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Top Tips in Gastrointestinal Surgery


EDITED BY
Ciaran J. Walsh
MB, BSc, MCh, FRCSI
Arrowe Park Hospital,
Upton, Wirral, UK

Neville V. Jamieson
MA, MD, FRCS
Addenbrooke's Hospital,
Cambridge, UK

Victor W. Fazio
MB, MS, FRACS, FRACS(Hon), FACS
The Cleveland Clinic Foundation,
Cleveland, USA
FOREWORD BY
Sir Roy Calne


Page ii
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Library of Congress Cataloging-in-publication Data
Top tips in gastrointestinal surgery/
edited by Ciaran J. Walsh,
Neville V. Jamieson, Victor Fazio.
p. cm.
ISBN 0-632-04253-2
1. Gastrointestinal system
Surgery. I. Walsh, Ciaran J.
II. Jamieson, Neville V.
III. Fazio, Victor W., 1940- .
[DNLM: 1. Digestive System
Surgical Procedures.
WI 900T6737 1999]
RD540. T66 1999
617.4'3059dc21
DNLM/DLC
for Library of Congress 98-38634
CIP
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Page iii

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

Page iv

General Surgical Techniques


How to Sew in a Drain 11
M.C.A. Puntis
Identification of the Two Free Suture Ends in a Standard 12
Two-Layer Anastomosis
P.W.R. Lee
The Schneeden Stitch 14
C.J. Walsh
Let Air into the Lesser Sac 14
C.J. Walsh
Babcocks for Haemostasis 15
C.J. Walsh
Greased Thread 16
C.J. Walsh
Ureteral Catheter Drainage 17
R.J. Rubin
Retraction for Pelvic Surgery 19
A. Masters
Making the Best of a Short Suture Length in a Deep, Dark 19
Hole
J. McLoughlin
Retracting the Uterus in Pelvic Surgery 20
C.J. Walsh
Retractors and Exposure in the Pelvis 21
V.W. Fazio

Page v

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


Page vi

A Safe Technique for Anastomosing a Normal Calibre Bile 37


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


Page vii

Surgery of the Duodenum and the Small Intestine


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


Page viii

The Loop End Ileostomy 74


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


Page ix

Taking Down Splenic Flexure 90


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


Page x

The Moran Triple-Stapling Technique: A Fail-Safe 109


Precaution Against Implantation Staple-Line Recurrence
R.J. Heald and B.J. Moran
Alternatives to Colonic J-Pouch 112
V.W. Fazio
Use of Hydrodissection to Mobilize the Rectum in Redo 113
Pelvic Surgery
E.L. Bokey
Reusable Transanal Anvils 115
F. Seow-Choen
Inserting Transanal Staplers in Ultra-Low Anterior 116
Resection
F. Seow-Choen
Getting the Small Bowel to Reach 117
V.W. Fazio
Insertion of the Stapler for an Ileal Pouch-Anal 118
Anastomosis
J.M. Church
Stapled Ileoanal Pouch Procedure 119
H.J. Sugerman
Combined Supine and Prone Jack-Knife Position for 121
Abdominoperineal Resection of the Rectum
C.J. Walsh
Thumbtack to Arrest Bleeding from Presacral Veins 123
C.J. Walsh
Dealing with Presacral Bleeding During an 125
Abdominoperineal Resection
R.G. Molloy


Page xi

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


Page xii

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


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


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


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

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


Page xvii

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


Page xix

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


Page 1

OPENING AND CLOSING THE ABDOMEN

Excising Old Scars:


One Cut, Two Scalpels.
C.J. Walsh
Excising an old midline abdominal scar is usually desirable for
cosmetic reasons. The traditional method of sequentially incising on
either side of the scar is unsatisfactory because when you cut down
one side of the scar with a scalpel the wound springs open and tension
is lost. As a result a single clean cut is very difficult when excising the
other side of the scar and a jagged edge may result.
Place two scalpels side by side and hold them as shown in Fig. 1. The
distance between the parallel blades will accommodate most previous
laparotomy wounds. Now with one movement down the length of the
wound both sides of the scar will be cleanly detached from the
surrounding skin. All that remains is to make a V-shaped cut with a
single scalpel at each end of the wound, thus

Figure 1


Page 2
bringing the two edges together to form a long, thin ellipse of scar
tissue which is easily dissected off the underlying subcutaneous tissue.
This tip was shown to me by Mr Bruce George when we were
registrars at The Royal London Hospital.

Making a Smooth Curve Around the Umbilicus


R. W. Motson
Negotiating the umbilicus on a midline incision often results in an
irregular incision as the scalpel blade is turned to avoid the umbilicus.
The following tip will avoid this problem. A Lane's tissue-holding
forceps is used to grip the umbilicus and the assistant retracts on the
Lane's forceps to deviate the umbilicus from the midline. A straight
incision is then made along the midline. When the umbilicus is
released from the Lane's clamp there is a smooth curve of the incision
as it passes around the umbilicus and the skin is divided
perpendicularly like the rest of the incision (Fig. 2).

Figure 2


Page 3
To my knowledge this was first described by a member of the 1983
surgical travelling club and was also described by Mr C.G. Fowler of
The Royal London Hospital.

Finding the Midline in a Fat Abdominal Wall


J.H. Scholefield
Finding the linea alba in the midline of the anterior abdominal wall in
an obese patient can be difficult and bloody. I was shown a rapid and
relatively bloodless reliable method of finding the linea alba in such
patients by my former colleague Professor Robert Steele.
Once the skin and dermis have been incised in the midline, the
subcutaneous fat of the anterior abdominal wall can be incised
superficially to a depth of a few millimetres. The surgeon and the
assistant insert a large pack into each wound edge and exert strong
traction with both hands in the wound, in a direction towards their
own abdomens (Fig. 3). A plane in the fat invariably opens which
invariably exposes the linea alba. This may need to be repeated
several times along the length of the wound. The plane opened is
almost bloodless.
I have noticed that using this technique tends to separate the fat from
the midline over 2 cm or so and this helps in obtaining good bites of
the sheath in closing the wound. Although initially I was concerned
about bruising in the fat and subcutaneous tissues this has not been a
problem in practice. I have used this technique on many occasions and
commend its use to other surgeons.


Page 4

Figure 3

Around the Falciform Ligament, not Through It


R. Miller
After gaining access to the peritoneal cavity at the beginning of a
laparotomy through a midline incision, one extends cephalad and
caudad for as long as required. On extending the wound cephalad one
encounters the falciform ligament. This contains numerous small
vessels and if one continues in the midline, even using electrocautery,
dissection can be unnecessarily bloody. Instead go to one or other side
where the falciform


Page 5
ligament fuses with the parietal peritoneum on the anterior abdominal
wall and go along this line with electrocautery. This is relatively
avascular and the dissection proceeds more quickly.
Derek Alderson in Bristol taught me this.

Closing the Abdomen


F. Seow-Choen
Mass closure is the technique most commonly employed by surgeons
to close the abdomen after a midline incision.

Figure 4


Page 6
The problem as usual is accidental needle-stick injury to the small
bowel. This problem is especially acute during the last few bites as the
surgeon struggles to get good bites of the peritoneum, linea alba and
rectus sheath. I make it easy by starting superiorly where it is easy to
close the abdomen. When I get halfway between the umbilicus and
pubic symphysis, I close only the anterior rectus sheath (Fig. 4). After
the semilunar line at this point, the posterior rectus sheath is non-
existent and therefore there is no posterior sheath. The linea alba is
reconstituted by closing the anterior rectus sheaths alone. Using this
technique, mass closure is easy, without increasing wound dehiscence
rates and without fear of bowel injury.

Mass Closure With Two Sutures


C.J. Walsh
When performing mass closure of midline abdominal incisions the
ideal suture to wound length ratio is 4: 1. Failure to achieve this ratio
makes wound closures more prone to early and late failure. To help
achieve the optimal ratio, use two closing sutures rather than one.
Start one at each end of the wound and tie them in the middle. In this
way you are not tempted to get one suture to 'make do' as you
approach the far end of the wound and you avoid a suboptimal suture:
wound length ratio. Furthermore you do not have to struggle with a
short end of suture material when placing the final stitches in the dark
recesses of an undermined wound apex.


Page 7

Double-Loop Deep-Tension Suture for Abdominal Wall


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

Figure 5


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


Page 9

Subcutaneous Skin Closure.


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


Page 11

GENERAL SURGICAL TECHNIQUES

How to Sew in a Drain


M.C.A. Puntis
If a drain is used it needs to be fixed firmly in place.
Using no. I black silk take a bite of skin close to the drain and tie a
loose stitch at the centre of the black silk

Figure 6


Page 12
(Fig. 6a). Cut off the needle. Take one end of the black silk in each
hand and pass the ends around behind the drain, tie a single throw and
without letting go of the silk come back to the front of the drain (Fig.
6b). Now tie a surgeon's knot. Repeat this three timesaround the back
a single throw, round to the front a surgeon's knot. It is vital that when
you encircle the drain prior to tying the surgeon's knot the silk passes
squarely around the drain. When you pass the silk back around the
drain, pass it obliquely up the drain before tying the single knot (Fig.
6c).
This stitch can be tied without letting go of the silk so the tension can
be maintained and with practice you will not even need an assistant to
hold the drain. This stitch will not slip down the drain, which will be
held reliably in place for as long as it is needed.

