocated by many for the treatment of fol-
licular carcinoma. In contrast, Hurthle cell carcinoma can
spread to both the lymph nodes (30%) and hematogenously. Parathyroid
Preoperative lymph node assessment should be done in all
Hurthle cell carcinomas and a therapeutic compartmental Calcium is essential for a variety of physiological functions,
neck dissection included with the total thyroidectomy in including cellular signaling, muscle contraction, nerve con-
those with suspicious nodal disease. duction, and skeletal maintenance. Parathyroid hormone
Papillary thyroid cancer less than 1 cm in size (MicroPTC) (PTH) is the key hormone responsible for calcium homeosta-
is becoming a growing health-care problem for both patients sis. PTH is produced by the parathyroid glands in response to
and clinicians. With the increased utilization of head and neck a low ionized serum calcium. This 84 amino acid peptide has
US, MicroPTC are incidentally discovered with increasing a very short half-life (2–4 minutes) allowing for minute-by-
frequency. The concern as to whether all these lesions require minute regulation of serum calcium. PTH stimulates calcium
surgical removal has been raised. The Japanese have been suc- reabsorption in the distal nephron of the kidney, causes reab-
sorption of bone, and indirectly increases the absorption of HPT. Multiple endocrine neoplasia type I and type IIa,
calcium from the gastrointestinal tract via vitamin D. hyperparathyroidism-jaw tumor syndrome, and familial iso-
Hyperparathyroidism (HPT) is an inappropriate production lated HPT comprise the familial forms of PHPT. Hereditary
of PTH from hyperfunctioning parathyroid gland(s). There HPT syndromes are more likely due to multigland disease
are three types of hyperparathyroidism. Primary hyperpara- and are associated with additional endocrine and nonendo-
thyroidism (PHPT) is defined as an inappropriate autono- crine tumors. It is, therefore, important to obtain a family
mous production of PTH from a parathyroid adenoma history and consideration for genetic screening in young
(80–85%), diffuse parathyroid hyperplasia, or multiple ade- patients preoperatively.
nomas (15–20%), or parathyroid carcinoma (1%). Secondary Once the diagnosis is established, assessment of end-
hyperparathyroidism (SHPT) is an adaptive response of the organ disease is sought. Bone mineral density (BMD), an
parathyroid glands to chronic hypocalcemia and/or hyper- ultrasound of the kidney looking for occult kidney stones,
phosphatemia. Chronic renal failure is the most common 24-hour urinary calcium, and a creatinine clearance com-
cause of secondary HPT; however, other causes such as mal- plete the assessment. Preoperative imaging is not diagnostic
absorption syndromes, vitamin D deficiency, chronic lithium and should only be utilized for surgical planning. The indica-
therapy, liver disease, and juvenile rickets also result in tions for surgery include all symptomatic patients, patients
chronically low ionized calcium levels. In tertiary hyperpara- <50 years of age, those with t-scores ≥ −2.5 at any site on
thyroidism (THPT), one or more parathyroid glands function BMD, or documented fragility fracture, nephrolithiasis, and
autonomously and, thus, inappropriately secrete PTH. It high urinary calcium. Most patients with the diagnosis of
typically occurs after prolonged SHPT, despite the correc- PHPT should have a surgical assessment to discuss the risk
tion of the underlying cause of the low ionized calcium state versus benefit of a parathyroidectomy regardless of whether
such as a renal transplant. Each of these conditions is consid- they meet the guideline criteria outlined above.
ered in greater detail in the sections which follow. Preoperative imaging is recommended in all surgical can-
didates as it can help focus on the operation, provides insight
into the possibility of the disease being multigland or ecto-
Primary Hyperparathyroidism pic, and allows for assessment of concomitant thyroid nod-
ules prior to surgical exploration. Cervical ultrasound (US),
Primary HPT is the third most common endocrine disorder, technetium-99 m sestamibi scan (MIBI), and 4D-CT scans
with a prevalence of 1% in the adult population. It occurs are the most commonly utilized modalities. Single-photon
more commonly in women with the incidence increasing emission computed tomography (SPECT) MIBI has a dis-
drastically after the age of 55. Approximately 95% of all tinct advantage over planar imaging as it allows for more
cases of PHPT are sporadic. When first described in the late anatomical detail on the functional scan. Unfortunately,
1920s, the clinical manifestations of this disease were the MIBI scans are poor at distinguishing single- from multi-
result of the end-organ effects from prolonged untreated gland disease and ultrasounds are operator dependent, dem-
HPT such as osteitis fibrosis cystica, nephrolithiasis, and sig- onstrating that positive imaging is no substitute for an
nificant myopathies. Today these clinical manifestations are experienced parathyroid surgeon. Nonlocalizing MIBI scans
rarely seen with only 5% of patients presenting with osteitis can be seen in up to 40% of patients with PHPT and should
fibrosis cystica and 15–20% with nephrolithiasis. Most not be a deterrent for parathyroid exploration by an experi-
patients are diagnosed on routine laboratory evaluation dem- enced surgeon. The sensitivity and positive predictive value
onstrating an elevated serum calcium. Many symptoms asso- in patients with a solitary adenoma have been reported to be
ciated with PHPT are vague and nonspecific including 76% and 93% for US, 79% and 91% for MIBI, and 89% and
weakness, difficulty in concentrating, polyuria, and irritabil- 94% for 4D-CT.
ity. The vague nature of these symptoms has made it difficult
to quantify preoperatively, leading some to believe that the
majority of patients are asymptomatic. There are, however, Secondary and Tertiary Hyperparathyroidism
many prospective studies that have documented an improve-
ment in these vague nonspecific symptoms following suc- Secondary HPT is an adaptive response of the parathyroid
cessful parathyroidectomy, illustrating that these symptoms glands to chronic hypocalcemia and/or hyperphosphatemia,
are true manifestations of the disease. most commonly seen in chronic renal failure. As the renal
The diagnosis of HPT is biochemical. An elevated serum failure progresses, so does the SHPT moving from an adap-
calcium level, low-normal serum phosphate, with an inap- tive process to a pathological one. Medical management of
propriately elevated PTH level in the absence of hypocaluria dialysis patients directed at lowering the phosphate levels
confirms the diagnosis. Serum Vitamin D 25(OH) and creati- with phosphate binders, or calcium and vitamin D, or with
nine levels should also be included to rule out secondary calcimimetic drugs has delayed the need for surgical inter-
992 J. L. Pasieka
vention in these patients. Operative indications for progres- were not met. Today, even with preoperative imaging, up to
sive SHPT include: failure of medical management to control 35% of patients will still require conversion to the contralat-
hypercalcemia and/or hyperphosphatemia, PTH > 500 pg/ml, eral side due to inability to find the ipsilateral normal gland,
calciphylaxis, progressive myopathy, and a decreasing BMD. false-positive imaging, or multigland disease was found.
There is also a growing body of literature that recommends Many surgeons use this approach with the additional adjunct
surgery for severe progressive SHPT prior to renal transplant of iPTH to direct when a bilateral exploration due to asym-
to avoid significant hypercalcemia postoperatively. metrical hyperplasia or double adenoma is warranted; thus,
Long-standing SHPT causes parathyroid gland hyperpla- minimizing the exploration while achieving >97% success
sia, and failure of hyperplastic glands to involute following rate.
renal transplant leads to autonomous function. Tertiary HPT The third surgical approach is an imaged-directed or min-
is typically diagnosed 6 months following a renal transplant imally invasive parathyroidectomy. This is a focused explo-
and has a similar biochemical profile to that of PHPT. The ration, visualizing and removing only the parathyroid
incidence of THPT following transplantation is approxi- abnormality seen on preoperative imaging. To avoid failure
mately 10% (5–30%). Indications for surgery include persis- resulting from undiagnosed multigland disease, many sur-
tent symptomatic hypercalcemia, declining graft function, geons utilize iPTH. Although recently there have been con-
nephrocalcinosis, pancreatitis, pathologic bone fracture, pru- cerns raised about the longevity of this operation compared
ritus, musculoskeletal pains, or markedly increased PTH lev- to the bilateral procedure, it does appear to be successful in
els. In contrast to progressive SHPT, where all four glands correcting the hypercalcemia in over 95% of patients for at
are involved, recent literature suggests that approximately least 8–10 years. This procedure does rely on the accuracy of
20% of posttransplant THPT patients will have involuted preoperative imaging and is appropriate in approximately
some of their parathyroid glands, allowing for a limited 60% of patients with sporadic PHPT. Minimally invasive
resection following bilateral neck exploration. parathyroidectomy can be performed in a variety of ways;
from a focused open approach under regional block to an
endoscopic or remote access exploration.
Parathyroidectomy
There are three operations for HPT: bilateral neck explora- Adrenal
tion (BNE), unilateral exploration, and a focused, imaged-
directed procedure. Each procedure has advantages and The layers of the adrenal gland, the cortex and the medulla,
disadvantages, and the surgeon must appropriately select the have distinct embryological development explaining the
best operation for each patient. Bilateral neck exploration is diverse physiological functions of these paired organs. The
the gold standard operation. All four parathyroid glands are outer cortex derived from the mesoderm has three distinct
visualized and the abnormal one(s) removed. This operation layers: the zona glomerulosa, fasciculata, and reticularis.
does not require preoperative imaging, however, most sur- These layers are responsible for the production of aldoste-
geons would perform a cervical ultrasound; or does BNE rone, cortisol, and sex steroids, respectively. The inner
require intraoperative PTH (iPTH) to tell the surgeon if he/ medulla develops from neural crest cells from the spinal gan-
she is dealing with single- or multigland disease as the mor- glia. Ectopic adrenal tissue can be found along the path of
phological appearance of the glands in experienced hands embryologic migration; in the gonads, within or adjacent to
usually is adequate to achieve a > 98% success rate. BNE is the paraaortic sympathetic chain, or at the aortic
indicated in patients known or suspected to have multigland bifurcation.
disease (familial HPT, SHPT, and THTP), failure of iPTH to Primary tumors arising from the adrenal gland should be
fall during a more limited approach, and in many cases of classified as either benign or malignant and screened for
nonlocalizing preoperative imaging. overt function. Screening for function includes a detailed
Unilateral exploration is a morphological assessment of history and physical exam, aldosterone:renin ratio in hyper-
both parathyroid glands on the same side. This procedure, tensive patients, either a 24-hour urinary free cortisol or a
first described in 1976, was developed long before preopera- 1 mg overnight dexamethasone suppression test, and a serum
tive imaging was available. Given the fact is that >80% of DHEA-S if androgen function is suspected. To rule out cat-
patients with PHPT will have a solitary adenoma, if one echolamine excess, either 24-hour urinary metanephrines or
abnormal and one normal parathyroid glands were found on plasma free metanephrines should be done. As a rule, all
the first side explored, then the operation was terminated as functioning adrenal tumors should be removed. Small,
diffuse hyperplasia was ruled out. This approach in experi- benign nonfunctioning adrenal lesions can be safely
enced hands resulted in a 95% cure rate, albeit with a 50% observed, whereas indeterminate lesions regardless of size
conversion to the contralateral side when unilateral criteria may require resection for diagnosis. Larger lesions (> 6 cm)
have an increased risk of being adrenal cortical carcinomas and 4 cm need to be assessed by a multidisciplinary team for
(ACC) and should be assessed for surgical resection. The consideration of resection, further imaging with an alterna-
adrenal gland is a common site for metastases from such tive modality or close observation. Recent evidence suggests
malignancies as renal cell, breast, and melanoma. These sec- that the utilization of FDG-PET scans can help in this sce-
ondary adrenal lesions are found in 5% (0–18%) of series nario as positive uptake likely reflects a malignant process.
that include all patients with an adrenal mass. In highly
selected patients, resection of an isolated adrenal metastases
maybe indicated. Primary Aldosteronism
Primary aldosteronism (PA) is the most common cause of

Adrenal Incidentalomas secondary hypertension. The prevalence of this disease in the
hypertensive population is approximately 10%, and 25% in
An adrenal incidentaloma is an asymptomatic adrenal mass those patients with refractory hypertension. PA is character-
detected on imaging performed for nonadrenal indications. ized by autonomous secretion of aldosterone resulting in the
The widespread use of cross-sectional imaging has resulted suppression of plasma renin. Historically, hypokalemia was
in the increased discovery of asymptomatic adrenal lesions utilized as a screening tool for the diagnosis of PA. It is now
in medical practice. From autopsy series, the prevalence of recognized that less than 38% of patients with PA will pres-
clinically inapparent adrenal masses ranges from 1 to 9% ent with hypokalemia. The diagnostic screening modality
(mean of 2%). This prevalence increases with age, as adrenal utilized today is an aldosterone:plasma renin activity greater
lesions are rarely seen in patients under the age of 20, yet than 30. Several authors recommend a confirmatory salt-
approaches 10% in those over the age of 70. Most adrenal loading suppression test to be done prior to anatomical cross-
incidentalomas are nonfunctioning (75%). From mostly sur- sectional imaging. PA can be caused by a unilateral
gical series, 12% of these lesions will ultimately prove to be functioning adenoma (Conn’s syndrome) or by adrenal
producing cortisol, 3% aldosterone, and 7% will be hyperplasia (either bilateral (BAH) or, rarely, unilateral).
catecholamine-secreting pheochromocytomas. Older series stated that only 33% of PA patients have a uni-
Approximately, 8% of incidentally found lesions will be lateral adenoma, while recent series from hypertensive cen-
ACC. In patients with a known malignancy, the likelihood of ters that routinely perform adrenal vein sampling (AVS) have
the incidentaloma being a metastatic lesion is approximately demonstrated that 60% of PA patients have a unilateral
25–36%, whereas the prevalence is less than 0.5% in patients source for their disease, suggesting a significant underdiag-
with no previous history of cancer. In a recent review, how- nosis rate of Conn’s syndrome.
ever, Cawood suggested that the prevalence of functioning Identifying appropriate candidates for surgical interven-
and malignant lesions has likely been overestimated given tion can be challenging. The mean size of an aldosteronoma
most of the reported series in the literature are either surgi- is estimated to be 1.7 cm with 17% of adenomas less than
cal- or oncology-based series. 1 cm. As such a CT scan may not detect these small lesions.
The diagnostic workup of an adrenal incidentaloma In addition, the incidence of nonfunctioning adenomas
includes functional screening and an assessment on cross- increases with age. This has led many authors to recommend
sectional imaging. Adrenal myelolipomas, adrenal hemor- the routine use of AVS in all surgical candidates with
rhage, and simple adrenal cysts have classic characteristic PA. Comparison of cross-sectional imaging to AVS has dem-
findings on computed tomography (CT) or magnetic reso- onstrated that 20% of patients would not be offered surgical
nate imaging (MRI). Benign adrenal cortical adenomas con- correction of unilateral disease based on CT findings alone.
tain a variable amount of cytoplasmic lipid, which enables In 4% of patients, the CT findings would incorrectly identify
the use of Hounsfield units (HU) on CT or chemical shifts on the side of autonomous aldosterone production, and up to
MRI to characterize these lesions as benign. Nonenhanced 15% of patients, if CT alone was utilized, would have failed
lesions that are <10 HU are benign, as are those lesions that surgical intervention as AVS demonstrated BAH. However,
have a relative washout of contrast of >50% utilizing an AVS is not readily accessible to all surgeons and if done
“adrenal protocol” CT. Dual gradient-echo sequence MRI poorly is of limited value. Bilateral canalization of both adre-
can also characterize the lesion as a benign adenoma if there nal veins is paramount to the procedure and the success rate
is a loss of signal compared to in-phase imaging. Most surgi- in the literature ranges from 60% to 97%.
cal guidelines utilize the cutoff for resection at 4 cm, although BAH should be treated medically, whereas unilateral dis-
the risk of malignancy is only 10%. Large lesions >6 cm ease is best treated with an endoscopic adrenalectomy.
have a higher likelihood of being an ACC (25%) and should Surgical resection for Conn’s syndrome will lead to resolu-
be considered for surgical resection in appropriately selected tion of hypokalemia almost 100% of the time, cure of hyper-
patients. Radiographically intermediate lesions between 2 tension 35–45% of the time, improvement in blood pressure
994 J. L. Pasieka
control or decrease in antihypertensive medication in 50– Most guidelines recommend that all patients presenting
60%, and failure to change the hypertensive state in 5% of with a pheochromocytoma/paraganglioma be genetically
patients. screened for the known susceptible genes. To date, these
include: RET proto-oncogene associated with MEN 2
[RET], von Hippel-Lindau [vHL], type 1 neurofibromato-
Cushing’s Syndrome sis [NF1], and succinate dehydrogenase subunits [SDH –
A, B, C, and D] associated with familial paraganglioma
Endogenous Cushing’s syndrome is a result of overproduc- syndromes, MAX and TMEN127.
tion of cortisol from the adrenal glands. This is further clas- Diagnosis is established with either 24-hour urinary frac-
sified into adrenocorticotropic hormone (ACTH)-dependent tionated metanephrines or plasma free metanephrines.
(80%) and ACTH-independent (20%) Cushing’s syndrome. Urinary metanephrines have a high specificity (93–98%) and
ACTH-dependent Cushing’s syndrome is most commonly reasonable sensitivity (77–90%). Plasma free metanephrines
caused by an anterior pituitary adenoma (Cushing’s disease) when collected appropriately have a higher sensitivity (96–
or rarely from ectopic ACTH production from small-cell 100%) but lower specificity of 85–89%. Surgical resection
lung carcinomas, and neuroendocrine tumors including gas- should be undertaken for all functioning pheochromcytomas
trinomas, pheochromcytomas, and MTC. ACTH-and paragangliomas. Preoperative alpha-blockade and ade-
independent Cushing’s syndrome is caused by unilateral quate volume resuscitation are recommended prior to resec-
adrenal tumors (benign cortical adenomas in 10%), ACC tion to minimize the operative fluctuations in blood pressure.
(8%), or bilateral micro- or macronodular hyperplasia (2%).
Establishing the diagnosis of cortisol excess is the first
step in the diagnostic / treatment algorithm. A 24-hour uri- Surgical Approaches to the Adrenal Gland
nary free cortisol, a 1 mg overnight dexamethasone suppres-
sion test, or a midnight salivary cortisol can be utilized to The advent of endoscopic approaches to the adrenal gland
diagnosis hypercortisolism. Once confirmed, an ACTH mea- has greatly improved the surgical care of these patients.
surement will delineate whether it is ACTH independent or Endoscopic approaches have resulted in earlier mobilization,
not. If ACTH is elevated, then a pituitary MRI should be shorter length of stay, decrease analgesic requirements, and
ordered; and if negative, consideration of an ectopic source fewer postoperative complications compared to open adre-
should be explored. If the ACTH level is suppressed, then nalectomy. The adrenal can be approached either anteriorly
cross-sectional imaging of the adrenal glands is warranted. via a laparoscopic approach, or endoscopically via a poste-
Patients with unilateral adrenal lesions should be considered rior retroperitoneal approach (PRA). The PRA is an ideal
for adrenalectomy. Perioperative coverage with steroids is operation for tumors less than 6 cm or in patients with previ-
required as the contralateral adrenal gland is usually sup- ous abdominal surgery. The anterior laparoscopic adrenalec-
pressed and return of the normal hypothalamic pituitary tomy is a great approach for larger benign adrenal tumors.
adrenal axis can take up to 2 years to resolve. Open adrenalectomy is recommended for ACC or large
tumors (>10 cm) highly suspicious for ACC. Thus, the adre-
nal surgeon must master both open and endoscopic
Pheochromocytoma/Paraganglioma approaches to the adrenal gland and appropriately select the
surgical approach based on the patient and the tumor’s imag-
Pheochromocytoma is a tumor arising from the adrenal ing characteristics.
medulla, whereas a paraganglioma refers to a similar tumor
arising from the extraadrenal sympathetic and parasympa-
thetic ganglia. Pheochromocytomas and paragangliomas Further Reading
arising from the sympathetic ganglia secrete excess cate-
cholamines. Paragangliomos arising from the parasympa- Accardo G, et al. Genetics of medullary thyroid cancer: an overview. Int
J Surg. 2017;41(Suppl 1):S2–6.
thetic chain are usually nonfunctional. These excess Fagin JA, Wells SA. Biologic and clinical perspectives on thyroid can-
catecholamines cause episodic, paroxysmal hypertension, cer. N Engl J Med. 2016;375:1054–67.
headaches, palpations, and diaphoresis. The old “rule of Fassnacht M, et al. Management of adrenal incidentalomas: European
10” (10% are genetic, 10% are malignant, 10% are bilat- Society of Endocrinology Clinical Practice Guideline in collabora-
tion with the European network for the study of adrenal Tumors. Eur
eral, and 10% are found in children) no longer applies. It is J Endocrinol. 2016;175(2):G1–G34.
now estimated that over 25% of these tumors have a germ- Funder JW, et al. The Management of Primary Aldosteronism: case
line mutation; these are associated with far more bilateral detection, diagnosis, and treatment: an Endocrine Society clinical
tumors, and the identification of more tumors in children. practice guideline. J Clin Endocrinol Metab. 2016;101(5):1889–916.
Grant EG, et al. Thyroid ultrasound reporting lexicon: white paper of Pasieka JL. What should we tell our patients? Lifetime guarantee or is it
the ACR thyroid imaging, reporting and data system (TIRADS) 5- to 10- year warranty on a Parathyroidectomy for primary hyper-
committee. J Am Coll Radiol. 2015;12(12 Pt a):1272–9. parathyroidism. World J Surg. 2015;39(8):1928–9.
Haugen BR, et al. American Thyroid Association guidelines on the Rossi GP, et al. An expert consensus statement on use of adrenal vein
Management of Thyroid Nodules and Differentiated Thyroid Cancer sampling for the subtyping of primary Aldosteronism. Hypertension.
Task Force Review and recommendation on the proposed renam- 2014;63:151–60.
ing of encapsulated follicular variant papillary thyroid carcinoma Sahdev A. Recommendations for the management of adrenal inci-
without invasion to noninvasive follicular thyroid neoplasm with dentalomas: what is pertinent for radiologists. Br J Radiol.
papillary-like nuclear features. Thyroid. 2017;27(4):481–3. 2017;90(1072):20160627.
Horvath E, et al. An ultrasonogram reporting system for thyroid nodules Scharpf J, et al. Comprehensive management of recurrent thyroid
stratifying cancer risk for clinical management. J Clin Endocrinol cancer: an American head and neck society consensus statement:
Metab. 2009;94(5):1748–51. AHNS consensus statement. Head Neck. 2016;38(12):1862–9.
Kandil E, et al. Survival implications of cervical lymphadenec- Shindo M, et al. ‘The changing landscape of primary, secondary, and
tomy in patients with medullary thyroid cancer. Ann Surg Oncol. tertiary hyperparathyroidism: highlights from the American College
2011;18(4):1028–34. of Surgeons panel, “What’s new for the surgeon caring for patients
Machens A, Dralle H. Prognostic impact of N staging in 715 medullary with hyperparathyroidism”. J Am Coll Surg. 2016;222(6):1240–50.
thyroid cancer patients: proposal for a revised staging system. Ann Terzolo M, et al. AME position statement on adrenal incidentaloma.
Surg. 2013;257(2):323–9. Eur J Endocrinol. 2011;164(6):851–70.
Middleton WD, et al. Multiinstitutional analysis of thyroid nodule risk Udelsman R, et al. Surgery for asymptomatic primary hyperparathy-
stratification using the American College of Radiology Thyroid roidism: proceedings of the third international workshop. J Clin
Imaging Reporting and. Data System AJR Am J Roentgenol. Endocrinol Metabol. 2009;94(2):366–72.
2017;1–11 Wells SA, et al. Revised American Thyroid Association guidelines
Moley JF, et al. Management of the Parathyroid Glands during for the management of medullary thyroid carcinoma. Thyroid.
Preventive Thyroidectomy in patients with multiple endocrine neo- 2015;25(6):567–610.
plasia type 2. Ann Surg. 2015;262(4):641–6. Wilhelm SM, et al. The American Association of Endocrine
Niederle B, et al. Timing and extent of thyroid surgery for ben car- Surgeons Guidelines for definitive Management of Primary
riers of hereditary C cell disease - a consensus statement of the Hyperparathyroidism. JAMA Surg. 2016;151(10):959–68.
ESES. Langenbeck's Arch Surg. 2014;399:185–97.
Thyroidectomy
127
Geeta Lal
Indications • Ultrasonography
• Fine-needle aspiration cytology
• Congenital abnormalities • Radionuclide scintigraphy
• Goiter • CT scan
• Hyperthyroidism
• Selected solitary thyroid nodules
• Thyroid carcinoma Pitfalls and Danger Points
• See Chap. 128
• Trauma to recurrent laryngeal or superior laryngeal nerves
• Trauma to or inadvertent excision of parathyroid glands
Preoperative Preparation • Inadequate preoperative preparation of the toxic hyper-
thyroid patient resulting in postoperative thyroid storm
Patients undergoing thyroidectomy for hyperthyroidism • Inadequate surgery for thyroid cancer
require careful preoperative preparation to decrease the vas-
cularity of the thyroid and the risk of thyroid storm. To
accomplish this, agents commonly used are antithyroid med- Documentation
ications, beta blockers, and Lugol’s iodine (or supersaturated
potassium iodide SSKI) solution. Because of the long half- The operative note should document the visualization and
life of thyroxine (T4), treatment with beta blockers is gener- integrity of the recurrent laryngeal nerves as well as the para-
ally continued for 7–10 days postoperatively. thyroid glands. Note must be made of any reimplanted para-
In situations where preexisting vocal cord dysfunction is thyroid glands and their locations. If operating for cancer,
suspected or patients have had prior neck surgery or a large note any central (peri- and paratracheal) lymph node abnor-
goiter, either direct or indirect laryngoscopy may be benefi- malities and results of any intraoperative frozen sections.
cial to assess the baseline function of the vocal cords.
A patient suspected of having medullary carcinoma of the
thyroid should undergo preoperative studies to detect a pheo- Operative Strategy
chromocytoma or primary hyperparathyroidism, which com-
monly coexists in the setting of MEN-2 syndrome. It is Performance of thyroidectomy requires careful exposure,
important to treat the pheochromocytoma before undertak- meticulous hemostasis, and detailed knowledge of regional
ing surgery on the neck. anatomy. Variations in anatomy are common, and the thyroid
In case of thyroidectomy for the solitary thyroid nodule, surgeon must progress slowly, carefully, and identifying all
workup may include any or all of the following: structures in a bloodless field.
• Thyroid function tests

