LANGE Current Procedures SURGERY PDF

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Authors
Rebecca M. Minter, MD
Associate Professor
Department of Surgery
University of Michigan
Ann Arbor
Gerard M. Doherty, MD
NW Thompson Professor of Surgery
Department of Surgery
University of Michigan
Ann Arbor
Gorav Ailawadi, MD
Assistant Professor of Surgery
University of Virginia Health System
Brett A. Almond, MD, PhD

Fellow, Vascular Surgery and Endovascular Therapy
University of Florida
John B. Ammori, MD
Fellow, Surgical Oncology
Memorial Sloan-Kettering Cancer Center
Ramon Berguer, MD, PhD

Frankel Professor of Vascular Surgery
University of Michigan Health System
Michael Bernstein, MD, PhD

Saint Louis University
John D. Birkmeyer, MD
George D. Zuidema Professor of Surgery
Charles E. Binkley, MD
Attending Surgeon
Hepatobliary and Pancreatic Surgery
Kaiser Permanente Medical Center, San Francisco
Dan G. Blazer, III, MD

Duke University Medical Center
Melissa E. Brunsvold, MD
Richard E. Burney, MD
Professor of Surgery
Jennifer Cannon, MD
Fellow in Endocrine Surgery
University of Miami, Jackson Memorial Hospital
Paul S. Cederna, MD
Associate Professor of Surgery
Alfred E. Chang, MD
Hugh Cabot Professor of Surgery
Edwin Y. Chang, MD
Spokane Plastic Surgeons
Dawn M. Coleman, MD
Resident in General Surgery
Lisa M. Colletti, MD
C. Gardner Child Professor of Surgery
K. Barrett Deatrick, MD
Kathleen M. Diehl, MD
Derek A. DuBay, MD
Liver Transplant and Hepatobiliary Surgery
University of Alabama at Birmingham
Brent M. Egeland, MD
Resident in Plastic Surgery
Kimberly McCrudden Erickson, MD

Jonathan F. Finks, MD
Emily V.A. Finlayson, MD

Assistant Professor in Residence
University of California, San Francisco
Timothy L. Frankel, MD
Michael G. Franz, MD
Paul G. Gauger, MD
William J. Fry Professor of Surgery
Amir A. Ghaferi, MD
Richard V. Ha, MD
Fellow in Cardiothoracic Surgery
UCLA Medical Center
Awori J. Hayanga, MD, MPH

David G. Heidt, MD
Transplant Fellow
Peter K. Henke, MD
Daniel B. Hinshaw, MD
Emina H. Huang, MD
General Surgery/GI, Oncologic and Endocrine Surgery
Loay S. Kabbani, MD
Consultant Vascular Surgeon
Al Assad University Hospital
Damascus, Syria
Brian S. Knipp, MD
James A. Knol, MD
Jeffrey H. Kozlow, MD
Sean C. Kumer, MD, PhD

Fellow, Division of Transplant Surgery
University of Virginia Health System
C.J. Lee, MD
Benjamin Levi, MD
Jules Lin, MD
Assistant Professor of Thoracic Surgery
Christopher R. Longo, MD
Carolina Vascular Surgery and Diagnostics
Raymond J. Lynch, MD
Amit K. Mathur, MD
Constance M. Mobley, MD, PhD

Laura A. Monson, MD
Arden M. Morris, MD, MPH

Michael W. Mulholland, MD, PhD

Frederick A. Coller Distinguished Professor
Chair, Department of Surgery
George B. Mychaliska, MD
Erika Adams Newman, MD

Fellow, Pediatric Surgery
The University of Chicago Comer Children's Hospital
Kevin Tri Nguyen, MD, PhD
Hepatopancreaticobiliary Fellow
University of Pittsburgh
Mark B. Orringer, MD
John Alexander Distinguished Professor of Thoracic Surgery
Nicholas H. Osborne, MD
Shawn J. Pelletier, MD
Erica N. Proctor, MD
Kerianne H. Quanstrum, MD
Junewai L. Reoma, MD
Barry L. Rosenberg, MD, MBA

Project Leader
Boston Consulting Group
Michael S. Sabel, MD
Bedabrata Sarkar, MD
Peter Sassalos, MD
Brian D. Saunders, MD
Penn State Milton S. Hershey Medical Center
Michael S. Shillingford, MD
Cardiothoracic Surgery Fellow
Diane M. Simeone, MD
Greenfield Professor in Surgery and Molecular
And Integrative Physiology
Kristoffer Sugg, MD
Randall S. Sung, MD
Susan Tsai, MD
Fellow, Surgical Oncology
Johns Hopkins University
Gilbert R. Upchurch, Jr, MD

Leland Ira Doan Research Professor of Vascular Surgery
Frank C. Vandy, MD
Resident in Vascular Surgery
Chandu Vemuri, MD
Thomas W. Wakefield, MD
S. Martin Lindenauer Collegiate Professor of Vascular
Surgery
Jennifer Waljee, MD, MPH, MSc

Stewart C. Wang, MD, PhD

Professor and Director of Burn Surgery
Theodore H. Welling, III, MD

Andrew M. Zwyghuizen, MD
Copyright © The McGraw-Hill Companies. All rights reserved.

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Preface
Current Surgical Procedures is a new book intended to

provide straightforward, modern guidance to common
procedures performed during general surgery training.
Directed at a mid-level surgery resident, the information
should be equally useful to medical students, physicians
assistants, higher level residents and other staff who
benefit from an accessible resource to outline the key
features and steps of these operations. Preparation by the
faculty and house staff of the University of Michigan
ensures the compilation of expert approaches to these
procedures.
Outstanding Features
• All new drawings illustrate the current methods for these
procedures.
• Templated presentation of the material simplifies rapid
review.
• Inclusion of expected benefits, potential risks,
preoperative preparation and contraindications provides a
foundation for obtaining thorough informed consent prior to
the procedure.
• Step-by-step presentation of key procedure steps.
• Coverage of postoperative management, potential
complications, and clinical pearls complete a concise
resource for timely review.
Acknowledgments
As the editors, we would like to acknowledge our
tremendous good fortune to work in an outstanding
Department of Surgery led by Dr. Michael Mulholland, and
to be surrounded by a truly expert group of peers among
both the faculty and the house staff. Their personal
attention to the project has infused the text with the views
of proficient practitioners that make this work special. We
are particularly grateful for the patient and professional
staff from McGraw-Hill including Marsha Loeb Gelber,
Harriet Lebowitz, and Armen Ovsepyan, who have made
great contributions to the text in both time and
concentration, and allowed us to ensure an accurate, high-
quality edition. The various artists who have worked to
present our concepts as understandable drawings have our
admiration both for their talent, and for their determination
to translate our ideas into pictures. We appreciate the
careful attention and good humor of Mary Kay Anderson
who has provided the staff support of this work in Ann
Arbor. Finally, to our families, we appreciate your
indulgence of our attention to our work.
Rebecca M. Minter, MD
Gerard M. Doherty, MD
Ann Arbor, Michigan
June 2010

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Note: Large images and tables on this page may

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Current Procedures: Surgery > Chapter 1.

Thyroidectomy and Neck Dissection >
Indications
Thyroid Lobectomy
Unilateral toxic nodule.

Solitary adenoma or cyst.
Total Thyroidectomy
Thyroid carcinoma.
Graves' disease.
Hashimoto thyroiditis.
Multinodular goiter.
Substernal goiter.
Neck Dissection
Locally advanced head and neck carcinoma demonstrated

by presence of nodal disease clinically, by preoperative
imaging, or by sentinel node biopsy.
Contraindications
Few contraindications exist for thyroidectomy or neck
dissection.
Absolute (Neck Dissection)
Randomly scattered dermal metastases precluding a full-

thickness dissection.
Intracranial extension of tumor from the neck.
Tumor fixation to the skull base or the cervical spine.
Relative (Neck Dissection)
Tumor fixation to the internal carotid artery.

Locally advanced disease in the root of the neck.
Periosteal invasion of the skull base.
Informed Consent
Thyroid Surgery
Expected Benefits
Curative resection for actual or potential malignancy.

Relief of symptoms caused by toxic or large multinodular
goiters.
Relief of symptoms resulting from benign thyroid disease.
Potential Risks
Bleeding that may cause airway compression and require

reoperation.
Recurrent laryngeal nerve paresis or transection causing
hoarseness (temporary or permanent).
Hypocalcemia requiring oral calcium or vitamin D.
Scarring.
Infection.
Need for additional medical or surgical treatment.
Modified Radical Neck Dissection
Expected Benefits
Clearance of primary tumor and locally advanced

carcinoma from the neck at all nodal levels.
Potential Risks
Damage to vital adjacent structures, including spinal

accessory nerve, sternocleidomastoid (SCM) muscle,
internal jugular vein, and vagus nerve.
Lymphatic leak from thoracic duct trauma.
Equipment
No special equipment is required.

A self-retaining retractor may be used to assist in the
dissection.
A handheld recurrent laryngeal nerve stimulator is often
employed.
A harmonic scalpel may also be used to aid in the
dissection.
Patient Preparation
Nothing by mouth the evening before surgery.

Preoperative antibiotics if needed for valvular pathology,
artificial heart valves, artificial joints, etc.
Consultation with an anesthesiologist if necessary based
on airway examination or comorbid disease, or both.
Surgeon-directed ultrasound to identify thyroid lesion,
size of thyroid, location of surrounding structures, etc.
Additional preoperative imaging and studies to
demonstrate presence of lesion and potential metastatic
disease in malignancy.
Anesthesiology consultation (see later discussion).
Patient Positioning
The patient should be supine.

Airway management is of particular concern. Preoperative
anesthesiology consultation should alleviate positioning
concerns while ensuring proper airway safety during the
procedure.
A towel roll can be placed beneath the shoulder blades to
facilitate neck extension.
Arms may be tucked.
Procedure
Thyroid Procedures
Figure 1–1: A curvilinear incision is made in the neck a

fingerbreadth below the cricoid cartilage and
approximately 2 fingerbreadths above the sternal notch.
Additionally, a suitable skin crease in the lower neck

may be used for the incision location.
The subcutaneous tissue and the platysma may be
divided with cautery.
Skin flaps are made superiorly and inferiorly above
the level of the anterior jugular veins.
Figure 1–2: Access to the deeper neck is made by
dividing the strap muscles in the midline between the
anterior jugular veins.
A plane is established between the sternohyoid and

the sternothyroid muscles from medial to lateral.
A plane is established between the sternothyroid and
the thyroid gland sharply.
The middle thyroid vein is divided.
Figure 1–3: The gland is mobilized anteriorly to expose
the recurrent laryngeal nerve. The superior pole
attachments may be divided to assist in this mobilization.
The cricothyroid space is entered along the medial

aspect of the lobe to mobilize the superior pole of the
thyroid lobe.
The superior lobe attachments are divided close to
the gland to avoid injury to the superior laryngeal
nerve branches.
The superior parathyroid gland is identified posterior
to the recurrent laryngeal nerve.
The recurrent laryngeal nerve and its course are
identified and verified by the nerve stimulator.
The inferior parathyroid is identified anterior to the
nerve. The inferior pole attachments are then
divided.
The final attachments near the nerve and the
ligament of Berry are identified and divided
meticulously without traction or direct pressure on
the recurrent laryngeal nerve. Use of cautery around
the nerve and while dissecting with the thyroid
retracted anteriorly should be avoided.
Figure 1–4: The thyroid is then dissected from its
attachments on the trachea and divided at the isthmus for
a lobectomy.
Figure 1–1
Figure 1–2
Figure 1–3
Figure 1–4
Neck Dissection
If a neck dissection is needed, the incision is extended

laterally toward the posterior aspect of the neck.
The goal is to provide exposure of the anterolateral

neck and posterior triangles.
Figure 1–5: Neck dissection removes tumor involvement
in the nodal regions of the anterolateral and posterior
neck (in thyroid carcinoma, nodal levels II–V).
Figure 1–6: Skin flaps are made superiorly and inferiorly.
The figure shows the exposed musculature once flaps are
made.
Figure 1–7: The SCM muscle is encircled with a Penrose
drain for traction to provide exposure.
We prefer to initiate the dissection in the posterior
triangle.
The specimen's attachments to the trapezius are
taken down initially with blunt dissection, especially
prior to identification of the spinal accessory nerve.
In a modified radical neck dissection, efforts should
be made to preserve the nerve.
Figure 1–8: The progression of the dissection on the left
side (SCM not shown).
The specimen is dissected from lateral to medial with

attention to the underlying structures. Efforts should
be made to preserve the internal jugular vein. If the
vein cannot be separated from the surrounding
grossly positive nodal tissue, it is included in the
specimen.
The specimen is dissected from inferior to superior
(from levels IV–II).
The specimen is removed en bloc, marked, and
prepared for pathologic examination.
Figure 1–9: As the dissection is completed, the wound is
inspected for hemostasis.
A drain is placed through a separate stab incision in

the anterolateral neck.
The platysma and subcutaneous tissue is
reapproximated using absorbable suture, and the
incision is closed with a monofilament absorbable
suture or tissue glue.
Figure 1–5
Figure 1–6
Figure 1–7
Figure 1–8
Figure 1–9
Postoperative Care
For benign thyroid disease, thyroid hormone replacement

is initiated if total thyroidectomy has been performed.
For malignant disease, thyroid hormone replacement is
deferred until after postoperative radioactive iodine scan.
Postoperative calcium levels are monitored and calcium
replacement is given empirically.
Pain control should be initiated with intravenous agents
initially; once swallowing is adequate, the patient can be
transitioned to oral narcotics.
Diet should be advanced progressively.
Drains should be inspected for lymphatic leak, and
patients instructed on drain care.
Drains should be removed once output decreases to 30
mL or less per day.
Potential Complications
Nerve injury: spinal accessory nerve; recurrent laryngeal

nerve injury (if central neck dissection is included in the
procedure); brachial plexus.
Vascular injury: internal jugular vein; carotid artery
causing neck hematoma, which could potentially progress
to airway compromise.
Thoracic duct injury leading to lymphatic leak, possibly
requiring operative intervention and thoracic duct ligation.
Tracheal injury.
Esophageal injury.
Local disease recurrence.
Pearls and Tips
Perform neck dissection with careful attention to the

underlying neurovascular structures while maintaining the
goal of a complete oncologic resection.
References
Doherty GM. Complications of Thyroid and Parathyroid

Surgery. In: Mulholland MW, Doherty GM, eds. Complications
in Surgery. Philadelphia, PA: Lippincott Williams & Wilkins;
2006:575–593.
Gauger PG. Thyroid Gland. In: Mulholland MW, Lillemoe KD,

Doherty GM, et al, eds. Greenfield's Surgery: Scientific
Principles & Practice, 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:1310–1334.



Parathyroidectomy >
Indications
Symptomatic
Fractures (especially vertebral compression fractures).

Nephrolithiasis.
Severe neuromuscular weakness.
Easy fatigability.
Loss of stamina.
Sleep disturbance.
Depression.
Memory loss.
Pancreatitis.
History of an episode of life-threatening hypercalcemia.
Carcinoma.
Asymptomatic
Markedly elevated serum calcium (> 1.0 mg/dL above

normal).
Markedly elevated 24-hour urinary calcium excretion (>
400 mg).
Abnormal serum creatinine.
Reduced bone mineral density (T-score < –2.5).
Age younger than 50 years.
Carcinoma.
Contraindications
Pregnancy (first trimester).

Multiple comorbidities precluding safe intervention.
Idiopathic hypercalcemia.
Informed Consent
Expected Benefits
Treatment of symptomatic hypercalcemia.

Prevention of deleterious effects secondary to chronic
parathyroid hormone elevation and hypercalcemia.
Potential Risks
Bleeding requiring reoperation.

Weakness of the voice or hoarseness (temporary or
permanent).
Need for oral calcium/vitamin D supplements (short or
long term).
Visible neck scar.
Neck swelling beneath incision.
Infection.
Failure of operation to correct hypercalcemia or
recurrence of hypercalcemia.
Need for additional tests or procedures.
Equipment
Intraoperative parathyroid hormone (PTH) monitoring

capability with access and equipment for blood sampling
(peripheral or central).
Bipolar cautery, harmonic scalpel, LigaSure, or surgical
ties can be safely used for hemostatic control.
Patient Preparation

No preoperative antibiotics are necessary before surgery,
except when the patient has other indications (eg, cardiac
valvulopathy or orthopedic hardware).
Anesthesiology consultation as needed.
Patient Positioning
The patient should be supine with his or her legs slightly

reclined and the head and shoulders raised (lawn chair
position).
A towel roll or other small bump is placed beneath the
shoulder blades to allow for neck extension and exposure.
Procedure
Local or general anesthesia may be used.

Figure 2–1: An incision is made transversely
approximately 1 cm below the level of the cricoid cartilage
and measuring 3–5 cm in length.
Figure 2–2: This incision is carried through the level of
the platysma with electrocautery.
Subplatysmal flaps are fashioned superiorly, laterally,

and inferiorly with a combination of electrocautery
and blunt dissection.
The strap muscles and associated fascia are entered
through the midline taking care to avoid injuring the
anterior jugular veins.
Figure 2–3: Dissection proceeds to include all of the soft
tissue associated with the thyroid down to the
prevertebral fascia.
The thyroid is retracted medially by the assistant; the

carotid sheath is bluntly dissected on the medial
aspect so it can be retracted laterally, allowing
adequate exposure to identify the recurrent laryngeal
nerve, which usually courses superiorly in the
tracheoesophageal groove.
Occasionally, the middle thyroid vein must be ligated
and divided.
At this point in the operation, a baseline PTH level is
drawn and promptly placed on ice.
Figure 2–4: The parathyroid glands are dissected free
from the surrounding tissue, taking care to avoid
disrupting their vascular supply.
An additional PTH level may be drawn before excision

(by surgeon's choice) and PTH levels are also
monitored 5, 10, and 15 minutes following excision.
The inferior parathyroid glands are usually more
anterior than the upper glands; however, their
location is more variable.
Figure 2–5: The superior parathyroid glands are
dissected free from surrounding tissue and removed for
pathologic diagnosis. The upper glands are mostly located
on the posterior surface of the thyroid at its upper two
thirds.
Figure 2–6: Superior parathyroid glands are less variable
in location; however, they may migrate upward or
downward into the posterior mediastinum.
Inferior parathyroid glands may migrate into the

thymus, as well as the anterior or posterior
mediastinum.
Figure 2–1
Figure 2–2
Figure 2–3
Figure 2–4
Figure 2–5
Figure 2–6
Postoperative Care
Although uncomplicated adenoma resection may often be

performed as an outpatient procedure, patients who
undergo the procedure as inpatients should be admitted
for overnight observation and discharged the following
morning.
In the early postoperative period, patients receive calcium
carbonate, 1250 mg orally three times daily; or OsCal
500, 1 tablet orally three times daily (1 tablet OsCal 500
= 1 g CaCO3 = 400 mg elemental Ca or 20 mEq Ca),
which can generally be reduced within 2 weeks.
Acetaminophen or ibuprofen, as needed, is prescribed for
pain related to the procedure, and occasionally opioid
agents are needed for a short time postoperatively.
Neck hematoma.
May be self-limited if the airway is not compromised.

When the airway is compromised, there should be no
hesitation in reopening the neck incision, including
the strap musculature.
Hypoparathyroidism and hypocalcemia.
Typically present as perioral paresthesias, which may

progress to more serious conditions, such as cardiac
arrhythmias.
Treatment includes oral calcium carbonate,
intravenous calcium gluconate, and possibly vitamin
D.
Nerve injury: external branch of the superior laryngeal
nerve.
Supplies motor innervation to the inferior constrictor

muscles of the larynx.
Located near the superior pole vessels of the thyroid
before entering the cricopharyngeal muscle at its
superolateral aspect.
Damage will affect high-pitched singing or yelling.
Nerve injury: sympathetic chain/stellate ganglion.
Located posterior to the thyroid.

Damage will produce ipsilateral miosis, ptosis, and
anhidrosis (Horner syndrome).
Nerve injury: recurrent laryngeal nerve.
Courses inferiorly to superiorly within the bilateral
tracheoesophageal grooves and inserts at the inferior
border of the cricopharyngeal muscles.
Damage causes ipsilateral paralysis to the vocal cord
and may also affect the swallowing mechanism.
Thoracic duct injury, which may cause collection of chyle
at the site of injury.
Tracheal injury.
Esophageal injury.
Persistent or recurrent hyperparathyroidism.
Pearls and Tips
Preoperative imaging (technetium sestamibi or cervical

ultrasound) allows for directed operative intervention.
Dissection should proceed anteriorly, then laterally along
the posterior surface of the sternothyroid muscle.
The dissection should continue to free the carotid medially
and include all of the soft tissue down to the prevertebral
fascia.
This ensures that the parathyroid glands are included in
the dissection field and prevents the surgeon from
missing a potential normal or abnormal gland.
Successful removal of the symptomatic parathyroid gland
is demonstrated when intraoperative PTH monitoring
shows a decrease of 50% of the preoperative PTH level
and return of PTH levels to the normal range (< 70
pg/mL).
References
Doherty GM. Complications of Thyroid and Parathyroid

Surgery. In: Mulholland MW, Doherty GM, eds. Complications
in Surgery. Philadelphia, PA: Lippincott Williams & Wilkins;
2006:575–593.
Doherty GM. Parathyroid Glands. In: Mulholland MW, Lillemoe

KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific
Doherty GM, Moley JF. Conventional Exploration for

Hyperparathyroidism. In: Van Heerden JA, Farley DR, eds.
Operative Techniques in General Surgery. Philadelphia, PA:
WB Saunders; 1999:4–17.



Adrenalectomy >
Indications
General Indications
Clinically or biochemically apparent adrenal hormonal

hyperfunction.
Possible or certain malignant adrenal mass.
Adrenal mass of uncertain significance.
Specific Conditions and Disease States
Primary hyperaldosteronism.
Unilateral cortical adenoma causing Conn's

syndrome.
Bilateral hyperplasia with unilateral dominance
(established by adrenal vein sampling).
Hypercortisolism.
Unilateral cortical adenoma.

Refractory Cushing's syndrome (from Cushing's
disease, primary adrenal hyperplasia, or ectopic
adrenocorticotropic hormone [ACTH] syndrome).
Pheochromocytoma.
Unilateral cortical adenoma causing virilization.
Myelolipoma (in selected situations).
Adrenal cyst (if refractory or symptomatic).
Adrenocortical carcinoma.
Incidentaloma with indeterminate or concerning imaging
characteristics.
Adrenal metastases of other primary cancers (in selected
situations).
Contraindications
Laparoscopic Adrenalectomy
Absolute
Adrenocortical carcinoma (certain or likely).

Refractory coagulopathy.
Comorbidities precluding safe general anesthesia.
Relative
Previous ipsilateral partial adrenal resection.

Previous extensive upper abdominal or retroperitoneal
surgery.
Very large adrenal tumors (> 6–8 cm).
Suboptimal medical preparation for pheochromocytoma
resection.
Open Adrenalectomy
Absolute
Refractory coagulopathy.
Comorbidities precluding safe general anesthesia.
Relative
Suboptimal medical preparation for pheochromocytoma

resection.
Informed Consent
Expected Benefits
Resolution of clinical symptoms related to adrenal

hypersecretory function.
Treatment of primary or metastatic adrenal malignancies.
Treatment of symptomatic benign adrenal masses.
Potential Risks
For laparoscopic procedure, risk of conversion to an open

procedure.
Glucocorticoid insufficiency (most commonly following
preoperative hypercortisolism, bilateral adrenalectomy, or
previous contralateral adrenalectomy).
Recurrence of tumor.
Scarring.
Infection.
Failure of operation to correct hypertension or adrenal
hyperfunction.
Equipment
Standard laparoscopic and open instrument trays.

Surgical energy device such as harmonic scalpel or
LigaSure.
Open Adrenalectomy
Major exploratory laparotomy instrument tray.

Retraction system such as Bookwalter or Thompson
retractor.
Surgical energy device such as harmonic scalpel or
LigaSure.
Patient Preparation
General Preparation
Nothing by mouth before surgery.

No preoperative antibiotics are necessary before surgery
except when the patient has other indications (eg, cardiac
valvulopathy, orthopedic hardware).
Invasive blood pressure monitoring if required for
pheochromocytoma or other medical condition.
Deep vein thrombosis (DVT) prophylaxis (for laparoscopic
cases this should include sequential compression
devices).
Disease-Specific Preparation
Preoperative control of hypertension for patients with

pheochromocytoma.
-Adrenergic blockade is achieved using

phenoxybenzamine, 10 mg orally three times daily,
titrated upward until mild orthostatic symptoms
occur.
Requires 7–10 days minimum preparation.
Phenoxybenzamine should be continued until the
morning of the procedure and given with a sip of
water.
If necessary, -adrenergic blockade is added after
blockade is established to treat tachycardia and
prevent unopposed blockade.
Stress-dose steroids administered to patients having
adrenalectomy for hypercortisolism (benign or malignant
causes) due to suppression of hypothalamic-pituitary-
adrenal axis involving the contralateral adrenal gland.
Preoperatively, hydrocortisone, 100 mg, is given

intravenously.
Postoperatively, supraphysiologic doses are weaned
to physiologic replacement doses of oral steroids.
Patient Positioning
General anesthesia is induced with the patient supine.

An orogastric tube and a Foley catheter are placed.
The patient is placed in the lateral decubitus position with
the ipsilateral side up.
The table is gently flexed to widen the angle between the
costal margin and iliac wing.
An axillary roll is placed and a beanbag used to hold the
patient in position.
Arms, head, and legs are appropriately padded and not
abducted beyond 90 degrees.
Open Adrenalectomy
A nasogastric tube and a Foley catheter are placed.

The patient is placed supine with his or her arms resting
on arm boards and with legs padded.
Procedure
Laparoscopic Left Adrenalectomy: Figure 3–1
Figure 3–1
A small skin incision is made to the left and superior to

the umbilicus for open port placement.
The abdomen is entered in layers under direct vision. A
securing suture is placed in the external fascial layer.
Alternatively, an optical port may be used.
The Hasson port is then placed and the abdomen
insufflated to 13 cm H2O pressure.
With the 30-degree camera in the abdomen, placement of
the other two working ports is established approximately
2 fingerbreadths inferior to the subcostal margin and
triangulated with the camera port.
These ports may be 5 mm or 10 mm depending on
surgeon preference and available instrumentation.
The splenic flexure of the colon may require minor inferior
mobilization by division of the lienosplenic ligament.
The ultrasonic dissector is then used to divide the lateral
peritoneal attachments of the spleen and lienophrenic
ligament, often until the fundus of the stomach comes
into view.
As the spleen is reflected medially, the tail of the pancreas
is mobilized with it. The splenic vein and splenic artery
may be seen.
If the adrenal gland and adrenal tumor are difficult to
locate, laparoscopic ultrasonography may be helpful.
Direct grasping of the tumor must be avoided, and
grasping of the normal adrenal tissue must be very
judicious and gentle.
A plane medial to the adrenal gland and lateral to the
aorta is bluntly developed.
The superior pedicle (inferior phrenic vessels) is dissected
and divided with clips or using the ultrasonic dissector.
The central adrenal vein is dissected as it drains to the
left renal vein. It is divided between double clips or with
an endoscopic stapler.
The inferior and lateral attachments of the adrenal gland
are divided with the ultrasonic dissector to mobilize the
gland out of the suprarenal fossa. Often this exposes the
capsule of the superior renal pole.
Once liberated, the adrenal gland is placed in a specimen
retrieval bag and withdrawn from the abdomen using the
original Hasson port site.
While insufflation is maintained, the suprarenal fossa is
inspected for hemostasis. The abdomen is then irrigated
using saline.
If 10-mm port sites are used, they are closed using a
Carter-Thomason device.
Local anesthetic is infiltrated into the muscle and skin of
all port sites.
The Hasson port site is closed with fascial sutures.
The skin is then closed using absorbable monofilament
suture and dressed with occlusive dressings.
Laparoscopic Right Adrenalectomy: Figure 3–2
Figure 3–2
A small skin incision is made to the right and superior to
the umbilicus for open port placement.
The abdomen is entered in layers under direct vision. A
securing suture is placed in the external fascial layer.
The Hasson port is then placed and the abdomen
insufflated to 13 cm H2O pressure.
With the 30-degree camera in the abdomen, placement of
the other two working ports is established approximately
2 fingerbreadths inferior to the subcostal margin and
triangulated with the camera port.
These ports may be 5 mm or 10 mm depending on
surgeon preference and available instrumentation.
The lateral attachments of the liver to the diaphragm
(triangular ligament) are divided with the ultrasonic
dissector.
Once the right lobe of the liver is substantially mobilized
and can be retracted medially nearly 90 degrees off the
horizontal view, a separate medial port is placed to
accommodate a laparoscopic retractor for the liver. Port
size is determined by the instrument used.
The peritoneum overlying the medial aspect of the
adrenal gland is opened from inferior to superior using the
ultrasonic dissector.
Direct grasping of the tumor must be avoided, and
grasping of the normal adrenal tissue must be very
judicious and gentle.
A plane medial to the adrenal gland and posterolateral to
the vena cava is bluntly developed.
The central adrenal vein is circumferentially mobilized as
it drains to the vena cava. It is divided between double
clips or with an endoscopic stapler.
The superior pedicle (inferior phrenic vessels) is dissected
and divided with clips or the ultrasonic dissector.
The inferior and lateral attachments of the adrenal are
divided with the ultrasonic dissector to mobilize the gland
out of the suprarenal fossa. Often this exposes the
capsule of the superior renal pole.
Once liberated, the adrenal gland is placed in a specimen
retrieval bag and withdrawn from the abdomen using the
original Hasson port site.
While insufflation is maintained, the suprarenal fossa is
inspected for hemostasis. The abdomen is then irrigated
using saline.
If 10-mm port sites are used, they are closed using a
Carter-Thomason device.
Local anesthetic is infiltrated into the muscle and skin of
all port sites.
The Hasson port site is closed with fascial sutures.
The skin is then closed using absorbable monofilament
suture and dressed with occlusive dressings.
Open Anterior Adrenalectomy—Left: Figures 3–3 and 3–4
Figure 3–3
Figure 3–4
A bilateral subcostal or midline incision is made.
The gastrocolic omentum is opened or the omentum
mobilized superiorly to enter the lesser sac.
The splenic flexure is reflected caudad.
The inferior margin of the pancreas is mobilized to the
exposed adrenal gland. Occasionally, division of the
inferior mesenteric vein may be required.
The tail of the pancreas is gently retracted upward to
expose the anterior surface of the adrenal gland (see
Figure 3–3).
The superior vascular pedicle (inferior phrenic vessels) is
divided to allow caudad retraction of the tumor.
The central adrenal vein is dissected and divided at the
inferior and medial aspect of the adrenal gland as it drains
to the left renal vein.
The remaining soft tissue attachments are divided to
complete the adrenalectomy.
For large tumors, the infrapancreatic approach described
earlier, and shown in Figure 3–3, may not provide
adequate exposure. In that case, medial mobilization of
the pancreas and spleen may be required (see Figure 3–
4).
For adrenocortical cancers, en bloc splenectomy, distal
pancreatectomy, or nephrectomy may be necessary.
Open Anterior Adrenalectomy—Right: Figure 3–5
Figure 3–5
A bilateral subcostal or midline incision is made.
The hepatic flexure of the colon is mobilized as necessary.
A partial Kocher maneuver is performed as necessary to
expose the infrahepatic vena cava.
The right lobe of the liver is mobilized by dividing the
triangular ligament and then retracting it medially to
expose the adrenal gland.
The lateral and inferior margins of the adrenal gland are
mobilized.
The superior vascular pedicle (inferior phrenic vessels) is
divided and controlled. Hemostatic clips may be useful as
exposure and working space are limited.
The medial superior and medial margins of the adrenal
gland are mobilized away from the vena cava to expose
the central adrenal vein.
Care should be taken as accessory veins or

anomalous drainage of the right hepatic vein may be
present.
Again, hemostatic clips may be useful to control
bleeding.
The remaining soft tissue attachments are divided to
complete the adrenalectomy.
Capsular breach and tumor spill should be assiduously
avoided during the preceding maneuvers.
Large or invasive tumors will require more extensive vena
caval control, including the suprahepatic vena cava and
infrahepatic vena cava superior to the renal veins.
If adrenalectomy is performed for a large adrenocortical
cancer, en bloc resection of the right hepatic lobe, right
kidney, or even a portion of the vena cava may be
required.
Postoperative Care
Incentive spirometry should be used to prevent

atelectasis and postoperative pneumonia.
Laparoscopic procedures often require less fluid
replacement than do open procedures.
Postoperative DVT prophylaxis should be maintained until
the patient is ambulatory.
Ambulation should be encouraged as early as
possible.
Following laparoscopic procedures, subcutaneous
heparin prophylaxis is appropriate if no concerns
exist about ongoing bleeding.
Early resumption of regular diet should be possible.
The Foley catheter may be discontinued once
hemodynamics, urinary output, and electrolytes are
stable and within the normal range.
Patients with Hyperaldosteronism
Potassium supplementation should be stopped

immediately postoperatively.
Antihypertensives should be weaned.
Electrolytes, including potassium, should be checked the
morning after surgery.
Patients with Pheochromocytoma
Patients should be monitored for signs of postoperative

hypotension resulting from vascular relaxation.
Significant intravenous fluid resuscitation or pressors

may be required, although this is less of a problem
following adequate blockade.
Blockade may be discontinued immediately
postoperatively and blockade weaned, except in cases of
residual metastatic pheochromocytoma.
Monitoring for hypoglycemia includes measurement of
serum glucose every 4 hours for the first 24 hours
postoperatively.
Patients with Preoperative Hypercortisolism

Following bilateral adrenalectomy or adrenalectomy for
Cushing's syndrome, hydrocortisone should be available
at the bedside.
Patients should be monitored for hypotension, decreased
urine output, gastrointestinal abnormalities,
hyponatremia, hyperkalemia, hypoglycemia, and fever.
Treatment should be immediate, with fluid resuscitation
followed by administration of parenteral steroids, typically
100 mg of intravenous hydrocortisone given every 8
hours.
This dose possesses sufficient mineralocorticoid

activity to preclude the need for fludrocortisone.
Fludrocortisone may be necessary in the event of
bilateral adrenalectomy and consequent lifelong
adrenal insufficiency.
Patients with Uncertain Suppression Status
The ACTH stimulation test may be performed to test the

adrenal hypothalamo-pituitary axis (HPA).
Baseline serum cortisol is measured.

Intramuscular ACTH, 250 mcg, is then administered,
and serum cortisol rechecked 30 and 60 minutes
later.
An increase of 7 mcg/dL from baseline, or an
absolute baseline of 20 mcg/dL of serum cortisol,
suggests a functional HPA for most patients.
Results lower than these values warrant steroid
replacement.
Bleeding.
Glucocorticoid insufficiency.
Pneumothorax.
Vascular injuries.
Hypertension.
Hypotension.
Wound infection.
Pneumonia.
Splenic injury.
Hepatic injury.
Pancreatic injury and resultant pancreatitis.
Incisional hernia.
Ileus.
Subphrenic abscess.
Nelson's syndrome (more specifically related to bilateral
adrenalectomy).
Mineralocorticoid insufficiency (more specifically related to
bilateral adrenalectomy).
Pearls and Tips
Ensure careful patient selection and matching of operative

approach to patient factors and disease factors.
Mobilization of the liver (for right adrenalectomy) and of
the pancreas and spleen (for left adrenalectomy) during
laparoscopic adrenalectomy always needs to be developed
more than might be expected to improve exposure of the
adrenal gland.
Avoid direct grasping of the adrenal gland early in
laparoscopic adrenalectomy because bleeding will occur.
Grasping is less traumatic after the gland has been
devascularized.
If the central adrenal vein is broader than can be safely
secured with an endoclip, use an endoscopic linear
stapler/cutter (eg, Endo-GIA).
References
Findling JW, Raff H. Cushing's syndrome: important issues in

diagnosis and management. J Clin Endocrinol Metab.
2006;91:3746–3753.[PubMed: 16868050] [Full Text]
Gauger PG. Complications of Adrenal Surgery. In: Mulholland

MW, Doherty GM, eds. Complications in Surgery. Philadelphia,
PA: Lippincott Williams & Wilkins; 2006:559–574.
Gawande A, Moore FD. Laparoscopic Adrenalectomy. In:

Zinner MJ, Ashley SW, eds. Maingot's Abdominal Operations,
11th ed. New York: McGraw-Hill; 2007:1205–1216.
Mishra AK, Agarwal A, Gupta S, et al. Outcome of

adrenalectomy for Cushing's syndrome: experience from a
tertiary care center. World J Surg. 2007;31:1425–1432.
[PubMed: 17534556] [Full Text]
Woodrum DT, Gauger PG. Benign and Malignant Tumors of the

Adrenal Gland. In: Sabel M, Sondak VK, Sussman JJ, eds.
Essentials of Surgical Oncology: Surgical Foundations.
Philadelphia, PA: Mosby/Elsevier; 2006:197.


Current Procedures: Surgery > Chapter 4. Surgery of the

Endocrine Pancreas >
Indications
Tumors may be functional (ie, a clinical syndrome of

excessive levels of such hormones as insulin, gastrin, VIP,
somatostatin, and glucagon) or nonfunctional (ie, normal
serum marker levels [excluding pancreatic polypeptide,
chromogranin A]).
Tumors may be sporadic or a manifestation of an
inherited endocrinopathy (multiple endocrine neoplasia
type 1 [MEN-1], von Hippel-Lindau [VHL]).
Nonfunctional tumors demonstrable via radiologic
examination should be resected.
All functional tumors should be resected.
Sinistral portal hypertension.
Contraindications
Inoperable, metastatic disease.

Small (< 1 cm), nonfunctional tumors in patients with an
inherited endocrinopathy.
Functional tumors with a medically controlled syndrome in
patients with an inherited endocrinopathy who have
undergone previous pancreatic resection.
Pregnancy (first trimester).
Multiple comorbidities precluding safe surgical
intervention.
Informed Consent
For major pancreatic resections, morbidity is roughly 10–

12% and mortality is 1–2%.
Expected Benefits
Treatment of pancreatic hypersecretory syndromes in

patients with functional tumors.
Treatment of potentially malignant neuroendocrine
tumors.
Potential Risks
Bleeding, possibly requiring blood product transfusion.

Surgical site infection.
Pancreatic fistula.
Biliary fistula.
Gastric outlet obstruction or delayed gastric emptying.
Overwhelming post-splenectomy sepsis.
Incisional hernia.
Glucose intolerance or diabetes.
Pancreatic exocrine insufficiency or malabsorption.
Equipment
Intraoperative ultrasound with a high-resolution 7.5–10

MHz probe should be available for primary tumor
localization or identification of hepatic metastatic disease.
Patient Preparation
Medical control of hormone excess (eg, with proton pump

inhibitors or somatostatin analogue therapy) to the
degree possible.
Any patient who is to undergo splenectomy should receive
the pneumococcal, Haemophilus influenzae B, and
meningococcal vaccines preoperatively.
Preoperative antibiotics.
Both mechanical and pharmacologic deep venous
thrombosis prophylaxis should be given.
Patient Positioning
The patient should be supine, preferably with the arms

extended.
Procedure
Figure 4–1: For patients with documented

hypergastrinemia, the primary tumor will almost always
lie in the gastrinoma triangle (bounded by the confluence
of the cystic and common hepatic ducts, the second and
third portion of the duodenum, and the confluence of the
neck and body of the pancreas).
A vertical, upper midline incision or a subcostal incision is
used.
The former is preferred for patients with a relatively

acutely angled costal margin.
The latter incision can either be predominantly left
sided for a distal pancreatectomy or bilateral in the
case of a pancreaticoduodenectomy.
Inspection of the abdomen for metastatic disease includes
visualization and palpation of the liver, peritoneal
surfaces, mesentery, omentum, and, in women, the
ovaries.
Figure 4–2: The entire pancreas is mobilized for
localization of the tumor.
This step begins with a mobilization of the pancreatic

head via release of the duodenum from its lateral
abdominal wall and retroperitoneal attachments
(Kocher maneuver).
This should be continued toward the patient's left
side until the aorta is encountered.
Figure 4–3: The body and tail of the pancreas is exposed
via entry through the lesser sac.
The gastrocolic ligament is opened, taking care not to

enter the transverse mesocolon or injure the middle
colic vessels.
The retroperitoneum at the inferior border of the
pancreas is opened with electrocautery or scissors.
The superior mesenteric vein (SMV) can be identified
at this stage by following the middle colic vein to its
insertion into the SMV.
Figure 4–4A, B: The avascular attachments of the
pancreas to the posterior wall of the pancreas are divided,
and the retroperitoneum overlying the superior edge of
the pancreas is opened.
The lateral peritoneal reflection of the spleen is
divided.
This allows for bimanual palpation of the entire
length of the pancreas.
Great care should be taken when a pancreatic neoplasm
has resulted in splenic vein occlusion, leading to sinistral
portal hypertension, because there may be many perilous
collateral vessels in the area of dissection. In this
scenario, early ligation and division of the splenic artery
may reduce flow in the collateral vessels.
Figure 4–5A-C: A thorough ultrasound examination of
the entire pancreas allows for identification of all
neuroendocrine tumors.
The main pancreatic duct and its spatial relationship

to the tumor can also be identified.
Endocrine tumors and their metastases are usually
hypoechoic relative to the surrounding parenchyma.
An operative plan can then be formulated, which may
involve pancreaticoduodenectomy, distal
pancreatectomy and splenectomy, tumor enucleation,
or a combination of enucleation and formal anatomic
pancreatic resection.
The operative approach in familial pancreatic
neuroendocrine tumors should attempt to resect all gross
disease while preserving normal pancreatic function.
Figure 4–6A-C: Benign tumors anywhere in the pancreas
can be enucleated with sharp dissection around the
capsule of the tumor, with care taken to avoid a
pancreatic ductal injury.
Cautery on the surface of the pancreas should be

used with caution to prevent the transmission of a
thermal injury to the pancreatic duct.
Closed suction drains should be left in place near the
site of an enucleation or an anatomic resection to
detect and control a possible pancreatic fluid leak.
Figure 4–7: In patients with hypergastrinemia, routine
digital exploration of the duodenum for a submucosal
tumor is recommended.
This is accomplished with a longitudinal duodenotomy

in the free wall of the second portion of the
duodenum.
Tumors may be as small as a few millimeters; these
can be resected by a full-thickness duodenal wall
resection, and closure of the defect from the inside.
Tumors that encroach on the ampulla of Vater may
require pancreaticoduodenectomy for resection.
The free wall of the duodenum is closed in two layers
in a transverse fashion to prevent duodenal
narrowing.
Also shown in this figure is a pancreas transected at
the level of the superior mesenteric vessels and two
tumor enucleation sites in the pancreatic head. (This
is the operation described and popularized by Dr.
Norman Thompson as initial treatment of MEN-1—
related pancreatic neuroendocrine disease.)
Figure 4–1
Figure 4–2
Figure 4–3
Figure 4–4A
Figure 4–4B
Figure 4–5 A–C
Figure 4–6 A–C
Figure 4–7
Postoperative Care
Routine postoperative admission to an ICU is not

mandatory. Rather, ICU observation (usually one night) is
guided by intraoperative blood loss as well as preexisting
cardiac and pulmonary comorbidities the patient may
have.
Nasogastric tube decompression is continued
postoperatively; the length of time the tube remains in
place is guided by the volume of output.
Patient-controlled intravenous or epidural analgesia is
routinely used.
Urinary catheterization continues while an epidural pain
catheter is in place.
Early ambulation and physical therapy consultation, if
indicated.
Oral diet is slowly introduced once ileus is fully resolved.
Strict management of glycemic control, with continuous
insulin infusion for repeated blood glucose measurements
> 140 mg/dL.
Closed suction drain output is tested for amylase and
lipase content prior to removal.
Routine use of octreotide therapy to reduce the pancreatic
fistula rate is not supported by published evidence.
After laparotomy: intravenous catheter infection, urinary

tract infection, pneumonia, cardiac dysrhythmias and
ischemia, deep venous thrombosis, superficial surgical
site infection, fascial dehiscence.
Pancreatic leakage and fistula occur in 5–8% of cases.
Leakage or fistula is confirmed by amylase and

lipase-rich drainage in closed suction drain output.
Nontoxic patients are treated with maintenance of
the drain.
Patients with fevers, tachycardia, acidosis, or
leukocytosis should undergo abdominal and pelvic CT
scan to evaluate for abscess or inadequately
controlled fistula.
Inadequately controlled fistula can usually be
managed with an additional percutaneous drain,
replacement of lost fluid and electrolytes, adequate
nutrition, and consideration of octreotide therapy for
high-output fistulas.
Postoperative hemorrhage, most commonly resulting from
a bleeding short gastric vessel or a gastroduodenal or
pancreaticoduodenal pseudoaneurysm.
Delayed gastric emptying.
Pearls and Tips
Most clinically recognized pancreatic endocrine neoplasms

are functional, producing clinically recognizable
syndromes.
Malignant pancreatic endocrine neoplasms are determined
by the presence of local invasion and lymph node or
hepatic metastases, not based on histologic examination.
The initial imaging technique for a pancreatic endocrine
neoplasm is a high-quality spiral CT scan.
Endoscopic ultrasonography is particularly useful for
localization of tumors in patients with gastrinoma and
insulinoma.
The characteristic severe dermatitis (necrolytic migratory
erythema) associated with a glucagonoma is effectively
treated with octreotide.
Nonfunctional islet cell tumors of the pancreas, although
often quite large at diagnosis, tend to grow slowly and
have a more indolent course than pancreatic ductal
cancer.
Chromogranin A and pancreatic polypeptide are useful
markers for surveillance following resection of a
pancreatic endocrine tumor.
References
Lairmore TC. Complications in Endocrine Pancreatic Surgery.

In: Mulholland MW, Doherty GM, eds. Complications in
Surgery. Philadelphia, PA: Lippincott Williams & Wilkins;
2006:594–602.
Lowney J, Doherty GM. Surgery for Endocrine Tumors of the

Pancreas. In: Doherty GM, Skogseid B, eds. Surgical
Endocrinology. Philadelphia, PA: Lippincott Williams & Wilkins;
2001:381–392.
Riall TS, Yeo CJ. Neoplasms of the Endocrine Pancreas. In:

Mulholland MW, Lillemoe KD, Doherty GM, et al, eds.
Greenfield's Surgery, Scientific Principles & Practice.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006:880–
891.
Thompson NW. Pancreatic Surgery for Endocrine Tumors. In:

Clark OH, Duh QY, Kebebew E, eds. Textbook of Endocrine
Surgery. Philadelphia, PA: Elsevier Saunders; 2005:737–744.


Current Procedures: Surgery > Chapter 5. Transhiatal

Esophagectomy >
Indications
Resectable esophageal carcinoma.

Barrett esophagus with high-grade dysplasia.
Carcinoma of the cardia or proximal stomach.
Achalasia.
Advanced disease (mega-esophagus).
Failed esophagomyotomy.
Benign (undilatable) stricture.
Recurrent hiatal hernia or reflux esophagitis following
multiple hiatal hernia repairs.
Contraindications
Absolute
Biopsy-proven distant metastatic (stage IV) esophageal

cancer.
Tracheobronchial invasion by upper or mid-third tumors
visualized on bronchoscopy.
Aortic invasion demonstrated on MRI, CT scan, or
endoscopic ultrasound (EUS).
Relative
Cardiopulmonary comorbidities.
Previous esophageal surgery causing excessive
mediastinal adhesions.
Previous radiation therapy (more than 6–12 months prior)
causing mediastinal and esophageal radiation fibrosis.
Informed Consent
In our series of patients, overall mortality is 1%, and

more than 70% of patients experience no postoperative
complications.
Expected Benefits
Resection of the intrathoracic esophagus and accessible

associated adenopathy for definitive therapy or local
management of disease, while restoring normal
swallowing and digestive function as much as possible.
Potential Risks
Cervical esophagogastric anastomotic leak (5–10%).

