Upper Abdominal Surgery

Brendon J. Coventry (ed.)Surgery: Complications, Risks and ConsequencesUpper Abdominal Surgery201410.1007/978-1-4471-5436-5_1

© Springer-Verlag London 2014

1. Introduction

Brendon J. Coventry¹  

(1)

Discipline of Surgery, Royal Adelaide Hospital, University of Adelaide, L5 Eleanor Harrald Building, North Terrace, 5000 Adelaide, SA, Australia

Brendon J. Coventry

Email: [email protected]

Abstract

Surgery of the abdomen, and in particular upper abdominal surgery, embraces a large component of General Surgery and has developed into a number of sub-specialties over recent years, chiefly to cope with the ever expanding repertoire of surgical techniques emanating from endoscopic and laparoscopic approaches. This volume deals with complications, risks, and consequences related to a range of procedures under the broad headings of general abdominal (laparotomy), esophageal surgery, gastric surgery, obesity surgery, small bowel surgery, biliary and duodenal surgery, liver surgery, and pancreatic surgery.

This volume deals with complications, risks, and consequences related to a range of procedures under the broad headings of general abdominal (laparotomy), esophageal surgery, gastric surgery, obesity surgery, small bowel surgery, biliary and duodenal surgery, liver surgery, and pancreatic surgery.

Important Note

It should be emphasized that the risks and frequencies that are given here represent derived figures. These figures are best estimates of relative frequencies across most institutions, not merely the highest-performing ones, and as such are often representative of a number of studies, which include different patients with differing comorbidities and different surgeons. In addition, the risks of complications in lower or higher risk patients may lie outside these estimated ranges, and individual clinical judgement is required as to the expected risks communicated to the patient, staff, or for other purposes. The range of risks is also derived from experience and the literature; while risks outside this range may exist, certain risks may be reduced or absent due to variations of procedures or surgical approaches. It is recognized that different patients, practitioners, institutions, regions, and countries may vary in their requirements and recommendations.

Individual clinical judgement should always be exercised, of course, when applying the general information contained in these documents to individual patients in a clinical setting.

The authors would like to thank the following experienced clinicians who discussed the chapters and acted as advisors: Professor Les Blumgart, New York, USA; Mr. Julian Britton, Oxford, UK; Mr. Nick Maynard, Oxford, UK; Professor Peter Friend, Oxford, UK; and Professor Derek Gray, Oxford, UK.

Brendon J. Coventry (ed.)Surgery: Complications, Risks and ConsequencesUpper Abdominal Surgery201410.1007/978-1-4471-5436-5_2

© Springer-Verlag London 2014

2. General Abdominal Surgery

Brendon J. Coventry¹   and Bruce Waxman²

(1)

Discipline of Surgery, Royal Adelaide Hospital, University of Adelaide, L5 Eleanor Harrald Building, North Terrace, 5000 Adelaide, SA, Australia

(2)

Academic Surgical Unit, Monash University, Monash Health and Southern Clinical School, Dandenong, Victoria, Australia

Brendon J. Coventry

Email: [email protected]

Abstract

General abdominal surgery is performed for diagnostic purposes, but is typically also part of more specific abdominal procedures. With the development of more sensitive and specific imaging procedures, such as helical CT, angiographic CT scans, PET, high-resolution ultrasound, and MRI scans, major improvements have occurred in nonoperative diagnosis. Although such investigations may abrogate the need for diagnostic abdominal surgery, either laparoscopic or open, there remains a definite place for diagnostic surgery of the abdomen. This chapter describes the risks and complications associated with laparotomy and laparoscopic surgery. These surgical procedures cover a wide spectrum of abdominal surgery from relatively straightforward laparoscopy to very complex. For other associated procedures, please refer to other chapters and volumes.