Preserving the Superior Laryngeal Nerve
G. Lal (*)
Department of Surgery, University of Iowa Hospitals and Clinics, The internal branch of the superior laryngeal nerve pene-
Iowa City, IA, USA trates the thyrohyoid membrane and is the sensory nerve of
e-mail: geeta-lal@uiowa.edu

https://doi.org/10.1007/978-3-030-81415-1_127
998 G. Lal
the larynx; the external branch controls the cricothyroid I dentification and Preservation of Recurrent
muscle. Although it is possible to damage both branches of Laryngeal Nerve
the superior laryngeal nerve by passing a mass ligature
around the superior thyroid artery and vein above the supe- The recurrent laryngeal nerve ascends slightly lateral to the
rior pole of the thyroid, the external branch is the one most tracheoesophageal groove. The nerve almost always makes
often injured. Transection of the external branch impairs the contact with the inferior thyroid artery, passing directly
patient’s ability to voice high-pitched sounds and may also under or over the artery. Sometimes the nerve passes between
lead to voice fatigue. Because the external branch may be the branches of the inferior thyroid vessel. Above the level of
intertwined with branches of the superior thyroid artery and the artery, the nerve ascends to enter the larynx between the
vein as shown in Fig. 127.1, avoiding damage to this nerve cricoid cartilage and the inferior cornu of the thyroid carti-
requires that each branch of the superior thyroid vessels be lage. In this area, the nerve lies in close proximity to the
isolated, ligated, and divided individually at the point where posterior capsule of the thyroid gland. It may divide into two
it enters the thyroid gland. If the superior thyroid artery and or more branches prior to entering the larynx. On rare occa-
vein are dissected above the superior pole of the thyroid, it is sions, the recurrent nerve does not recur but travels from the
necessary to identify and preserve the superior laryngeal vagus directly medially to enter the larynx near the superior
nerve and its branches. This step is not necessary if the ter- thyroid vessels or at a slightly lower level relative to the thy-
minal branches of the superior thyroid vessels are individu- roid gland. Nonrecurrent nerves are more common on the
ally isolated and ligated at the surface of the gland. right side.
Fig. 127.1
127 Thyroidectomy 999
Preserving Parathyroid Glands gland carefully away from the thyroid without impairing its
blood supply.
Preventing damage to the parathyroid glands requires the
surgeon to achieve thorough familiarity with the anatomic
location and appearance of these structures. The surgeon Operative Technique
who takes the time to identify the parathyroid glands during
every thyroid operation soon finds that this maneuver can be Intraoperative Preparation
accomplished with progressively more efficiency. The infe-
rior parathyroid gland is frequently found in the fat that sur- Position the patient supine on the operating room table. Place
rounds the inferior thyroid artery at the point where it divides a shoulder roll, if necessary, to assist with extension of the
into several branches. Normally, the inferior gland is antero- neck. Tuck the arms by the patient’s side and pad all pressure
medial to the recurrent laryngeal nerve, and the superior points. Then, place the operating table in a modified “beach-
parathyroid is posterolateral to the nerve. With the thyroid chair” position with slight reverse Trendelenburg. Antibiotics
gland retracted anteriorly, both parathyroids may assume an are not typically indicated for thyroid operations.
anteromedial position relative to the nerve. The superior
gland is generally situated on the posterior surface of the
upper third of the thyroid gland, fairly close to the cricoid Incision and Exposure
cartilage. Frequently, the parathyroids are loosely surrounded
by fat and are golden yellow in color. Measuring only about Make a slightly curved incision in a natural skin crease
5–8 mm in maximum diameter, the average gland weighs approximately 1 cm caudal to the cricoid cartilage. The inci-
about 30 mg. sion should extend approximately 4–5 cm for a normal-sized
One method for protecting the parathyroid glands is to gland. Take care to ensure symmetry. A longer incision may
preserve the posterior capsule of the thyroid gland by incis- be needed in patients with large goiters. Using a scalpel or
ing the thyroid along the line sketched in Fig. 127.2 (subtotal electrocautery, carry the incision down through the skin and
lobectomy, leaving 3–4 g of thyroid tissue). Also, divide the subcutaneous tissue to the platysma muscle. The latter is
branches of the inferior thyroid artery at a point distal to the easier to identify in the lateral portions of the incision.
origin of the blood supply to the parathyroids. Alternatively, Divide the platysma using electrocautery. Place skin
parathyroid glands can also be preserved by performing a hooks or Kelly clamps in the dermis to assist with the cre-
near-total thyroidectomy leaving <1 g of thyroid tissue. ation of subplatysmal flaps. Using a gauze sponge to provide
When a total lobectomy is performed, the only means of countertraction, begin medially and carry the dissection out
ensuring preservation of the parathyroid glands is to identify laterally. If the plane of dissection is carried down to the cer-
the inferior and superior glands positively. Then, dissect each vical fascia, a number of veins are encountered that produce
unnecessary bleeding. There is a thin layer of fat deep to the
platysma muscle, and leaving this layer on these veins avoids
this problem. Continue the dissection along the deep surface
of the platysma muscle in a cephalad direction using both
sharp and blunt maneuvers. Follow the avascular areolar
plane superiorly to the thyroid cartilage and inferiorly to the
suprasternal notch. A self-retaining retractor may be placed
to hold back the skin flaps.
Palpate the prominence of the thyroid cartilage to identify
the midline. Make an incision through the cervical fascia in
the midline and extend the incision to expose the full length
of the strap muscles (sternothyroid muscle and sternohyoid
muscle). Elevate the sternohyoid muscle in the midline; then,
elevate the sternothyroid muscle and dissect the thyroid cap-
sule away from it on both sides. This permits adequate digital
exploration of the entire thyroid gland. In most cases, retract-
ing the strap muscles laterally while the thyroid lobe is
retracted in the opposite direction provides good exposure
for thyroidectomy. If the gland is unusually large or the
exposure is inadequate, do not hesitate to transect the sterno-
Fig. 127.2 hyoid and sternothyroid muscles. Transect them in their
1000 G. Lal
Fig. 127.4
significant cosmetic deformity overlying the thyroid carti-

lage. It is also essential to remove the pyramidal lobe when
Fig. 127.3 operating for cancer as it may affect postoperative tumor
marker levels and radioactive iodine uptake levels.
Once this is accomplished, retract the lobe medially and
upper thirds as their innervation from the ansa cervicalis identify and ligate the middle thyroid vein. This may improve
enters from below (Fig. 127.3). the mobility of the thyroid and assist in exposure. Retract the
strap muscles laterally and the thyroid medially. Using blunt
and sharp dissection, sweep the lateral tissue away from the
I dentification and Ligation of the Isthmus lateral most aspect of the thyroid. The middle thyroid vein
and Middle Thyroid Vein should be visible in this plane. Ligate the vein using silk ties
or other devices, as indicated above (Fig. 127.4).
At this point, some surgeons opt to transect the isthmus of
the thyroid. After placing self-retaining retractors to hold
back the strap muscles, identify the isthmus. Dissect the isth- issecting the Superior Pole and Superior
D
mus off of the trachea both inferiorly and superiorly using Parathyroid Gland
blunt dissection and electrocautery. The isthmus may be
divided between clamps and vascular control obtained by With a retractor drawing the upper portion of the strap mus-
suture ligation or oversewing of the cut ends. Devices such cles in a cephalad direction, retract the superior pole of the
as a harmonic scalpel or vessel-sealing system may be used thyroid laterally and use a peanut sponge dissector to sweep
to transect the isthmus and may be used throughout the the upper pole of the thyroid away from the larynx. This
procedure in place of suture ligatures. The isthmus may also maneuver separates the upper pole from the external branch
be divided last, when entire dissection is completed. of the superior laryngeal nerve, which is closely applied to
Once the upper portion of the thyroid isthmus is identi- the cricothyroid muscle at this level (discussed below). Also
fied, a fingerlike projection of thyroid tissue may be seen free the lateral portion of the superior pole by blunt dissec-
extending from the region of the isthmus in a cephalad direction. One or two small veins may be entering the posterior
tion. It represents the pyramidal lobe of the thyroid, a vesti- portion of the upper pole. Be careful to identify and ligate
gial remnant of the thyroglossal tract. If a thyroidectomy is these branches if encountered. Then, identify the terminal
being performed for Graves’ disease, it is especially impor- branches of the superior thyroid artery and vein. Ligate and
tant to remove the pyramidal lobe. Otherwise, postopera- divide each of these vessels between suture ligatures or other
tively it may become markedly hypertrophied and cause a vessel-sealing devices. After they have been ligated and
divided, the superior pole of the thyroid is completely liber- immediately deep to or superficial to this artery and carefully
ated and can be lifted out of the neck. dissect the nerve in a cephalad direction until it reaches the
Now search along the posterior surface of the upper third cricothyroid membrane just below the inferior cornu of the
of the thyroid lobe for the superior parathyroid gland. The thyroid cartilage. Remember that the nerve may divide into
typical anatomy is shown in greater detail in Fig. 127.1. two or more branches in the area cephalad to the inferior
Variations are extremely common. Dissect the parathyroid thyroid artery. Once the nerve has been exposed throughout
gland away from the thyroid into the neck, carefully protect- its course behind the thyroid gland, it is a simple matter to
ing it. avoid damaging it.
A nerve stimulator may be used to assess function of the
nerve at various stages of the dissection. This is done by
Identification of Inferior Pole Vessels placing an index finger deep along the posterior lamina of the
cricoid and stimulating the recurrent laryngeal nerve with a
Next, attention turns to identification and ligation of the infe- neurostimulator to feel for contraction of the cricoarytenoid
rior pole vessels. Staying close to the thyroid tissue, dissect muscle through the wall of the hypopharynx. Additional
from medial to lateral and take care not to injure the recur- methods to assess functions of the nerve include direct laryn-
rent laryngeal nerve. Locate the inferior thyroid vessels and goscopy or continuous monitoring by electromyography.
ligate these vessels using suture ligature or vessel-sealing Intraoperative neural monitoring has gained acceptance as an
devices (Fig. 127.5). In some cases, the thyroid ima artery adjunct to the gold standard of visual identification of the
may be encountered at this point. Ligate this vessel in a simi- recurrent laryngeal nerve. It does have some limitations and
lar fashion. additional research and standardization of techniques and
results are needed.
Identify the inferior parathyroid gland, generally located
I dentification of the Recurrent Laryngeal close to the point at which the inferior thyroid artery divides
Nerve and Inferior Parathyroid Gland into its branches (Fig. 127.6). Divide each of these branches
of the inferior thyroid artery between ligatures medial to the
With both the superior and inferior poles of the thyroid parathyroid gland so the blood supply to the parathyroid is
mobilized, the recurrent laryngeal nerve is able to be identi- not impaired.
fied. Dissection may be carried out lateral to medial or vice At this point, the thyroid may be elevated off of the tra-
versa based on the surgeon’s preference. chea using either blunt or sharp dissection. Dissection may
For most surgeons, the best way to locate the recurrent
laryngeal nerve is to trace the inferior thyroid artery from the
point where it emerges behind the carotid artery to the point
where it crosses over or under the recurrent nerve. Often a
very slim vessel can be seen along the nerve. Using the infe-
rior thyroid artery as a guide, locate the recurrent nerve
Fig. 127.5 Fig. 127.6

1002 G. Lal
be carried out from a lateral to medial fashion, transecting passing close to the recurrent nerve in this ligament. Be care-
the ligament of Berry to elevate the thyroid from the trachea. ful to control this vessel without injuring the nerve before
Care is taken to ensure preservation of the recurrent laryn- dividing the ligament. After this ligament has been freed, the
geal nerve throughout this dissection. thyroid lobe can easily be liberated from the trachea by
clamping and dividing several small blood vessels until the
isthmus has been elevated.
Reimplantation of Parathyroid Glands The isthmus may be divided serially between hemostats,
leaving the other lobe of the thyroid in place, and then over-
If a parathyroid gland has been inadvertently excised, and sewn for hemostasis as seen in Figs. 127.7 and 127.8. If the
this is recognized during the operation, it is possible to reim- isthmus has been divided earlier in the surgery, the thyroid
plant the parathyroid. The parathyroid should be placed in a just needs to be dissected off the trachea using scalpel or
container filled with normal saline and then placed on ice. electrocautery.
When ready for reimplantation, cut the gland into small seg-
ments (approximately 1 × 1 mm) using a scalpel. These
segments may then be placed or injected into a pocket of the Partial Thyroid Lobectomy
sternocleidomastoid or brachioradialis muscle. Generally, a
permanent suture to close the pocket and clips are placed to On some occasions, what appears to be an obviously benign
mark the site. In addition, glands without visible vascular lesion occupies a small portion of the thyroid gland. Under
supply should be reimplanted. Intraoperative measurements these conditions, local excision or partial lobectomy may be
of PTH levels (less than 10 pg/mL) during total thyroidec- indicated. The stapling device is sometimes useful under
tomy may suggest the need for reimplantation. these conditions. Figs. 127.9 and 127.10 illustrate removal of
the lower half of the right thyroid lobe, a stapling device hav-
ing been used first to close and control bleeding from the
Subtotal Thyroid Lobectomy remaining segment of thyroid, and then, to divide the isth-
mus. Remember that identification and preservation of the
If subtotal resection of the lobe is the operation elected, free recurrent nerve must be achieved early in the dissection. If
the upper pole completely and divide the lobe along the line the gland is fairly thick, use 4.8 mm staples.
of resection as outlined in Fig. 127.2. At this level of the dis-
section, both parathyroid glands and the recurrent nerve, all
of which have been previously identified, may be left in their
normal locations. Divide the remaining gland between
hemostats or using a vascular sealing device until the ante-
rior surface of the trachea has been reached. If hemostats are
used, the cut surface will need to be oversewn. At this point,
transect the isthmus as described below if this maneuver was
not performed earlier in the surgery. Some surgeons suture
the lateral margin of the residual segment of thyroid to the
trachea, but this step is not essential. When subtotal thyroid-
ectomy is being performed for Graves’ disease, leave no
more than 2–4 g of thyroid tissue on each side.
Total Thyroid Lobectomy
Before considering total lobectomy, be certain you have pos-

itively identified the recurrent nerve and the superior and
inferior parathyroid glands. After these structures have been
dissected away from the thyroid, proceed with the total
lobectomy. The gland is firmly attached to the two upper tra-
cheal rings by dense fibrous tissue that constitutes the liga-
ment of Berry (Fig. 127.5). The upper portion of the recurrent
laryngeal nerve passes close to the point where this ligament
attaches to the trachea. Moreover, often there is a small artery Fig. 127.7
Fig. 127.8
Fig. 127.9
Closure
Prior to closure, irrigate the operative field with saline and a major artery. Under rare circumstances, it is necessary
obtain complete hemostasis by ligatures, clips, or electrocau- to remove all sutures in the skin and strap muscles to
tery. Always keep the recurrent nerve and the parathyroid release the blood clot at the patient’s bedside. In most
glands in view while taking these steps. In the situation cases, evacuate the blood clot in the operating room. After
where the strap muscles have been transected, reapproximate removing a large goiter, occasionally there is gradual
these two muscles by means of sutures of 2-0 Vicryl, as illus- swelling of the tissues of the neck due to slow venous
trated in Fig. 127.11. In other cases simply suture the right bleeding that infiltrates the tissues. It may produce respi-
and left strap muscles together loosely with interrupted 3-0 ratory distress due to laryngeal edema. This patient
Vicryl sutures. It is not necessary to place drains in the requires orotracheal intubation and evacuation of the clot
thyroidectomy bed. After the strap muscles have been reap- in the operating room. It is rare that exploration or a tra-
proximated, suture the divided platysma muscle together cheostomy must be done at the patient’s bedside.
using interrupted 3-0 Vicryl stitches. Close the skin using a • Following total thyroidectomy, check for hypocalcemia by
running subcuticular 4-0 absorbable suture. Skin glue may measuring the serum calcium level (typically twice daily)
also be used. until the patient is discharged. Hypocalcemia may occur due
to inadvertent damage to the parathyroid glands. Observe for
signs and symptoms of hypocalcemia: paresthesia of the
Postoperative Care extremities or face, Trousseau’s sign, or Chvostek’s sign.
These generally appear when the calcium level drops below
• Carefully observe the patient’s neck for signs of swelling 7–8 mg/dL. Give oral calcium carbonate tablets (2–8 g/day)
or ecchymosis. Active bleeding in the bed of the excised as required to maintain the serum calcium level. If calcium
thyroid gland can rapidly compress the trachea and cause administration alone does not control the symptoms, supple-
respiratory obstruction, especially if the bleeding is due to mental vitamin D may be given (typically as calcitrol). Treat
1004 G. Lal
Fig. 127.11
Complications
Fig. 127.10 • Infections are rare, however, cellulitis and abscesses may
occur. Antibiotics and drainage may be needed.
• Hematoma with possible tracheal compression and respi-
the symptoms with intravenous calcium gluconate (1 g of a ratory distress requiring bedside evacuation may occur.
10% solution several times a day or a continuous intravenous Getting control of the airway and bleeding is best per-
infusion) if the symptoms persist despite oral supplementa- formed in the operating room as indicated above.
tion. The milder form of hypocalcemia following thyroid • There may be injury to the recurrent laryngeal nerve.
surgery is usually transient because it is caused by minor Recurrent nerve injury may be transient or permanent. If
trauma to the parathyroid glands. Severe postoperative hypo- the injury is unilateral, it generally produces some degree
parathyroidism is often permanent. of hoarseness and weakness of the voice. Postoperative
• Patients undergoing total thyroidectomy will also develop hoarseness may be also due to transient vocal cord edema
hypothyroidism and require thyroid hormone supplemen- or vocal cord injury caused by the endotracheal tube used
tation. Replace with levothyroxine (synthetic T4) starting for anesthesia. The patient who has undergone trauma to
at a dose of 1.6 μg/kg. TSH levels should be reassessed both recurrent laryngeal nerves may develop complete
after 6 weeks of therapy. Patients undergoing lobectomy airway obstruction from marked narrowing of the glottis
or bilateral subtotal thyroidectomy may also need thyroid requiring prompt endotracheal intubation and then trache-
hormone supplementation, depending on the volume of ostomy. This complication may become evident immedi-
thyroid tissue remaining, and especially, if there is under- ately after extubation in the operating room with the
lying Hashimoto’s thyroiditis. Monitoring of these development of stridor or hours later. If this occurs,
patients’ TSH levels at periodic intervals is advised. immediate reintubation is necessary. This complication is
• In patients with Graves’ disease, carefully monitor vital rare. The airway may later be improved by an
signs to detect early evidence of thyroid storm. Patients arytenoidectomy.
who were prepared for operation with propranolol require • Superior laryngeal nerve injury may result in the patient
treatment with this medication for 7–10 days following being unable to utter high-pitched sounds and voice
the operation. fatigue.
• Hypoparathyroidism, transient or permanent, results from greater than 30 mm, history of thyroiditis or prior neck sur-
inadvertent removal of or trauma to several of the para- gery, and advanced stage cancers. Although these techniques
thyroid glands. If during operation it is noted that one or have been shown to be feasible, further long-term studies are
more parathyroid glands have been removed, they should needed to determine their advantages and cost-effectiveness
be reimplanted. If the fragments are sufficiently small, over the more traditional open approach.
satisfactory function may develop. Transient hypopara-
thyroidism, lasting as long as several months, may result
from manipulation of the parathyroid glands without per- Further Reading
manent damage.
• Thyroid storm may develop following thyroidectomy for Block MA. Surgery of thyroid nodules and malignancy. Curr Probl
Surg. 1983;20:137.
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Neck Dissection for Thyroid Cancer
128
Maheshwaran Sivarajah and Rebecca S. Sippel
Indications deep venous thrombosis prophylaxis should be implemented