Cervical dysphagia or esophageal stricture requiring early
postoperative dilation (50–60%).
Postvagotomy dumping symptoms (25–50%).
Recurrent laryngeal nerve injury (< 5%).
Chylothorax (< 2%).
Mediastinal hemorrhage (< 1%).
Membranous tracheal injury (< 1%).
Gastric tip necrosis (< 1%).
Surgical site infections and systemic complications
common to any major operation (eg, pneumonia, venous
thromboembolism, and cardiovascular events).
Equipment
A table-mounted "upper hand" retractor facilitates

exposure of the operative field.
Endoscope for preoperative visualization of the
esophageal abnormality and to ensure an adequate
normal proximal margin.
14-inch right-angle clamps.
Extra-long 16-inch electrocauterizing device.
Gastrointestinal anastomosis (GIA) stapler
Patient Preparation
Preoperative Planning
Thorough preoperative staging evaluation is essential

before performing transhiatal esophagectomy for
malignancy.
Esophagoscopy and biopsy, to establish the location

of the tumor and histology.
CT scanning, to demonstrate the local extent of the
tumor and presence of distant metastatic disease.
EUS, to define the depth of tumor invasion within the
esophageal wall and surrounding tissues. EUS can
also identify dissemination of tumor into regional
lymph nodes and can be combined with fine-needle
aspiration for confirmation of malignancy.
Positron emission tomography has recently become a
standard part of the staging evaluation and
determines occult distant metastatic disease.
For patients with a history of gastric disease or previous
gastric surgery, or patients with esophagogastric junction
tumors that may necessitate resection of a major portion
of the stomach, a barium enema should be performed to
assess the colon as an alternate conduit if the stomach is
not suitable.
Maximizing the patient's preoperative cardiopulmonary
status is paramount to successful recovery.
Patients should abstain from cigarette smoking and
alcohol use for a minimum of 3 weeks before the
operation.
Patients should use an incentive spirometer on a regular
basis (10 deep breaths three times daily), and walk at
least 1–3 miles per day.
For patients with severe dysphagia, weight loss, or
dehydration, liquid supplementation by either oral or
nasogastric routes should be considered.
Placement of percutaneous gastrostomy and jejunostomy
tubes should be avoided for preoperative feeding as they
increase the risk of surgical site infection, risk injuring the
right gastroepiploic artery, and complicate subsequent
mobilization of the stomach at the time of operation.
Patients who may require colonic interposition should
receive a preoperative bowel preparation.
Anesthetic Management
Continuous radial intra-arterial blood pressure monitoring.

Two large-bore peripheral intravenous catheters.
Epidural catheter for postoperative analgesia.
Standard endotracheal tube.
Foley catheter.
Patient Positioning
After induction of general anesthesia, flexible endoscopy

is performed by the operating surgeon to verify the exact
location of the mass or abnormality and to ensure that
there is an adequate normal length of proximal esophagus
above for construction of a cervical esophagogastric
anastomosis.
Following completion of endoscopy, a 16 French
nasogastric tube is placed to evacuate air from the
stomach.
Figure 5–1: The patient should be supine with a folded
blanket under the shoulders to provide adequate neck
extension.
The head is turned to the right and supported on a

padded head ring.
The skin of the neck, chest, and abdomen is prepared
and draped from the angle of the mandible superiorly
to the pubis inferiorly, and from both midaxillary lines
anteriorly.
Both arms are padded and tucked at the patient's
side following the placement of arterial and venous
access lines.
Figure 5–1
Procedure
Overview
Transhiatal esophagectomy is widely used for the

resection of both benign and malignant esophageal
disease.
In experienced hands, it is a safe and well-tolerated
alternative to transthoracic esophagectomy, and it avoids
the morbidity of mediastinitis resulting from an
intrathoracic anastomotic leak.
Using this approach, the thoracic esophagus is resected
through a widened diaphragmatic hiatus and a cervical
incision.
Alimentary continuity is restored with a gastric conduit
anastomosed to the remaining cervical esophagus above
the level of the clavicles.
Abdominal Phase
The abdomen is entered through a midline supraumbilical

incision (see Figure 5–1).
Exploration of the abdomen is performed to confirm that
the stomach is an appropriate conduit and is not
extensively replaced by tumor nor contracted from prior
surgery or caustic ingestion.
Mobilization of the stomach.
Following exploration, the triangular ligament of the

liver is divided using electrocautery.
A self-retaining, upper hand, table-mounted retractor
is used to facilitate exposure, and the left lobe of the
liver is padded and retracted to the right with a liver
blade.
The greater curvature of the stomach is visualized,
and the course of the right gastroepiploic artery is
identified.
Beginning at the midpoint of the greater curvature of
the stomach, the greater omentum is separated from
the stomach to the level of the pylorus between
right-angled clamps, using 2-0 silk ties for
hemostasis.
Care is taken to apply the clamps 1–2 cm below the
right gastroepiploic artery to avoid injury to this
vessel.
Attention is then directed to the superior aspect of
the greater curvature of the stomach. The left
gastroepiploic artery and short gastric vessels are
identified and divided between right-angled clamps
using 2-0 silk ties for hemostasis.
To prevent gastric necrosis, it is important to avoid
ligation of these vessels too close to the stomach.
Additionally, the surgeon must take care to avoid
injury to the spleen during this portion of the
dissection.
Figure 5–2: Mobilization of the lower esophagus.
Following the division of these vessels, attention is

turned to the diaphragmatic hiatus.
The peritoneum overlying the esophageal hiatus is
incised, and the esophagus is encircled with a 1-inch
Penrose drain.
The gastrohepatic omentum is then incised, taking
care to preserve the right gastric artery.
The left gastric artery and vein are divided between
clamps and doubly ligated, avoiding injury to the
celiac axis.
The artery is ligated and divided at its origin from the
celiac axis, sweeping any adjacent lymph nodes
toward the stomach.
Throughout this dissection, the surgeon should be
mindful of aberrant vascular anatomy, particularly an
aberrant left hepatic artery arising from the left
gastric artery, which might need to be preserved.
To maximize the reach of the stomach superiorly, a
generous Kocher maneuver is performed, and the
duodenum is mobilized sufficiently so that the pylorus can
be grasped and moved to the level of the xiphoid process
medially.
Two traction sutures are placed, one at the superior
and one at the inferior pole of the pylorus.
A 2-cm long pyloromyotomy is created, beginning 1.5
cm on the gastric side and extending through the
pylorus and onto the duodenum for 0.5–1 cm.
This is performed using the cutting current of a
needle-tipped electrocautery device and a fine-tipped
vascular mosquito clamp to dissect the gastric and
duodenal submucosa away from the overlying
muscle.
The pylorus is marked with two metallic silver clips
on the traction sutures for future radiographic
localization.
Downward traction is placed on the Penrose drain
encircling the esophagogastric junction.
The diaphragmatic hiatus is progressively dilated
manually until the surgeon's hand can be inserted
into the posterior mediastinum through the hiatus.
A narrow Deaver retractor is placed into the hiatus to
allow visualization, division, and ligation of the lateral
attachments of the distal half of the esophagus.
Gentle blunt dissection is used in combination with
electrocautery and a long right-angled clamp to
expose the lateral esophageal attachments and
mobilize the distal 5–10 cm of the lower esophagus.
The low posterior mediastinum is gently packed with a
gauze "lap pack" as attention is now turned to the neck.
A feeding jejunostomy tube should be placed in all
patients.
A 14 French rubber jejunostomy tube is inserted

approximately 8–10 inches beyond the ligament of
Treitz.
This is secured in place using two 4-0 polypropylene
purse-string sutures and a 4-cm long Weitzel
maneuver.
The tube is clamped and anchored to the operative
drapes until later in the procedure when the
jejunostomy is brought out through the left
abdominal wall.
Figure 5–2
Figure 5–3
Cervical Phase
Figure 5–3: Cervical incision and mobilization of the

cervical esophagus.
Palpation of the cricoid cartilage indicates the level of

the cricopharyngeal sphincter, the beginning of the
esophagus.
A 5–7 cm incision is created along the left anterior
border of the sternocleidomastoid (SCM) muscle from
the sternal notch to the level of the cricoid cartilage.
An incision superior to this point provides no added
exposure of the cervical esophagus, which is located
inferior to the cricoid cartilage.
The platysma muscle is incised.
The fascia along the anterior edge of the SCM muscle
is incised in the direction of the wound, and the SCM
muscle is retracted laterally to expose the omohyoid
muscle.
The omohyoid muscle and its contiguous fascial
sheath are divided, exposing the underlying carotid
sheath.
The SCM muscle and carotid sheath and its contents
are gently retracted laterally, while the larynx,
thyroid, and trachea are retracted medially using only
a finger. Hand-held retractors should not be used for
this purpose to prevent injury to the recurrent
laryngeal nerve lying in the tracheoesophageal
groove.
The middle thyroid vein is divided.
The inferior thyroid artery, which is always found at
the level of the cricoid cartilage and upper
esophageal sphincter, is identified, divided, and
ligated. The dissection is carried directly posterior
until the prevertebral fascia is identified.
Blunt finger dissection into the superior mediastinum
separates the cervical and upper thoracic esophagus
from the prevertebral fascia.
Upward retraction on the cervical esophagus by a
finger placed gently along the tracheoesophageal
groove elevates the upper thoracic esophagus from
the superior mediastinum into the cervical wound,
and sharp dissection posterolateral to the
tracheoesophageal groove is used to free the anterior
surface of the esophagus away from the trachea.
The cervical esophagus is encircled with a 1-inch
Penrose drain. With upward traction on the Penrose
drain, the cervical esophagus is mobilized
circumferentially to the level of the carina by the
surgeon's index finger, which is kept directly against
the esophagus.
Mediastinal Dissection
Figure 5–4A: Posterior mobilization of the intrathoracic

esophagus.
Back in the abdomen, working through the

diaphragmatic hiatus, the surgeon palpates the
esophagus to assess its mobility and establish that
transhiatal resection is feasible.
The surgeon inserts one hand through the
diaphragmatic hiatus posterior to the esophagus.
The hand is advanced superiorly, keeping as close to
the spine as possible along the prevertebral fascia.
At the same time, the cervical esophagus is gently
retracted anteriorly and medially using the rubber
Penrose drain.
A "sponge-on-a-stick" is inserted through the cervical
incision behind the esophagus. By advancing the
sponge stick inferiorly, the esophagus is dissected
free from the prevertebral fascia.
Working upward from the diaphragmatic hiatus and
downward through the cervical incision, posterior
mobilization of the esophagus is completed using a
combination of finger dissection and dissection with
the sponge stick.
The sponge stick is advanced downward until it
meets the surgeon's hand inserted through the
diaphragmatic hiatus.
At this point, a 28 French Argyle Saratoga sump
catheter is placed through the cervical incision into
the mediastinum along the dissected path to
evacuate blood.
Figure 5–4B: Anterior mobilization of the intrathoracic
esophagus.
While the esophagogastric junction is retracted

inferiorly with its encircling Penrose drain, the
surgeon places his or her hand against the anterior
esophagus, palm downward.
The hand is advanced into the mediastinum, gently
dissecting the esophagus from the posterior
pericardium and the carina.
The cervical esophagus is retraced superiorly and
laterally, and the surgeon places his or her hand
against the anterior wall of the esophagus.
The hand is advanced inferiorly with two fingers
dissecting along the wall of the anterior esophagus to
free the esophagus from the posterior membranous
trachea.
Care must be taken to avoid injury to the trachea
during this process.
With the anterior and posterior esophageal
attachments divided, the cervical esophagus is gently
retracted superiorly into the cervical wound as the
lateral attachments of the upper esophagus are
progressively swept away by blunt dissection.
Approximately 5–8 cm of the upper thoracic
esophagus is circumferentially mobilized in this
fashion.
Attention is then turned to the abdominal field.
The previously placed lap pad is removed from the

posterior mediastinum.
The hand is inserted palm downward through the
diaphragmatic hiatus and advanced along the
anterior esophagus until the circumferentially
mobilized upper thoracic esophagus can be identified
by palpation.
The remaining lateral esophageal attachments and
vagal branches are gently avulsed by drawing the
hand inferiorly along the esophagus in a "raking"
motion.
If difficulty is encountered in this dissection, the
upper sternum can be divided to provide exposure of
the upper thoracic esophagus in the superior
mediastinum and division of its lateral attachments
under direct visualization.
Throughout the mediastinal dissection, intra-arterial blood
pressure is monitored with a radial artery catheter to
avoid prolonged hypotension due to displacement of the
heart.
Once the entire thoracic esophagus has been mobilized,
the nasogastric tube is withdrawn to a level above the
upper esophageal sphincter.
The cervical esophagus is elevated out of the wound and
divided approximately 8–10 cm distal to the upper
sphincter using a GIA surgical stapler.
Approximately 5 cm of excessive cervical length

should be left to ensure a tension-free
reconstruction.
The thoracic esophagus and stomach are then delivered
downward through the diaphragmatic hiatus, and the
sump catheter is advanced down into the posterior
mediastinum from the neck incision.
A narrow Deaver retractor is inserted into the
diaphragmatic hiatus to allow the surgeon to inspect the
mediastinum for bleeding and the mediastinal pleura for
injury that indicates the need for a chest tube.
If the pleura has been violated, a 28 French chest tube is
inserted in the appropriate anterior axillary line in
approximately the sixth intercostal space, sutured in
place, and connected to an underwater seal chest tube
suction system.
The posterior mediastinum is packed again with a large
gauze abdominal lap pad to control minor bleeding, and
the cervical wound is covered with a moist pack as the
surgeon returns to the abdomen for preparation of the
gastric conduit.
Figure 5–4A
Figure 5–4B
Creation of the Gastric Conduit and Abdominal Closure
Figure 5–5A: Preparing the gastric conduit.
With the mobilized stomach and attached esophagus

placed on the patient's anterior chest wall, the site
along the greater curvature of the stomach that will
reach most superior is identified by gently pulling the
fundus toward the cervical incision.
Once this point is identified, it is continuously
retracted superiorly, as the fat along the lesser
curvature is cleared between clamps and ligated at
the level of the second "crow's foot."
The upper stomach is progressively divided by
sequential applications of the GIA stapler, starting at
the lesser curvature and working toward the fundus.
Traction on the fundus during this maneuver must be
maintained to straighten the stomach sufficiently to
reach the neck.
The proximal stomach is divided approximately 5 cm
distal to the esophagogastric junction, and the
specimen is passed off of the field. The staple line
along the lesser curve of the stomach is oversewn
with a running 4-0 polypropylene Lembert stitch.
Figure 5–5B: Completed gastric conduit.
The completed gastric conduit should reach 4–5 cm

above the left clavicle.
Figure 5–6: Delivery of the gastric tip into the cervical
wound in preparation for the anastomosis.
Using a narrow Deaver retractor to expose the

diaphragmatic hiatus, the superior tip of the gastric
fundus is placed through the hiatus.
The surgeon's hand should remain on top of the
stomach, gently guiding it upward through the
posterior mediastinum, underneath the aortic arch
and into the superior mediastinum.
When the gastric fundus can be palpated in the
superior mediastinum with a finger inserted through
the cervical incision, a Babcock clamp is inserted into
the superior mediastinum and the gastric tip gently
grasped. The jaws of the clamp are not completely
closed to minimize trauma to the gastric tip.
The gastric tip should not be pulled into the cervical
wound, but rather the stomach pushed upward and
the tip guided with the hand inserted through the
diaphragmatic hiatus into the cervical wound.
The surgeon should ensure that the stomach is not
twisted by noting that the staple line along the lesser
curvature of the stomach is facing toward the
patient's right side and by palpating the stomach
through the diaphragmatic hiatus and the cervical
incision.
The gastric tip should remain pink and without
evidence of ischemia throughout the remainder of the
procedure.
The position of the stomach in the neck wound is
maintained by packing a small moistened gauze pad
into the thoracic inlet alongside the stomach to
prevent it from retracting downward into the
mediastinum.
Attention is redirected to the abdomen, which is inspected
for hemostasis.
After delivery of the gastric conduit into the cervical
incision, the pyloromyotomy will lie 3–4 cm below the
level of the diaphragmatic hiatus.
The diaphragmatic hiatus is closed loosely using one

or two interrupted No. 1 silk sutures until three
fingers slide easily alongside the stomach in the
hiatus.
Additionally, one or two interrupted 3-0 silk sutures
are placed between the anterior gastric wall and the
adjacent hiatus to discourage migration of a loop of
small intestine through the hiatus into the chest.
Finally, the left lobe of the liver is returned to its anatomic
location, and the triangular ligament is sutured over the
hiatus to prevent future herniation of abdominal contents.
The jejunostomy tube is brought out of the left upper
abdominal wall through a separate stab incision and
tacked to the adjacent peritoneum using interrupted 3-0
silk sutures.
The jejunostomy tube is secured to the skin using a

2-0 polypropylene suture.
The abdomen is then closed using No. 1 looped PDS
suture on the muscle fascia, running 2-0 chromic catgut
suture on the subcutaneous tissue, and running 3-0 nylon
suture on the skin.
The abdominal incision is isolated from the field with a
sterile towel to prevent wound contamination by oral
flora, which can occur once the cervical esophagus is
opened for performance of the anastomosis.
A sterile drape is placed over the abdominal field.
Figure 5–5A
Figure 5–5B
Figure 5–6
Cervical Esophagogastric Anastomosis
Figure 5–7A-D, Figure 5–7E-F: Creation of the cervical

esophagogastric anastomosis.
After closure of the abdomen, attention is turned to

the cervical wound.
The tip of the divided cervical esophagus is grasped
with an Allis clamp and retracted superiorly and to
the right.
The anterior wall of the stomach is grasped using a
Babcock clamp, and the staple line is rotated more
medially.
A seromuscular traction suture is placed in the
anterior gastric wall to elevate the stomach into the
wound, the cervical esophagus is aligned with the
stomach, and the site of the anastomosis selected.
A 1.5-cm vertical gastrotomy is created in the
anterior gastric wall to allow later insertion of a 3-cm
Endo-GIA staple cartridge (Figure 5–7A).
The cervical esophageal staple line is amputated
obliquely, allowing for enough redundancy to
accommodate later retraction of the stomach into the
thoracic inlet (Figure 5–7B).
The staple line is then sent for pathologic
examination as the proximal esophageal margin.
Two stay sutures are placed, one at the anterior tip of
the divided esophagus and the other between the
posterior end of the divided esophagus and the
superior end of the gastrotomy (Figure 5–7C).
These stay sutures align the back wall of the cervical
esophagus and the front wall of the stomach for
construction of the anastomosis.
An Endo-GIA-30 stapler is placed in the stomach as the
traction sutures are drawn inferiorly, gently pulling the
stomach and esophagus downward as the stapler is
advanced inward and closed (Figure 5–7D).
Two lateral suspension sutures of 4-0 Vicryl are

placed between the cervical esophagus and the
stomach on either side of the anastomosis to
alleviate tension on the anastomosis.
The stapler is fired and removed, thereby creating a
3-cm-long side-to-side stapled esophagogastric
anastomosis.
The previously placed 16 French nasogastric tube is
guided across the anastomosis and into the
intrathoracic stomach.
The gastrotomy and esophagotomy are closed in two
layers of running and interrupted 4-0 monofilament
absorbable suture, and each side of the anastomosis
is marked with a hemoclip for future radiographic
localization (Figure 5–7E, F).
The wound is irrigated, and a 0.25-inch Penrose drain is
placed adjacent to the anastomosis.
The drain is sutured to the skin.
The neck incision is closed loosely by reapproximating the
SCM muscle fascia to the omohyoid muscle, fascia, and
platysma using absorbable interrupted 3-0 Vicryl sutures,
and the skin edges are reapproximated with running 4-0
nylon.
Figure 5–8: Final anatomic position of the gastric
conduit.
Sterile dressings are applied, and the thoracostomy tubes
are placed on suction.
A postoperative chest radiograph should be obtained in
the operating room to confirm full expansion of both
lungs, absence of hemothorax or pneumothorax requiring
an additional chest tube, and appropriate positioning of
the tip of the nasogastric tube above the silver clips
marking the pylorus.
Figure 5–7A–D
Figure 5–7E–F
Figure 5–8
Postoperative Care
Immediate postoperative chest radiograph while the

patient is in the operating room to exclude unrecognized
pneumothorax or hemothorax.
Extubation in the operating room and initiation of epidural
anesthesia.
Early use of an incentive spirometer within several hours
of awakening from anesthesia.
Early ambulation beginning on postoperative day (POD) 1.
Ice chips by mouth (not to exceed 30 mL/h) for throat
comfort until the nasogastric tube is removed on POD 3.
Initiation of oral liquids on POD 4, with progressive daily
advancement to full liquids, then mechanical soft (pureed)
diet, and a soft diet by POD 7.
Initiation of jejunostomy tube feedings on POD 3 and
tapering as oral intake increases.
Monitoring for resolution of ileus.
Barium swallow examination on POD 7 to document
integrity of the anastomosis, adequate gastric emptying
through pylorus and hiatus, and absence of obstruction at
the jejunostomy site.
If oral intake is poor, nocturnal jejunostomy tube feeding
supplementation can be used.
If the patient is eating well and has no complications, the
jejunostomy tube can be removed 4 weeks
postoperatively during follow-up examination.
Intraoperative
Pneumothorax.
Hemothorax.
Uncontrollable mediastinal bleeding (< 1%).
Need for thoracostomy tubes due to entry into pleural
cavity (75%).
Iatrogenic splenectomy (3%).
Membranous tracheal laceration (< 1%).
Injury to the gastric or duodenal mucosa during
pyloromyotomy (< 2%).
Early Postoperative
Recurrent laryngeal nerve injury (< 1–2%) causing

hoarseness and difficulty swallowing.
Chylothorax (1%).
Cardiac arrhythmia (atrial fibrillation).
Sympathetic pleural effusion.
Pneumonia and atelectasis (2%).
Cervical esophagogastric anastomotic leak (4%).
Gastric tip necrosis (1%).
Dysphagia.
Regurgitation.
Postvagotomy "dumping."
Anastomotic stricture requiring dilation.
Delayed gastric emptying due to incomplete
pyloromyotomy, narrowing of the diaphragmatic hiatus, or
jejunostomy tube site obstruction.
Late
Cervical anastomotic stricture.

Diaphragmatic hernia.
Small bowel obstruction due to torsion at the jejunostomy
tube site (< 1%).
Pearls and Tips
Marking the pyloromyotomy and cervical esophagogastric

anastomosis with hemoclips allows for visualization on
postoperative imaging to assess the position of the
stomach in the chest and gastric emptying.
Use only a fingertip to retract the cervical esophagus,
thyroid, and trachea medially during mobilization of the
cervical esophagus. To minimize the chance of injury to
the recurrent laryngeal nerve, do not place metal
retractors against the tracheoesophageal groove.
Minimize gastric trauma during mobilization and
particularly to the gastric tip so that a healthy stomach
can be anastomosed to the esophagus, reducing the risk
of postoperative anastomotic leak.
When creating the gastric conduit, preserve as much of
the stomach as possible to maximize collateral circulation.
Repeatedly assess the color and viability of the stomach
after mobilization of the stomach, when the gastric tube is
delivered into the cervical wound, and after the closure of
the diaphragmatic hiatus to be certain that there is no
venous congestion or ischemia from mechanical causes.
Avoid use of suspension sutures to tack the gastric tip to
the prevertebral fascia because of the risk of vertebral
osteomyelitis.
Use a radial artery catheter to monitor for intraoperative
hypotension, particularly during the mediastinal
dissection. Hypotension can be caused by cardiac
displacement or hemorrhage from injury to mediastinal
structures.
Aggressive preoperative conditioning with abstinence from
cigarette smoking, regular use of an incentive spirometer,
and walking are rewarded by a less complicated
postoperative course.
References
Orringer M. Transhiatal esophagectomy without thoracotomy.

Operative Techniques in Thoracic and Cardiovascular Surgery.
2005;10:63–83.
Orringer MB, Marshall B, Chang AC, et al. Two thousand

transhiatal esophagectomies: changing trends, lessons
learned. Ann Surg. 2007;246:363–372.[PubMed:
17717440] [Full Text]
Orringer MB, Marshall B, Iannettoni MD. Eliminating the

cervical esophagogastric anastomotic leak with a side-to-side
stapled anastomosis. J Thorac Cardiovasc Surg. 2000;119:
277–288.[PubMed: 10649203] [Full Text]


Current Procedures: Surgery > Chapter 6. Operative

Management of Gastric Lesions >
Indications
Malignant tumors.
Benign tumors.
Intractable bleeding.
Chronic ulceration and inflammation.
Contraindications
Absolute
Inability to completely resect primary cancer.

Distant metastases.
Relative
High operative risk because of age or comorbidities.
Informed Consent
Operative mortality rates range from 3%–7%.

Resection of the spleen, pancreas, or colon may be required
if a gastric tumor has invaded adjacent organs.
Expected Benefits
Surgical treatment of gastric malignancy with curative intent.

Resolution of bleeding or obstruction from benign or
malignant gastric tumors or disease processes.
Potential Risks
Anastomotic leak.
Wound infection.
Pancreatic fistulae.
Intra-abdominal abscesses.
Equipment
A self-retaining retractor is necessary for optimal exposure.

Gastrointestinal anastomosis (GIA), thoracoabdominal (TA),
and end-to-end anastomosis (EEA) staplers are often used
for resection and reconstruction, and should be available.
Patient Preparation
All patients should undergo fiberoptic endoscopy when

neoplasm is suspected, and the diagnosis should be
confirmed by multiple biopsies.
Preoperative tests should be performed to determine whether
distant metastases are present.
Abdominal and pelvic CT scans, endoscopic ultrasound,

or laparoscopy may be required for adequate staging.
A first- or second-generation cephalosporin is adequate as
antibiotic prophylaxis for most gastric operations.
Deep venous thrombosis prophylaxis should be administered.
Bowel preparation is only useful in complicated cases when
intestinal decompression is required and may serve to lessen
the bacterial load if an intestinal resection is required.
Electrolyte and coagulation deficits should be corrected
before operation.
Patient Positioning
The patient should be supine, with the operating surgeon on

the right side of the patient.
An upper midline incision is made from the xiphoid to the
umbilicus to enter the abdomen.
Reverse Trendelenburg positioning facilitates exposure.

Once the abdomen has been entered, a routine exploration
should be performed and a nasogastric tube placed by the
anesthetist.
Procedure
Overview and Surgical Anatomy
Figure 6–1A-C: Overview of surgical options for resection of

gastric lesions.
For lesions involving the cardia of the stomach,

esophagogastrectomy with esophagogastrostomy is
performed (Figure 6–1A). A thoracotomy combined with
laparotomy may be required. To ensure blood supply to
the gastric remnant, the right gastroepiploic vessels are
preserved.
For lesions in the body of the stomach, total gastrectomy
with esophagojejunostomy is typically performed (Figure
6–1B).
For antral lesions, subtotal gastrectomy with
gastrojejunal reconstruction is performed (Figure 6–1C).
Figure 6–2: Surgical anatomy of the stomach.
The esophagus terminates in the stomach after

penetrating the diaphragm at the esophageal hiatus.
The stomach is divided into the fundus, body, and
antrum based on differences in mucosal histology.
The fundus lies to the left and superior to the
esophagogastric junction.
The junction of the body and antrum is approximately 6–
8 cm proximal to the pylorus along the lesser curvature,
to a point one-third the distance from the pylorus to the
esophagogastric junction along the greater curvature.
Subtotal gastrectomy resects up to 75% of the stomach,
and resection is defined as distal if at least 50% remains
after resection.
Figure 6–1A–C
Figure 6–2
Distal and Subtotal Gastrectomy
For distal lesions, distal or subtotal gastrectomy has an

equivalent oncologic result and fewer complications when
compared with total gastrectomy.
A partial gastrectomy begins with a full Kocher maneuver
that mobilizes the duodenum.
The lesser sac must then be entered to allow early evaluation
of the posterior stomach and to aid in division of the greater
omentum. With cephalad retraction of the greater omentum,
the avascular plane above the transverse colon is entered to
the left of the midline, avoiding disruption of the middle colic
vessels.
Figure 6–3: The gastrocolic omentum is then dissected from
the stomach. The dissection begins at the pylorus with
ligation of the right gastroepiploic artery and continues along
the greater curvature. In the circumstances of benign
disease, the gastroepiploic vessels may be preserved.
Figure 6–4: For 50% resection, the dissection ends halfway
between the pylorus and the esophagogastric junction,
sparing the left gastroepiploic artery and the short gastric
vessels. For a subtotal or 75% resection, the left
gastroepiploic artery and a portion of the short gastric
vessels are divided.
The tissue attachments of the posterior antrum are then
separated from the anterior pancreas and the base of the
transverse mesocolon.
Figure 6–5: The gastrohepatic ligament is incised, and the
lesser curvature is dissected.
Figure 6–6: The right gastric vessels are ligated close to the
stomach. If the pylorus is inflamed, care must be taken in
this area to avoid injury to both the hepatic artery and the
common bile duct.
Figure 6–7: The proximal duodenum is divided carefully,
avoiding injury to the common bile duct.
Figure 6–8: The proximal stomach is divided with a TA-90 or
a GIA stapler.
Figure 6–9: The gastric staple line is oversewn at the
superior portion with either a continuous or running suture.
Traction sutures may be used at either end of the stapled
closure to prevent retraction of the gastric remnant from the
operative field.
Figure 6–3
Figure 6–4
Figure 6–5
Figure 6–6
Figure 6–7
Figure 6–8
Figure 6–9
Gastric Reconstruction for Distal and Subtotal Gastrectomy
Figure 6–10A-C: Billroth I/Gastroduodenostomy.
For gastroduodenostomy reconstruction, the duodenum

is apposed to the inferior gastric staple line (Figure 6–
10A). Posterior seromuscular sutures are placed using
interrupted silk sutures. The stapled end of the
duodenum and the inferior gastric staple line are then
excised using electrocautery.
All layers of the duodenum and stomach are
incorporated in the inner mucosal closure, using a
continuous absorbable suture (Figure 6–10B).
The closure is continued anteriorly and a final anterior
seromuscular layer is placed using interrupted silk
sutures (Figure 6–10C).
A stapled gastroduodenostomy may also be created using an
EEA stapling device (not shown).
A gastrotomy is created on the anterior stomach, at

least 3 cm from the stapled closure using electrocautery.
The EEA is passed into the anterior gastrotomy without
the anvil, with the rod advancing through the posterior
gastric wall.
The anvil is then reattached.
The EEA anvil is introduced into the duodenum after a
purse-string suture has been placed using an automatic
device, and the purse-string suture is tied.
The stapler is fired and the anastomosis is inspected for
hemostasis.
The anterior gastrotomy is closed using a TA stapling
device.
Figure 6–11A-D: Billroth II/Gastrojejunostomy.
For gastrojejunostomy reconstruction, a proximal loop of
jejunum is delivered through an incision in the
transverse mesocolon or anterior to the transverse colon
(Figure 6–11A). Interrupted sutures are placed in a
seromuscular fashion between the posterior gastric wall
and the antimesenteric border of the jejunum. Incisions
are then created with electrocautery in the jejunum and
stomach, partially excising the stapled gastric closure.
The posterior mucosal closure is initiated with a
continuous absorbable suture. Corner stitches should
include the anterior gastric wall, the posterior gastric
wall, and the jejunum (Figure 6–11B).
The posterior mucosal suture is continued along the
length of the anterior aspect of the anastomosis (Figure
6–11C).
An anterior layer of interrupted nonabsorbable sutures
completes the closure (Figure 6–11D).
A stapled gastrojejunostomy may also be created using a GIA
stapling device (not shown).
The anastomotic site on the posterior gastric wall is

usually 2–3 cm proximal from the stapled closure.
The GIA limbs are inserted in matching gastrotomy and
antimesenteric enterotomy incisions are made with
electrocautery.
The staple line is inspected for hemostasis, and the GIA
defect is closed using a TA stapler.
A gastrojejunostomy may also be created in a Roux-en-Y
fashion (see Figures 6–17A, 6–17B, C, 6–18, and 6–19).
Figure 6–10A–C
Figure 6–11A–D
Total Gastrectomy
For large or proximal gastric lesions, a total gastrectomy is

required.
Figure 6–12A: The initial steps of total gastrectomy mirror
those of distal gastrectomy.
Figure 6–12B: The dissection requires a complete
omentectomy and continues along the length of the greater
curvature, to include the left gastroepiploic artery and the
short gastric vessels (if the neoplasm does not involve the
spleen).
Figure 6–13: Division of the gastrohepatic ligament.
The right gastric artery is ligated, and if the inferior

phrenic vein is encountered it can be controlled with
clamps and ligated.
The dissection is continued proximally by dividing the
peritoneum overlying the esophagus.
Figure 6–14: The stomach is then retracted cephalad to
expose the left gastric artery. The vascular pedicle is
encircled and clamps are placed. It is important to avoid
injury to the nearby pancreas.
Figure 6–15: When the entire stomach has been mobilized,
the surgeon can inspect the distal esophagus and determine
whether additional esophageal length is required.
Mobilization of the distal esophagus within the mediastinum
may be required if the neoplasm extends into the esophagus.
Figure 6–16A, Figure 6–16B: Once satisfied that adequate
esophageal length has been achieved, stay sutures are
placed laterally in the distal esophagus to prevent retraction
(Figure 6–16A).
The esophagus is transected, and the stomach is

removed.
A purse-string suture is placed in the distal esophagus
using monofilament suture in preparation for the
esophagojejunal anastomosis (Figure 6–16B).
Figure 6–12A
Figure 6–12B
Figure 6–13
Figure 6–14
Figure 6–15
Figure 6–16A
Figure 6–16B
Gastric Reconstruction for Total Gastrectomy
Figure 6–17A, Figure 6–17B,C: Roux-en-Y

esophagojejunostomy.
The proximal jejunum is divided approximately 10–20

cm distal to the ligament of Treitz (Figure 6–17A).
An opening is made in the transverse mesocolon to the
left of the middle colic vessels above the ligament of
Treitz (Figure 6–17B).
The Roux limb/distal end of the transected jejunum is
passed in a retrocolic fashion to the area of the distal
esophagus (Figure 6–17C). The Roux limb must be
placed carefully, without angulation or tension.
Figure 6–18: Esophagojejunal anastomosis.
The stapled jejunal end is excised to permit passage of

an EEA stapler.
The EEA stapler is introduced through the open end of
the Roux-en-Y limb. The rod should be positioned to exit
3 cm proximally along the antimesenteric border of the
jejunum.
The anvil is then inserted into the distal esophagus
through the purse-string suture and the purse-string is
secured.
The stapler is fired, completing an end-to-side
esophagojejunostomy. The EEA device is removed and
inspected for intact tissue rings from the esophagus and
the jejunum.
The anastomosis is inspected for hemostasis, and the
defect of the EEA device in the jejunum is closed with a
TA stapler.
A nasogastric tube may then be placed with the
surgeon's guidance through the anastomosis and may be
used to test for anastomotic integrity after the operative
field has been filled with saline. The absence of bubbling
after air insufflation of the anastomosis suggests an
intact suture line.
Figure 6–19A, B: Completion of Roux-en-Y reconstruction.
The completed esophagojejunal anastomosis is shown

(Figure 6–19A).
Intestinal continuity is restored by an end-to-side
enteroenterostomy, approximately 50 cm distal to the
esophagojejunal anastomosis (Figure 6–19B). The
mesenteric defect is closed to prevent internal
herniation.
Figure 6–17A
Figure 6–17B, C
Figure 6–18
Figure 6–19A–B
Lymph Node Distribution for Gastric Cancer: Figure 6–20
Figure 6–20
For a potentially curative resection of gastric cancer, en bloc
resection of the lymph node groups draining the primary
tumor should also be performed. This should include
omental, pyloric, and lesser curvature lymph nodes.
For lesions of the proximal stomach and along the greater
curvature, splenectomy should also be considered to include
the splenic hilar nodes.
For adequate TNM staging, a minimum of 15 lymph nodes
must be excised and examined histopathologically before
assigning an exact N-classification.
Anatomic gastric nodal groups have been described as:
N1 (lesser and greater curvature perigastric nodes).

N2 (splenic, left gastric, celiac axis nodes).
N3 (distant hepatoduodenal and root of mesentery
nodes).
N4 (distant aortic and middle colic areas).
Gastric resection has been classified as:
D0: Removal of involved stomach and less than all

relevant N1 nodes.
D1: Removal of involved stomach or the entire stomach,
complete omentectomy, and all N1 lymph nodes (safe
standard).
D2: Excision of omental bursa along with the front leaf
of the transverse mesocolon, and removal of all N1 and
N2 lymph nodes; splenectomy is also required.
D3: Resection of above structures, as well as N3 and N4
nodes.
More radical surgery (beyond D1) has not been shown to
increase survival in western countries and may lead to higher
complication rates.
Postoperative Care
Nothing by mouth.
Monitoring for return of bowel function.
Early nutritional support.
Parenteral or jejunal feedings are not routinely

necessary but may be considered for delayed bowel
function or delayed emptying.
Postgastrectomy diet (six or more small meals daily,
high protein, low carbohydrate, decreased liquids with
meals).
Early
Complications from general anesthesia.

Wound infection.
Anastomotic leak.
Bleeding.
Subphrenic or intra-abdominal abscess and peritonitis.
Early dumping syndrome.
Acute afferent loop syndrome.
Rupture of duodenal stump.
Late
Late dumping syndrome.

Obstruction.
Marginal ulcer disease (in jejunum no more than 2 cm from
gastrojejunal anastomosis).
Pernicious anemia (caused by vitamin B12 deficiency).
Alkaline reflux gastritis.
Chronic afferent and efferent loop syndromes.
Pearls and Tips
The extent of gastric resection required is determined by the

ability to obtain microscopic disease-free margins.
For distal gastrectomy, the dissection ends halfway between
the pylorus and the esophagogastric junction, sparing the left
gastroepiploic artery and short gastric vessels.
For subtotal resection, the left gastroepiploic artery and a
portion of the short gastric vessels are divided.
For total gastrectomy, the dissection includes the right and
left gastroepiploic arteries, and the right and left gastric
vessels.
In western countries, extensive lymph node resection for
gastric cancer has not been shown to increase survival rates
and may have more complications. A D1 resection is
considered a safe standard in the United States.
References
Ajani J, Bekalii-Saab T, D'Amico TA, et al. Gastric Cancer. In:

NCCN Practice Guidelines in Oncology, v.1.2006. Available at:
http://www.nccn.org/professionals/physician_gls/PDF/gastric.pdf.
Bell RH Jr, Rikkers LF, Mulholland MW, eds. Digestive Tract

Surgery. Philadelphia, PA: Lippincott-Raven Publishers; 1996.
Braasch JW, Sedgewick CE, Veidenheimer MC, Ellis FH Jr, eds.

Atlas of Abdominal Surgery. Philadelphia, PA: WB Saunders;
1991.
Sabiston DC Jr, ed. Atlas of General Surgery. Philadelphia, PA:

WB Saunders; 1994.
Zinner MJ, Schwartz SI, Ellis H, eds. Maingot's Abdominal

Operations. Stamford, CT: Appleton & Lange; 1997.


Current Procedures: Surgery > Chapter 7. Surgery of the

Hiatus >
Indications
Laparoscopic and Open Nissen Fundoplication
Evidence of gastroesophageal reflux disease (GERD) plus:
Sequelae of GERD refractory to medical therapy (eg,

esophageal strictures, Barrett's esophagus, recurrent
aspiration, or pneumonia).
Persistent reflux symptoms despite maximal medical
therapy.
Paraesophageal hernia.
Laparoscopic and Open Paraesophageal Hernia Repair
Objective evidence of paraesophageal herniation.

Many patients are asymptomatic and a large number of
cases are found incidentally.
Contraindications
Absolute
Inability to tolerate general anesthesia.
Uncorrectable coagulopathy.
Relative
Numerous previous abdominal operations (for

laparoscopy).
Previous esophageal or hiatal surgery (for laparoscopy).
For morbidly obese patients with GERD, consider bariatric
surgery rather than Nissen fundoplication.
Informed Consent
Expected Benefits
Approximately 80–90% long-term control of reflux

symptoms.
Cessation of medical antireflux therapy may be possible
postoperatively.
Treatment of extraesophageal reflux symptoms such as
aspiration.
Potential Risks
Esophageal perforation and splenic injury (< 1% of

patients).
Wrap migration into the chest (up to 10% of patients).
Dysphagia (common early in the postoperative period but
diminishes over time; 10–15% of patients experience
occasional mild dysphagia in the first few weeks after the
operation but only 1–2% require esophageal dilation).
Excess gas and bloating (common), which usually resolve
with time.
Conversion from laparoscopic to open fundoplication
(occurs < 5% of the time).
Expected Benefits
Prevention of strangulation, volvulus, incarceration,

bleeding, and perforation of the herniated stomach.
Many patients with paraesophageal hernias also have a
defective lower esophageal sphincter; therefore, an
antireflux procedure or fundoplication is also typically
performed at the time of operation with the expected
benefits listed earlier.
Potential Risks
Mortality rate of up to 50% for patients presenting with

acute surgical emergencies related to the hernia; this
occurs in up to 17% of patients with paraesophageal
hernias.
Conversion from laparoscopic to open repair
(approximately 3–5%).
Surgical complications include:

Bleeding.
Injury to the esophagus and stomach.
Early disruption of the repair, with recurrence rates
as high as 20–40%.
Complication rates vary widely from 2–17%.
Equipment
Laparoscopic instrument set including:

Straight (0 degree) and angled laparoscopes (30 or
45 degree).
Atraumatic liver retractor.
Atraumatic grasping instruments.
Bipolar or monopolar electrosurgical devices.
Ultrasonic dissector.
General instrumentation set in case of conversion to open
procedure.
Patient Preparation
A 24-hour pH test is the gold standard to confirm the

presence of gastroesophageal reflux but is not mandatory
in patients with esophagitis and typical symptoms
(heartburn, regurgitation).
Before surgery, all patients should undergo upper
endoscopy to rule out Barrett esophagus and malignancy.
Esophageal manometry is required in all patients
preoperatively to rule out severe motility disorders (eg,
achalasia or scleroderma).
An upper gastrointestinal contrast study may be useful to
define the anatomy in patients with hiatal hernia.
All patients should have a barium esophagram for

diagnosis and anatomic delineation.
Upper endoscopy is necessary to rule out malignancy.
This often demonstrates a second orifice adjacent to

the gastroesophageal junction, with gastric rugae
ascending into the hernia upon retroflexion in the
stomach.
Anatomic distortion of the stomach may make it
difficult to identify and cannulate the pylorus.
Symptomatic patients may undergo 24-hour pH
monitoring and esophageal manometry, although some
degree of dysmotility is common in patients with long-
standing paraesophageal herniation.
A thorough cardiopulmonary workup should be completed
for all patients.
Patient Positioning
After induction of general anesthesia and endotracheal

intubation, the patient is placed supine with legs abducted
or in modified lithotomy position.
Placing the table at about 30 degrees reverse
Trendelenburg further optimizes patient positioning and
exposure of the esophageal hiatus.
Figure 7–1A, Figure 7–1B: The surgeon stands
between the patient's abducted legs, and the assistant
usually stands to the patient's left side.
Video monitors are positioned at the head of the table.
A nasogastric or orogastric tube is inserted for gastric
decompression.
Figure 7–1A
Figure 7–1B
Procedure
An open or closed technique may be used to access the

peritoneal cavity.
Port placement for laparoscopic Nissen fundoplication
(Figure 7–1A):
A 10-mm camera port is placed midline, typically

above the umbilicus.
A 5- or 10-mm port is placed midline below the
xiphoid for insertion of the liver retractor.
A 5-mm port and a 10-mm port are placed below the
right subcostal margin and left upper epigastrium,
respectively. These will function as the surgeon's
working ports.
A 5-mm assistant's port is placed in the left anterior
axillary line, just below the costal margin.
If laparoscopy is not feasible, a midline incision is
made extending from the xiphoid to the umbilicus
(Figure 7–1B).
Figure 7–2: Appropriate retraction is obtained on the left
lobe of the liver to expose the gastrohepatic ligament; the
stomach is retracted caudally and to the left.
Hiatal exposure is begun by dividing the

gastrohepatic ligament just superior to the hepatic
branch of the vagus nerve.
An accessory left hepatic artery may accompany the
hepatic branch of the vagus nerve in up to 12% of
patients and should be preserved or, if necessary,
divided between surgical clips.
The gastrohepatic ligament is divided up to the level
of the right crus of the diaphragm.
Figure 7–3: The phrenoesophageal and phrenogastric
attachments (hiatus sling fibers) are then carefully
released.
During this dissection, the anterior vagus nerve is

identified running along the anterior surface of the
esophagus.
As the hiatus sling fibers are dissected free, the
caudate lobe of the liver, the right crus of the
diaphragm, and the esophageal hiatus should be
exposed.
Mobilization of the right side of the esophagus is first
begun by establishing a plane between the right crus
and the esophagus with blunt dissection.
While right lateral retraction is maintained on the
right crus, the esophagus and paraesophageal tissues
are gently swept to the left.
As the distal esophagus is mobilized, the posterior
vagus nerve is identified and is swept along with the
esophagus to the left.
The dissection should allow for mobilization of the
esophagus in a cephalad direction as far as possible,
and caudally to the decussation of the crura.
Figure 7–4: Once the right side of the esophagus is
adequately mobilized, attention is directed to mobilizing
the left side of the esophagus.
The left diaphragmatic crus is freed from the

phrenoesophageal attachments. This maneuver
creates a retroesophageal window that allows for
posterior dissection of the esophagus.
The gastrosplenic ligament or spleen, or both, should
be seen from the right side as adequate posterior
dissection is completed.
The remainder of the retroesophageal dissection (and the
mediastinal dissection) is performed after mobilization of
the stomach.
The entire fundus is mobilized using ultrasonic dissection
to divide the short gastric vessels, beginning
approximately 10 cm from the angle of His and extending
up to the left crus.
The posterior attachments between the stomach and
pancreas are then divided to complete the mobilization of
the fundus.
With adequate posterior dissection, the caudate lobe
should be visible from the left side.
Once this mobilization is complete, a Penrose drain is
placed around the esophagus to help with retraction
during the mediastinal dissection.
Dissection of the esophagus into the mediastinum is
performed, which will ultimately lengthen the abdominal
portion of the esophagus.
The distal portion of the esophagus should be at least 3
cm long without tension. If the length of the esophagus
below the diaphragm is < 3 cm, an esophageal
lengthening procedure, such as a Collis gastroplasty,
should be performed.
Careful attention is made in identifying the vagus nerves,
and more importantly the left pleura, which can be
inadvertently injured during this dissection.
Figure 7–5: This diagram shows the exposure of the
hiatus as seen during an open Nissen fundoplication.
As the distal esophagus is mobilized, the short gastric
vessels are divided with the ultrasonic dissector to
free the gastric fundus.
Upon mobilization of the distal esophagus and gastric
fundus, a Penrose drain is passed through the
retroesophageal window and around the esophagus.
The Penrose drain is then used to apply caudal left
lateral as well as anterior traction on the esophagus
to expose the origin of the diaphragmatic crura at the
hiatus.
Figure 7–6: The hiatal defect is subsequently repaired by
placing interrupted, nonabsorbable sutures to
reapproximate the crura posterior to the esophagus.
In the case of a large hiatal hernia, mesh cruroplasty

may reduce the risk of wrap herniation.
Figure 7–7: The mobilized gastric fundus is then brought
through the retroesophageal window.
Figure 7–8: Atraumatic graspers are used to pass the
gastric fundus behind the esophagus from the left to the
right.
The fundoplication should remain in place without

being held; otherwise further mobilization may be
required to release tension on the wrap.
Without adequate mobilization, the lower esophagus
will twist under tension from the fundoplication.
At this point, a bougie dilator should be carefully
placed by the anesthetist to create a "floppy"
fundoplication, reducing the risk of postoperative
dysphagia. A 56 French bougie is used for women
and a 60 French bougie for men.
Figure 7–9A, B: The 360-degree fundoplication is
created.
The length of the wrap should be no more than 2 cm

on the lower esophagus.
The wrap should be created in a tension-free manner
using nonabsorbable sutures.
Deep seromuscular bites of the fundus should be
taken, approximating the leading edge of the
wrapped fundus to the gastric fold right of the
esophagus. Sutures should also incorporate the
anterior esophageal wall to anchor the wrap and
prevent slippage (Figure 7–9A).
Some surgeons may choose to place an additional
anchoring suture to the crura as shown in Figure 7–
9B.
With the wrap completed, the liver retractor is removed,
and the liver is examined for injury.
The abdomen is examined carefully to ensure hemostasis
and rule out occult bowel injury.
The ports are then removed under direct vision, and
pneumoperitoneum is released.
The fascia of any port sites larger than 5 mm should be
closed with sutures. Midline incisions are closed in
standard fashion.
Figure 7–2
Figure 7–3
Figure 7–4
Figure 7–5
Figure 7–6
Figure 7–7
Figure 7–8
Figure 7–9
Figure 7–10
Paraesophageal hernia constitutes approximately 5% of

all hiatal hernias.
Type III: the most common type of paraesophageal

hernia (approximately 85%), involving herniation of
both the fundus and the gastroesophageal junction
into the mediastinum.
Type II: only the fundus herniates through the
diaphragm while the gastroesophageal junction
remains in the abdomen.
Paraesophageal hernia repair can be divided into four
major components:
Exposure of the hiatus and hernia reduction.

