Académique Documents
Professionnel Documents
Culture Documents
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
© 1999 by
Blackwell Science Ltd
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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
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
Page vii
Page viii
Page ix
Page x
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
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.
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.
Page 4
Figure 3
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.
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.
Page 7
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
Page 11
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.
Page 13
Figure 7
Page 14
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.
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
Page 18
Figure 8
Page 19
Page 20
Figure 9
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.
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
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.
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.
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.
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
Page 30
Figure 15
Page 31
HEPATOBILIARY SURGERY
Figure 16
Page 33
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.
Page 37
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
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.
Page 41
Page 42
Figure 20
Page 43
Page 45
PANCREATIC SURGERY
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.
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.
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.
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.
Page 58
Figure 28
Page 59
Figure 29
Page 60
Figure 30
Page 61
Page 62
Figure 31
Page 63
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
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
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
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.
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.
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
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).
Page 83
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
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.
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
Figure 45
Page 90
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).
Page 92
Page 94
end can be delivered and used to fashion the colostomy (Fig. 47).
Figure 47
Page 95
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.
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
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.
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.
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.
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.
Page 111
Figure 57
Page 112
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).
Page 114
Figure 59
Page 115
Figure 60
Page 116
Figure 61
Page 117
Page 118
desmoids or desmoplastic reaction within the mesentery often causes
a foreshortening of the mesentery.
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.
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.
Page 123
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
Figure 65
Page 127
ANORECTAL SURGERY
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).
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
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
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
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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.
Figure 75
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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
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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
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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
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liver (cont.):
transplantation, common bile duct anastomosis to Roux loop 40
traumatized, packing 345
Cambridge technique 356
Lloyd-Davies forceps 136
'looped pulley' suture 1389
loop ileostomy
closure 812
loop end 746
reversal 789
side-to-side anastomoses 80, 81, 82
siting 6970
stapled closure 7980
without a rod 734
M
Makuuchi's ligament 31
mesenteric vessels
damage and haemostasis method 15
see also inferior mesenteric artery (IMA); superior mesenteric vein
mesentery
colon see mesocolon
division
levels/sites 634
method 656
ileal, after left colonic resection 97
suture ligation 656
mesocolon, transverse
adhesion separation 467
separation of greater omentum 1415
Moran triple-stapling technique 10911
N
needle decompression, obstructed colon 92
O.
obesity
finding midline in abdominal wall 34
loop end ileostomy 746
morbid, gastric bypass 278
oesophagectomy, transhiatal using vein stripper 267
oesophagogastric junction, exposure, liver lobe retraction 234
oesophagogastric surgery 2330
oesophagojejunostomy, high (intrahiatal), anastomosis 246
omentum, greater, separation from transverse mesocolon 1415
P
packing, traumatized liver 346
pancreas
arterial supply and venous drainage 46
division 4853
exposure method 468
head
exposure 467
lesion resection 4853
neck
exposure 467
safe approach method 456
necrosis 55
tail, exposure 478
pancreatic necrosectomy 55
pancreaticoduodenal resection 4853
reconstruction after 523
pancreaticoduodenectomy, Whippies 535
pancreaticojejunal anastomosis 501
pancreaticojejunostomy 535
pancreatic surgery 4555
paracolostomy hernia, repair 834
pelvic dissection
bleeding from presacral veins 1234, 125
laparoscopic vascular stapler 1079
pelvic surgery
laparoscopic vascular stapler 1079
redo, rectum mobilization 11314
retractors used 212
small bowel retraction 19
uterus retraction 201
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pelvis, exposure and retractors for 212
perianal sepsis, induration location 139
perianal wound, care 1412
perineal wound, closure, 'looped pulley' suture 1389
Peyr's clamp 29
Polyglactin (Vicryl), greased 16
position, jack-knife 1212, 1278
presacral veins, bleeding
Sengstaken tube use to arrest 125
thumbtack method to arrest 1234
proctectomy, small bowel lengthening methods after 11718
proctosigmoidectomy, anterior 956
purse-string sutures
anterior resection of rectum 1045
inversion appendicectomy 88
placement and repair 99101
wound closure after stoma takedown 82
pyloromyotomy, Ramstedt's, mucosal perforation prevention 59
pylorus, resection 52
R
Ramstedt's pyloromyotomy, mucosal perforation prevention 59
rectal surgery 85125
rectum
abdominoperineal resection, positioning for 1212
anterior resection
circular stapling device 1047
colonic pouch-anal anastomosis after 112
inferior mesenteric artery identification 1034
stapled, double-purse-string 115
transanal staplers and 116
colon reaching, methods for 956
excision, laparoscopic vascular stapler 1079
lesions, transanal excision, exposure 1289
mobilization, in redo pelvic surgery 11314
resections, bleeding from presacral veins 1234, 125
sponges in, during transanal excision of lesions 1289
swab insertion for anorectal surgery 1278
retractors used in pelvic surgery 212
Roux loop 52
common bile duct anastomosis to 3940
oesophagojejunostomy 246
pancreaticojejunal anastomosis 501
pancreaticojejunostomy after Whippies resection 535
S
sacrum, venous drainage 124
St Mark's retractor 21, 22, 24
scars, old abdominal, excising 12
Schneeden stitch 14
Sengstaken tube, presacral bleeding control 125
seton
cutting, for fistula-in-ano 141
insertion, for fistula-in-ano 13940
skin, subcutaneous closure 9
small bowel mesentery see mesentery
small intestine
ball-bearing to detect strictures 67
lengthening methods for anastomoses 11718
needle-stick injury prevention 6
resection level in Crohn's disease 634
retraction for pelvic surgery 19
surgery 5767
tumour resection 57