General Perspective and Overview

The relative risks and complications increase proportionately according to the type of surgery, nature of the pathology, site of the abdominal problem, extent of procedure performed, technique, the complexity of the problem, and lesion size. Extensive or complex surgery usually carries higher risks of bleeding and infection than smaller procedures, in general terms. Similarly, risk is relatively higher for recurrent and complex abdominal problems, for associated lymph node dissections, and especially for those closer to or involving major vascular or neural structures (e.g., aorta, vena cava, renal vessels, or lumbar plexus). Complex procedures are typically associated with a higher frequency and greater range of complications compared to simpler procedures. This is principally related to the surgical accessibility and risk of organ/tissue/vascular/nerve/lymphatic injury. Of course, with diagnostic laparotomy or laparoscopy, or even when the cause is determined, the findings may be unexpected and necessitate surgery that is different from that which has been anticipated. For example, the possibility of a colostomy or ileostomy might be broached with the patient preoperatively, where appropriate, perhaps noting that this is a very small risk, if this may occur.

In general, for many abdominal operations, the complications are similar in type and frequency. Laparoscopic approaches carry specific risks of gas embolism and trochar injury, but open procedures often carry risk of more direct tissue injury and longer convalescence. Knowledge of the anatomy and the variations commonly seen is helpful in minimizing nerve, vessel, and organ injury. Surgeons argue the benefits of one approach over the other, but there is somewhat variable tangible data to demonstrate differences in terms of the observed or reported complications. Other surgeons will argue that the use of drains adds to the complication rates, but this needs to be balanced with the extent and risks of bleeding and lymphatic leakage.

Possible reduction in the risk of misunderstandings over complications or consequences from abdominal surgery might be achieved by:

Good explanation of the risks, aims, benefits, and limitations of the procedure(s)

Useful planning considering the anatomy, approach, alternatives, and method

Avoiding likely associated vessels and nerves

Adequate clinical follow-up

Multisystem failure, systemic sepsis, and death are uncommon after abdominal surgery, even with extensive resection, but are reported and remain a risk. However, the nature of the underlying problem and comorbidities remain the major determinants of morbidity and mortality.

Positioning on the operating table has been associated with increased risk of deep venous thrombosis and nerve palsies, especially in prolonged procedures.

The use of specialized units with standardized preoperative assessment, multidisciplinary input, and high-quality postoperative care is essential to the overall success of complex abdominal surgery and can significantly reduce the risk of complications or aid early detection, prompt intervention, and cost.

With these factors and facts in mind, the information given in this chapter must be appropriately and discernibly interpreted and used.

Important Note

It should be emphasized that the risks and frequencies that are given here represent derived figures. These figures are best estimates of relative frequencies across most institutions, not merely the highest-performing ones, and as such are often representative of a number of studies, which include different patients with differing comorbidities and different surgeons. In addition, the risks of complications in lower or higher risk patients may lie outside these estimated ranges, and individual clinical judgement is required as to the expected risks communicated to the patient, staff, or for other purposes. The range of risks is also derived from experience and the literature; while risks outside this range may exist, certain risks may be reduced or absent due to variations of procedures or surgical approaches. It is recognized that different patients, practitioners, institutions, regions, and countries may vary in their requirements and recommendations.

For diagnostic fine or core needle biopsy complications, see Chap. 2 of Volume 2; for lymph node surgery, Chap. 5 of Volume 3; or for specific abdominal, pediatric, or vascular procedures, see the relevant volume(s).

General Exploratory Laparotomy +/− Biopsy

Description

General anesthesia is used almost exclusively, except for rare occasions when spinal or epidural anesthesia may be utilized for lower abdominal approaches. The modified Lloyd-Davies position may be useful when the pathology is in the pelvis and access to the perineum may be needed.

The aim is to inspect the abdominal cavity thoroughly, which may include a biopsy or other procedure. Generally, a midline approach is the most common. This can be upper, central or lower abdominal, or a full laparotomy, from xiphoid process to pubis. Other incisions include transverse, oblique, subcostal, paramedian, pfannenstiel, thoracoabdominal, and combinations of these. During laparotomy a systematic inspection of the abdominal wall and components is conducted and a variety of approaches can be used (e.g., clockwise or anticlockwise examination and palpation of the organs), so as not to miss any abnormality. Tissue biopsies can be taken if required. Primary mass-type closure of the abdominal wall is usual, and the skin is separately closed primarily, or delayed, depending on the degree of contamination and the risk of infection.