Dissection of the diaphragmatic crura and excision of
the hernial sac.
Repair of diaphragmatic crura.
Fundoplication.
Port placement for the procedure is similar to that for
laparoscopic Nissen fundoplication (see Figure 7–1A, B).
Figure 7–10: A liver retractor is placed to retract the left
lobe of the liver.
The herniated viscera should be visible and is

reduced into the abdomen using atraumatic graspers.
If extensive adhesions are encountered, meticulous
sharp dissection should be used to mobilize
structures.
To further facilitate exposure of the hiatus, the
gastrohepatic ligament should be divided, being wary
of the possible presence of an aberrant hepatic
artery.
Once the stomach has been reduced, the hernial sac
should be visible anterior to the esophagus.
To avoid injury to the lesser curvature vessels, which
may lie close to the right crus, dissection of the
hernial sac begins at the left crus.
The sac is divided sharply away from the crus and
opened anteriorly, taking care to avoid injury to the
anterior vagus and esophagus.
Figure 7–11: Once an avascular plane has been
identified, the peritoneal sac is bluntly dissected away
from the mediastinal fascia and completely reduced into
the abdomen, ending with its attachments to the right
crus.
Care must be taken to avoid injury to the pleura. If
pleural injury does occur, a red rubber catheter can be
inserted into the pleural cavity from the abdomen in order
to equalize the pressure and reduce the risk of tension
capnothorax.
Unless the sac is especially bulky, it does not need to be
divided from its attachments at the gastroesophageal
junction.
Once the sac has been reduced, the esophagus is freed
from its mediastinal attachments in order to reduce the
distal esophagus into the abdomen.
Mobilization of the fundus by division of the short gastric
vessels may facilitate access to the retroesophageal
space. Once this space has been developed, a Penrose
drain is looped around the esophagus (see Figure 7–6) to
give gentle anterior traction allowing for exposure
posterior to the esophagus.
Blunt and sharp dissection with the ultrasonic dissector is
then used to divide the posterior attachments to the
esophagus.
Care must be taken to avoid injury to the esophagus
and posterior vagus nerve.
The hiatus should be well exposed and both leaflets
of the crura should be clearly visible upon completion
of the posterior esophageal dissection.
If at least 3 cm of distal esophagus cannot be reduced
without tension into the abdomen, an esophageal
lengthening procedure, such as a stapled-wedge
gastroplasty, should be performed.
Figure 7–12: The crural defect is generally repaired
posteriorly with several interrupted nonabsorbable
sutures. The size of the defect determines the number of
sutures needed.
The surgeon should be aware of the close medial

location of the aorta during the repair.
If the crural leaflets are thin, pledgeted sutures are
indicated to reduce the risk of tearing.
Bites of the crura that are at least 1 cm or larger
should be taken.
Reinforcement of the closure by anchoring mesh to
the posterior crura may reduce the risk of hernia
recurrence; however, care must be taken to avoid
mesh erosion into the esophagus.
A 55–60 French bougie dilator can be passed with
extreme care to ensure that the repair is not too
tight.
Figure 7–13: If the short gastric vessels have not
already been divided, this should be done to mobilize the
fundus and ensure a tension-free fundoplication. A 2-cm
tension-free wrap is performed with interrupted
nonabsorbable suture to approximate the fundal folds.
Full-thickness bites of the stomach are incorporated with
an anchoring bite of the anterior esophagus.
Figure 7–14: A gastropexy may be performed, especially
if a fundoplication was not performed.
The superior fundus is anchored with interrupted

nonabsorbable suture to the crura and the
diaphragm.
The body of the stomach is then anchored to the
anterior abdominal wall, often with placement of a
gastrostomy tube.
After careful inspection of the crural repair and the
fundoplication, the ports are removed under direct
visualization.
The fascia of port sites 10 mm or larger are closed
with interrupted absorbable sutures.
Pneumoperitoneum is evacuated.
Midline incisions are closed in standard fashion if an
open procedure was performed.
Figure 7–11
Figure 7–12
Figure 7–13
Figure 7–14
Postoperative Care
Antiemetics should be administered to prevent early

postoperative vomiting as this can lead to disruption of
the crural closure and migration of the wrap into the
chest.
Clear liquids are allowed postoperatively and a soft diet
on postoperative day 1. Patients are maintained on a soft
diet for 2–4 weeks as perifundoplication edema can
narrow the esophagus in the early postoperative period.
If pain is more than expected, or the patient vomits in the
early postoperative period, a water-soluble contrast
swallow study should be obtained to evaluate for
disruption of the wrap or unrecognized visceral injury.
Patients should avoid heavy lifting for 4–6 weeks following
the operation.
Postoperative chest radiographs are not routine but

should be obtained if significant mediastinal dissection
was required.
Nasogastric decompression is not necessary.
Clear liquids are allowed postoperatively and a soft diet
on postoperative day 1, if tolerating liquids well. Patients
are maintained on a soft diet for the first 2–4 weeks as
edema-related dysphagia is common in the early
postoperative period.
If pain is more than expected, or the patient vomits in the
early postoperative period, a water-soluble contrast
swallow study should be obtained to evaluate for
disruption of the wrap or unrecognized esophageal and
gastric injury.
Patients should avoid heavy lifting for 4–6 weeks following
the operation.
Pleural injury and pneumothorax.

Esophageal and gastric perforation.
Splenic injury.
Wrap disruption or intrathoracic migration (Nissen
fundoplication).
Early disruption of repair (paraesophageal hernia repair).
Pearls and Tips
To prevent esophageal injury, perform careful

circumferential dissection of the esophagus under direct
vision. Do not directly grasp the esophagus and avoid use
of thermal energy when close to the esophagus.
Take care to identify and avoid injury to the anterior and
posterior vagus nerves.
A minimum of 3 cm of esophagus must rest within the
abdomen without tension.
Be prepared to perform an esophageal lengthening

procedure in the event of a shortened esophagus.
The hernial sac must be completely reduced from the
mediastinum to help avoid recurrence.
Consider mesh reinforcement of the crural closure to
reduce risk of recurrence.
Use caution during dissection to avoid injury to the
pleura, esophagus, and vagus nerves.
Carefully monitor airway pressures and end-tidal CO2 and
have a low index of suspicion for unrecognized pleural
injury.
References
DeMeester TR, Bonavina L, Albetucci M. Nissen fundoplication

for gastroesophageal reflux disease: evaluation of primary
repair in 100 consecutive patients. Ann Surg. 1986;204:9–20.
Edye MB, Canin-Endres J, Gattorno F, Salky BA. Durability of

laparoscopic repair of paraesophageal hernia. Ann Surg.
1998;228:528–535.[PubMed: 9790342] [Full Text]
Frantzides CT, Carlson MA. Laparoscopic versus conventional

fundoplication. J Laparoendosc Surg. 1995;5:137–143.
Peters JH, DeMeester TR, Crookes P, et al. The treatment of

gastroesophageal reflux disease with laparoscopic Nissen
fundoplication: prospective evaluation of 100 patients with
"typical" symptoms. Ann Surg. 1998;228:40–50.[PubMed:
9671065] [Full Text]
Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic

paraesophageal hernia repair. Arch Surg. 1997;132:586–589.


Current Procedures: Surgery > Chapter 8. Emergency

Operations for Peptic Ulcer Disease >
Indications
General
Duodenal or gastric ulcer.

Bleeding.
Perforation.
Vagotomy for Bleeding Duodenal Ulcer
With current antacid therapies, indications have

become more selective.
Chronic ulcers that are Helicobacter pylori—

negative and have failed medical therapies.
NSAID dependence or noncompliance.
Previous H pylori treatment failure.
Previous ulcer complication.
Contraindications
Absolute

Uncorrectable coagulopathy.
Relative
Factors that may influence the aggressiveness of the

surgical procedure:
Age.
Preexisting comorbidities.
Shock.
Delay in diagnosis.
Large ulcer size.
Noncompliance with medical therapy or risk factor
modification.
Previous H pylori treatment failure.
Failed vagotomy and drainage procedure.
Informed Consent
Expected Benefits
Control of bleeding and repair of perforation may be

accomplished by various surgical options; however,
with current antacid medication and triple-therapy
treatment of H pylori, the surgical options are routinely
less radical.
Historically ulcer recurrence is < 2% for vagotomy and
antrectomy, and 10% for vagotomy and pyloroplasty.
Triple therapy eradicates H pylori in 90% of patients
completing therapy.
Potential Risks
Recurrent ulceration.
Pancreatitis.
Leak.
Wound infection, intra-abdominal abscess.
Dumping syndrome.
Equipment
General instrumentation set.

Laparoscopic instrument set including 10-mm 30-
degree laparoscope; 5-mm, 10-mm, and 15-mm ports;
5-mm needle holder; 5-mm atraumatic grasper; and
clip applier.
Gastrointestinal anastomosis (GIA) stapler.
Patient Preparation
Fluid and electrolyte resuscitation.

Nasogastric suction or Ewald gastric lavage tube as
necessary.
Systemic antibiotics.
For bleeding ulcers, surgery is generally preceded by
previous attempts at endoscopic therapies.
Performance of initial endoscopy within 24 hours of

bleeding has been associated with improved
outcome.
Risk of rebleeding after endoscopic therapy is 10–
30%.
Endoscopic retreatment has a success rate of 50–
70%.
Failure of endoscopic therapy has been associated
with advanced age, large ulcer, active hemorrhage,
and hypotension.
For perforated ulcers, diagnosis is made by history,
physical examination, and radiographic imaging
demonstrating free air or fluid. Risk factors associated
with operative mortality include medical comorbidities,
preoperative shock, and long-standing perforation (>
48 hours).
Patient Positioning
After induction of general anesthesia and endotracheal

intubation, the patient is placed supine.
Procedure
Perforated Duodenal Ulcer
Open Graham Patch
Figure 8–1: The right upper quadrant may be

accessed through an upper midline incision.
The lesser curvature of the stomach is followed to

the pylorus. The perforation is usually along the
anterior wall of the duodenum. If this is not the
site, the remaining anterior stomach, intra-
abdominal esophagus, and lesser sac are explored.
Three or four nonabsorbable sutures are placed
through the edge of the defect, approximately
0.5–1.0 cm from the edge of the perforation. The
suture line should start and stop 0.5 cm from the
apices of the perforation.
The stitch is brought through the wall on one side
and the needle tip should pass through the
perforated defect and through the contralateral
wall. These stitches should be left untied. All
sutures should be placed before being tied.
Figure 8–2: Adjacent omentum is placed over the
perforation site.
The sutures are tied to secure the omental patch

in place. It is important that the stitches secure
the patch in place, without causing ischemia.
It is not necessary for the ulcer to be sewn shut.
The abdomen is copiously irrigated with a large
volume of warm saline.
Figure 8–1
Figure 8–2
Laparoscopic Graham Patch
The patient is placed supine with arms abducted.

A 10-mm infraumbilical port is inserted and a 10-mm
laparoscope is introduced. The patient is placed in
reverse Trendelenburg position.
Once the perforation is identified, a 5-mm port may be
inserted on the patient's right and a 15-mm port on the
left abdomen, approximately 20 cm from the site of
perforation. These ports serve as the working ports.
Three 2-0 Vicryl sutures cut to 30 cm are used for
intracorporeal suturing. The sutures are placed in the
same manner as previously described for open repair,
starting with the most inferior stitch.
Each stitch should be taken in two bites to ensure that
an adequate amount of tissue is taken on each side of
the perforation.
The suture ends are held by a single metal clip to form
a loop. The needles are cut and removed. In a similar
manner, the most superior stitch is placed.
The middle suture is inserted last to avoid crossing of
the sutures under the perforation. The ends are not
clipped.
The patient is placed in Trendelenburg position and a
tongue of omentum is positioned over the perforation
without tension.
The uppermost stitch is tied first using intracorporeal
knot tying.
The patient is repositioned in reverse Trendelenburg
position and the remaining two stitches are secured.
The peritoneal cavity is copiously irrigated with warm
saline.
Bleeding Duodenal Ulcer
Oversewing of a Bleeding Ulcer
Figure 8–3: Access to the right upper quadrant is

obtained through an upper midline incision.
A Kocher maneuver is performed for mobilization

of the duodenum.
The pyloric vein may be used as a landmark of the
pylorus.
Two 2-0 silk stay sutures are placed at the 3
o'clock and 9 o'clock positions adjacent to the
planned duodenotomy to aid exposure of the
posterior wall.
A longitudinal incision is made on the anterior
surface of the duodenum.
When an actively bleeding ulcer is identified,
digital pressure may be used to control of
bleeding.
The most likely source of bleeding is posterior
duodenal erosion into the gastroduodenal complex,
involving the gastroduodenal artery and the
transverse pancreatic branch.
Figure 8–4: Three U-stitches of 2-0 silk suture are
placed to control the gastroduodenal artery proximally
and distally and to include the transverse pancreatic
branch medially. It is important to identify the common
bile duct prior to placing these stitches.
Figure 8–3
Figure 8–4
Truncal Vagotomy and Pyloroplasty
Pyloroplasty.
Two 2-0 silk stay sutures are placed superior and

inferior to the pylorus.
A 2-cm longitudinal incision is made on each side
of the pylorus through all layers of the anterior
wall using electrocautery.
The duodenum and stomach can be explored
through this incision. Oversewing of the bleeding
ulcer is performed as described earlier.
The longitudinal incision is then closed transversely
in a Heineke-Mikulicz fashion in one layer with full-
thickness interrupted 3-0 silk sutures.
Truncal vagotomy.
After the pyloroplasty has been completed, the left
lobe of the liver is retracted away from the
esophageal hiatus.
Downward traction on the greater curvature of the
stomach may aid exposure.
The diaphragmatic peritoneal covering is incised
transversely and, using blunt dissection, the
esophagus is dissected circumferentially. The
esophagus should be dissected 5 cm above the
gastroesophageal junction to fully identify all vagal
branches.
The anterior vagal trunk is located anterior to the
esophagus between the 12 o'clock and 2 o'clock
positions and is usually closely adherent to the
esophagus.
The posterior vagal trunk is located between the 6
o'clock and 8 o'clock positions. It is usually some
distance from the esophagus and thus is more
difficult to identify.
Once both nerves are identified, they should be
dissected free. Medium clips are placed
approximately 2 cm apart and the nerves are
divided. The nerves should be sent for histologic
confirmation.
The lower 5 cm of the esophagus should then be
cleared of all nerve fibers. If the hiatus admits two
or more fingers, a cruroplasty should be performed
with 0 silk suture to narrow the hiatus to the size
of 1 fingerbreadth.
Gastric Ulcers
Figure 8–5A-C, Figure 8–5D: Classification of gastric

ulcers.
Type I: most common; occurs along lesser
curvature, usually at the incisura angularis.
Type II: usually two ulcers, in the body of the
stomach and in the duodenum.
Type III: prepyloric.
Type IV: least common; occurs high on the lesser
curvature near the gastroesophageal junction.
Types I, IV: not related to acid production.
Types II, III: related to acid hypersecretion.
Unstable patient.
In an unstable patient with a bleeding gastric ulcer,

an anterior gastrotomy with oversewing of the
ulcer is acceptable. Biopsy specimens of the ulcer
should be obtained for pathologic examination and
histologic H pylori confirmation.
Perforated gastric ulcers in unstable patients may
be managed with a Graham patch.
Aggressive postoperative anti-acid therapies
should be administered.
Stable patient.
Bleeding or perforated type II or III gastric ulcer

may be managed using antrectomy with truncal
vagotomy and Billroth I or II reconstruction.
Antrectomy with Billroth I or II reconstruction and
medical therapy with proton pump inhibitors
postoperatively is also acceptable.
Bleeding or perforated type I gastric ulcers may be
managed using distal gastrectomy with Billroth I or
II reconstruction. There is no need for vagotomy.
Bleeding type IV gastric ulcers may be managed
using gastrotomy with oversewing of the ulcer.
Recurrent or perforated type IV ulcers may require
resection of the gastric antrum and body up to the
gastroesophageal junction and reconstruction with
a Roux-en-Y limb of jejunum (Csendes procedure).
Figure 8–5A–C
Figure 8–5D
Truncal Vagotomy and Antrectomy
A truncal vagotomy is usually performed after the

gastrectomy and reconstruction has been completed.
The procedure is reviewed earlier.
To perform an antrectomy, a supraumbilical midline
incision is used.
A Kocher maneuver is performed to assess the

suitability of the duodenum for anastomosis.
The lesser sac is entered through division of the
gastrocolic ligament at the middle of the greater
curvature of the stomach.
The posterior wall of the stomach is inspected. The
gastrocolic ligament is then divided close to the
gastric wall for a short distance in preparation for
subsequent resection and anastomosis.
The dissection is carried along the greater
curvature of the stomach toward the duodenum.
The right gastroepiploic vessels are identified and
divided close to their origin from the
gastroduodenal artery.
The dissection is then carried along the lesser
curvature of the stomach. The right gastric artery
can be identified at the superior border of the
proximal duodenum. It should be divided close to
the duodenal wall.
The duodenum is divided using a GIA stapler.
The stomach is divided using the GIA stapler at
approximately a 45-degree angle from the lesser
curvature. We prefer to oversew the staple line
with 3-0 silk Lembert sutures. A short segment of
the staple line toward the greater curvature is
preserved for the anastomosis.
Figure 8–6A: Billroth I anastomosis.
A Billroth I reconstruction can be attempted if the

duodenal stump is not inflamed and is mobile
enough to permit a tension-free anastomosis.
Two 3-0 silk stay sutures are placed through the
lesser curvature of the stomach to the
antimesenteric duodenal wall, and similarly
through the greater curvature of the stomach to
the medial duodenal wall.
A row of 3-0 silk stay sutures is then placed in the
posterior wall of the anastomosis.
The gastric and duodenal anastomotic staple lines
are removed using electrocautery.
A 3-0 double-armed Vicryl suture is used for a
continuous running inner layer.
To complete the double-layer anastomosis, the
anterior wall is then reinforced using interrupted 3-
0 silk sutures. The stay sutures are also tied.
Figure 8–6B: Billroth II anastomosis.
If there is concern about excessive inflammation or

scarring of the duodenum, or if it appears that a
Billroth I reconstruction would be under tension, a
Billroth II reconstruction can be performed.
We prefer to oversew the duodenal staple line with
interrupted 3-0 Lembert silk suture, provided it
does not cause additional ischemia.
The first or second portion of the jejunum is
mobilized and placed in a retrocolic fashion
opposite the greater curvature of the stomach. The
jejunum may be placed in an isoperistaltic or
antiperistaltic fashion. Two 3-0 silk stay sutures
placed at the ends help to align the stomach and
jejunum.
Interrupted 3-0 silk sutures are placed along the
posterior gastric wall to the antimesenteric border
of the jejunum.
The equal length anastomotic staple lines are
removed using electrocautery.
A 3-0 double-armed Vicryl suture is used for a
continuous running inner layer. The anterior wall is
then reinforced using interrupted 3-0 silk sutures.
The stay sutures are tied.
The anastomosis is then delivered beneath the
transverse mesentery and is secured in this
position with sutures from the mesentery to the
gastric wall.
Figure 8–6A
Figure 8–6B
Csendes Procedure
Type IV gastric ulcers are typically within 2 cm of the

gastroesophageal junction and are not associated with
a high-acid environment. Resection of this lesion
therefore involves resection of the lesser curvature of
the stomach with preservation of much of the greater
curvature of the stomach.
Reconstruction after resection of the lesser curvature
poses a problem in that the standard
gastrojejunostomy would narrow the distal esophagus.
Figure 8–7A, B: The initial part of this procedure is as
described earlier for an antrectomy. However the line of
resection extends along the lesser curvature up to the
esophagus.
A Roux-en-Y jejunal loop is created and brought up

in an antecolic fashion.
The jejunum is anastomosed to the entire opening
in the stomach, including the opening in the distal
esophagus. This enlarges the circumference of the
distal esophagus.
Figure 8–7A–B
Postoperative Care
All patients with complicated duodenal or gastric ulcers

should undergo workup for H pylori by serum, fecal
testing, urease testing, or biopsy. Those who are
positive for H pylori should undergo 14 days of triple
therapy. Endoscopy may be performed 4–6 weeks post-
procedure to document ulcer response to therapy.
All patients with duodenal, type II, or type III gastric
ulcers should receive aggressive anti-acid
pharmacologic therapies with proton pump inhibitors or
H2 blockers.
NSAIDs should be avoided when possible. The synthetic
prostaglandin analogue misoprostol decreases the
incidence of recurrent bleeding when NSAIDs cannot be
discontinued.
Generally, the nasogastric tube may be left in place
until the output is < 1 L/day. Subsequently the diet
may be advanced accordingly. Postvagotomy patients
are not routinely placed on antidumping diets.
If the patient continues to have severe pain, fevers, or
persistent gastric ileus, CT scan with oral contrast
should be considered to evaluate for leak or undrained
abscess. Alternatively, a water-soluble upper
gastrointestinal contrast study may be performed to
evaluate for an anastomotic leak.
Anastomotic leak.
Duodenal leak.
Injury to the common bile duct.
Bleeding (splenic injury or suture line bleeding).
Postsurgical gastroparesis.
Gastric outlet obstruction.
Small bowel obstruction after Billroth II reconstruction
(migration of the jejunal limbs above the transverse
mesentery).
Dumping syndrome.
Afferent loop syndrome, intussusception.
Cancer in the gastric remnant.
Pearls and Tips
Graham Patch
Do not attempt to approximate the edges of the

perforation with sutures. If the tissue is friable, this
may cause more damage. In addition, the omental
patch is more secure when applied to the open defect.
When performing this procedure laparoscopically, place
the inferior stitch first as this will help serve as a point
of retraction.
Oversewing of a Duodenal Ulcer
It is important to identify the course of the common

bile duct as it passes under the first and second
portions of the duodenum. If necessary the ampulla
may be probed with a silver tip probe to identify the
structure as the hemostatic stitches are placed.
Truncal Vagotomy and Pyloroplasty
Avoid repetitive entrances and exits of hands, drains,

and instruments around the gastroesophageal junction
to prevent inadvertent injuries.
Downward traction on the stomach with the surgeon's
hand may be more effective that the use of a Penrose
drain.
Initial identification of the posterior vagus nerve may
be made more effectively by palpation than by
visualization.
Truncal Vagotomy and Antrectomy
Careful attention to identification the portal triad is

important when performing an antrectomy as these
structures may be injured inadvertently during the
resection.
If closure of the duodenal stump is difficult or
precarious, a catheter duodenostomy may be
employed. A T tube may be placed through a separate
opening in the duodenal wall and secured with two
purse-string sutures. An additional drain may be placed
in the area. Both tubes are then brought out through
the abdominal wall.
References
Fischer J, Bland K, Callery M, et al, eds. Mastery of

Surgery, 5th ed. Philadelphia, PA: Lippincott, Williams, &
Wilkins; 2006.
Lam P, Lam M, Hui E, et al. Laparoscopic repair of

perforated duodenal ulcers. Surg Endosc. 2005;19:1627–
1630.[PubMed: 16247576] [Full Text]
Millat B, Fingerhut A, Borie F. Surgical treatment of

complicated duodenal ulcers: controlled trials. World J
Surg. 2000;24:299–306.[PubMed: 10658064] [Full Text]
Millat B, Hay JM, Valleur P, et al. Emergency surgical

treatment for bleeding duodenal ulcer: oversewing plus
vagotomy versus gastric resection, a controlled randomized
trial. World J Surg. 1993;17:568–574.[PubMed:
Rokkas T, Karameris A, Mavrogeorgis A, et al. Eradication
of Helicobacter pylori reduces the possibility of rebleeding
in peptic ulcer disease. Gastrointest Endosc. 1995;41:1–4.


Current Procedures: Surgery > Chapter 9. Surgical

Therapies for Morbid Obesity >
Indications
Body mass index (BMI) > 40.

BMI between 35 and 40 and presence of such comorbid
conditions as severe obstructive sleep apnea, pickwickian
syndrome, obesity-related cardiomyopathy, degenerative
joint disease, diabetes mellitus, hypertension, and
hyperlipidemia.
Failed dietary attempts at weight loss.
Contraindications
Absolute
Active substance abuse.

Severe psychiatric disorders.
Pregnancy.
Untreated esophagitis.
Relative
BMI < 35.

Age older than 60 years.
Desire to become pregnant within 2 years.
Informed Consent
Expected Benefits
Loss of 50–80% of excess weight.

Improvement of comorbid factors.
Potential Risks
Overall mortality < 1%.

Anastomotic leak (1%).
Anastomotic stricture (5–10%).
Wound complications (infection, hernia) more common
with open surgery (15–20%) than with laparoscopic
procedure (2–5%).
Systemic complications of major surgery (pneumonia,
venous thromboembolism, and cardiovascular events).
Equipment
Operating table capable to accommodate the morbidly

obese patient.
Extra-large sequential compression device (SCD)
stockings.
For laparoscopic surgery, video telescopic equipment with
two monitors and extra-long instruments (laparoscope,
graspers, staplers, ultrasonic dissector, suction/irrigator).
For gastric bypass procedure, end-to-end anastomosis
(EEA) stapler.
Patient Preparation
Upper endoscopy if indicated by symptoms (heartburn,

regurgitation, dysphagia, epigastric pain, anemia).
Right upper quadrant ultrasound to rule out cholelithiasis
if indicated by symptoms.
Cardiovascular evaluation.
Psychiatric evaluation.
Nutritionist evaluation.
Patient Positioning
Open Operation
The patient should be supine with arms abducted and

extended.
Laparoscopic Operation
The patient should be supine with arms abducted and

extended.
Split-leg position is preferable.
Contact and pressure points should be padded.
The patient must be well secured to the operating table.
Procedure
Roux-en-Y Gastric Bypass: Open and Laparoscopic
Figure 9–1: The typical port placement for a laparoscopic

approach.
Following port placement, the abdomen is explored.
The jejunum is divided approximately 30–40 cm from the
ligament of Treitz and the alimentary (Roux) limb is
tagged with Penrose drain.
Figure 9–2: Creation of a side-to-side stapled
enteroenterostomy 100–150 cm from the stapled end of
the alimentary limb.
The mesenteric defect is closed with permanent sutures.
The omentum is divided with an ultrasonic dissector.
A Nathanson liver retractor is used to elevate the left
lateral segment, exposing the proximal stomach.
The patient is placed into steep reverse Trendelenburg
position.
Peritoneal attachments between the diaphragm and the
cardia at the angle of His are bluntly divided.
The lesser omentum is incised at the pars flaccida portion
and divided up to the proximal lesser curvature with an
endoscopic stapler.
A gastrotomy is made in the body of the stomach with an
ultrasonic dissector. This will be closed with an endoscopic
stapler after anvil introduction.
The anvil from a 25-mm EEA stapler is introduced through
the 15-mm port site and inserted into the gastrotomy.
The anvil tip is brought out through the proximal
stomach, near the lesser curvature, between the first and
second lesser curvature vessels.
Figure 9–3: Creation of a lesser curvature—based
proximal gastric pouch with serial firings of the
endoscopic stapler.
The anvil is placed into the stomach via the

gastrotomy and pierced through the proximal gastric
wall.
The gastrotomy is then stapled, and a 30-mL gastric
pouch is created below the anvil.
The alimentary limb is brought into an antecolic,
antegastric position.
The stapled end of the alimentary limb is opened with the
ultrasonic dissector.
Figure 9–4: The 25-mm EEA stapler is introduced
through the 15-mm port site.
The stapler is inserted into the cut end of the

alimentary Roux limb and advanced 5–6 cm.
The stapler is opened with the spike exiting the
antimesenteric portion of the bowel and readied to
connect with the anvil in the gastric pouch.
Figure 9–5: The anvil and stapler are mated, taking care
that no extraneous tissue comes between the stomach
and bowel. The stapler is then fired and removed from the
abdomen, and the donuts are assessed for integrity.
The end of the alimentary limb is divided with an
endoscopic stapler and removed.
Figure 9–6: Final reconstruction results in a 100-cm
Roux limb for patients with a BMI < 50 or a 150-cm Roux
limb for patients with a BMI > 50. The distance between
the ligament of Treitz and the jejunojejunostomy will
similarly range from 30 cm to 100 cm depending on the
BMI of the patient.
Upper endoscopy is then performed to rule out an
anastomotic leak and to assess for hemostasis.
A 10-mm Jackson-Pratt drain is placed posterior to the
gastrojejunostomy and brought out through the right
lateral port site.
The fascia of the 15-mm port site is closed with
interrupted absorbable sutures.
Figure 9–1
Figure 9–2
Figure 9–3
Figure 9–4
Figure 9–5
Figure 9–6
Laparoscopic Adjustable Gastric Band
Figure 9–7: Laparoscopic port placement for gastric

band procedure.
A Nathanson liver retractor is used to elevate the left
lateral segment of the liver, exposing the proximal
stomach.
Attachments between the diaphragm and the cardia at
the angle of His are bluntly divided.
The gastroesophageal fat pad is excised with an ultrasonic
dissector.
The lesser omentum is divided with an ultrasonic dissector
beginning at the pars flaccida portion and extending
toward the diaphragm to expose the right crus.
The peritoneum overlying the right crus is incised at
approximately the level of the crural decussation.
A bowel grasper from the right lateral port is passed
posterior to the esophagogastric junction, emerging at the
angle of His.
The band is inserted into the abdomen through the 15-
mm port. The band tubing is pulled around the stomach
using the retrogastric grasper.
Figure 9–8: The band tubing is fed through the buckle
until the flanges are through and the band is locked. The
band should rotate easily around the stomach.
An anterior fundoplication is performed with
nonabsorbable suture. Interrupted gastrogastric sutures
are placed to cover the band, beginning at the leftmost
portion of the fundus and advancing toward the right.
Care must be taken to avoid tension and prevent any part
of the fundoplication from covering the buckle of the
band.
The band tubing is brought out through the 15-mm port
and secured. The liver retractor and remaining ports are
then removed and the abdomen is deflated.
The end of the tubing is removed and the tubing is mated
to the access port. The port is anchored to the anterior
rectus fascia lateral to the 15-mm port site with four
interrupted permanent sutures. The incision is then closed
in layers.
Figure 9–7
Figure 9–8
Postoperative Care
An upper gastrointestinal study with water-soluble

contrast is obtained on postoperative day 1 for the
following reasons:
To rule out obstruction or leak from the
gastrojejunostomy following Roux-en-Y gastric
bypass (open and laparoscopic).
To rule out perforation or obstruction.
To document pouch size and band position following
adjustable gastric band placement.
Early ambulation is encouraged.
Deep venous thromboembolism prophylaxis is provided
with sequential compression devices and unfractionated
or low-molecular-weight heparin.
The patient is discharged home on a full liquid diet for 2
weeks. The diet is advanced to pureed and then solid food
over the next 4 weeks.
Following Roux-en-Y gastric bypass, patients must remain
on lifelong supplementation with a multivitamin, calcium,
and vitamin B12. They receive a proton pump inhibitor
(PPI) for 3 months to prevent marginal ulceration and
ursodeoxycholic acid for 6 months to reduce the risk of
cholelithiasis.
Anastomotic leak.
Occurs within 10 days postoperatively.

May be treated either conservatively or surgically.
Stomal stenosis.
Occurs as a late complication, usually within 4–6

weeks of surgery.
Most patients respond to endoscopic dilation.
Refractory cases require operative revision.
Marginal ulceration.
Occurs in 5–10% of patients.

Patients have epigastric pain or upper gastrointestinal
bleeding, or both.
Perforation is less common but has been reported.
Usually responds to PPI but may require endoscopic
or surgical intervention.
Internal hernia.
May occur as an early or late complication in 3–5% of

patients.
Patients typically present with acute or chronically
intermittent obstructive symptoms.
Treatment is surgical.
Incisional hernia (may occur in up to 15% of open
operations).
Acute esophageal obstruction.

Gastric prolapse ("slipped band") and pouch dilation.
Band erosion.
Esophageal dilation or dysmotility.
Port and tubing complications (eg, breakage, migration,
infection).
Pearls and Tips

A checklist of important operative steps (eg, closure of
the gastrotomy, removal of the spike) should be
maintained by the circulating nurse to avoid missed steps.
Care must be taken to correctly identify alimentary and
biliary limbs and to prevent twisting of the mesentery.
This should be checked and rechecked.
The mesenteric defect should be completely closed with
permanent suture.
The angle of His must be clearly identified during creation
of the proximal pouch to prevent injury to spleen or
esophagus.
Passage of the bowel grasper behind the esophagogastric

junction should occur without any resistance. If resistance
is encountered, withdraw the grasper and reinsert it 5–10
mm caudad.
Complete excision of the gastroesophageal fat pad is
important to reduce the risk of esophageal obstruction
and facilitate placement of the fundoplication sutures.
Avoid placement of the fundoplication over the buckle of
the band to minimize the risk of band erosion.
Carefully anchor the port to the anterior fascia lateral to
the 15-mm port to prevent port migration or rotation.
Late port site infections indicate band erosion until proven
otherwise.
References
McGrath V, Needleman BJ, Melvin WS. Evolution of the

laparoscopic gastric bypass. J Laparoendosc Adv Surg Tech.
2003;13:221–227.[PubMed: 14561250] [Full Text]
NIH conference. Gastrointestinal surgery for severe obesity.
Consensus Development Conference Panel. Ann Intern Med.
1991;115:956–961.
Ren CJ, Fielding GA. Laparoscopic adjustable gastric banding:

surgical technique. J Laparoendosc Adv Surg Tech. 2003;13:
257–263.[PubMed: 14561254] [Full Text]


Current Procedures: Surgery > Chapter 10. Enteral

Access >
Indications
Gastrostomy
Long-term (> 4–6 weeks) gastric feeding required

under the following circumstances:
Patient is unable to swallow.

Oral feeding is precluded.
Oral intake alone is inadequate.
Long-term gastric decompression.
Intolerance to nasogastric or Dobbhoff tube, or both.
In cases requiring access to the gastric lumen for

< 4–6 weeks, a nasogastric or Dobbhoff tube
generally suffices.
Percutaneous endoscopic gastrostomy (PEG) is the
procedure of choice, when feasible, for gastrostomy
placement alone. If the stomach is not accessible
percutaneously or if gastrostomy is performed at the
time of another upper abdominal operation, an open
technique is used.
Witzel Jejunostomy
Secondary procedure during extensive upper digestive

tract surgery (eg, esophagectomy, total gastrectomy)
to enable early enteral feeding, particularly when
recovery is expected to be long and potentially
complicated.
Sole procedure in patients in whom oral feeding is
precluded and postpyloric feeding is desired (eg,
patients with duodenal trauma, gastroparesis, or
pancreatitis).
Contraindications
Gastrostomy
Absolute
Absence of stomach (subtotal gastrectomy, transhiatal

esophagectomy with gastric pullup).
For PEG, esophageal obstruction. (Stamm gastrostomy
remains feasible.)
For PEG, lack of access to esophagus (eg, trismus,
teeth wired shut). (Stamm gastrostomy remains
feasible.)
Relative
Severe gastroesophageal reflux or incompetent lower

esophageal sphincter.
Anatomy that prevents direct apposition of the stomach
with the abdominal wall (eg, interposition of an
enlarged liver; severe kyphoscoliosis).
For PEG, morbid obesity. (Stamm gastrostomy remains
feasible.)
Ascites.
Irreversible coagulopathy.
Witzel Jejunostomy
Absolute
Distal intestinal obstruction.

Small bowel dysmotility.
Relative
Hostile abdomen (adhesions, malignancy).

Inflammatory bowel disease or postradiation enteritis
involving the jejunum.
Ascites.
Irreversible coagulopathy.
Significant bowel wall edema.
Severe immunodeficiency.
Informed Consent
Gastrostomy
Expected Benefits
Permits gastric feeding or decompression more

conveniently and comfortably than by nasogastric tube.
Potential Risks
Gastric leak.
Injury to adjacent organs, including colon, small
intestine, and liver.
Gastrocutaneous fistula.
Bleeding.
Infection.
Risks inherent to sedation or general anesthesia.
Metastatic oropharyngeal cancer rarely occurs at the
PEG site (< 1% occurrence), and usually occurs in
rapidly progressive disease with other sites of
metastasis.
Witzel Jejunostomy
Expected Benefits
Provides a means for enteral feeding that bypasses the

stomach and upper digestive system.
Potential Risks
Damage to surrounding structures, including bowel wall

injury.
Enteroenteric or enterocutaneous fistula.
Bleeding.
Infection.
Risks inherent to general anesthesia.
Equipment
Percutaneous Endoscopic Gastrostomy
Upper gastrointestinal endoscope.

PEG kit (commercially available).
Stamm Gastrostomy
18–22 French Malecot, Pezzer, or equivalent catheter,

such as a 20 French Ponsky replacement PEG tube.
Witzel Jejunostomy
12–16 French red rubber catheter.
Patient Preparation
Thorough history and physical examination are

generally sufficient to rule out the presence of
conditions that would preclude or contraindicate the
procedure.
There must be sufficient space between incisors to pass
an endoscope without compromising the airway.
In the case of previous abdominal surgery or an
otherwise questionable abdominal examination, a
limited abdominal CT scan can be obtained to
determine whether direct apposition of the stomach
and anterior abdominal wall is possible.
Nothing by mouth for 4 hours before the procedure.
Antibiotic prophylaxis is optional.
Stamm Gastrostomy and Witzel Jejunostomy
Same as for any major abdominal operation.

Both procedures are most easily performed under
general anesthesia.
Alternate methods of anesthesia such as deep sedation
and local anesthesia can be performed in special
circumstances.
Patient Positioning

The head of the bed may be elevated to 45 degrees as
the scope is passed, but the best percutaneous access
to the stomach is achieved when the patient is fully
supine.
Stamm Gastrostomy and Witzel Jejunostomy
Procedure
The patient is given intravenous conscious sedation

before beginning the procedure.
A nurse assistant should monitor the blood pressure,
pulse, and oxygenation.
The posterior pharynx is anesthetized with a topical
agent. A bite block is placed between the incisors.
The upper gastrointestinal endoscope is passed through
the pharynx and esophagus and into the stomach.
The stomach is insufflated with air.
The anterior wall of the stomach is localized through
the left upper quadrant abdominal wall by gentle digital
palpation, transillumination, or both.
Gentle pressure of a finger on the abdominal wall
should visibly depress the stomach on endoscopic view.
The best gastrostomy site is usually left subcostal, near
the midclavicular line. It is helpful to mark the skin at
the desired puncture site.
Figure 10–1A: Following sterile preparation and
draping, local anesthetic is injected first intradermally
and then into the muscle and peritoneum through
which the tube will pass at an angle perpendicular to
the skin.
A few moments is allowed for the anesthetic to take
effect. A scalpel is then used to make an 8–10-mm
incision in the skin.
Figure 10–1B: A needle/cannula is passed through
this abdominal wall incision and into the stomach.
Entry into the gastric lumen is observed through the
endoscope.
A snare passed through the endoscope is looped

around the cannula. The needle may be removed
or retracted from the cannula.
A guidewire is passed through the cannula into the
gastric lumen, where it is grasped by the snare.
The snare holding the guidewire and the
endoscope are pulled out together through the
patient's mouth.
At the end of this maneuver, the guidewire
provides a continuous pathway through the mouth,
esophagus, gastric lumen, and abdominal wall (see
Figure 10–1C).
An alternative method, if a suitable snare is not
available, is to pass the guidewire through the
accessory channel of the endoscope and directly
out through the cannula.
Figure 10–1C: The tapered end of the special
percutaneous gastrostomy tube is threaded completely
over the wire that exits from the patient's mouth.
The guidewire is held at the flanged end of the

tube as the wire is pulled out through the
abdominal wall, bringing the tapered end of the
tube down through the esophagus and out through
the abdominal wall.
Once the tapered tip of the tube emerges through
the skin, the tube is grasped and quickly pulled
through the abdominal wall until the flanged end is
brought into apposition with the internal gastric
wall.
Counterpressure is held against the anterior
abdominal wall during this maneuver to prevent
the abdominal wall from being pulled up and away
from the stomach.
The tube is secured in place by sliding an external
crossbar over the tapered end of the tube until it is
snug against the abdominal wall.
The external portion of the gastrostomy tube is cut
to an appropriate length and capped with an
adapter.
Figure 10–1
Stamm Gastrostomy
Figure 10–2: The site at which to bring out the tube is

selected and marked approximately 3 cm to the left of
the midline and 2–3 cm below the costal margin.
Following sterile preparation and draping, a 5–6-cm
midline incision is then made at the level of the chosen
gastrostomy site.
Once the peritoneal cavity is entered, the stomach is
identified.
The tube should be placed as proximally as

possible in the stomach.
The greater curvature of the stomach is pulled
downward gently with Babcock clamps until
resistance is met.
A gastrotomy site is chosen on the anterior gastric wall
near the greater curvature. Placement is checked to
ensure that this site will reach the abdominal wall at
the exit site previously chosen.
Figure 10–3: An absorbable or nonabsorbable purse-
string suture is placed at the site chosen for the
gastrotomy and left untied.
A gastrotomy is made in the center of the purse-

string using electrocautery.
Penetration to mucosa is confirmed and the edges
of the gastrotomy are held with Allis clamps while
the tube is inserted into the stomach through the
gastrotomy.
The purse-string suture is tied down.
A second purse-string suture is placed around the first
for further security (not shown).
Figure 10–4: A stab wound is then made at the
previously marked exit site on the abdominal wall, and
a clamp is pushed bluntly through the abdominal wall,
entering peritoneum at least 2 cm from the midline
fascial incision. The external end of the tube is pulled
partway through this opening.
Figure 10–5: The free intra-abdominal portion of the
tube is used to manipulate the stomach while four
sutures are placed to secure the stomach to the
abdominal wall.
Figure 10–6: After the sutures are placed, the tube is
pulled completely through the abdominal wall apposing
the stomach to the abdominal wall's underside, and the
sutures are tied down. The external portion of the tube
is anchored to the skin with an external crossbar,
suture, or both.
Finally, the original midline incision is closed.
Figure 10–2
Figure 10–3
Figure 10–4
Figure 10–5
Figure 10–6
Witzel Jejunostomy
If jejunostomy is the sole procedure being performed,

a short midline incision is made in the abdomen.
Once the peritoneum has been entered, the small
bowel is identified and traced to the ligament of Treitz.
A loop of jejunum approximately 20 cm from the
ligament of Treitz is brought up into the wound.
Figure 10–7: A 3-0 absorbable or nonabsorbable
purse-string suture is placed in the antimesenteric wall
of the jejunum at the planned enterotomy site and left
loose. A second purse-string suture may be placed
concentrically around the first; this is also left loose.
Figure 10–8: The catheter is brought onto the field
and placed through an enterotomy made in the center
of the purse-string sutures into the bowel lumen.
The tube is advanced a distance of 8–10 cm or
more and the purse-string sutures are tied down.
A Witzel serosal tunnel is created by bringing the
bowel wall over the tube for a distance of 4–6 cm
proximal to its insertion site using a series of
interrupted Lembert seromuscular 3-0 silk sutures.
The tube, including its insertion site into the small
bowel, is completely invaginated in this way with
great care taken not to overly narrow the lumen of
the jejunum at the site of tube entry and Witzel
tunnel.
The external end of the catheter is brought out
through a stab wound in the abdominal wall.
Figure 10–9: The jejunum is anchored to the
peritoneum using interrupted 3-0 silk sutures for a
length of 2–3 cm proximal to the serosal tunnel in
order to prevent volvulus around the tube.
The external portion of the catheter is secured to the
skin with nylon suture or other external fixation device.
Finally, the original midline incision is closed.
Figure 10–7
Figure 10–8
Figure 10–9
Alternative Techniques
A jejunostomy tube can also be placed using the needle

catheter technique.
A 9 French catheter is passed via a needle/cannula

through the abdominal wall, through a submucosal
tunnel in the jejunal wall, and then into the jejunal
lumen.
The jejunum is sutured to the anterior abdominal
wall to prevent volvulus around the catheter
insertion site.
Although this technique is simple and can be
performed quickly, it has a higher complication
rate than standard jejunostomy. The small
catheter is more prone to clogging and kinking and
is difficult to replace, making it unsuitable for long-
term use. There have also been reports of serious
infections occurring after needle catheter
jejunostomy.
If a patient has a gastrostomy and postpyloric feedings
are desired, a gastrojejunostomy (G-J) extension tube
can be used.
The original gastrostomy tube is removed and a G-

J tube is inserted.
Under endoscopic control, the jejunal extension is
threaded through the gastrostomy portion of the
G-J tube and placed in the fourth portion of the
duodenum.
Postoperative Care
A percutaneous gastrostomy may be used for

medication administration immediately and for feeding
within 6–12 hours. The patient should be instructed
that the retention bar, which is initially snug, may be
loosened slightly after 24–48 hours.
Stamm Gastrostomy
Unlike a PEG, an open gastrostomy tube is connected

to gravity drainage for 12–24 hours before being used
for feeding. This allows for verification that gastric
emptying is taking place.
Witzel Jejunostomy
The jejunostomy tube can be used immediately

following the procedure.
Tube feedings should be started slowly, at one-fourth or
one-half strength, to avoid osmotically induced
ischemic injury.
Gastrostomy
Intraperitoneal leakage of gastric contents.

External leakage of gastric contents around the tube,
especially if the tube is too loose or if the tube has
been placed in the antrum rather than the body of the
stomach.
Gastric outlet obstruction if the tube has been placed
distally in the stomach and occludes the pylorus.
Puncture of the colon, small intestine, or liver (greater
risk with PEG).
Cellulitis or subcutaneous abscess at the tube exit site.
Accidental dislodgment of the tube.
Witzel Jejunostomy
Failure to place the tube in the proximal jejunum.

Rotation or volvulus of the small bowel around the
jejunostomy site.
Bowel obstruction due to narrowing and edema at the
site of tube entry and Witzel tunnel.
Kinking of the tube at the tube insertion site.
Intraperitoneal leakage at the jejunostomy site.
Intra-abdominal or subcutaneous abscess formation.
Enterocutaneous fistula.
Pearls and Tips

The procedure may be done in an endoscopy suite or at

the bedside in an ICU. However, if the patient is poorly
cooperative (eg, developmentally disabled) or cannot
protect his or her airway, the procedure is best done in
an operating room with full anesthesia support.
It is helpful to have a Dobbhoff tube already in place to
follow when passing the endoscope in patients who
cannot swallow effectively or in those whose
oropharyngeal anatomy is distorted by tumor or prior
operation.
If the external crossbar is too tight, the risk of infection
is increased. If the site is painful or if infection develops
around the tube, the crossbar should be loosened to
relieve pressure on the skin and to permit drainage.
Free air may be seen on a chest film after a PEG is
placed. This does not necessarily imply leakage. A
contrast study through the tube is the best way to rule
out a gastric leak.
When there is uncertainty about the patient's anatomy,
obtain a contrast study to locate the stomach
anatomically and determine suitability for the
procedure. A blind puncture should not be done.
Stamm Gastrostomy
It is technically much easier to place the second purse-

string suture in the stomach after the tube has been
inserted and the first purse-string suture tied down.
Lifting the stomach wall by gently pulling up on the
tube facilitates placement of the second purse-string
suture.
It is technically easier to place the sutures securing the
stomach to the abdominal wall before the stomach is
pulled up tight against it. Initially pulling the
gastrostomy tube only halfway through the exit site
facilitates circumferential suture placement.
If using a Malecot or similar tube, an external crossbar
can be fashioned by cutting a segment of a large red
Robinson catheter and trimming a small hole on each
side through which to pull the gastrostomy tube. A
silastic crossbar is included with the Ponsky tube.
A Foley catheter can be used if nothing else is
available, but it is not durable and gastric contents tend
to leak around the tube.
If the stomach cannot be brought to the abdominal
wall, a Witzel technique can be used to place the
gastrostomy tube, obviating the need for gastropexy
(see later discussion).
It is always best to bring the tube out through a
separate stab wound rather than through the midline
incision.
Witzel Jejunostomy
Jejunostomy tubes are easily pulled out because they

do not have an inner flange. If this occurs shortly after
tube placement, it can be difficult to reinsert the tube
because the Witzel tunnel closes down rapidly.
Fluoroscopy may be helpful for attempting reinsertion.
If using a red rubber catheter for the jejunostomy tube,
cut the tip off of the tube so that exchange over a
guidewire is possible if the tube clogs in the early
postoperative period.
Supplemental free water must be given in addition to
tube feedings, particularly if tube feedings are
hyperosmolar. Do not start with full-strength tube
feedings.
References
Cruz I, Mamel JJ, Brady PG, Cass-Garcia M. Incidence of
abdominal wall metastasis complicating PEG tube
placement in untreated head and neck cancer. Gastrointest
Endosc. 2005;62:708–711.[PubMed: 16246684] [Full Text]
Johnston WD, Lopez MJ, Kraybill WG, Bricer EM. Experience

with a modified Witzel gastrostomy without gastropexy.
Ann Surg. 1982;195:692–699.[PubMed: 7044320] [Full
Text]
Rolandelli RH, Bankhead R, Boullata JL, Compher CW, eds.