only after careful consideration, as the risk of bleeding post-
• A therapeutic neck dissection is performed for well- operatively may outweigh the risk of developing a venous
differentiated thyroid carcinoma with evidence of nodal thromboembolism in this population. In selected high-risk
involvement (either clinical or radiographic evidence con- patients, a preoperative dose of 5000 units of subcutaneous
firmed by fine-needle aspiration) in either the central and/ unfractionated heparin for prophylaxis is usually given up to
or lateral neck. 2 hours preoperatively. Since these patients are ambulatory
• A prophylactic central neck dissection may be considered in the immediate postoperative period, prolonged prophy-
for large papillary thyroid cancers (T3 or T4 lesions) or laxis postoperatively is rarely indicated.
when extrathyroidal tumor extension is present. A pro- Accurate preoperative imaging is key to determining the
phylactic central neck dissection is also performed when appropriate extent of the operation. Preoperative ultrasound
treating medullary thyroid cancer. with lymph node mapping is essential to determine the loca-
• A reoperative neck dissection is performed when a nodal tion of the nodal disease and to plan the appropriate extent of
recurrence is identified following a previous thyroidec- resection. For patients with large necks, bulky disease, or
tomy and/or lymphadenectomy. prior neck operations, additional imaging with a contrasted
neck CT may help to clarify the location of all diseases.
However, caution must be used when interpreting neck CT
Preoperative Preparation scans as radiological findings may not necessarily represent
true pathologic disease.
Neck dissections are considered clean operations and the risk Intraoperative localization is essential to ensure a com-
of infections is <1%. Due to the low risk of infection, pro- plete resection is performed. Ultrasound is particularly help-
phylactic antibiotics are typically not required, unless the ful in the operating room once the patient is positioned on the
upper aerodigestive tract (i.e., trachea or esophagus) is operating room table to orient the surgeon to the anatomy
entered. Antibiotics should be considered in reoperative and delineate the extent of dissection that is needed. Adjuncts
fields or fields that have been previously radiated due to such as blue dye or a charcoal suspension can also be injected
compromised blood flow to the region. preoperatively under ultrasound guidance into the area of
Since a neck dissection is only done in patients with meta- interest or intraoperatively to help guide dissection, particu-
static cancer, these patients are at a higher risk for deep larly when the lesion is in a reoperative field. Ultrasound can
venous thrombosis than other thyroid operations. Because of also be used after the resection is completed to ensure that all
this increased risk, intermittent pneumatic compression disease seen on imaging preoperatively has been appropri-
devices should be used on all patients. The use of chemical ately removed.
As for any major operation, the patient should be pre-
pared with age-appropriate laboratory tests, including elec-
M. Sivarajah
Acute Care Surgery, St. Barnabas Hospital, Bronx, NY, USA trocardiogram and chest radiographs, when indicated based
on comorbidities. Preoperative evaluation is accomplished
R. S. Sippel (*)
Division of Endocrine Surgery, Department of Surgery, University in conjunction with the anesthesiologist prior to surgery.
of Wisconsin School of Medicine and Public Health, An assessment of the patient’s disease, comorbidities, and
Madison, WI, USA treatment goals is required. If an operation is going to be
e-mail: sippel@surgery.wisc.edu

https://doi.org/10.1007/978-3-030-81415-1_128
1008 M. Sivarajah and R. S. Sippel
performed in the central neck, it is valuable to get a base- I njury to the Thoracic Duct
line calcium and parathyroid hormone (PTH) level to assess The thoracic duct is located low in the left neck and inserts
the function of the parathyroid glands, as they will be put at into the internal jugular vein. The walls of the thoracic duct
risk with a dissection in this area. For patients with differ- are very thin and can be easily injured during a left lateral
entiated thyroid cancer, preoperative testing with thyro- neck dissection. It is important to be looking for this duct as
globulin levels can be used as a baseline to assess the you dissect lateral to the internal jugular vein in Level IV of
response to surgery. the left neck. If the duct is injured, you will see clear fluid
Assessment of the patient’s vocal function preoperatively accumulating in the wound. The fluid becomes cloudy only
is essential. A more formal vocal cord assessment with fiber- after the patient has had a fatty meal, so intraoperatively the
optic laryngoscopy is appropriate if there are any voice fluid will rarely be milky in color. If you are concerned about
changes, if the patient has had a prior neck operation, or if an injury, you can administer heavy cream down a nasogas-
the tumor is near the recurrent laryngeal nerve (RLN) or the tric tube and that will turn the fluid milky in color to facilitate
vagus nerve (CN X). identification. If the duct is injured, it is important to care-
Preoperative planning includes obtaining informed con- fully ligate it with a suture or small clip. If you are concerned
sent from the patient. It is appropriate to explain to a patient that it is not effectively ligated, you can reinforce the area
why a neck dissection is being performed and what, if any, with a muscle flap from the adjacent sternohyoid muscle. If
alternative forms of therapy might be employed. The patient there is concern about an injury to the thoracic duct, you
must understand the risks of the surgery as well as the should always leave a drain postoperatively.
expected recovery after surgery. Risks of a central neck dis-
section include injury to the recurrent and superior laryngeal
nerves and the parathyroid glands as well as a risk of bleed- Seroma
ing or infection. For a lateral neck dissection, it is essential to
also discuss possible injuries to CN X, phrenic, spinal acces- Fluid accumulates in the operative space after any neck dis-
sory (CN XI), hypoglossal (CN XII), and cervical sensory section. Swelling typically peaks around day 5. Drains can
nerves, as well as the risk of a chyle leak or seroma. be used postoperatively to monitor how much fluid accumu-
lates, but most patients do not require a drain or can have it
safely removed the next day. Cutting small lymphatics is
Pitfalls and Danger Points what leads to seroma formation. The key to minimizing
seroma formation is to look for major lymphatic channels
Scarring Due to Prior Surgery and to ligate, clip, or seal the lymphatics as they are divided.
At the end of the surgery, having the anesthesiologist per-
Reoperative neck dissections can be technically challenging form a Valsalva maneuver can help you to identify any poten-
due to the distorted anatomy and fascial planes. Preoperative tial lymphatic leaks that need to be addressed prior to
marking with blue dye or charcoal suspension and intraop- closing.
erative ultrasound can assist in identifying pathologic nodes.
If necessary, a fresh incision can be made directly over a
localized lymph node to avoid an extensive dissection Documentation
through a reoperative field to reach the area of interest.
Neck dissection operations may be elective when done for
clinically occult metastases, therapeutic for clinical apparent
Nerve Injuries metastases or may be a salvage procedure when the patient’s
neck was previously treated with surgery and/or radioactive
Several important nerves are at risk with a neck dissection iodine and residual or recurrent disease is identified. Your
(hypoglossal, vagus, phrenic, spinal accessory, and recurrent documentation must clearly state if the dissection was pro-
laryngeal). The key to avoiding injury to these nerves is to phylactic or therapeutic and if it was a reoperation.
understand their anatomic pathways and the key landmarks A neck dissection is defined as a compartment-oriented
that can facilitate their identification. When dividing tissue in removal of all the fibroadipose tissue and lymphatic tissues
the lateral neck, it is important to dissect out the tissue com- en bloc from a given compartment within the neck while pre-
pletely so that you can clearly see what you are dividing so serving critical structures. “Berry picking” (i.e., selective
that you can avoid inadvertently dividing a nerve. Use of an removal of single, grossly involved nodes) is not a
intraoperative nerve monitoring system can facilitate the compartment- oriented dissection. When documenting a
identification of the nerves and ensure their function at the lymph node dissection, it is important to outline exactly
end of the case. which nodal basins were removed. It is also important to
128 Neck Dissection for Thyroid Cancer 1009
document which nerves were identified and if they were able A comprehensive MRND is rarely indicated for the treat-
to be preserved. ment of thyroid cancer, as involvement of Level I is quite
rare. Most patients with thyroid cancer are treated with a
more selective lateral neck dissection. Selective lateral neck
Operative Strategy dissections are classified according to the cervical lymphatic
regions that are resected. A selective neck dissection is done
The lymph nodes of the neck are divided into six levels: for limited cervical metastases. It involves the removal of <5
nodal basins from Levels I to V and is directed by the pat-
• Level I is bound by the stylohyoid muscle posteriorly, terns of lymphatic drainage from the primary tumor, while
anterior belly of the contralateral digastric muscle anteri- preserving CN XI, the IJV, and the SCM. For patients with
orly, mandible bone superiorly, and hyoid bone thyroid cancer, patients frequently have removal of Levels
inferiorly. III, IV, IIA, and VB. Disease in VA and IIB is uncommon and
–– Level IA (submental triangle) bound by the anterior removal of nodes from this area is not required in most
bellies of the digastric muscle and hyoid bone. patients.
–– Level IB (submandibular triangle) containing the sub- A bilateral central neck dissection encompasses resecting
mandibular gland and its nodes. lymph nodes from only Level VI, including the prelaryngeal
• Level II encompasses the skull base to the hyoid bone. and pretracheal nodes, and both right and left paratracheal
The posterior border is marked by the posterior border of lymph node basins. A central neck dissection may be unilat-
the sternocleidomastoid muscle (SCM) and anterior bor- eral or bilateral. If disease is identified in the lateral neck, it
der by the stylohyoid muscles, respectively. Lymphatic should be assumed that there is also disease in the central
tissue obtained anterior and posterior to CN XI corre- neck and a dissection of both regions should be performed.
sponds to Levels IIA and IIB accordingly.
• Level III extends between the hyoid bone and inferior
border of the cricoid cartilage. The anterior boundary is Operative Technique
marked by the sternohyoid muscle and posteriorly by the
SCM posterior margin. Position the patient supine on the operative table with a pil-
• Level IV is framed by the inferior border of the cricoid low or inflatable pressure bag under the shoulders to obtain
cartilage superiorly and the clavicle inferiorly. The ante- the proper angle for surgery. Extend the neck and turn the
rior margin is the sternohyoid muscle and posterior bor- head to the opposite side for unilateral neck dissections.
der is the posterior border of the SCM. Cushion the occiput on a donut pillow against the upper
• Level V extends from the posterior border of the SCM end of the table. Elevate the head of the table for surgery.
anteriorly and trapezius muscle posteriorly. It stretches Shave, prep, and drape the patient’s neck and upper chest.
from the mastoid tip to the clavicle and is subdivided by a Surgical draping must provide access to the clavicle inferi-
line from the inferior border of the cricoid cartilage into orly, the trapezius most posteriorly, and the tip of the ear-
Level VA superiorly and Level VB inferiorly. lobe superiorly. Place five towels onto the skin; one
• Level VI encompasses the central compartment of the horizontally across the angles of the mandible, two from
neck bound by the carotid arteries in the lateral aspect, each shoulder to the midline, and another two from each
hyoid bone superiorly, and inferiorly by the suprasternal angle of the mandible to the corresponding shoulder. Cover
notch. Level VII is in the superior mediastinum and is the patient’s torso and extremities with a sheet, and use a
considered a thoracic component. second open sheet to cover everything except the field of
operation. Use general anesthesia but do not use muscle
A comprehensive or therapeutic lateral neck dissection relaxants so the surgeon can be aware of the degree of con-
involves clearance of all nodal and fibroadipose tissue from traction when approaching the main nerves in the neck,
Levels I to V and may either be a radical neck dissection locating and preserving these nerves. A nerve monitoring
(RND) or modified radical neck dissection (MRND). An system can be utilized to facilitate identification of the
RND includes resection of the ipsilateral SCM, CN XI, and recurrent laryngeal nerve, CN X, as well as CN
internal jugular vein (IJV). MRND preserves one or more of XI. Appropriate placement of the endotracheal tube is
these structures: MRND type I preserves the CN XI, MRND essential for monitoring of the recurrent laryngeal nerve or
type II preserves CN XI and either the IJV or SCM, and CN X. Using a video-based laryngoscope can ensure proper
MRND type III preserves all three structures. An extended placement of the electrodes between the vocal folds.
neck dissection includes additional lymphatic or nonlym- The incisions used vary, and are influenced by the site of
phatic groups not usually included in the comprehensive the underlying tumor and laterality of the dissection to be
neck dissection. performed, as well as the experience and preference of the
surgeon. The criteria for choice of incision include the muscles to facilitate exposure to the central neck. A central
following: neck dissection can be done in conjunction with the thyroid-
ectomy or may be done after a previous surgery if the lymph
• Access required to resect the primary tumor nodes were not recognized prior to the first operation. Once
• Maximizing exposure to the field the thyroid has been removed, you identify and dissect the
• Preserving vascularity of the skin flaps RLN caudally at the posterior suspensory ligament of Berry
• Anticipating the potential for postoperative radiotherapy (lateral thyrohyoid ligament) with an atraumatic technique
• Acceptable cosmetic result along its entire course minimizing manipulation and traction.
There is huge variability of the position of the RLN, and the
course and relationship to neighboring anatomical structures.
Central Compartment Neck Dissection You can palpate the RLN as a cord-like structure against the
trachea, and it can be visually identified by its small vessels
The boundaries of a central neck dissection are as follows: running on its surface. The left RLN usually lies deep to the
inferior thyroid artery in the tracheoesophageal groove,
• Superiorly: the hyoid bone while the right RLN ascends more obliquely, particularly in
• Inferiorly: the innominate artery the lower third of the neck. Be familiar with variations in
• Laterally: the ipsilateral carotid artery RLN, which include passing anterior to and between
• Anteriorly: the superficial layer of the deep cervical branches of the inferior thyroid artery.
fascia With gentle traction, dissect en bloc the fibroadipose tissue
• Posteriorly: the deep layer of the deep cervical fascia anterior and medial to the RLN and its branches, medially to
laterally. Be familiar with the significant positional variability
A compartment-oriented approach is the customary of the parathyroid glands. Although the position may be
method for the removal of the prelaryngeal, pretracheal, and inconsistent, they are usually symmetric. The glands are mus-
both the right and left paratracheal nodal basins in a bilateral tard in color and must remain along with its primary blood
central neck dissection. A central neck dissection can typi- supply from the superior branch of the inferior thyroid artery.
cally be performed through the same incision as the thyroid- Bleeding within this area will make it troublesome to identify
ectomy. The incision is placed about 1 cm below the cricoid the parathyroid glands, so ensure careful hemostasis. Be
cartilage near the isthmus of the thyroid. The cricoid carti- familiar with the significant positional variability of the supe-
lage is a better landmark than the sternal notch given the rior parathyroid glands (undescended, parapharyngeal, retro-
variability in location of the thyroid based on neck anatomy. pharyngeal, retrotracheal, or within the mediastinal
If the nodal involvement extends into Level VII in the upper compartment). The glands are usually posterior to the RLN
mediastinum, a lower incision may allow better access to the and 1–2 cm superior to the junction of the nerve with the infe-
disease. The incision can be extended to the borders of the rior thyroid artery, and within 1 cm of the entry point of the
SCM for a large goiter or into the lateral neck if a concurrent RLN into the ligament of Berry. Preserve the glands in situ
lateral neck dissection will be performed. The skin is divided and keep the blood supply intact leaving them viable. The
sharply and the subcutaneous tissue and platysma are divided inferior parathyroid glands, located anterior to the RLN, is
with cautery. Once the platysma is divided, it is grasped with most often found in the anterior mediastinal compartment in
straight clamps and elevated, and the strap muscles are the thyrothymic tract. They can also be found inside the thy-
retracted inferiorly exposing the subplatysmal plane. This roid capsule on the inferior portion of the thyroid lobes. Tease
avascular areolar tissue is opened using cautery or a knife the inferior parathyroid glands laterally ensuring viability by
and the dissection is carried superiorly to expose the thyroid preserving the pedicle. If there is a concern for devasculariza-
cartilage and inferiorly down to the suprasternal notch. tion, parathyroid autotransplantation is performed after con-
During this dissection, you remain superficial to the anterior firmation with intraoperative frozen section to reduce the risk
jugular veins. Hold apart these skin flaps with self-retaining of inadvertent autotransplantation of a nodal metastasis. To
retractors or suture each to the overlying surgical drape to accomplish this, dice the gland into 1 mm cubes and insert
keep in place during the dissection. Divide the midline fascia them into the SCM. The position of the autotransplant should
of the sternohyoid and sternothyroid muscles and retract be marked with a permanent suture and/or a small clip.
them laterally; take care to recognize and divide the small The central compartment contents should be cleared later-
crossing veins between the anterior jugular veins, typically ally from the strap muscle and carotid artery and caudally
located above the cricoid cartilage and near the sternal notch. toward the sternal notch including thymic tissue if the gland
You can separate the sternohyoid muscle from the sternothy- contains palpable abnormal nodes. There are typically addi-
roid muscle, which can facilitate your lateral retraction. If tional paratracheal nodes present posterior to the RLN, espe-
needed, you can transect the sternohyoid and sternothyroid cially on the right, and this area needs to be mobilized and
removed as well. The area posterior and lateral to the RLN ing the thoracic duct as it empties into the IJV near the junc-
should be carefully dissected and any nodal tissue removed. tion with the subclavian vein, when dissection is in the left
A common place that nodal disease is missed is just posterior neck. You should preserve the thoracic duct. If the duct is
to the RLN near its insertion into the cricothyroid muscle. transected, carefully ligate it with a nonabsorbable suture.
Before closing the wound, ask the anesthetist to perform Ensure closure of the leak prior to closure of the neck wound.
a Valsalva maneuver to elicit unsecured bleeding vessels and Suture ligate or place vessel clips on all soft tissue while dis-
to look for lymphatic leaks. After ensuring hemostasis, reap- secting across the inferior extent of Level IV to prevent addi-
proximate the strap muscles at the midline with absorbable tional chyle leaks.
interrupted sutures followed by the platysma. Close the skin The nodal packet is mobilized laterally from the IJV. Grasp
incision with an absorbable suture. You may also close the this tissue with a Babcock clamp and identify the posterior
skin wound with nonabsorbable suture, which is removed in cervical fascia deep to this tissue. Elevate the nodal tissue off
the OR or on postoperative day #1, and is reinforced with the posterior cervical fascia as a single packet taking care to
wound closure strips or with a surgical glue. preserve the phrenic nerve, which is posterior to the plane of
dissection and anterior to the scalene muscle. Resect the tis-
sue superior to the nerve and inferiorly at the level of the
Lateral Compartment Neck Dissection subclavian vein. Keep the dissection of the nodal tissue from
Levels III and IV superficial to the scalene muscle to pre-
A variety of incisions can be used to adequately access the serve the branches of the cervical plexus, which lie on top of
lateral compartment. The decision regarding which incision the muscle. Much of this dissection can be done bluntly and
to use will relate to the anatomy of the neck as well as the the nodal packet is kept intact.
location of the nodes that require removal. If a neck dissec- Once the inferior extent of the dissection is complete, you
tion is being done in conjunction with a thyroidectomy, the can isolate the omohyoid muscle and elevate it with a Penrose
thyroidectomy incision can often just be extended along a drain so that the tissue can be carefully resected from around
natural skin crease into the lateral neck. If the incision is too it (Fig. 128.1). Mobilize the nodal packet superior to the
low to adequately access Level II, then the incision can be
curved up in a hockey stick fashion along the posterior aspect
of the SCM or a counter incision can be made high in the
neck overlying Level II. For other head and neck cancers, a
wide apron flap incision (Gluck incision) or a Y-shaped inci-
sion (Martin incision) may be used. The extent of dissection
generally depends upon the location of the nodal disease.
The American Thyroid Association recommends that a lat-
eral compartment neck dissection for thyroid cancer should
encompass resection of fibroadipose and lymphatic tissue
from Levels IIA, III, IV, and VB.
The first step of the procedure after incising through the
skin, subcutaneous fat, and platysma muscle is to raise sub-
platysmal flaps leaving superficial veins and fascia of the
SCM down. You should carry your dissection superiorly to
the submandibular gland, but do not dissect superior to this
gland as you can injure the marginal mandibular nerve. The
marginal mandibular nerve runs approximately 1 cm anterior
to the angle of the mandible and it crosses lateral to the sub-
mandibular gland and facial vessels. Inferiorly you should
raise flaps to the level of the clavicle. Begin the dissection
inferior to the superior belly of the omohyoid muscle and
identify the IJV. Dissect along the IJV until you reach the
anterior scalene muscle. You should use a sharp dissection
technique instead of using electrocautery near all major neu-
rovascular structures. Identify and leave the external jugular
vein and greater auricular nerve overlying the SCM. Dissect
the IJV along its length inferiorly to the junction with the
subclavian vein. A Valsalva maneuver can assist in identify- Fig. 128.1
omohyoid muscle up to the bifurcation of the carotid artery.