Anatomical Points

Apart from situs inversus, which is exceedingly rare, malrotations can occur but are also infrequent. The abdominal organs are usually relatively fixed in their location and most can be inspected relatively easily, either by palpation or by visualization. The organs that classically present some difficulty in examination are the duodenum (which may require a Kocher’s type mobilization for inspection); the diaphragm; the kidneys, adrenals, pancreas, and aorta (that are retroperitoneal); the posterior/superior aspects of the spleen and liver; and the posterior aspects of the colon, including the appendix when retrocecal. These usually require special attention to adequately exclude pathology. Congenital fibrous bands may also occur.

Table 2.1

General (exploratory) laparotomy +/− biopsy: estimated frequency of complications, risks, and consequences

aDependent on underlying pathology, anatomy, surgical technique and preferences

bHigher with pelvic surgery

Perspective

See Table 2.1. The initial pathology for which the procedure is being performed largely determines the spectrum or risks and complications. Infection is the most serious complication and is associated with contamination, often from preexisting viscus perforation. Iatrogenic injury to the bowel may also occur, especially during division of adhesions. Established infection may lead to multisystem organ failure and requirement for intensive care in susceptible individuals. The presence of distal tube obstruction, in many situations, increases the risk of infection due to stasis and bacterial overgrowth. Postoperative leakage from an anastomosis or viscus repair may be catastrophic, leading to localized or generalized peritonitis or intra-abdominal abscess(es). Bleeding is usually not commonplace, if good operative technique is used. Occasionally, ileostomy or colostomy is required for safe management. Wound infection, small bowel obstruction, enterocutaneous fistula, and incisional hernia are significant, but fortunately uncommon complications or consequences.

Major Complications

The type of laparotomy, procedure, and patient characteristics largely dictate the risks and complications. Infection is potentially the most serious complication, and in the most severe form can lead to peritonitis, multisystem failure, and risk of death. Organ injury and bleeding can be significant and may require blood transfusion, although this is not common for most laparotomies. Occasionally, splenectomy is required for splenic injury, especially with left upper abdominal procedures. Deep venous thrombosis and pulmonary embolism is uncommon, but a higher risk is associated with pelvic surgery. Colostomy or ileostomy are significant consequences, which occasionally are necessary for bowel pathology, and may occur unexpectedly, which the patient should ideally be warned about for completeness. Wound infection, small bowel obstruction, enterocutaneous fistula, and incisional hernia are significant complications and consequences that should also be mentioned, but the less common nature of these can be emphasized to the patient.

Consent and Risk Reduction

Main Points to Explain

GA risk

Bleeding/hematoma

Infection (local/systemic)

Pain/discomfort/neuralgia

Possible tumor recurrence*

Other abdominal organ injury

Possible stoma

Respiratory complications

Venous thromboembolism

Possible blood transfusion

Renal impairment

Risks without surgery

*Dependent on pathology and type of surgery performed

Diagnostic Laparoscopy +/− Biopsy

Description

General anesthesia is used. The modified Lloyd-Davies position may be useful when the pathology is in the pelvis and access to the perineum may be needed. The aim is to inspect the abdominal cavity thoroughly, using the laparoscopic approach, which may include a biopsy or other procedure. Generally, insertion of an umbilical and several other ports with the patient supine is the most common approach. Ports can be inserted in the upper, central, or lower abdomen depending on the desired procedure, but a central insertion of the laparoscope can usually afford good vision of the entire abdominal cavity. During laparoscopy a systematic inspection of the abdominal wall and components is conducted and a variety of approaches can be used (e.g., clockwise or anticlockwise examination of the organs), so as not to miss any abnormality. Tissue biopsies can be taken if required. Primary closure of the abdominal wall port-site holes is usual, and the skin is separately closed primarily or may be occasionally delayed, depending on the degree of contamination and the risk of infection. The laparoscopic approach is generally less traumatic than open laparotomy, with quicker recovery, but open laparotomy allows better palpation and perhaps inspection of organs. Ideally, the patient should be forewarned of the risk of conversion from laparoscopic to open surgery. Surgeons should never hesitate to convert to an open incision if the safety of the operation is jeopardized through increased risk of injury, if progress is poor, or if vision is inadequate.