Clinical Nutrition—Enteral and Tube Feeding, 4th ed.
Philadelphia, PA: Elsevier Saunders, 2005.
Rombeau JL, Caldwell MD, Forlaw L, Guenter PA, eds. Atlas

of Nutritional Support Techniques. Boston: Little, Brown,
1989.
Shellito PC, Malt RA. Tube gastrostomy. Techniques and

complications. Ann Surg. 1985;201:180–185.[PubMed:
Tapia J, Murguia R, Garcia G, et al. Jejunostomy:

techniques, indications, and complications. World J Surg.
1999;23:596–602.[PubMed: 10227930] [Full Text]


Current Procedures: Surgery > Chapter 11. Laparoscopic

Cholecystectomy >
Indications
Biliary colic.
Chronic cholecystitis.
Acute cholecystitis.
Acalculous cholecystitis.
Gallstone pancreatitis.
Choledocholithiasis.
Contraindications
Absolute
Inability to tolerate an operation under general anesthesia

(eg, patients with end-stage cardiopulmonary disease or
hemodynamic instability).
Suspicion of gallbladder cancer based on preoperative
imaging.
Relative
Pregnancy (first or third trimester).
Previous abdominal operations precluding laparoscopic
access.
Cirrhosis, portal hypertension, or bleeding disorders.
Informed Consent
Expected Benefits
Patients with gallstone pancreatitis or biliary obstruction

from choledocholithiasis risk recurrent complications if the
gallbladder is not removed.
Biliary colic will most likely recur unless the

gallbladder is removed.
Acute cholecystitis may progress to gallbladder
necrosis and possibly sepsis unless cholecystectomy
is performed.
Potential Risks
Possible complications include:
Bleeding (from the cystic artery stump, gallbladder

fossa, abdominal wall, omental or mesenteric
adhesions).
Surgical site infection (either superficial or deep).
Bile leak (most likely from the cystic duct stump),
biliary tract injury, or both.
Bowel injury.
Systemic complications of abdominal surgery
(pneumonia, venous thromboembolism, and
cardiovascular events).
Postoperative choledocholithiasis.
Equipment
Standard laparoscopic equipment:
5-mm and 10-mm trocars, 5-mm or 10-mm 30-

degree laparoscope.
Atraumatic graspers.
Electrocautery instrument (hook or spatula).
Maryland dissector.
Clip applier.
Laparoscopic scissors.
Other equipment available as necessary:
Suction-irrigator.
Disposable specimen retrieval bag.
Cholangiography equipment.
Patient Preparation
Abdominal ultrasound and liver function tests.

Preoperative endoscopic retrograde
cholangiopancreatography (ERCP) for patients with
clinical, laboratory, or radiographic evidence of
choledocholithiasis. (Some surgeons with advanced
laparoscopy experience may prefer laparoscopic common
duct exploration.)
Cardiopulmonary evaluation as needed.
Nothing by mouth for 6 hours before surgery.
Prophylactic antibiotics for patients with acute
cholecystitis. (Although preoperative antibiotics are
recommended by many surgeons, their benefit in patients
with uncomplicated biliary colic or chronic cholecystitis
has not been established.)
Patient Positioning
The patient should be supine with the arms perpendicular

to the body or tucked to the side.
After general anesthesia, the abdomen is prepped from
nipple to pubis and sterilely draped.
The primary surgeon stands on the patient's left side,
while the assistant stands on the patient's right.
Procedure
General anesthesia is used.

A small periumbilical incision is made, with the location
and orientation depending on the patient's body habitus
and cosmetic considerations. Although most surgeons
employ a closed technique to establish
pneumoperitoneum and initial access (usually with a
Veress needle), an open technique is also appropriate.
Figure 11–1: Port positions:
5-mm (preferred) or 10-mm port in the periumbilical

position for a 5-mm or 10-mm laparoscopic scope.
10-mm port in the subxiphoid position with the intra-
abdominal portion located to the right of the falciform
ligament.
5-mm port 2 fingerbreadths below the costal margin
and close to the midclavicular line, to position the
port over the gallbladder intra-abdominally.
5-mm port laterally along the anterior axillary line for
gallbladder fundus retraction.
The laparoscope is used to explore the abdomen for
adhesions and potential injuries that may have occurred
during port placement (the subxiphoid and subcostal
ports are placed under direct visualization to minimize
risk of injury).
Figure 11–2: A ratcheted grasper is inserted through the
lateral 5-mm port to retract the gallbladder fundus in
cephalad fashion.
If the gallbladder is too distended to be grasped, it

may be first decompressed with a needle or using the
suction device.
An atraumatic grasper is inserted through the middle
5-mm port to retract the gallbladder infundibulum
laterally, exposing the anteromedial aspect of the
triangle of Calot.
The primary surgeon uses a two-handed technique
and begins the dissection.
Adhesions to the body of the gallbladder are released
using blunt or sharp dissection, as appropriate.
A hook cautery is used to carefully incise the
peritoneum overlying the triangle of Calot, continuing
along the medial aspect of the proximal gallbladder.
Figure 11–3: As the infundibulum is retracted
superomedially, peritoneum overlying the posterolateral
aspect of the triangle of Calot is similarly incised using
hook cautery.
Figure 11–4: All remaining connective tissue is dissected
out of the triangle of Calot using blunt dissection and
hook cautery as needed to fully mobilize the gallbladder
infundibulum.
Figure 11–5: The cystic duct is dissected free.
Figure 11–6: The cystic artery is dissected free.
At this point, only two tubular structures (the cystic

duct and artery) remain connected to the proximal
gallbladder; this represents the "critical view of
safety."
Figure 11–7: If a cholangiogram is to be performed, a
clip is applied on the cystic duct at the junction to the
infundibulum. An anterolateral cystic ductotomy is made
just distal to the clip.
Figure 11–8: A cholangiogram catheter is inserted
through the ductotomy and secured using either clips or a
cholangiogram clamp.
The whole system should be flushed with 2–3 mL of

saline before placement of the cholangiocatheter as
well as initially upon placement in the cystic duct to
remove any air bubbles, which might produce an
artifact on the cholangiogram.
Approximately 15–20 mL of contrast dye diluted 1:1
with saline is injected under fluoroscopy with the
table tilted slightly to the left. The contrast is injected
slowly at first to visualize the distal common bile duct
and then at higher pressures and volumes to
visualize the entire biliary tree.
An adequate cholangiogram requires visualization of
the biliary tree proximal to the biliary bifurcation
(revealing both right and left hepatic ducts and
branches) and evidence of dye passage into the
duodenum.
If common bile duct stones are identified, they can
be managed via laparoscopic bile duct exploration or
postoperative ERCP, depending on surgeon
preference and experience.
Figure 11–9: After the cholangiogram, the cystic duct is
double clipped proximal to the ductotomy and divided.
The cystic artery is likewise divided between the
previously placed clips.
Figure 11–10: The gallbladder is then dissected out of
the gallbladder fossa using hook cautery.
Figure 11–11: The gallbladder is retrieved via the
umbilical or subxiphoid port, depending on surgeon
preference. A disposable specimen bag may be used for
this purpose, particularly in cases of acute cholecystitis or
gallbladder perforation during dissection (to prevent stone
spillage).
The ports are removed under direct vision to evaluate for
potential bleeding.
If a 10-mm trocar is used at the umbilicus, the residual
fascial defect is closed with interrupted 0 Vicryl sutures.
The fascia at the epigastric trocar site is closed in similar
fashion.
Figure 11–12A: Open cholecystectomy is performed
through a 10–15-cm right subcostal incision.
A Bookwalter retractor is used to retract the liver and
bowel, exposing the gallbladder.
Figure 11–12B: An antegrade approach is used to
dissect the gallbladder out of the gallbladder fossa from
the fundus down toward the porta hepatis.
The triangle of Calot is exposed just as in the laparoscopic
approach.
Figure 11–12C: The cystic artery is identified and ligated
Figure 11–12D: The cystic duct is isolated and ligated.
Figure 11–1
Figure 11–2
Figure 11–3
Figure 11–4
Figure 11–5
Figure 11–6
Figure 11–7
Figure 11–8
Figure 11–9
Figure 11–10
Figure 11–11
Figure 11–12A–D
Postoperative Care
Orogastric tubes and Foley catheters, if placed

preoperatively, are removed at the end of the procedure.
Diet is advanced as tolerated.
Oral pain medications are prescribed.
Patients undergoing laparoscopic cholecystectomy are
typically discharged on the day of surgery; open
cholecystectomy usually requires a short hospital stay
(eg, 1–3 days).
Ambulation should be initiated as soon as possible.
Veress needle or trocar injury to great vessels or bowel.

Must be recognized early and repaired, either
laparoscopically or after conversion to open surgery,
depending on the injury and the surgeon's experience.
Bile leak.
May occur from the cystic duct stump or a bile duct

injury to the common bile duct.
Patients usually present several days after
cholecystectomy with symptoms that include
abdominal pain, fever, nausea, anorexia, and
jaundice.
Evaluation should include ultrasound to evaluate for
free abdominal fluid and, if the diagnosis remains
uncertain, HIDA scan to demonstrate biliary
extravasation.
Treatment includes percutaneous abdominal drain
placement for biloma and ERCP with stenting,
sphincterotomy, or both.
Failure to control the bile leak with ERCP implies the
need for reoperation (laparoscopic or open), with
repair depending on the etiology of the leak.
Bile duct injury.
Most frequently occurs because of misidentification of

anatomic structures (common bile duct or aberrant
right hepatic duct mistaken for the cystic duct).
Can also result from overzealous use of
electrocautery or clips to control bleeding in the
region of the porta hepatica, or due to excessive
traction on the cystic duct and common bile duct
during dissection.
Management depends on the nature and severity of
the injury, when it is recognized (intraoperatively vs
postoperatively), and the relative experience of the
surgeon with biliary reconstruction techniques.
In some circumstances, patients are best managed
by prompt referral to a tertiary medical center with
expertise in hepatobiliary surgery.
Retained spilled stones.
Spillage of stones occurs in more than 10% of

laparoscopic cholecystectomies.
Although rarely resulting in serious complications (eg,
intra-abdominal abscess), spilled stones should be
retrieved as completely as possible using a specimen
bag.
Retained common bile duct stones.
Patients may present with abdominal pain, jaundice,

light-colored stools, dark urine, pancreatitis,
cholangitis, elevated liver function tests (bilirubin,
alkaline phosphatase, transaminases), or dilated
common bile duct or intrahepatic ducts on
ultrasound.
Primary management consists of ERCP for stone
clearance and sphincterotomy.
Laparoscopic or open bile duct exploration,
depending on surgeon experience, is required in
unusual instances where ERCP is unsuccessful.
Pearls and Tips
To minimize risks of bile duct injury, use the "critical view"

technique to clear the triangle of Calot and completely
identify and isolate the cystic duct and artery before
dividing these structures.
Obtain a cholangiogram if the anatomy cannot be
precisely identified.
References
Colletti LM. Complications of Biliary Surgery. In: Mulholland

MW, Doherty GM, eds. Complications in Surgery. Philadelphia,
PA: Lippincott Williams & Wilkins; 2006:423–462.
Massarweh NN, Flum DR. Role of intraoperative

cholangiography in avoiding bile duct injury. J Am Coll Surg.
2007;204:656–664.[PubMed: 17382226] [Full Text]
Nakeeb A, Ahrendt SA, Pitt HA. Calculous Biliary Disease. In:

Greenfield's Surgery: Scientific Principles & Practice, 4th ed.
999.
Strasberg SM. Avoidance of biliary injury during laparoscopic

cholecystectomy. J Hepatobiliary Pancreat Surg. 2002;9:543–


Current Procedures: Surgery > Chapter 12. Management

of Complex Biliary Stone Disease >
Indications
Open Common Bile Duct Exploration
Clearance of biliary obstruction due to calculus disease if

endoscopic techniques (eg, endoscopic retrograde
cholangiopancreatography) are unavailable, have failed,
or are not feasible due to patient anatomy or status.
Transduodenal Sphincteroplasty
Impacted stone at the ampulla of Vater.

Previous attempt at common bile duct exploration.
Most often performed at the time of cholecystectomy
when common bile duct exploration has failed to clear a
stone impacted in the distal common bile duct.
Choledochoduodenostomy
Unresectable malignant distal common bile duct

obstruction, as a palliative procedure.
Benign strictures of the distal common bile duct.
Salvage drainage procedure in the presence of large
primary stones or numerous stones in the distal common
bile duct.
Contraindications
Absolute
None.
Relative
Previous biliary bypass.
Absolute
None.
Relative
Fibrotic ampulla.
Inability to pass a 3-mm probe through the ampulla.
Abnormal-appearing ampulloduodenal junction on
cholangiography.
Common bile duct diameter > 2 cm.
Long common bile duct stricture.
Absolute
Duodenal obstruction.
Relative
Primary resection of the obstructing lesion or clearance of
the obstructing calculi.
Nondilated bile duct.
Proximal duodenal inflammation.
Potential duodenal obstruction.
Sclerosing cholangitis.
Informed Consent
Expected Benefits
Removal of the stone (or stones) from the common bile

duct.
Prevention of cholangitis and cholestatic liver injury.
Potential Risks
Bleeding requiring transfusion or reoperation.

Retained bile duct stones requiring prolonged T-tube
drainage, additional procedures by interventional
radiology, or possible additional surgical intervention.
Bile leak requiring prolonged T-tube drainage.
Iatrogenic injury to the biliary tree or duodenum.
Surgical site infection requiring drainage or antibiotics.
Expected Benefits
Removal of the stone (or stones) from the distal common

bile duct.
Prevention of cholangitis and cholestatic liver injury.
Potential Risks

Bile leak requiring prolonged drainage, drain placement,
or reoperation.
Duodenal leak.
Iatrogenic injury to the bile duct or duodenum.
Pancreatitis.
Biliary stricture.
Surgical site infection requiring incision and drainage or
antibiotics.
Expected Benefits
Restoration of enteric biliary drainage.

Prevention of cholangitis and cholestatic liver disease.
Potential Risks

Bile leak requiring prolonged drainage, drain placement,
or reoperation.
Surgical site infection requiring drainage or antibiotics.
Conversion to choledochojejunostomy if
choledochoduodenostomy cannot be performed.
Equipment
Cholangiography catheter with occluding balloon.

Contrast material, diluted to half strength if necessary.
Imaging capability for intraoperative cholangiography,
either fluoroscopy or plain film.
Flexible choledochoscope with a working port and Dormia
basket for stone extraction.
Glassman stone extractors.
Fogarty biliary catheter.
No. 14 or 16 French T-tube.
Bakes biliary dilators.
Surgical magnification loupes may be beneficial.

No. 14 French T-tube.
No special equipment required.
Patient Preparation

Magnetic resonance cholangiopancreatography may be
useful to define biliary anatomy.
Serum transaminases, total bilirubin, alkaline
phosphatase, coagulation studies (PT, PTT).
Coagulopathies should be treated with vitamin K, fresh
frozen plasma, or both, accordingly.
Preoperative broad-spectrum antibiotics.
Patient Positioning
For all procedures, the patient should be supine.

Procedure
General anesthesia with endotracheal intubation is

required.
Open common bile duct exploration is most often
performed at the time of cholecystectomy.
Incision and exposure:
A right upper quadrant incision is made parallel to

the right costal margin. This is approximately 3
fingerbreadths below the costal margin and should
extend from the right of midline to the right anterior
axillary line.
If not previously completed, a cholecystectomy is
performed.
Using an abdominal retractor, the liver is elevated
superiorly and the small bowel is packed inferiorly.
A Kocher maneuver is performed to mobilize the first and
second portions of the duodenum.
Intraoperative cholangiography through the cystic duct
stump should be performed before beginning common
bile duct exploration in order to define the location and
extent of calculi.
Figure 12–1: The common bile duct is identified and its
anterior aspect is dissected in preparation for longitudinal
choledochotomy.
If the location of the common bile duct is in question,

cholangiography or aspiration of bile will confirm its
identity.
Stay sutures of 4-0 silk are placed on either side of
the planned incision on the anterior wall of the
common bile duct.
A 1.0–1.5-cm incision is made longitudinally
immediately distal to the cystic duct along the
anterior aspect of the common bile duct between the
previously placed 4-0 silk sutures.
If not previously done, cholangiography should be
performed.
The common bile duct should be palpated from the
choledochotomy distally through the head of the
pancreas. Any palpable calculi may be "milked"
proximally for extraction through the
choledochotomy.
Figure 12–2: Several maneuvers can be used to clear
calculi from the bile duct.
Bakes biliary dilators can be used to gently dilate the

bile duct and aid in stone retrieval.
A Fogarty balloon catheter can be passed through the
choledochotomy distally and through the ampulla.
The catheter can then be withdrawn back into the
distal common bile duct and the balloon inflated to
drag stones proximally and through the
choledochotomy. Care must be taken to avoid either
duodenal or biliary injury by excessive force on the
catheter or overinflation of the balloon.
Choledochoscopy can be performed using a flexible
choledochoscope with a working port through which a
Dormia wire basket can be placed for stone retrieval
and extraction.
A Glassman stone extractor may be passed distally
into the bile duct, while maintaining tactile feedback
of the instrument by direct palpation. The surgeon
may be able to palpate the stone through the
anterior duodenal wall and place it into the stone
extractor to be removed.
Figure 12–3: After the stone is extracted and a
completion cholangiogram is performed confirming
complete clearance of the bile duct, a 14 or 16 French T-
tube is inserted through the choledochotomy. The
choledochotomy is then closed over the T-tube limbs with
interrupted 4-0 absorbable monofilament sutures. The
tube is brought out through a separate stab incision in the
anterior abdominal wall and connected to gravity
drainage.
A closed suction drain is placed posterior to the bile

duct.
Figure 12–1
Figure 12–2
Figure 12–3
General anesthesia with endotracheal intubation is

required.
Sphincteroplasty is most often performed at the time of
cholecystectomy when common bile duct exploration has
failed to clear a stone impacted in the distal common bile
duct.
A right upper quadrant incision is made parallel to
the right costal margin. This is approximately 3
fingerbreadths below the costal margin and should
extend from the right of midline to the right anterior
axillary line.
If not previously completed, a cholecystectomy is
performed.
Using an abdominal retractor, the liver is elevated
superiorly and the small bowel is packed inferiorly.
A Kocher maneuver is performed to mobilize the first and
second portions of the duodenum.
Intraoperative cholangiography through the cystic duct
stump should be performed in order to define the location
and extent of calculi.
Figure 12–4: Stay sutures of 4-0 silk are placed and a
1.0–1.5-cm anterior choledochotomy is performed in
preparation for common bile duct exploration.
If not previously done, cholangiography and common

bile duct exploration should be performed.
A Fogarty balloon catheter or a fine probe is placed
through the choledochotomy and distally through the
ampulla in order to identify the ampulla for
duodenotomy.
the planned longitudinal duodenal incision.
Using needle tip electrocautery, a 5-cm longitudinal
duodenotomy is performed, centered directly over
the ampulla.
Figure 12–5A: Adequate exposure of the ampulla is
required. If anterograde placement of either a fine probe
or Fogarty biliary catheter was not possible, retrograde
placement should be attempted to reliably identify the
course of the common bile duct for sphincterotomy.
Surgical magnification loupes may prove beneficial,

particularly in identification of the pancreatic duct.
Using needle tip electrocautery, the ampulla is
opened for a distance of 4–5 mm in the 11 o'clock
position.
The cut edge of the ampulla is approximated to the
duodenum using 4-0 or 5-0 interrupted absorbable
monofilament sutures.
The pancreatic duct should be identified and any
injury to it avoided.
Figure 12–5B: The ampulla can be incised with cautery
another 4–5 mm with placement of sutures to
approximate the ampulla to the duodenum as previously
performed.
The stone is either extracted through the opened

sphincter or pushed proximally to be removed
through the choledochotomy.
Figure 12–5C: The sphincteroplasty is completed and
the pancreatic duct identified.
The duodenotomy is closed longitudinally in two

layers. A running 3-0 braided absorbable suture is
used for the inner layer followed by interrupted 3-0
silk sutures placed in a Lembert fashion. Care is
taken not to narrow the duodenum.
As with a common bile duct exploration, a T-tube
should be placed and the choledochotomy closed as
previously described.
A closed suction drain should be placed lateral to the
duodenotomy.
The abdominal wall is closed in a routine manner.
Figure 12–4
Figure 12–5A–C
General anesthesia is required.

A right subcostal or an upper midline incision is

made.
General abdominal exploration is performed.
Figure 12–6: Cholecystectomy.
A generous Kocher maneuver is performed and the

first and second portions of the duodenum are
mobilized from the foramen of Winslow distally.
The anterior aspect of the common bile duct is
dissected and exposed from the cystic duct stump to
the proximal extent of the obstruction.
The surgeon should ensure that the duodenum can
be easily elevated to the common bile duct, allowing
a tension-free anastomosis.
the planned anterior longitudinal choledochotomy.
A 2–2.5-cm longitudinal incision is made, centered on
the anterior common bile duct below the cystic duct
entrance.
If the procedure is performed for biliary calculi, the
common bile duct is palpated for stones and "milked"
proximally for removal. A common bile duct
exploration can also be performed through the
choledochotomy.
A 1.5–2.0-cm longitudinal incision is made on the
adjacent anterior aspect of the proximal duodenum.
Figure 12–7: The anastomosis is begun using 4-0
absorbable monofilament sutures by placing corner
anchoring sutures between the midportion of the
choledochotomy and the edges of the duodenotomy in
order to "tent" the anastomosis open. These should be
tied on the outside.
The anastomosis should employ full-thickness bites of

both the bile duct and the duodenum in order to
effect a duct-to-mucosa approximation.
The posterior anastomosis is continued by
approximating the distal portion of the
choledochotomy to the superior edge of the
duodenotomy, using interrupted 4-0 absorbable
monofilament sutures.
Waiting until the entire back row of sutures is placed
before they are tied may aid in forming the
anastomosis.
Figure 12–8: Complete the anastomosis between the
bile duct and duodenum by placing the anterior row of
sutures. These are then tied and cut.
Figure 12–9: The completed anastomosis is shown
utilizing the longitudinal choledochotomy made at a right
angle to the longitudinal duodenotomy in order to tent
open the anastomosis.
A closed suction drain may be placed adjacent to the

anastomosis. It can be removed several days
postoperatively if there is no bile in the drain.
Figure 12–6
Figure 12–7
Figure 12–8
Figure 12–9
Postoperative Care
A T-tube cholangiogram is performed on postoperative

day 3. If there is no residual obstruction, it can be
clamped to allow for internal biliary drainage.
The T-tube can be removed in the office 3–4 weeks
postoperatively.
If there are retained calculi, the T-tube tract can be used
for stone extraction by interventional radiology.
Nasogastric decompression via low continuous wall

suction should be continued for 3–5 days to allow for
resolution of transient duodenal obstruction from
duodenal edema.
After the nasogastric tube is removed, with the return of
bowel function, clear liquids can be started and the diet
advanced as tolerated.
If no bilious output occurs after resumption of diet, the
drain can be removed.
If no bilious output is noted, the drain can be removed a

few days after the procedure.
A nasogastric tube attached to low continuous wall
suction should be continued for 3–4 days postoperatively.
With the resolution of ileus, it can be discontinued and the
diet advanced as tolerated.
Iatrogenic injury to the common bile duct or duodenum.

Retained stone despite exploration.
Bile leak from the T-tube.
Cholangitis.
Excessive bile loss requiring fluid replacement.
Iatrogenic injury to the pancreatic duct, bile duct, or

duodenum.
Bile leak, duodenal leak, or pancreatic leak.
Wound infection or intra-abdominal abscess.
Bile leak.
Stenosis of the anastomosis.
"Sump" syndrome, which affects 1% of patients, occurs
when debris collects in the distal segment of the bile duct
below the anastomosis. This can cause obstruction of the
anastomosis or even pancreatitis.
Pearls and Tips
If there is evidence of bile leak (bile in the closed suction

drain) or obstruction (elevated transaminases, bilirubin,
jaundice) after the T-tube is clamped, immediately
reinstitute gravity drainage and obtain a cholangiogram.
If there is any sign of cholangitis, reconnect the T-tube to
gravity drainage and start broad-spectrum antibiotics.
A combination of manipulation through the

sphincteroplasty and choledochotomy may be required for
severely impacted stones.
To avoid injury, identify the pancreatic duct early.
A double-layer anastomosis is unnecessary and may

narrow the anastomotic orifice.
If the duodenum does not mobilize despite extensive
Kocherization, a choledochojejunostomy may be a better
choice.
References
Carboni M, Negro P, D'Amore L, Proposito D. Transduodenal

sphincteroplasty in a laparoscopic era. World J Surg.
2001;25:1357–1359.[PubMed: 11596903] [Full Text]
Ellison CE, Carey LC. Cholecystostomy, Cholecystectomy, and

Intraoperative Evaluation of the Biliary Tree. In: Baker RJ,
Fischer JE, eds. Mastery of Surgery, 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2006.
Ellison CE, Melvin WS, Moon SG. Current Application of

Lateral Choledochoduodenostomy and Transduodenal
Sphincteroplasty. In: Baker RJ, Fischer JE, eds. Mastery of
Surgery, 5th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2006.
Girard RM, Legros G. Retained and recurrent bile duct stones.

Surgical or nonsurgical removal? Ann Surg. 1981;193:150–
Hutter MM, Rattner DW. Open Common Bile Duct Exploration:

When Is It Indicated? In: Cameron JL, ed. Current Surgical
Therapy, 8th ed. St Louis, MO: Mosby; 2004.
Madura JA, Madura JA II, Sherman S, Lehman GA. Surgical

sphincteroplasty in 446 patients. Arch Surg. 2005;140:504–



of Bile Duct Injuries and Biliary Strictures >
Indications
Iatrogenic biliary injuries associated with laparoscopic

cholecystectomy (most common), or other foregut
operations.
Operative approach depends on the time the injury is
diagnosed (eg, immediately, early [ 4 weeks after
injury], or late [> 4 weeks after injury]).
If the patient is hemodynamically stable, immediate

biliary reconstruction is indicated when an injury is
identified intraoperatively during a laparoscopic
cholecystectomy or other operation and a
hepatobiliary surgeon is available to perform the
repair.
For patients with early or late injuries, operative
management typically requires delayed biliary
reconstruction with a biliary-enteric anastomosis.
The aim of operative intervention is definitive treatment
of patients with iatrogenic common bile duct or more
proximal biliary injuries after the residual inflammation
from the acute injury has resolved.
If the injury has been thoroughly evaluated and the
biliary system has been sufficiently decompressed and
drained for 6 weeks or more, reconstruction is required if
a biliary stricture persists or if biliary-enteric discontinuity
remains.
Contraindications
Biliary Decompression
Few contraindications exist for biliary decompression. This

may be achieved using a percutaneous transhepatic
approach or endoscopic retrograde-guided stent
placement. Rarely, operative decompression may be
required.
Percutaneous Transhepatic Approach
Absolute
Active coagulopathy.
Relative
Hepatic malignancy.
Hydatid disease.
Ascites.
Contrast-related anaphylaxis.
Endoscopic Retrograde Approach
Absolute
Patients who cannot cooperate with the study.
Relative
Active or recent acute pancreatitis.
Recent myocardial infarction.
Severe cardiopulmonary disease.
Biliary Stricture Dilation
Contraindications depend on approach (transhepatic or

endoscopic retrograde), as outlined earlier.
Biliary Reconstruction
Absolute
Incomplete preoperative evaluation.

Surgeon's lack of expertise in performing complex biliary
reconstruction.
Relative
Acute cholangitis.
Early biliary injury without adequate biliary drainage (< 6
weeks).
Informed Consent
Biliary Stenting, Drainage, and Dilation
Expected Benefits
Treatment of life-threatening cholangitis.

Treatment of biliary stricture.
In patients with short strictures (< 2 cm), biliary

stenting with successive dilation may successfully
resolve the stricture without operative reconstruction.
Prevention of cholestatic liver injury in situations where
cholestasis cannot be definitively relieved within 2–4
weeks.
In patients with bilirubin > 20 mg/dL, biliary
decompression allows recovery of liver function prior to
operative therapy.
Assists in identification of hilar bile ducts at the time of
operative biliary reconstruction.
Potential Risks
Bleeding.
Biliary sepsis.
Pancreatitis.
Damage to liver or adjacent structures.
Failure of drainage.
Need for periodic stent changes until reconstruction.
Need for additional interventions or procedures.
Expected Benefits
Internal drainage of obstructed bile flow by providing

enteric drainage of the biliary tree.
Correction of biliary strictures results in decreased

risk of biliary cirrhosis, cholangitis, intrahepatic
gallstones, hepatic abscesses, portal hypertension,
and resulting progressive liver failure.
Alleviation of strictures also lessens the risk of future
development of cholangiocarcinoma.
Potential Risks
Late failure of reconstruction resulting in biliary cirrhosis,
cholangitis, intrahepatic gallstones, hepatic abscesses,
portal hypertension, and resulting progressive liver
failure.
Need for additional invasive or operative procedures.
Usual postoperative complications (eg, infection, injury to
adjacent structures, cardiopulmonary complications).
Equipment
Biliary Injury Evaluation
Access to CT, percutaneous transhepatic cholangiogram

(PTC), diagnostic and therapeutic endoscopic retrograde
cholangiopancreatogram (ERCP), magnetic resonance
cholangiopancreatogram (MRCP), and intraoperative
cholangiogram are imperative.
General instrumentation set.

Vascular instrumentation should be available.
Intraoperative ultrasound.
Self-retaining retractor.
Intraoperative cholangiogram capability (C-arm, contrast,
cholangiogram catheters).
Device to divide liver parenchyma.
Choledochoscope should be available.
Patient Preparation
Preoperative Evaluation
Figure 13–1: Management algorithm for patients with
suspected biliary injury, based on timing of diagnosis.
Management of iatrogenic injuries depends on the

time at which they are diagnosed. A combination of
imaging studies may be required to properly
understand the anatomy of the injury.
Complete diagnostic evaluation is necessary for
successful reconstruction.
The goal of preoperative therapeutic interventions is
to relieve biliary obstruction, drain bilomas, and
assist in identification of hilar bile ducts for a future
reconstructive operation.
External or internal biliary drainage, as warranted by type
of injury.
Treatment of sepsis and recurrent cholangitis is the

goal of therapy.
Common duct strictures may be stented via an
endoscopic retrograde approach.
Patients with more proximal strictures may benefit
from both external and internal biliary drainage with
interval dilation over time and delayed
reconstruction.
A transected common duct requires external biliary
drainage.
All bilomas and bile leaks should be drained.
Concomitant injuries to the hepatic vasculature may also
be present, and may require preoperative angiographic
evaluation.
Review of operative reports from the index operation and
direct discussion with the initial surgeon may improve
understanding of the injury.
Patients presenting with a stricture late after biliary
surgery should be evaluated for other potential stricturing
processes (Table 13–1), which should be ruled out
before proceeding with operative intervention.
Figure 13–1
Management algorithm for patients with suspected biliary
injury, based on timing of diagnosis.
Table 13–1. Causes of extrahepatic biliary stricture.
Infectious: viral, Clonorchis

Ampullary adenoma
sinensis
Ampullary carcinoma Mirizzi syndrome
Biliary adenoma Pancreatic adenocarcinoma
Blunt or penetrating
Postoperative stricture
trauma
Cholangiocarcinoma Primary sclerosing cholangitis
Cholangiohepatitis Radiation therapy-related
Choledocholithiasis Retroperitoneal fibrosis
Chronic pancreatitis Stenosis at sphincter of Oddi
Crohn disease Toxic drugs
Duodenal adenocarcinoma
Duodenal ulcers
Source: Based on information in Lillemoe KD. Biliary Injuries

and Strictures and Sclerosing Cholangitis. In: Mulholland MW,
Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery:
Scientific Principles & Practice, 4th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2006:999–1014.
At the Time of Elective Biliary Reconstruction
Preoperative nutritional supplementation, if necessary.

Intraoperative placement of a Foley catheter.
Intraoperative placement of nasogastric suction.
External or internal biliary drains in the right ductal
system often exit very far laterally and do not necessarily
need to be included in preparation of the operative field.
Left-sided external or internal biliary drains should be
included in preparation of the operative field.
Care should be taken not to manipulate these tubes while
positioning the patient. The skin sutures anchoring the
left-sided catheter should be loosened to maintain
catheter position during the operation, as elevation of the
anterior abdominal wall can dislodge left-sided catheters
during the dissection.
Prophylactic antibiotics.
Pharmacologic deep vein thrombosis prophylaxis.
Patient Positioning
The patient should be supine with biliary drainage

catheters positioned as outlined earlier.
Procedure
Classification of Biliary Injuries
Postoperative strictures are related to multiple direct

causes, including cautery-related burn injury to the biliary
tree, transection or sharp injury to the common bile duct
or the right or left hepatic ducts, stapling of the bile duct,
ischemia-related injury due to vessel ligation, or a
combination of these injury types.
Complex injuries may or may not be surgically

reconstructible.
Figure 13–2A–H: Strasberg classification of biliary
injuries.
Type A injuries (Figure 13–2A) are reserved for cystic duct
stump leaks, which are usually managed with very good
results via a combination of sphincterotomy and
endoscopically placed plastic stents.
Interval ERCP is conducted after 4–6 weeks.

Stents may be removed if the leak has resolved, as
outlined in Figure 13–1.
Type B (Figure 13–2B) and C (Figure 13–2C) injuries
involve the division of an aberrant right hepatic duct. Type
B injuries involve ligation of the aberrant proximal duct,
but type C injuries involve persistent biliary leak through
the aberrant duct from the right hepatic lobe.
Most laparoscopic cholecystectomy-related biliary

injuries involve division of the bile duct going to the
right anterior liver, which aberrantly inserts onto the
common duct instead of inserting as the first radical
of the right hepatic duct.
Operative strategies for these types of injury are
dictated by the amount of liver dependent on biliary
drainage through that duct.
If the biliary flow through the transected duct is low,
this duct may be electively ligated. The patient
should subsequently be followed for the development
of cholangitis.
Large hepatic segments with significant flow through
this duct may need biliary reconstruction or hepatic
resection.
Reconstruction can be considered if the bile duct is at
least 1 cm in length and > 3 mm in diameter.
If reconstruction is not feasible, the liver segments at
risk should not be salvaged.
Type D (Figure 13–2D) injuries represent a lateral injury
to the common hepatic duct. These may resolve with
stenting and dilation, depending on the anatomy of the
injury and the size of the defect in the duct.
Large defects usually require reconstruction.

Type E injuries are subclassified into five injury types,
according to the Bismuth classification.
E1 and E2 (Figure 13–2E) injuries involve common

hepatic duct transection.
E3 (Figure 13–2F) and E4 (Figure 13–2G) injuries are
complex hilar injuries, and may also be associated
with hepatic artery injuries.
E5 (Figure 13–2H) injuries involve strictures of the
common hepatic duct with an associated stricture or
injury to an aberrant right sectorial duct.
Biliary reconstruction, depending on the exact
anatomy of the injury and viability of the remaining
bile ducts, may involve a single biliary-enteric
anastomosis or multiple anastomoses.
Figure 13–2 A–H
Injuries Identified at the Index Operation
If an injury is suspected during a laparoscopic

cholecystectomy, an intraoperative cholangiogram should
be performed to identify the exact nature and extent of
the injury.
Consideration of immediate reconstruction should only be
entertained by surgeons with sufficient training and
experience in managing complex operative and
nonoperative hepatobiliary problems.
The area should be widely drained with Jackson-Pratt or
Blake drains. Proximal bile ducts should be marked, if
possible, with careful attention to avoid worsening the
injury.
Retrograde external biliary drainage catheters should be
avoided.
A hepatobiliary surgeon or a tertiary referral center
should be contacted and the patient transferred as quickly
as possible. Reconstructions performed for even complex
injuries within 72 hours have been successful in our
experience.
The relevant workup (as outlined in Figure 13–1) should
be performed expeditiously to enable the patient to
proceed to a well-planned reconstruction within 72 hours.
For biliary reconstruction, a retrocolic Roux-en-Y biliary-
enteric anastomosis is our preferred method, and is
described later.
Delayed Reconstruction
The right upper quadrant and the liver hilum can be

accessed through a variety of incisions. We attempt to use
a previous incision, otherwise a Kocher incision or upper
midline offers adequate exposure.
Right upper quadrant and upper abdominal adhesions
may be present and should be taken down sharply.
Careful dissection of the hepatoduodenal ligament is
necessary.
Palpation of the porta hepatis for the biliary catheters
assists in identification of the injured bile ducts in a
scarred field. Intraoperative ultrasound may be helpful in
identifying the hepatic artery and portal vein.
The bile duct should be dissected sharply in a distal to
proximal direction.
Large lymphatics should be ligated.
Careful attention must be paid to avoid injuring or ligating
hepatic artery branches, which often run anterior to the
right and left bile ducts.
In particular, the left hepatic artery travels anterior to

the left hepatic duct.
Right hepatic arteries may also run anterior to the
right duct but may have been ligated at the index
operation due to misidentification.
The Roux limb is constructed by dividing the jejunum and
its mesentery approximately 15–20 cm from the ligament
of Treitz. A GIA stapler is used to divide the bowel, and
the crossing mesenteric vessels are ligated with silk
sutures.
The hepatic flexure of the colon is mobilized in the usual
fashion.
A window is opened behind the hepatic flexure of the
colon, anterior to the duodenum, between the middle
colic and right colic arteries.
The Roux limb is delivered to the liver hilum through this
window, with careful attention to avoid twisting the
mesentery.
Figure 13–3: Dissection of the biliary tree at the liver
hilum. The injured bile ducts are visible and have been
dissected with the assistance of preoperatively placed
biliary catheters.
The distal common bile duct is suture-ligated or
oversewn.
The Roux limb is also pictured, and is placed without
tension near the hilum of the liver against the transected
bile duct.
Depending on the type of injury, exploration of the distal
common bile duct prior to ligation may be warranted.
The goal is to identify and treat choledocholithiasis in

the distal duct.
This may be achieved by incising the duct and
inserting a choledochoscope, visually inspecting the
duct, and removing the stones. The duct may then be
closed.
Splitting the liver may be necessary if adequate length or
exposure of the bile duct is not achieved. This division is
very helpful in accessing the right anterior bile duct.
Dissection proceeds proximally along the interlobar

plane anterior to the hilum.
A short distance of liver dissection may yield
sufficient bile duct length and exposure for
reconstruction.
Preoperatively placed external or internal biliary drains
can be helpful if maintained postoperatively in several
situations.
Postoperative edema may cause poor bile drainage,

and external drainage may be warranted.
Anastomotic leaks or strictures may develop,
requiring external biliary drainage and stenting.
Technically difficult biliary-enteric anastomosis may
lead to these situations.
Interrogation of the anastomosis may be clinically
warranted postoperatively, and catheter access to the
biliary tree is extremely helpful.
The preoperative external or internal biliary drain is
transected approximately 1–2 cm proximal to the
intended anastomosis or may be retained through the
anastomosis.
Bile cultures should be obtained upon entering the
proximal biliary tree.
Figure 13–4A: The biliary-enteric anastomosis. Creation
of the anastomosis involves a few key points:
Bile duct spatulation.

Biliary-enteric alignment.
Tension-free approximation.
Every attempt should be made to maximize the
circumference of the biliary-enteric anastomosis by
spatulating the bile duct. This may be accomplished
by incising the bile duct longitudinally on the anterior
aspect of the bile duct. Careful attention should be
paid to avoid shortening the length of the duct.
The bowel is aligned with the spatulated duct and
sharply incised in the diameter of the duct on its
antimesenteric surface.
We do not recommend spatulating the right and left
ducts and syndactylizing them for long distances (> 1
cm) proximal to the anastomosis. Syndactylizing the
right and left hepatic ducts only at the point where
they are closest will allow a single large anastomosis,
rather than two small ones.
The anastomosis is performed in an interrupted
fashion using 4-0 PDS sutures. The anterior sutures
should be placed on the bile duct first, with the
needles left on. These sutures may act as a handle to
expose the posterior wall.
The posterior wall is then completed, and the knots
are tied in the lumen after all the back row stitches
are placed.
Figure 13–4B: Front wall of the biliary-enteric
anastomosis.
Once the back wall is complete, the front wall is

closed in a similar fashion. The knots are tied on the
outside.
Figure 13–5: Roux-en-Y hepaticojejunostomy. The use of
tacking sutures from the Roux limb to the liver capsule
anteriorly reduces tension on the bowel.
The mesocolon should also be tacked to the serosa of

the Roux limb to prevent internal hernias.
The enteroenterostomy is constructed 40 cm from
the anastomosis, which may be performed using a
hand-sewn or stapled technique.
A 10-mm Jackson-Pratt drain is typically used, and is
placed in Morrison's pouch. The drain is not placed against
the anastomosis.
If internal or external biliary drains have been removed in
the operating room, and the exit tracts from the liver are
exposed, drains are placed near these holes. These tracts
drain bile until they heal, and drains placed in the
operating room control these leaks well.
Figure 13–3
Figure 13–4A
Figure 13–4B
Figure 13–5
Postoperative Care
Antibiotics
Systemic antibiotics are administered and tailored

according to the bile culture from the operating room
sample.
Deep Vein Thrombosis Prophylaxis
Pharmacologic deep vein thrombosis prophylaxis is

routine with subcutaneous unfractionated or low-
molecular-weight heparin.
Early ambulation should be encouraged.
Drain Management
Drains are monitored for bilious output and are removed if

bilious drainage is not present following advancement to a
regular diet.
Persistent bilious drain output (drain fluid bilirubin level >
3.0 mg/dL) should warrant cholangiography on or after
postoperative day 4.
If an anastomotic leak is detected, the external or

internal biliary drains can be exchanged if needed,
and advanced past the anastomosis. Percutaneous
drains control the ongoing peritoneal contamination.
After 6 weeks, cholangiography should be repeated.
If the leak has resolved, the drains can be removed.
Biliary Duct Catheters
External or internal biliary drain catheters should be

removed 6 weeks after surgery if there is no evidence of
an anastomotic leak.
If a leak is suspected, cholangiography should be
performed through the biliary drain catheter. If a leak is
present, the drain catheter should be exchanged for an
appropriately sized catheter, and it should be advanced
through the anastomosis.
After 6 more weeks, a repeat cholangiogram should be
performed. If the leak has resolved, the catheters can be
removed.
Early
Superficial or deep surgical site infection.

Bleeding.
Bile leak.
Cholangitis.
Biliary anastomotic edema.
Biliary anastomotic leak.
Enteric anastomotic leak or enterocutaneous fistula.
Pancreatitis.
Sepsis.
Multiple organ failure.
Death.
Late
Stricture.
Cholangitis.
Intrahepatic bile duct stones.
Liver abscess.
Varices.
Biliary cirrhosis.
Portal hypertension.
Further biliary injury related to ischemia or technical
issues from repeated attempts at reconstruction, resulting
in nonreconstructible anatomy. These patients should be
referred for liver transplant evaluation.
Pearls and Tips
Reconstruction of iatrogenic biliary injuries that are

diagnosed during the index operation should only be
undertaken by hepatobiliary surgeons, or those who have
training or expertise in the operative and nonoperative
management of complex hepatobiliary problems.
Wide drainage and expedient contact of a referral

center or appropriately trained or experienced
surgeon is warranted and optimally done while in the
operating room with the patient on the table.
Clear communication with receiving surgeons is
imperative.
Nonoperative management of the iatrogenic biliary
injuries aims to identify the extent of the injury
anatomically, followed by biliary decompression with
drainage to prevent ongoing cholestatic liver injury and
provide relief of cholangitis.
Some short segment strictures may be managed
nonoperatively with PTC tube or ERCP-placed stents and
interval dilation, with reasonable rates of resolution.
Metal wall stents should not be used in the biliary tree for
benign strictures.
Identification of the injured bile duct is difficult in an
inflamed or scarred liver hilum; preoperative PTC or
endobiliary drain placement facilitates this maneuver.
Appropriate biliary drainage and delayed operation lead to
the best results from biliary reconstruction.
Retrocolic Roux-en-Y biliary-enteric anastomosis is the
preferred approach for reconstruction. Anastomotic
tension can be relieved by securing the Roux limb to the
liver capsule.
Spatulation of the bile duct decreases the risk of
postoperative anastomotic strictures.
Maintenance of the external or internal biliary drain is
useful for potential evaluation of bile leaks.
References
Cameron JL, Sandone C. Atlas of Gastrointestinal Surgery,

2nd ed, vol 1. Hamilton, ON: BC Decker; 2007.
Colletti LM. Complications of Biliary Injury. In: Mulholland MW,

Doherty GM, eds. Complications in Surgery. Philadelphia, PA:
Lillemoe KD. Biliary Injuries and Strictures and Sclerosing

Cholangitis. In: Mulholland MW, Lillemoe KD, Doherty GM, et
al, eds. Greenfield's Surgery: Scientific Principles & Practice,
4th ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2006:1310–1334.
Strasberg SM. Avoidance of biliary injury during laparoscopic

cholecystectomy. J Hepatobiliary Pancreat Surg. 2002;9:543–
547.



Hepatectomy >
Indications
Metastasis (colon, breast, neuroendocrine).

Hepatocellular carcinoma.
Cholangiocarcinoma.
Hepatoblastoma.
Gallbladder carcinoma.
Hepatic sarcoma.
Adenoma.
Biliary cystadenoma.
Symptomatic hemangioma or focal nodular hyperplasia.
Hepatic tumor of unknown etiology.
Contraindications
Distant metastatic disease for primary liver tumors.

Presence of extrahepatic metastases for metastatic
lesions (relative).
Severe medical comorbidity.
Inability to achieve negative margins.
Insufficient estimated liver remnant following resection.
Significant cirrhosis or portal hypertension.
Informed Consent
Expected Benefits
Surgical treatment of primary and metastatic hepatic

malignancies.
Treatment of symptomatic benign hepatic mass.
Potential Risks
Bleeding requiring reoperation or transfusion.

Infection or abscess.
Embolic events.
Bile leak or stricture.
Tumor recurrence.
Possibility of unexpected findings intraoperatively.
Hepatic dysfunction or failure.
Death.
Equipment
Intraoperative ultrasound equipment.

Self-retaining retractor (eg, Omni or Thompson).
Electrocautery, Cavitron Ultrasonic Surgical Aspirator
(CUSA), Hydrojet, automatic clip applier, and possibly
Tissue Link, LigaSure, or SonoSurg devices, depending
on surgeon preference.
Patient Preparation

Preoperative antibiotics.
Adequate intravenous access (at least two > 16G
intravenous lines and central venous pressure [CVP]
line at the surgeon's discretion).
Foley catheter.
Orogastric tube decompression.
Anesthesiology consultation and coordination.
Patient Positioning
The patient should be supine with arms extended.
Procedure
Figure 14–1: Familiarity with hepatic segmental

anatomy is important (Couinaud) to allow for resection
planning along with intraoperative ultrasound.
Figure 14–2A, B: Important vascular landmarks for
planning of anatomic resections showing hepatic veins
and main portal venous branches. Planes of transection
for major hepatectomies are as follows:
Right lobectomy, right trisegmentectomy

(extended right lobectomy) (Figure 14–2A).
Left lobectomy, left trisegmentectomy (extended
left lobectomy), and left lateral segmentectomy
(Figure 14–2B).
Figure 14–3: Right hepatic lobectomy or extended
right hepatic lobectomy. Identification and isolation of
the right hepatic artery and right hepatic duct.
right hepatic lobectomy. Identification of right portal
vein.
Biliary and vascular structures can be divided

before hepatic transection or after, depending on
surgeon preference.
The portal vein should be oversewn with Prolene
suture or secured with a vascular stapler.
right hepatic lobectomy.
Additional mobilization of the right hepatic lobe is

performed by reflecting it lateral to medial.
Caudate hepatic vein branches as well as
accessory right hepatic venous branches are
ligated.
The right hepatic vein can be divided before or
during parenchymal dissection and oversewn with
Prolene or secured with a vascular stapler.
Figure 14–6: Right hepatic lobectomy.
Parenchymal transection is performed by using

vascular demarcation (if inflow is divided) or along
the transection plane as detailed in Figure 14–2
(marked by ultrasound).
Transection is performed under intermittent inflow
occlusion and maintaining a low CVP (3–7 mm
Hg). Manual compression can also minimize blood
loss from small hepatic veins.
Transection is initiated with electrocautery followed
by CUSA or Hydrojet dissection to identify vascular
or biliary radicals. These can be divided with
autoclips, ligature, cautery, or Tissue Link device,
depending on size.
Figure 14–7: Right extended hepatic lobectomy.
Maneuvers are carried out as in Figures 14–3, 14–

4, and 14–5, with the addition of identification of
portal branches to segment 4, which can be taken
during parenchymal dissection or extrahepatically
if desired.
The line of parenchymal dissection should proceed
to the right of the falciform ligament, preserving
the ascending branch of the left portal vein.
Figure 14–8: Left hepatic lobectomy or extended left
hepatic lobectomy.
The pars flaccida is divided, along with any

accessory or replaced arterial anatomy.
The left hepatic artery, left hepatic duct, and left
portal vein can be identified in the porta hepatis.
The left portal vein can be oversewn with Prolene
or secured with a vascular stapler.
Figure 14–9: Left hepatic lobectomy.
The parenchyma is divided as in Figure 14–6, with

division of the left hepatic vein performed usually
during parenchymal dissection and secured by
oversewing with Prolene suture or securing with a
vascular stapler.
Figure 14–10: Left lateral segmentectomy.
No vascular dissection is required.