Identification of The Two Free Suture Ends in a Standard


Two-Layer Anastomosis
P.W.R. Lee
A two-layer anastomosis (e.g. gastroenterostomy) may involve using
two identical sutures for the inner and outer layers. It is helpful to
mark the free end of the inner layer by looping it inside an artery
forceps. When the inner layer is complete and the finishing knot is to
be tied, it is then a simple matter to select the correct free suture to use
(Fig. 7a & b).


Page 13

Figure 7


Page 14

The Schneeden Stitch


C.J. Walsh
This technique is very useful for the anterior 'all coats' layer of a two-
layer gastrointestinal anastomosis, for example gastroenterostomy or
enteroenterostomy. It has the advantage of being haemostatic and also
of burying the mucosa by inverting the suture line.
This quite simply is a running over and over stitch but starting and
finishing each pair of bites on the inside rather than the outside of the
bowel wall. This inverts the anterior all coats layer and all that
remains is for the anterior seromuscular sutures to be placed.
This technique was shown to me by Mr John Hall, Consultant
Surgeon at Peterborough District Hospital.

Let Air into the Lesser Sac


C.J. Walsh
Separation of the greater omentum from the transverse mesocolon is
an important manoeuvre common to a variety of different operations,
for example gastrectomy and colectomy. The manoeuvre depends on
being able to accurately identify each tissue layer as well as the plane
between the two (the lesser sac). The two surfaces are often applied to
one another and the surface tension between the two can make
identification and separation difficult, particularly in the very thin
patient with a very flimsy, transparent greater omentum. To facilitate
the separation of the two surfaces, first gain access to the lesser sac by
breaking through the lesser (gastrohepatic) omentum with the tip of
the left index finger. By wiggling


Page 15
the finger around and then removing it, air will enter into the lesser
sac and separate the back of the greater omentum from the front of the
transverse mesocolon. Now dissection of one from the other is
significantly easier.
This tip was shown to me by Mr John Hall at Peterborough District
Hospital.

Babcocks for Haemostasis


C.J. Walsh
1 Damage to a small mesenteric vessel will often require suture
ligation rather than simple ligation for both accuracy and security. It is
not always easy to accurately identify the vessel as it often recedes
below the free edge of the peritoneum and may be associated with a
small mesenteric haematoma, particularly in Crohn's disease. As a
result it may not be amenable to the accurate placement of the tip of
an artery forceps.
Rather than directly suturing the area with the traditional 2/0 rescue
stitch or applying an artery forceps along its curvature and risk
damaging other mesenteric vessels, the situation is rapidly and
accurately dealt with by applying a Babcock tissue clamp just beyond
the free edge of the peritoneum and incorporating the small but
expanding mesenteric haematoma. This will arrest the bleeding and
prevent extension of the haematoma and gentle traction upwards on
the Babcock clamp will permit accurate placement of a figure-of-eight
haemostatic stitch.
This tip was shown to me by Dr Jeff Milsom whilst at The Cleveland
Clinic.

Page 16
2 Vascular clamps and sutures are not usually readily available on
general surgical or gastrointestinal sets. Should you be in a situation
where a side hole has been made in a large vein which needs to be
preserved rather than tied off, the situation can be rapidly brought
under control by placing a Babcock across the rent in the vein. This
will act as a vascular clamp and allow you to generate distal and
proximal control in the traditional way whilst procuring the
appropriate vascular instruments and sutures for the repair.

Greased Thread.
C.J. Walsh
Polyglactin (Vicryl) and chromic catgut sutures are often favoured for
bowel anastomoses and stoma formation, respectively. Among other
reasons for the choice in these settings are their handling and knot
tying properties. Both sutures, but chromic catgut in particular, can be
abrasive and traumatic to the bowel if drawn through it at anything
other than right-angles. To get around this, place a dab of glycerol on
the tips of the thumb and forefinger and run the suture length through
them. As a result there will be a great reduction in the coefficient of
friction and the suture will now glide freely through the tissues
without any alteration in the knot tying properties.


Page 17

Ureteral Catheter Drainage


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


Page 18

Figure 8


Page 19

Retraction for Pelvic Surgery


A. Masters
An effective technique to prevent the small bowel tumbling into the
pelvis during pelvic surgery is to use a caeser roll (a gauze roll 20 cm
× 10 m). This is laid out at the root of the small bowel mesentery (the
caecum may also be mobilized to improve retraction) and then
partially unrolled over the small bowel. The roll can be retained in
place with the middle blade of a Goligher retractor. The rigidity of the
roll prevents loops of small bowel herniating down into the pelvis as
often happens when conventional large swabs are used.

Making the Best of a Ahort Suture Length in a Deep,


Dark Hole*
J. McLoughlin
When working deep in the pelvis or abdomen you will occasionally
complete a suture line with only a short length remaining, which you
need to use to throw your knot. While you can struggle to tie the knot
with what is usually a short loop of suture, a simpler solution is to slip
a length of any available suture material (e.g. Vicryl) through the loop
using a pair of right-angled forceps (Fig. 9). This in effect provides an
extension to your suture, allowing you to throw the knot and it can be
pulled out before cutting the ends to length. It takes only a few
seconds but can save a lot of aggravation.
This was shown to me by Gary Lieskovsky of Los Angeles.
*Reproduced from McLoughlin, J. & O'Boyle, P.J. (eds) (1995) Top Tips
in Urology. Blackwell Science, Oxford.


Page 20

Figure 9

Retracting the Uterus in Pelvic Surgery


C.J. Walsh
When performing rectal surgery in females it is often helpful to retract
the uterus forwards by suturing the uterine fundus to the bottom end
of the lower midline incision. If a stitch is merely passed through the
uterine fundus, either as a single or double bite and then sewn to the
abdominal wall, the uterus is liable to bleed when this retracting stitch
is cut out at the end of the operation. To prevent this potential source
of postoperative bleeding, take a double bite of the uterine fundus
with an absorbable suture and then tie this suture snugly before
passing the needle through the lower end of the incision and tying the
uterus to the skin. At the end of the


Page 21
operation you merely need to cut the suture at the level of the skin.
This will release the uterus with an absorbable haemostatic stitch still
in place in the fundus.
This tip was shown to me by Mr Thornton Holmes at Peterborough
District Hospital.

Retractors and Exposure in the Pelvis


V.W. Fazio
A variety of good pelvic retraction instruments are available. At
different points in the operation (in the pelvis) different retractor types
are used. Light attachments make the operation much easier. These are
used in preference to headlights as the movement and contortions of
the pelvic surgeon make even the most secure headlights move. This
leads to neck- and eyestrain for the surgeon. In the upper pelvis,
during the anterior dissection of the rectum, a lighted Deaver retractor
(Fig. 10a) is used initially. It is broad to allow for bladder retraction.
This may be aided by bladder or uterine suspension using a 0 chromic
stitch and securing this to the inferior angle of the midline wound or
the cross bar of a self-retaining retractor. The same instruments are
useful for the early part of the posterior pelvic dissection between the
investing layer of fascia of the rectum and Waldeyer's fascia. In the
mid-pelvis the best retractor of the mesorectum and rectum is a lipped
St Mark's retractor (Fig. 10b).
For the lower pelvis my preference is for the Brabbee's retractor (Fig.
10c) which comes in a narrow 5 cm and a narrower 4 cm blade. This
retractor type allows entry into the very narrow male pelvis and
further allows elevation as well as forward retraction of the
mesorectum and

Page 22
rectum. The key to pelvic deflection is traction and counter-traction
and in this context the counter-traction is easily generated using a
narrow straight-bladed lipped retractor such as a Britetrac retractor
(Fig. 10d).

Figure 10
(a) Deaver retractor with handle (50 mm × 300 mm).
(b) St Mark's deep pelvic retractor: (i) long without
lip (62 mm × 178 mm); (ii) long with lip (62 mm × 178
mm); (iii) short without lip (56 mm × 127 mm). (c) Deep
pelvic retractor (known at The Cleveland Clinic as
'Vic's toy'); standard blade width 65 and 50 mm, narrow
width 55 and 40 mm. (d) Britetrac retractor. ((ac)
Courtesy of Electro Surgical Instrument Company,
Rochester, NY; (c) originated by Dr G.W. Brabbee.
(d) Courtesy of Johnson & Johnson Professional,
Inc., Raynham, MA.)


Page 23

OESOPHAGOGASTRIC SURGERY

Retraction of the Left Lobe of the Liver to Expose the


Oesophagogastric Junction.
N. V. Jamieson
The left lateral segment of the liver commonly lies across the front of
the oesophagogastric junction and tends to get in the way during
surgery to this region. Mobilization of the left lateral segment by
dividing the left triangular ligament is often used to improve
exposure, but may result in damage to the liver with tears to the liver
substance with resultant bleeding and is unnecessary if the following
tip is used.

Figure 11


Page 24
Leave the left triangular ligament intact and use a lipped St Mark's
pelvic retractor instead of the usual smooth-bladed upper abdominal
retractors (Fig. 11). The lip of the retractor is placed under the
posterior edge of the left lateral segment of the liver and gentle
retraction applied in an anterior and lateral direction. This lifts the left
lobe out of the way and allows excellent exposure of the
oesophagogastric junction.