Anatomical Points

Apart from situs inversus, which is exceedingly rare, malrotations can occur but are also infrequent. The abdominal organs are usually relatively fixed in their location and most can be inspected relatively easily, either by palpation or by visualization. The organs that classically present some difficulty in examination are the duodenum (which may require a Kocher’s type mobilization for inspection); the diaphragm; the kidneys, adrenals, pancreas, and aorta (that are retroperitoneal); the posterior/superior aspects of the spleen and liver, and the posterior aspects of the colon, including the appendix when retrocecal. These usually require special attention to adequately exclude pathology. Adhesions or pathology may make laparoscopic inspection difficult or impossible. Congenital fibrous bands may also occur.

Table 2.2

Diagnostic laparoscopy +/− biopsy: estimated frequency of complications, risks, and consequences

aDependent on underlying pathology, anatomy, surgical technique, and preferences

bHigher with pelvic surgery

Perspective

See Table 2.2. The initial pathology for which the procedure is being performed largely determines the spectrum or risks and complications. Infection is the most serious complication and is associated with contamination, often from preexisting viscus perforation. Adequate exposure, good port placement, preoperative prophylactic antibiotics, and copious lavage of the abdominal cavity and the wounds with large volumes of warm saline may also assist, if perforation or infection is present. Iatrogenic injury to bowel may also occur, especially during insertion of ports or division of adhesions. Established infection may lead to multisystem organ failure and requirement for intensive care in susceptible individuals and even mortality. The presence of distal tube obstruction, in many situations, increases the risk of infection due to stasis and bacterial overgrowth. Postoperative leakage from an anastomosis or viscus repair may be catastrophic, leading to localized or generalized peritonitis or intra-abdominal abscess(es). Bleeding is usually not commonplace, if good operative technique is used. Occasionally, ileostomy or colostomy is required for safe management. Wound infection, small bowel obstruction, enterocutaneous fistula, and incisional hernia are significant, but fortunately uncommon complications or consequences. Gas embolism is associated with Veress needle insertion, which can be virtually eliminated by open cutdown methods. Similarly, injury to bowel or vessels during port insertion can usually be avoided by open cutdown insertion methods. Pneumothorax is a rare, idiosyncratic complication, probably from diaphragmatic leakage of gas.

Major Complications

The type of laparoscopy, procedure, and patient characteristics largely dictate the risks and complications. Infection is potentially the most serious complication causing peritonitis, abscess formation, fistula or sinus formation, and systemic sepsis, and in the most severe form can lead to multisystem failure and risk of death. Preexisting comorbidities including age, established generalized peritonitis, and immunosuppression can increase risk of infection greatly. Organ injury and bleeding can be significant and may require blood transfusion, although this is not common for most laparotomies. Occasionally, splenectomy is required for splenic injury, especially with left upper abdominal procedures. Ureteric injury or iliac arterial injury is exceedingly rare but can be catastrophic. Deep venous thrombosis and pulmonary embolism is uncommon, but a higher risk is associated with pelvic surgery. Wound infection, small bowel obstruction, enterocutaneous fistula, and incisional hernia are significant complications and consequences that should also be mentioned, but the less common nature of these can be emphasized to the patient. Prolonged ileus and, later (even decades later), small bowel obstruction can occur but are surprisingly uncommon even with extensive adhesions. The possibility of an open laparotomy and even a colostomy or ileostomy are significant consequences which occasionally are necessary for bowel pathology and may occur unexpectedly, which the patient should ideally be warned about for completeness if other pathology is found, although uncommon. Nerve injury, either at surgery or later scar adhesions, can cause severe discomfort and rarely chronic pain problems. Gas embolism is a very rare but catastrophic complication.