Identify CN XII at the superior extent of the lateral dissec-
tion as it crosses superior to the carotid bifurcation. CN XI,
which divides Level II into Levels IIA and IIB, is identified
superior to the greater auricular nerve that originates poste-
rior to the SCM. As the dissection is carried superiorly, ligate
or preserve the facial artery and vein. Dissect free the node-
bearing adipose tissue from Level IIA. If macroscopic nodal
disease is identified at Level IIA, you should proceed with
the removal of nodal tissue from Level IIB.
Medially you should identify the carotid sheath which
envelopes the IJV, common carotid artery, and CN X. It is
interposed between the superficial and prevertebral layers of
the cervical fascia. Additional nodal tissue is often present
within the sheath and needs to be removed with the specimen.
Open the sheath and dissect anteriorly along CN XII and the
digastric muscle. CN XII crosses superior to the bifurcation
of the carotid artery, near the facial vein. Preserve the neuro-
vascular contents in the carotid sheath while dissecting along
the IJV. Remove the fascia from the IJV by passing the scal-
pel along the wall of the vein up and down along its entire
length. With the blade pointing away from the IJV wall,
move the scalpel obliquely with respect to the vein until it is
completely released from its fascial covering. Continue the
dissection over the carotid artery. Identify CN XI, which is
encountered approximately 2 fingerbreadths below the pos-
terior belly of the digastric muscle. Remove the nodal tissue
Fig. 128.2
from the nerve and digastric muscle. Branches of the occipi-
tal artery may be encountered and need to be ligated close to
the muscle. Free the dissected tissue from the SCM as far as
CN XI and elevate anteriorly lateral to the deep cervical
muscles.
Dissect inferiorly along CN XI and divide the tissue at
this level to incorporate all of Level VB but preserve Level
VA posterior to CN XI (Fig. 128.2). Given the lymphatics
coursing through this tissue, divide it with a sealing device or
tie it with a suture. Send the node-containing tissue to pathol-
ogy as a single specimen containing Levels IIA, III, IV, and
VB (Fig. 128.3). Drain insertion should be done selectively
if at all, as it will not prevent seroma formation or bleeding.
If there is concern for a chyle leak, place a drain and have the
patient eat a fatty meal to ensure that the fluid does not
change to a milky consistency. Attach drains to a bulb and
initiate suction immediately to prevent clot formation while
closing the skin. Perform the closure of the wound as Fig. 128.3
described in the Central Compartment Neck Dissection sec-
tion above. incisions that form a long, narrow, poorly vascularized flap.
Preservation of the platysma and specific vessels such as the
facial artery may help. Keeping the flap moist with saline-
Avoiding Postoperative Complications soaked sponges to prevent desiccation, periodically return-
ing the flap to its anatomic position, and preventing prolonged
Skin flap loss can be disastrous, leading to exposure of the skin flap retraction are maneuvers that can be employed to
vital structures. This can largely be prevented by avoiding prevent flap loss.
Meticulous identification and dissection of the neurovas- Complications

cular bundles of the neck are essential to avoiding injury to
these structures. Nerve monitoring systems are available • A surgical bed hematoma occurring in the immediate
which can facilitate the identification and confirm the func- postoperative period is often due to inadequate hemosta-
tionality of the nerves during a dissection. Stimulation of a sis during the procedure. The use of drains may facilitate
motor nerve will lead to contraction of the end muscle, which earlier recognition of a hematoma, but will not manage or
may be able to be palpated or seen visually or captured with effectively prevent a hematoma as the drain often becomes
an electromyographic (EMG) monitor. nonfunctional due to clot. Once a hematoma is identified
Dissection from Levels IV and V must be meticulously or suspected, exploration in the operating room is manda-
performed to avoid injuring or ligating lymphatic tributaries tory, which involves opening the surgical wound, irrigat-
leading to the left or right neck thoracic duct to prevent a ing to remove the clot, and identifying the bleeding vessel.
chyle fistula. A Valsalva maneuver can be performed prior to Unfortunately, most of the times, no bleeding site is
closure to help elicit unsecured bleeding vessels and identified.
unwanted chyle leakage. If a chyle leak is encountered, it is • A postoperative seroma may develop later in the postop-
critical to securely tie off the thoracic duct and ensure that erative course. Seromas most commonly manifest by
the leakage is controlled prior to closing. Occasionally, a about postoperative day 5. If swelling is mild, it can often
muscle flap is required to help seal off a leak. If there is a be managed conservatively, and the swelling will subside
concern for a chyle leak, a drain should be placed in the over the next few days. If the patient is highly symptom-
wound bed to facilitate early identification and drainage of atic, then a simple bedside aspiration under ultrasound
the area. guidance can relieve the pressure. Aspirations must be
performed under sterile conditions or you risk converting
a sterile postoperative fluid collection into an abscess.
Postoperative Care • Profuse neck drainage, especially from the left-sided neck
drains, suggests the presence of a chyle fistula. If a small
• Postoperatively a compression dressing can be used to leak is identified, it may cease with conservative manage-
promote wound coaptation and reduce the incidence of ment, such as medium-chain triglyceride diet, parenteral
postoperative seromas, hematomas, and wound edema. nutrition, and a pressure dressing. Occasionally, a high-
Drains have historically been used for all neck dissec- output leak will require intrathoracic ligation of the tho-
tions, but experience has shown that many patients can be racic duct, fibrin sealant placement, or flap closure.
managed effectively without drains. If drains are used,
they are placed to bulb suction, to help facilitate drainage
of the space, and to monitor for chyle or lymphatic leaks.
The drains are maintained until output is low and there are Further Reading
no signs of chyle leakage. Drains usually can be removed
the following day. An alternative to drain placement is to Caron NR, Tan YY, Ogilvie JB, et al. Selective modified and radical
neck dissection for papillary thyroid cancer – is level I, II and V dis-
place a fibrin sealant within the dissected space and then section always necessary? World J Surg. 2006;30:833–40.
to apply pressure to the neck to allow the tissues to coapt Carty SE, Cooper DS, Doherty GM, et al. Consensus statement on the
effectively obliterating the space. terminology and classification of central neck dissection for thyroid
• Physical therapy of the shoulder should be considered in all cancer. Thyroid. 2009;19(11):1153–9.
Cooper DS, Doherty GM, Haugen BR, Kloos RT, et al. Revised
patients in whom CN XI was dissected, especially if both American Thyroid Association management guidelines for patients
Levels VA and VB have to be dissected. This is particularly with thyroid nodules and differentiated thyroid cancer. Thyroid.
critical if CN XI had to be sacrificed or was injured during the 2009;19:1167–214.
dissection. Shoulder pain with movement (“shoulder syn- de Carvalho AY, Chulam TC, Kowalski LP. Long-term results of obser-
vation vs prophylactic selective level VI neck dissection for papil-
drome”) is not an uncommon complication of a lateral neck lary thyroid carcinoma at a cancer center. JAMA Otolaryngol Head
dissection, especially if Level VA has been removed. Loss of Neck Surg. 2015;141(7):599–606.
trapezius support allows the shoulder to droop, resulting in Ferlito A, Robbin KT, Shah JP, Medina JE, Silver CE, Al-Tamimi S,
decreased shoulder mobility and pain. Exercises for range of et al. Proposal for a rational classification of neck dissections. Head
Neck. 2011;33(3):445–50.
motion should be undertaken to prevent shoulder fibrosis. Gavilán J, Herranza J, DeSanto LW, et al. Functional and selective neck
• Management of hypocalcemia postoperatively for patients dissection. New York: Thieme Medical Publishers, Inc.; 2002.
undergoing a central neck dissection is similar to that after a Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid
thyroidectomy. Serum calcium and PTH levels are obtained Association management guidelines for adult patients with thyroid
nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1.
postoperatively, and calcium supplementation can be given
according to an algorithm or symptom-based treatment.
Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet Sippel RS, Carty SE, Chen W. Central and lateral compartment lymph-
GW. Standardizing neck dissection terminology. Official report adenectomy (neck dissection) for differentiated thyroid cancer.
of the Academy’s Committee for Head and Neck Surgery and UpToDate. 2017.
Oncology. Arch Otolaryngol Head Neck Surg. 1991;117:601–5. Sitges-Serra A, Lorente L, Sancho JJ. Technical hints and potential pit-
Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha falls in modified radical neck dissection for thyroid cancer. Gland
A, Som P, Wolf GT. Neck dissection classification update: revi- Surg. 2013;2(4):174–9.
sions proposed by the American Head and Neck Society and the Stack BC Jr, Ferris RL, Goldenberg D, Haymart M, Shaha A, Sheth
American Academy of Otolaryngology – Head and Neck Surgery. S, Sosa JA, Tufano RP. American Thyroid Association consensus
Arch Otolaryngol Head Neck Surg. 2002;128:751–8. review and statement regarding the anatomy, terminology, and
Robbins KT, Shaha AR, Medina JE, Califano JA, Wolf GT, Ferlito A, rationale for lateral neck dissection in differentiated thyroid cancer.
Som PM, Day TA. Consensus statement on the classification and Thyroid. 2012;22(5):501–9.
terminology of neck dissection. Arch Otolaryngol Head Neck Surg.
2008;134(5):536–8.
Parathyroidectomy
129
Sonia L. Sugg
Indications I), 10–40% of patients with MEN-IIA, and rarely in those

with MEN-IIB. Primary hyperparathyroidism is a result of
• Primary hyperparathyroidism is a common disease. The single-gland disease (adenoma) in 80–90%, and multiple-
diagnosis is made by finding persistent hypercalcemia and gland disease (multiple adenomas or hyperplasia) in
an elevated serum parathyroid hormone (PTH) concentra- 10–20%. Parathyroid cancer is rare.
tion. Other causes of hypercalcemia are ruled out by the • Secondary hyperparathyroidism results from chronic renal
history, particularly the use of lithium and thiazide diuret- failure (CRF) or malabsorption and is characterized by hypo-
ics. A 24-hour urine collection is valuable for document- calcemia and hyperphosphatemia. It is common in patients
ing the extent of hypercalciuria and to rule out familial with CRF and usually responds to treatment with phosphate
hypocalciuric hypercalcemia (FHH). Parathyroidectomy binders, calcimimetics, or Vitamin D analogues (KDIGO
is recommended in most patients to prevent the osseous 2017). About 5–10% of these patients require parathyroidec-
and renal complications of hyperparathyroidism and to tomy because of refractory hyperparathyroidism and/or
relieve symptoms such as fatigue and bone pain. symptoms such as bone pain, pruritus, and myopathy
Complications of untreated primary hyperparathyroidism (Berkoben and Quarles n.d.). In patients with tertiary hyper-
include hypercalcemic crisis, kidney stones, decreased parathyroidism after successful renal transplantation, persis-
renal function, decreased bone mineral density (BMD), tent hypercalcemia is an indication for parathyroidectomy.
and fractures. Cinacalcet, a calcimimetic that reduces
serum calcium and PTH concentrations, is a nonoperative
option. However, it is expensive, often poorly tolerated, Preoperative Preparation
and is primarily used in patients who are poor surgical
candidates (Messa et al. 2011). Some patients with mild • Preoperative imaging: If a four-gland exploration is planned,
hypercalcemia and no symptoms may be observed. The preoperative imaging is unnecessary. A decision to operate
American Association of Endocrine Surgeons’ guidelines should be based on the biochemical diagnosis and symp-
for surgery in 2016 state that surgery should be considered toms, and not on results of the imaging study. Many patients
for most asymptomatic patients as it is more cost-effective with indications for surgery (10–40%) will have negative
(Wilhelm et al. 2016). Incorporating the medical perspec- imaging studies. Minimally invasive parathyroidectomy
tive, the Fourth International Workshop issued revised (MIP) (Chap. 130) may be planned but four-gland explora-
guidelines on the indications for surgery in patients with tion will be required in a significant number of patients.
asymptomatic primary hyperparathyroidism (Bilezikian • Intraoperative PTH monitoring (IOPTH): Parathyroid
et al. 2014). The cause for primary hyperparathyroidism in hormone levels are monitored before and after removal of
most patients is unknown. A small number of cases may be the parathyroid adenoma using a rapid assay performed
familial in origin or associated with a history of neck irra- intraoperatively. If the level drops appropriately, it con-
diation. Hyperparathyroidism occurs in at least 90% of firms single-gland disease and predicts operative success
patients with multiple endocrine neoplasia type I (MEN- with the minimally invasive approach (see Chap. 130). It
can also be used in the setting of secondary hyperparathy-
S. L. Sugg (*) roidism to assess the adequacy of resection; however, the
Department of Surgery, University of Iowa Carver College criteria are not as well established.
of Medicine, Iowa City, IA, USA • Laryngoscopy may be done routinely or selectively in
e-mail: sonia-sugg@uiowa.edu
patients with voice symptoms or prior neck surgery.
https://doi.org/10.1007/978-3-030-81415-1_129
1016 S. L. Sugg
• Patients with secondary hyperparathyroidism may undergo Preserving the Recurrent Laryngeal Nerve
dialysis with regional heparinization the day before surgery.
The superior parathyroids are lateral and posterior to the
nerve, and the inferior parathyroids are generally anterior
Pitfalls and Danger Points and medial to the nerve (Fig. 129.1) (Akerstrom et al. 1984).
The recurrent laryngeal nerve inserts into the larynx just cau-
• The major pitfall is failing to cure the disease because of dad to the caudad edge of the cricothyroideus muscle, so the
missing multiglandular disease or failing to find the superior pole of thyroid can be mobilized cephalad to this
offending adenoma. muscle without worrying about damage to this nerve. Even a
• Injury to the recurrent laryngeal nerve is possible with nonrecurrent recurrent laryngeal nerve (which occurs on the
resultant change in voice, aspiration of liquids, failure to right side with an incidence of only 1%) still inserts into the
protect the airway, and possible upper airway obstruction. larynx caudad to the cricothyroideus muscle. The nerve can
Damage to the motor branch of the superior laryngeal bifurcate, but generally it does so within about 1 cm of its
nerve produces changes in the voice pitch and strength. insertion into the larynx. Gross identification of the nerve is
• Recurrence of hypercalcemia is low after excision of a aided by the presence of a vasa vasorum that looks like a “red
solitary parathyroid adenoma but higher with hyperplasia, racing stripe” on the anterior surface of the nerve. The nerve
familial disease, or secondary hyperparathyroidism. runs slightly obliquely in the tracheoesophageal groove.
• Removal of too much parathyroid tissue is also possible, Structures running along this course are not the inferior thy-
especially if everything found at operation is biopsied or roid artery (which is a misnomer). This artery actually cor-
excised. responds in position to the middle thyroid vein. Unfortunately,
Operative Strategy
Curing the Disease
The sine qua non of parathyroid surgery is a bloodless field.

The presence of blood around a lymph node or a bit of fat
will make it look like a parathyroid gland. It is for this reason
that we perform careful dissection with fine instruments. We
do not use electrocautery close to the recurrent laryngeal
nerve to avoid injuring it by local spread of the electrical
current.
The role of a pathologist is mostly supportive. They can
confirm that parathyroid tissue was removed or biopsied, and
weigh the material. The decision about what to do is based
on the gross findings.
A minimally invasive or focused parathyroidectomy is Sup.
parathyroid
guided by preoperative imaging, and will be covered in
greater detail in Chap. 130. IOPTH monitoring confirms
adequate removal of hyperfunctioning parathyroid tissue. Recurrent
A subtotal parathyroidectomy or a total parathyroidec- laryngeal n.
tomy with autotransplantation (of fresh or cryopreserved tis-
sue) is performed for hyperplasia, MEN-I, MEN-IIA, and
secondary hyperparathyroidism. The choice of which proce- Inf.
parathyroid
dure to use depends on the findings at operation, the relative
risks of hypocalcemia and recurrent hypercalcemia, the
availability of cryopreservation, patient reliability, and sur-
geon preference.
The cervical thymus is removed from patients with pri-
mary or secondary hyperplasia because of the 15–25% inci-
dence of supernumerary parathyroids (many of which are in
the thymus) in these conditions (KDIGO 2017). Fig. 129.1
129 Parathyroidectomy 1017
the nomenclature suggests to the novice that the artery should Operative Technique
be running from an inferior location cephalad to the thyroid,
whereas it runs transversely in the neck. The recurrent laryn- Incision and Exposure
geal nerve is most commonly injured at the ligament of
Berry, as the nerve can be closely adherent to or even run Mark a line (a skin crease or one of Langer’s lines) at the
through the substance of the ligament. base of the neck with the patient sitting in a comfortable
position (with arms folded in the lap) to achieve the best cos-
metic result. To wait until the patient is supine and then mark
Preserving the Superior Laryngeal Nerve the incision belies the fact that most people see the patient
erect. The shift in the skin line when they do become supine
The motor branch of the superior laryngeal nerve may varies two to three fingerbreadths above the sternal notch,
descend low and anterior to, interdigitate with branches of, and the depth of the sternal notch varies from patient to
or be enveloped in the same fascial sheath as the superior patient, making the incision line variable in its ultimate
thyroid artery (Fig. 129.2). This makes injury to the nerve location.
possible particularly during thyroid lobectomy. It is less of a Place a folded sheet longitudinally along the thoracic
problem during parathyroidectomy but still must be borne in spine to allow the shoulders to roll laterally. Extend the neck
mind. Some surgeons verify the position of this nerve on the gently with a rolled towel underneath the neck and the
basis of electrical stimulation to see movement of the crico- patient’s head in a donut or padded support. Move the patient
thyroideus muscle. to the barber chair position with arms at the side and flexion
at the hips and the knees (redraw picture).
Make a 3–8 cm skin incision with a No. 15 blade. The
Preserving Normal Parathyroid Tissue length of the incision depends upon the patient’s anatomy,
the surgeon’s experience, and the type of surgery planned.
In a four-gland exploration, the neck should be explored on Divide the subcutaneous tissues and platysma muscle trans-
both sides before excising or biopsying tissue. Parathyroids versely. The platysma may be represented by its fascia in a
that are normal grossly should not be excised. We tend to be small incision, as the muscle itself may be located lateral to
conservative in our operations, preferring to excise only the midline. Elevate subplatysmal skin flaps cephalad to the
abnormally enlarged parathyroids and biopsy the next largest notch of the thyroid cartilage and caudad to the sternal
normal parathyroid. Gross identification of the parathyroids notch. Incise the investing layer of the deep cervical fascia
is adequate if the surgeon is experienced. in the midline from notch to notch. Separate the strap mus-
cles from each other and from their contralateral partners.
Divide the areolar tissue between the thyroid and the strap
muscles.
I dentify Crossing of the Inferior Thyroid Artery

and the Recurrent Laryngeal Nerve
Mobilize the thyroid lobe medially to separate it from the

carotid sheath. The middle thyroid vein need not be
divided. The recurrent laryngeal nerve runs posterior
(most commonly) or anterior to the inferior thyroid artery
and sometimes even interdigitates with branches of the
artery. The relation of the inferior thyroid artery and
recurrent laryngeal nerve is important because we locate
the parathyroids relative to the crossing of the nerve and
the artery.
Find the nerve low in the neck and trace it cephalad by
careful blunt dissection anterior to the nerve. This generally
allows you to find and preserve the bifurcation and avoid
injury to the nerve at the ligament of Berry.
Fig. 129.2
1018 S. L. Sugg
Identifying Inferior and Superior Parathyroids identification. Control the bleeding with a hemostatic clip,
which also marks the position of this gland.
The two parathyroids on each side are often surprisingly
close to each other. The superior parathyroids are usually
located next to the cricoid cartilage, and the inferior parathy- Subtotal Parathyroidectomy
roids are usually within a 2 cm radius of the inferior pole of
the thyroid. Inspect the posterior capsule of the thyroid and The term “three and a half gland parathyroidectomy” is
the areas posterior and lateral to the thyroid. Gently palpate imprecise and should be abandoned. First fashion a well-
these areas to detect masses. Follow the course of the vascularized remnant of the most normal-looking parathy-
recurrent laryngeal nerve. It may be necessary to mobilize roid away from the recurrent laryngeal nerve. Excise tissue
the superior pole of the thyroid to find the superior parathy- sharply from the antihilar end until the remnant is about
roid. A reddish-brown color is the visual clue to an adenoma. 50 mg (5 × 3 × 2 mm). Mobilize and excise each of the other
It is different in appearance from the thyroid, bits of fat, or parathyroids sequentially, looking back to confirm the viabil-
lymph nodes. It moves independently of its surroundings. ity of the original remnant before excising the next gland. If
The normal parathyroid is yellow-brown and generally oval this remnant is not viable, fashion another well-vascularized
and flattened, although it can have other shapes, conforming remnant from one of the remaining glands. This practice pro-
to structures around it. vides four opportunities to obtain a well-vascularized
remnant.
Resecting the Adenoma

Total Parathyroidectomy
Mobilize the adenoma from surrounding tissues gently, mak- with Autotransplantation
ing sure you have preserved the recurrent laryngeal nerve.
Divide the hilar blood supply to the adenoma between Remove all four parathyroids. Set aside parathyroid tissue
clamps and ties of fine permanent sutures. Do not grasp the for autotransplantation immediately (on ice) or after cryo-
adenoma with forceps, which would increase the chance of preservation (slow freezing).
breaking the capsule, leading to implantation of parathyroid Make a longitudinal incision in the volar aspect of the
tissue and recurrent hypercalcemia. nondominant forearm. Sharply divide subcutaneous tissues
down to the fascia of the forearm musculature. Create 12–15
pockets in the volar aspect of the forearm musculature using
Biopsying Normal Parathyroid the electrocautery unit for the fascia and careful blunt dissec-
tion in the direction of the muscle fibers to avoid eschar and
Biopsy the next largest parathyroid gland (Fig. 129.3). hematoma formation, respectively. Mince a parathyroid into
Mobilize the antihilar one-third to one-fourth of the parathy- 1 × 1 × 1 mm pieces. Place each piece in an individual mus-
roid sharply and excise it as a biopsy. The cut edge of a para- cle pocket, and close it over with a fine permanent suture;
thyroid typically bleeds uniformly, which helps with its mark it with a hemoclip. Close the skin with absorbable sub-
cuticular sutures and adhesive skin strips.
Sequence for an Unfound Parathyroid Gland
Explore for the missing gland in all the usual locations

(Berkoben and Quarles n.d.). Follow the branches of the
inferior thyroid artery, which can be a clue to its location.
Incise the thyroid capsule over any area of discoloration that
might be due to devascularization of an intrathyroidal para-
thyroid. Mobilize the thyrothymic ligament to help mobilize
the cervical thymus to search for an intrathymic parathyroid
adenoma. Inspect and palpate behind the pharynx and esoph-
agus. Open the carotid sheath to inspect for parathyroids
associated with the vagus nerve. Inspect and palpate again
along the embryologic course of the parathyroids from the
Fig. 129.3 hyoid bone to the aortic arch.
129 Parathyroidectomy 1019
With ultrasound, most intrathyroidal parathyroid adeno-

mas may be identified preoperatively or intraoperatively.
Though rarely performed, you may consider performing a
thyroid lobectomy on the side of a missing superior parathy-
roid adenoma. The technique is similar to that shown in
Chap. 127.
Perform a cervical thymectomy for a missing inferior
parathyroid adenoma. Grasp thyrothymic fat and thymus
with an Allis clamp or ring forceps. Sharply mobilize the tis-
sue off the trachea between the recurrent laryngeal nerves as
far caudad as you can reach. Bluntly mobilize it from under-
neath the manubrium aided by a rocking, back-and-fourth
motion of the ring forceps grasping the tissue (Fig. 129.4).
Excise this tissue.
Closure
Achieve hemostasis using fine suture-ligatures or clips (small

or micro) for bleeding close to the recurrent laryngeal nerve.
Close the strap muscles in layers with interrupted absorbable
sutures and the investing layer of the deep cervical fascia
with a running absorbable suture. Close the platysma muscle
Fig. 129.5
with interrupted absorbable sutures, and approximate the
skin edges with subcuticular absorbable sutures and adhesive
skin strips. Posterior Approach
This is a useful approach if the suspected adenoma is localized