The parenchymal dissection plane should be along
the medial side of the falciform ligament,
preserving the ascending branch of the left portal
vein.
Figure 14–11: Hepatic artery perfusion catheter
placement.
If regional chemotherapy is considered, the

common and proper hepatic arteries are dissected
free.
The left and right gastric arteries are ligated along
with supraduodenal branches.
The distal gastroduodenal artery is ligated and
cannulated proximally and secured in place such
that the catheter tip is located at the orifice of the
gastroduodenal artery.
Figure 14–1
Figure 14–2A–B
Figure 14–3
Figure 14–4
Figure 14–5
Figure 14–6
Figure 14–7
Figure 14–8
Figure 14–9
Figure 14–10
Figure 14–11
Postoperative Care
Adequacy of resuscitation should be monitored closely,

and any concern for bleeding should be promptly
evaluated.
Assessment of liver function should be followed closely
in the postoperative period (neurologic status,
coagulation factors, liver function tests).
Benzodiazepines and hepatotoxic medications should
be avoided in the early postoperative period.
Deep vein thrombosis prophylaxis should be provided.
Oral diet can be advanced as tolerated; if not tolerated,
other forms of enteral nutrition should be initiated.
Close monitoring for possible complications is required
(see later).
Bleeding.
Bile leak.
Manifested by bile staining in drains or evidence of

cholestasis on liver function tests.
Symptoms may involve increased abdominal pain,
ileus, fever, or tachycardia.
Many bile leaks are self limited and can be treated
with percutaneous drainage alone.
More severe bile leaks will require endoscopic
retrograde cholangiopancreatography (ERCP) with
sphincterotomy and biliary stent placement, or
placement of a percutaneous transhepatic
cholangiocatheter (PTC) in situations where ERCP
is not technically possible.
Abscess or infection.
Hepatic dysfunction, which can be manifested by the
following:
Acidosis.
Impaired mental status.
Hypoglycemia.
Coagulopathy.
Hyperbilirubinemia.
Transaminitis.
Renal failure.
Predisposition to infection.
Care is primarily supportive, but evaluation should
be performed to exclude major biliary or vascular
complications.
Tumor recurrence.
Embolism (usually intraoperative).
Can be diagnosed using intraoperative

transesophageal echocardiography if necessary.
Prevented by optimizing CVP during parenchymal
dissection.
Pearls and Tips
Preoperative imaging using CT angiography or triple

phase CT is usually required. Alternatively MRI with
contrast is useful, especially in cases of hepatocellular
carcinoma.
Preoperative PTC cholangiogram or magnetic resonance
cholangiopancreatogram (MRCP) may be required in
cases of cholangiocarcinoma.
Perform portal lymph node dissection in cases of
cholangiocarcinoma or gallbladder carcinoma.
Use of intraoperative ultrasound should be routine as it
often alters the planned operative management.
References
Blumgart LH, Fong Y, eds. Surgery of the Liver and Biliary

Tract, 3rd ed. Philadelphia, PA: Saunders; 2006.
Knol JA. Complications of Hepatic Surgery. In: Mulholland

MW, Doherty GM, eds. Complications in Surgery.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
Warren KW, Jenkins RL, Steele G, eds. Atlas of Surgery of

the Liver, Pancreas, and Biliary Tract. Norwalk, CT:
Appleton & Lange; 1991.



Pancreaticoduodenectomy >
Indications
Malignant lesions involving the head of pancreas, ampulla

of Vater, distal end of the common bile duct, or
duodenum.
Absence of metastasis.
Absence of arterial involvement.
Refractory severe pain from chronic pancreatitis.
Refractory to medical therapy.

Repeat hospital admissions.
Majority of disease limited to the head of the
pancreas.
Contraindications
Absolute
Evidence of metastatic disease.

Evidence of para-aortic nodes outside the field of
dissection.
Involvement of the aorta or vena cava.
Involvement of the superior mesenteric artery, hepatic
artery, or celiac axis.
Relative
Informed Consent
Survival following resection of periampullary and

pancreatic lesions depends on the site of the primary
tumor and stage.
The overall 5-year survival rate is 20–30% but may

be significantly better in patients with limited disease
burden.
Using prognostic modeling, a patient with a well-
differentiated small tumor (1 cm) and no nodal
involvement would have a 50% 5-year survival.
A patient with a poorly differentiated lesion > 4 cm
and 10 positive lymph nodes would have an
estimated 10% 3-year survival rate.
Expected Benefits
To remove malignancies involving the head of the

pancreas, ampulla, distal common bile duct, or duodenum
while restoring continuity of the biliary-pancreatic system.
Potential Risks
Surgical site infections (superficial or deep, abscess).

Bleeding.
Pneumonia.
Cardiovascular events.
Venous thromboembolism.
Delayed gastric emptying (15–40% of patients).
Anastomotic leak (most commonly from the
pancreaticojejunal anastomosis).
Abscess.
Biloma.
Pseudocyst.
Pancreatic fistulas.
Incomplete resection and positive margins.
Equipment
General surgery instrument tray.

Self-retaining abdominal retractor to aid exposure.
A surgical energy device (eg, harmonic scalpel or
LigaSure) is useful for dividing the jejunal mesentery.
Thoracoabdominal (TA) stapler.
Patient Preparation
Assessment of tumor resectability.
Fine-cut (3-mm) pancreatic protocol CT.

MRI and magnetic resonance
cholangiopancreatography (MRCP) can be useful to
clarify the relationship of the tumor to the blood
vessels and biliary system.
Endoscopic retrograde cholangiopancreatography
(ERCP) should be reserved for patients with
obstructive jaundice and no mass noted on CT.
ERCP with stent placement may be used for deeply
jaundiced patients.
Endoscopic ultrasound (EUS) is helpful in assessing
lymph node involvement and relationship to the
major vasculature.
Assessment of cardiovascular risk.
Patient Positioning

The entire abdomen is shaved and prepped.
The abdomen is entered through a midline incision or
bilateral subcostal "Chevron" incision, depending on
surgeon preference.
Procedure
The procedure can be divided into three stages:

assessment of resectability, resection, and
reestablishment of continuity.
Figure 15–1: The round ligament and falciform
ligaments are divided to provide adequate exposure.
A Kocher maneuver is performed initially to expose

the proximal duodenum and pancreas and ensure
that no direct extension of the tumor involves the
aorta or inferior vena cava.
The duodenum is retracted medially under tension,
and the peritoneum is incised along the lateral edge
of the duodenum.
The retroperitoneum is entered carefully to avoid
injury to the vena cava.
The gastrocolic omentum is divided and the lesser
sac is entered to expose the anterior surface of the
pancreas.
The right and transverse colon is reflected completely
down to expose the entire inferior portion of the
pancreas. During this step the gastroepiploic vein is
ligated and divided, and the middle colic vein can
also be divided if necessary to facilitate exposure of
the inferior border of the pancreas.
A cholecystectomy is performed in the standard
fashion.
After appropriate exposure, the resectability of the
lesion is assessed.
Figure 15–2: The hepatoduodenal ligament is dissected
to expose the common bile duct and hepatic artery.
The anterior surface of the portal vein is usually

identified by careful dissection between the common
bile duct and hepatic artery.
The gastroduodenal artery should also be identified
along the anterior surface of the pancreas, beneath
the first portion of the duodenum, and its takeoff
from the common hepatic artery should be carefully
identified.
The portal vein is freed from the posterior surface of
the neck of the pancreas using careful blunt
dissection.
The middle colic vein should be identified and
followed down to the inferior border of the pancreas
to help identify the superior mesenteric vein, as
shown in Figure 15–1.
Additional careful dissection should be performed to
create a "tunnel" under the neck of the pancreas,
demonstrating that the plane between the neck of
the pancreas and the portal vein and superior
mesenteric vein is free and that there is no evidence
of tumor involvement.
Alternatively, the right and transverse colon can be
extensively mobilized, allowing identification of the
superior mesenteric vein as it crosses over the third
portion of the duodenum and goes under the neck of
the pancreas.
No further dissection, and more specifically, no
structures should be divided prior to confirming that
the vein is free of tumor involvement, unless the
surgeon is prepared to proceed with en bloc vein
resection.
Figure 15–3: The antrum of the stomach is stapled and
divided using the landmarks of a Billroth I
hemigastrectomy.
The hepatic artery within the hepatoduodenal

ligament is palpated and dissected free to identify the
gastroduodenal and right gastric vessels, which can
be doubly ligated and divided.
Prior to division of the gastroduodenal artery, it is
important to briefly occlude this artery ("pinch test")
while palpating the hepatic artery to confirm that
there is no decrease in the hepatic arterial flow.
On occasion, in individuals with a celiac stenosis or
other congenital arterial anomalies, the majority of
the hepatic arterial blood flow may come via
collateral vessels through the gastroduodenal artery.
Although rare, hepatic necrosis can occur in these
patients following division of the gastroduodenal
artery. In such cases, a Whipple procedure is
contraindicated unless hepatic arterial flow can be
reestablished via other mechanisms, including
possible arterial bypass or endovascular intervention.
The proximal stomach is packed away in the left
upper quadrant, and the distal stomach is retracted
inferiorly and to the right to aid exposure of the
common bile duct.
The common bile duct is divided and the distal end is
ligated using a silk suture.
The proximal common bile duct can be occluded
temporarily with a Bulldog clamp.
Figure 15–4: The duodenum is dissected free from the
ligament of Treitz.
Multiple small feeding arteries and veins in the

duodenal mesentery must be clamped and tied to
minimize bleeding or sealed using a surgical energy
device (eg, harmonic scalpel, LigaSure).
The proximal jejunum is divided about 10 cm distal
to the ligament of Treitz using a GIA stapler, and the
jejunal mesentery is divided between clamps and
ligated with silk sutures down to the level of the
ligament of Treitz.
The divided end of the jejunum can then be delivered
beneath the mesentery of the small bowel.
Figure 15–5: Hemostatic transfixion sutures are placed
both inferiorly and superiorly in the pancreas body on
either side of the line of planned transection.
The pancreas can be divided using electrocautery or

sharply with a scalpel.
The pancreatic duct is identified, and any bleeding
vessels are suture ligated with 4-0 or 5-0 Prolene.
Figure 15–6: The uncinate process is dissected free from
the superior mesenteric vein.
The superior and inferior pancreaticoduodenal veins

are ligated and divided along with all other small
branches that enter the lateral superior mesenteric
and portal vein.
Figure 15–7: The superior mesenteric vein is retracted
medially, exposing the retropancreatic tissue.
The retropancreatic attachments to the uncinate

process are then divided.
Either a TA stapler or traditional clamping and tying
can be used. Clamping and tying is preferred for
resection of malignancies. The TA stapler is preferred
for benign disease.
The specimen, which should now be entirely free,
should be sent for pathologic and frozen section
examination of the biliary and pancreatic margins.
The retroperitoneal margin should be inked by the
surgeon prior to sending the specimen for pathologic
examination.
Figure 15–8: The jejunal limb is delivered up to the right
upper quadrant in a retrocolic fashion through an
avascular window in the transverse mesocolon.
The pancreaticojejunostomy is performed using an

end-to-side anastomosis.
The outer layer of the pancreaticojejunostomy is
performed using interrupted 3-0 or 4-0 silk sutures
between the capsule of the pancreas and the
seromuscular layer of the jejunum.
The inner layer of the anastomosis is performed
using interrupted absorbable suture (4-0 or 5-0 PDS
or Vicryl) between the pancreatic duct and a full-
thickness layer of jejunum.
Occasionally, a sterile 5 or 8 French pediatric feeding
tube with extra side holes cut into it can be used to
stent the pancreatic-jejunal anastomosis.
The choledochojejunostomy is subsequently
performed in an end-to-side fashion using a singled
layer of interrupted absorbable suture, such as 4-0 or
5-0 PDS or Vicryl.
The defect in the mesocolon is closed surrounding the
delivered limb of jejunum to avoid internal
herniation.
The gastrojejunostomy is then completed with an
antecolic loop of jejunum and creation of a two-
layered hand-sewn anastomosis.
The outer layer of the anastomosis is performed
using interrupted seromuscular 3-0 silk sutures and
the inner layer is a full-thickness running layer of 3-0
Vicryl or other absorbable suture.
The abdomen is copiously irrigated and two drains
are placed within the abdominal cavity in apposition
to the biliary and pancreatic anastomoses.
The midline incision is then closed using standard
techniques.
Figure 15–1
Figure 15–2
Figure 15–3
Figure 15–4
Figure 15–5
Figure 15–6
Figure 15–7
Figure 15–8
Postoperative Care
Nothing by mouth with nasogastric tube decompression.

Oral diet is advanced following removal of the nasogastric
tube and once ileus has resolved, usually within 48–72
hours postoperatively.
Monitoring of abdominal drain fluids for evidence of a
biliary or pancreatic leak.

Pancreatic leak.
Surgical site infections.
Gastroduodenal artery pseudoaneurysm.
Pearls and Tips
If metastatic disease is suspected but cannot be

confirmed using radiologic studies or EUS, consider
diagnostic laparoscopy prior to formal laparotomy.
Diagnostic laparoscopy can detect carcinomatosis and
some liver metastases, but it is not helpful in determining
blood vessel or retroperitoneal involvement.
No organs should be divided and no irreversible
maneuvers performed until resectability is confirmed.
If a patient has significant involvement of the portal vein
or superior mesenteric vein, consider preoperative
chemotherapy and radiation prior to an attempt at
resection.
Portal vein or superior mesenteric vein involvement does
not render a patient's tumor unresectable, and an
aggressive surgical approach with vein resection and
reconstruction should be considered in appropriate
patients.
Perform a "pinch test" (eg, occlusion of the
gastroduodenal artery) prior to division of the
gastroduodenal artery to confirm that there is no
significant arterial flow to the hepatic artery via collaterals
through the gastroduodenal artery.
References
Brennan MF, Kattan MW, Klimstra D, Conlon K. Prognostic

nomogram for patients undergoing resection for
adenocarcinoma of the pancreas. Ann Surg. 2004;240:293–
Nakeeb A, Lillemoe KD, Yeo CJ, Cameron JC. Neoplasms of
the Exocrine Pancreas. In: Mulholland MW, Lillemoe KD,
Simeone DM. Complications of Pancreatic Surgery. In:

Mullholand MW, Doherty GM, eds. Complications in Surgery.
472.


Current Procedures: Surgery > Chapter 16. Distal

Pancreatectomy >
Indications
Distal pancreatic solid mass.
Neuroendocrine tumor.
Pancreatic adenocarcinoma.
Solid neoplasm of indeterminate diagnosis.
Distal pancreatic mucinous cystic neoplasms.
Asymptomatic, 3 cm in size.
Symptomatic, any size.
Presence of a solid component.
Dilated main pancreatic duct.
Distal pancreatic symptomatic serous cystadenoma.
Chronic calcific pancreatitis or small symptomatic
pseudocyst limited to pancreatic tail (less common).
Contraindications
Absolute
Proximal mass requiring pancreatoduodenectomy.
Known metastatic disease.
Local invasion of structures that cannot be resected en
bloc with the pancreas.
Mass encasing mesenteric vessels, with loss of usual fat
planes noted on preoperative imaging (CT, MRI, or
endoscopic ultrasound [EUS]).
Relative
Splenic vein thrombosis.
Informed Consent
Expected Benefits
Surgical cure of a neoplasm in the distal pancreas.

Prevention of malignant transformation of mucinous cystic
neoplasms.
Treatment of symptomatic benign disease.
Potential Risks
Surgical site infection, bleeding, and damage to adjacent

structures.
Removal of the spleen.
Should this be necessary, patients are at risk for the

rare complication of post-splenectomy sepsis.
Complications unique to operations on the pancreas
include:
Postoperative pancreatitis.
Pancreatic leaks.
Pancreatic fistula formation.
Equipment
No special equipment is needed.

A self-retaining retractor helps facilitate exposure of the
operative field.
A surgical energy device (eg, harmonic scalpel, LigaSure)
is extremely useful.
Depending on surgeon preference, a surgical stapler may
be used to transect the pancreatic tail. In that case, a
thoracoabdominal (TA) or gastrointestinal anastomosis
(GIA) stapler is used.
Patient Preparation
Thorough preoperative evaluation is essential before

undertaking this procedure.
For symptomatic patients, delineation of the presenting
symptoms and correlation of these symptoms with the
mass in the pancreatic tail or body is critical.
Potentially useful tests include:
Abdominal CT, ultrasonography.

(ERCP) or EUS.
Magnetic resonance cholangiopancreatography
(MRCP).
For cystic neoplasms, cyst fluid is often obtained during
EUS and analysis is performed to differentiate mucinous
from serous cystic lesions and to determine cyst fluid CEA
levels.
Side branch versus main duct intraductal papillary
mucinous neoplasms should be differentiated
preoperatively using ERCP, MRCP, or EUS, if at all
possible.
Patients with persistent hypoglycemia and suspected
insulinoma should receive glucose supplementation.
Patients with refractory ulcers, elevated gastrin levels,
and the suspicion of a gastrinoma should receive
preoperative treatment for acid secretion and appropriate
fluid and electrolyte supplementation.
If splenectomy is planned, patients should undergo
immunization for encapsulated organisms at least 2
weeks before surgery.
Patient Positioning

The skin is prepared from the level of the nipples to the
pubis, extending along the flank.
The abdomen is entered through a midline incision.
Alternatively, a bilateral subcostal incision may be used.
Procedure
Figure 16–1: Ligation of the short gastric vessels.
For resection of the distal pancreas, the standard

approach is through an upper midline incision.
The pancreas is approached as in other pancreatic
procedures through the lesser sac of the omentum.
The peritoneal covering along the inferior border of
the pancreas is divided from the superior mesenteric
vessels laterally toward the tail.
Vessels encountered in this space should be ligated
and divided or sealed with the surgical energy device.
If concern exists for malignancy, then splenectomy is
always performed; however, if pancreatectomy is
being performed for benign disease, then spleen-
preserving distal pancreatectomy is possible and the
decision regarding splenectomy will be up to the
surgeon.
If splenectomy is to be performed, the spleen is
mobilized anteriorly and to the right, and off of the
left kidney in the retroperitoneum (Gerota's fascia).
To mobilize the tail of the pancreas, the short gastric
vessels that connect the splenic hilum with the
greater curvature of the stomach must be isolated
and divided.
This can be done either via standard division and
ligation with fine silk sutures, or with the use of the
surgical energy device.
Figure 16–2: Division of the splenocolic ligament.
Once the spleen, still attached to the distal pancreas,

has been liberated from the greater curvature of the
stomach, its peritoneal attachment to the splenic
flexure of the colon, the splenocolic ligament, must
be divided.
The spleen is rotated gently to the right and clamps
are placed across the splenocolic ligament, as shown.
The ligament itself is then divided sharply and the
ends ligated.
Figure 16–3: Mobilization of the spleen.
Once the splenocolic ligament has been divided, the
spleen (attached to the tail of the pancreas) is
rotated to the right.
Figure 16–4: Dissection along the inferior pancreatic
margin.
The inferior and posterior peritoneal attachments of

the pancreas are sharply divided.
The inferior mesenteric vein, if identified during this
step, may be ligated and divided.
Figure 16–5: Mobilization of the spleen and pancreatic
tail.
Once the posterior peritoneal attachments have been

divided and the tail of the pancreas freed, the entire
distal portion of the organ may be rotated medially.
Figure 16–6: Division of the splenic artery and vein.
The splenic artery is identified at its origin from the

celiac trunk and traced distally along the posterior
aspect of the gland.
It is encircled, then doubly clamped and ligated.
The proximal (celiac) portion is transfixed with a
suture ligature.
The splenic vein is then isolated, and its confluence
with the portal vein is carefully identified.
The vein is then divided between clamps, and the
proximal (remaining) portion is oversewn with a 5-0
Prolene suture.
Figure 16–7: Division of the pancreas.
The pancreas is rotated medially via traction on the

splenic tail into the operative field.
A TA (shown) or GIA stapler can be used to divide the
pancreas.
If a TA stapler is used, the pancreas is then divided
sharply using a scalpel.
The duct should be oversewn and transfixed with a
suture if visible.
Figure 16–8A, B: Suturing the remainder of the
pancreas.
If the pancreas is thick and a stapler cannot be used,

it can be divided sharply with a scalpel or with a
surgical energy device.
The duct is then transfixed with a suture (Figure 16–
8A).
A row of interrupted mattress sutures is placed
through the body of the residual pancreas and tied
(Figure 16–8B).
Additional bites should be taken at sites of bleeding.
Depending on surgeon preference, a drain can be left in
the left upper quadrant near the transected pancreas,
whether stapled or oversewn.
Figure 16–1
Figure 16–2
Figure 16–3
Figure 16–4
Figure 16–5
Figure 16–6
Figure 16–7
Figure 16–8A–B
Postoperative Care

Oral diet is resumed following removal of the nasogastric
tube and resolution of postoperative ileus.
Pancreatic leak.
Pancreatic fistula.
Pancreatitis.
Bleeding.
Pearls and Tips
Intraoperative ultrasound can be useful if there is

difficulty identifying the mass (cystic or solid) in the
pancreas at the time of operation.
To avoid inadvertent injury to the common hepatic artery,
trace the splenic artery back to its origin from the celiac
axis and visualize all branches prior to ligation of the
splenic artery.
For benign lesions, spleen-preserving distal
pancreatectomy is possible and a medial-to-lateral
approach is preferred.
References
Bell RH Jr, Rikkers LF, Mulholland MW. Digestive Tract

Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven
Publishers; 1996.
Doherty GM, Way LW. Pancreas. In: Doherty GM, Way LW,
eds. Current Surgical Diagnosis and Treatment, 12th ed. New
York, NY: McGraw-Hill; 2005.
Riall TS, Yeo CJ. Neoplasms of the Endocrine Pancreas. In:

Greenfield's Surgery: Scientific Principles and Practice, 4th ed.



Management of Chronic Pancreatitis >
Indications
Longitudinal Pancreaticojejunostomy
Severe persistent pain from chronic pancreatitis.
Refractory to medical therapy.

Repeated hospital admissions.
Dilated pancreatic duct > 8 mm in diameter.
Pancreatic Pseudocyst-Gastrostomy and Pseudocyst-

Jejunostomy
Persistent pancreatic pseudocyst present for > 6 weeks

(ie, at which time the wall should be mature enough to
hold sutures).
Contraindications
Absolute
Absence of pain.
Pancreatic cancer.
Cirrhosis.
Relative

Jejunostomy
Absolute
Cystadenocarcinoma is a contraindication to enteric

drainage and should be resected.
Pseudocyst that has been present for < 6 weeks.
Relative
Informed Consent
Expected Benefits: Longitudinal Pancreaticojejunostomy
To provide pain relief while preserving pancreatic function.

Pain is improved in 60–70% of cases.
Expected Benefits: Pancreatic Pseudocyst-Gastrostomy and

Pseudocyst-Jejunostomy
Pseudocysts generally do not resolve spontaneously if

present for > 6 weeks; therefore, operative drainage is
often entertained following that interval.
Potential Risks Associated with Both Procedures

Surgical site infection (either deep or superficial).
Bleeding.
Systemic complications of major surgery (pneumonia,
venous thromboembolism, and cardiovascular events).
Pancreatic leaks and fistula, while possible, are relatively
less common than with operations on less fibrotic
pancreatic parenchyma.
Equipment

A self-retaining retractor is useful to facilitate exposure of
the operative field, and a gastrointestinal anastomosis
(GIA) stapler for dividing the small bowel.
Patient Preparation
A thorough preoperative workup is essential before

recommending a pancreaticojejunostomy.
The goal is to confirm the diagnosis and rule out

other causes of pain.
Sources other than the patient should confirm that he
or she has abstained from alcohol use for a
significant period of time.
The diameter of the pancreatic duct and location of
the inflammation should be determined.
Any biliary or duodenal obstruction or pancreatic
pseudocysts should be identified so that these
conditions can be addressed concurrently.
Potentially useful studies include:
Abdominal CT scanning.
Ultrasonography.
(ERCP).
Magnetic resonance cholangiopancreatography.
CT scans can show pancreatic ductal dilation as well as
calcifications, pseudocysts, masses, and biliary dilation.
If a pseudocyst is present, abdominal CT scan or
ultrasonography can usually determine the size,
chronicity, and location of the pseudocyst in relation to
the stomach or duodenum.
The patient's physiologic fitness should also be assessed.
Patient Positioning

Procedure
Figure 17–1: Abdominal CT in a patient with chronic

pancreatitis shows a dilated pancreatic duct (arrow).
Figure 17–2: Location of the pancreatic duct.
After entering the lesser sac, the stomach is reflected

upward.
The posterior wall of the stomach may be adherent to
the anterior surface of the pancreas due to
peripancreatic inflammation.
After the adhesions are carefully divided, the
pancreas is palpated to identify the pancreatic duct.
The dilated duct is aspirated with a 22-gauge needle.
If the duct cannot be identified, a Greenlee maneuver
can be performed with an oblique incision made
anteriorly near the junction of the body and tail until
the duct is identified.
Intraoperative ultrasound can also be used to identify
the duct.
Narrowing of the distal common bile duct occurs in
10–15% of cases of chronic pancreatitis and should
be treated at the same time.
Cholangiography typically shows a dilated common
bile duct with a smooth elongated narrowing of the
intrapancreatic bile duct.
Figure 17–3: After the dilated pancreatic duct has been
identified, a longitudinal incision is made.
The incision is then extended along the entire length

of the duct from the tail of the pancreas to within 2–3
cm of the duodenum.
Any debris or calculi identified are removed.
The fibrotic pancreatic tissue is not well vascularized,
although larger vessels are present near the
duodenum.
Hemostasis is obtained with electrocautery and
suture ligatures.
The Roux-en-Y limb is then prepared by dividing the
jejunum approximately 20 cm from the ligament of
Treitz using a linear GIA stapler.
After the staple line is oversewn, the distal limb is
brought through the transverse mesocolon and
incised along the antimesenteric border.
Figure 17–4: The posterior wall of the anastomosis is
formed with interrupted nonabsorbable sutures.
The duct wall and overlying parenchyma are
thickened and fibrotic and hold sutures well.
Full-thickness bites are taken of the jejunum and the
pancreatic duct with the overlying fibrotic pancreatic
tissue.
Some surgeons complete the anastomosis in two
layers, with an additional layer incorporating the
pancreatic capsule and seromuscular layer of the
jejunum.
Figure 17–5: After the posterior layer has been finished,
the anterior wall is completed in a similar fashion, taking
full-thickness bites of the jejunum and the pancreatic duct
with the overlying pancreatic tissue.
Figure 17–6: The completed longitudinal
pancreaticojejunostomy.
The proximal enteroenterostomy has been performed

in an end-to-side fashion approximately 50 cm from
the pancreatic anastomosis.
The Roux limb is sutured to the transverse mesocolon
to prevent internal hernias.
Figure 17–1
Figure 17–2
Figure 17–3
Figure 17–4
Figure 17–5
Figure 17–6
Jejunostomy
Figure 17–7: The abdominal CT scan shows a pancreatic

pseudocyst anterior to the pancreatic body. This is closely
adherent to the posterior aspect of the stomach (arrow).
A pancreatic pseudocyst adherent to the posterior

wall of the stomach can be drained by a pseudocyst-
gastrostomy when the cyst wall has matured
sufficiently to be able to hold sutures.
Figure 17–8: A 5-cm long gastrotomy is made in the
anterior wall of the stomach. Care is taken to avoid the
antrum.
Figure 17–9: An 18-gauge needle is inserted through the
posterior wall of the stomach to confirm the location and
presence of the pseudocyst. A sample of the fluid is sent
for cytologic testing.
Figure 17–10: The common wall between the posterior
stomach and anterior pseudocyst is incised and an
elliptical section is removed and sent for frozen section
analysis to rule out the presence of a cystic neoplasm (ie,
cystadenoma or cystadenocarcinoma). The debris and
fluid within the pseudocyst should be removed gently to
prevent significant hemorrhage.
Figure 17–11: The posterior wall of the stomach is
sutured to the anterior wall of the pseudocyst using
interrupted nonabsorbable sutures.
Some surgeons use a running suture to improve

hemostasis while others do not think that sutures are
necessary as long as there is adequate hemostasis
since the stomach and pseudocyst are densely
adherent.
The gastrotomy is then closed in two layers.
Figure 17–12: When the pseudocyst is not adherent to
the stomach or duodenum but the wall is mature enough
to hold sutures, a cyst-jejunostomy can be performed.
The pseudocyst is aspirated with an 18-gauge needle.

An elliptical section is removed at the most
dependent portion and sent for frozen section
analysis.
The interior of the pseudocyst is examined, and
biopsy specimens are obtained from any suspicious
areas.
A Roux limb of jejunum is then brought up anterior to
the transverse colon and anastomosed in a side-to-
side fashion to the pseudocyst.
Full-thickness bites are taken using interrupted
nonabsorbable sutures.
The mesenteric defect is then closed to prevent
internal hernias.
Large pseudocysts adherent to the stomach but extending
well below the greater curvature of the stomach are
better drained with cystojejunostomy than
cystogastrostomy.
Figure 17–7
Figure 17–8
Figure 17–9
Figure 17–10
Figure 17–11
Figure 17–12
Postoperative Care

Oral diet is advanced following removal of the nasogastric
tube and resolution of the postoperative ileus.
Pancreatic leak.
Surgical site infections.
Bleeding from within the pseudocyst cavity.
Can occur intraoperatively or postoperatively and be

very difficult to control.
Angiographic techniques (eg, embolization) can
sometimes be effective in controlling hemorrhage
from the pseudocyst cavity.
Pearls and Tips
Operative pancreatography or intraoperative ultrasound

can be used if there is difficulty identifying the pancreatic
duct.
During division of the duct, a biliary probe or tip of a
finger can be used to follow the path of the pancreatic
duct.

Jejunostomy
Be gentle with the internal surface of the cyst to avoid

causing hemorrhage.
Ensure that the cystogastrostomy opening is large enough
to pass necrotic tissue into the gastrointestinal tract.
The cyst resolves rapidly if completely drained, and
esophagogastroduodenoscopy can document complete
healing of the cystogastrostomy site within several days.
References
Duval MK Jr. Caudal pancreaticojejunostomy for chronic

relapsing pancreatitis. Ann Surg. 1954;140:775–785.
Frey CF. Pancreatic pseudocyst—operative strategy. Ann Surg.

1978;188:652–662.[PubMed: 309751] [Full Text]
Kohler H, Schafmayer A, Ludtke FE, et al. Surgical treatment

of pancreatic pseudocysts. Br J Surg. 1987;74:813–815.
Puestow CB, Gillesby WJ. Pancreaticojejunostomy for chronic

relapsing pancreatitis: an evaluation. Surgery. 1967;50:859.



Splenectomy >
Indications
Splenic trauma with hemorrhage.

Splenic cysts or splenic mass.
Splenic abscess.
Hematologic disorders.
Idiopathic thrombocytopenic purpura.

Hemolytic anemia.
Hereditary spherocytosis.
Other hereditary or autoimmune anemias.
Severe hypersplenism.
Perisplenic malignancy.
Splenic artery aneurysm.
Splenic vein thrombosis with left-sided portal
hypertension.
Contraindications
Portal hypertension due to liver disease.
Thrombocytopenia is not a contraindication of
splenectomy.
Although preoperative transfusion is not

recommended, intraoperative transfusion may be
required should coagulopathic bleeding occur.
Informed Consent
Expected Benefits
Cessation or prevention of life-threatening hemorrhage.

Treatment of hematologic disorders, malignancy, or
symptomatic mass or hypersplenism.
Potential Risks
Post-splenectomy sepsis.
Bleeding.
Infection (wound or intra-abdominal abscess).
Pancreatitis or pancreatic leak.
Damage to surrounding structures (stomach,
diaphragm, colon, etc).
Recurrence of primary disease (thrombocytopenia,
etc).
Equipment
Self-retaining retractor (eg, Bookwalter, Thompson,

Upper Hand, etc).
Bipolar cautery, LigaSure, harmonic scalpel, or similar
instrument is needed for the laparoscopic procedure
and may be used for the open procedure as well.
Patient Preparation
Patients should be vaccinated against encapsulated

organisms preoperatively.
Pneumococcus.
Meningococcus.
Haemophilus influenzae.
Patient Positioning
Laparoscopic splenectomy is preferentially performed in

the right lateral decubitus position but may also be
performed with the patient supine.
Open splenectomy is performed in the supine position.
Procedure
Laparoscopic Splenectomy
Figure 18–1: The gastrosplenic ligament contains the

short gastric vessels and must be divided to obtain
access to the splenic vessels, whereas the
splenophrenic and splenorenal ligaments are relatively
avascular.
Figure 18–2A, B: Laparoscopic splenectomy can be
performed either in the supine (Figure 18–2A) or right
lateral decubitus (Figure 18–2B) positions using similar
port placement. The lateral decubitus position is
preferred.
Figure 18–3: The gastrosplenic ligament is transected
using bipolar cautery or harmonic scalpel to ensure
hemostasis of the short gastric vessels, thereby
obtaining access to the splenic vessels.
Figure 18–4: Next, the relatively avascular splenocolic
and splenorenal ligaments are divided along with the
other attachments, freeing the spleen.
Figure 18–5: A vascular stapler is used to divide the
splenic artery and vein. The artery is always divided
before the vein.
The specimen is placed into an endoscopic retrieval
bag. Depending on its size, the spleen may require
maceration with a ring forceps or finger before it can
be removed from the body.
Figure 18–1
Figure 18–2A–B
Figure 18–3
Figure 18–4
Figure 18–5
Open Splenectomy
Figure 18–6: Open splenectomy may be performed

through a midline or left subcostal incision.
To reduce intraoperative blood loss, some surgeons

choose to begin by opening the lesser sac and
ligating the splenic artery.
Figure 18–7: The surgeon's left hand is passed
laterally to the spleen, bluntly dissecting the
splenophrenic and splenorenal ligaments, and
mobilizing the spleen anteromedially into the wound.
Figure 18–8: With the spleen fully mobilized, the
splenic vessels are either taken between clamps and
ligated or taken with a vascular stapler. Again, the
artery is always ligated before the vein.
Any remaining short gastric vessels or other
attachments are divided, freeing the spleen from the
abdomen.
Figure 18–6
Figure 18–7
Figure 18–8
Postoperative Care
Nasogastric decompression.
For 12–36 hours after open splenectomy.

Optional for laparoscopic splenectomy.
Diet is advanced as tolerated after removal of the
nasogastric tube.
If the patient has not been vaccinated preoperatively
(eg, in cases of splenectomy for trauma or iatrogenic
injury), this should be done promptly.
Postoperative bleeding or hemorrhage.
Classically associated with the short gastric

vessels.
Gastric injury or leak.
Pancreatic injury resulting in pancreatitis or pancreatic
leak or fistula.
Thrombocytosis.
Aspirin is prescribed if this occurs.
Splenic vein thrombosis.

Left lower lobe atelectasis or pneumonia.
Superficial or deep space surgical site infection.
Recurrence of disease (if splenectomy is performed
for hematologic disease).
Pearls and Tips
Consider preoperative embolization in patients with

severe hypersplenism.
This may reduce intraoperative blood loss.

After a difficult or traumatic dissection, consider
placement of a drain in the left upper quadrant at the
conclusion of the operation.
Test the drain effluent for evidence of a pancreatic

leak after the patient resumes a normal diet and
before removing the drain.
Instruct patients to seek prompt medical evaluation for
signs of infection, which may indicate post-splenectomy
sepsis.
References
Fraker DL. Splenic Disorders. In: Mulholland MW, Lillimoe
KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific
Mourtzoukou EG, Pappas G, Peppas G, Falagas ME.

Vaccination of asplenic or hyposplenic adults. Br J Surg.
2008;95:273–280.[PubMed: 18278784] [Full Text]
Poulin EC, Schlachta CM, Mamazza J. Splenectomy. In:

Souba WW, Fink MP, Jurkovich GJ, et al, eds. ACS Surgery:
Principles and Practice. WebMD Professional Publishing;
2007.
Rescorla FJ, West KW, Engum SA, Grosfeld JL. Laparoscopic

splenic procedures in children: experience in 231 children.
Ann Surg. 2007;246:683–688.[PubMed: 17893505] [Full
Text]


Current Procedures: Surgery > Chapter 19. Small Bowel

Resection >
Indications
Tumor.
Ischemia or incarceration.
Trauma or perforation.
Fistula.
Ulcer or bleeding.
Obstruction.
Stricture or Crohn's disease.
Contraindications
Absolute
Poor blood supply to bowel ends (ie, radiation-injured

bowel).
Unclear bowel viability after a revascularization
procedure.
Both ends of the small bowel may be brought up to

skin level as temporary ostomies if the distal small
bowel is involved. A proximal small bowel ostomy will
create a high-output fistula that is difficult to
manage.
Alternatively, both ends can be stapled closed and a
plan made for a second-look laparotomy in 24–48
hours.
In extreme situations (eg, acute mesenteric ischemia
with gangrene extending from the ligament of Treitz
to mid colon), the likelihood of survival is very small.
This is an absolute contraindication to attempted
resection and anastomosis.
Inadequate tumor margins.
If a tumor is unresectable, and small bowel

obstruction is likely to occur, a side-to-side
anastomosis in uninvolved bowel proximal and distal
to the obstruction may be performed as a bypass
procedure, leaving the tumor in situ.
Relative
Peritoneal sepsis.
Hemodynamically precarious patient.
Extensive Crohn's disease.
Stricturoplasty should be considered to minimize the

need for extensive resection and risk of short gut
syndrome; 90 cm is the approximate shortest length
of small bowel that might still support a viable oral
nutrition program.
Informed Consent
Expected Benefits
Relief of obstruction.
Control of gastrointestinal hemorrhage.
Treatment of gastrointestinal ischemia, necrosis, or
perforation.
Potential Risks
Common complications include:
Surgical site infection (either deep or superficial).

Bleeding.
Systemic complications of major surgery, including
pneumonia, venous thromboembolism, and
cardiovascular events.
Small bowel obstruction, stricture, and need for further
surgery are also potential risks of small bowel resection.
Patients with extensive intra-abdominal sepsis or who are
in a malnourished state are at increased risk for
anastomotic leak and enteric fistula.
Equipment
Self-retaining retractors are useful to help provide

adequate exposure and access.
Gastrointestinal anastomosis (GIA) stapler or
thoracoabdominal (TA) stapler, or both (depending on
surgeon's preference for anastomotic technique).
Patient Preparation
Preoperative Evaluation
CT scan.
Small bowel follow-through versus small bowel
enteroclysis.
As indicated for bleeding:
Esophagogastroduodenoscopy, push enteroscopy, or

double balloon enteroscopy.
Capsule endoscopy.
Nuclear scan.
Angiography.
At the Time of the Procedure
Nutritional status should be optimized preoperatively if

possible.
Treatment of systemic illness.
Intravenous perioperative antibiotics.
Nasogastric tube, in cases of obstruction.
Patient Positioning

The abdomen is usually entered through a midline
incision.
Procedure
Hand-Sewn Anastomosis
The abdomen is entered via a standard midline incision.

A thorough four-quadrant examination should be
performed, with lysis only of those adhesions necessary
to gain access to the area of pathology.
Figure 19–1: After the margins of resection have been
determined (dotted line), electrocautery is used to score
the mesentery to encompass only vessels and lymph
nodes (if cancer operation) related to the section to be
removed.
The first step in resection is to make a window in the
mesentery adjacent to the bowel that is free of blood
vessels at the site of the planned margins. This can be
done using gentle dissection with a right-angle or Coller
clamp.
Figure 19–2A,B: Creation of this window allows a GIA
stapler to be passed through on either side of the
segment of bowel to be divided (Figure 19–2A). Typically
the blue load (3.8 mm) is used to divide the bowel,
creating two staple lines and two ends (Figure 19–2B).
After the bowel is divided, the mesentery can be divided
using a combination of electrocautery for further
dissection plus hemostats with free ties, suture ligatures,
or a harmonic scalpel along the previously scored line.
Figure 19–3: After applying atraumatic bowel clamps,
the first (posterior) layer of 3-0 silk suture is placed in an
interrupted fashion taking seromuscular bites. This is the
Lembert stitch. Stay sutures on either end help keep the
bowel ends oriented appropriately to facilitate accurate
placement of stitches.
Figure 19–4: The staple line is excised using the cut
setting of the electrocautery device. A 2-cm area should
be allowed at the edge of the bowel clamp for a two-layer
anastomosis.
Figure 19–5: The inner layer is started using a double-
armed 3-0 absorbable (PDS or Vicryl) suture.
Starting in the midpoint with a full-thickness bite, the

suture is tied. Then with one arm, the posterior inner
layer is closed by including full-thickness bites of
mucosa, submucosa, and seromuscular tissue in
continuous fashion.
Care should be taken to avoid inverting too much
mucosa, which would narrow the anastomosis.
Instead, just enough mucosa (1–2 mm),
approximately half the thickness of the other layers,
should be taken.
To reduce strangulation of tissues within the
anastomosis, the posterior full-thickness sutures are
often locked to prevent the purse-string effect. This is
usually a matter of surgeon's preference.
Figure 19–6: After the corner has been turned, a
transition stitch from suturing inside the bowel to outside
is taken to facilitate completion of the anterior layer.
Typically a narrow full-thickness horizontal mattress

suture is used to end up with the suture on the
outside.
This is repeated with the other arm of the continuous
suture heading in the opposite direction.
After the transition stitch is completed, the suture is
set up to complete the anterior layer.
A continuous Connell (horizontal mattress) stitch
minimizes mucosal inversion and is another way to
optimize luminal diameter.
Continuing with the over-and-over stitch is
acceptable as well. The other arm of the suture can
meet in the middle and be tied down to complete the
full circumference of the anastomosis.
Figure 19–7: The outer anterior layer of interrupted
seromuscular (Lembert) stitches can then be placed
easily.
Confirmation of a patent lumen can be made by

gently pinching the thumb and first finger at the
bowel anastomosis to verify that a patent lumen is
present.
Figure 19–8: The mesentery should then be closed with
3-0 interrupted or continuous silk sutures to prevent
internal herniation.
Figure 19–1
Figure 19–2A–B
Figure 19–3
Figure 19–4
Figure 19–5
Figure 19–6
Figure 19–7
Figure 19–8
Stapled Anastomosis
All staplers are sized 3.8 mm unless the bowel is thick, in

which case a 4.8-mm stapler is used.
Figure 19–9A-C: First, the two segments of the small
bowel to be used for the anastomosis are positioned in
antiparallel apposition.
The bowel segments should be checked to ensure

that no mesentery is trapped between them.
Adjacent corners of the staple lines are cut off
(Figure 19–9A) and a GIA-60 mm or GIA-80 mm
cutting stapler is inserted, with one limb of the
stapler in the distal small bowel and the other limb in
the proximal small bowel segment (Figure 19–9B).
The stapler is fired, which should make a connection
with the length of the stapler between the two ends
of the bowel, creating a side-to-side, functional, end-
to-end anastomosis (Figure 19–9C).
The staple line is inspected by eversion to identify
any sites of bleeding. Small interrupted 4-0 silk
sutures can be placed to control any bleeding, or,
alternatively, very light and controlled application of
electrocautery may suffice.
Figure 19–10A, B: The resultant enteroenterotomy is
then closed using a TA stapler.
Firing of the stapler completes the anastomosis.

The staple line is often inverted by placing an outer
layer of 3-0 silk interrupted Lembert sutures.
Figure 19–9A–C
Figure 19–10A–B
Postoperative Care
Epidural analgesia can decrease the amount of

postoperative pain and ileus.
The nasogastric tube should be left in place until
resolution of postoperative ileus with nasogastric output <
200 mL per 8-hour shift. Diet should be advanced slowly
after the passage of flatus.
Perioperative antibiotics can be discontinued
postoperatively if there has been no intraoperative
contamination.
Parenteral nutrition should be considered if the patient
was malnourished preoperatively, if delayed resumption of
oral intake is anticipated, or if prolonged postoperative
ileus is expected.
Wound infection.
Prolonged ileus.
Mechanical obstruction.
Anastomotic bleeding.
Anastomotic leak.
Enterocutaneous fistula.
Pearls and Tips
To determine adequacy of the blood supply, note the color

of bowel ends and the presence of pulsatile flow in
terminal arterial branches at bowel ends.
Free up the bowel ends to ensure sufficient mobility to
achieve a tension-free anastomosis.
Accurate apposition of the layers of bowel is critical:
submucosa to submucosa and seromuscular to
seromuscular layers.
There should be no fat, other tissues, or hematoma within
the anastomosis. This can be a barrier to healing, and can
increase the risk of leak.
Clear no more than a 1-cm wide area of serosa for
anastomosis to avoid devitalization.
Avoid excessive force or tension when suturing the
anastomosis to prevent strangulation and leak. Allow for
some amount of postoperative edema.
Avoid excessive manipulation of the bowel ends with
forceps to prevent further injury and bruising.
References
Irvin TT, Goligher JC. Aetiology of disruption of intestinal

anastomosis. Brit J Surg. 1973;60:461–464.[PubMed:
Ravitch MM, Steichen FM. Techniques of staple suturing in the

gastrointestinal tract. Ann Surg. 1972;175:815–837.
Scott-Conner CE, ed. Chassin's Operative Strategy in General

Surgery, 3rd ed. New York, NY: Springer; 2001.
Souba WW, Fink MP, Jurkovich GJ, et al, eds. ACS Surgery:
Principles and Practice. WebMD Professional Publishing; 2003.



Appendectomy >
Indications
Clinical suspicion of appendicitis in an ill-appearing

patient.
Contraindications
Absolute
None.
Relative
Presence of large periappendiceal abscess, which may be

treated best with initial drainage and interval
appendectomy.
Suspicion of Crohn's disease involving the cecum at the
base of the appendix.
Informed Consent
Expected Benefits
Treatment of acute appendicitis.
Potential Risks

Surgical site infection (deep or superficial).
Fecal fistula.
Conversion to open appendectomy.
Need for midline laparotomy.
Open wound.
Equipment
The open procedure requires no special equipment.

The laparoscopic procedure requires the following
equipment:
5-mm angled laparoscope.

Veress needle or Hasson trocar.
Endoscopic stapler.
Endoscopic retrieval bag for removal of the appendix.
Patient Preparation
No oral intake; maintenance intravenous fluids.

Preoperative antibiotics to cover enteric flora.
Patient Positioning
Open Appendectomy
The patient should be supine with both arms extended.
The entire abdomen is prepared and draped in case a
midline incision is needed (eg, unexpected disease is
encountered or the operative course dictates it).
Laparoscopic Appendectomy
Figure 20–1: The patient is supine with both arms

tucked at the sides. The operating surgeon and assistant
stand on the patient's left.
A Foley catheter is placed to decompress the bladder.
The patient's entire abdomen is prepared and draped.
Figure 20–1
Procedure
Open Appendectomy
The classic transverse incision can be made with two
thirds of the incision lateral to McBurney's point.
Alternatively, the point of maximal tenderness or the
location of the appendix based on preoperative imaging
can be used to determine the location of the incision.
Figure 20–2: A scalpel is used to incise the epidermis
and the dermis. Bovie electrocautery is used to dissect
down to the external oblique aponeurosis.
The aponeurosis is opened in a superolateral to

inferomedial direction along the direction of its fibers
to expose the internal oblique muscle.
The internal oblique muscle is bluntly divided
perpendicular to the direction of its fibers.
The transverse abdominal muscle is similarly divided
and the peritoneum is identified.
Figure 20–3: The peritoneum is grasped with forceps
and incised with a 15-blade knife.
Attention is now focused on locating the appendix.
If the cecum is visualized, it can be used as a guide

to help identify the appendix.
Babcock forceps can be used to grasp the taeniae coli
and advanced until the appendix is externalized.
Alternatively, a finger can be swept around the cecum,
beginning superolaterally and continuing inferomedially to
locate the appendix.
Figure 20–4: Once identified, the mesoappendix is
dissected and the appendiceal vessels are divided
between clamps and ligated with silk sutures.
Figure 20–5: A silk purse-string suture is placed around
the base of the appendix. A right-angle clamp is applied
to the base of the appendix and used to crush the tissue.
The clamp is moved distally and an absorbable suture is
used to ligate the appendix at the base at the site of the
crushed tissue. A 15-blade is used to excise the appendix
proximal to the level of the clamp.
Figure 20–6A, B: The mucosa of the appendiceal stump
may then be obliterated with electrocautery (Figure 20–
6A). The purse-string suture is then used to invert the
stump (Figure 20–6B).
The wound is irrigated with warm saline to remove any
inflammatory debris and hemostasis is achieved.
Figures 20–7 and 20–8. The peritoneum and fascial
layers are closed with running absorbable sutures.
The skin is closed with monofilament absorbable suture.
Figure 20–2
Figure 20–3
Figure 20–4
Figure 20–5
Figure 20–6A–B
Figure 20–7
Figure 20–8
Laparoscopic Appendectomy
A 12-mm infraumbilical incision is made and access to the

abdomen is achieved using either a Veress needle or
Hasson technique (see Figure 20–1). The peritoneal cavity
is then insufflated with carbon dioxide gas and a 5-mm
angled laparoscope is inserted.
A 5-mm port is placed in the midline above the pubic
bone and a second 5-mm port is placed laterally in the
left lower quadrant (see Figure 20–1). The laparoscope is
inserted through this lateral port, while the surgeon
operates through the midline ports.
Exploration of the abdomen is performed to rule out other
disease. Attention then turns to the right lower quadrant.
The patient is placed into steep Trendelenburg position
with right side up to facilitate exposure.
The omentum and small bowel are swept cephalad.
The terminal ileum is identified by its antimesenteric fat
(fold of Treves).
The terminal ileum is then followed to the cecum. The
appendix can usually be identified by following the teniae
of the cecum.
In the case of a retrocecal appendix, the cecum and
ascending colon may need to be mobilized by division of
the lateral retroperitoneal attachments.
Inflammatory adhesions between small bowel, cecum,
and appendix are often encountered and can usually be
divided using blunt dissection, although sharp dissection
may be required.
Cautery should be avoided near the bowel.
Once visualized, the tip of the appendix is grasped and
elevated anteriorly off of the cecum.
A Maryland dissector is used to create a window between
the base of the appendix and the mesoappendix as shown
in Figure 20–4.
The safest orientation of dissection is to place the
appendix and its mesoappendix parallel to the lateral
abdominal wall, thus minimizing the risk of bowel injury.
The mesoappendix is divided with an endoscopic stapler
using a vascular staple load.
The appendix is divided at its base using a second load of
the endoscopic stapler, making sure that the stapler is
apposed to the cecum so that an appendiceal stump is not
left in place.
The appendix is placed into an endoscopic retrieval bag
and removed through the supraumbilical port.
The appendiceal and mesoappendiceal staple lines are
assessed for integrity and hemostasis.
The abdomen is irrigated in all quadrants to prevent
abscess formation.
The small bowel is returned to the lower abdomen and
the omentum is draped over the appendiceal stump.
The laparoscope is placed back into one of the midline
ports, and the remaining ports are removed under direct
visualization to ensure hemostasis at the anterior
abdominal wall.
The 5-mm ports do not require fascial closure, but the
fascia of the supraumbilical port should be closed with
absorbable sutures.
The skin is closed with monofilament suture or skin
adhesive.
Postoperative Care
Patients should be advanced to a regular diet as tolerated

and discharged home when they can tolerate oral intake
and manage pain with oral medication only.
Injury to bowel or other adjacent structures.