Hand-Sewn Anastomosis for High (Intrahiatal)


Oesophagojejunostomy
S. Paterson-Brown
Although many surgeons prefer stapled anastomosis to a hand-sewn
oesophagojejunostomy following radical total gastrectomy and lower
distal oesophagectomy this is not always possible. However,
conventional hand-sewn anastomosis can be extremely difficult in this
area, particularly after a failed attempt using a circular stapler.
Following lower oesophagectomy and excision of the surrounding
crura, stay sutures are placed as high in the oesophagus as possible
and a soft right-angled clamp positioned gently above the stay sutures.
The distal oesophagus is then transected in the appropriate place and
the Roux-en-Y limb of jejunum fashioned and brought up into the
upper abdomen. The anterior layer of sutures are then placed into the
oseophagus as demonstrated in Fig. 12a, with the needles running
from outside to inside. These are then clipped with artery forceps,
taking care to position the forceps close to the needle and the distal
part of the suture so as not to damage the part of the suture which will
be used for tying the knot. Once all the anterior sutures have been
placed in position they can

Page 25

Figure 12


Page 26
be used to retract the opening of the distal oesophagus, exposing the
posterior wall. The posterior sutures are then placed between the
posterior wall of the oesophagus and the Roux-en-Y limb of jejunum
with the knots tied on the inside as shown in Fig. 12b. The anterior
layer of the anastomosis is now completed by picking up the needles
from the anterior layer of sutures, previously placed through the
oesophagus. These are passed from inside to outside through the
anterior layer of the Roux-en-Y limb of jejunum and then tied.
This technique is identical to that used for a high hepaticojejunostomy
anastomosis and has the advantage over the standard technique of
suturing the posterior wall before the anterior wall, in that the anterior
layer of sutures helps to hold open the lumen of the proximal bowel,
facilitating placement of the posterior sutures while at the same time
making it easier to complete the anterior layer of anastomosis.

Transhiatal Oesophagectomy Using a Vein Stripper


R. G. Molloy
The technique described is an alternative method for dissecting or
mobilizing the thoracic oesophagus during a transhiatal
oesophagectomy. The abdominal part of the operation with
mobilization of the distal oesophagus is carried out in the standard
fashion. The cervical oesophagus is also exposed in the traditional
way and then a vein stripper is passed up the oesophageal lumen from
distal to proximal. The vein stripper is taken out through the side of
the cervical oesophagus via an enterotomy (Fig. 13b). The head is
placed on the vein stripper and secured to the distal segment of
cervical


Page 27

Figure 13
oesophagus after the cervical oesophagus has been transected (Fig.
13c). The vein stripper is then pulled distally, i.e. the oesophagus is
stripped rather than bluntly mobilized. The rest of the
oesophagectomy and subsequent anastomosis in the neck continues in
the usual fashion.

Gastric Bypass for Morbid Obesity


H.J. Sugerman
Gastric bypass has been shown to be an effective and safe operation
for the treatment of morbid obesity (body mass index (BMI) 35 kg
m-2 (100 lbs) above ideal body weight) and more effective than a
vertical banded gastroplasty, especially for patients addicted to
'sweets'. The Achilles' heel of the stapled gastric bypass has been


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

Figure 14


Page 29

A Partial Gastrectomy Without Clamps on the Gastric


Remnant
R. W. Motson
This technique is particularly useful when the gastrectomy extends
high on the lesser curve, close to the oesophagus. Following
mobilization of the stomach, a large Peyr's crushing clamp is placed
diagonally across the stomach, from the greater to the lesser curve. A
double-armed suture is stitched through the lesser curve above the
clamp and tied in the centre of the suture (Fig. 15a). One needle is
then set aside. The stomach is then divided 1 cm at a time above the
Peyr's clamp and a running suture is used to close the stomach
sequentially (Fig. 15b). It is often helpful to give a scalpel to the
assistant to make the successive 1-cm incisions along the clamp, while
following the suture oneself. One continues until the amount
remaining in the clamp is the correct width for either
gastroenterostomy or anastomosis of the duodenum, as appropriate
(Fig. 15c). The second suture is then run down the new lesser curve to
invert the initial suture line and tied to the first suture (Fig. 15d).


Page 30

Figure 15


Page 31

HEPATOBILIARY SURGERY

Clearance of the Vena Cava During Right-Sided Hepatic


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

Page 32
Mobilization of the liver in this way ensures that during the lateral
hilar and hepatic parenchymal dissection, the surgeon can avoid
damage to the vena cava and minimize the risk of uncontrolled venous
haemorrhage.

Figure 16


Page 33

Mobilization of Left Lobe of Liver and Isolation of


Suprahepatic Inferior Vena Cava.
J.M. Henderson
The trick to mobilizing the left lobe of the liver and isolating the
retrohepatic vena cava is based on three lines of dissection (Fig. 17).
Step 1: The first line of dissection is the left triangular ligament which
needs to be dissected medially to the left hepatic vein.
Step 2: The second line of dissection is the gastrohepatic ligament that
is opened superiorly until it comes to the same point of dissection as
the left triangular ligament at the left hepatic vein. In 20% of the
population there may be an accessory left hepatic artery traversing the
superior portion of this ligament.

Figure 17


Page 34
Step 3: The third line of dissection is the left side of the retrohepatic
inferior vena cava. Commencing at the infrahepatic portion of the
inferior vena cava, the overlying peritoneum needs to be incised and
divided along the whole length of the retrohepatic vena cava. As the
superior portion is approached this is then brought forward to join the
above described two points.
Once these three lines of dissection have been made, the retrocaval
plane can then be developed by retraction to the left of the posterior
leaf of peritoneum overlying the vena cava. This gives a safe plane
into the back of the suprahepatic vena cava that will then very easily
be joined to the mobilized right lobe of the liver if total hepatectomy
is being performed or there is a need to cross clamp the suprahepatic
vena cava.

Packing the Traumatized Liver


G.P. McEntee
A significant proportion of patients with liver trauma can be managed
non-operatively. For those who continue to bleed, surgery is required
but significant problems are created in the belief that suturing of
'bleeders' deep within the parenchyma of a fractured liver is required
for haemastasis. Many units of blood may be lost in the process and
because of difficult access, suture ligation is rarely effective. The
simplest and best way to control haemorrhage from deep lacerations
not in direct communication with the peritoneal cavity (i.e. inferior
vena cava (IVC) or hilar lesions) is to pack the liver properly.
If the bleeding is seen to be coming from deep within the lacerated
liver, no attempt should be made to open

Page 35
up the lacerations. Following the Pringle manoeuvre the traumatized
liver is mobilized completely from its peritoneal attachments. A
medium gauze swab (22.5 cm × 22.5 cm) is placed over the
traumatized surface which helps to keep the opposing lacerated
surfaces from pressing together and facilitates retraction. The left
lateral ligament is divided with scissors and diathermy from the
splenic tip to the IVC. The right lateral ligament is divided and
mobilized completely on the surface of the right lobe up to the level of
the suprahepatic cava and posteriorly to the retrohepatic IVC. Large
gauze swabs (45 cm × 45 cm) are then packed behind the right lobe
along the entire lateral margin of the IVC and packing continued
laterally, superiorly, anteriorly and finally inferior to obtain complete
and adequate compression of the right lobe. The left lobe is similarly
compressed with packing around its entire circumference. Packs may
be gently removed after 48 h. Repacking may be required but this is
unusual. If necessary the 'packed' patient can then be safely
transferred to an appropriate surgical unit.

Packing of the Liver for Liver Trauma


The Cambridge Technique
N. V. Jamieson
Substantial liver trauma can result in heavy bleeding which is difficult
to control. Attempts to mobilize the liver to resect or suture the
injured segments can exacerbate the situation. We recommend simply
packing the liver as follows.
No attempt is made to mobilize the liver. Broad gynaecological rolls
(20-cm wide and 10-m long) are carefully packed in a layered fashion,
first above the liver

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


Page 37

A Safe Technique for Anastomosing a Normal Calibre


Bile Duct
G.P. McEntee
Anastomosing a dilated bile duct to a Roux loop or the duodenum is
rarely a problem. However, accurate positioning of sutures can be
difficult when dealing with a normal or small calibre duct. I use a
technique based on

Figure 18


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

Page 39

Technique for the Anastomosis of the Common Bile


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

Figure 19


Page 40
within the jejunum through the partially constructed anastomosis and
into the common bile duct. The anterior wall of the anastomosis is
then constructed with interrupted 5/0 PDS. The probe is then
withdrawn from the jejunum and the small incision proximally in the
Roux loop is closed with PDS sutures.
This technique is beneficial where the anastomosis involves a
common bile duct of narrow calibre, particularly in children. It
enables the anterior wall of the anastomosis to be constructed without
risk of inadvertently picking up mucosa from the posterior wall of the
anastomosis. I have found this technique to be very helpful
particularly in paediatric liver transplantation but also in other cases of
choledochojejunostomy.

Improved Access to the Gall Bladder at Open


Cholecystectomy
C.J. Walsh
Access to the gall bladder at the time of an open cholecystectomy may
be improved by putting your hand up over the dome of the liver
between it and the right hemidiaphragm. By so doing the 'vacuum'
between the right hemidiaphragm and the liver is broken, air is let in
and the liver and thus the gall bladder descends. This simple
manoeuvre can often improve exposure to the gall bladder and the
common duct when exposed through a Kocher incision.


Page 41

A Snugger for Peroperative Cholangiograms During


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


Page 42

Figure 20


Page 43

Excision of the Gall Bladder.


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


Page 45

PANCREATIC SURGERY

Safe Approach to Superior Mesenteric Vein and Neck of


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

Page 46

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

Exposure of the Pancreas


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


Page 47

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


Page 48
above, leads to the posterior surface of the tail of the pancreas. This is
particularly important, and easy when there is splenomegaly
displacing the tail of the pancreas caudally and medially. The
manoeuvre greatly facilitates exposure.