Reoperation to one side, especially in the reoperative neck. Incise the
investing layer of deep cervical fascia between the strap mus-
Reoperation may be indicated if the patient does not achieve cles and the sternocleidomastoid muscle on that side
normocalcemia and has significant disease. Localization (Fig. 129.5). Dissect down to the carotid sheath. Divide or
studies are required, and we prefer two concordant localizing mobilize and retract the omohyoid muscle. Find the recurrent
studies prior to reoperation. Reoperation without definitive laryngeal nerve. Approach the thyroid from its lateral aspect,
localization is often unrewarding. avoiding scars from the previous operation. If the suspected
adenoma has not been localized, reexploration on both sides is
necessary. Do this in a systematic way, exploring the usual
locations first, as the missing adenoma is usually there.
A partial or full median sternotomy is almost never done
at the initial exploration but may be necessary if the sus-
pected adenoma is in the chest. Alternatively, some adeno-
mas may be approached via mediastinoscopy and consultation
with a thoracic surgery colleague may be valuable regarding
the surgical approach.
Postoperative Care
• Cover the incision with a dry sterile dressing. Advance

patients to a regular diet if tolerated. Be alert for upper
airway obstruction, symptoms, and signs of damage to the
parathyroids or laryngeal nerves. Check the serum cal-
Fig. 129.4 cium level daily while in the hospital. Incisional pain is
1020 S. L. Sugg
generally tolerable and responds to acetaminophen with require reintubation or tracheostomy. Finally, laryngeal
or without codeine. tetany can cause upper airway obstruction because of
• Special considerations in patients with secondary hyper- hypocalcemia from hypoparathyroidism. It responds
parathyroidism due to kidney failure. Dialyze patients quickly to parenteral calcium.
1–2 days after operation using regional heparinization. • Recurrent laryngeal nerve palsy can arise simply from
These patients are prone to prolonged and severe hypocal- dissecting the nerve (without a direct injury). Identifying
cemia. The blood level of ionized calcium should be mea- the recurrent laryngeal nerve at operation decreases the
sured every 4–6 hours for the first 48–72 hours after chance of permanent palsy in thyroidectomy but has not
surgery, and then twice daily until stable. been studied in parathyroidectomy. A nerve transection
• If the blood levels of ionized or corrected total calcium during neck exploration should be repaired using magni-
fall below normal (<3.6 mg/dL [0.9 mmol/L] correspond- fication, microsurgical instruments, and fine permanent
ing to corrected total calcium of 7.2 mg/dL [1.80 mmol/L]), sutures to approximate the neurilemmal sheath. Vocal
a calcium gluconate infusion should be initiated at a rate cord function will not recover, but improved tone may
of 1–2 mg elemental calcium per kilogram body weight result from the repair.
per hour and adjusted to maintain an ionized calcium in • Superior laryngeal nerve palsy is uncommonly detected.
the normal range (4.6–5.4 mg/dL [1.15–1.36 mmol/L]). A It should be a problem only to patients who use their voice
10 mL ampule of 10% calcium gluconate contains 90 mg professionally, such as the opera star Amelita Galli-Curci,
of elemental calcium. The calcium infusion should be whose career was cut short by injury to this nerve at
gradually reduced when the level of ionized calcium thyroidectomy.
attains the normal range and remains stable. • Patients may develop hypocalcemia as the disease
• When oral intake is possible, the patient should receive reverses itself after successful parathyroidectomy. It is
calcium carbonate 1–2 g three times a day, as well as cal- usually temporary and responds to parenteral and oral cal-
citriol of up to 2 μg/day, and these therapies should be cium. Give calcium gluconate 1 g IV and then calcium
adjusted as necessary to maintain the level of ionized cal- carbonate 1.5 g PO qid. For significant hypocalcemia, I
cium in the normal range. usually add calcitriol 0.25–0.50 μg PO per day. If the
• If the patient was receiving phosphate binders prior to serum calcium is normal 1–2 weeks postoperatively on
surgery, this therapy may need to be discontinued or oral calcium alone, the calcium dose can usually be
reduced as dictated by the levels of serum phosphorus. tapered and stopped or reduced to replacement doses
given for optimal bone health.
Complications
References
• Bleeding is a possibility after any neck exploration and is
of vital concern when it causes tracheal compression and Akerstrom G, Malmaeus J, Bergstrom R. Surgical anatomy of human
respiratory compromise. It usually manifests in the eve- parathyroid glands. Surgery. 1984;95(1):14–21.
ning of the operation as dyspnea and is managed by evac- Berkoben M, Quarles LD. Refractory hyperparathyroidism and
indications for parathyroidectomy in adult dialysis patients.
uating the hematoma emergently using a sterile clamp
Up to Date. n.d. https://www.uptodate.com/contents/refractory-
that has been taped to the bed for just this possibility. Take hyperparathyroidism-and-indications-for-parathyroidectomy-in-
the patient to the operating room to explore the neck. adult-dialysis-patients.
Usually, no single bleeding point is found. Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the manage-
ment of asymptomatic primary hyperparathyroidism: summary
• There are several causes of upper airway obstruction in
statement from the fourth international workshop. J Clin Endocrinol
addition to hematoma. The most common is soft tissues, Metab. 2014;99(10):3561–9.
usually the tongue, falling posteriorly. This complication KDIGO 2017 clinical practice guideline update for the diagnosis, eval-
typically occurs in the recovery room and is usually uation, prevention,and treatment of chronic kidney disease-mineral
bone disorder (CKD-MBD). Kidney Int Suppl. 2017;7:1–59.
reversed by the chin lift or jaw thrust maneuver. Recurrent
Messa P, Alfieri C, Brezzi B. Clinical utilization of cinacalcet in
laryngeal nerve palsy, particularly bilaterally, can cause hypercalcemic conditions. Expert Opin Drug Metab Toxicol.
upper airway obstruction. It is typically seen right after 2011;7(4):517–28.
operation but may be delayed because of swelling, caus- Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of
Endocrine Surgeons guidelines for definitive management of pri-
ing paresis of the nerve 1–2 days postoperatively. It may
mary hyperparathyroidism. JAMA Surg. 2016;151(10):959–68.
Minimally Invasive Parathyroidectomy
130
Philip M. Spanheimer and Sonia L. Sugg
Indications and Preoperative Preparation • We, however, advocate for MIP in primary hyperparathy-
roidism even without localization because there is little
• The indications for parathyroidectomy were discussed in the downside. Single-gland disease is found in 80% of
previous chapter. The advantages of minimally invasive para- patients and a randomly selected side will contain that
thyroidectomy (MIP) include improved cosmesis from a gland ½ of the time, resulting in up to 40% of patients
smaller incision, and the preservation of intact tissue plains in being spared four-gland exploration. If an adenoma is not
one side of the neck. The technique can be performed under found or appropriate PTH drop is not observed, the inci-
sedation with a cervical block rather than general anesthesia sion can be lengthened and the other side explored.
and decreases operative time with proper localization.
• Minimally invasive parathyroidectomy should not be per-
formed if parathyroid carcinoma is suspected. Pitfalls and Danger Points
• Once the diagnosis of hyperparathyroidism is established
and the decision for parathyroidectomy is made, the oper- • The major pitfall in MIP is missing multigland disease and
ative planning should include assessment for MIP. Only failure to cure the hyperparathyroidism. For this reason,
patients with primary hyperparathyroidism should be monitoring IOPTH and appropriate interpretation of those
considered for MIP because patients with secondary and results is essential. Careful review of preoperative imaging
tertiary hyperparathyroidism have multigland disease. is important to maximize the likelihood of finding an ade-
The use of MIP in patients with MEN associated hyper- nomatous gland with limited exploration as well as identi-
parathyroidism is controversial as they are more likely to fying patients more likely to have multigland disease.
have multigland disease than the general population. • MIP involves exploration of only one side of the neck,
• The primary determination of eligibility for MIP in obviating risk of bilateral nerve injury, and resultant air-
patients with primary hyperparathyroidism is localization way compromise; however, unilateral nerve injury caus-
with preoperative imaging. A combination of ultrasound, ing voice changes and the potential for aspiration can
sestamibi (+/− SPECT and SPECT/CT), and 4D-CT is occur with MIP.
used at most centers. In most cases, imaging studies are • All patients with hyperparathyroidism are at risk for
able to localize a likely adenomatous gland, however, recurrence of disease. With proper IOPTH monitoring,
even a combination of modalities and concordant imaging these risks are equivalent in patients having undergone
result in incorrect localization or failure to identify multi- MIP (Chen et al. 2005; Udelsman et al. 2011).
gland disease up to one-third of the time. Failure to local-
ize or discordant imaging is frequently viewed as a
contraindication to MIP. Documentation
Precisely describe the location and appearance of any identi-

P. M. Spanheimer (*)
Department of Surgery, Memorial Sloan Kettering Cancer Center, fied glands, detailing clearly glands that are removed and left
New York, NY, USA in situ. This description is essential for the identification of
e-mail: spanheip@mskcc.org glands if reoperation is required for hyperparathyroidism
S. L. Sugg and for preservation of glands during any subsequent
Department of Surgery, University of Iowa Carver College thyroidectomy.

https://doi.org/10.1007/978-3-030-81415-1_130
1022 P. M. Spanheimer and S. L. Sugg
Operative Strategy which is not compromised by the clearance of two abnormal

glands on the initially explored side. This approach, versus
The operative strategy for MIP is similar to the strategy for immediate four-gland exploration and characterization of
parathyroidectomy detailed in the previous chapter. A blood- normal and abnormal glands, could be criticized. Dual ade-
less field is essential for the identification of anatomic struc- nomas although rare do occur in roughly 5% of patients with
tures and differentiation of parathyroid adenomas from primary hyperparathyroidism, and there is risk of missing
normal parathyroid tissue, fat, and lymph nodes. Good oper- four-gland disease. However, the IOPTH levels are the most
ative technique also avoids use of electrocautery near the predictive indicator of adequate excision of hyperfunction-
recurrent laryngeal nerve. ing parathyroid tissue, and although not validated in this con-
Preoperative imaging should be carefully reviewed. For text, provide a reasonable indication of disease control. If the
any suspected parathyroid adenoma, it is important to note second gland on that side does not grossly appear to be an
the side and location for operative planning. Often noting the adenoma or the PTH levels do not drop after excision, the
location as anterior (inferior) or posterior (superior) is a contralateral side must be explored.
more reliable determination of the embryologic origin versus
the traditional inferior/superior designation. Additionally,
identifying the relationship of the suspected adenoma with Avoiding Postoperative Complications
anatomic structures such as the thyroid and cricoid cartilage,
tracheoesophageal groove, and for posterior glands, proxim- Preserving the Recurrent Laryngeal Nerve
ity to vertebrae can aid in efficient intraoperative identifica-
tion of the intended gland. The superior parathyroids are lateral and posterior to the
nerve, and the inferior glands are generally anterior and
medial to the nerve. A detailed description of RLN anatomy
Intraoperative PTH Monitoring (IOPTH) is in the previous chapter. Prior to excision of a superior ade-
noma, the RLN should be identified. This is because the
Performance of MIP with acceptable rates of recurrent and blood supply to the posterior gland can be closely associated
persistent hyperparathyroidism relies on intraoperative with the RLN in a location where the nerve is turning from
PTH monitoring. Timing of PTH draws is surgeon depen- its course up the TE groove toward the larynx. This can result
dent but requires a baseline level (commonly a preoperative in misidentification of the nerve as the blood supply to the
level or a post-induction level). The consensus cutoff is a superior parathyroid and subsequent ligation. Due to its ante-
50% drop in PTH level and a post excision PTH level in the rior location, the blood supply to the inferior parathyroid fre-
normal range to determine the adequacy of resection quently is not associated as closely with the RLN and it is
(Wilhelm et al. 2016). It should be noted that PTH levels in therefore not essential to identify the nerve routinely when
the blood rise due to manipulation of the gland during sur- performing inferior parathyroidectomy. Careful dissection
gery, and in some instances, this increase can be quite dra- must be performed with the avoidance of ligating structures
matic (Yang et al. 2001). Additionally, renal function and until the parathyroid is completely mobilized and the blood
patient-specific factors can influence the half-life. For these supply can be clearly identified entering the gland. If this
reasons, we routinely draw levels at 5, 10, 15, and 30 min- anatomy cannot be clearly defined, the RLN should be found
utes post excision which provide multiple data points to in the midneck and traced inferiorly to prevent inadvertent
infer the trajectory of PTH levels and sufficient time post ligation.
excision to establish a new baseline. This approach avoids Hematoma in the neck can result in airway compromise
equivocal or difficult to interpret single values and can pre- and frequently requires return to the operating room. For this
vent operating room time waiting for results when PTH lev- reason, vessels should be tied or clipped and meticulous
els are re-sent. hemostasis assured before closing the neck.
If PTH levels do not meet criteria after excision of an
adenoma, further exploration must be undertaken. Our strat-
egy is to first identify the remaining ipsilateral gland. If the Operative Technique
appearance is grossly consistent with an adenoma, we per-
form excision with monitoring of PTH levels. If the second Incision and Exposure
excision results in appropriate reduction in PTH levels, the
procedure is terminated. If levels do not drop appropriately, Mark a line in the neck in a prominent skin crease with the
the contralateral side must be explored. This situation indi- patient standing or sitting in the preoperative area. Ideally
cates four-gland disease and 3.5-gland parathyroidectomy this will be just inferior to the cricoid cartilage. In general, a
should be performed as detailed in the previous chapter, larger incision placed in a skin crease provides better cosme-
130 Minimally Invasive Parathyroidectomy 1023
sis than a smaller incision outside a skin crease. The patient an easily interpreted dataset that reflects spikes in PTH dur-
is positioned supine on the operating table with a folded ing manipulation of the gland and establishment of a post
sheet or IV bag placed along the thoracic spine to roll the resection baseline.
shoulders laterally and extend the neck. The head is placed If the PTH level falls >50% and within the normal range,
on a donut and the table positioned in the barber chair con- the surgeon can conclude that all hyperfunctioning parathy-
figuration with the arms tucked at the sides to facilitate sur- roid tissues have been removed and terminate the operation.
geon access to the neck. Post induction and prior to incision, Failure to meet these criteria results in increased risk of per-
the surgeon should request a PTH level be drawn and sent to sistent and recurrent hyperparathyroidism and exploration
establish a baseline level. should be continued. As previously described, an approach
Make a 3 cm or larger incision along the previously of first evaluating the remaining ipsilateral gland followed by
marked skin crease with a #15 scalpel. The length of incision four-gland exploration if necessary allows some patients to
depends on the patient body habitus, experience of the sur- avoid bilateral exploration while keeping the risk of recur-
geon, and location of the gland relative to the skin crease rent or persistent hyperparathyroidism low.
used for incision. Some authors advocate an incision ori- When the exploration and excision is complete meticu-
ented on the side of MIP, but we prefer the cosmetic result of lous hemostasis should be obtained using fine sutures or
an incision centered in the midline, although this theoreti- clips. Close the cervical fascia with absorbable sutures leav-
cally could require a longer incision. ing a space at the inferior aspect of the incision through
Divide the subcutaneous tissue and platysma transversely which a neck hematoma could decompress. Close the pla-
with electrocautery until the fascia of the strap muscles is tysma muscle with interrupted absorbable sutures to prevent
identified. Then, raise subplatysmal flaps from the sternal undesirable cosmesis of scarring of the skin to the strap mus-
notch to the thyroid cartilage. Incise the cervical fascia in the cles. Close the skin with a subcuticular absorbable sutures
midline and retract the strap muscles laterally. After the strap and adhesive skin strips, which are preferable to skin glue in
muscles have been divided and the isthmus of the thyroid the folds of the neck.
identified, focus attention on the side of the localized gland.
Divide the areolar tissue between the thyroid and strap mus-
cles on this side. Postoperative Care
Based on review of the preoperative imaging, either an
enlarged superior or inferior gland should be suspected. A Patients can start liquids and initiate a diet when they are
superior gland will be posteriorly located, most commonly alert after anesthesia. Have the patient phonate in the recov-
lateral to the upper half of the thyroid gland. It can be located ery unit to rule out injury to the nerve. Check a serum cal-
in the tracheoesophageal groove and commonly drops into cium the evening of surgery and initiate calcium replacement
an inferior position when enlarged. An inferior gland will be if necessary. Most patients can be discharged the day of sur-
anterior, usually adjacent to the inferior thyroid lobe or in the gery after unilateral exploration. If the patient remains in the
thyrothymic tract. Retract the thyroid lobe with a Kittner, or hospital, check a calcium and PTH the morning after sur-
a finger on a sponge. After the abnormal gland is located, gery. Pain control is usually established with oral Tylenol
gently dissect it away from the surrounding tissue and iden- and rarely requires narcotics.
tify and ligate its blood supply with a fine suture or clip.
Avoid handling the gland as it will bleed, making the dissec-
tion more difficult, and can fracture which increases the Complications
chance of leaving behind adenomatous parathyroid tissue
resulting in persistent hyperparathyroidism. Avoid electro- • Bleeding causing hematoma and tracheal compression with
cautery as the nerve can be close, and it is usually not neces- respiratory compromise is rare but can happen after any neck
sary as the proper dissection plane is avascular. The other exploration. Any patient with postoperative neck hematoma
parathyroid gland does not need to be identified and if the should be evaluated for airway compromise and a low
adenoma is completely mobilized and the blood supply threshold should be had for reoperation and evacuation.
meticulously identified and ligated, it is not necessary to Even without airway compromise, washout of the hematoma
identify the nerve. A lower threshold should be had for for- improves postoperative pain and wound healing.
mal identification of the nerve for superior adenomas as the • Injury to the recurrent laryngeal or superior laryngeal
blood supply can more easily be mistaken for the nerve. nerves is also possible, but rare, with minimally invasive
Prior to ligation of the blood supply, the surgeon should parathyroidectomy. These injuries have been discussed in
inform the anesthesia provider that PTH levels will need to depth in the previous chapter.
be drawn and establish the timing of blood draws. As out- • Patients can develop hypocalcemia after parathyroidec-
lined previously, levels at 5, 10, 15, and 30 minutes provide tomy. This is usually the result of calcium absorption
1024 P. M. Spanheimer and S. L. Sugg
from depleted bones and delayed function of chronically Spanheimer PM, Stoltze AJ, Howe JR, Sugg SL, Lal G, Weigel RJ. Do
giant parathyroid adenomas represent a distinct clinical entity?
suppressed normal parathyroid tissue. Patients with large Surgery. 2013;154(4):714–8.
parathyroid adenomas, high preoperative PTH levels, and Udelsman R, Lin Z, Donovan P. The superiority of minimally invasive
high preoperative calcium levels are at increased risk for parathyroidectomy based on 1650 consecutive patients with pri-
symptomatic postoperative hypocalcemia (Spanheimer mary hyperparathyroidism. Ann Surg. 2011;253(3):585–91.
Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, Doherty
et al. 2013). After minimally invasive parathyroidectomy, GM, et al. The American Association of Endocrine Surgeons guide-
hypocalcemia is transient and can be managed with oral lines for definitive management of primary hyperparathyroidism.
and IV calcium. In almost all cases, calcium supplemen- JAMA Surg. 2016;151(10):959–68.
tation can be tapered and stopped around the first postop- Yang GP, Levine S, Weigel RJ. A spike in parathyroid hormone dur-
ing neck exploration may cause a false-negative intraoperative assay
erative visit. result. Arch Surg. 2001;136(8):945–9.
References
Chen H, Pruhs Z, Starling JR, Mack E. Intraoperative parathyroid hor-
mone testing improves cure rates in patients undergoing minimally
invasive parathyroidectomy. Surgery. 2005;138(4):583–90.
Open Adrenalectomy
131
James R. Howe
Indications gland itself from another site, lack of control of that primary
tumor and other sites of metastases beyond the adrenal gland.
Indications for adrenalectomy include functional adrenal The patient’s performance status should also be carefully
tumors of any size, non-functional tumors greater than considered in the decision to operate, as well as the possibil-
4–5 cm in size, lesions that continue to enlarge, and those ity of adjacent organ or major vascular involvement.
that are indeterminate on imaging and therefore suspicious
for metastasis, adrenocortical carcinoma, or pheochromocy-
toma. Currently, the majority of adrenal tumors are removed Preoperative Preparation
by laparoscopic adrenalectomy (see Chap. 132), but there are
still indications for open adrenalectomy in specific circum- Many adrenal tumors are found on cross-sectional imaging
stances. The most common reason to perform an open adre- performed for various abdominal or thoracic symptoms or
nalectomy is for larger tumors, typically those >5 to 6 cm in conditions. Others may be discovered during evaluation for
size. Although it is technically feasible to remove larger hypertension, which will lead to a work-up for hyperaldoste-
tumors laparoscopically, the risk of rupture of the tumor or of ronism, Cushing’s syndrome, or pheochromocytoma. If an
leaving residual adrenal tissue makes an open approach pref- adrenal mass has been discovered by a CT scan or MRI of
erable, because these larger lesions raise more concerns for the abdomen, its functional status should be determined by
malignancy. Furthermore, removal of regional lymph nodes checking for the presence of an elevated serum aldosterone
can be performed more effectively using an open technique, to renin ratio (>20–40), a morning cortisol level that does not
and if the tumor is adherent to adjacent tissues such as the suppress after a 1-mg dexamethasone given the night before,
liver on the right or stomach or pancreas on the left, an open and elevation of serum metanephrines and/or normetaneph-
approach affords the opportunity for resections with better rines. A 24-hour collection for urinary free cortisol and frac-
margins. Other relative indications for an open approach tionated catecholamines, VMA, and metanephrine may also
could be previous abdominal surgeries where laparoscopic be substituted for serum testing. A CT scan should be per-
access would be difficult, however, because the adrenals are formed with thin cuts through the adrenal, and the findings of
retroperitoneal, in most cases, previous operations do not Hounsfield units <10 on a noncontrast view are suggestive of
rule out a laparoscopic approach. Laparoscopic procedures a benign adenoma, as are a 50% decrease in Hounsfield units
may need to be converted to an open procedure when there is from the initial contrast CT as compared to a 10- to 15-minute
difficulty removing the adrenal gland, when it is found to be delay. If these two conditions are not satisfied, then the lesion
adherent to nearby structures, and most commonly, if during is classified as indeterminate. Indeterminate lesions with
dissection significant bleeding is encountered. high Hounsfield units may be pheochromocytomas, meta-
Contraindications to adrenalectomy would be distant static tumors, or ACC. The latter may have a more irregular
metastases from adrenocortical carcinoma (ACC) or pheo- shape and this should be looked for preoperatively, and for
chromocytoma, or in the case of a metastasis to the adrenal such lesions, an open approach is preferred for larger lesions
or those adherent to adjacent structures. On MRI, adenomas
have loss of intensity on out-of-phase images, while pheo-
J. R. Howe (*)
Department of Surgery, Surgical Oncology and Endocrine Surgery, chromocytomas tend to be bright on T2-weighted images.
Roy J. and Lucille A. Carver University of Iowa College of Further nuclear imaging with metaiodobenzylguanidine
Medicine, Iowa City, IA, USA (MIBG) can be performed to help confirm the presence of a
e-mail: james-howe@uiowa.edu

https://doi.org/10.1007/978-3-030-81415-1_131
1026 J. R. Howe
pheochromocytoma; however, this is seldom used and imag- Patients with excess cortisol production will require stress
ing may not be that helpful unless one is considering a thera- dose steroids and an IV steroid taper in the immediate post-
peutic trial of radioactive MIBG. 18FDG-PET scans may be operative period, followed by a prolonged oral steroid taper
useful in the setting of metastatic disease, and 68Ga-DATAPET lasting 3–6 months after discharge. These patients are at
for primary and metastatic pheochromocytomas and para- higher risk for complications due to the immunosuppressive
gangliomas, but are not required in most cases. effects and the problems with wound healing associated with
If the biochemical work-up is negative for excess aldoste- glucocorticoid excess.
rone, cortisol, or catecholamines, then the decision to oper-
ate is based upon the size of the lesion and its appearance on
imaging. Lesions <4 cm are rarely malignant (<2%) and Pitfalls and Danger Points
therefore can be observed, whereas lesions that are 4–6 cm
have an approximate risk of malignancy of 6%, and those One major pitfall is the decision to operate in an open versus
over 6 cm have a 25% risk. Most surgeons would advocate laparoscopic fashion. Whenever there is concern about the
the removal of non-functional lesions >4 cm in size because possibility of ACC, and the lesion is over 5–6 cm, an open
most ACCs are larger than this, and the risk of malignancy approach should be carefully considered. There is less risk
increases above this size. If the functional work-up is posi- of capsular disruption when performing the resection open
tive for hyperaldosteronism, it is important to carefully eval- as opposed to laparoscopically. If the capsule of the adrenal
uate the contralateral adrenal on imaging and rule out gland is disrupted and the patient has a malignant pheochro-
possible hyperplasia or nodularity on the other side. If there mocytoma or ACC, then there is a high risk that there will be
is any concern (and some would suggest that in all cases), seeding of tumor cells throughout the abdominal cavity.
selective venous sampling of both adrenals should be per- Therefore, it is very important to handle the adrenal gland
formed with measurement of aldosterone and cortisol levels gently and to avoid violating the capsule. On the left side,
and comparison of the values from each side. If the ratio of the pancreas and spleen may need to be mobilized in order
aldosterone and cortisol on one side is threefold more than to gain access to the adrenal gland. Therefore, injury to the
the contralateral side, then an adrenalectomy on that side is pancreas, spleen, or stomach must be carefully avoided. One
indicated. If this is not the case, the patient may have bilat- must also be careful not to injure the left renal vein as one
eral adrenal hyperplasia, and in this circumstance, medical takes the adrenal vein from its takeoff from the left renal
management may be preferable to bilateral adrenalectomy. vein. On the right side, the liver must be mobilized and
If the patient has elevation of metanephrines or normeta- rotated anteriorly in order to gain access to the posteriorly
nephrines, then preoperative alpha blockade followed by located adrenal gland. The right adrenal vein is very short
beta blockade will be required to protect the patient from and great care must be taken when dividing it in order to
intra- and postoperative complications resulting from cate- avoid significant hemorrhage from the IVC. In pheochro-
cholamine excess (hypertension, arrhythmia) or volume mocytomas especially, it has historically been advocated to
depletion from chronic vasoconstriction (hypotension, car- ligate the adrenal vein early in the procedure to reduce the
diovascular collapse). Generally, we start patients on 10 mg potential problems of excess catecholamine release during
of Phenoxybenzamine twice a day for 3–4 days, and then surgery, but we have found that with adequate preoperative
gradually increase this to 10 mg TID for 3–4 days, then alpha blockade that this is seldom necessary. However, any
20 mg BID for 3–4 days, and finally 20 mg in the morning, time one is operating on a pheochromocytoma, there is great
10 mg at noon, and 20 mg of Phenoxybenzamine at night for potential for both hypertension and hypotension, and there-
3–4 days. It is important to give the last dose of phenoxyben- fore, the anesthesiologist must be prepared to give vasodila-
zamine the evening before surgery because this irreversibly tors or vasopressors during the operation, and frequently,
inhibits alpha receptors. Once preoperative alpha blockade both classes of agents will be required at various times. The
has been mostly achieved, we will add a beta blocker such as surgeon should also be aware that if the patient develops
Propranolol 10 mg TID for the last 3 days preceding surgery significant hypertension, it may be necessary to stop manip-
with the last dose being given the morning of surgery. During ulating the adrenal gland while the anesthesiologist reduces
this 2-week period, it is important that patients drink a lot of the blood pressure to a safe level. Another complication
fluid to help them reconstitute their plasma volume and which may occur postoperatively is adrenal insufficiency.
check their daily pulse and blood pressures to look for ortho- This will universally occur in patients undergoing bilateral
stasis. Generally, patients with good blockade may feel dizzy adrenalectomy or removal of their second adrenal gland. In
standing up and even have difficulty walking across the patients with glucocorticoid excess, such as in Cushing’s
room, as well as developing a stuffy nose. If phenoxybenza- syndrome, the contralateral gland is often suppressed, and
mine is too expensive or unavailable, Doxazosin may be therefore, patients will also require post-op steroid
used for alpha blockade. medication.
131 Open Adrenalectomy 1027
Documentation
Important points to include in the operative note are the size