Consent and Risk Reduction

Main Points to Explain

GA risk

Bleeding/hematoma

Infection (local/systemic)

Pain/discomfort

Possible tumor recurrence*

Other abdominal organ injury

Possible stoma

Respiratory complications

Venous thromboembolism

Possible blood transfusion

Gas embolism

Renal impairment

Possible open operation

Risks without surgery

*Dependent on pathology and type of surgery performed

Further Reading, References, and Resources

Calne RY. Colour atlas of surgical anatomy of the abdomen in living subject. London: Wolfe Medical Publications; 1988.

Clemente CD. Anatomy – a regional atlas of the human body. 4th ed. Baltimore: Williams and Wilkins; 1997.

Jamieson GG. The anatomy of general surgical operations. 2nd ed. Edinburgh: Churchill Livingston; 2006.

Brendon J. Coventry (ed.)Surgery: Complications, Risks and ConsequencesUpper Abdominal Surgery201410.1007/978-1-4471-5436-5_3

© Springer-Verlag London 2014

3. Esophageal Surgery

Glyn G. Jamieson¹   and Brendon J. Coventry¹  

(1)

Discipline of Surgery, Royal Adelaide Hospital, University of Adelaide, L5 Eleanor Harrald Building, North Terrace, 5000 Adelaide, SA, Australia

Glyn G. Jamieson (Corresponding author)

Email: [email protected]

Brendon J. Coventry

Email: [email protected]

Abstract

Esophageal surgery embraces a wide range of procedures from esophagoscopy through fundoplication to esophagectomy with reconstruction. This chapter aims to provide useful information on esophageal surgical complications, risks, and consequences. For other associated procedures refer to the relevant chapter and volume.

General Perspective and Overview

Esophagogastric surgery has changed somewhat over the last two or three decades with the advent of endoscopic techniques for more accurate diagnosis and laparoscopic approaches. However, the basic approaches to esophageal carcinoma and esophagectomy have advanced in a more measured way.

Complex esophageal problems in older patients with higher comorbidities for open surgery have become more commonplace, as have the refinements in investigation and assessment of esophageal disease (e.g., CT, MRI, and PET scans), such that patient selection has become more refined.

This chapter needs to be read with these changes in mind, because much of the literature has been based upon previous data from previous eras, with differing groups of patients to those who currently present for surgery.

The main complications from esophagogastric surgery are related to infection and leakage, especially from anastomoses and stomas. Bleeding is usually controllable at the time of surgery. Other complications relate to altered anatomy and function, especially of feeding, causing a range of symptoms related to meal size and tolerance.

With these factors and facts in mind, the information given in this chapter must be appropriately and discernibly interpreted and used.

The use of specialized units with standardized preoperative assessment, multidisciplinary input, and high-quality postoperative care is essential to the overall success of complex esophagogastric surgery and can significantly reduce risk of complications or aid early detection, prompt intervention, and cost.

Important Note

It should be emphasized that the risks and frequencies that are given here represent derived figures. These figures are best estimates of relative frequencies across most institutions, not merely the highest-performing ones, and as such are often representative of a number of studies, which include different patients with differing comorbidities and different surgeons. In addition, the risks of complications in lower or higher risk patients may lie outside these estimated ranges, and individual clinical judgement is required as to the expected risks communicated to the patient, staff, or for other purposes. The range of risks is also derived from experience and the literature; while risks outside this range may exist, certain risks may be reduced or absent due to variations of procedures or surgical approaches. It is recognized that different patients, practitioners, institutions, regions, and countries may vary in their requirements and recommendations.

For diagnostic fine or core needle biopsy complications, see Volume 2; for lymph node surgery, Volume 3; or for thoracotomy, Volume 6.

Esophagoscopy

Description

Local anesthetic spray or gel and a sedative agent are usually used. Usually a flexible scope is used; however, a rigid scope is sometimes used, especially for extraction of foreign material. The aim is to pass an endoscope via the oral cavity into the pharynx, esophagus, and usually into the stomach and duodenum in order to inspect the mucosa of these organs. The view of the oral cavity and pharynx is usually less satisfactory with a rigid or fiber optic pharyngo- or laryngoscope. However, the view of the esophagus is usually excellent and endoscopic procedures can be performed, for example, tissue biopsies, esophageal balloon dilatations, or esophageal stent placement. Endoscopic phototherapy is also used in some