Four Tips that Facilitate Pancreaticoduodenal Resection


A. Cooperman and L. Gellman
Tip One
Assessing Resectability of Head of Pancreas Lesions
In assessing resectability of head of pancreas lesions, early division of
the bile duct and gastroduodenal artery allows the interface between
portal vein and neck of pancreas to be visualized and entered. If the
lesion is deemed unresectable, the proximal duct may be used for
bypass. This manoeuvre, utilized since 1980, shortens and facilitates
the operation (Fig. 23).
To perform this manoeuvre the distal bile duct is first tied and a stay
suture is placed on the proximal duct and secured to the drapes with a
haemostat. This secures and provides traction to the liver. The same is
done to the gastroduodenal artery and the proximal side is tied,
clipped and tacked to the drape.


Page 49

Figure 23

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


Page 50

Figure 24

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


Page 51

Figure 25


Page 52

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

Figure 26


Page 53
slow gastric emptying which can be rapid after pyloric resection.
4 The jejunojejunostomy is created last in an end-to-side fashion.

Pancreaticojejunostomy Following Whipples


Pancreaticoduodenectomy
A. Kingsnorth
Following standard Whipples resection or pylorus preserving
resection, the jejunum has been divided just beyond the
duodenojejunal flexure. The author's technique is to bring this free
end up through the mesocolon to the right of the middle colic vessels
and anastomose it end-to-end to the stomach remnant or the duodenal
stump. The bile duct is then sutured end-to-side to this length of
jejunum 510 cm distal the first anastomosis.
The pancreatic remnant now remains to be sutured to the jejunum.
This is achieved to an isolated Roux loop. For convenience this Roux
loop is fashioned and anastomosed as a pancreaticojejunostomy
before any other reconstructive anastomosis because it lies posterior
to all the other structures in the upper abdomen.
The jejunum is therefore divided 6080 cm from its previously divided
proximal end. The distal loop is brought up through the mesocolon to
the left of the middle colic artery to lie side-to-end to the divided
pancreatic stump. A two-layer anastomosis is now performed in which
the outer layer of sutures is a capsuleto-serosa layer of which the
posterior layer is inserted first. A duct-to-mucosa layer is now
performed in two stages beginning with the posterior layer utilizing


Page 54
absorbable sutures (Fig. 27a). Approximately 610 sutures will achieve
duct-to-mucosa anastomosis and no stents are used. The two-layer
anastomosis is completed with an anterior capsule-to-serosa suture
and the completed

Figure 27


Page 55
configuration of the reconstruction after the Whippies resection is
shown in Fig. 27b.

A Strategy for Pancreatic Necrosectomy


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

Page 57

SURGERY OF THE DUODENUM AND THE SMALL


INTESTINE

Reconstruction Technique After Resection of Duodenal


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


Page 58

Figure 28


Page 59

How to Avoid Mucosal Perforation When Performing a


Ramstedt's Pyloromyotomy
R. W.. Motson
After delivering the pyloric tumour through the abdominal wound,
rather than using a scalpel, Denis Browne or artery forceps to split the
hypertrophic muscle, try using a sterile ampoule file which slowly
saws through the muscle fibres (Fig. 29). As one approaches the
mucosa, even individual fibres can be divided by the ampoule file
without the risk of perforating the mucosa.

Figure 29


Page 60

Technique to Avoid the Posterior Wall When Oversewing


a Perforated Duodenal Ulcer.
R. G. Molloy
When closing a perforated duodenal ulcer one needs to ensure that the
suture does not pick up the posterior duodenal wall whilst closing the
anterior perforation. To help prevent this complication, place a Lahy
forceps in the actual perforation in order to lift the anterior wall
forward and prevent the stitch from catching the posterior wall (Fig.
30).

Figure 30


Page 61

How to Make a Feeding Jejunostomy


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


Page 62

Figure 31


Page 63

Choosing Levels of Resection in Small Bowel Crohn's


Disease
V.W. Fazio
The proximal extent of the disease is first assessed by noting the
presence of fat wrapping, curlicue vessels or point of obstruction. The
best guide to the proximal extent of disease is palpation along the
enteric mesenteric margin. Non-diseased bowel proximal to the
affected segment may be dilated but there is no mesenteric thickening.
One is able to palpate a step between the edge of the bowel wall and
the mesentery. A segment with

Figure 32
Cross-sections through the distal
ileum and its mesentery. Palpation
between finger and thumb at the
mesenteric edge of the bowel allows
one to determine the proximal limit
of resection. At this point a definite
step is palpable between the
mesentery and the mesenteric
bowel margin.


Page 64

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


Page 65

Method of Dividing Small Bowel Mesentery in Crohn's


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

Page 66

Figure 34
Technique for division of small bowel
mesentery using overlapping Kocher
clamps and suture ligation. Stitch
enters at the tip of one Kocher clamp
(A) and emerges at the
tip of the overlapping one (B).
previous pair. The mesentery is divided in a likewise fashion to the
preselected site at the other mesenteric border of the bowel. The
vessels in the mesentery are controlled by suture ligation with heavy
absorbable suture material. By overlapping the Kocher clamps, no
segment of small bowel mesentery escapes suture ligation.


Page 67

Ball-Bearing to Detect Small Bowel Strictures


R. Miller
At the time of bowel resection or stricturoplasty for Crohn's disease, it
is important to determine if there are any further small bowel
strictures which need to be dealt with. Most commonly this is done by
placing 5 ml in the balloon of a Foley catheter and then trawling this
through the small bowel to detect narrowings. This can be
cumbersome and time consuming.
I suggest you do not use a Foley catheter. Instead use a sterile metal
ball-bearing with a 2-cm diameter. Drop this into the small bowel at
the site of the initial enterotomy made to perform either a resection or
stricturoplasty. First let it run in a retrograde direction towards the DJ
flexure. Simply lift the loops of intestine one after the other and let the
weight of the ball-bearing carry it towards the duodenum. If there are
any significant strictures the ball-bearing will be held up, the stricture
can be dealt with, and the procedure repeated until the DJ flexure has
been reached. Afterwards simply roll the ball-bearing back in an
orthograde direction towards the ileocaecal valve. This is an
extremely quick, easy and reliable way to detect small bowel
strictures. You might need a 1.5-cm ball-bearing for children.


Page 69

STOMA SURGERY

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


Page 70

Figure 35
The abdominal cavity is opened after
the ileostomy site is fashioned.


Page 71

The 554 Ileostomy*.


C. Hall, C. Myers and R.K.S. Phillips
There are no published guidelines to ideal ileostomy length and
configuration. Stomatherapies request a spout long enough to avoid
skin excoriation but not so long in women as to be incompatible with
their feminine body image. In addition, the effluent should be directed
forward and slightly downwards.
It is usual when constructing an ileostomy to place sutures at 90° to
each other at 12, 3, 6 and 9 o'clock and place intervening sutures as
necessary. Mucosal followed by serosal bites some distance proximal
on the bowel wall are taken before stitching the skin. The problem
with such an approach is that the small bowel mesentery is at 12
o'clock so there the second serosal bite must be omitted. Inevitably,
when the sutures are tied the superior margin becomes shorter than the
others and the ileostomy spout faces upwards.
Surgical technique. Sutures are placed at 10 and 2 o'clock on either
side of the small bowel mesentery. In these positions it is possible to
place a serosal stitch 5 cm proximally before taking a subcuticular bite
of skin. Inferiorly at 6 o'clock, the serosal stitch is placed 4 cm
proximally (Fig. 36a) before the suturing is completed in the usual
way with the addition of intervening stitches as necessary (which omit
the incorporation of the serosa). The resulting ileostomy has a 2-cm
inferior margin and a 2.5-cm superior margin (Fig. 36b).
*Reproduced from Hall, C., Myers, C. & Phillips, R.K.S. (1995) The 554
ileostomy. British Journal of Surgery 82 (10), 1385.


Page 72

Figure 36
Discussion. This is a simple technique that produces a good result
every time. Care must be taken when placing serosal stitches in the
proximal bowel wall to avoid full thickness penetration as this can
lead to fistula formation particularly in Crohn's disease. It is not
necessary when using this technique to use aids to stoma eversion.


Page 73

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

Page 74
to the seromuscular layer of the bowel. Similarly, sutures are placed
from the skin edge to the proximal everted component, picking up the
serosa of the emerging bowel so that these sutures help to stabilize the
loop ileostomy against the abdominal wall.
The message is: make the enterotomy in the distal limb small then the
bowel can be folded back on itself to sit comfortably without a rod.