of the tumor and whether it is adherent to any adjacent struc-
tures. If one has resected an adjacent organ such as the liver
or kidney, this should be carefully noted in the operative
report. Whether there is capsular disruption should also be
noted and whether there was significant bleeding at the time
of surgery. The general color of the gland is also important,
with most benign adenomas having a yellow to orange color,
whereas pheochromocytomas tend to be more gray in color.
This is best assessed by having the Pathologist “bread loaf”
the specimen and return with it to the operating room; this
also helps one to confirm that the entire lesion has been
removed without the need for frozen section. The presence
of enlarged nodes, the smooth or irregular nature of the
tumor, the normal color of the kidney after resection, and the
presence or absence of liver lesions are also important fea-
tures to take note of.
Operative Strategy
For open adrenalectomy, there are multiple possible

approaches (Fig. 131.1). A midline incision can be used if
one needs to access both adrenal glands whereas a left or
right subcostal incision would provide excellent exposure to
the adrenal gland on that side. For large adrenal tumors, tho- Fig. 131.1 (From Brennan MF, Open transabdominal adrenalectomy
racoabdominal incisions may also be used, which allow good for malignant neoplasms, in Howe JR, ed. Atlas of Endocrine and
exposure to the chest which is especially important in cases Neuroendocrine Surgery, pp.145, Fig 10.1A. Springer-Verlag,
New York, 2017, with permission)
of large right-sided ACCs for control of the IVC. Through
one of these incisions, the abdomen will be explored, and it
is important to rule out metastatic disease to the liver and to nal vein comes off the renal vein, and on the right, it comes
assess for the possibility of local invasion by palpation. If a directly off the inferior vena cava (Fig. 131.2). The right
subcostal incision is to be used, then it is helpful to place a adrenal vein is very short and it is imperative to avoid injury
folded sheet underneath the ipsilateral side to raise that side in order to circumvent significant bleeding.
up 10°–15°.
On the right side, it is important to completely mobilize
the liver by taking down the right triangular ligaments in Operative Technique: Right Adrenalectomy
order to get to the posteriorly located adrenal gland. The
hepatic flexure of colon may need to be freed up and it is Place the patient supine on the operating room table, and
advantageous to expose the vena cava below the liver by per- make either a midline right subcostal incision. The subcostal
forming a limited Kocher maneuver. The liver is then rotated incision will need to be carried several centimeters to the left
medially to gain access to the retroperitoneal space. On the of midline and laterally to beyond the edge of the external
left side, for larger tumors, it is often necessary to take down oblique muscles. The subcutaneous tissues are then divided
the diaphragmatic attachments of the spleen and then mobi- with electrocautery down to the anterior fascia of the rectus
lize the spleen and pancreas medially. In the case of smaller abdominis muscle. This fascia is then divided by cautery and
tumors, it may be possible to remove these by entering the the rectus abdominis muscle is lifted up and divided with
lesser sac and then dissecting just above the pancreas, with- electrocautery, taking care to get excellent hemostasis and
out having to mobilize the spleen and pancreas. looking out for the inferior epigastric vessels. The posterior
The adrenal glands have three arteries derived from the fascia is then incised, and then the peritoneum to gain access
aorta, the phrenic, and the renal arteries. On the left, the adre- to the abdominal cavity. The muscles are then divided further
1028 J. R. Howe
Fig. 131.3
Fig. 131.2 (From Brennan MF, Open transabdominal adrenalectomy

for malignant neoplasms, in Howe JR, ed. Atlas of Endocrine and
Neuroendocrine Surgery, pp.145, Fig 10.1A. Springer-Verlag,
New York, 2017, with permission)
laterally to include a portion of the external and internal

obliques and transversalis.
Place a self-retaining retractor in the incision with blades
elevating the costal margin. Explore the abdomen, including
careful palpation of the liver, the diaphragmatic surfaces, and
the tumor itself to determine whether it is adherent to adja-
cent structures. Run the small bowel, inspect the colon, and
the pelvis. Palpate the stomach and duodenum.
Next, take down the right triangular ligament with elec-
Fig. 131.4
trocautery. Carefully elevate the diaphragm and divide the
peritoneal attachments between it and the dome of the liver
with cautery. Take care to avoid injury to the right hepatic kidney taking care not to injure the renal vein (Fig. 131.3).
vein as this incision is extended cephalad and medially. Mobilize the mass from the retroperitoneum superiorly, lift-
Carefully divide the peritoneum attaching the posterior ing it from the diaphragm and dividing the superior attach-
aspect of the liver to the retroperitoneum from lateral to ments to the surrounding perinephric fat.
medial along the inferior/posterior border of the liver. On the Next, direct attention toward the medial aspect of the
medial side, identify the infrahepatic IVC. adrenal gland, and divide the peritoneum over the edge of the
Then, rotate the liver medially so that the adrenal mass IVC. Extend this incision superiorly to the spot of the previ-
now comes into view. If necessary for better exposure of the ous superomedial dissection. Carefully divide the soft tissue
IVC, perform a Kocher maneuver and lower the hepatic flex- between the inferior pole of the adrenal and the IVC, often
ure of the colon. with an energy device and develop the space between the
Make an incision in the retroperitoneum lateral to the IVC and the adrenal gland (Fig. 131.4). Follow the IVC
mass, and continue it superiorly and medially up to the edge cephalad until the right adrenal vein is encountered. At this
of the liver, and inferiorly to the edge of the IVC. Carefully point, carefully dissect the soft tissue above the adrenal vein
separate the inferior border of the adrenal gland up off of the using an energy device and connect this with the upper aspect
be necessary in order to get the adrenal tumor free with an

adequate margin from the liver. It is helpful in these cases
to use a technique that will avoid significant hepatic paren-
chymal bleeding, such as an Aquamantis device or the
CUSA. If the adrenal tumor is stuck to the diaphragm, a
portion of the diaphragm should be taken, and if the adre-
nal gland invades into the kidney, consider performing a
partial nephrectomy . Remember that the first operation is
the best chance for avoiding local recurrence, which can be
very troublesome. It is essential to resect en bloc any tis-
sues which are adherent to the adrenal tumor as well as to
not rupture the capsule. Fibrofatty tissue along the IVC,
aorta, and right renal vessels can be removed and the
pathologist can assess for regional lymph node
involvement.
Fig. 131.5 Left Adrenalectomy
For left adrenalectomy, a midline or left subcostal incision

can be used as described on the right. Enter the peritoneal
cavity and explore the abdomen. For smaller tumors, divide
the omentum between the stomach and colon and then retract
the stomach up out of the way using a self-retaining retractor.
Next, incise the space just above the pancreas and splenic
artery using electrocautery or an energy device. It helps to
palpate the location of the kidney to get an idea of where the
suprarenal gland will sit and to palpate for the adrenal mass
at this point.
Sometimes it will be difficult to get good access because
the adrenal gland lies very posteriorly with the splenic artery
and vein sitting anterior to the mass. If the mass is superior
to these structures, then an energy device can be used to dis-
sect out the lateral aspect of the adrenal gland by opening the
fascia over the retroperitoneal space and then carefully dis-
secting counterclockwise for 180° from approximately the 6
o’clock to the 12 o’clock position. The artery and veins will
lie on the other side and this should be a relatively avascular
plane with just fibrofatty attachments to the retroperitoneal
Fig. 131.6 fat and kidney.
Next open the peritoneum around the edge of the gland,
progressing medially from 12 o’clock to 6 o’clock
of the previous dissection, extending all the way back to the (Fig. 131.7). Take down the superior attachments with an
diaphragm. energy device and when this is used, one will often not see
At this point, encircle the adrenal vein with a vessel loop the arterial inflow which will be divided safely by the energy
(Fig. 131.5) and divide it either with an EndoGIA stapler device. This dissection is carried out medially to the edge of
with a vascular load, large clips, or between clamps and then the aorta and posteriorly to the diaphragm. Once this is freed
suture ligate with a running 3-0 or 4-0 Prolene under the up, then the dissection proceeds inferiorly.
clamp (Fig. 131.6). Divide any further soft tissue that is pres- Identify the left renal vein by carefully dissecting out the
ent with an energy device and pass the adrenal off as a fibrofatty tissue inferior to the adrenal gland. The adrenal
specimen. vein may be encountered before the renal vein, but it should
Special considerations would be if the adrenal gland is be followed back to the renal vein to ensure that it is indeed
very adherent to the liver then a partial liver resection may the adrenal vein. Once this is identified, either doubly clip
1030 J. R. Howe
Fig. 131.9
this dissection, both the inferior and the medial adrenal arter-
ies will be taken.
In the cases with larger tumors, the approach of dissecting
Fig. 131.7 over the pancreas will not be possible and the most reliable
approach is to mobilize the spleen from its attachments to the
diaphragm. This is generally done with an energy device.
Open the peritoneum along the inferior edge of the pancreas
using the energy device, and then roll the spleen and pan-
creas medially. Protect them with a lap and hold out of the
way with a self-retaining retractor (Fig. 131.9). Next open
the retroperitoneum and take the vessels as described earlier
in this section. In these larger tumors, large arteries and veins
feeding the tumor will be encountered, and these should be
carefully dissected out and ligated.
Postoperative Care
In patients with pheochromocytoma, there is a high likeli-

hood that they will be hypotensive after surgery for some
period of time, usually for 4–12 hours. For this reason, these
patients should go to the ICU in case they need vasopressor
support. In patients with cortisol-secreting tumors, a postop-
erative steroid taper will be required. In patients with large,
non-functional tumors, the patients can often go the floor
Fig. 131.8 unless they have an extensive resection. On the first postop-
erative day, we check a CBC, a basic metabolic profile, and
a cortisol level (this will not be valid to look for adrenal func-
and divide it, take it with a GIA stapler, or suture ligate it tion if the patient received dexamethasone at the end of the
(Fig. 131.8). operation, which is commonly done to reduce postoperative
Next, use the energy device to divide the fibrofatty tissue nausea and vomiting). If the cortisol level is significantly low
between the adrenal gland and the aorta and take this medial and the patient did not receive dexamethasone, then the
plane cephalad to clear all the fatty tissue between the adre- patient should be started on steroids, which can be done with
nal, aorta, and diaphragm. Lymph nodes in the area of the daily oral prednisone or twice daily hydrocortisone, with
aorta can be removed with the gland, when present. During plans for a prolonged taper upon discharge. The patient can
drink clear liquids the first day after operation and a diet can tant to lower the blood pressure as soon as possible so as to
gradually be advanced over the next few days. Patients are avoid the possibility of a stroke or a cardiac event. If hypo-
generally in the hospital for about 5 days. tension is encountered, then the blood pressure must be
raised by phenylephrine or other vasopressors so as not to
cause problems with hypoperfusion.
Complications • If the patient has had a previous adrenalectomy, then
removing the second adrenal will risk Addisonian crisis.
• The most common complication of adrenalectomy is Therefore, postoperative steroids will be required and the
bleeding. On the right side, this may be from the IVC or the patient will need to be maintained on lifelong steroid
right adrenal vein. If this is encountered, then a vascular replacement, commonly with 15 mg of hydrocortisone in
clamp can be placed along the edge of the vena cava for the morning and 10 mg in the afternoon plus fludrocorti-
control, and then, this area is oversewn under the vascular sone 0.1 mg every day to every other day.
clamp with a 4-0 Prolene. On the left side, bleeding is most • Patients with ACC can develop hematogenous metastases
likely to come from the spleen after mobilization of the or local recurrence quickly, and for that reason follow-up
spleen or from the adrenal vein if it is not specifically iden- CT scans every 3 months are advised to rule out liver and
tified during dissection. A hole in the diaphragm can be lung metastases, as well as local recurrence. If the capsule
made on either side as one mobilizes the adrenal gland and of an adrenal tumor is disrupted, this may lead to perito-
adjacent fat off its undersurface. If this occurs, the dia- neal dissemination which may later manifest as multiple
phragmatic defect can be closed with absorbable sutures, intraabdominal lesions. Some tumors will recur in the
with caution to evacuate the air from the chest with a red adrenal bed if not completely removed and may need
rubber catheter and syringe while having the anesthesiolo- repeat surgery to remove the adrenal remnant when it is
gist perform a Valsalva maneuver to push the air out of the seen, especially in the cases of ACC.
chest as you tie the suture. Another complication is inad-
vertent transection of a superior pole renal artery or vein,
which will cause the kidney to become dusky and purple Further Reading
rather than the healthy reddish-pink color of the normal
kidney. If this happens, patients may develop hypertension Carr JC, Spanheimer PM, Rajput M, Dahdaleh FS, Lal G, Weigel RJ,
Sugg SL, Liao J, Howe JR. Discriminating pheochromocytomas
in the future, and it is difficult to repair a small superior from other adrenal lesions: the dilemma of elevated catecholamines.
pole vessel. As described, patients with pheochromocyto- Ann Surg Oncol. 2013;20:3855–61.
mas prior to alpha blockade can be severely volume Gaujoux S, Brennan MF. Recommendation for standardized surgi-
depleted and that is why alpha blockade is very important. cal management of primary adrenocortical carcinoma. Surgery.
2012;152:123–32.
In the absence of preoperative blockade, when a pheochro- Lafemina J, Brennan MF. Adrenocortical carcinoma: past, present, and
mocytoma is removed, the patients will likely experience future. J Surg Oncol. 2012;106:586–94.
cardiovascular collapse, which will be very difficult to Mege D, Taieb D, Lowery A, Loundou A, DE Micco C, Castinetti F,
treat. Because phenoxybenzamine is an irreversible alpha Morange I, Henry JF, Sebag F. Contemporary review of large adrenal
tumors in a tertiary referral center. Anticancer Res. 2014;34:2581–8.
blocker, patients may remain hypotensive for several hours Miller BS, Ammori JB, Gauger PG, Broome JT, Hammer GD, Doherty
after surgery. Other potential complications with pheochro- GM. Laparoscopic resection is inappropriate in patients with known
mocytomas can be arrhythmias, and this can be mitigated or suspected adrenocortical carcinoma. W J Surg. 2010;34:1380–5.
by the preoperative use of propranolol or another beta NIH state-of-the-science statement on management of the clinically
inapparent adrenal mass (“incidentaloma”) NIH Consensens State
blocker. If intraoperative hypertension occurs, it is impor- Sci Statements. 2002;19:1–25.
Laparoscopic Adrenalectomy
132
Emily E. K. Murphy and Tracy S. Wang
Indications cortisol excess. Family history of adrenal issues and endocri-

nopathies should also be explored. On physical exam, corti-
• Primary tumors of the adrenal gland sol excess can manifest as changes in fat distribution with
–– Nonfunctional tumors ≥4 cm moon facies or a buffalo hump, as well as purple striae.
–– Functional tumors Hypertension is a finding of cortisol excess, pheochromocy-
� Primary aldosteronism toma, and aldosterone-producing tumors.
� Cortisol-secreting tumor Biochemical evaluation for an adrenal tumor should
� Pheochromocytoma include:
• Metastases to the adrenal gland
• Adrenal hyperplasia • Basic metabolic panel
• Dehydroepiandesterone (DHEA)
• Serum cortisol
Relative Contraindications • Adrenocorticotrophic hormone (ACTH)
• Two of the following: 24-hour urine cortisol, two late-
• Tumors with suspicion/known adrenocortical carcinoma night salivary cortisol levels, and/or a 1 mg (low-dose)
• Tumors >6 cm dexamethasone suppression test
• Serum aldosterone and plasma renin activity
• Fractionated plasma-free metanephrines
For patients in whom a clinical diagnosis of a functional
Most adrenal nodules are discovered incidentally on imaging adrenal tumor has been made, without previous imaging, an
studies that are obtained for other concerns. All patients with adrenal protocol CT or MRI, including venous washout,
an adrenal nodule identified on imaging should have a thor- should be obtained. Non-contrast nodules ≤10 Hounsfield
ough history and physical exam and a biochemical evalua- units are largely benign. Enhancement washout compares
tion. Many will benefit from additional adrenal imaging. the attenuation of the enhanced scan with the value of the
Several points of pertinent history should be included in delayed scan, with a washout of 60% or greater representing
the workup of incidental adrenal nodules. A history of palpi- a likely benign nodule.
tations, headaches, diaphoresis, and severe hypertension
might represent the “spells” of pheochromocytoma.
Uncontrolled hypertension despite multiple medications Special Considerations
could indicate an aldosterone-producing tumor. A history of
fatigue and easy bruising can be elicited from patients with For patients with biochemical confirmation of primary aldo-
steronism (Conn’s syndrome), adrenal venous sampling is
E. E. K. Murphy the gold standard for differentiating between unilateral and
Surgical Institute of South Dakota, Sioux Falls, SD, USA bilateral adrenal disease. The test can be performed with or
T. S. Wang (*) without ACTH stimulation. It relies on interventional radiol-
Section of Endocrine Surgery, Froedert & Medical College of ogy access to the adrenal veins and inferior vena cava (IVC),
Wisconsin, Milwaukee, WI, USA typically through the femoral vein. First, catheter positioning
e-mail: tswang@mcw.edu

https://doi.org/10.1007/978-3-030-81415-1_132
1034 E. E. K. Murphy and T. S. Wang
is confirmed with comparison of adrenal vein cortisol to • Tumor capsule rupture—minimize significant manipula-
peripheral vein (IVC) cortisol levels; a ratio of >4:1 is confir- tion of gland, use endocatch bag to prevent spillage of
matory. After confirmation of catheter position, the ratio of adrenal contents during removal from the abdomen
aldosterone to cortisol levels between the right and left adre- • Incomplete resection of the tumor—examine specimen
nal vein is calculated; a ratio of >4:1 suggests a dominant for completeness when removed from abdominal cavity,
side of aldosterone excess. Adrenal vein sampling is key to examine operative bed
lateralizing aldosteronomas as the tumors are often small • Hypertensive crisis—minimize gland manipulation, par-
and contralateral adenomas can be present; in addition, ticularly with pheochromocytomas
patients with bilateral aldosterone excess are typically treated • Hypotension—particularly after ligation of the adrenal
with medical therapy (mineralocorticoid antagonists). vein during adrenalectomy for a pheochromocytoma
Patients with a pheochromocytoma should have preopera- • Conversion to open—not necessarily a failure when
tive alpha-blockade, optimally titrated to achieve mild extent of disease is greater than anticipated or aberrant
orthostatic hypotension. Medications can include nonselective anatomy complicates procedure, but failure to open in
alpha-blockers, such as phenoxybenzamine, or selective alpha- cases of uncontrolled bleeding, insufficient resources or
blockers, most commonly doxazosin. Phenoxybenzamine is limitations of operative skill can result in poor outcomes
usually initiated at a dose of 10 mg twice daily. The advantage
of phenoxybenzamine is that unlike selective alpha-blockers, it
is an irreversible antagonist, but still requires frequent dosing Postoperative
as new alpha receptors are rapidly produced. In addition to
orthostatic hypotension, nasal congestion, blurred vision and • After surgical resection, patients with preoperative long-
gastrointestinal upset are common side effects. Its use is lim- acting alpha-blockade for pheochromocytoma can expe-
ited by drug availability and price. Selective alpha-blockers, rience hypotension, which might require additional
include drugs such as doxazosin, which is usually initiated at support (most often intravenous fluids, though vasopres-
2 mg daily. Advantages include daily dosing and fewer side sors might be required). This is usually self-limiting as
effects and increased availability, but catecholamine spikes can more alpha receptors are produced. Similarly, patients
overcome its competitive receptor inhibition. In some cases, who have required multiple drugs for primary aldoste-
after complete alpha-blockade, reflex tachycardia can be ronism can have postoperative hypotension and a meticu-
treated with the addition of a beta-blocker. Recent reports from lous plan for antihypertensive medications should be
high-volume European centers have suggested might be unnec- made. Hypotension can also represent bleeding and adre-
essary in the preoperative treatment of pheochromocytoma, but nal insufficiency.
this has not yet been translated into standard of care, particu- • After adrenalectomy for hypercortisolism, adrenal insuffi-
larly in the United States. ciency, which manifests as electrolyte abnormalities, hypo-
tension, weakness, or fatigue can present. It can be avoided
with empiric physiologic glucocorticoid replacement or
Pitfalls and Danger Points determined by postoperative-day-one cosyntropin stimula-
tion testing for selective glucocorticoid replacement.
Preoperative
• A thorough preoperative evaluation can mitigate potential Documentation

consequences intraoperatively, such as failure to recog-
nize the presence of a pheochromocytoma or possible pri- Documentation of both the laparoscopic and retroperitoneal
mary adrenocortical carcinoma. This might affect both approaches should include side-specific details, as well as
the perioperative and intraoperative management, as well the indications for the procedure and any complications
as the choice of surgical approach to adrenalectomy. encountered. This should include any issues with bleeding or
violation of the diaphragm or complications mobilizing other
organs. The management of the adrenal vein—its identifica-
Intraoperative tion and how it was ligated—also should be reported.
• Bleeding—decreased risk with adherence to dissection