Intra-abdominal abscess.
Superficial wound infection (more common with open
appendectomy).
Colonic fistula.
Pearls and Tips
It is useful to place the incision where the patient's pain is

the greatest or where preoperative imaging has identified
the appendix. This is particularly important in pregnant
patients, as the appendix may be in an atypical location.
Conversion to an open procedure should be considered if
visualization or dissection is difficult during laparoscopic
appendectomy.
References
Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus

placebo for prevention of postoperative infection after
appendicectomy. Cochrane Database Syst Rev. 2005;3:
CD001439.
Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for

diagnosis of appendicitis in children and adults? A meta-
analysis. Radiology. 2006;241:83–94.[PubMed:
16928974] [Full Text]
Jones PF. Suspected acute appendicitis: trends in

management over 30 years. Br J Surg. 2001;88:1570–1577.
Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus

open surgery for suspected appendicitis. Cochrane Database
Syst Rev. 2004;4:CD001546.


Current Procedures: Surgery > Chapter 21. Loop

Colostomy, End Ileostomy, and Loop Ileostomy >
Indications
To defunctionalize bowel.
Protection of distal anastomosis.
Relief of obstruction.
Contraindications
Absolute
None.
Relative
Carcinomatosis precluding mobilization of bowel.

Morbid obesity such that mesentery or stoma cannot
reach the skin surface.
Informed Consent
Expected Benefits
Decompression of bowel obstruction.
Protection of distal anastomosis to allow healing with
decreased risk of intra-abdominal sepsis.
Relative Risks
Bleeding.
Wound infection.
Parastomal hernia.
Need for ostomy revision secondary to stenosis or
ischemia.
Equipment
Standard general surgery set for major gastrointestinal

surgery.
Patient Preparation
Nasogastric tube in cases of perforation or obstruction.

Resuscitation to correct any fluid and electrolyte
abnormalities.
Perioperative antibiotics and additional doses in the event
operative time is prolonged.
No bowel preparation is necessary for small bowel
procedures.
Preoperative evaluation and marking of optimal stoma
position by an enterostomal therapist.
Patient Positioning

Procedure
Loop Colostomy
Figure 21–1: When ostomy is performed for diversion of

the fecal stream due to distal obstruction, the dilated
colon may be decompressed with a needle or catheter
attached to wall suction. The collapsed bowel is easier to
manipulate, and there is decreased risk of injury and
perforation.
Figure 21–2: An incision is made along the apex of the
selected loop of bowel to prepare for stoma creation on
the antimesenteric wall of the bowel.
Figure 21–3: The cut edges of the bowel are everted and
interrupted sutures are placed using full-thickness bites of
colon wall and subdermal bites of skin.
A rod or red rubber catheter may be placed under the
loop of colon being brought up; however, this step is not
necessary and may interfere with placement of the
ostomy appliance.
Figure 21–1
Figure 21–2
Figure 21–3
End Ileostomy
Figure 21–4A: For creation of an end ileostomy, a

circular incision approximately 2.5 cm in diameter is made
overlying the rectus muscle.
Figure 21–4B: Blunt dissection is used to divide the soft
tissue to the level of the fascia.
A cruciate incision is made in the fascia and carried 2

cm in both directions.
The rectus muscle fibers are split using the clamps
and retractors.
Figure 21–4C: The posterior sheath is opened with a
cruciate incision sufficient to permit passage of two
fingers.
Figure 21–4D, E: The small bowel is brought through
this fascial opening using a Babcock clamp until 5 cm of
ileum protrudes above the surface, with care taken to
avoid twisting the mesentery.
Four Brooke-type sutures are then placed to evert

the bowel. These are created by placing interrupted
sutures through the full-thickness of the cut bowel
edge, a seromuscular bite through the bowel wall at
the level of the skin, and finally a subdermal skin
bite.
These sutures are placed in four quadrants avoiding
the mesentery.
The sutures are tied down, thus everting the bowel
edges and elevating the lumen above the skin.
Additional interrupted sutures from the cut edge of the
bowel to the dermis may be placed in between the four
Brooke-type sutures.
Figure 21–4A–E
Loop Ileostomy
Figure 21–5A-D: An ileal loop is brought out through the

abdominal wall (Figure 21–5A) and an incision is extended
to roughly 80% of the circumference of the distal limb
(Figure 21–5B). The cut edge is everted over the proximal
limb and secured with interrupted sutures (Figures 21–
5C, D).
This results in elevation of the proximal limb of the stoma
and leaves the defunctionalized or distal limb flush with
the skin surface.
Figure 21–5A–D
Postoperative Care
Stoma may appear dusky with edema during the first

postoperative week.
Enterostomal therapists can assist with patient education
about appliance care as well as treatment of any
peristomal skin irritation.
Skin irritation from gastrointestinal contents.

Ostomy retraction (common in obese patients).
Mechanical obstruction due to an overly tight fascial
closure around the stoma.
Parastomal hernia.
Prolapse.
Fistula.
Stenosis (may be treated with careful dilation).
Necrosis of the ostomy due to ischemia (requires
reoperation for resection).
Pearls and Tips
For ease of appliance changes, optimal selection of a

stoma site on flat skin, avoiding skin folds, prior scars,
and bony prominences, is critical. Also avoid placement in
the "belt line" or waistline area.
Avoid fecal contamination to prevent postoperative
infection and incisional hernia.
Ensure an adequate blood supply to the stoma by noting
the color of the bowel and pulsatile flow of terminal
arterial branches at bowel ends following division.
Ensure that the stoma is not rendered ischemic by an
overly small opening in the abdominal wall at the level of
the fascia.
To create a tension-free stoma, ensure sufficient mobility
of the bowel to easily reach the abdominal wall.
Avoid twisting or kinking of the bowel and mesentery as
the bowel is brought through the abdominal wall.
Handle the bowel gently when suturing the ostomy to
prevent ischemia, necrosis, and leak. Expect some
amount of postoperative bowel wall edema.
Avoid excessive manipulation of the bowel ends with the
forceps to prevent further edema and bruising.
References
Souba WW, Fink MP, Jurkovich GJ, et al, eds. ACS Surgery,
Principles and Practice. New York, NY: WebMD Professional
Publishing; 2006.
Zollinger RM Jr, Zollinger RM Sr. Zollinger's Atlas of Surgical

Operations, 8th ed. New York, NY: McGraw-Hill; 2002.



Management of Inflammatory Bowel Disease >
Indications
Emergency
Total abdominal colectomy with end ileostomy is the only

operation typically performed in the emergent setting for
the following indications:
Ulcerative colitis: toxic megacolon, perforation,

fulminant colitis, hemorrhage.
Crohn's disease: same indications, plus obstruction.
Elective
Ulcerative Colitis (Curative)
Either total proctocolectomy with end ileostomy or ileal

pouch anal anastomosis (IPAA) may be selected,
depending on patient factors.
Indications for proctocolectomy include:
Dysplasia or malignancy.
Condition refractory to medical management;
intractability.
Growth retardation in children.
Complications secondary to adverse effects of
medical treatment.
Crohn's Disease (Palliative)
Total proctocolectomy with end ileostomy only; IPAA is

not an option (see Contraindications later).
Indications for proctocolectomy include:
Internal fistula.
Abscess.
Malignancy.
Intractability.
Contraindications
Ileal Pouch Anal Anastomosis
Absolute
Crohn's disease.
Emergency procedure.
Low rectal neoplasia.
Disseminated carcinoma.
Incontinence (fecal).
Inability to tolerate a long period of general anesthesia
(4–6 hours) due to comorbidities.
Relative
Indeterminant colitis.
Obesity (thick mesentery precludes adequate
mobilization).
Ongoing high-dose steroid therapy (eg, prednisone, 50–
60 mg/day); a staged approach may be preferable.
Malnutrition (serum albumin < 2 g/dL).
Total Proctocolectomy with End Ileostomy
If a patient is extremely ill, as in the emergent setting,

total abdominal colectomy with end ileostomy should be
performed, leaving the rectum intact at that operative
setting.
Informed Consent
Expected Benefits
Total Abdominal Colectomy with End Ileostomy (Emergent

Surgery)
Removal of the bulk of the diseased colon, allowing the

patient to improve from a medical standpoint while
enabling a restorative procedure to be performed at a
later date.
Ileal Pouch Anal Anastomosis
Restoration of gastrointestinal continuity precluding the

need for permanent ostomy.
Significantly reduces risk of developing colorectal
malignancy secondary to chronic inflammatory bowel
disease.
Total Proctocolectomy with End Ileostomy
Prevents the development of colorectal malignancy

secondary to chronic inflammatory bowel disease.
Provides effective treatment for fistulous perineal disease.
Potential Risks
Men (All Procedures)
Urinary retention.
Erectile dysfunction.
Retrograde ejaculation.
Women (All Procedures)
Dyspareunia.
Decreased fertility.
Urinary dysfunction.
Enlarged uterus may necessitate hysterectomy at the
time of operation.
Both Men and Women
Need for diverting ileostomy (IPAA).

Anastomotic leak abscess or sepsis poor pouch
function (IPAA).
Anastomotic stricture (IPAA).
Bowel obstruction (all procedures).
Anal leakage (IPAA).
Pouch failure requiring revision to end ileostomy (IPAA).
Pouchitis (IPAA).
Equipment
Lone-Star retractor (useful for exposure during the

perineal dissection).
Self-retaining retractor (helpful for the abdominal portions
of the procedure to facilitate exposure of the operative
field).
End-to-end anastomosis (EEA) stapler (optional).
Patient Preparation
Anesthesia consultation, as indicated by patient

comorbidities.
Preoperative consultation with enterostomal therapist for
teaching and preoperative marking of the stoma site.
Mechanical and antibiotic bowel preparation the day
before surgery (although controversy exists in the current
literature regarding the necessity of this practice).
Nothing by mouth after midnight on the evening before
surgery. (Again, there is some controversy in the
literature as to the necessity of prolonged fasting. Current
institutional practice dictates 6 hours without solid food.)
Perioperative antibiotics with appropriate coverage (gram-
negative bacilli, anaerobes, enterococci, etc),
administered within 30 minutes of skin incision (by
anesthesia personnel) and redosed as indicated during
surgery.
Deep vein thrombosis prophylaxis, initiated before
induction of anesthesia.
Foley catheter insertion after anesthetic induction.
Consideration of stress-dose steroids, depending on the
patient's current and past medication regimen.
Consideration should also be given to placement of
ureteral stents preoperatively.
Patient Positioning
The patient should be in modified lithotomy position, with

the legs supported in noncompressing stirrups.
This position allows easy access to both the abdomen

and the perineum.
Arms may be tucked at the sides or extended on arm
boards.
During the operation, steep Trendelenburg position is
helpful for obtaining access and exposure to the pelvis
and perineum.
Procedure
Total Abdominal Colectomy with End Ileostomy (Emergent

Setting)
In emergent cases, a two- or three-stage procedure is

employed.
Total abdominal colectomy with management of the

rectal stump and end ileostomy.
Either completion proctectomy with end ileostomy or
IPAA with diverting loop ileostomy.
If IPAA is selected, then a third stage is required for
reversal of the loop ileostomy.
Total Abdominal Colectomy with End Ileostomy
Thorough abdominal exploration is performed through a

midline incision, with special attention paid to the small
intestine to detect any evidence of Crohn's disease.
Figure 22–1: A standard abdominal colectomy is
performed (see Chapter 23), dividing the small bowel as
close to the cecum as possible in order to preserve
maximal length. The ileum is only mobilized sufficiently to
reach the abdominal wall for ostomy creation. Oncologic
principles do not apply, and wide mesenteric resection is
not necessary.
Figure 22–2: The inferior mesenteric vessels are
preserved and ligated individually during removal of the
sigmoid colon, which minimizes damage to pelvic
autonomic nerves and reduces scar formation.
Preservation of the ileocecal artery is desired,

although in most instances it is ligated if a
subsequent restorative pouch procedure is
performed, with the arterial supply maintained via
the superior mesenteric artery.
The rectal stump can be managed by a simple Hartmann
pouch, either stapled or hand sewn, ideally at the level of
the sacral promontory.
If the tissue is friable, a mucus fistula may be

matured to the skin.
Alternatively, if there is insufficient length, the fistula
may be brought through the fascia at the lower end
of the midline incision and sutured in the
subcutaneous space.
Transanal drainage of the rectal stump may further
reduce the risk of pelvic sepsis.
An end ileostomy is then constructed in standard Brooke
fashion.
Figure 22–1
Figure 22–2
Total Proctocolectomy with End Ileostomy (Elective Setting)
This is the conventional operative approach and gold

standard against which other procedures are compared. It
may be considered a first-line procedure in patients for
whom IPAA is unsuitable.
A midline incision is made and thorough abdominal
exploration is performed.
As earlier, a standard abdominal colectomy is performed
(see Chapter 23 for additional details). If surgery is
indicated for malignancy or dysplasia, oncologic principles
should be followed (ie, wide excision of the mesentery
and removal of the entire colon).
The maximum length of small bowel should be preserved
by dividing the terminal ileum immediately adjacent to
the cecum.
The ureters should be identified; the rectum is then
carefully mobilized, preserving the pelvic nerves.
Figure 22–3: Once the rectum is mobilized from the
abdominal approach, an intersphincteric perineal
dissection allows removal of the diseased organ, creating
a smaller wound than that typically made for
abdominoperineal resection.
Figure 22–4: The resultant wound is closed in several
layers. A drain may be placed according to surgeon
preference.
A standard Brooke ileostomy is matured.
Figure 22–3
Figure 22–4
Ileal Pouch Anal Anastomosis (Elective Setting)
The operation is best considered in four phases:
Excision of the intra-abdominal colon.

Dissection and removal of the rectum, taking care to
spare pelvic nerves and preserve the anal sphincter
mechanism.
Construction of the ileal pouch.
Anastomosis of the pouch to the anal canal.
Excision of the Intra-Abdominal Colon
Following midline incision and abdominal exploration, a

standard abdominal colectomy is carried out as previously
described.
Dissection and Removal of the Rectum
As earlier, a close rectal dissection is performed. The

rectum is mobilized first posteriorly, preserving the
presacral nerves, and then moving anteriorly 1 cm above
the peritoneal reflection.
Anterior dissection proceeds posterior to Denonvilliers'
fascia and is carried down to the lower one third of the
vagina or the lower border of the prostate. This mobilizes
the rectum fully to the level of the levators and the
anorectal junction.
The rectum is then transected.
The level of transection remains controversial:
Preservation of the anal transition zone retains

neorectal sensation and may improve post-procedure
function; however, a small area of potentially
neoplastic tissue remains, leading some surgeons to
prefer mucosectomy. (Additionally, even in the most
experienced hands, islands of tissue with neoplastic
potential may remain following mucosectomy.)
If mucosectomy is performed, the dentate line is
exposed and dilute epinephrine is injected into the
submucosa to prevent bleeding and to elevate the
tissue. Needle-tip cautery is used to excise the
mucosa.
Construction of the Ileal Pouch
Figure 22–5: After excision of the colon, the small bowel

mesentery is fully mobilized by releasing peritoneal
attachments.
Although multiple pouch constructions exist, the J

pouch is most popular.
The terminal portion of the ileum is folded upon itself
to create a J shape with the apex 15–20 cm from the
end of the ileum.
An apical enterotomy is made and the pouch is
created by serial firings of a linear GIA stapler (use of
the GIA-80 mm stapler will allow fewer firings),
taking care to keep the mesentery free as the bowel
is accordioned onto the stapler.
To estimate whether the created pouch will reach the anal
canal, the apex of the pouch (or the segment of bowel
destined to become the apex prior to construction) may
be grasped and measured to ensure that it will reach
approximately 4–6 cm beyond the pubic symphysis.
Figure 22–5
Anastomosis of the Pouch to the Anal Canal
Figure 22–6A, B: Once the pouch is created, either a
double-stapled or, if mucosectomy is performed, a hand-
sewn ileoanal anastomosis (see Figure 22–7) is
performed.
For a double-stapled anastomosis, the anvil of the

circular EEA stapler is secured with a purse-string
suture in the apical enterotomy of the J pouch
(Figure 22–6A).
The stapler is passed transanally, and the pointed
shaft is directed just posterior to the staple line on
the anorectum.
The shaft is removed, stapler and anvil are joined
and fired in customary fashion, and the donuts of
tissue are examined for integrity (Figure 22–6B).
In women, particular care must be taken to avoid
inclusion of the vagina in the staple line.
The anastomosis is then tested via transanal
insufflation with the staple lines submerged in saline
and the small bowel occluded manually proximal to
the anastomosis.
Figure 22–7: A hand-sewn IPAA entails radial
placement of absorbable sutures at the dentate line,
incorporating a small portion of the internal anal
sphincter. The apex of the pouch is brought to the
anal verge and the previously placed sutures are
serially placed through the ileum (full thickness) and
tied down.
Figure 22–6A–B
Figure 22–7
Diverting Loop Ileostomy
A loop of ileum approximately 30–45 cm proximal to the

pouch is brought up to the right lower quadrant (or
previously marked location) and a standard loop
ileostomy is created.
To provide maximal length for absorption, a too-proximal
limb should be avoided.
Controversy exists over the need for diversion; the
morbidity associated with both creation of an ostomy and
subsequent ostomy reversal must be weighed against
potentially increased anastomotic complications in the
absence of diversion. Some surgeons forego ileostomy
creation in favor of a single-stage procedure.
Postoperative Care
Await resolution of ileus.

For total proctocolectomy, vigilant care of the perineal
wound and avoidance of pressure or weight bearing on
the perineum.
Close monitoring for signs and symptoms of anastomotic
leak and pelvic sepsis.
Tapering of stress-dose steroids, if appropriate.
Patient education regarding dehydration, including
information on:
Signs and symptoms of dehydration.

Recognition of risk factors for becoming dehydrated.
Proper maintenance of appropriate oral fluid intake.
Recognition of and treatment for high ostomy output.
Enterostomal therapist education of patient and family
regarding ostomy care.
Nutritional counseling.
Dehydration and electrolyte abnormalities.
Although a diverting ostomy is in place, patients may

require readmission to the hospital for hydration and
correction of electrolyte derangements.
If this problem is recurring or severe, it may
necessitate early reversal of ostomy.
Small bowel obstruction occurs in 15% of patients (half
require operative intervention).
Common causes include adhesions, internal hernia,

and volvulus.
Sepsis.
Pelvic abscess.
Anastomotic leak.
Fistula.
Pouch-vagina.
Perineal.
Potentially indicative of Crohn's disease if it occurs
after IPAA.
Anastomotic stricture.
Usually resolves with digital or balloon dilation.

May require pouch revision.
Pouchitis.
Poorly understood entity, occurring in 30–50% of

pouch patients.
Generally responds to treatment with antimicrobial
drugs (metronidazole, fluoroquinolones).
Patients with extraintestinal manifestations of
ulcerative colitis, particularly primary sclerosing
cholangitis, are at increased risk.
In 10–15% of patients with chronic pouchitis, pouch
excision and end ileostomy is required.
Malignancy.
May occur irrespective of whether mucosectomy was

performed.
Continued screening is required for all patients.
Pouch failure.
Occurs in 5–10% of patients.

Risk factors include tension on the anastomosis,
compromised blood supply, hand-sewn anastomosis,
unsuspected Crohn's disease, leak or sepsis, and use
of a diverting ileostomy.
Sexual dysfunction.
Men: occurs due to injury of the parasympathetic

nerve trunks during rectal dissection in 1–3% of
patients; may be transient or permanent. Problems
include impotence, difficulty emptying the bladder,
and retrograde ejaculation.
Women: problems include decreased fertility
(sometimes due to adhesions), dyspareunia, and
leaking during intercourse. Normal pregnancies and
deliveries are possible, but patients may have
increased incontinence or temporary stoma
dysfunction. There is no specific contraindication to
vaginal delivery unless indicated for obstetric
reasons, although scarred perineum may be an
indication for cesarean delivery.
Pearls and Tips
If it is not clear that a tension-free anastomosis can be

performed, various maneuvers can be used to increase
length:
Figure 22–8: The small bowel mesentery can be

mobilized to the third portion of the duodenum.
Figure 22–9: Peritoneal windows in the mesentery
can be created over vessels causing tension and may
provide additional length. This maneuver can be
repeated on both sides of the mesentery.
Transillumination and confirmation of adequate blood flow
by Doppler ultrasound is useful to identify vessels that
may be sacrificed.
Elective operations may be completed via laparoscopic-
assisted techniques.
Figure 22–8
Figure 22–9
Indications
Jejunoileitis with single or multiple fibrotic strictures.

History of multiple small bowel resections and risk for
development of short-gut syndrome.
Disease with history of rapid recurrence.
Isolated duodenal strictures.
Contraindications
Abscess.
Fistula.
Generalized peritonitis.
Phlegmon or acute inflammatory reaction.
Long, high-grade strictures.
Severe malnutrition (serum albumin < 2 g/dL).
Informed Consent
Expected Benefits
Palliative measure to relieve obstructive symptoms.
Potential Risks
Operation is not curative.

Findings at operation may require abortion of the
procedure or change of the planned procedure, including
the need for an ostomy.
Malignancy may be discovered at the site of the stricture.
Surgical risks include:
Disease recurrence.
Bleeding at suture lines.
Leak or dehiscence at suture lines.
Need for a bowel resection if strictures are not
amenable to stricturoplasty.
Equipment

A self-retaining retractor is useful to facilitate exposure of
the operative field.
Patient Preparation
Contrast radiography prior to any surgical undertaking is

essential to rule out surgical contraindications, and to
define the indication for operation. CT enterography is
preferred.
Perioperative antibiotics with appropriate coverage (gram-
negative bacilli, anaerobes, enterococci, etc),
administered within 30 minutes of skin incision (by
anesthesia personnel) and redosed as indicated during
surgery.
Deep vein thrombosis prophylaxis, initiated prior to
incision.
Consideration of stress-dose steroids, depending on the
patient's current and past medication regimen.
Patient Postioning
The patient should be supine on the operating table.

The arms may be tucked at the sides or extended on arm
boards.
Procedure
Heineke-Mikulicz Stricturoplasty
Suitable for strictures < 7–10 cm.

A midline incision is made and the abdominal cavity is
thoroughly explored to rule out unanticipated findings
that would alter the planned operative approach.
Figure 22–10: A longitudinal incision is made in the
antimesenteric border of the stricture and carried 1–2 cm
into normal-appearing bowel on either side.
The mucosa is carefully inspected and biopsy

specimens are taken from any suspicious-looking
areas to evaluate for possible occult malignancy.
Stay sutures are placed on either side of the midpoint
of the enterotomy, traction is applied, and the
longitudinal incision is closed horizontally in one or
two layers.
Figure 22–10
Finney Stricturoplasty
Used for strictures 10–15 cm in length.

Figure 22–11A-C: A longitudinal incision is made on the
antimesenteric side of the bowel, extending the
enterotomy into normal bowel (Figure 22–11A).
The mucosa is inspected and biopsy specimens are

taken as indicated.
Stay sutures are placed at each end of the incision
and on the superior side of the midpoint of the
incision.
The bowel is then folded upon itself, creating an
inverted U shape.
A side-to-side anastomosis is performed with
absorbable suture. The posterior wall is completed
first, beginning at the apex and continuing anteriorly
(Figure 22–11B, C).
This suture line is then reinforced with
nonabsorbable, interrupted, inverted Lembert
sutures.
Figure 22–11A–C
Postoperative Care

Tapering of stress-dose steroids, if indicated.
Hemorrhage from the suture line.

Dehiscence.
Abscess.
Long strictures treated with Finney stricturoplasty may
result in functional intestinal bypass with bacterial
overgrowth in the resultant diverticulum.
Fistula formation.
Pearls and Tips
Areas of small bowel stricture too long to be treated with

stricturoplasty should be resected.
Frozen sections obtained from areas under consideration
for stricturoplasty should be sent for pathologic evaluation
to rule out malignancy.
Consider marking sites of stricturoplasty with metal clips
to enable radiographic tracking for recurrence.
When short-gut syndrome is of significant concern, or a
patient has multiple strictures in close proximity, a "side-
to-side isoperistaltic" or Michelassi stricturoplasty (not
described here) may be considered.
References
Cima RR, Pemberton JH. Medical and surgical management of

chronic ulcerative colitis. Arch Surg. 2005;140:300–310.
Cohen JL, Strong SA, Hyman NH, et al. Practice parameters

for the surgical treatment of ulcerative colitis. Dis Colon
Rectum. 2005;48:1997–2009.
Cohen Z, Senagore AJ, Dayton MT, et al. Prevention of

postoperative abdominal adhesions by a novel,
glycerol/sodium hyaluronate/carboxy-methylcellulose-based
bioresorbable membrane: a prospective, randomized,
evaluator-blinded multicenter study. Dis Colon Rectum.
2005;48:1130–1139.
Galandiuk S. Crohn's Disease. In: Souba WW, Fink MP,

Jurkovich GJ, et al, eds. ACS Surgery, Principles and Practice.
New York, NY: WebMD Professional Publishing; 2005:665–
673.
Huang E. Ulcerative Colitis. In: Mulholland MW, Lillemoe KD,

Hurst RD, Michelassi F. Fulminant Ulcerative Colitis. In: Souba

WW, Fink MP, Jurkovich GJ, et al, eds. ACS Surgery, Principles
and Practice. Online Edition. New York, NY: WebMD
Professional Publishing; 2005.
Michelassi F, Hurst RD, Fichera A. Crohn's Disease. In:

807.


Current Procedures: Surgery > Chapter 23. Colectomy >
Indications
Colon cancer.
Colon polyps not amenable to colonoscopic polypectomy.
Diverticular disease.
Perforation of the colon for which ostomy is not needed.
Inflammatory bowel disease.
Volvulus.
Stricture.
Ischemia.
Bleeding.
Slow-transit constipation refractory to medical therapy.
Contraindications
Widely metastatic colon cancer that is nonoperative or

requires a palliative ostomy.
Severe peritonitis requiring diverting ostomy, in which
primary anastomosis would have an unacceptable leak
rate.
Hemodynamic instability requiring expeditious ostomy,
making primary anastomosis inappropriate.
Informed Consent
Expected Benefits
Treatment of established colon cancer (or prevention of

development).
Relief of functional or mechanical colonic obstruction.
Treatment (or prevention) of intra-abdominal sepsis
secondary to colonic perforation.
Treatment of colonic bleeding.
Potential Risks
Bleeding.
Infection.
Damage to adjacent structures, including ureter, bowel,
spleen, and others.
Need for further operations.
Anastomotic leak.
Need for ostomy.
Unresectability.
Recurrence of cancer.
Cardiopulmonary or other organ failure.
Death.
Equipment
Bookwalter or similar self-retaining abdominal retractor.

Long instruments.
Gastrointestinal anastomosis (GIA), linear cutting stapler.
Linear thoracoabdominal (TA) stapler.
Intraluminal circular end-to-end anastomosis (CEEA)
stapler.
Laparoscopic equipment if procedure will be performed
using laparoscopic techniques, to include:
Angled laparoscope.
Atraumatic bowel graspers.
Laparoscopic GIA staplers.
Device for dividing mesenteric vasculature (ie, GIA
vascular staple load, LigaSure device, etc).
Patient Preparation
Preoperative blood work:
Complete blood count to rule out anemia.

Type and screen.
Carcinoembryonic antigen level.
Examination of abdomen for prior incisions.
Full colonoscopy to cecum before elective operation, and
tattooing of lesions with permanent ink as appropriate.
CT scan of abdomen and pelvis with oral and intravenous
contrast to evaluate for liver metastasis in patients with
cancer.
Other diagnostic imaging as appropriate.
Mechanical bowel preparation.
Deep vein thrombosis prophylaxis with sequential
compression devices and consideration of subcutaneous
heparin dosing before induction of anesthesia, especially if
the patient has been diagnosed with cancer.
For patients older than 50 years, -blockade before
induction of anesthesia.
General anesthesia.
Foley catheter.
Nasogastric tube.
Preoperative antibiotics covering skin and bowel flora (eg,
second- or third-generation cephalosporin or penicillin
derivative).
Patient Positioning
The patient should be supine, with the entire abdomen

prepared and draped.
Consider lithotomy position if splenic flexure mobilization
may be necessary, and for sigmoid colectomy.
Procedure
Laparotomy is performed via a midline incision about the

umbilicus.
The abdomen is explored to palpate the liver for
metastasis, visualize peritoneum, examine omentum and
lymph nodes, and "run" the bowel. A Bookwalter retractor
is placed.
Figure 23–1: Vascular anatomy of the colon.
The superior mesenteric artery (SMA) supplies the

cecum, ascending colon, and proximal transverse
colon. The SMA divides into the ileocolic artery (ICA),
right colic artery (RCA), and middle colic artery
(MCA). Note the hepatic (right) and left branches of
the middle colic artery.
The inferior mesenteric artery (IMA) supplies the
distal transverse colon, splenic flexure, descending
colon, sigmoid colon, and upper rectum. The IMA
divides into the left colic artery (LCA) and the
sigmoid artery (SA), and terminates in the superior
hemorrhoidal artery.
The marginal artery of Drummond provides collateral
circulation along the colon.
The inferior mesenteric vein (IMV) meets the splenic
vein at the inferior border of the pancreas.
Figure 23–2A-D: Extent of resection for colon cancer.
Cecal mass: right colectomy is indicated for a mass in

the cecum or ascending colon (Figure 23–2A).
Transverse colon mass: transverse colectomy or
extended right colectomy is indicated for a mass in
the transverse colon (Figure 23–2B).
Splenic flexure mass: left colectomy is indicated for a
mass in the splenic flexure or descending colon
(Figure 23–2C).
Sigmoid colon mass: sigmoid colectomy is indicated
for a sigmoid colon mass (Figure 23–2D).
Right Colectomy
Indicated for a mass in the cecum or right colon.

Resection will include distribution of the ileocolic and right
colic arteries, and the hepatic branch of the middle colic
artery.
Figure 23–3A, B: Lateral peritoneal reflection of the
right colon.
The right colon is mobilized along the retroperitoneal

fold, which forms an avascular attachment of the
right colon to the lateral peritoneal wall. A gauze
sponge is used to dissect the underlying loose areolar
tissue (Figure 23–3A).
The duodenum is identified, with care taken to avoid
injury. When dissection is carried out in the correct
plane, the duodenum should be visualized but not
elevated. A soft sponge can be used to keep the
duodenum down. Care should be taken to avoid
injury to the kidney or Gerota's fascia (Figure 23–
3B).
Figure 23–4: Transection of the right colon mesentery
and named vessels.
The right colon is now completely free, except for its

mesentery. The right colon is elevated and the
mesentery transilluminated to identify avascular
tissue for cutting with Bovie electrocautery. As
vessels are encountered, they should be clamped as
proximally as possible, transected, and ligated.
The right colic artery (if present) is ligated at its
origin.
If the right colic artery is absent and the ileocolic
artery arises directly from the superior mesenteric
artery, the ileocolic artery is ligated at its origin.
The right (hepatic) branch of the middle colic artery
is also ligated, sparing the main middle colic artery.
Named vessels, including the ileocolic and right colic
arteries, and the hepatic branch of the middle colic
artery, should be tied twice on the patient's side to
reduce bleeding risk.
If cancer is suspected, generous mesentery is
removed with the goal of achieving a maximal
lymphadenectomy.
Figure 23–5A-C: Two-load GIA-stapled anastomosis for
right colectomy.
The right colon is completely free of peritoneal and

mesenteric attachments.
The planned anastomosis site is now identified by
bringing together 5 cm of terminal ileum proximally
and the hepatic branch of the middle colic artery
distally.
Atraumatic bowel clamps are placed 5 cm beyond the
planned anastomotic site on each end to prevent
spillage.
The surgeon should verify that the planned
anastomosis will not be under tension when bringing
together the antimesenteric border of the two bowel
loops.
Stay sutures are placed (Figure 23–5A), and
hemostats are attached to them.
A small enterotomy is made in antimesenteric side of
each bowel loop. One fork of the GIA-80 stapler is
introduced into each enterotomy (Figure 23–5B).
The GIA-80 stapler is fired along the antimesenteric
border to anastomose the bowel.
Next a second load of the GIA-80 stapler is used to
amputate the specimen, including the two
enterotomy sites, thereby simultaneously closing the
end luminal defects (Figure 23–5C).
Alternatives to the two-load GIA-stapled anastomosis
include a hand-sewn end-to-end anastomosis (see Figure
23–7), a hand-sewn side-to-side anastomosis, or a four-
load GIA-stapled anastomosis.
Closure of the resultant mesenteric defect is optional.
The abdomen is irrigated with warm saline and closed in
standard fashion.
Figure 23–1
Figure 23–2A–D
Figure 23–3A–B
Figure 23–4
Figure 23–5A–C
Transverse Colectomy
Based on the right colectomy, the transverse colectomy or

extended right colectomy for a mass in the transverse
colon also includes resection of the right omentum,
division of the hepatocolic ligaments, and inclusion of the
entire middle colic artery in the resection.
Left Hemicolectomy
Indicated for a mass in the splenic flexure or descending

colon.
Resection includes the left colic artery and may be
extended to include the sigmoid colectomy discussed
later.
Begin by incising the white line of Toldt (lateral peritoneal
reflection) to mobilize the left colon.
This mobilization is extended up to the splenic flexure.
Figure 23–6A, B: Mobilization of the splenic flexure.
In mobilizing the splenic flexure, the goal is to divide

all colonic attachments in a safe manner while
preserving the mesentery. Traditionally, the
dissection proceeds retrograde.
The renocolic ligament is identified and incised
(Figure 23–6A). The base of the spleen should now
be visible.
Next the attachments between the omentum and the
spleen, and between the omentum and the colon, are
divided.
Care should be taken to avoid excessive traction on
the colon, which can cause a splenic capsule tear.
The splenocolic and pancreaticocolic ligaments are
identified and incised (Figure 23–6B).
Alternatively, the dissection can proceed anterograde,
by elevating the omentum to access the lesser sac.
The attending physician may stand between the
patient's legs to facilitate this dissection. The splenic
flexure is freed.
Similar to Figure 23–4, the left colon is elevated and its
mesentery transilluminated to identify avascular tissue to
be divided with the electrocautery device.
As they are encountered, large vessels are clamped and
divided at their origin, and ligated twice on the patient
side. If cancer is suspected a broad en bloc mesenteric
resection is performed to remove as many lymph nodes
as possible.
Figure 23–7A-E: Hand-sewn, double-layer, end-to-end
anastomosis for left colectomy.
The left colon specimen has been passed off the field.
End-to-end hand-sewn anastomosis begins by placing
atraumatic bowel clamps 5 cm past the GIA staple
line to prevent spillage of stool. Next, the GIA staple
lines are excised.
Alignment of bowel: the mesenteric and
antimesenteric portions of the remaining bowel
should be aligned. Stay sutures are placed at the
mesenteric and antimesenteric borders of the
planned anastomosis, and hemostats are attached to
them. If there is a size mismatch, a small Cheatle slit
can be created in the antimesenteric border of the
smaller diameter segment (Figure 23–7A).
Posterior outer layer Lembert stitches: interrupted 3-
0 Lembert sutures are placed in the posterior
seromuscular layer to form the posterior outer layer
of the anastomosis (Figure 23–7B).
Inner layer running stitch: a double-armed 4-0
absorbable monofilament suture is used to create the
inner layer of the anastomosis in a running fashion,
with full-thickness bites. The submucosa provides the
strength (Figure 23–7C, D).
Anterior outer layer Lembert stitches: interrupted 3-0
Lembert sutures are placed in the seromuscular layer
to form the anterior outer layer, which completes the
two-layer anastomosis (Figure 23–7E).
The anastomosis is examined to verify that it is
widely patent, has an excellent blood supply, shows
no evidence of hematoma or leak, and is not under
tension.
Alternatives to the hand-sewn end-to-end anastomosis
include a hand-sewn side-to-side anastomosis (not
shown), a two-load GIA stapled side-to-side anastomosis
(see Figure 23–5), and an EEA stapled end-to-end
anastomosis (not shown).
Closure of the resultant mesenteric defect is optional.
The abdomen is irrigated with warm saline and closed in
standard fashion.
Figure 23–6A–B
Figure 23–7A–E
Sigmoid Colectomy
Indicated for a mass in the sigmoid colon or for

diverticulitis.
Principles are similar to those for left colectomy.
Figure 23–8: Mobilization of the sigmoid colon.
Particular attention must be paid to avoid damaging

the left ureter, which is extremely close to the
sigmoid colon as it passes over the left iliac artery.
Consider preoperative placement of a ureteral stent,
especially if significant inflammation or scar tissue is
anticipated in the area.
It may not be necessary to always mobilize the splenic
flexure; however, a tension-free anastomosis must be
achieved.
The anastomosis may be hand sewn end to end, hand
sewn side to side, stapled side to side using a GIA stapler,
or stapled end to end using an EEA stapler.
Figure 23–8
Laparoscopic Colectomy
The patient is placed in deep Trendelenburg position, and
the right side of the table is then rotated up.
Consideration should be given to preoperative placement
of an infrared ureteral stent, which can be seen using a
special laparoscope.
We prefer to approach the colon medially, thereby letting
the lateral peritoneal fold provide initial retraction.
Figure 23–9A-D: Laparoscopic assisted right colectomy.
Port sites: 5-mm ports are placed in the midline at the
epigastric and suprapubic positions, and a 12-mm port
and 5-mm port are offset to the left side of the umbilicus,
maintaining a hand's breadth of space between each port
(Figure 23–9A).
Avascular mesenteric windows are created with

cautery. An endovascular stapler is then used to
staple vessels, beginning with the ileocolic artery, and
repeating for the right colic artery (Figure 23–9B).
The lateral peritoneal reflection is divided (Figure 23–
9C).
Next, a 5-cm long incision is made on the right side
of the abdomen. The rectus is swept medially for a
rectus-sparing incision through the posterior rectus
sheath. The right colon is then externalized (Figure
23–9D).
A two-load GIA-stapled simultaneous colon resection
and extracorporeal anastomosis is performed, as
previously described (see Figure 23–5).
Figure 23–9A–D
Postoperative Care
Diet is advanced as tolerated after confirming flatus.

A Foley catheter is inserted to monitor adequacy of urine
output for the first 24 hours.
-Blockade is continued if appropriate.
Deep vein thrombosis prophylaxis should be continued.
Patients are encouraged to be ambulatory and should be
out of bed three times daily on postoperative day 1.
Intraoperative and Technical
Injury to the ureter.

Injury to the duodenum.
Injury to other bowel.
Small deserosalizations can be repaired with Lembert

stitches. Care should be taken to avoid grasping the
bowel during the operation. Epiploic appendages
should be grasped instead.
Injury to the spleen.
A topical hemostatic agent can be applied or

splenorrhaphy or splenectomy performed.
Inadequate blood supply at the anastomosis.
Additional bowel should be resected. Consider using

Doppler ultrasound to evaluate blood flow to the
anastomosis if concerned.
Anastomosis under tension.
Additional bowel can be mobilized.

Stool spillage and tumor cell spillage, creating the
potential for abscess or "drop metastases."
Noncrushing bowel clamps should be used proximal

and distal to the line of colonic division.
Early Postoperative Period

Wound infection.
Staples should be removed as needed, followed by

confirmation that fascia are intact. The wound should
then be packed and allowed to heal by secondary
intention.
Anastomotic leak.
In some patients, tachycardia may be the only sign;

others may have prolonged ileus or appear septic.
Typically diagnosed by CT scan on postoperative days

5–7.
Can often be treated using a percutaneous drain
placed by the radiology service.
May be secondary to an anastomotic leak.
Colocutaneous fistula.
Late Postoperative Period
Anastomotic stricture.
Anastomotic recurrence of cancer.
Incisional hernia.
Internal hernia.
Ureteral stricture from ureteral devascularization.
Pearls and Tips
Take no chances with the anastomosis. Ensure that the

anastomosis is widely patent, has an excellent blood
supply, shows no evidence of hematoma or leak, and is
not under tension. Assess visually, tactilely, and via
Doppler ultrasound if necessary. Do not leave the
operating room if the viability of the anastomosis is
questionable.
When mobilizing the splenic flexure, always avoid
excessive traction on the colon to prevent tearing of the
splenic capsule.
Suspect intra-abdominal abscess in patients with
postoperative fever, tachycardia, or prolonged ileus.
Diagnose with CT scan.
References
Ballantyne GH. Atlas of Laparoscopic Surgery. Philadelphia,

PA: WB Saunders; 2000.
Cameron JL. Current Surgical Therapy. Philadelphia, PA:

Elsevier Mosby; 2004:211–216.
Scott-Conner CE. Chassin's Operative Strategy in General

Surgery. New York, NY: Springer; 2002:359–418.
Zollinger RM Jr, Zollinger RM Sr. Zollinger's Atlas of Surgical

Operations. New York, NY: McGraw-Hill; 2003:112–139.



Management of Rectal Tumors >
Indications
Transanal Excision of Tumor
Stage T1 tumors:
Mobile and < 4 cm in diameter.

Involving < 40% of the rectal wall circumference.
Located within 6 cm of the anal verge.
Well or moderately differentiated histology only.
Absence of vascular and lymphatic invasion.
No evidence of nodal involvement on preoperative rectal
ultrasound or MRI.
Low Anterior Resection (LAR) with Total Mesorectal Excision
Malignant lesion of the rectum diagnosed by evaluation of

a tissue biopsy specimen obtained within 2 cm of the anal
sphincter in moderately or well-differentiated tumors or
within 5 cm for poorly differentiated tumors.
Abdominoperineal Resection (APR) with Total Mesorectal

Excision

a tissue biopsy specimen obtained < 2 cm from the anal
sphincter for moderately or well-differentiated tumors or
< 5 cm for poorly differentiated tumors.
Contraindications
Tumors stage greater than T1N0M0.

Fixed tumors.
Tumors > 4 cm in diameter or involving > 40% of the
circumference of the rectal wall.
Tumors located > 6 cm from the anal verge.
Tumors with poorly differentiated histology or
angiolymphatic invasion, or those that show evidence of
nodal involvement on preoperative rectal ultrasound or
MRI.
LAR with Total Mesorectal Excision

a tissue biopsy specimen obtained < 2 cm from the anal
sphincter for moderately or well-differentiated tumors or
< 5 cm for poorly differentiated tumors.
APR with Total Mesorectal Excision
Malignant lesion of the lower rectum diagnosed by

evaluation of a tissue biopsy specimen showing local
invasion into the pelvic sidewall or pelvis that could
benefit from neoadjuvant treatment to facilitate possible
curative resection.
Informed Consent
Expected Benefits
Removal of tumor with preservation of anus.

Avoidance of radical surgery.
Potential Risks

Rectal stricture.
Need for further resection based on pathologic findings.
Fistula to prostate or vagina.
Injury to the urethra for distal anterior tumors in men.
LAR or APR with Total Mesorectal Excision
Expected Benefits
Treatment of rectal cancer.

Potential prevention of colonic obstruction, tenesmus, and
invasion of adjacent pelvic structures.
Potential Risks
Bleeding requiring reoperation from presacral or splenic

injuries (LAR or APR) or from the anastomosis (LAR).
Infection, including intra-abdominal or pelvic abscesses
resulting from anastomotic leaks (LAR) or infected intra-
abdominal or pelvic fluid collections (LAR or APR).
Fistula formation from anastomotic leak (LAR).
Postoperative ileus (LAR or APR).
Ureteral injury (LAR or APR).
Need for a permanent or temporary stoma (LAR).
Bladder or sexual dysfunction (LAR or APR).
Fecal incontinence (LAR).
Clustering of bowel movements (LAR).
Equipment
Self-retaining (Ferguson) anoscope.

Lone Star retractor (for more proximal lesions).
Self-retaining retractors.
Bookwalter abdominal retractor with a lighted St. Mark's
retractor.
Lone Star retractor (for perineum).
Handheld lighted St. Mark's retractor and long
instruments (crucial for delicate dissection in the pelvis).
End-to-end anastomosis (EEA) stapler (LAR).
Thoracoabdominal (TA) stapler (LAR).
Patient Preparation
Clearance of bowel for synchronous lesions by

colonoscopy.
CT scan of the chest, abdomen, and pelvis to evaluate for
metastatic disease of the lungs, liver, or peritoneum.
Endorectal ultrasound or endorectal MRI for local staging
(T and N staging).
Patients with uT1N0 tumors may be appropriate
candidates for transanal excision.
Patients with uT3NX or uTXN+ disease should be
considered for possible neoadjuvant chemoradiation
therapy.
Consider preoperative tattooing of the lesion with
permanent ink, especially if the lesion is small or the
patient will receive neoadjuvant chemoradiotherapy.
Preoperative carcinoembryonic antigen level.
Mechanical bowel preparation according to surgeon's
preference.
Preoperative antibiotics and preoperative subcutaneous
heparin.
Stoma marking by an enterostomal therapist for patients
undergoing LAR or APR.
Patient Positioning
For posterior lesions, the patient should be in a supine

lithotomy position in gentle Trendelenburg using well-
padded stirrups.
For anterior lesions, the prone jackknife position is
preferred.
Sequential pneumatic compression devices should be
applied.

The patient should be in a supine lithotomy position in
gentle Trendelenburg using well-padded stirrups.
Sequential pneumatic compression devices should be
applied.
A Foley catheter and nasogastric or orogastric tube should
be placed, especially if mobilization of the splenic flexure
is contemplated.
Consideration should also be given to the placement of a
left ureteral stent if a difficult pelvic dissection is
anticipated.
Procedure
Regional anesthesia may be adequate, although general

anesthesia is sometimes required.
A self-retaining retractor is placed and a 1:100,000
epinephrine solution is infiltrated into the submucosa to
facilitate dissection.
Figure 24–1: Stay sutures are placed circumferentially 1
cm from the gross margin of the lesion.
Figure 24–2: Full-thickness excision of the lesion is
performed down to the level of perirectal fat using
electrocautery.
The specimen is carefully marked to delineate the correct
orientation for the pathologist.
Figure 24–3: The defect in the rectal wall is closed
transversely with absorbable suture.
Proctoscopic examination of the rectum is performed at
the conclusion of the procedure to ensure patency of the
rectum.
Figure 24–1
Figure 24–2
Figure 24–3
General anesthesia is required.