The Loop End Ileostomy


V.W. Fazio
Fashioning an end ileostomy in the obese patient may be difficult. The
bulky and foreshortened ileal mesentery may make it difficult to
deliver the terminal ileum through the trephine in the anterior
abdominal wall. Attempts to manipulate it through may lead to
damage to mesenteric vessels with bleeding and devascularization. In
these obese patients it is often easier to perform a loop end ileostomy
(Fig. 37). Staple off the end of the ileum and invert the staple line with
a running absorbable suture. Identify a point on the ileum proximal to
the staple line which is suitable for formation of a loop stoma. To do
this, bend the distal ileum over on itself (as one might do in forming a
J-pouch). A 'natural apex' of this loop will become apparent based on
the anatomy of the mesenteric arcades. Make a small hole in the
mesentery at the mesenteric edge of the bowel with a haemostat and
pass a linen tape around the small bowel at this point. Now mark the
downstream and upstream sides by placing sutures of different
colours, for example catgut and Vicryl, in the antimesenteric border of
the bowel I cm either side of the tape. This will facilitate opening the
correct part of


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


Page 76

Figure 37


Page 77

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

Figure 38


Page 78
bowel for serosal or seromuscular injury, as if undetected and not
repaired this injury could lead to postoperative perforation.
When restoration of intestinal continuity necessitates a laparotomy
(patients with a Hartmann's procedure or a mucous fistula), the above
procedure to mobilize the stoma(s) may be carried out as the first
stage. The stoma is then sealed prior to rescrubbing and retowelling.
Perform the laparotomy with a new set of instruments.

Reversal of Ileostomy
K. Barry and J. Hyland
Reversal of an end or loop ileostomy is facilitated by careful traction
of the base of the stoma. It is our own practice to place four sutures
through the mucocutaneous junction at 3, 6, 9 and 12 o'clock positions
(Fig. 39). 3/0 Vicryl on a 20-mm round-bodied needle is ideal for this
purpose. The ends of each suture are grasped in turn with

Figure 39
Upward traction is provided
by placement of four sutures
at the mucocutaneous
junction.


Page 79
a mosquito forceps. The four mosquito forceps are then held together
perpendicular to the anterior abdominal wall and twisted in a
clockwise direction to wrap the four sutures for a common distance of
45 cm. This accumulated wrap is double-looped over one limb of an
artery forceps which is then closed to prevent slipping of the wrap.
The suture ends are cut to release the mosquito forceps.
The artery forceps is now held by the operator to provide excellent
atraumatic traction of the stoma, as dissection proceeds in standard
fashion around the base of the stoma and through the layers of the
anterior abdominal wall. This traction method is particularly useful to
ensure that all intraperitoneal adhesions to the stoma have been
divided. In the case of a loop ileostomy, we close the intestinal lumen
with a single layer of interrupted 3/0 Vicryl sutures before returning
the small bowel to the abdominal cavity.

Stapled Closure of Loop Ileostomy


J.H. Scholefield
Loop ileostomy offers a number of advantages over loop colostomy as
a method of defunctioning a low anastomosis in the pelvis. However,
closure of the loop ileostomy has gained a reputation as a technically
difficult procedure, largely because of the size disparity between the
two limbs. A stapled side-to-side anastomosis overcomes this
difficulty, it is both simple and effective.
The stoma is mobilized to the peritoneal cavity. Using a linear stapler
such as the TLC75 (Ethicon) or the GIA (Autosuture), one limb of the
stapler is inserted into each of the afferent and efferent limbs of the
ileum (Fig. 40).

Page 80

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


Page 81

Closure of Loop Ileostomy.


P.W.R. Lee
Loop ileostomy has become the preferred method of covering low
colorectal anastomoses. Closure of the loop can be a difficult and
tedious procedure. It is important that all adhesions involving both
limbs be divided and that sufficient length of both limbs be mobilized
for the closure anastomosis.

Figure 41


Page 82
Once the loop has been ellipsed and dissected down to the peritoneal
level, it is helpful to extend the circular defect vertically either
proximally or distally for a distance of 34 cm (Fig. 41b). This should
be done full thickness including the anterior abdominal wall and the
skin. A 'mini laparotomy' is created which facilitates easy and full
dissection of the loop. Closure of the bowel defect by hand is difficult
and produces a narrow lumen; it is recommended that the closure then
proceeds as a stapled, side-to-side anastomosis of at least 7-cm length,
using a linear cutter and a straight linear stapler (Fig. 41e-f).

Wound Closure after Take-Down of a Stoma


R. Miller
After take-down of an ileostomy or colostomy many surgeons like to
leave the stoma wound open because of the risk of infection. This
wound takes many weeks to finally heal. A tip to avoid this delay in
wound healing, and yet not formally closing the wound with the
associated risk of infection, is to place a subcuticular Prolene purse-
string around the circumference of the wound and then draw the
purse-string tight. Use a tapercut needle. This purse-string technique
will reduce the skin defect by more than 75%, yet leave the wound
open to drain. The purse-string is left long so as to be found and
removed easily at a clinic visit or a nursing visit some weeks later.
The end result is a small, cosmetically acceptable punctate scar.
I am grateful to N.K.S. Phillips for showing me this.


Page 83

Repair of Paracolostomy Hernias


P. Vukasin and R.W. Beart Jr
Herniation complicates 3040% of stomas, but relocation is often not
desirable or feasible. Repair with the following technique gives
durable results with minimal morbidity. The stoma and hernia
contents are completely mobilized through a laparotomy without
disrupting the mucocutaneous anastomosis. The hernia sac is resected
when possible and the resultant fascial defect is closed with a large,
monofilament, non-absorbable suture to a point that only two fingers
can be admitted alongside the bowel. The repair is reinforced with a
1-mm Gore-tex 10 cm × 12 cm sheet fashioned as shown in Fig. 42.
The sheet is divided 3/4 of the way through its midpoint. Six
additional 1.5-cm cuts are made at 45° angles radiating from a point
1.5 cm proximal to the end of the original cut, creating an eight-point
star. The stoma is then

Figure 42


Page 84
encircled by the sheet from the inside such that it lies against the
peritoneum dorsal to the rectus sheath, covering the sutured defect,
with the 'fingers' of the star splayed over the bowel pointing away
from the fascia. The remaining slit of the sheet is closed snugly about
the bowel with 3/0 silk. The sheet is then stretched to its full size and
secured to the abdominal wall with a herniastapling device or silk
sutures.


Page 85

COLON AND RECTAL SURGERY

Identification of the Left Ureter


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

Page 86

Figure 43


Page 87

Acute Appendicitis?
Re-Examine Abdomen When Patient Anaesthetized on
Operating Table
C.J. Walsh
In cases of suspected acute appendicitis re-examine the abdomen after
the patient is anaesthetized. In older adults, the presence of a mass not
previously palpable in the awake patient may prompt one to choose an
incision through which a right hemicolectomy can be performed
rather than a grid-iron incision. In children, detection of this occult
mass will aid appropriate placement of the appendicectomy incision.

Appendicectomy Without Breaching the Integrity of the


Intestine
A.J.L. Brain
Incidental appendicectomy may increase the risk of sepsis during an
otherwise clean laparotomy. Bowel is opened with the potential for
bacterial soiling of the peritoneum. Inversion appendicectomy enables
a normal appendix to be removed without this risk.
1 First, devascularize the appendix by ligating the mesoappendix. The
vessels on the appendix side should be ligated separately and not in
bunches. This allows the appendix to be inverted with ease.
2 Crush the base of the appendix with a haemostat.
3 Use a probe to invert the appendix into the caecal lumen, leaving a
few millimetres not inverted (Fig. 44).
4 Tie an absorbable ligature tightly around the base of the appendix
after withdrawing the probe. This completely devascularizes the
inverted appendix which will then slough off into the caecal lumen.

Page 88

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


Page 89

Mobilization of the Hepatic and Splenic Flexures of the


Colon.
F. Seow-Choen
It is safest and easiest to mobilize the ascending, descending and
sigmoid colon by starting mobilization at the white line representing
the congenital peritoneal adhesions and then to reflect the colonic
mesentery medially to isolate the vascular pedicles. The hepatic and
splenic flexures, however, are safest and fastest mobilized by curving
the incision towards the colon and dissecting as near the flexures as
possible (Fig. 45). This is the true bloodless plane of the flexures and
will enable efficacious mobilization.

Figure 45


Page 90

Taking Down Splenic Flexure


V.W. Fazio
Usually the best approach to the splenic flexure is a combination of
left colon mobilization along the white line of Toldt (taking the
incision anterior to, but not breaching, Gerota's prerenal fascia) and
dissection of the greater omentum from the transverse colon, entering
the lesser sac and progressing to the left towards the flexure. By
downward and medial traction on both transverse and left colon, the
flexure at the splenic hilum is eased out, allowing direct
electrocautery dissection of the new transverse mesocolon to further
'ease out' the colon and mesocolon from the spleen.
If the patient is in the Lloyd-Davies position, mobilization of the
splenic flexure may be facilitated by the operator standing between
the patient's legs.
Very occasionally access to the splenic flexure via a midline
laparotomy wound can be very difficult both in the asthenic as well as
the obese patient, particularly if

Figure 46
Transverse extension of midline
laparotomy wound to facilitate
mobilization of the difficult
splenic flexure.


Page 91
the flexure is high and/or 'embedded' into the hilum of the spleen. In
this instance, exposure may be facilitated by making a T-extension of
the wound in a left transverse direction (Fig. 46). This transverse
extension of the midline laparotomy wound for difficult splenic
flexures was shown to me by Dr Rupert Turnbull.
Very occasionally the splenic flexure may be overly distended. In this
instance one can deflate the colon by needle decompression (see
Needle decompression of the obstructed colon, p. 92).

Mobilization of the Splenic Flexure


R. Miller
Most surgeons approach the splenic flexure mobilization by first
dividing the adhesions along with the left paracolic gutter. On
occasion there is a tendency to continue this dissection without
altering the exposure and as one goes higher and further up into the
darker reaches of the left upper quadrant the procedure can become
quite tedious, even when the surgeon is in the correct plain of
dissection. If progress slows down, just stop. Pull downwards gently
on the transverse colon. What was once a difficult high splenic flexure
often now comes down into the wound and makes further
mobilization significantly easier.