planes and identification of adrenal and renal vasculature Operative Strategy
• Iatrogenic injury to the surrounding organs, for example,
liver, duodenum, hepatic flexure of the colon (right adre- The choice of surgical approach can influence the success of
nalectomy) or spleen, pancreas, splenic flexure of the a procedure. Indications for the retroperitoneoscopic approach
colon (left adrenalectomy) include patients without excessive retroperitoneal fat or
132 Laparoscopic Adrenalectomy 1035
previous violation of the retroperitoneum; larger tumor size endocrine-specific complications. General complications
and increased body mass index are relative contraindications include risk of anesthesia, infection, and bleeding.
for this approach. Indications for transabdominal laparoscopic Appropriate preoperative evaluation should cardiac evalua-
approach include patients who would otherwise be good can- tion as well as pulmonary evaluation for known pulmonary
didates for laparoscopic surgery. Relative contraindications to disease, which could preclude safely proceeding with sur-
the transabdominal laparoscopic approach include multiple gery. The anesthesia team should be involved in a timely
intra-abdominal procedures, causing intra-abdominal adhe- fashion, especially in cases of pheochromocytoma, which
sions. Absolute contraindications to either transabdominal can be associated with swings in blood pressure
laparoscopic or retroperitoneoscopic approaches include a intraoperatively.
large tumor, concern for adrenocortical carcinoma, and a sur- Review of preoperative imaging can help predict aberrant
geon who is not trained in laparoscopic adrenalectomy. anatomy, such as variations in adrenal veins (multiple veins,
Preoperatively, placement of an oragastric tube and a deviant drainage patterns) or low-lying hepatic vasculature,
Foley catheter, which are both removed at the end of the case which could affect the surgical approach and mobilization of
if the patient is hemodynamically stable, allows for decom- surrounding structures during adrenalectomy. To minimize
pression of the stomach and bladder. These are placed prior potential injury to the liver, spleen, or pancreas during the
to positioning for ease of placement. Preoperative antibiot- transabdominal approach, gentle retraction of these organs is
ics, usually a cephalosporin, are also administered. Adequate best performed with a wide laparoscopic retractor. These
IV access is ensured, including a central venous catheter for come in convertible, inflatable, and expandable iterations,
patients who might require intraoperative vasopressors. but we prefer a 10-mm laparoscopic paddle retractor to
Nearly all patients with a pheochromocytoma should have broadly retract the intra-abdominal viscera. Attention should
arterial access for monitoring of blood pressure lability. also be paid to anatomic anchor points of these organs to
Without indication for some baseline medical issue, arterial avoid fracture at areas like the lateral attachments of the
access is usually otherwise not required for most other adre- spleen and the falciform ligament at the liver. In case of
nalectomies. Routine use of chemical preoperative antico- bleeding, venous ooze usually can be controlled with topical
agulation is probably unnecessary without preexisting hemostatic agents, though larger scale bleeding might require
indications (i.e., morbid obesity, known malignancy, etc.), laparoscopic clips or endoloop devices, or even conversion
but patients should at least have pneumatic compression to an open procedure.
devices on their lower extremities during the procedure. Postoperatively, the risk of adrenal insufficiency in
Port placement is critical during laparoscopic adrenalec- patients with cortisol excess might not be preventable; how-
tomy, particularly for the retroperitoneoscopic approach. In ever, the early identification of this process with either stan-
this approach, early visualization of the superior pole of the dard physiologic steroid dosing or postoperative day one
kidney will facilitate dissection of the adrenal gland. From cosyntropin stimulation tests can prevent its symptoms.
the transabdominal approach, mobilization of surrounding Patients with pheochromocytoma can have hypotension after
organs is essential; on the right, this includes mobilization of adrenalectomy from preoperative alpha-blockade, which is
the liver and identification of the inferior vena cava. Minimal usually self-limiting as new alpha receptors are rapidly
mobilization of the hepatic flexure is required. In contrast, on regenerated.
the left, mobilization of the splenic flexure and left peritoneal
attachments of the colon and superior and medial rotation of
the spleen and pancreas are critical in visualization of the Operative Technique
adrenal gland.
The primary aims in laparoscopic adrenalectomy are Transabdominal Approach
removal of all abnormal tissue (usually the entire gland
unless a cortical-sparing technique is employed) and control To perform a transabdominal laparoscopic adrenalectomy,
of the adrenal vein. The arterial supply is generally well con- after induction of anesthesia and placement of an orogastric
trolled with harmonic scalpel, but the vein usually requires tube and Foley catheter, position the patient with the assis-
either clips or an endo-stapling device for division. Usually tance of a bean bag in a semilateral decubitus position with
the venous drainage is controlled prior to control of the arte- the ipsilateral arm supported across the body with appropri-
rial supply. ate padded arm rests and positioning devices (Fig. 132.1). An
axillary roll is also used to decrease pressure points in posi-
tioning. Pillows are placed between the legs and safety straps
Avoiding Postoperative Complications are used to secure positioning. The operating bed is then
flexed to extend the distances between the ribs and the ante-
The most common complications following adrenalectomy rior iliac crest, with the kidney rest raised to maximize
include those related to any surgical procedure as well as extension.
adrenal gland. Ligate and divide the peritoneal attachments

with the harmonic scalpel. Once the splenic flexure has been
mobilized, identify the tail of the pancreas. Superiorly, divide
the splenorenal ligament, again with the harmonic scalpel, to
the level of the diaphragm. This allows medial visceral rota-
tion of the spleen and tail of pancreas. This maneuver exposes
the superior and lateral aspects of the perinephric fat and
adrenal gland. A soft paddle retractor inserted through a 10-
to 12-mm port or a laparoscopic Kittner through a 5-mm port
placed at the midline to the left of the falciform ligament can
be assist in this exposure. Pay careful attention to the tips of
the instrument, so as not to tear the splenic capsule.
With medial retraction of the spleen and pancreas, retract
the kidney laterally to identify the adrenal gland, which is
usually identified along the posterosuperior aspect of the kid-
Fig. 132.1 ney. Once identified, it is helpful to identify the left crus of the
diaphragm, to ensure that the most medial aspect of the adre-
nal gland is completely resected. Begin the dissection at the
most inferior aspect of the adrenal gland, utilizing the har-
monic scalpel to separate adrenal tissue from Gerota’s fascia.
With gentle upward dissection of the adrenal gland, identify
the renal vein and the adrenal vein. Develop the space between
the inferior aspect of the adrenal gland, kidney, and adrenal
vein so that there is enough length to adequately ligate the
adrenal vein (Fig. 132.2). Dissection and control of the adre-
nal vein is the key portion of this surgery. The adrenal vein
can be ligated with 5 mm clips; rarely, an endostapling device
will be needed to divide a larger adrenal vein. Two clips
should be placed on the proximal side of the adrenal vein and
one distally; the adrenal side of the vein should be grasped
Fig. 132.2 with a nontraumatic grasper to maintain the control of the
specimen. The vein is divided with a laparoscopic scissors or
the harmonic scalpel. Grasp the specimen by the stump of the
The surgeon stands on the ventral side of the patient. Place adrenal vein, and dissect the adrenal gland from the adjacent
the initial port in the anterior axillary line, inferior to the ribs. tissue with the energy device. Multiple feeding arteries are
Depending on the preference of the surgeon, this can either be usually safely divided with harmonic scalpel.
performed with a Veress needle, Optiview, or Hassan approach Place the specimen in an endocatch bag and remove it.
and insufflate the abdomen. There is some risk to injury to the Check the abdomen carefully and assure meticulous hemo-
liver with Veress approach on the right. Place a 10- to 12-mm stasis. Check the specimen to ensure complete resection;
port at this site, which allows for use of a 10-mm, 30-degree also inspect the adrenal bed for any residual tumor, particu-
camera. Introduce the laparoscope into the abdomen and place larly in patients with hypercortisolism, where remnant frag-
additional trocars under direct visualization. These include a ments can undergo stimulation and regrowth. Remove
5-mm trocar just anterior to the midaxillary line, about a laparoscopic ports under direct visualization. Ports ≥10 mm
hands-breadth from the previous port, and another 5-mm tro- are closed at the fascial level with absorbable braided suture,
car approximately at the midclavicular line in a similar plane either under direct visualization or using the Carter-
to the first two ports. If needed, an additional port can be Thomason port closure system. Skin is closed with absorb-
placed for retraction of the pancreas and spleen on the left or able monofilament and dressed with surgical glue and topical
the liver on the right; this port is typically placed in the mid- dressings.
line, inferior to the xiphoid process. During a right adrenalectomy, port positioning is similar
To perform a left adrenalectomy, start by mobilizing the to that described for the left. Introduce the camera into the
splenic flexure and dissecting the colonic mesentery off anterior axillary port and place the additional ports. First,
Gerota’s fascia, to free the lower aspect of the kidney and open the right triangular ligament with the harmonic scalpel
allow visualization of the renal vein and inferior aspect of the at the peritoneal reflection and continue the dissection supe-
riorly, taking care to stay inferior to the right hepatic vein.

Extend the dissection medially along the inferior aspect of
the liver, taking care to avoid aberrant hepatic vasculature. A
soft paddle retractor inserted through a subxiphoid port can
help to gently medially and superiorly rotate the liver to
allow for the identification of the inferior vena cava, which
assists in isolation of the adrenal vein. Take care to avoid
excessive traction on the liver, which can cause capsular
tears and bleeding or bile spillage. Significant mobilization
of the hepatic flexure is not usually necessary. Open Gerota’s
fascia to identify the superior pole of the kidney and inferior
investing fat of the adrenal gland.
The critical step in right adrenalectomy is control of the Fig. 132.3
adrenal vein. Dissect along the anteriolateral surface of the
IVC to expose the vein. Clips on the proximal (IVC/renal
vein) and distal (specimen) side are generally sufficient,
although a laparoscopic stapling device may be required for
larger adrenal veins. Then divide the vein with either har-
monic scalpel or laparoscopic scissors. Grasp the stump of
the vein on the specimen side with an atraumatic grasper and
use it to manipulate the adrenal gland. Use the harmonic
scalpel to dissect the gland completely from the retroperito-
neal fat. Arterial branches are usually safely divided with the
harmonic scalpel. Place the gland in an endocatch bag and
remove it from the abdomen.
As both adrenal glands reside in close proximity to the
diaphragm, perform a postoperative chest X-ray to rule out
pneumothorax. Common postoperative chest X-ray findings
include intra-abdominal air, mediastinal air, and subcutane-
ous air, none are particularly concerning and are monitored
by physical exam alone.
Retroperitoneoscopic Approach
To perform a retroperitoneoscopic adrenalectomy on either

the right or the left, place the patient in the prone/jackknife
position with hips and knees bent at 90 degree angles. Bolster
the hips and chest with prone positioning pads. Further sup-
port the knees with pillows and secure them with padded
straps. Position the upper extremities with the hands parallel to
the head in a manner that avoids tension on the shoulders. Fig. 132.4
Secure the head with a prone positioning pillow, which avoids
pressure on the endotracheal tube and prevents pressure break-
down on the face. Then further jackknife the table to increase retroperitoneum to approximately the tip of the 11th rib
the space between the pelvis and the lower ribs (Fig. 132.3). allows identification of the site of optimal trocar placement.
Make a 10–12 mm incision at the inferior tip of the 12th Place a 5-mm port under finger-directed guidance laterally at
rib and continue the dissection with a Metzenbaum scissors this site and then lace an additional 5-mm port medially after
through the paraspinous muscles into the retroperitoneum. blunt dissection just slightly superior to the 10-mm port site,
Palpation of the underside of 12th rib assures appropriate again under finger-directed direct guidance. We prefer 5-mm
positioning. This incision will be the site of the 10-mm blunt balloon trocars with blunt (not bladed) tips. Then place the
tip balloon port trocar. For the placement of the additional 10-mm blunt tip balloon port trocar, assisted by a generous
two 5-mm ports, blunt finger dissection laterally along the amount of water soluble lubricant (Fig. 132.4).
Next, insufflate the retroperitoneum to 20–25 mmHg. The anterior and lateral aspects of the gland with a harmonic
degree of insufflation is higher than for the transabdominal scalpel with care on the right to avoid aberrant hepatic vascu-
approach and is generally well-tolerated by most patients. lature. On the left, the pancreas is a retroperitoneal and care
This increased insufflatory pressure is especially helpful in is taken to avoid it. Take care not to entire the peritoneal cav-
patients with moderate to large amounts of retroperitoneal ity; of itself, this is not troublesome, but does increase the
fat. Introduce a 5-mm, 30-degree scope into the 10-mm port. risk of damage to in the intra-abdominal viscera. Violation of
Dissect the retroperitoneal soft tissue with scissors con- the peritoneum will show intraperitoneal air on postoperative
nected to elecrocautery to allow complete visualization of chest X-ray.
the tip of the medial trocar and place the camera into this When all attachments have been divided, place the adre-
port. Maintain medial visualization of the camera; this is nal gland in a laparoscopic bag and remove it from the retro-
critical in identifying the adrenal gland. Separate the retroperitoneum. Examine the specimen to ensure total resection,
peritoneal fat from Gerota’s fascia with a combination of check the operative site for meticulous hemostasis, and
sharp dissection, using scissors connected to electrocautery, decrease the retroperitoneal pressure in a stepwise fashion,
and blunt dissection using a laparoscopic Kittner. Then open paying particular attention to the clips on the adrenal vein.
Gerota’s fascia with the scissors or harmonic scalpel to Remove the ports. Depending on the depth of the patient, the
reveal the superior pole of the kidney. Move the retroperito- subcutaneous tissue might also be approximated with an
neal fat superiorly and bluntly dissect the kidney and adrenal absorbable suture. Skin is closed with monofilament absorb-
down, thus dividing the posterior attachments. Complete the able suture and dressed with surgical dermal glue and topical
dissection along the superior pole of the kidney and the infe- dressings. The patient is then returned to the supine position
rior aspect of the adrenal gland both bluntly and with the and extubated when appropriate. There is a small risk of
laparoscopic harmonic scalpel. Retract the kidney inferiorly entering the pleura with this approach, so postoperatively, a
and continue the dissection until the renal vein is identified. post-anesthesia recovery unit portable chest X-ray is per-
On the right, the vein is usually a short branch draining into formed to rule out pneumothorax. It is common to have sub-
and coursing perpendicular to the IVC and dissection along cutaneous free-air, though this is usually self-limiting.
the IVC can help expose a troublesome vein (Fig. 132.5).
While on the left, the adrenal vein generally drains into the
left renal vein, following a more parallel course to the major Special Circumstances
intra-abdominal vasculature.
Energy sealing devices and endostapling devices have While transabdominal robotic approaches using both single-
been described to successfully divide the adrenal vein, but port and multiport approaches and transabdominal laparo-
we prefer laparoscopic clips with at least two clips on the scopic single-port approaches have been described, it is
proximal (venous) side. The vein is then divided with either beyond the scope of this chapter to discuss these further.
laparoscopic scissors or harmonic scalpel after the specimen
side is controlled with an atraumatic grasper. We use the
stump of the vein on the specimen side as a handle to guide Postoperative Care
retraction for complete resection of the gland. Divide the
• While most postoperative care for either transabdominal
laparoscopic or retroperitoneoscopic adrenalectomy is based
on the indication for the procedure (see below), the patient
should be observed for signs of bleeding and infection. We
also perform postoperative chest X-rays on all patients who
undergo either transabdominal laparoscopic or retroperito-
neoscopic adrenalectomy to rule out pneumothorax. Some
degree of intra-abdominal air and possibly mediastinal air is
expected with the transabdominal approach. Subcutaneous
emphysema can be seen with the retroperitoneoscopic
approach. Both are generally self-limiting and physical exam
is followed to determine resolution. All patients should be
monitored for signs of adrenal insufficiency, which include
hypotension, dizziness, hypoglycemia, nausea/vomiting,
muscle aches, and generalized fatigue.
• Disease-specific postoperative care includes monitoring
Fig. 132.5 patients who have had adrenalectomy for pheochromocy-
toma for hypotension as residual alpha-blockade might immobilization during this procedure can be associated
remain. Support with IV fluids, and in some cases vasopres- with deep vein thrombosis and/or pulmonary embolism,
sors, is sufficient and this hypotension should be self-limiting; so pneumatic compression devices are recommended dur-
some patients may require recovery in the intensive care unit ing the procedure.
for hemodynamic monitoring. Patients who have had adre- • Both approaches also carry the risk of pneumothorax,
nalectomy for aldosterone-producing tumors are likely to which is evaluated with postoperative chest X-ray. But
require significantly less blood pressure medication postop- most concerning is adrenal insufficiency. While treatment
eratively so a plan to wean antihypertensive medications includes exogenous glucocorticoids +/− mineralocorti-
should be made; hypokalemia will resolve immediate post- coids and it might be temporary or permanent, patients
operatively and serum potassium levels should be obtained should be made aware of signs and symptoms of adrenal
prior to discharge, with discontinuation of preoperative crisis and should be counseled on the potential need for
potassium supplementation. Other causes of postoperative additional steroids in times of physiologic stress.
hypotension can include bleeding, cardiac dysfunction, and
electrolyte abnormalities.
• The adrenal status of patients who have had adrenalectomy Further Reading
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institutional assays. We have found that half of our patients Lee C, Walz M, Park S, Park J, Jeong J, Lee S, Kang S, Nam K, Chung
do not require postoperative steroids after undergoing adre- W, Park C. A comparative study of the transperitoneal and posterior
nalectomy for hypercortisolism, saving both costs and risks retroperitoneal approaches for laparoscopic adrenalectomy for adre-
of potential side effects of glucocorticoid replacement. nal tumors. Ann Surg Oncol. 2012;19(8):2629–34.
Perrier N, Kennamer D, Bao R, Jimenez C, Grubbs E, Lee J, Evans
D. Posterior retroperitoneoscopic adrenalectomy: preferred tech-
nique for removal of benign tumors and isolated metastases. Ann
Complications Surg. 2008;248(4):666–74.
Stefanidis D, Goldfarb M, Kercher K, Hope W, Richardson W, Fanelli
R. Guidelines for the minimally invasive treatment of adrenal
• Like any laparoscopic procedure, laparoscopic adrenalec- pathology. SAGES publication #37. 2013.
tomy carries with it the risk of bleeding, surgical site Zeiger M, Thompson G, Duh Q, Hamrahian A, Angelos P, Elaraj
infection, and damage to adjacent organs. Laparoscopic D, Fishman E, Kaharlip J. American Association of Clinical
port sites also carry a risk of hernia. Foley catheterization Endocrinologists and American Association of Endocrine Surgeons
medical guidelines for the management of adrenal incidentalomas.
is associated with a risk of urinary tract infection. Rarely, Endocr Pract. 2009;15(Suppl 1):1–20.
Parotidectomy
133
Indications doing a partial superficial lobectomy. One alternative tech-

nique is termed extracapsular dissection (see further reading
• Tumors of the parotid gland at the end of the chapter). This chapter describes the classical
• Chronic sialadenitis or calculi of the parotid ducts performance of superficial and total parotidectomy.
• Radical lymph node dissection of parotid region for Malignant tumors of the parotid gland, unless unusually
melanoma small, should be removed by total parotidectomy with exci-
sion of that portion of the facial nerve lying within the tumor.
Microsurgical techniques allow the nerve to be reconstructed
Pitfalls and Danger Points with a graft, which is often taken from the auriculotemporal
nerve.
• Damage to facial nerve and its branches
• Failure to excise a parotid tumor with a sufficient margin
of normal parotid tissue Locating and Preserving the Facial Nerve
There are two methods for identifying and dissecting the

Operative Strategy facial nerve. Some surgeons prefer to locate the major trunk
of the facial nerve by first identifying a peripheral branch,
Extent of Resection such as the marginal mandibular branch. They then trace this
nerve backward toward its junction with the cervical facial
Although the parotid gland is not anatomically a truly branch and finally to the main facial trunk. We prefer the
bilobed structure, the surgeon may visualize it as having a more common technique of first identifying the main trunk
superficial lobe and a deep lobe, with the branches of the of the facial nerve posterior to the parotid gland. Before it
facial nerve passing between these two structures. enters the parotid gland, the main facial nerve is a large
Consequently, it is feasible to excise the superficial lobe with structure, often measuring 2 mm in diameter. Once this main
the preservation of the branches of the facial nerve. This dis- trunk is identified, the key to the dissection technique is to
section is indicated for most patients who have benign use either fine, blunt-tipped Jones scissors or a mosquito
tumors of the parotid gland. A few benign tumors arise in the hemostat. The closed hemostat tip is inserted in the plane
deep lobe of the gland. In these cases, perform a superficial immediately anterior to the nerve. After the surgeon gently
parotid lobectomy to identify each of the facial nerve opens the hemostat, the assistant cuts the loose fibrous tissue
branches. Then, with the preservation of the facial nerve, that attaches the nerve to the overlying parotid gland. Never
remove the deep lobe. divide any parotid tissue before identifying the facial nerve
Occasional small benign tumors require dissection of the and its branches.
facial nerve only in the region of the tumor. The tumor may If the proper plane of dissection is maintained, bleeding is
then be resected with a good margin of parotid tissue by rarely a problem. Most bleeding arises from small veins, and
it generally stops with application of gauze pressure. An
C. E. H. Scott-Conner (*) important part of the dissection technique is for the surgeon
Department of Surgery, University of Iowa Carver College to apply pressure on the tissue posterior to the nerve with
of Medicine, Iowa City, IA, USA gauze while the assistant applies tension to the superficial