The patient should be in the lithotomy position with the
legs elevated at approximately 15 degrees and spread at
45 degrees. Positioning of the anus and buttocks at the
end of the table is important for access.
A median laparotomy incision from the pubis symphysis
to above the umbilicus is performed.
For an LAR or APR, a self-retaining retractor is placed and
the small intestine is retracted superiorly and to the right
under a moistened towel.
The left colon is freed from its lateral peritoneal
attachments along the avascular line of Toldt, and the
splenic flexure is mobilized (see Chapter 23) as needed
for a tension free anastomosis.
The peritoneum of the pelvic colon is opened using
electrocautery.
Care must be taken to identify the ureters, on the left in
particular.
The left ureter is identified as it crosses the pelvic

brim over the left common iliac artery.
Especially in patients with a significant amount of
adipose tissue, widely encircling the ureter with a
vessel loop can aid in safe mobilization of the distal
rectum.
The inferior mesenteric artery is identified at its origin and
suture-ligated.
The distal descending colon is then divided with a GIA-60
stapling device at least 5 cm proximal to the tumor.
Figure 24–4: The distal rectum is then sharply mobilized
posteriorly to remove the mesorectum intact with its
fascial envelope (see also Figures 24–7A and 24–7B).
The bladder is retracted superiorly and the anterior rectal
wall is separated from the seminal vesicles and the
posterior capsule of the prostate in a man.
The lateral dissection encompasses the lateral peritoneal
reflections, and middle hemorrhoidal vessels are ligated
and divided.
Figure 24–5: The proximal rectum is then clamped and a
linear stapling device is applied across the rectum at least
2 cm distal to the tumor.
The proximal rectum is divided and the specimen is
removed.
Figure 24–6A, B: Creation of the stapled LAR
anastomosis.
The staple line of the descending colon is opened and

a nonabsorbable purse-string suture is placed.
The anvil of a circular stapler is placed within the
descending colon through the purse-string suture,
and the suture is tied.
The assistant then passes the circular stapler through
the anus, deploying the "spike" just anterior to the
staple line on the rectum.
The anastomosis is completed as the surgeon marries
the anvil placed in the end of the divided descending
colon to the stapler exiting the rectum.
The surgeon guides the end of the stapler together,
taking care that no other tissue (ie, bladder or
vagina) is intervening in the anastomosis, and the
assistant fires the stapler.
The rings of tissue ("donuts") are inspected for any
defect.
The assistant then inspects the integrity of the
anastomosis by insufflating the rectum using a rigid
sigmoidoscope, while the surgeon manually occludes
the distal colon with the anastomosis submerged in
sterile saline. The presence of any bubbling from the
anastomosis suggests an anastomotic leak.
Figure 24–4
Figure 24–5
Figure 24–6A–B
Total Mesorectal Excision
Care must be taken with lower lying rectal cancers to

perform a total mesorectal excision to prevent leaving
nodal tumor deposits behind.
The superior hemorrhoidal artery is identified and ligated.
Figure 24–7A-C: There should be wide incision at the
peritoneal reflection and sharp division of the Waldeyer's
fascia posterior to the fascia propria of the rectum, as well
as incision of Denonvilliers' fascia and separation of the
rectal wall from the seminal vesicles and the posterior
capsule of the prostate anteriorly.
Figure 24–8A, B: The correct and incorrect dissection
planes for total mesorectal excision are depicted.
Figure 24–7A–C
Figure 24–8A–B
Coloanal Anastomosis
If it is not possible to obtain a distal rectal margin of at

least 2 cm, a coloanal anastomosis may be contemplated.
Figure 24–9A-C: The distal rectum is divided proximal to
the dentate line following rectal dissection and total
mesorectal incision.
A 5–6-cm colonic J pouch can be fashioned using a

GIA stapler. The end-to-side J pouch coloanal
anastomosis is then created by sewing the full-
thickness colon to the mucosa and internal sphincter
of the anus. Absorbable sutures are used to create
this anastomosis, and the colotomy created to allow
admission of the GIA stapler when creating the J
pouch is used for the anastomosis (Figure 24–9A,
Figure 24–9C).
If there is insufficient length for a colonic J pouch, an
end-to-end anastomosis can be fashioned using a
circular stapler or hand-sewn anastomosis as outlined
above (Figure 24–9B, C).
Figure 24–9A
Figure 24–9B–C
Abdominoperineal Resection for Low-Lying Rectal Cancers
This procedure requires the same attention to obtaining

adequate radial margins via total mesorectal excision.
Figure 24–10: The sigmoid artery proximal to the
takeoff of the superior hemorrhoidal artery is ligated.
Figure 24–11A, B: The distal margin of resection should
include the levators, as visualized from the perineal
portion of the operation.
Figure 24–12: The closure of the perineal incision should
be in layers, beginning with the levators followed by the
deep tissues and skin.
Drains are placed in the deep space and are brought out
through the lower abdominal wall.
Figure 24–10
Figure 24–11A–B
Figure 24–12
Postoperative Care
Early ambulation is encouraged and diet is advanced as

soon as tolerated.
Patients requiring abdominal incision receive epidural
analgesia and are transitioned to oral pain medications as
soon as they can tolerate solids.
Patients with ileostomies may require aggressive
management of fluid status after the resumption of bowel
function. We promote aggressive isotonic liquid
consumption by the patient, with avoidance of caffeine
and chocolate, and prefer first to use fiber bulking agents,
followed by the addition of the antimotility agent
loperamide.
Daily examination of the perineal wound is mandatory
following APR, and sitting should be discouraged for the
first 5 postoperative days. Walking, however, should be
aggressively encouraged.
Pelvic drains are generally removed on postoperative day
5.
As excision of the rectal wall is carried out below the

peritoneal reflection, intra-abdominal leak is generally not
a problem.
Deep space infections can occur and should be treated by
local drainage.
More commonly, pathologic evaluation reveals more
extensive disease than was appreciated preoperatively,
necessitating further local or more radical resection.
LAR and APR with Total Mesorectal Excision
Postoperative ileus is common, usually lasting 2–3 days

and rarely requiring nasogastric decompression.
Colonic ileus lasting longer than 2–3 days after LAR
should prompt suspicion of an anastomotic hematoma,
mechanical obstruction, or peritonitis associated with an
anastomotic leak.
Anastomotic leak is a potentially devastating complication
following LAR and typically occurs 5–7 days following
resection.
Fever, leukocytosis, ileus, and distention may be

early signs of a leak.
Peritonitis mandates exploration with proximal
diversion if a leak is discovered.
More subtle clinical presentations may require
imaging with water-soluble contrast enema for
identification.
Intra-abdominal abscesses from breaks in surgical
technique may require intravenous antibiotics, bowel rest,
and percutaneous drain placement.
Splenic injury can occur when mobilization of the splenic
flexure is necessary to perform a tension-free
anastomosis (LAR), or as necessary for the colon to be
easily brought up for end colostomy (APR).
Ureteral injury can result from altered rectosigmoid
anatomy associated with malignancy, inflammation, and
neoadjuvant radiotherapy.
Bladder or sexual dysfunction can occur due to injury of
the sympathetic or parasympathetic nerves in the pelvis.
Pearls and Tips
Pin the specimen out on suture card or cardboard and

deliver it to the pathologist with correct orientation.
Perform proctoscopy at the end of the procedure to
ensure that the rectal lumen has not been sutured closed.
Patients are usually hospitalized overnight for
observation.
Fever > 38.8°C is not uncommon in the immediate
postoperative period, but if fever continues through the
first postoperative night, blood and urine cultures as well
as plain films of the chest should be ordered to evaluate
for other, treatable sources of infection.
LAR and APR with Total Mesorectal Excision
For low rectal anastomosis, fill the pelvis with sterile

saline and insufflate the rectal stump before
reanastomosis with the circular stapler.
If a leak is identified in the linear staple line on the

rectum, posterior dissection should extend posteriorly
to the level of the coccyx to identify the site of
leakage.
The circular stapler can then be brought out through
the defect, a purse-string suture placed around the
spike, and the purse-string suture excluded after
firing the circular stapler.
During perineal dissection, maintain constant attention to
palpation of the Foley catheter to avoid inadvertent
urethral injury.
References
Chang AE, Morris AM. Colorectal Cancer. In: Mulholland MW,

Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery:
Scientific Principles & Practice, 4th ed. Philadelphia, PA:
Huang EH. Complications of Appendectomy and Colon and

Rectal Surgery. In: Mulholland MW, Doherty GM, eds.
Complications in Surgery. Philadelphia, PA: Lippincott



Management of Rectal Prolapse >
Indications
Symptomatic rectal prolapse with or without fecal

incontinence.
Contraindications
Resection Rectopexy
Elderly patients with limited life expectancy.

Patients with severe comorbidities or those unable to
tolerate general anesthesia or major abdominal surgery.
Perineal Rectosigmoidectomy (Altemeier Procedure)
None.
Informed Consent
Resection Rectopexy
Expected Benefits
Resection rectopexy is more durable than perineal
rectosigmoidectomy and can often be performed via a
laparoscopic approach.
Potential Risks
Bleeding or hematoma development requiring

reoperation.
Wound infection.
Injury to one or both ureters requiring repair.
Sexual dysfunction, including impotence or retrograde
ejaculation in men.
Incisional hernia.
Possible temporary or permanent colostomy.
Expected Benefits
Preferred over an abdominal approach in high-risk

patients.
Potential Risks
Infection, most notably perirectal abscess.

Bleeding, primarily from the sacral venous plexus but also
potentially from the mesenteric vascular supply divided as
part of the procedure.
Anastomotic dehiscence.
Recurrence of rectal prolapse.
Loss of or failure to regain fecal continence.
Equipment
Resection Rectopexy
Standard general surgery set used in gastrointestinal
surgery.
Lone Star retractor.
Patient Preparation
Complete colonoscopy (preferable) or barium enema and

sigmoidoscopy to rule out malignancy or other colonic
disease.
Bowel preparation according to surgeon preference.
Patient Positioning
Resection Rectopexy

A Foley catheter is placed to decompress the bladder.
Either a nasogastric or an orogastric tube is placed to
decompress the stomach.
The patient may be positioned either in the lithotomy

position or in the prone jackknife position.
A Foley catheter is inserted to decompress the bladder.
A Lone Star retractor is used for exposure.
Procedure
Resection Rectopexy
Figure 25–1: As the normal rectal attachments become
lax, the rectum intussuscepts through the pelvic floor,
telescoping through the anus.
Figure 25–2: The redundant sigmoid colon is resected in
the usual manner, down to the peritoneal reflection.
The peritoneum is incised posteriorly and laterally to

mobilize the rectosigmoid out of the pelvis, but the
lateral attachments of the rectum are left intact.
Redundant rectosigmoid is resected.
The proximal colon is then anastomosed to the
rectum to provide intestinal continuity and the
rectum is sutured to the presacral fascia to fix it in
place.
Figure 25–3: The completed procedure is shown, with
the anastomotic line at or below the peritoneal reflection
and tacking sutures between the rectum and the presacral
fascia fixing the colon in place.
Figure 25–1
Figure 25–2
Figure 25–3
Figure 25–4: After the patient is positioned on the table

and prepped in the usual fashion, the prolapsed bowel is
grasped with a Babcock clamp and tension is applied in an
outward direction.
Four absorbable 3–0 stay sutures are placed in the

midline anterior and posterior to the rectum and
laterally on either side.
The outermost layer of the rectum is then incised
circumferentially approximately 5–10 mm distal to
the everted dentate line.
The incision is carried through the mucosa and
muscular layer, with care taken not to enter the
muscular layer of the underlying intussuscepted
rectum (see Figure 25–1 for further illustration of this
relationship).
Figure 25–5: Once the entire outer layer of
intussuscepted rectum has been incised, it is folded
outward and the mesenteric attachments to the
intussusception are divided as they are encountered.
As mesenteric attachments are divided, more

rectosigmoid colon can be pulled out.
The location for transection of the redundant
rectosigmoid colon is identified when no more
sigmoid can be pulled through and the anastomosis
can be made with minimal tension.
Figure 25–6: The redundant rectosigmoid colon is
divided axially along the anterior and left lateral surfaces
and stay sutures are placed through at the base of these
cuts, through the mucosa and muscular wall, attaching
them to the cut edge of the distal mucosa.
The redundant tissue between these stay sutures is

resected and the first quadrant, from 12 o'clock to 3
o'clock, is closed with interrupted fine, absorbable
sutures.
Another axial cut is made along the posterior surface
of the redundant mucosa, a stay suture is placed at 6
o'clock and the second quadrant is closed with
interrupted fine, absorbable sutures.
This procedure continues by quadrants until the
entire anastomosis is complete and the redundant
sigmoid colon is removed.
Figure 25–7: Once the anastomosis is complete, the four
stay sutures along the anastomosis are cut and the
anastomosis is allowed to retract through the anal canal.
Figure 25–8: Sagittal section of the completed
reconstruction. Note that the anastomotic line is
significantly lower for this procedure than for the
resection rectopexy.
Figure 25–4
Figure 25–5
Figure 25–6
Figure 25–7
Figure 25–8
Postoperative Care
Resection Rectopexy
The patient should be managed in the hospital

postoperatively, with attention paid to fluid balance and
gastrointestinal function.
Standard postcolectomy perioperative care principles
apply.
Patients are usually maintained on intravenous fluids only
with nothing by mouth for the initial 24–48 hours or until
there is return of bowel function.
Epidural or patient-controlled analgesia is appropriate.
Patients should have minimal pain.

The patient should be monitored in the hospital
postoperatively with attention paid to bowel function.
Nothing should be inserted per rectum.
The diet is advanced as tolerated.
The patient may use sitz baths three times daily and after
all bowel movements.
Stools softeners should be used to keep stools from
becoming hard and disrupting the anastomotic suture
line.
Digital rectal examination should be deferred and no
rectal suppositories should be given in the first 2–4 weeks
postoperatively.
Resection Rectopexy
Mortality rate of 0% in all but one published study (which

had one death in 15 patients for a 6.7% mortality rate).
Recurrence rates range from 0–5%.
Postoperative constipation rates range from 18–80% in
reported surgical series.
Incontinence may not improve with the procedure.
Mortality rate of 0% in all studies except one (which had

one death in 20 patients for a 5% mortality rate).
Rectal prolapse recurrence rate is higher with the
Altemeier procedure than with resection rectopexy,
ranging from 0–16%.
Bowel injury can occur upon entering the hernia sac in the
anterior plane of dissection, particularly when the patient
is in the lithotomy position.
Pearls and Tips
Resection Rectopexy
The recognition of full-thickness rectal prolapse as

distinguished from redundant or prolapsed mucosa,
severe hemorrhoidal disease, or skin tags is classically
based on detecting circular mucosal layers rather than
radially oriented folds on external examination.
Examination of the patient after sitting and straining on a
commode can facilitate visualization of the extent of
prolapse.
Defecography can be helpful if there is any question about
the diagnosis.
Care must be taken when incising the anterior surface of

the intussuscepted rectosigmoid, as intra-abdominal
contents such as small intestine may be present in the
pouch of Douglas.
References
Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J.

Nineteen years' experience with the one-stage perineal repair
of rectal prolapse. Ann Surg. 1971;173:993–1006.[PubMed:
Madiba TE, Baig MK, Wexner SD. Surgical management of

rectal prolapse. Arch Surg. 2005;140:63–73.[PubMed:
15655208] [Full Text]

Current Procedures: Surgery > Chapter 26. Benign

Anorectal Procedures >
Indications
Hemorrhoidectomy
Internal hemorrhoids: grade III and IV hemorrhoids,

symptomatic combined internal and external
hemorrhoids, bleeding, incarceration, or failure of
conservative management.
External hemorrhoids: acute thrombosis < 72 hours post-
onset.
Pilonidal Cyst Excision and Marsupialization
Recurrent acute pilonidal infections.

Chronic pilonidal sinus.
Anorectal Abscess and Fistula
Acute perirectal abscess.

Anorectal fistula.
Contraindications
Hemorrhoidectomy
Absolute
Anorectal Crohn's disease or Crohn's proctitis.

Acquired immunodeficiency syndrome.
Relative
Pregnancy.
Coagulopathy.
The presence of cancer requires additional treatment.
Multiple fistulous tracts in a patient with Crohn's disease

may require additional studies of the colon and sphincter
mechanism prior to definitive surgical treatment.
Informed Consent
Hemorrhoidectomy
Expected Benefits
Resolution of hemorrhoids and symptoms.
Potential Risks
Common complications include significant postoperative

pain, urinary retention, bleeding, incontinence, infection,
and anal stenosis.
Risk of bleeding is increased with emergent
hemorrhoidectomy, during pregnancy, and in patients with
portal hypertension or coagulopathy.
Rectal perforation, rectovaginal fistula, and
retroperitoneal and pelvic sepsis are rare risks of circular
stapled hemorrhoidopexy and may be avoided with proper
technique.
Expected Benefits
Resolution of cyst and infection.

Prevention of recurrence.
Potential Risks
Primary cyst excision with marsupialization requires daily

wound scrubbing and strict attention to shaving hair in
wound proximity.
Time to healing may be several months.
Rate of recurrence is approximately 6%.
Rate of wound breakdown is 2–3%.
Expected Benefits
Resolution of abscess or fistula.
Potential Risks
Common complications of surgery include:
Fistula in ano.
Abscess.
Incontinence due to iatrogenic sphincter injury.
Equipment
No special equipment is required for hemorrhoidectomy,

pilonidal cyst excision, or the treatment of anorectal
abscess and fistula.
Circular Stapled Hemorrhoidopexy
33-mm hemorrhoidal circular stapler.
Patient Preparation
Hemorrhoidectomy
Thorough preoperative workup to confirm diagnosis,

hemorrhoid grade, and symptomatic status is essential
before recommending hemorrhoidectomy.
If bleeding is the indication for hemorrhoidectomy,
examination of the colon and rectum for other potential
sources of bleeding may be indicated.
In patients with portal hypertension, hemorrhoids must
be distinguished from anorectal varices.
The rectum may be evacuated with an enema
immediately before the operation.
Digital rectal examination should be performed to

evaluate for a presacral tumor.
The patient is examined to identify the location of pits and
presence of infection or abscess.
Surrounding hair is shaved after patient positioning on the
operative table.

A thorough preoperative workup is essential to confirm
the diagnosis, evaluate the immune status of the patient,
and determine the presence of an underlying disease
process such as Crohn's disease that might require
additional studies prior to surgical therapy.
Preoperative anorectal examination to determine the
complexity of the process may guide anesthetic choices
and surgical planning.
Patient Positioning
Hemorrhoidectomy
The patient should be in the prone jackknife position with

buttocks taped aside.
The procedure is performed under general anesthesia or
intravenous sedation with local anesthesia.
Left anterolateral positioning and local anesthesia are
suggested for pregnant patients.
The patient should be in the prone jackknife position;

lateral decubitus position may also be used.
The procedure may be performed under general
anesthesia or local anesthesia with intravenous sedation.
The patient should be in the prone jackknife position with

buttocks taped aside.
The procedure is performed under general anesthesia,
regional anesthesia, or intravenous sedation with local
anesthesia.
Procedure
Surgical Hemorrhoidectomy
A Hill-Ferguson retractor is inserted to obtain exposure.

Figure 26–1A: The internal hemorrhoid is grasped with
forceps and retracted outward. A suture ligature is placed
at the proximal aspect of the vascular pedicle. This suture
should not be cut.
Figure 26–1B: The internal hemorrhoid and external
component are grasped with a clamp.
Electrocautery is used to make a V-shaped incision in

the mucosa around the hemorrhoidal bundle starting
at the base of the internal hemorrhoid beyond the
anal verge and continuing toward the ligated pedicle.
The hemorrhoid is then carefully dissected from the
underlying anal sphincter.
Dissection should be continued cephalad in the
avascular plane between the hemorrhoid and internal
sphincter using Metzenbaum scissors or
electrocautery.
When the internal portion of the hemorrhoid is
elevated off the sphincter muscle to the level of the
pedicle, the pedicle should again be suture-ligated
followed by excision of the hemorrhoid.
Figure 26–1C: After the hemorrhoid is excised, the
mucosal defect should be reapproximated using running
3-0 Vicryl or other absorbable suture of adequate tensile
strength starting proximally at a site immediately
adjacent to the suture-ligated base of the hemorrhoid.
Figure 26–1D: The completed hemorrhoidectomy,
showing reapproximation of the mucosal defect with
running absorbable suture.
Figure 26–1A–B
Figure 26–1C–D
A retracting anoscope and dilator is inserted and the

obturator is removed. Upon removal of the obturator,
prolapsed tissue should fall into the dilator lumen. The
operating anoscope is then inserted and a purse-string
suture is placed.
Figure 26–2: A monofilament purse-string suture is
placed 4–5 cm above the dentate line taking care to avoid
suture gaps by starting the new stitch where the previous
stitch exits.
A circular stapler is carefully placed through the purse-
string suture and the suture is tied down to the stapler
rod. The suture ends are brought through the lateral
openings in the stapler.
The purse-string suture is retracted with moderate
traction to pull the anorectal mucosa into the stapler and
the stapler is closed.
Tissue around the stapler should be examined before

firing the stapler to ensure that the dentate line is
not incorporated into the staple line.
In women, a digital vaginal examination should be
performed to ensure that the posterior vaginal wall is
not tethered to the staple line.
After firing, the stapler is kept in place for 20 seconds to
ensure hemostasis. The stapler should then be removed
carefully and the site inspected.
Anoscopic examination will reveal persistent internal
hemorrhoids as this technique does not completely excise
hemorrhoidal tissue.
Figure 26–2
A probe is inserted into the midline opening, and the skin

superficial to the probe is opened with a scalpel or Bovie
electrocautery.
Secondary tracts are unroofed in an analogous manner.
Curettage is performed at the base of the wound. Once all
tract and pits have been exposed, a symmetric elliptical
skin incision is marked that incorporates all openings.
An en bloc excision of the cyst, pits, secondary openings,
and areas of inflammation is performed with creation of a
shallow funnel-shaped wound.
Care should be taken to avoid undermining the wound
edges.
Figure 26–3: Marsupialization is performed by sewing
the skin edges to the fibrotic base of the wound using a
2-0 absorbable suture in a continuous locking fashion.
The goal of marsupialization is to minimize the wound size
and prevent premature wound closure.
After hemostasis is obtained, petroleum jelly gauze and a
dry dressing are applied.
Figure 26–3
Simple Abscess Drainage
Figure 26–4: Classification system for anorectal

abscesses.
After the area of maximal erythema or fluctuance, or
both, is identified, the perianal skin is prepared with
povidone-iodine.
A local anesthetic solution, typically lidocaine with
epinephrine, is administered.
A cruciate or elliptical incision is made and the skin edges
are trimmed to allow adequate drainage and prevent
closure of the skin prior to adequate granulation of the
abscess cavity.
The site is inspected to ensure hemostasis and the cavity
is then lightly packed with gauze.
Figure 26–4
Anorectal Fistula
Figure 26–5: Classification of fistula in ano. A,

Subcutaneous. B, Intersphincteric. C, Transsphincteric. D,
Supralevator. E, Extrasphincteric.
The perianal area is prepared with povidone-iodine.
The external opening of the fistula is identified on the
perianal skin.
An anoscope is inserted to evaluate the anal canal

and rectum and identify the internal opening of the
fistula.
A probe is gently passed from the internal opening of
the fistula toward the external opening to determine
the direction of the fistulous tract.
If the internal opening is not easily identified, hydrogen
peroxide can be injected through the external opening
using a 10-mL syringe and an 18-gauge angiocatheter. If
the injection is successful, the internal opening will be
marked by the presence of bubbles.
Careful palpation is performed to assess the involvement
of the anal sphincter. If < 50% of the sphincter muscle is
involved, a fistulotomy should be performed by passing
the metal probe along the entire length of the fistula tract
and dividing the tissue overlying the probe.
Curettage is performed on the opened tract to

remove epithelialized tissue.
If > 50% of the sphincter is involved, a vessel loop
should be attached to the probe, introduced through
the fistula tract, and secured to form a seton around
the sphincter.
Figure 26–5
Postoperative Care
Hemorrhoidectomy
Postoperative care includes analgesia, stool softeners,

fiber supplementation, and sitz baths.
Wound care includes daily showers or sitz baths, cleansing

of wound, and removal of all hair within 3–4 cm of wound
edges. The wound should be packed wet-to-dry with
normal saline twice daily.

Antibiotics are generally not indicted in healthy patients
with a simple abscess. Antibiotics should be given for
abscesses in patients with immunosuppression, diabetes,
valvular heart disease or prosthetic valves, extensive soft
tissue cellulitis, and signs of systemic infection or sepsis.
Wound care includes sitz baths twice daily and after bowel
movements. Following abscess drainage, the cavity is
lightly packed with a gauze tape.
Patients should receive adequate analgesia and stool
softeners.
Hemorrhoidectomy
Early
Pain.
Urinary retention.
Bleeding.
Infection.
Fecal impaction.
Late
Anal stricture.
Anal tags.
Incontinence.
Mucosal prolapse.
Ectropion.
Recurrent pilonidal sinus formation.

Infection.
Bleeding.
Delayed wound healing.
Anorectal Abscess Drainage
Incomplete drainage may lead to recurrent anorectal

abscesses, especially in patients with ischioanal and
intersphincteric abscesses.
Incontinence from iatrogenic injury to the sphincter.
Necrotizing perineal infection occurs in < 1% of patients.
Fistula in ano.
Sepsis.
Anorectal Fistula
Fecal incontinence.
Bleeding.
Recurrent fistula.
Pearls and Tips
Surgical Hemorrhoidectomy
Pudendal and perianal nerve block with local anesthetic

may be administered to improve relaxation of anal
sphincter muscles.
If multiple hemorrhoidal piles are to be excised, be sure
to retain an adequate tissue bridge between the various
excision sites to reduce the risk of stricture.
Procedure is best reserved for grade II and III

hemorrhoids not adequately treated with banding and
grade IV hemorrhoids if reducible under general
anesthesia.
Limit the purse-string suture to the mucosa and
submucosa to avoid incorporating the muscular layer of
the rectal wall or the vaginal wall.
Bleeding from the staple line may be easily controlled by
oversewing the bleeding point.
To avoid sphincter injury, be aware of proximity to the

anus.
Anorectal Abscess
A modified Hanley procedure is indicated for horseshoe

abscess.
Anorectal Fistula
Avoid passing the probe through the external opening of a

fistula to identify the tract as this may create a false
passage.
The Goodsall rule is often more accurate in women and
may be misleading for external openings > 3 cm from the
anal verge.
The lay open fistulotomy technique may be used for
intersphincteric and low transsphincteric fistulae. Seton
placement is appropriate for high transsphincteric fistulae.
References
Cintron JR, Abcarian H. Benign Anorectal Hemorrhoids. In:

Wolff BD, Fleshman JW, Beck DE, et al, eds. ASCRS Textbook
of Colon and Rectal Surgery. New York, NY: Springer;
2007:156–177.
Hull TL, Wu J. Pilonidal disease. Surg Clin North Am.
2002;82:1169–1185.[PubMed: 12516846] [Full Text]
Vasilevsky CA, Gordon PH. Benign Anorectal Abscess and

Fistula. In: Wolff BD, Fleshman JW, Beck DE, et al, eds.
ASCRS Textbook of Colon and Rectal Surgery. New York, NY:
Springer; 2007:192–214.



Management of Breast Cancer >
Indications
Breast Lumpectomy
Definitive therapy for a benign solid breast mass.

Atypical cells or lobular carcinoma in situ on fine needle
aspiration or core needle biopsy of a breast or
mammographic abnormality.
Stage I and II breast cancer (if combined with sentinel
lymph node biopsy and adjuvant radiation therapy [XRT]
to accomplish breast conservation therapy).
Ductal carcinoma in situ.
Nonpalpable mammographic abnormalities (eg,
calcifications).
Modified Radical Mastectomy
Local management of stage II breast cancer when breast

conservation therapy is contraindicated or is not the
patient's preference.
Residual large cancer after adjuvant therapy.

Multicentric cancer.
Patient preference.
Contraindication to subsequent radiation therapy.
Local management of stage III breast cancer.
Lymph node metastases discovered during sentinel lymph
node biopsy or fine needle aspiration for a clinically
palpable node.
Sentinel Lymph Node Biopsy
Clinical stage I and II breast cancer.
May be performed in conjunction with breast-

conserving therapy or simple mastectomy.
Axillary nodal status is the most powerful prognostic
feature available in stratifying the risk of breast cancer
relapse.
Areolar Duct Excision
Lactiferous ductal dilation on imaging.

Nipple discharge isolated to a single duct or quadrant of
the nipple.
Mass or mammographic abnormality underlying the
nipple-areolar complex.
Contraindications
Breast Lumpectomy
Absolute
Multicentric disease (tumors in separate quadrants).

Persistent positive margins after reasonable surgical
attempts
Pregnancy: first and second trimester (if XRT is intended
with the goal of breast conservation therapy). Breast
conservation therapy may be feasible in the third
trimester if radiation therapy is deferred to the
postpartum period.
Prior therapeutic irradiation to the breast that would
result in retreatment to an excessively high radiation dose
(if XRT is intended with the goal of breast conservation
therapy).
Diffuse, malignant-appearing microcalcifications.
Tumor size > 5 cm.
Relative
History of collagen vascular disease (eg, scleroderma or

systemic lupus erythematosus) especially if steroid
dependent (if XRT is intended with the goal of breast
conservation therapy; these patients may experience
excessive radiation toxicity).
Extensive gross multifocal disease in the same quadrant.
Large tumor in a small breast that would offer suboptimal
cosmetic results.
Patient preference for mastectomy.
Male breast cancer (rarely feasible).
Skin cellulitis and open wounds.
Stage IV disease.
Absolute
None.
Relative
Stage IV disease.
Absolute
Clinically positive adenopathy on physical examination.

Pregnancy, lactation.
Relative
Previous regional breast surgery or radiation.

Stage III or IV disease.
Prior axillary surgery.
Locally advanced primary cancer (> 5 cm).
Absolute
Inflammatory breast cancer.

Stage III or IV invasive breast cancer.
Relative
Skin cellulitis and open wounds.
Informed Consent
Breast Lumpectomy
Expected Benefits
Complete removal of a breast mass with a margin of

normal-appearing glandular tissue to achieve a tissue
diagnosis.
Definitive therapy for a benign breast mass.
Local management of stage I and II breast cancer and
ductal carcinoma in situ.
Potential Risks
Common complications:
Surgical site infections (either deep or superficial).

Bleeding.
Hematoma.
Seroma.
Less likely to occur:
Sampling error.
Recurrent breast edema and cellulitis.
Chronic incisional pain.
Brachial plexopathy from positioning.
Thrombosis of the thoracoepigastric vein.
Pneumothorax (a rare complication for wire-localizing
procedures).
Expected Benefits
Removal of any previous biopsy scar, skin, nipple-areola

complex, breast tissue, and axillary lymph nodes (levels I,
II, +/– level III) for local management of invasive breast
cancer with lymph node metastases.
Potential Risks

Bleeding.
Hematoma.
Seroma.
Chronic upper extremity edema with associated

angiosarcoma.
Axillary webs.
Chyle leak.
Skin flap necrosis.
Axillary vein thrombosis.
Neurovascular injury resulting in axillary or upper arm
sensory deficits and shoulder weakness.
Expected Benefits
Identification, using lymphatic mapping with isosulfan

blue dye (Lymphazurin) or colloids labeled with
radioactive isotopes (usually technetium) with or without
lymphoscintigraphy, of the first lymph node that receives
drainage from a cancer in an effort to accurately stage
invasive breast cancer and thus guide additional surgical
and adjuvant therapy.
Potential Risks

Bleeding.
Hematoma.
Seroma.
Chronic upper extremity edema with associated

angiosarcoma.
Axillary webs.
Chyle leak.
Axillary vein thrombosis.
Neurovascular injury resulting in axillary or upper arm
sensory deficits and shoulder weakness.
Expected Benefits
Excision of the lactiferous ducts en bloc for definitive

management of benign breast disease and to establish
tissue diagnosis.
Potential Risks

Bleeding.
Hematoma and seroma.
Nipple-areolar necrosis and paraesthesia.
Difficulties with breast feeding.

Equipment
Breast Lumpectomy, Modified Radical Mastectomy, and Areolar

Duct Excision
No special equipment is necessary.
5 mL of isosulfan blue dye for preoperative injection.

Gamma probe to detect radioactive colloid.
In instances where isosulfan blue dye is unavailable,
methylene blue dye may be substituted. Care should be
taken to avoid methylene blue dye injection into the
dermis as it may cause skin necrosis.
Patient Preparation
Breast Lumpectomy
An appropriate history and physical examination should

include risk stratification for breast cancer and a thorough
bilateral breast examination.
Nodal disease and any evidence of inflammatory or T4
disease should be excluded on clinical examination.
Additionally, an appropriate preoperative workup for a
breast lesion should include ultrasound, with or without
fine needle aspiration, as well as mammogram if the
patient is older than 40 years.
If a patient is undergoing wire-localized lumpectomy, a
localization wire is placed preoperatively in radiology
within 1 cm of the lesion. These patients should receive
preoperative intravenous antibiotics before skin incision.
All patients will have had prior biopsy of some variety to

support the diagnosis of invasive breast cancer with
lymph node metastases.
Ensure that a bilateral mammogram has been obtained.
A thorough history and physical examination
preoperatively should assess for signs and symptoms of
metastatic disease and gross axillary nodal involvement
and should document a baseline neurologic examination.
Additional studies (eg, CT scan, bone scan, chest
radiograph, and liver function studies) are guided by
clinical concern.
The morning of or the night before surgery, radioactive

colloid (eg, technetium-99m—tagged sulfur colloid) is
injected via three or four separate injections at the cancer
site or retroareolar.
Additionally, we suggest preoperative lymphoscintigraphy
for further visual assistance in locating the sentinel lymph
node.
+/– Ductography (well tolerated with local anesthesia).

Retroareolar ultrasound and mammography should be
obtained for all patients.
Patient Positioning
Breast Lumpectomy, Modified Radical Mastectomy, and Areolar

Duct Excision
The patient should be supine with the ipsilateral arm

abducted 90 degrees.
Attention should be paid to appropriately padding
pressure points.
The patient should be supine with arms abducted 90

degrees.
All pressure points should be padded appropriately.
The axilla may be shaved.
Preoperative antibiotics should be administered prior to
skin incision.
Procedure
Breast Lumpectomy
Figure 27–1: Optimal cosmesis is considered when

planning the incision.
Upper-inner quadrant incisions should be avoided

when possible because of their greater visibility.
Circumareolar and inframammary incisions provide
very good results.
Curvilinear incisions that parallel the Langerhans lines
also offer acceptable scarring.
Some surgeons advocate a radial incision for lower
breast lesions; this approach should be avoided in
the upper half of the breast given the risk of scar
contracture and resulting displacement of the nipple-
areola complex.
Finally, the incision should be small and immediately
overlying the mass.
As further resection may be indicated, the incision
should be placed within the appropriate boundaries of
a mastectomy skin incision, while also allowing for a
1-cm skin margin around the scar.
Figure 27–2: Following sharp skin incision, skin flaps are
raised on either side of the incision with electrocautery to
ensure hemostasis.
Thin flaps (< 7–10 mm) should be avoided to prevent

skin flap ischemia and tissue necrosis.
Allis forceps are used to grasp normal glandular
tissue surrounding the palpable lesion, and this tissue
is placed under gentle traction.
The dissection proceeds around the lesion in an
attempt to encompass the entire mass.
Once excised, the specimen is oriented in three
dimensions and sent for pathologic examination.
With hemostasis obtained, the wound is irrigated.
Deep dermal skin layers are approximated with
interrupted 3-0 Vicryl sutures followed by skin
approximation with a 4-0 Monocryl suture placed in a
running subcuticular fashion or skin adhesive.
Needle-localized breast biopsy or lumpectomy.
For nonpalpable mammographic lesions, wire

localization is indicated.
This requires the placement of a localization wire
preoperatively in mammography within 1 cm of the
lesion.
The skin incision is placed directly over the lesion and
dissection proceeds toward the wire.
Once visible, the wire with surrounding normal tissue
is grasped with an Allis clamp and placed under
gentle traction to facilitate dissection around the
angled distal tip of the wire.
This approach should encompass the lesion in
question. Following excision, the biopsy specimen is
oriented and sent for radiographic or pathologic
examination to confirm that the lesion of interest was
in fact removed. Clips are placed in the lumpectomy
bed.
Figure 27–1
Figure 27–2
Figure 27–3A: A horizontal or an oblique elliptical

incision is incised sharply with an axillary extension to
facilitate the axillary dissection. This must encompass any
previous biopsy scar in addition to the nipple-areola
complex.
Figure 27–3B: This incision may be tailored if an
immediate reconstructive procedure or skin-sparing
mastectomy is intended.
Figure 27–4: Superior and inferior skin flaps are raised
with electrocautery to ensure hemostasis.
Gentle traction is applied to the specimen to facilitate

the dissection.
Thin flaps (< 3 mm) should be avoided to prevent
skin flap ischemia and tissue necrosis; however, this
is balanced with the goal of removing as much fat
and subcutaneous tissue as possible (especially the
nodal-containing fat of the axilla).
The superior flap extends to the level of the clavicle
superiorly and the lateral aspect of the sternum
medially.
The inferior flap extends to the inframammary fold
inferiorly and to the edge of the latissimus dorsi
muscle laterally.
Figure 27–5: With the flaps developed, the specimen is
gently retracted inferiorly for the dissection of the breast
tissue off the pectoralis muscles.
The glandular tissue is dissected starting superiorly

at the level of the clavicle and proceeds with
electrocautery parallel to the muscle fibers in a
superior to inferior and medial to lateral direction.
Pectoralis major fascia is removed with the specimen.
Intercostal perforating arterial branches that supply
the breast may require ligation.
Figure 27–6: The pectoralis muscle is then retracted
medially to expose the pectoralis minor muscle.
The intrapectoral space is explored for the presence

of enlarged Rotter's nodes.
The thin tissue overlying the axillary vein may be
incised to allow for exposure.
Figure 27–7: With the axillary vein identified, careful
dissection within the axilla ensues.
The lateral border of the latissimus dorsi muscle is

identified and tissue dissection proceeds with cautery
to ensure hemostasis. Care must be taken to avoid
axillary nerves.
Clips and 3-0 suture ligation are used to secure all
blood vessels and lymphatics encountered.
The clavipectoral fascia is incised along the lateral
aspect of the pectoralis minor.
With the pectoralis muscles retracted superior and
medially, the fibrofatty tissue containing level I and II
lymph nodes (lateral and inferior to the pectoralis
minor muscle, respectively) is removed en bloc with
the specimen.
Care must be taken to avoid the medial and lateral
nerves supplying the pectoralis major. The medial
nerve passes through the pectoralis minor in
approximately 70% of patients; in a minority of
patients it passes lateral to the muscle. The lateral
nerve passes medial to the pectoralis muscle and is
typically found in close proximity to the
thoracoacromial artery.
The axillary dissection proceeds inferolaterally and
progresses carefully with the identification of several
important structures.
The long thoracic nerve is identified and preserved
deep to the axillary vein and extends inferiorly along
the serratus anterior.
The intercostobrachial nerve is identified originating
beneath the second rib and extending transversely.
Finally, the thoracodorsal vein is identified originating
from the axillary vein and extending inferiorly,
associated with the artery.
The corresponding thoracodorsal nerve is located
posteromedial to the vein; the entire bundle should
be preserved.
Figure 27–8: In the setting of grossly palpable apical
axillary nodes, the axillary dissection is extended to
include the level III lymph nodes medial to the pectoralis
muscle.
This is termed a Patey modification and begins with

the division of the pectoralis minor from its insertion
on the coracoid process.
The operator's gloved finger protects the underlying
brachial plexus.
Figure 27–9: With the critical vessels and nerves
identified and preserved, the fibrofatty contents of the
axilla are removed down to the level of the subscapularis
muscle posteriorly and to the level of the latissimus dorsi
muscle laterally with the breast tissue.
The specimen should be oriented and tagged for

pathologic examination.
The surgical bed is inspected for hemostasis and all
visible bleeding points should be controlled with
electrocautery or clip/suture ligature.
Two No. 10 Blake surgical drains are placed through
separate stab incisions after copious wound irrigation.
One drain should lie in the axillary bed; the other is
placed along the inferior flap.
The drains are secured in position to the skin with 2-
0 nylon suture.
The deep dermal layer of skin is reapproximated with
interrupted 3-0 Vicryl sutures and the skin is
reapproximated with skin adhesive or a 4-0 Monocryl
suture in a running subcuticular fashion.
Figure 27–3A–B
Figure 27–4
Figure 27–5
Figure 27–6
Figure 27–7
Figure 27–8
Figure 27–9
Figure 27–10: Approximately 5 mL of isosulfan blue dye

is injected into the breast in a similar fashion to the
previously injected radioactive colloid.
The injection is placed deep to the tumor or biopsy

cavity but not into the cavity, and may also be
injected intradermally over the tumor or biopsy
cavity, or retroareolar based on surgeon preference.
The area is massaged for 5 minutes to encourage
incorporation and flow into the dermal lymphatics.
A gamma probe is waved over the axillary nodal
basin scanning for the area with the highest focus of
radioactivity.
Once this area is localized, a limited skin incision is
made sharply, directly over the area in a transverse
fashion that will allow for scar incorporation if
subsequent axillary lymph node dissection is
indicated.
Dissection then proceeds with electrocautery in an
attempt to identify a blue node.
Figure 27–11: Visually tracing the blue lymphatics
combined with gamma probe feedback will localize "hot"
nodes.
These sentinel nodes are typically blue in color and

demonstrate notable radioactivity with the gamma
probe.
These nodes should be resected, minding hemostasis
and lymphatic vessels.
Once the nodes are removed, the wound should be
scanned with the gamma probe to locate further
radioactivity.
All blue, grossly enlarged and firm nodes should be
resected.
All nodes that demonstrate 10% radioactivity on
gamma probe of the "hottest" and theoretical
sentinel node are resected as well.
Resected nodes are sent for permanent pathology.
Once hemostasis is ensured, the wound is irrigated.
The subcutaneous tissue is reapproximated with
interrupted 3-0 Vicryl sutures.
The skin is reapproximated with skin adhesive or a 4-
0 Monocryl suture placed in a running subcuticular
fashion.
Figure 27–10
Figure 27–11
Figure 27–12: If no palpable lesion is noted on clinical

examination, a curvilinear skin incision is used as
illustrated around the nipple-areolar complex.
If there is a palpable lesion, a conservative skin incision is
made sharply in a curvilinear or radial fashion over the
abnormality, allowing for future incorporation into a
mastectomy incision if indicated.
Figure 27–13: Superior and inferior flaps are raised
sharply with Metzenbaum scissors beneath the nipple-
areolar complex.
Suture or teethed forceps are used to place the

areolar complex under gentle traction.
Care is taken not to "buttonhole" the tissue.
An Allis forceps is used to grasp the ductal tissue with
any palpable abnormality and place this tissue under
gentle traction.
Dissection continues until the ductal system is
isolated from surrounding breast parenchyma and
the specimen encompasses the entire lesion, if
palpable.
Excision extends from the terminal duct proximally to
approximately 2 cm into the breast parenchyma.
Figure 27–14: The proximal duct is ligated sharply flush
with the nipple, while the remaining deeper dissection
into the breast parenchyma is accomplished with
electrocautery to ensure hemostasis.
The specimen is tagged and sent for permanent

pathology.
Once hemostasis is ensured, the wound is irrigated.
The underlying dermal layer is closed with
interrupted 3-0 Vicryl sutures and the overlying skin
is reapproximated with skin adhesive or a 4-0
Monocryl suture placed in a running subcuticular
fashion.
Figure 27–12
Figure 27–13
Figure 27–14
Postoperative Care
Breast Lumpectomy
Patients typically go home the same day.

A supportive bra or breast binder and routine wound care
instructions are advised.
A supportive bra or binder is provided.

Routine drain care and wound care instructions are
advised.
The drains should remain in place until output is < 30
mL/day per drain.
Outpatient and pathology follow-up should be ensured to
promptly facilitate initiation of any indicated adjuvant
therapy.
Routine wound care and judicious follow-up.

Patients typically can be discharged the day of surgery
with oral pain medication.
Routine wound care and judicious follow-up is advised.

Patients typically may be discharged the day of surgery
with oral pain medication and a supportive bra or breast
binder.
Breast Lumpectomy
Bleeding and hematoma.

Seroma.
Wound infection, deep and superficial.
Sampling error (increased incidence with nonpalpable
lesions).
Pneumothorax (if wire localization is used).

Seroma.
Cellulitis and wound infection, deep and superficial.
Chronic upper extremity edema and associated
angiosarcoma of the upper extremity (Stewart-Treves
syndrome).
Axillary webs.
Chyle leak.
Skin flap necrosis.
Nerve and vascular injury.
Damage to the intercostobrachial nerve results in

axillary and upper arm sensory deficits.
The axillary vein is susceptible to frank trauma with
resulting injury and hemorrhage as well as
retraction-associated thrombosis.
Damage to the thoracodorsal bundle denervates the
latissimus dorsi and results in weakened internal
rotation and shoulder abduction.
Damage to the long thoracic nerve denervates the
serratus anterior and results in a "winged" scapula.
Damage to the medial and lateral pectoralis nerve
results in atrophy of the pectoralis major.

Seroma.
Chronic upper extremity edema and associated
angiosarcoma of the upper extremity (Stewart-Treves
syndrome); however, this risk is notably much lower than
with a formal axillary lymph node dissection.
Axillary webs.
Chyle leak.
Sampling error.

Seroma.
Nipple or areolar paresthesia and flap necrosis.
Difficulties with future breast feeding.
Pearls and Tips
Breast Lumpectomy
Place clips around the circumference of the lumpectomy

cavity at the base of the surgical bed to guide adjuvant
radiation therapy.
Consider protective Bovie tips and insulated retractors to
prevent thermal injury to the skin edges.
Consider protective Bovie tips and insulated retractors to

prevent thermal injury to the skin edges.
The easiest way to identify the long thoracic nerve is to
identify the crossing vein from the thoracodorsal vein
passing laterally toward the chest wall.
Avoid rapid movements with the probe and allow counts

to settle out.
Direct the probe away from the site of breast injection to
avoid "shine-through."
Taking > 50% of the subcutaneous tissue beneath the

nipple risks nipple sloughing.
Preoperative imaging can ensure identification of any
abnormality distal in the duct that should be included in
the surgical excision.
References
Morrow M, Strom EA, Bassett LW, et al. Standard for breast

conservation therapy in the management of invasive breast
carcinoma. CA Center J Clin. 2002;52:277–300.[PubMed:
12363326] [Full Text]
Newman L, Sabel M. Advances in breast cancer detection and

management. Med Clin North Am. 2003;87:997–1028.



Management of Melanoma >
Indications
Wide Local Excision of Melanoma
Biopsy-proven cutaneous melanoma.
Inguinal Lymph Node Dissection
Documented metastatic disease in the inguinal lymph

nodes with no evidence of distant metastases.
Metastases detected in the inguinal nodes by sentinel
lymph node (SLN) biopsy or by fine needle aspiration or
excisional biopsy in a patient with a clinically evident
lymph node metastasis.
Full-Thickness Skin Graft
Coverage of large defects created by wide local excision of

a melanoma that cannot be closed primarily or with a
local flap.
Contraindications
Absolute
Inability to close donor site incision.
Relative
Concern about incomplete resection (positive margins).

Poor wound conditions (poor vascularization, exposed
bone, open joint surfaces).
Informed Consent
Expected Benefits
Removal of all melanoma cells at the primary site in order

to provide durable local disease control for all patients,
even when the likelihood for distant relapse is high, and
to effect a cure in patients at low risk of harboring occult
metastatic disease.
Potential Risks

Bleeding or hematoma formation.
Scarring.
Return of melanoma at the surgical site or a distant site.
Need for reexcision in the event of positive margins.
Expected Benefits
Removal of all node-bearing tissue within the femoral

triangle and suprainguinal location (superficial inguinal
lymph node dissection) and possibly the iliac and
obturator nodes (superficial and deep, or ilioinguinal
lymph node dissection).
Potential Risks

Skin edge necrosis.
Wound dehiscence.
Paresthesia.
Lymphocele.
Chronic lymphedema.
Expected Benefits
Autologous coverage of a large skin defect created by the

excision of a melanoma.
Potential Risks
Surgical site or donor site infection.

Bleeding.
Hematoma.
Seroma.
Partial or complete graft loss.
Equipment
Patient Preparation

A review of the histologic findings of the biopsied lesion
should be undertaken before planning a local excision.
The necessary surgical margins (in centimeters) for
excision are determined by the Breslow depth (in
millimeters) of the melanoma.
In situ lesions require a 0.5-cm margin.