Page 92

Needle Decompression of the Obstructed Colon


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

Page 93

Hartmann's Operation in Presence of Colon Obstruction


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


Page 94
end can be delivered and used to fashion the colostomy (Fig. 47).

Figure 47


Page 95

Getting the Colon to Reach


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

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


Page 96
division of base of transverse mesocolon to mid-colic vessels.
These techniques are usually sufficient to bring a well-vascularized
colonic pedicle to the lower rectum or anal canal. Occasionally other
manoeuvres are required and these include the following.
Delivery of proximal colon through the window between the ileocolic
vessels and the superior mesenteric vessels;
Should the former fail, then division of both branches of the mid-colic
vessels can be performed, thus leaving the hepatic flexure or mid-
ascending colon as the new proximal line of transection and this is
supplied by the ileocolic vessels through the marginal arcades. Very,
rarely one might want to consider a caeco- to low rectal, or caeco-anal
anastomosis, or exceptionally one may consider ileal interposition
between the hepatic flexure and distal rectum.

Achieving Adequate Bowel Length for Anastomosis after


a Left Colonic Resection
D.E. Beck
After completing the appropriate resectional procedure, sufficient
proximal and distal mobilization provides tension-free bowel ends for
a secure anastomosis. Difficulty in obtaining tension-free bowel
occurs more commonly with a left-sided (e.g. colorectal) anastomosis.
Additional left colon length is obtained with the following procedures:
division of the lateral colonic attachments;
division of the splenic flexure attachments;
division of the inferior mesenteric artery at its aortic takeoff; and

Page 97
division of the inferior mesenteric vein at the inferior border of the
pancreas.
If these manoeuvres do not provide adequate bowel length, branches
of the distal middle colic artery and veins may need to be divided.
However, this may compromise the blood supply to the remaining
colonic end. If this occurs, the ischaemic bowel must be resected and
additional vessels divided to provide the required length. In some
cases, the middle colic vessels will have to be divided proximally and
the blood supply of the residual colon will need to be based on the
right, or ileocolic artery. In most patients, these vessels will provide
adequate blood supply to the proximal transverse colon or hepatic
flexure, which can be made to reach to the rectum with one or two
techniques.

Figure 49
(a) Opening in mesentery is created
medial to the ileocolic artery and
vein. (b) Transverse colon is
brought through the ileal
mesenteric opening to reach
the pelvis.

Page 98

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


Page 99

Placement and Repair of Purse-String Sutures.


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

Page 100

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


Page 101
are placed too far from the bowel end and too tightly, the bowel wall
may be injured which can result in leakage despite a secure
anastomosis. If open-ended clamps (e.g. Babcock clamps) are used, it
is possible for the purse-string to go through the end of the clamp and
the clamp or the purse-string suture will have to be cut. Use of solid-
end clamps eliminates the chance of this happening. Large clamps
increase the difficulty of inserting an anvil in bowel with a diameter
close to that of the anvil.
Several of these techniques were learned from Dr V.W. Fazio at The
Cleveland Clinic.

Proximal Ligation of the Ileocolic Artery


D.E. Beck
In performing an ileocolic or right colonic resection, ligation of the
ileocolic artery and vein are required. If the indication for resection is
a malignancy, proximal ligation of these vessels is preferred. Early
vascular ligation is accomplished in the following manner. The small
bowel is elevated superiorly by the assistant and the avascular plane
between the duodenum and the ileocolic artery is incised (Fig. 52a).
The index and middle finger of the surgeon's right hand (palm up) are
inserted between the duodenum and ileocolic artery. By bending these
two fingers up, the avascular plane between the right colic and
ileocolic artery is identified (Fig. 52b). The peritoneum is incised with
the electrocautery. The index and middle finger of the surgeon's left
hand then replace the right fingers. After the fingers are bent up, the
avascular plane between the ileocolic and superior mesenteric artery
(SMA) is identified (Fig. 52c). After incision of this mesentery, the
ileocolic artery and vein are encircled and the vessels

Page 102

Figure 52
(a) Incision of the avascular plane between
duodenum and the ileocolic artery. (b) Elevation
of the ileocolic artery. (c) Isolation of the ileocolic
artery below the superior mesenteric artery.


Page 103
can be thinned. Correct location for division of the artery and vein is
confirmed and they are clamped, divided, and ligated close to the
arterial takeoff from the SMA.
This technique was learned from Dr V.W. Fazio at The Cleveland
Clinic.

Identification of the Inferior Mesenteric Artery During


Anterior Resection of the Rectum
R. Miller
Accurate identification of the inferior mesenteric artery (IMA) is a
critical early part of an anterior resection. This is not only critical to
facilitate ligation, whether this be a high or low tie, but also because
the IMA is the key to the correct plane for subsequent pelvic
dissection, being in front of the presacral nerves but behind the fascia
propria of the rectum. The IMA is the guide to the plane of dissection
which facilitates nerve preservation and total mesorectal excision.
Standing on the patient's right side, first dissect along the white line of
Toldt dividing the congenital adhesions between the sigmoid colon
and the parietal peritoneum above the level of the sacral promentary
on the patient's left side. Following initial sharp dissection with either
scissors or electrocautery, air is seen to enter the areolar tissue and the
plane between the sigmoid mesentery and the parietes opens up. One
of the keys to developing the correct plane at this point is your
traction on the sigmoid mesentery to the patient's right with the
assistant offering counter-traction on the left. The first structures to
find are the gonadal vessels. Dissect or sweep these laterally (gently
or they will bleed). Next look for the ureter and

Page 104
push that laterally off the mesentery. Next find the sympathetic nerve
fibres which run distally to form the presacral nerves. As you
approach the midline with the combination of sharp and blunt (peanut)
dissection you will come across a glistening, smooth rolled edge of
tissue. This is the posterior aspect of the IMA and lies just anterior to
the sympathetic nerve fibres. Pass an index finger behind the smooth
rolled edge towards the patient's right side and hook the finger gently
forwards, thus tenting up the peritoneum over your index finger tip.
You are now around the IMA pedicle and the vessel can be
skeletonized at any level of your choice and divided. Prior to
clamping the IMA at this point, once again check that the proximal
left ureter does not get into the tips of the clamp.
This technique, and in particular the identification of the smooth
rolled edge which represents the posterior aspect of the IMA, was
taught to me by John Northover at St Mark's Hospital.

Anterior Resection of the Rectum Using the Circular


Stapling Device (Double-Staple Technique)
P. W.R. Lee
The proximal purse-string can be inserted using the Autosuture purse-
string device, the Ethicon modified Fournell clamp or by hand. Hand-
suture treatment is cheap, reliable and accurate. Number 0 Ethibond
(braided polyester on a round-bodied 30-mm needle, Ethicon UK,
suture no. W975) is recommended: it is strong, has no memory, ties
easily and requires only three throws on the knot. Once the purse-
string suture has been placed in the


Page 105

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


Page 106

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


Page 107

Figure 55
short anorectal stump to the low staple line of an ileoanal pouch
procedure.

Laparoscopic Vascular Stapler to Facilitate Pelvic


Sidewall Clearance
A.M. Cohen
The optimal approach to pelvic dissection for excision of the rectum
in low anterior resection, abdominoperineal resection or various
exenterative procedures performed for cancer, involves scissors and/or
cautery dissection under direct vision in the areolar plane posterior to
the visceral plane of the mesorectum. The anterior dissection is also
performed under direct vision along the rectovaginal septum in
women, anterior or posterior to Denonvillier's fascia in men, or
anterior to the bladder in exenterations.


Page 108

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


Page 109
of large clamps with subsequent suture ligation usually damages the
autonomic nerves. The 30-mm vascular stapler facilitates division of
these anterolateral pedicles with bidirectional (medial and lateral)
vascular control and with minimal risk to the autonomic nerves. The
stapler is easily placed parallel to the S3 nerve, even with poor
visualization, and the 23 'fires' free the pelvic sidewall.

The Moran Triple-Stapling Technique:


A Fail-Safe Precaution Against Implantation Staple-Line
Recurrence
R.J. Heald and B.J. Moran
The laparoscopic revolution has stimulated reappraisal of techniques
and attitudes across the whole field of surgery, better pain relief is the
most obvious example. Similarly, the port site recurrence debate
should point us towards 'Listerian' principles to prevent implantation
of malignant cells on to tissues made vulnerable by surgery. The
intraluminal mucus beyond a colorectal cancer is one obvious danger
which should not be allowed to contaminate the operative field.
Prevention of such contamination demands reliable 'sealing' of the
excised specimen and extensive lavage of the lumen distal to the seal
before transection or stapling of the bowel which is to remain within
the patient. Thus the dual hazards of cut and crushed host tissues and
viable malignant cells are eliminated.
The Moran triple-stapling technique uses a PI 30® or PI 55® linear
stapler with the green cartridge (4.8-mm long staples) to provide a
fail-safe routine. The long, narrow PI 30® can reach to the bottom of
the narrowest

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


Page 111

Figure 57


Page 112

Alternatives to Colonic J-Pouch


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

Figure 58


Page 113
(1997) A novel colonic reservoir and comparison of it's short term
function with a straight coloanal and colonic J-pouch anastomosis in
the pig. Gastroenterology 112, p. A1487).