https://doi.org/10.1007/978-3-030-81415-1_133
lobe of the parotid gland using Allis clamps or small retrac- to this nerve causes weakness in the area of the lateral por-
tors. An occasional small vein must be clamped with a small tion of the lower lip.
mosquito hemostat and tied with a fine absorbable ligature.
Electrocautery may be used for hemostasis in areas of the
dissection away from the facial nerve and its branches. Documentation Basics
The surgeon should have sufficient familiarity with the
appearance of the facial nerve to make a positive visual iden- • Findings
tification. Occasionally, some fibers of questionable nature • Extent of resection
attach to the facial nerve branches. They may be tested by
gently pinching or stimulating the fiber and then looking at
the cheek for muscle twitching. This test, of course, requires Operative Technique
that the entire cheek and the corner of the eye be exposed
when the surgical field is draped. Incision and Exposure
The key to successful nerve preservation is early identifi-
cation of the main facial trunk. The facial nerve emerges Although many incisions have been devised for this operation,
from the skull through the stylomastoid foramen, which is we prefer the one illustrated in Fig. 133.1. It starts in a skin
situated just anterior to the mastoid process and just below crease just anterior to the tragus and continues in the form of a
the external auditory canal. Beahrs emphasized that if the Y, as shown. Continue the posterior limb of the incision over
surgeon places the tip of the index finger over the mastoid the mastoid process in a caudal direction roughly parallel to the
process with the fingertip aimed toward the nose, the middle underlying sternomastoid muscle down to a point about 1 cm
of this finger is pointing to the facial trunk, which emerges below the angle of the mandible. Do not make the angle of the
about 0.5 cm anterior to the center of the fingertip and per- Y too acute. Carry the incision through the platysma muscle.
haps 1 cm deep to the external surface of the mastoid pro- Obtain hemostasis with accurate electrocautery. Apply small
cess. An idea of the depth at which the nerve emerges can be rake retractors to the anterior skin flap and strongly elevate the
gained by identifying the posterior digastric muscle and trac-
ing it toward its insertion deep to the mastoid process. The
nerve crosses at a level equivalent to the surface of the digas-
tric muscle. In other words, dissect along the anterior surface
of the sternomastoid muscle and the mastoid process poste-
rior to the parotid gland. There are no vital structures in this
plane crossing superficial to the main trunk of the facial
nerve.
There is a tiny arterial branch (posterior auricular artery)
crossing just superficial to the facial trunk. If the exposure is
not adequate for accurate clamping and ligating, simple pres-
sure stops bleeding from this vessel if it has been transected.
Consequently, focus intense attention on an area about 1 cm
in diameter just anterior to the mastoid process and about
1 cm deep to its surface. This is where the facial trunk is
found unless a tumor in the deep portion of the parotid gland
has displaced the nerve to a more superficial plane. The
cephalad margin of this 1 cm area of intense attention may be
considered to be the fissure between the external auditory
canal and the superior portion of the mastoid process.
One should be cautious while elevating the skin flap along
the inferior border of the parotid to avoid nerve damage.
Avoid elevating the caudal portion of the flap beyond the
anterior edge of the parotid gland before the facial nerve dis-
section because the marginal mandibular branch of the facial
nerve emerges from the parotid gland together with the pos-
terior facial vein with which the nerve may be in contact.
This is the smallest branch of the facial nerve and the easiest
to injure because it is quite superficial at this point. Damage Fig. 133.1
133 Parotidectomy 1043
tissue in the plane just deep to the platysma. As soon as the process. Divide the branch of the great auricular nerve that
surface of the parotid gland is exposed, continue the dissection enters the parotid gland. Adjacent to this nerve is found the
with small Metzenbaum scissors. Some of the fibrous tissue external jugular vein, which is generally also divided and
attaching the parotid gland to the overlying tissue resembles ligated posterior to the parotid gland (Fig. 133.2). Expose the
tiny nerve fibers. There are no facial nerve fibers superficial to anterior border of the sternomastoid muscle and continue
the parotid gland. Therefore, each of these fibers may be rap- this dissection in a cephalad direction toward the mastoid
idly divided. If a total superficial lobectomy is planned, con- process. When dissecting the tissues away from the anterior
tinue the dissection in a cephalad direction to the level of the surface of the mastoid process, there may be some bleeding
zygomatic process and anteriorly to the anterior margin of the from branches of the superficial temporal vessels. It can be
parotid gland. Do not continue the dissection beyond the ante- controlled by accurate clamping or electrocautery.
rior and inferior margins of the gland, as the small facial nerve
branches may inadvertently be injured if this is done before
identifying the facial nerve. Locating the Facial Nerve
Elevate the skin flaps and the lobe of the ear in a cephalad
posterior direction to expose the underlying sternomastoid Running from the tympanomastoid fissure to the parotid
muscle, mastoid process, and cartilage of the external audi- gland is a fairly dense layer of temporoparotid fascia. Elevate
tory canal. Elevate the posterior flap to expose 1–2 cm of this layer of fascia with a small hemostat or right-angle
underlying sternomastoid muscle. Obtain complete hemosta- clamp and divide it (Fig. 133.3). Continue the dissection
sis. Some surgeons prefer to place a few sutures to attach the deep along the anterior surface of the mastoid process.
skin flaps temporarily to the underlying cheek, maintaining Remember that the main trunk of the facial nerve is located
exposure of the gland. in a 1-cm area anterior to the tympanomastoid fissure and the
upper half of the mastoid process at 0.5–1.0 cm depth. Try to
identify the small arterial branch of the posterior auricular
xposing the Posterior Margin of the Parotid
E artery in this area. Divide and ligate it. If it has been inadver-
Gland tently divided and accurate clamping cannot be achieved,
simply apply pressure for a few minutes to stop the bleeding.
Identify the great auricular nerve overlying the surface of the Continue the blunt dissection using a hemostat until the pos-
sternomastoid muscle about 3–4 cm caudal to the mastoid terior portion of the parotid gland can be retracted away from
Fig. 133.2
the mastoid process. Continuing to separate and divide the

fibrous tissue in this area uncovers the main trunk of the
facial nerve. Although the nerve usually runs in a transverse
direction from the mastoid process toward the gland, it some-
times can run obliquely from the upper left portion of the
operative field toward the right lower portion as it enters the
parotid gland. Some idea of how deep the dissection must be
carried to expose the facial nerve can be obtained by
observing the depth of the surface of the posterior digastric
muscle as it reaches its origin behind the mastoid process.
The nerve is at or just superficial to this vessel (Fig. 133.4).
Dissecting Facial Nerve Branches
Apply traction to the superficial lobe of the parotid using

several Allis clamps or retractors. Insert a small hemostat in
the plane just superficial to the facial nerve. Ask the assistant
to divide the fibrous tissue being elevated by the hemostat
(Fig. 133.4). Continue the dissection in this plane until each
of the branches of the facial nerve has been separated from
the overlying parotid tissue. Pay special attention to the cer-
Fig. 133.3
vical division and its marginal mandibular branch, as it per-
mits elevation of the lowermost portion of the parotid gland.
As the dissection reaches the anterior margin of the parotid
gland, identify Stensen’s duct. Ligate with 3-0 PG and divide
the duct (Fig. 133.5). After all of the nerve branches have
been identified and the duct has been divided, remove the
superficial lobe of the gland.
Hemostasis during the nerve dissection can generally be
achieved by gauze pressure. At this point in the dissection,
carefully identify each bleeding point and clamp it with a
mosquito hemostat. Ligate with 4-0 or 5-0 PG. Do not use
electrocautery in areas close to the nerve.
emoving Deep Lobe of Parotid Gland (When

R
Indicated)
Fig. 133.4 To remove the deep lobe of the parotid gland, first excise the
superficial lobe of the parotid as described above; then care-
fully free the lower division of the facial nerve from the
underlying tissue. By retracting one or more of these divi-
sions, one can begin to mobilize the deep lobe.
Identify the posterior facial vein. Separate the marginal
mandibular nerve branch from the vein; then divide and
ligate the posterior facial vein with 4-0 PG as in Fig. 133.6.
Now divide the superficial temporal artery and vein as in
Fig. 133.7. Elevate the lower border of the gland and divide
and ligate the external carotid artery; then divide and ligate
the internal maxillary and the transverse facial arteries at the
anterior border of the gland. The deep lobe may now be
Fig. 133.5
133 Parotidectomy 1045
Fig. 133.8
Fig. 133.6 interrupted 5-0 PG sutures to the platysma and subcutaneous

fat. Close the skin with interrupted 5-0 nylon sutures.
Postoperative Care
Leave the closed suction drain in place until the drainage has
essentially ceased (3–4 days).
Complications
• Facial weakness due to nerve damage.

• Hematoma.
• Infection.
• Gustatory sweating. Otherwise known as Frey syndrome,
it manifests as almost painful sweating in the skin of the
operative area while eating. It occurs to some extent in as
many as 25% of patients. This is believed to be due to the
regrowth of parasympathetic motor nerve fibers of the
auriculotemporal nerve into cutaneous nerve fibers of the
skin flap.
• Such crossed innervation of the sweat glands produces
uncomfortable gustatory sweating. Loré stated that it may
be prevented by removing a section of the auriculotempo-
ral nerve during surgery of the parotid gland.
Fig. 133.7
• Salivary fistula. This may appear when a significant por-
tion of the parotid gland has been left intact. It generally
removed. The appearance of the operative field after remov- corrects itself with expectant treatment.
ing the deep lobe is seen in Fig. 133.8.
Drainage and Closure Further Reading
Place a small Silastic closed suction drain through a puncture Christensen NR, Jacobsen SD. Parotidectomy: preserving the posterior
branch of the great auricular nerve. J Laryngol Otol. 1997;111:556.
wound posterior to the incision. Close the incision using
De Ru JA, van Benthem PP, Hordijk GJ. Morbidity of parotid gland Loree TR, Tomljanovich PI, Cheney RT, et al. Intraparotid sentinel
surgery: results one year postoperative. Eur Arch Otorhinolaryngol. lymph node biopsy for head and neck melanoma. Laryngoscope.
2006;263:582. 2006;116:1461.
Dulguerov P, Quinodoz D, Cosendai G, et al. Prevention of Frey syn- Rice DH. Malignant salivary gland neoplasms. Otolaryngol Clin N Am.
drome during parotidectomy. Arch Otolaryngol Head Neck Surg. 1999;32:875.
1999;125:833. Terrell JE, Kileny PR, Yian C, et al. Clinical outcome of continu-
Kadletz L, Grasl S, Grasl MC, Perisanidis C, Erovic BM. Extracapsular ous facial nerve monitoring during primary parotidectomy. Arch
dissection versus superficial parotidectomy in benign parotid Otolaryngol Head Neck Surg. 1997;123:1081.
gland tumors: the Vienna Medical School experience. Head Neck. Viera MB, Maia AF, Riberio JC. Randomized prospective study of the
2017;39:356–60. validity of the great auricular nerve preservation in parotidectomy.
Kato MG, Erkul E, Nguyen SA, Day TA, Hornig JD, Lentsch EJ, Arch Otolaryngol Head Neck Surg. 2002;128:1191–5.
Gillespie MB. Extracapsular dissection vs superficial parotidectomy Wertz AP, Durham AB, Malloy KM, Johnson TM, Bradford CR,
of benign parotid lesions: surgical outcomes and cost-effectiveness McLean SA. Total versus superficial parotidectomy for stage III
analysis. JAMA Otolaryngol Head Neck Surg. 2017;143:1092–7. melanoma. Head Neck. 2017;39:1665–70.
Larian B. Parotidectomy for benign parotid tumors. Otolaryngol Clin
North Am. 2016;49(2):395–413.
Cricothyroidotomy
134
Jennifer Shanklin and Kathleen Romanowski
Indication trolling the trachea and ensuring passage of the tube into
the airway, particularly in patients with thicker necks or
To establish an emergency airway when the patient cannot be where bleeding has been encountered and visualization is
adequately ventilated and oxygenated by other means, gen- impaired.
erally when either oral or nasal endotracheal intubation can- • Erroneous incision in thyrohyoid membrane: Making the
not be achieved. incision above the thyroid cartilage in the thyrohyoid
membrane instead of below it in the cricothyroid region
may cause serious damage to the structures of the larynx.
Preoperative Preparation The incision is made at the lower border of the thyroid
cartilage between the thyroid and the cricoid cartilages.
While cricothyroidotomy was previously sometimes used as • Esophageal injury: Hold the scalpel close to the blade for
an elective alternative to tracheostomy, it is now almost control and do not incise deeper than 1.3 cm into the
always performed under emergent conditions. Other than trachea.
study and practice (for the surgeon), preoperative prepara- • Bleeding: Occasionally, a vein in the subcutaneous space
tion is usually not possible. is transected. The cricothyroid artery and vein cross over
the anterior surface of the cricothyroid membrane; in
most people traversing the upper half. Incision should
Pitfalls and Danger Points ideally be made on the lower aspect of the membrane.
Bleeding may also be encountered from a pyramidal lobe
This is by nature an emergent and a rare procedure and, of the thyroid or small vessels located on the midline of
therefore, is usually performed under conditions of high the membrane (Develi et al. 2016). Injury to jugular or
stress and limited experience. While speed may be of the carotid vessels is rare but will require either repair or liga-
essence, an extra moment to double-check anatomy is better tion. In the emergency setting, bleeding may be temporar-
for the patient than multiple failed attempts leading to pro- ily controlled by pressure or packing. Definitive
longed hypoxia. hemostasis can be obtained once the patient is stabilized
and the airway secured.
• False passage: Failing to place the tube into the trachea,
especially if not recognized immediately, may be fatal. A
tracheotomy hook used for retraction under either the thy- Operative Strategy
roid or cricoid cartilage can be extremely helpful for con-
Depending on the circumstances, anything from local to gen-
J. Shanklin eral anesthesia may be used. In desperate situations in a mor-
Acute Care Surgery, University of Iowa Hospitals and Clinics, ibund patient, of course, no anesthesia is necessary.
Iowa City, IA, USA Correct identification of anatomy is essential for success.
K. Romanowski (*) Identify the thyroid and associated cartilage by palpation.
Department of Surgery, University of California, Davis School of Grasp the lateral margins of the thyroid cartilage between the
Medicine, Sacramento, CA, USA
thumb and the middle finger of the left hand, and use the tip
Shriners Hospitals for Children, Sacramento, CA, USA of the index finger to palpate the space between the lower
e-mail: kathleen-romanowski@uiowa.edu

https://doi.org/10.1007/978-3-030-81415-1_134
1048 J. Shanklin and K. Romanowski
margin of the thyroid cartilage and the upper margin of the Gently insert a tracheostomy hook, generally by sliding it
cricoid. With this maneuver, one can accurately pinpoint the along the blade of the knife into the trachea with the hook
proper site for the incision. Under conditions of desperate sideways, then turning it to hook under the thyroid cartilage
emergency in the field without instruments, it is possible to and retract it cephalad. Enlarge the stab wound with a small
perform this procedure with a sharp penknife by inserting the hemostat or a Trousseau dilator, if available (Fig. 134.2).
tip of the blade through the skin and the cricothyroid mem- Then, insert heavy Mayo scissors into the incision and spread
brane with one motion. Then twist the blade 70–90° to pro- the tissues transversely (Fig. 134.3) until the opening is suf-
vide a temporary airway until some type of tube can be ficiently large to insert a tube (Fig. 134.4). The tube should
inserted into the trachea. have an internal diameter of 6 mm; larger devices may be
Whenever securing an airway, it is important to have at
least one back-up plan, including additional instruments and
airway devices.
• Indications
• Size of tube placed
Operative Technique
Time and spinal precautions permitting, place a shoulder

roll—a 1 L bag of saline works well—between the shoulder
blades to extend the neck. After the usual skin preparation,
grasp the lateral margin of the thyroid cartilage between the
thumb and the middle finger of the left hand. Palpate the cri-
cothyroid space accurately with the tip of the index finger;
then infiltrate the line of the incision with local anesthesia.
Make a 2- to 2.5-cm long transverse incision in the cricothy-
roid space. If the anatomy is unclear, a vertical incision may
be preferred as it can easily be extended if the initial incision
is too high or too low. Carry the incision down to the crico-
thyroid membrane. Occlude any bleeding points with liga-
tures, electrocoagulation, or pressure with the left hand. Use
a scalpel to make a transverse incision on the lower aspect of
the cricothyroid membrane (Fig. 134.1) Fig. 134.2
Fig. 134.1 Fig. 134.3

134 Cricothyroidotomy 1049
above. The four steps are palpation, incision, traction, and

intubation (Brofeldt et al. 1996).
A number of cricothyrotomy kits have been developed,
mostly based on percutaneous entry utilizing Seldinger tech-
nique. Data on the best approach are conflicting with studies
limited by sample size and by mostly involving cadavers—
the open surgical approach is generally considered sa

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Chassin’s

Chassin’s Operative Strategy

ISBN 978-3-030-81414-4 ISBN 978-3-030-81415-1 (eBook)

© Springer Nature Switzerland AG 2014, 2022

New York, NY, USA Jameson L. Chassin, MD

Iowa City, IA, USA Carol E. H. Scott-Conner, MD, PhD

Part I General Principles

1 Concepts and Strategies of Surgery ��������������������������������������������������������������������� 3

4 Dissecting and Suturing����������������������������������������������������������������������������������������� 23

Tissue Properties of the Stapled Anastomosis ��������������������������������������������������������� 39

Importance of Surgical Skills and Technique������������������������������������������������������� 53

Percutaneous Drainage of Abdominal Abscesses with Computed Tomography

13 Concepts in Esophageal Surgery��������������������������������������������������������������������������� 95

Total Mechanical Stapling with Modified Collard Technique ������������������������� 135

18 Laparoscopic Nissen Fundoplication for Gastroesophageal

Part III Stomach and Duodenum

24 Concepts in Surgery of the Stomach and Duodenum����������������������������������������� 191

Billroth II Gastrojejunal Anastomosis, Handsewn����������������������������������������������� 240

Part IV Small Intestine and Appendix

41 Concepts in Surgery of the Small Intestine and Appendix��������������������������������� 313

Open One-Layer Anastomosis ����������������������������������������������������������������������������� 326

Incision and Exposure��������������������������������������������������������������������������������������� 339

Part V Large Intestine

53 Concepts in Surgery of the Large Intestine ��������������������������������������������������������� 395

Pitfalls and Danger Points����������������������������������������������������������������������������������������� 421

57 Sigmoid Resection and Left Hemicolectomy (Open, Laparoscopic) ����������������� 443

Variations of Colo-anal Anastomosis (To Improve Short-Term Function)����������� 478

Ligation of the Inferior Mesenteric Artery����������������������������������������������������������� 493

63 Proctocolectomy with Ileal Pouch-Anal Anastomosis

65 Creation of Transverse Colostomy (Loop, Prasad-Type)����������������������������������� 519

Pitfalls and Danger Points����������������������������������������������������������������������������������������� 531

Choice of the Platform ����������������������������������������������������������������������������������������� 544

Part VI Anus, Rectum, and Pilonidal Region

76 Doppler-Guided Hemorrhoidal Artery Ligation������������������������������������������������� 589

Common Local Rectovaginal Repairs ����������������������������������������������������������������� 604

Open Sphincterotomy������������������������������������������������������������������������������������������� 615

83 Operations for Pilonidal Disease��������������������������������������������������������������������������� 629

Part VII Hepatobiliary Tract

87 Concepts in Hepatobiliary Surgery����������������������������������������������������������������������� 655

Intraoperative Cholangiography��������������������������������������������������������������������������� 657

95 Concepts in Surgery of the Pancreas��������������������������������������������������������������������� 737

Adenocarcinoma of the Pancreas����������������������������������������������������������������������������� 740

Premalignant Conditions��������������������������������������������������������������������������������������� 763

100 Pancreaticojejunostomy for Chronic Pancreatitis����������������������������������������������� 785

101 Concepts in Splenic Surgery ��������������������������������������������������������������������������������� 795

Part X Hernia Repairs, Operations for Necrotizing Faciitis,

105 Concepts in Hernia Repair, Surgery for Necrotizing Fasciitis,

Prosthetic Mesh Repair����������������������������������������������������������������������������������������� 827

108 Mesh Repair of Inguinal Hernia��������������������������������������������������������������������������� 849

Use of Absorbable Sutures����������������������������������������������������������������������������������� 862

Repeat Laparotomy for Recurrence of Abdominal Sepsis����������������������������������� 895

Part XI Breast and Melanoma

115 Concepts in Breast Surgery����������������������������������������������������������������������������������� 907

Breast Conservation Therapy (BCT) ������������������������������������������������������������������� 913

118 Lumpectomy for Breast Cancer ��������������������������������������������������������������������������� 931

120 Skin and Nipple Sparing Mastectomy������������������������������������������������������������������ 947

Management of the Regional Lymph Nodes ����������������������������������������������������������� 964

Indications for Deep Groin Dissection and Exposure������������������������������������������� 980

Part XII Thyroid, Parathyroid, and Adrenal, Parotidectomy,

126 Concepts in Thyroid, Parathyroid, and Adrenal Surgery����������������������������������� 987

Dissecting the Superior Pole and Superior Parathyroid Gland����������������������������� 1000

Emily L. Albright, MD Department of Surgical Oncology, University of Iowa,

Mark C. Horattas, MD Department of Surgery, Northeast Ohio Medical University,

New York, NY, USA Jameson L. Chassin, MD

Iowa City, IA, USA Carol E. H. Scott-Conner, MD, PhD

Part I General Principles

1 Concepts and Strategies of Surgery �� 3

4 Dissecting and Suturing�� 23

Tissue Properties of the Stapled Anastomosis �� 39

Importance of Surgical Skills and Technique�� 53

13 Concepts in Esophageal Surgery�� 95

Total Mechanical Stapling with Modified Collard Technique �� 135

18 Laparoscopic Nissen Fundoplication for Gastroesophageal

Part III Stomach and Duodenum

24 Concepts in Surgery of the Stomach and Duodenum�� 191

Billroth II Gastrojejunal Anastomosis, Handsewn�� 240

Part IV Small Intestine and Appendix

41 Concepts in Surgery of the Small Intestine and Appendix�� 313

Open One-Layer Anastomosis �� 326

Incision and Exposure�� 339

Part V Large Intestine

53 Concepts in Surgery of the Large Intestine �� 395

Pitfalls and Danger Points�� 421

57 Sigmoid Resection and Left Hemicolectomy (Open, Laparoscopic) �� 443

Variations of Colo-anal Anastomosis (To Improve Short-Term Function)�� 478

Ligation of the Inferior Mesenteric Artery�� 493

63 Proctocolectomy with Ileal Pouch-Anal Anastomosis

65 Creation of Transverse Colostomy (Loop, Prasad-Type)�� 519

Pitfalls and Danger Points�� 531

Choice of the Platform �� 544

Part VI Anus, Rectum, and Pilonidal Region

76 Doppler-Guided Hemorrhoidal Artery Ligation�� 589

Common Local Rectovaginal Repairs �� 604

Open Sphincterotomy�� 615

83 Operations for Pilonidal Disease�� 629

Part VII Hepatobiliary Tract

87 Concepts in Hepatobiliary Surgery�� 655

Intraoperative Cholangiography�� 657

95 Concepts in Surgery of the Pancreas�� 737

Adenocarcinoma of the Pancreas�� 740

Premalignant Conditions�� 763

100 Pancreaticojejunostomy for Chronic Pancreatitis�� 785

101 Concepts in Splenic Surgery �� 795

Part X Hernia Repairs, Operations for Necrotizing Faciitis,

105 Concepts in Hernia Repair, Surgery for Necrotizing Fasciitis,

Prosthetic Mesh Repair�� 827

108 Mesh Repair of Inguinal Hernia�� 849

Use of Absorbable Sutures�� 862

Repeat Laparotomy for Recurrence of Abdominal Sepsis�� 895

Part XI Breast and Melanoma

115 Concepts in Breast Surgery�� 907

Breast Conservation Therapy (BCT) �� 913

118 Lumpectomy for Breast Cancer �� 931

120 Skin and Nipple Sparing Mastectomy�� 947

Management of the Regional Lymph Nodes �� 964

Indications for Deep Groin Dissection and Exposure�� 980

Part XII Thyroid, Parathyroid, and Adrenal, Parotidectomy,

126 Concepts in Thyroid, Parathyroid, and Adrenal Surgery�� 987

Dissecting the Superior Pole and Superior Parathyroid Gland�� 1000

Developing a Concept • Reflect on personal experience with complications and

Introduction Before You Scrub

Achieving Exposure with fiberoptic lighting. This provides optimal visualization

For most operations, a more complex system of self-

Operative Technique for a Midline Incision

Making the Incision

Closure of Midline Incision

tandard Running Closure

duodenum and pancreas is reached, beyond the diseased Sewing Technique

Continuous Versus Interrupted Sutures

the bowel. Occasionally, under ideal conditions, it is pos- Types of Stitches

Continuous Simple Over-and-Over Stitch

Horizontal Mattress Stitch

Single-Layer Bowel Anastomosis Seromuscular Lembert Stitch

Nonabsorbable Sutures ynthetic Nonabsorbable Monofilaments

Characteristics of Staples depending on device selection. An aligning pin isolates the

Surgical Stapling Technology

Fig. 5.2 issue Properties of the Stapled

auses of Failure Following Stapled

Intraoperative Leak Testing Summary

General Principles of Resuscitation Control of Hemorrhage

The management of a bleeding patient must involve close Thoracic Hemorrhage

ung Parenchymal Injuries