Use of Hydrodissection to Mobilize the Rectum in Redo


Pelvic Surgery.
E.L. Bokey
This technique is especially valuable in redo pelvic surgery or surgery
for recurrent disease. A laparoscopic suction irrigator (LSI) is used
(Fig. 59a). A small incision is made in the peritoneum, usually to the
right of the rectum and well away from the principal phlegmon or
recurrence (Fig. 59b). The suction irrigator is introduced and 50100
ml of warm saline are pumped into the current plane (anterior and
medial to the hypogastric plexus). This opens up the plane and greatly
facilitates dissection.
The technique is also very useful in adhesiolysis, especially when
multiple loops of small intestine are stuck in the pelvis.


Page 114

Figure 59


Page 115

Reusable Transanal Anvils


F. Seow-Choen
In the performance of a stapled double-purse-string anterior resection,
the intraluminal stapler is inserted transanally, whereas the anvil is
detached and inserted into the proximal colon. The insertion of the
intraluminal stapler without the cone-headed anvil is traumatic and
often lacerates or catches redundant mucosa and sometimes this
results in a less than satisfactory anastomosis. I sterilize used anvils of
different sizes and insert them into the stapler shaft for transanal
insertion. Following satisfactory transanal insertion, the used anvil is
removed and the current anvil and shaft attached in the normal fashion
for anastomosis (Fig. 60).

Figure 60


Page 116

Inserting Transanal Staplers in Ultra-Low Anterior


Resection
F. Seow-Choen
Insertion of a transanal intraluminal stapler may be difficult during the
performance of a double-stapled ultra-low anterior resection. The anal
canal of about 3 cm hardly allows for a lot of manipulation. Indeed
excess force will perforate the linearly stapled rectal stump. I use two
pairs of Allis clamps at the anal verge for counter-traction (Fig. 61). In
this fashion, insertion of a transanal intraluminal stapler is usually
easy and safe.

Figure 61


Page 117

Getting the Small Bowel to Reach


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


Page 118
desmoids or desmoplastic reaction within the mesentery often causes
a foreshortening of the mesentery.

Insertion of the Stapler for an Ileal Pouch-Anal


Anastomosis
J.M. Church
One of the trickiest stages of a double-stapled ileal pouchanal or colo-
anal anastomosis is the transanal insertion of the end-to-end stapler.
The anvil has been removed and the blunt end of the cartridge must be
inserted through the sphincters into the anal stump. When the
horizontal staple line has been placed low across the rectum there is
very little room to accommodate the cartridge. In a patient with tight
sphincters where a large cartridge is being used (I prefer a 33-mm
stapler) there is a real danger of the cartridge tearing the bowel or
even being thrust through the transverse staple line. This necessitates
removal of the anal stump and a hand-sewn anastomosis. To avoid an
uncontrolled and potentially dangerous cartridge insertion I suggest a
bi-manual technique.
When the operation has proceeded to a stage where the anastomosis is
to be done, an assistant stands between the patient's legs and dilates
the anus gently to accommodate three fingers. The surgeon, who is on
the patient's right, places his/her left hand in the patient's pelvis and
grasps the stapler with his/her right hand (Fig. 62). The surgeon now
inserts the cartridge through the anus, using his/her left hand (in the
pelvis) to support the anorectal stump and even to gently push the
internal sphincter over the edge of the stapler. The surgeon can feel
when the stapler cartridge is through the sphincters, nestling in the
stump. The cartridge can be placed so that

Page 119

Figure 62
the rod will protrude either in the centre or just inferior to the centre of
the transverse staple line. The surgeon then hands the stapler to the
assistant, who rotates the knob to extrude the rod. The surgeon
regloves and the anastomosis proceeds.

Stapled Ileoanal Pouch Procedure


H.J. Sugerman
When performing a one-stage stapled ileoanal pouch procedure, the
rectum and anal cuff are stapled as close as possible to the dentate line
and levator ani muscles with a 30-mm horizontal stapler. A 15-cm
ileal J-pouch is constructed with two firings of a 90-mm GIA® stapler
(Autosuture Company, US Surgical Corp., Norwalk, CT, USA) and
the J-pouch is anastomosed to the anus with a Premium Plus EEA
31® (Autosuture Company, US


Page 120

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


Page 121
can be safely managed without ileal diversion if the leak is proven to
be confined to the pelvis by water-soluble contrast enema and there
are no signs of peritonitis. We prefer the PI 30® to a reticulated 30-
mm stapler, as it is not as wide, permitting a lower application on the
anal canal. Occasionally the pelvis is too narrow to place the PI 30®
stapler on the distal level of dissection on the levator ani muscles. In
such a circumstance the rectum can be everted and the medium PI
30® horizontal stapler placed from below with its long plane vertical.
Again it is fired twice to obtain two superimposed rows of staples.

Combined Supine and Prone Jack-Knife Position for


Abdominoperineal Resection of the Rectum
C.J. Walsh
Anterior dissection and mobilization of the rectum from the prostate
can be difficult in the male patient with a bulky or locally advanced
anterior rectal tumour requiring abdominoperineal resection. This
dissection between the anterior rectal wall and the prostate is one of
the most important parts of the operation from an oncological point of
view in this patient population. When the patient is in the more
traditional Lloyd-Davies position, visualization of this area and
therefore accurate sharp dissection can be difficult. To overcome this
problem do the perineal portion of the operation with the patient in the
prone jack-knife position.
The abdominal portion of the operation is performed with the patient
supine on the operating table and the steps are the same as the
conventional method of performing the procedure. Divide the
proximal colon with a cutting stapler rather than dividing it between
clamps.

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


Page 123

Thumbtack to Arrest Bleeding from Presacral Veins.


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


Page 124

Figure 64
(a) Venous system of the sacrum (sagittal
view). (b) Thumbtack occlusion of a
bleeding basivertebral vein.
(From Nivatvongs, S. & Fang, D.T. (1986)
The use of thumbtacks to stop massive
presacral hemorrhage. Diseases
of the Colon and Rectum 29, 590.)


Page 125

Dealing With Presacral Bleeding During an


Abdominoperineal Resection
R.G. Molloy
Presacral bleeding following pelvic dissection can on occasion be
very difficult to stop. When this occurs during an abdominoperineal
resection tamponade can be affected by placing a Sengstaken tube into
the pelvis via the perineal wound and inflating the gastric balloon
(Fig. 65). This can be deflated after 24 h and the tube removed if there
is no further bleeding.
This tip was shown to me by Mr J. McCourtney.

Figure 65


Page 127

ANORECTAL SURGERY

A Better View in Anorectal Surgery


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


Page 128

Figure 66
(a) Opened 10 cm × 10 cm gauze swab. (b)
Swab in position mid-rectum. Note: swab
has 'Ratex' radiopaque line on swab for
identification (black) and nylon suture for
retrieval (blue; double ligature at swab).

Exposure for Transanal Excision of Rectal Lesions


J.M. Church
One of the difficulties of open transanal excision of rectal lesions is
adequate exposure. Anal retractors allow good exposure of the lower
rectum but above this level the rectal walls tend to fold together (Fig.
67a).


Page 129

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


Page 130

Transanal Dissection Using Electrocautery:


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

Figure 68
Use a heavy artery forceps
to bend the tip to 90°.


Page 131

Easier Haemorrhoidectomy
J.H. Scholefield
Haemorrhoidectomy is a common procedure but one which is often
badly taught. A tip which I have found useful is to start the excision of
the skin component of the haemorrhoid a few millimetres further
away from the haemorrhoid than might at first seem appropriate (Fig.
69). This allows the surgeon to avoid the spongy tissue in the skin
component of the haemorrhoid and identify the internal anal sphincter
more easily. In so doing the surgeon reduces the blood loss from the
anal verge. The surgeon must of course still preserve the skin and
mucosal bridges.
Injection of 0.25% Marcain with adrenaline into each of the identified
and marked haemorrhoids followed by massaging of the injection into
the surrounding tissue not only simplifies identification of the
submucosal planes but also provides postoperative analgesia.


Page 132

Figure 69


Page 133

Injection of Haemorrhoids.
P.W.R. Lee
In the UK, injection of first- and second-degree haemorrhoids using
5% phenol in almond oil is often the preferred method of treatment.
Conventionally ~3 ml of the solution has been injected submucosally
into the apex of the three pile masses in the right anterior, right
posterior and left lateral position (Fig. 70a). Equally satisfactory
results can be obtained by two slightly larger injections at the 3
o'clock and 9 o'clock positions (Fig. 70b). This is easier to perform,
saves the patient an additional injection and often facilitates the
injection of a larger volume of sclerosing fluid. If the first injection
occludes the view down the proctoscope, a 1.5-cm ball of cotton wool
is placed over the injected area and pushed slightly proximally. This
secures an adequate view of the other side to facilitate the second
injection (Fig. 70c).


Page 134

Figure 70


Page 135

Rubber-Band Ligation of Haemorrhoids Made Easier


P.W.R. Lee
There are three useful tips when using the standard McGivney
haemorrhoid ligator (Aesculap, Sheffield, UK).
1 The surgeon requires two free hands for grasping the haemorrhoid
and placement of the bands. The patient should be in the left lateral
position. If a nursing assistant is not available to hold the proctoscope
it is a simple matter to ask the patient to hold the proctoscope handle
with his or her own right hand (Fig. 71).

Figure 71


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

Figure 72


Page 137
An assistant to hold the proctoscope is mandatory. The rubber-bands
are grasped with long straight artery forceps clicked down one rachet
(to steady the bands). They are then cut through with a single firm
movement with a 15-gauge knife-blade on a long 160-mm scalpel
handle (no. 7 BP Swan Morton, Sheffield, UK) (Fig. 73).

Figure 73


Page 138

The 'Looped Pulley' Suture in Perineal Wound Closure


Under Tension
R.J. Rubin
When wide perineal excision is required there may be tension on the
perineal wound. This is also true of trans-sacral longitudinal incisions.
The 'looped pulley' suture (Fig. 74) approximates the skin edges with
much less

Figure 74


Page 139
tension than a routine vertical mattress suture. We usually employ
three or four 'looped pulley' sutures along the wound and then close
the skin with clips.
A routine heavy (no. 0 or no. 1) vertical mattress suture is placed.
Then the suture is directed between the exiting point and the skin edge
on the side opposite from which the routine suture exits the skin edge.
This forms a pulley. Three or four such sutures are all that are required
to buttress the closure of the perineum. They can be left in place for
several weeks.
This suture was shown to me by Dr Robert Paradny who was my
Chief resident when I was a Surgical Resident at Mt Sinai Hospital in
New York City.

Lubrication to Find the Induration


A.D. Wells
The induration which so often is the tell-tale sign of perianal sepsis or
a fistula tract can, on occasion, be difficult to detect with the gloved
examining finger. A tip is to lubricate the perianal area and the
examining finger with KY jelly. In this way the examining finger
slides over the tissues more easily and it is easier to differentiate
normal supple tissues from abnormal indurated tissues.

Seton Insertion for Fistula-in-Ano


R.J. Rubin
It is often quite difficult to insert a seton into a fistulous track after the
track has been probed with a blunt probe that has passed through the
track, particularly in patients with multiple perianal fistulae associated
with Crohn's

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

Figure 75


Page 141

Cutting Seton for Fistula-in-Ano


R. Miller
One tip that I picked up from the Minneapolis/St Paul group of
colorectal surgeons is in the management of trans-sphincteric fistula-
in-ano with a cutting seton.
An easy way to tighten the seton is to construct the original seton
from a double band of the sloops used to sling arteries by vascular
surgeons. This double loop is brought through the fistula track having
divided the skin and possibly the internal sphincter in the line which
will be cut by the seton. The sloops are tied together on the outside
and then to tighten them, Baron's bands used for banding
haemorrhoids, can be loaded on to the vascular sloops and then back
up against the knot. The more bands you put on, the tighter the seton
becomes and this can easily be tightened in the clinic, thereby
avoiding repeated trips to theatre for replacement of the seton.

Perianal Wound Care


J.P.S. Thomson
Most perianal wounds (following operations for fistula, fissure,
pilonidal disease and operations to remove the rectum) heal without
difficulty. In some, delay in healing for long periods may occur
because:
1 the wound is not shaped to allow maximum drainage;
2 hairs from the wound edge grow into the granulation tissue;
3 exuberant granulation tissue prevents epithelialization.
To get around these problems:
1 It is important to ensure that there is an adequate external wound (a
Salmon back-cut) to establish good drainage (Fig. 76a).


Page 142

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


Page 143

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


Page 144

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

Page 145
gastroenterostomy, Schneeden stitch 14
general surgical techniques 1122
glycerol, greasing of suture threads 16
greater omentum, separation from transverse mesocolon 1415
gynae rolls 36
H
haemorrhage
Babcock clamps for 1516
basivertebral vein, thumbtack occlusion 124
hepatic trauma 346
prevention in pancreatic necrosectomy 55
see also presacral veins
haemorrhoidectomy
easier procedure 1312
postoperative analgesia 131
haemorrhoids
drawing into banding gun 136
injection 1334
rubber-band ligation 1357
haemostasis, Babcock clamps for 1516
Hartmann's operation, in colonic obstruction 934
hepatic flexure, mobilization 89
hepaticojejunostomy 52
hepatic resection, clearance of vena cava 312
hepatobiliary surgery 3143
hepatocaval ligament 31
hernia, paracolostomy, repair 834
hydrodissection, rectum mobilization 11314
I
ileal pouch-anal anastomosis
ileal reach and lengthening methods 11718
one-stage stapled, procedure 11921
stapler insertion for 11819
'ileal reach', restrictions 117
ileocolic artery, proximal ligation 1013
ileocolic resection, ileocolic artery ligation 1013
ileostomy
554 712
loop see loop ileostomy
loop end 746
mobilization 778
reversal 789
siting 6970
wound closure after take-down 82
induration, lubrication to locate 139
inferior mesenteric artery (IMA), identification 1034
inferior vena cava
retrohepatic 33
in right-sided hepatic resection 312
uprahepatic, isolation 334
intersigmoid fossa 85
intestinal obstruction see colon, obstruction
J
jejunojejunostomy 52, 53
jejunostomy, feeding 612
jejunum
pancreas anastomosis 501
Roux loop see Roux loop
J-pouch
colonic, alternatives 112
ileal, anal anastomosis 11921
lengthening manoeuvres 11718
L
Lane's forceps 2
laparoscopic suction irrigator (LSI) 113, 114
laparoscopic vascular stapler 1079
laparotomy, incision around falciform ligament 45
laparotomy wound, splenic flexure access 90
lesser sac, air into 1415
linea alba, finding in obese patients 34
liver
mobilization, left lobe 334
resection, clearance of vena cava 312
retraction and oesophagogastric junction exposure 234


Page 146
liver (cont.):
transplantation, common bile duct anastomosis to Roux loop 40
traumatized, packing 345
Cambridge technique 356
Lloyd-Davies forceps 136
'looped pulley' suture 1389
loop ileostomy
closure 812
loop end 746
reversal 789
side-to-side anastomoses 80, 81, 82
siting 6970
stapled closure 7980
without a rod 734
M
Makuuchi's ligament 31
mesenteric vessels
damage and haemostasis method 15
see also inferior mesenteric artery (IMA); superior mesenteric vein
mesentery
colon see mesocolon
division
levels/sites 634
method 656
ileal, after left colonic resection 97
suture ligation 656
mesocolon, transverse
adhesion separation 467
separation of greater omentum 1415
Moran triple-stapling technique 10911
N
needle decompression, obstructed colon 92
O.
obesity
finding midline in abdominal wall 34
loop end ileostomy 746
morbid, gastric bypass 278
oesophagectomy, transhiatal using vein stripper 267
oesophagogastric junction, exposure, liver lobe retraction 234
oesophagogastric surgery 2330
oesophagojejunostomy, high (intrahiatal), anastomosis 246
omentum, greater, separation from transverse mesocolon 1415
P
packing, traumatized liver 346
pancreas
arterial supply and venous drainage 46
division 4853
exposure method 468
head
exposure 467
lesion resection 4853
neck
exposure 467
safe approach method 456
necrosis 55
tail, exposure 478
pancreatic necrosectomy 55
pancreaticoduodenal resection 4853
reconstruction after 523
pancreaticoduodenectomy, Whippies 535
pancreaticojejunal anastomosis 501
pancreaticojejunostomy 535
pancreatic surgery 4555
paracolostomy hernia, repair 834
pelvic dissection
bleeding from presacral veins 1234, 125
laparoscopic vascular stapler 1079
pelvic surgery
laparoscopic vascular stapler 1079
redo, rectum mobilization 11314
retractors used 212
small bowel retraction 19
uterus retraction 201


Page 147
pelvis, exposure and retractors for 212
perianal sepsis, induration location 139
perianal wound, care 1412
perineal wound, closure, 'looped pulley' suture 1389
Peyr's clamp 29
Polyglactin (Vicryl), greased 16
position, jack-knife 1212, 1278
presacral veins, bleeding
Sengstaken tube use to arrest 125
thumbtack method to arrest 1234
proctectomy, small bowel lengthening methods after 11718
proctosigmoidectomy, anterior 956
purse-string sutures
anterior resection of rectum 1045
inversion appendicectomy 88
placement and repair 99101
wound closure after stoma takedown 82
pyloromyotomy, Ramstedt's, mucosal perforation prevention 59
pylorus, resection 52
R
Ramstedt's pyloromyotomy, mucosal perforation prevention 59
rectal surgery 85125
rectum
abdominoperineal resection, positioning for 1212
anterior resection
circular stapling device 1047
colonic pouch-anal anastomosis after 112
inferior mesenteric artery identification 1034
stapled, double-purse-string 115
transanal staplers and 116
colon reaching, methods for 956
excision, laparoscopic vascular stapler 1079
lesions, transanal excision, exposure 1289
mobilization, in redo pelvic surgery 11314
resections, bleeding from presacral veins 1234, 125
sponges in, during transanal excision of lesions 1289
swab insertion for anorectal surgery 1278
retractors used in pelvic surgery 212
Roux loop 52
common bile duct anastomosis to 3940
oesophagojejunostomy 246
pancreaticojejunal anastomosis 501
pancreaticojejunostomy after Whippies resection 535
S
sacrum, venous drainage 124
St Mark's retractor 21, 22, 24
scars, old abdominal, excising 12
Schneeden stitch 14
Sengstaken tube, presacral bleeding control 125
seton
cutting, for fistula-in-ano 141
insertion, for fistula-in-ano 13940
skin, subcutaneous closure 9
small bowel mesentery see mesentery
small intestine
ball-bearing to detect strictures 67
lengthening methods for anastomoses 11718
needle-stick injury prevention 6
resection level in Crohn's disease 634
retraction for pelvic surgery 19
surgery 5767
tumour resection 57

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