Invasive melanomas < 1 mm require a 1-cm margin.
Melanomas > 2 mm in depth require a 2-cm margin.
Melanomas between 1 and 2 mm should be excised
with 2-cm margins when possible, but 1.5-cm or
even 1-cm margins are reasonable when 2-cm
margins are not feasible without a skin graft or would
require an excessively tight closure.
SLN biopsy is typically performed in conjunction with wide
local excision for melanomas 1.0 mm and for melanomas
between 0.76 mm and 1.0 mm if other adverse factors
are present (ulceration, high mitotic rate, angiolymphatic
invasion). (See Chapter 27 for details of SLN biopsy.)
When palpable adenopathy is present in the groin, a

staging workup should be performed to rule out distant
metastases and to evaluate the pelvic lymph nodes. CT
scan of the chest, abdomen, and pelvis will accomplish
this goal.
If iliac or obturator adenopathy is observed, or metastasis
to the deep inguinal nodes is established on SLN biopsy, a
superficial and deep inguinal node dissection is indicated.
Some surgeons also advocate the addition of a deep nodal
dissection in patients with disease of Cloquet's node (the
first node encountered in the femoral canal), three or
more positive superficial nodes, or palpable superficial
adenopathy.
If the staging workup demonstrates evidence of stage IV
disease, the decision to proceed with a palliative
dissection should be based on the extent of both regional
and distant disease and systemic therapy options.
The anticipated site of coverage should be measured and

an appropriate donor site selected.
Patient Positioning
Patient position depends on the location of the melanoma

to be excised.
Patients may need to be supine, prone, or in lateral
decubitus position.
The patient should be supine with the leg slightly flexed at

the knee and externally rotated (frog leg position).
A Foley catheter is placed.
The abdominal wall, inguinal region, and proximal thigh
are prepped and draped into the surgical field.
Patient position depends on the location of the defect to

be covered and the donor site.
Procedure

If SLN biopsy is to be performed in conjunction with wide
excision, the injection of the radionuclide tracer
(technetium- 99m—tagged colloid sulfur) and subsequent
lymphoscintigraphy should take place prior to the
patient's arrival in the operating room.
After the induction of general anesthesia, the site of the
melanoma is prepped with alcohol and isosulfan blue dye
(Lymphazurin) is injected intradermally in four quadrants
around the melanoma (or biopsy scar). The site is
massaged for 5 minutes prior to prepping and draping.
Figure 28–1A: The surgical incision should be carefully
measured and marked using a ruler and a pen with water-
soluble ink.
The margins are measured from the periphery of the

lesion or the previous biopsy scar, not simply from
the center of the scar.
An elliptical incision is made to facilitate closure.
The long axis should be oriented along the lymphatic
drainage to the ipsilateral nodal basin.
On the extremities, the apices of the ellipse should be
longitudinal with the extremity.
The long axis of the ellipse should ideally be 3.5–4
times the width of the excision, although a 3:1 ratio
may be acceptable.
Figure 28–1B: The cross-sectional view of the excision
demonstrates the 2-cm margins as well as a 0.5-cm
subcutaneous beveling of the margin to ensure capture of
deep subdermal lymphatic channels.
Care is taken to avoid beveling toward the melanoma

and compromising the margin.
The excision is carried down to the underlying fascia.
The fascia does not need to be excised with the
specimen.
Orientation of the specimen should be indicated for
the pathologist to enable designation of close or
positive margins.
Tension-free closure of the resulting defect is facilitated
by elevation of the flaps just above the fascia, as much as
twice the size of the excised skin margins.
After assuring meticulous hemostasis, the wound is
typically closed with deep dermal absorbable sutures
followed by interrupted nylon sutures, typically vertical or
horizontal mattress sutures.
A subcuticular absorbable suture may be used if there is
minimal tension.
Closed-suction catheter drainage is rarely necessary.
When the ratio of the length to width is < 3.5:1,
excessive tissue ("dog ears") may be apparent. These can
be excised using a V-plasty technique.
Figure 28–1A–B
Figure 28–2A, B: The classic incision for the inguinal

lymph node dissection is the "lazy S" curvilinear incision.
This begins 3–4 cm medial to the anterior superior

iliac spine, crosses the inguinal crease and then
extends distally to the apex of the femoral triangle.
If a previous excisional (or SLN) biopsy was
performed, the incision should include an ellipse of
skin around the previous scar. Likewise, an ellipse of
skin should be taken over any palpable adenopathy.
It is sometimes desirable to avoid an incision that
crosses the inguinal crease. In this case, a dissection
may be performed through a curvilinear incision
beneath the inguinal crease with or without a second
incision above the crease.
Figure 28–3: The important anatomic borders of the
superficial dissection include the sartorius muscle
(lateral), inguinal ligament (superior), and adductor
longus muscle (medial), which together comprise the
femoral triangle.
There are contiguous superficial nodes superior to the

inguinal ligament and this tissue must be included in
the dissection.
The tissue to be included lies above the external
oblique aponeurosis to the level of the umbilicus
between the pubic tubercle and the anterior superior
iliac spine.
If the incision is below the inguinal crease, a
sufficient superior flap must be raised to include this
tissue.
Figure 28–4: Skin flaps are raised laterally to the
sartorius muscle, medially to the adductor longus, and
superiorly to the level of the umbilicus.
These flaps should not be too thin, as this increases

the risk of wound complications.
The thickness of the skin flaps should be tapered so
they gradually increase toward the base.
Figure 28–5: Dissection of the nodal tissue usually
begins with the suprainguinal tissue.
The superior boundary of the dissection is divided
through the subcutaneous tissue and Scarpa's fascia
down to the external oblique aponeurosis.
This tissue is dissected inferiorly off the aponeurosis
and muscle to the level of the inguinal ligament.
The fascia over the medial sartorius is divided (to
avoid injury to the lateral femoral cutaneous nerve)
and the fibrofatty tissue is raised medially to expose
the femoral vessels.
Likewise the lateral border of the fascia over the
adductor longus is divided and the tissue raised
laterally. The saphenous vein is encountered here.
Although many surgeons advocate routine sacrifice of
the saphenous vein, we only recommend this when
there is gross involvement or disease in close
proximity to it. If it is to be included, it should be
ligated at this point.
The fibrofatty tissue can then be skeletonized off the
femoral vessels from the femoral triangle to the
inguinal ligament.
If the saphenous vein was divided earlier, the
saphenofemoral junction is identified and divided.
The stump may be closed with a silk suture ligation
or a vascular suture.
The only remaining tissue at this point is the tissue
running under the inguinal ligament; this represents
the location where Cloquet's node is often
encountered. If a deep dissection is not planned, the
specimen is divided and Cloquet's node marked for
the pathologist with a silk suture.
If an iliac dissection is to be performed, the deep lymph
nodes can be accessed by a separate incision through the
external oblique aponeurosis.
This incision extends from the anterior superior iliac
spine to the external ring, 2 fingerbreadths above the
ligament.
The external oblique and internal oblique muscles
and transversalis fascia are incised to allow for
retroperitoneal dissection.
Alternatively, the inguinal ligament and external
oblique muscle may be divided to allow access to the
deep nodes. A vertical incision 3–4 cm medial to the
anterior superior iliac spine is made in the external
oblique and the inguinal ligament is divided medial to
the femoral artery.
The peritoneum is bluntly dissected and retracted
cephalad and medially to expose the iliac vessels.
The inferior epigastric vessels are ligated to avoid
iatrogenic injury.
Care is taken not to open the peritoneum, and in men
care must be taken to avoid injury to the spermatic cord
structures.
Figure 28–6: The node-bearing tissue is dissected from
the common iliac artery and vein and continued between
the internal and external iliac artery.
The anterior surface of the external iliac vein is

skeletonized down to the level of the inguinal
ligament.
The ureter is identified as it courses over the iliac
artery.
The fibrofatty tissue is dissected off the bladder wall.
It is necessary to ligate the inferior epigastric vessels
a second time at this point.
The obturator nerve is identified and the obturator
nodes are resected en bloc with the specimen,
clearing out the tissue between the nerve and the
internal iliac artery.
A drain may be placed in the pelvis through a separate
stab incision.
The transversalis and internal and external obliques are
reapproximated with nonabsorbable sutures.
If the inguinal ligament was divided, it may be repaired
directly with nonabsorbable suture.
The defect in the femoral canal is closed by attaching the
inguinal ligament to Cooper's ligaments.
Figure 28–7A, B: Coverage of the exposed femoral
vessels is achieved by dividing the attachments of the
sartorius muscle at its origin (anterior superior iliac spine)
and rotating it medially.
Be careful to preserve as much of the medial blood

supply as possible.
The sartorius is secured to the inguinal ligament
using absorbable U-type suture.
The sartorius is routinely transpositioned when a
deep dissection is performed but may be used
selectively for a superficial dissection, depending on
the thickness and viability of the flaps and exposure
of the vessels.
A superficial drain is placed through a separate stab
incision.
The skin is reapproximated with interrupted absorbable
deep dermal sutures followed by nylon sutures, staples,
or a running subcuticular stitch.
Figure 28–2A–B
Figure 28–3
Figure 28–4
Figure 28–5
Figure 28–6
Figure 28–7A–B
It was previously thought that a split-thickness skin graft

was preferable for the closure of a defect left by a
melanoma resection as it provided a better means for
detecting local recurrences. However, it has subsequently
been shown that the type of closure has no impact on risk
for local recurrence or survival.
Full-thickness skin grafts give a much better cosmetic
result, as they develop a subcutaneous layer beneath the
graft resulting in greater mobility. They are also less likely
to contract and are more resistant to mechanical wear.
Most patients undergoing melanoma resection are good
candidates for a full-thickness skin graft.
In patients for whom the margin status after wide
excision is in question (particularly the deep margin), it is
preferable to use a temporary graft (allograft or
bioartificial graft) and defer a permanent skin graft until
negative margins are assured.
In patients for whom a suitable donor site for a full-
thickness skin graft cannot be identified, a split-thickness
skin graft should be performed.
Typical donor sites for full-thickness graft harvest include
the skin from natural body creases so that the donor site
incision is well concealed.
Thickness, texture, pigmentation and the presence or
absence of hair should be matched as closely as possible.
Outside of the head and neck, the most common
melanoma resections that require skin grafting are on the
distal extremities.
When an SLN biopsy is planned in conjunction with a wide
local excision, it is often useful to harvest the skin graft
from the biopsy site.
The SLN biopsy incision is made in an elliptical

fashion, large enough to accommodate the wide local
excision defect and oriented in such a way that a
subsequent lymph node dissection can be easily
incorporated if necessary.
The skin should be harvested with a scalpel.
After incising the ellipse, the skin is elevated with a
skin hook and sharply dissected off the underlying
subcutaneous fat.
After the graft is removed, any residual fat is
removed with sharp curved scissors until only the
white glistening dermis remains.
Several small perforations should be made in the
graft.
The SLN biopsy is performed through this incision
and the wound is closed primarily with the excision of
any dog ears.
Before placing the graft into the defect, the recipient site
is reinspected for hemostasis.
Figure 28–8: Once hemostasis of the recipient site is
assured, the graft is placed dermal side down and
trimmed to fit the defect without excessive wrinkling or
stretching.
Although many surgeons use staples to secure the

graft, we prefer sutures as removal of staples is
painful.
The graft can be secured with absorbable sutures,
which do not need to be removed, or with silk
sutures that can then be used to bolster the graft.
If absorbable sutures are used, a bolster made from
foam rubber molded to the contour of the wound is
secured radially around the wound with
nonabsorbable sutures or staples.
We prefer to secure the graft with silk sutures left
long and then tied over a bolster made from
Xeroform folded over mineral oil—soaked cotton
balls. These bolsters prevent shearing as well as
seroma or hematoma formation beneath the graft.
A splint is typically used to prevent excessive motion
and shearing forces that can disrupt graft adherence.
Figure 28–8
Postoperative Care
Routine wound care.

Removal of any external sutures at an interval of 7–14
days postoperatively, depending on wound tension and
location (eg, shorter interval for facial sutures).
Patients should protect the surgical site from excessive
sun exposure during the first year to prevent darkening of
the scar.
Patients are admitted overnight with the Foley catheter

left in place and the leg elevated.
Antibiotics are maintained for 24 hours postoperatively.
Patients may be discharged the next day.
If the sartorius was transposed, we prefer to send the
patient home with crutches and toe-touch weight bearing
only.
Patients are encouraged to wear compression stockings as
soon as possible to minimize lymphedema.
The drain to bulb suction is continued until output is < 30
mL per 24 hours for 2 consecutive days.
The drain should not remain in place longer than 3–4

weeks.
It may be better to accept a lymphocele than a
wound infection.
Sutures are removed after 10–14 days.
Patients are followed closely for infection or other wound
complications.
Routine wound care for the donor or SLN biopsy site.

The bolster is removed approximately 5 days after
placement (sooner if there is evidence of bleeding or
infection). For a tie-over bolster, after the silk sutures are
cut, the bolster is moistened and carefully removed to
avoid lifting the graft off the underlying wound bed.
A nonadherent dressing can be placed over the graft.
Immobilization, if needed, can be stopped 7–10 days after
grafting.
Any areas of graft loss heal by secondary intention with
debridement of any sloughed graft and twice-daily wound
care with "wet-to-dry" saline dressings.
Wound infection.
Need for reexcision if positive margins are encountered on
final pathology examination.
Wound infection.
Wound necrosis or dehiscence.
Hematoma.
Lymphocele.
Lymphedema.
Graft failure.
The most likely reasons are hematoma beneath the

graft, seroma formation, infection, shear forces,
technical error, or a poor recipient site.
Infection or wound separation of the donor site.
It is important to verify that enough skin can be

harvested without leading to overly tight closure of
the donor site.
Pearls and Tips
Attempt to maintain the surgical scar within the natural

creases of the skin for a cosmetically acceptable result.
A common mistake while skeletonizing the vessels is to

consider the proximal femoral vein as the medial
boundary of the dissection. This ignores the medial node-
bearing tissue at the level of the femoral canal between
the pubic tubercle and vein (Remember NAVEL: nerve,
artery, vein, empty space, lymphatics). This fibrofatty
tissue should be excised down to the underlying pectineus
muscle and included in the dissection. Retraction of the
vein laterally with a vein retractor will help.
If the inguinal ligament is divided, it is helpful to place
two long sutures on each side to facilitate
reapproximation.
Wound complications are often secondary to vascular
compromise. Prior to closure, trim any flaps that appear
too thin (without causing too much tension) and avoid
tying skin sutures too tight.
References
Sabel MS. Oncology. In Doherty GM, ed. Current Diagnosis

and Treatment: Surgery. New York, NY: McGraw-Hill; 2010:
1209–1232.



Management of Soft Tissue Sarcoma >
Indications
Any soft tissue mass that is large or growing should be

evaluated by biopsy using the techniques described
later.
When the diagnosis of sarcoma is established, surgery
remains the mainstay of therapy.
Contraindications
Medical comorbidities such as severe cardiopulmonary

compromise may preclude safe surgery.
Informed Consent
Expected Benefits
Limb preservation for soft tissue sarcomas of the

extremity.
Potential Risks
Major neurovascular structures may need to be

sacrificed to achieve oncologic goals, but management
strategies designed to preserve these structures are
preferable.
Risk of recurrent disease.
Equipment
No special equipment is needed.

Occasionally, for deep lesions or lesions that have
dramatically decreased in size with neoadjuvant
therapy, intraoperative ultrasound may be useful to
identify the lesion and to plan the incision.
A self-retaining retractor can assist with exposure.
Patient Preparation
Optimal management of soft tissue sarcomas requires

a multidisciplinary approach at a high-volume center.
Input from medical and radiation oncologists
experienced in managing this disease is critical.
Biopsy results should be evaluated by pathologists
experienced with sarcoma.
MRI, ultrasound, and CT scanning are all routinely used
to evaluate soft tissue sarcomas of the extremity.
Quite often, patients undergo extensive preoperative
radiation therapy and chemotherapy before surgery.
Plastic surgical assistance for reconstruction can be
necessary for wound closure.
Patient Positioning
The patient may be placed supine, prone, or in lateral

position depending on the location of the lesion.
If a soft tissue flap reconstruction is planned,
communication with the plastic surgery team is
essential when positioning the patient.
Procedure
Figure 29–1: Core needle biopsy.
For any soft tissue mass that is enlarging,

symptomatic, or > 3–5 cm, biopsy should be
performed.
Core needle biopsy is a reliable method to obtain
sufficient material for accurate pathologic
diagnosis.
Biopsy with ultrasound or CT guidance may be
useful.
Figure 29–2: Incisional biopsy and placement of
incision for resection.
For lesions > 5 cm, incisional biopsy may be

appropriate.
Proper orientation of the incision is critical.
The incision must be in a plane parallel to the long
axis of the limb and one that can be subsequently
excised by a more definitive surgical procedure, if
necessary.
Hemostasis is important to avoid development of
hematomas that can expand along fascial planes
and compromise a more definitive wide excision of
the lesion at a later date.
Radical resection of soft tissue sarcomas involves
careful operative planning.
Similar to incisional biopsy principles, the operative
incision should be in a plane parallel to the long
axis of the limb.
The skin incision should be oriented such that any
previous biopsy sites are included en bloc with the
specimen.
Figure 29–3: Skin flaps.
After the appropriate incision is made based on the

above principles, skin flaps are raised to allow for
an appropriate margin of excision.
Figure 29–4: Radical resection of tumor.
There is generally a pseudocapsule around the

tumor; however, tumor infiltration may extend
beyond the pseudocapsule.
The goal of operation is resection of the tumor with
a 2-cm margin of surrounding normal soft tissue.
Skin, subcutaneous tissue, and soft tissue adjacent
to the tumor should be taken en bloc with the
specimen.
Resection of entire muscle compartments is not
necessary.
Limb-sparing and preservation of limb function are
cornerstone principles.
Figure 29–5A, B: Preservation of the neurovascular
bundle.
In most circumstances, identification and

preservation of the neurovascular bundle in an
extremity is a key component of the operation and
does not compromise the oncologic outcome.
Careful dissection of the perineurium from a nerve
(Figure 29–5A).
Completed dissection with nerve preservation
(Figure 29–5B).
Figure 29–6: Closure of the incision.
The skin is generally closed with staples or

interrupted vertical mattress sutures over closed
suction drains.
Closed suction drains are generally left in place for
a few days to prevent seroma accumulation.
Figure 29–1
Figure 29–2
Figure 29–3
Figure 29–4
Figure 29–5A–B
Figure 29–6
Postoperative Care
Patients are quickly advanced to a regular diet.

Activity restrictions vary and depend on the location of
surgery and type of plastic surgical reconstruction, if
any.
Common complications include surgical site infection,

hematoma, seroma, and wound breakdown (especially
in previously irradiated tissue).
Sarcomas may lie in proximity to major neurovascular
structures that may be inadvertently damaged or taken
purposefully en bloc with the specimen.
Other systemic complications of major surgery
(pneumonia, venous thromboembolism, and
cardiovascular events) can also occur.
Pearls and Tips
A multimodality treatment approach is the rule.

Soft tissue sarcomas are rare and should be referred to
high-volume centers with the expertise necessary to
properly manage this disease.
In addition to surgical expertise, proper management
requires input from medical oncology, radiation
oncology, pathology, and radiology services.
References
Brennan MF, Lewis JJ. Diagnosis and Management of Soft

Tissue Sarcoma. London: Martin Dunitz; 2002.
Delman KA, Cormier JN. Soft-Tissue and Bone Sarcoma.

In: Feig B, Berger D, Fuhrman G, eds. The MD Anderson
Surgical Oncology Handbook, 4th ed. Philadelphia, PA:
Pollock RE. Soft Tissue Sarcomas. Hamilton, ON: BC

Decker; 2002.

Current Procedures: Surgery > Chapter 30. Renal

Transplantation >
Indications
Donor Nephrectomy
Appropriate volunteer to donate to a person with renal

failure.
Renal Transplantation
All causes of impending or established end-stage renal

disease.
Contraindications
Donor Nephrectomy
Absolute
Impaired renal function (generally considered to be a

glomerular filtration rate < 80 mL/min per 1.73 m2).
Active infection.
Diabetes.
Pregnancy.
Poorly controlled psychosis.
Relative (Open or Laparoscopic)
Proteinuria or hematuria.
History of malignancy.
Kidney stones.
Disorder requiring anticoagulation.
Cardiovascular disease.
Chronic illness.
Hypertension.
Abnormal urologic anatomy.
Family history of diabetes.
History of kidney stones.
Obesity.
Relative (Laparoscopic)
Previous laparotomies.
History of pyelonephritis.
Horseshoe kidney.
Short right renal vein.
Multiple renal arteries.
Absolute
Untreated ongoing infection.

Active malignancy with short life expectancy.
Chronic illness (with life expectancy < 1 year).
Poorly controlled psychosis.
Relative
Cardiovascular disease.
Infection.
Cerebrovascular disease.
Obesity.
Proven habitual noncompliance with medical
recommendations.
Informed Consent
Donor Nephrectomy
This procedure is unique in that it involves operating on a

patient who has no chance for medical benefit from
surgical intervention. For this reason, an extensive
psychosocial evaluation is required prior to surgery.
The motivation of the volunteer must be established as
genuinely altruistic and the patient must be aware that he
or she can opt out at any time.
Postoperative pain, transient urinary retention, and
superficial surgical site infections are common minor
complications.
Compared with an open approach, laparoscopic donor
nephrectomy is associated with a quicker convalescence.
Operative mortality and major complications are
infrequent, but not nonexistent.
Major complications include systemic complications of

major surgery (pulmonary emboli, cardiovascular
events, pneumonia, sepsis, infection, and bleeding).
Other risks include pancreatitis; injury to bowel,
spleen, or adrenal gland; small bowel obstruction;
and conversion to an open procedure when a
laparoscopic approach is planned.
Importantly, there is no increased risk of renal failure
after donor nephrectomy.
Expected Benefits
For most patients with end-stage renal disease, renal

transplantation is superior to dialysis in terms of long-
term mortality risk. Therefore, candidates commonly
undergo transplantation once a suitable donor is identified
and appropriately allocated.
Potential Risks
Systemic complications associated with any major surgery

(cardiovascular events, pneumonia, pulmonary emboli,
and venous thromboemboli).
Other operative risks include:
Acute rejection.
Arterial or venous thrombosis.
Post-transplantation renal dysfunction.
Urine leaks.
Ureteral obstruction.
Wound infection.
Abscess.
Seroma.
Allograft fracture.
Lymphocele and hemorrhage.
Late complications include:
Acute or chronic rejection episodes.

Renal artery stenosis.
Infection.
Malignancy.
Equipment
Donor Nephrectomy
Open Nephrectomy
Laparoscopic Transperitoneal Donor Nephrectomy
Laparoscope with 30-degree lens.

Standard laparoscopic surgical instruments.
Standard open vascular surgical instruments.

A self-retaining retractor allows the procedure to be
performed by the surgeon and one assistant.
Patient Preparation
Donor Nephrectomy
Comprehensive evaluation of potential donors is essential

to establish donor suitability. This entails thorough
assessment of the donor's physical and psychological
condition and confirmation of normal kidney function prior
to surgery.
The first steps in the initial screening process include:
Brief history and physical examination to rule out

medical conditions that would preclude donation.
ABO determination.
Cross-matching.
The subsequent complete evaluation should include:
Psychosocial history.
Chest radiograph.
Electrocardiogram.
Urinalysis.
Comprehensive blood work.
Laboratory screening should include:
Complete blood count.

Chemistry panel.
Liver function tests.
Creatinine clearance.
Serology for hepatitis B and C, HIV, cytomegalovirus,
and Epstein-Barr virus.
Rapid plasma reagin (RPR) or VDRL tests.
Possibly glucose tolerance test (for diabetic families).
As a final step, the renal anatomy of the donor is defined
to determine which kidney will be removed and to rule out
any anatomic abnormalities.
In general, the left kidney is easier to remove and
transplant than the right kidney because of the
longer length of the renal vein.
Evaluation of the renal anatomy can be done with an
intravenous pyelogram and renal arteriogram in
combination, or with a CT angiogram alone.
Extensive pretransplantation assessment focuses on

evaluating the recipient's cardiovascular status, excluding
malignancies and infections that would contraindicate
transplantation, and clearly defining the renal disease.
Initial routine screening laboratory tests include:

Chemistry panel.
Coagulation assays.
Liver function tests.
ABO blood typing.
HLA tissue typing.
Standard panel reactive antibody (PRA) testing.
Virology screening tests for cytomegalovirus, HIV,
Epstein-Barr virus, and hepatitis B and C and the
tuberculum skin test are routinely ordered.
An ECG in conjunction with a pharmacologic or exercise
stress test is obtained to evaluate cardiovascular status
(particularly in diabetic patients).
Patients with ischemic heart disease should undergo
angiography or a revascularization procedure as deemed
appropriate with follow-up angiograms or stress tests
repeated within 1 year of the actual transplantation.
A baseline chest radiograph should be obtained.
Screening colonoscopy, mammography, and Pap smear
should be performed as indicated by standard guidelines.
A complete genitourinary workup is probably only
necessary for patients with recurrent infections, bladder
dysfunction, or congenital abnormalities as the cause of
renal failure. For these patients, urodynamics and a
voiding cystourethrogram are indicated.
Some centers advise that all patients undergo

screening renal ultrasonography prior to
transplantation.
Vaccination status of the recipient should be reviewed and
influenza, hepatitis B, and pneumococcus vaccinations
administered as necessary.
Once an organ is procured for the recipient, the
immediate preoperative care includes:
Urinalysis.
Coagulation assay.
Comprehensive metabolic panel.
Type and screen.
Repeat chest radiograph.
Electrocardiogram.
If needed, arrangements for dialysis should be made,
especially if potassium levels are elevated.
There is no consensus for induction therapy after

renal transplantation.
Typical regimens use a combination of three or four
drugs (corticosteroids, cyclosporine or tacrolimus,
mycophenolate, and antibodies).
Patient Positioning
Donor Nephrectomy
Figure 30–1: The patient should be in the right lateral

decubitus position (for left nephrectomy) and carefully
padded.
The operating table is flexed to extend the left flank and
maximize exposure.
For open procedures, an oblique incision is made from a
point just lateral to the lateral border of the rectus
abdominus muscle and continued below the 12th rib to
the paraspinous muscles posteriorly.
Figure 30–1
The patient should be supine on the operating table (for

orientation see Figure 30–9, later).
The abdomen is prepared and draped in standard sterile
surgical fashion.
A curvilinear incision is made in the left lower quadrant
extending from 1 cm above the pubic symphysis to 2–4
cm lateral to the anterior superior iliac spine.
Figure 30–9
Procedure
Open Donor Nephrectomy
Figure 30–2: Extraperitoneal exposure of the kidney is

achieved by first dividing the muscle with electrocautery
and then mobilizing the peritoneum medially.
Gerota's fascia is incised longitudinally and the kidney is
mobilized using electrocautery and sharp dissection.
Figure 30–3: The renal vessels and ureter are dissected
free from surrounding tissues along a plane as close as
possible to the aorta and below the adrenal and gonadal
venous branches.
The gonadal, adrenal, and any lumbar veins are

ligated and divided during the dissection as required.
The ureter is mobilized distally to the common iliac
artery, ligated, and divided.
After transection of the ureter, diuresis is confirmed.
After the renal hilum is completely dissected, the patient
receives mannitol and furosemide to aid in diuresis.
Arterial vasospasm is treated with a topical solution of
papaverine (30 mg/mL).
Figure 30–4: Once adequate lengths of renal artery and
vein have been mobilized, a vascular clamp is placed on
the renal artery, a Satinsky clamp is placed on the left
renal vein below the gonadal and adrenal branches, and
the vessels are transected. The renal vessels are doubly
ligated or oversewn.
The kidney is delivered from the operative field and
immersed in ice-cold saline.
The vein is opened and the kidney is immediately
perfused with cold kidney preservation solution through
the renal artery or arteries. Perfusion is complete once
the entire kidney blanches (usually after perfusion of
200–300 mL of solution).
The kidney is packaged for transport to the recipient
operating room. The incision is closed in layers with
absorbable sutures. If needed, a chest radiograph is
obtained in the recovery room to evaluate for a
pneumothorax.
Figure 30–2
Figure 30–3
Figure 30–4
Laparoscopic Transperitoneal Donor Nephrectomy
Figure 30–5A, B: A small midline incision is made and a

pneumoperitoneum is established. Once the operative
field is expanded, the scope is inserted and additional
ports are placed under direct visualization.
Typically, four ports are placed in the abdomen and

the kidney is ultimately extracted through a 6–8-cm
incision.
The small intestines and omentum are allowed to fall
into the contralateral half of the abdominal cavity.
Alternatively, a hand port may be used. A
minilaparotomy is made at the umbilicus and 10-mm
and 12-mm trocars are placed below the left costal
margin and in the left lateral abdomen, respectively.
Figure 30–6: Mobilization of the colon is achieved by
incising the lateral peritoneal reflection and dissecting
along the line of Toldt from the splenic flexure to the level
of the iliac vessels. The colorenal and splenorenal
ligaments are divided.
Figure 30–7: Retraction of the colon and its mesentery
allows visualization of the renal hilum.
The gonadal, adrenal, and lumbar veins are

identified, clipped, and divided during the dissection.
After the renal hilum is completely dissected, the
patient receives mannitol and furosemide to aid in
diuresis.
Elevation of the lower pole of the kidney allows
identification of the ureter.
The ureter is dissected free to the level of the iliac
bifurcation.
Dissection proceeds from the renal hilum caudally
along a plane medial to the gonadal vein in order to
preserve the ureteral blood supply.
The distal ureter is clipped at the level of the iliac
vessels and divided.
The renal vein is dissected medially away from
surrounding tissues.
The renal artery, which lies posterior to the vein, is
identified.
The renal artery is dissected medially to a point as
close to the aorta as possible.
Arterial vasospasm is treated with a topical solution
of papaverine (30 mg/mL).
In preparation for removal of the kidney, a 6–8-cm
Pfannenstiel incision is made for the retrieval device and
carried down to, but not through, the peritoneum to
maintain the pneumoperitoneum. Alternatively, if the
hand-assisted method is used, the kidney can be
retrieved through the hand port.
If heparin is given, the patient should receive the dose
prior to division of the vascular pedicle.
Figure 30–8A, B: The artery is divided at its origin close
to the aorta using an endovascular stapler (Figure 30–
8A). Next, the renal vein is divided anterior to the aorta
using an endovascular stapler (Figure 30–8B).
The kidney is then retrieved under direct vision with care
to ensure that the kidney, vessels, and ureter are not
damaged during extraction.
The peritoneum is then entered through the previous
incision and the kidney is delivered from the abdomen.
If anticoagulation was used, it is reversed with protamine
sulfate.
The kidney is immersed in ice-cold saline and immediately
flushed with kidney preservation solution.
The fascia is closed and a pneumoperitoneum is
reestablished.
The field is carefully inspected for hemostasis.
The instruments are removed and the port sites and
abdominal incisions are closed.
Figure 30–5A–B
Figure 30–6
Figure 30–7
Figure 30–8A–B
Figure 30–9: Following patient positioning, as outlined
earlier, the incision is carried down through the
subcutaneous tissue and fascia with care taken not to
enter the peritoneum.
The contents of the peritoneum are retracted medially to
expose the retroperitoneum.
Figure 30–10: The retroperitoneum is entered and the
external iliac artery and vein are mobilized free from
surrounding connective tissue, taking care to ligate all
lymphatics to prevent lymphocele formation.
In men, the spermatic cord is secured with a vessel

loop and retracted away from the operative field.
In women, the round ligament is identified, ligated,
and divided.
Figure 30–11: Once the external iliac artery and vein
are completely skeletonized, the donor kidney is brought
into the operative field.
The iliac vein is occluded with a single Satinsky

clamp.
An appropriately sized venotomy is made and the
renal vein is anastomosed to the external iliac vein in
an end-to-side fashion.
Figure 30–12: Typically the external iliac artery is
anastomosed to the renal artery in an end-to-side
fashion.
The external iliac artery is clamped proximally and
distally, and an arteriotomy is made on the anterolateral
aspect of the artery.
Figure 30–13A-C: The small incision is completed using
a circular punch to provide clean edges (Figure 30–13A).
Two sutures are placed at opposite sides of the
arteriotomy (Figure 30–13B), and the anastomosis is
completed by running a continuous suture along each side
(Figure 30–13C).
The clamps are released and blood flow through the
vessels is assessed.
The kidney should become pink immediately upon
reperfusion, and may begin to produce clear urine.
Figure 30–14A-C: For the ureteral anastomosis, the
anterolateral aspect of the bladder is exposed.
The detrusor muscle is divided for approximately 3

cm, exposing the mucosa (Figure 30–14A).
The mucosa of the bladder is opened for
approximately 1 cm and the ureter is anastomosed to
the mucosa of the bladder using absorbable suture
(Figure 30–14B).
Interrupted sutures are used to close the muscle
layer of the bladder over the distal portion of the
ureter to limit reflux (Figure 30–14C).
Hemostasis is achieved, and the condition of the
kidney is noted prior to closing.
The abdominal wound is irrigated and closed in layers.
Ureteral stents can be used if there is concern for the
integrity of the bladder and the ureter.
Alternative methods for reimplantation of the ureter
include ureteroureterostomy over a double JJ stent,
extravesical single-stitch (U-stitch) technique, and
Politano-Leadbetter transvesical ureteroneocystostomy.
Figure 30–10
Figure 30–11
Figure 30–12
Figure 30–13A–C
Figure 30–14A–C
Postoperative Care
Donor Nephrectomy
Analgesia.
Oral intake when tolerated.
Appropriate immunosuppression.
Fluid management should be adequate to ensure good
diuresis without fluid overloading. Hourly urine output
should be replaced with 0.45% normal saline at 1.0 mL
saline per milliliter urine.
Monitoring of electrolytes.
Nothing by mouth.
Kayexalate should not be given as this may cause colonic
necrosis.
Donor Nephrectomy
Pneumothorax.
Infection.
Bleeding.
Urinary obstruction.
Arterial or venous thrombosis.
Infection.
Ureteral anastomotic leak.
Bleeding.
Pearls and Tips
Donor Nephrectomy
Mobilizing the ureter before extensive dissection of the

vessels allows quicker removal of the kidney if bleeding is
encountered.
Small accessory arteries to the superior pole can be
sacrificed with minimal deleterious effect. However, small
accessory arteries to the inferior pole may supply the
ureter and need to be preserved or reconstructed.
The right renal vein is thin and delicate and must be
handled carefully.
Staple the renal artery with an endovascular stapler.
Clips, including locking clips, are more likely to fall off
(laparoscopic donor nephrectomy).
A hand port allows manual compression and control of
bleeding and may increase safety of the laparoscopic
approach (laparoscopic donor nephrectomy).
In type 1 diabetic patients, consider placing the kidney on

the left to enable a future pancreatic transplantation
procedure on the right side.
Keeping the dissection extraperitoneal aids exposure by
sequestering the bowel out of the surgical field and
keeping the kidney in a smaller compartment, which helps
to prevent intraperitoneal bleeding.
References
Fabrizio, MD, Ratner, LE, Montgomery, RA, Kavoussi LR.

Laparoscopic live donor nephrectomy. Urol Clin North Am.
1999;26:247–256.
Kasiske BL, Cangro CB, Harihan S, et al. The evaluation of

renal transplant candidates: clinical practice guidelines. Am J
Transplantation. 2001;1(Suppl 2):7–95.
Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor
nephrectomy. Transplantation. 1995;60:1047–1049.[PubMed:


Current Procedures: Surgery > Chapter 31. Pancreas

Transplantation >
Indications
May be performed in diabetic patients with end-stage

renal disease either as simultaneous pancreas-kidney
(SPK) transplantation, or as pancreas-after-kidney (PAK)
transplantation.
Pancreas transplantation has minimal impact on

immunosuppression.
Nonuremic patients with type 1 diabetes usually receive
pancreas transplantation alone (PTA).
Risk of immunosuppression is added to the surgical

risk.
Contraindications
Absolute
Untreated or recent malignancy.

Active or chronic infection.
Inability to comply with postoperative immunosuppression
and follow-up.
Relative
Advanced extrarenal complications of diabetes (coronary

artery disease).
Evidence of insulin resistance (type 2 diabetes, insulin
requirements > 1 unit/kg, BMI > 30).
Informed Consent
Expected Benefits
Improved quality of life.
Provides optimum glucose control.

Improves or minimizes complications of diabetes.
Reverses early diabetic nephropathy in both native
and graft kidneys.
Results in euglycemia without hypoglycemia.
Conveys a survival benefit for type 1 diabetic patients
with end-stage renal disease.
5-year graft survival is 57–71%.
Potential Risks
Inherent risks of postoperative immunosuppression.

Venous thrombosis (affects 3–5% of grafts in the first 24–
48 hours).
Complications of exocrine drainage:
Cystitis and balanitis in bladder-drained grafts.

Abscess or leak in enteric drainage.
Bleeding.
Pancreatitis.
Equipment
Sterile ice for back-table preparation and surface cooling

of the graft.
Fixed retractor for optimal exposure.
Patient Preparation
Donor
Freedom from malignancy and infectious disease.

Donor age, mechanism of death, medical history, and
perimortem hyperglycemia or hyperamylasemia affect
suitability of the pancreatic graft.
Inspection at the time of donation.
Recipient
Eligibility is based on utility of a pancreatic graft as well

as individual fitness for operation, with emphasis given to
preoperative weight loss as necessary.
Preoperative evaluation is directed toward identification
and treatment of diabetic complications, most importantly
coronary artery disease, and includes:
Stratified cardiac evaluation (all recipients).

Assessment for coexistent pulmonary vascular
obstructive disease in the absence of a femoral pulse.
Investigation of aortoiliac occlusive disease with
noninvasive flow studies, MR angiogram, CT
angiogram, or standard angiography.
Preoperative preparation includes placement of arterial
and central venous lines, nasogastric tube, and Foley
catheter, as well as sequential compression devices.
Patients should also receive preoperative antibiotic
prophylaxis.
Patient Positioning
For both donor and recipient procedures:

Procedure
Donor Pancreatectomy
Figure 31–1: The lesser sac is entered by dividing the

gastrocolic ligament.
The stomach is retracted superiorly and the

transverse colon inferiorly to expose the pancreatic
body and tail.
Careful palpation of the pancreas to detect masses or
abnormalities is followed by careful dissection of the
gastrohepatic and hepatoduodenal ligaments.
The common bile duct, gastroduodenal artery, right
gastric artery, and coronary vein are sequentially
divided.
The celiac axis is exposed, the left gastric artery
ligated, and the supraceliac aorta controlled.
The posterior aspect of the pancreas is inspected
using a Kocher maneuver, with division of the
gastroepiploic vessels to facilitate mobilization.
Figure 31–2: The short gastric vessels, splenophrenic,
splenocolic, and splenorenal ligaments are divided,
freeing up the spleen.
The spleen is used as a handle for further

mobilization of the pancreas.
Dissection is extended back toward the midline.
Figure 31–3: The nasogastric tube is advanced into the
duodenum and flushed with 200 mL of an antimicrobial
solution.
The tube is then withdrawn into the stomach and a

multirow cutting (gastrointestinal anastomosis [GIA])
stapler is used to divide the duodenum just distal to
the pylorus and again just proximal to the ligament
of Treitz.
A multirow noncutting (thoracoabdominal) stapler
with a vascular load is used to divide the root of the
mesentery, including the superior mesenteric artery
(SMA) and vein (SMV).
When dissection of other organs to be transplanted is
complete, heparin anticoagulation is given and the
infrarenal aorta is cannulated.
Chilled preservation solution is infused through the
infrarenal aorta, and the pancreas is bathed in sterile
slush. After infusion of approximately 3 L of
preservation solution, the organs are removed from
the donor.
The SMA is removed with a small aortic patch, unless a
replaced right hepatic artery is present. In that case the
SMA is transected distal to the origin of the right hepatic
artery.
If the patient is also a liver donor, the splenic artery is
taken close to its origin for later reconstruction. If the
liver is not to be procured, the celiac and SMA are taken
with a common aortic patch.
The portal vein is usually divided at the level of the
coronary vein to allow adequate length for both liver and
pancreas grafts.
The pancreas is generally removed after the liver and
placed in sterile, 4°C preservation solution for transport.
The liver and pancreas may also be removed en bloc and
separated on ice on the back table.
Segments of donor vessels, including the right iliac
arterial bifurcation and common iliac vein, are explanted
and stored in preservation solution.
Figure 31–1
Figure 31–2
Figure 31–3
Pancreas Transplantation
Figure 31–4A, B: Back-table preparation of the

pancreatic graft is carried out in a pool of chilled
preservation solution.
The spleen is first removed by ligation of its vascular

supply, and the distal duodenum is trimmed off to the
level of the uncinate process. The proximal and distal
staple lines, as well as the staple line across the
mesenteric root, may be reinforced with running
sutures (Figure 31–4A).
For the recipient operation, the graft SMA and splenic
artery must be joined into one conduit (Figure 31–
4B).
If a common aortic patch was taken, no
reconstruction is necessary.
If the two arteries are separate, however, a Y-graft is
formed from donor iliac bifurcation, with vascular
anastomosis of the internal iliac to the splenic artery,
and external iliac to the SMA.
Each leg of the Y-graft should be 1–2 cm long, with
adjustments to allow for suture lines that are tension
and torsion free.
Should the donor's iliac vessels be unsuitable for a Y-
graft, another option is the donor brachiocephalic
trunk. End-to-side tube interposition segments
between splenic artery and SMA may be employed if
needed.
The portal vein is next mobilized with minimal
dissection. If the donor portal vein segment is too
short to allow implantation, a length of donor iliac
vein may be attached end to end.
Figure 31–5: The recipient procedure is preferentially
performed on the right side, as the iliac vessels are more
superficial and the vein lies lateral to the artery in the
neutral position.
The operation is begun with a low midline

laparotomy, and dissection is carried down in the
plane between the cecum and retroperitoneum. The
right ureter is isolated and gently mobilized from the
iliac vessels.
The arterial supply usually needs no mobilization, but
a tension-free venous anastomosis may require
ligation of the hypogastric veins. The distal inferior
vena cava may also be used for the venous
anastomosis.
With the patient systemically heparinized, the
proximal common iliac vessels and distal external and
internal vessels are all clamped. The locations of the
arteriotomy and venotomy in relation to each other
vary with cephalad or caudal positioning of the graft
and individual anatomy.
Figure 31–6: The most common method of pancreas
transplantation is systemic venous drainage with enteric
exocrine drainage.
With the vessels clamped, a venotomy is made and

corner stitches of 6-0 nonabsorbable suture are
placed.
A final check of the vascular anatomy is made before
taking the graft out of the ice. The pancreas is
brought into the operative field and placed in the
pelvis with the duodenal segment directed either
cephalad or caudad.
Excess donor portal vein is trimmed off to minimize
kinking, and corner sutures are carried through
corresponding points on the donor vessel. These
sutures are tied, and the end-to-side venous
anastomosis is secured by running the corner stitches
to each other.
The arteriotomy is made next and 6-0 corner sutures
are placed. The arterial anastomosis is similarly
secured and the vascular clamps are removed. The
anastomosis, ligated donor vessels, mesenteric root,
and duodenal staple lines are all meticulously
A loop of mid-jejunum is brought down and laid flat
to identify a good point for the side-to-side enteric
anastomosis. Ideally, the exocrine secretions are
directed into the jejunum approximately 50–60 cm
past the ligament of Treitz to minimize postoperative
diarrhea.
Enterotomies are made in the antimesenteric borders
of the two segments, each about 4 cm in length, and
an inner layer of running 4-0 absorbable suture is
used to approximate the edges. This is reinforced
with an outer layer of interrupted 4-0 nonabsorbable
sutures. Caution is used around the area of the
ampulla of Vater to avoid impingement.
Alternatively, the anastomosis may be made with a
GIA or an end-to-end anastomosis (EEA) stapler, and
backed with a layer of nonabsorbable sutures.
Figure 31–7: Systemic venous drainage with bladder
exocrine drainage was the most popular technique for
pancreas transplantation in the 1990s but has fallen from
favor due to the associated risk of severe dehydration and
urologic complications.
Initial dissection includes mobilization of the anterior

and lateral attachments of the bladder, taking care to
avoid injury to the ureter.
Revascularization of the graft is performed just as in
enteric drainage, but the pancreas is directed
caudad.
A horizontal posterior cystostomy is made, about 4
cm in length, with a matching enterotomy made in
the antimesenteric aspect of the duodenum.
The duodenocystostomy is closed with a running 4-0
absorbable suture line and an exterior layer of
interrupted nonabsorbable stitches.
Figure 31–8: Enteric drainage of exocrine secretions
may be combined with portal venous drainage for more
physiologic insulin release and metabolism.
In this variant, the arterial supply is through the
common iliac artery, and venous drainage is
accomplished by end-to-side anastomosis of the
donor portal vein to the recipient SMV.
The graft lies above the small bowel mesentery, with
the arterial Y-graft traversing the mesentery.
While the pancreatic graft is on the back table, an
extension onto the single limb of the Y-graft is made
by placing excess external iliac end to end onto the
proximal common iliac segment. Of note, portal
drainage does not allow use of a common Carrel
patch due to the short length of this conduit.
The recipient operation is performed through a
midline laparotomy, and the transverse colon is
retracted superiorly.
The small bowel mesentery is stretched out
horizontally, and the SMA is palpated. The SMV lies to
the right and is dissected out with careful ligation of
surrounding lymphatics.
A 1–2-cm window is made through an avascular
section of mesentery to allow tunneling of the Y-graft
down to the common iliac artery.
The patient is heparinized, clamps are applied to the
vessels, and revascularization is performed as in
systemic venous drainage.
Following revascularization, a duodenojejunostomy is
created for management of exocrine secretions.
Figure 31–4A–B
Figure 31–5
Figure 31–6
Figure 31–7
Figure 31–8
Postoperative Care
Nothing by mouth until return of bowel function.

Exogenous insulin should not be necessary.
Exceptions: cases of delayed graft function or use of

high-dose steroids for treatment of rejection.
Refer to Informed Consent, earlier.

Enteric drainage is associated with leak, peritonitis, and
abscess.
Bladder drainage is associated with urethritis or cystitis,
and dehydration.
Pearls and Tips
Direct handling of the pancreas should be kept to a

minimum.
During back-table preparation, avoid mass ligation of
small vessels in the mesentery to prevent later
development of arteriovenous fistula.
In SPK transplantation procedures, or in renal
transplantation procedures in which the recipient is a
candidate for PAK, the kidney should be placed on the
left, leaving the right side for placement of the pancreas.
References
Punch JD. Organ Transplantation. In Doherty GM, ed. Current

Diagnosis and Treatment: Surgery. New York, NY: McGraw-
Hill; 2010:1233–1250.


Current Procedures: Surgery > Chapter 32. Liver

Transplantation >
Indications
End-stage liver disease in patients who meet the minimal

criteria for placement on the liver transplantation list as
defined by the American Association for the Study of Liver
Diseases.
Fulminant acute liver failure.
Hepatocellular carcinoma fulfilling Milan criteria (tumor >
2 cm but < 5 cm or up to three tumors each < 3 cm).
Some pediatric metabolic liver diseases as defined by the
United Network for Organ Sharing (UNOS).
Contraindications
Absolute
Recidivism to alcohol and drug abuse (6-month

abstinence- free period essential).
Significant portal venous thrombosis that precludes
venous reconstruction.
Extrahepatic malignancies.
Systemic sepsis and certain untreated chronic infections
(eg, tuberculosis, Mycobacterium avium-intracellulare).
In the case of hepatocellular carcinoma:
Vascular or biliary tree invasion.

Tumors outside Milan criteria.
Relative
Significant cardiopulmonary disease or other medical

illnesses, with the exception of liver or biliary tree specific
disease and renal disease.
Certain chronic infections (eg, HIV infection).
Profound physical deconditioning.
Advanced age (older than 70 years).
Poor psychosocial support (eg, homeless).
Inability to obtain immunosuppressive medications.
Informed Consent
The 1-year survival following liver transplantation is 86–

90% in the United States, with a death rate of
approximately 5% per year death thereafter.
Approximately 20% of patients will require
retransplantation.
Expected Benefits
Restoration of hepatic function.
Potential Risks
Potential complications in the perioperative period are

numerous given the magnitude of the procedure.
Specific complications include:
Infection: 66% total (bacterial, 35–70%; fungal, 20–

42%; viral, 5–26%).
Rejection (40–70%).
Biliary complications (7–29%).
Bleeding (10–25%).
Primary nonfunction (7%).
Hepatic artery thrombosis (2–10%).
Portal vein thrombosis (1–2%).
Equipment
Rigorous fixed retractor (mandatory to facilitate exposure

of the operative field).
Argon beam coagulator (useful in patients with severe
coagulopathy or in retransplantation).
Cell saver (reduces allogenic packed red blood cell
transfusion but should not be used in patients with
hepatic malignancy).
Patient Preparation
Patients are typically evaluated and deemed appropriate

candidates for transplantation based on their preoperative
transplant clinic evaluation.
On the day of transplantation, laboratory values, ECG,
and chest radiograph should be obtained and reviewed for
potential contraindications soon after the patient is called
to the hospital.
Radiographic verification of portal vein patency should be
up to date (within 6 months).
Patients with known hepatoma should have up-to-date
imaging of the chest, abdomen, and pelvis. The admission
chest radiograph should be closely examined for evidence
of metastatic disease.
History and physical examination should specifically
assess for potential contraindications to liver
transplantation (eg, active infections, evidence of active
alcohol or drug use).
Patient Positioning

The left arm is extended and the axilla prepped in the
sterile field (to provide access to the left axillary vein
should venovenous bypass be required).
The right arm can be tucked or extended.
Procedure
Figure 32–1: Incision and retractor placement.
The chest and abdomen are prepped from the nipples

to the pubis.
A bilateral subcostal incision is made 2 fingerbreadths
below the costal margin, or lower if the patient has
significant ascites.
The incision should extend from the lateral border of
the left rectus muscle to the right anterior axillary
line.
In patients with a high costal margin, exposure of the
suprahepatic vena cava is facilitated by a paraxiphoid
midline extension.
Bilateral anchoring retractor posts are placed at the
level of the nipples; the angle of the cephalad
retractors is anterolateral to maximize cephalad
exposure.
A separate anchoring post may be placed at either
hip to support a lower bar to retract the viscera away
from the portal structures.
Figure 32–2: Recipient hepatectomy–-hilar dissection.
The falciform ligament is divided and retractor blades

are positioned to expose the porta hepatis.
The cystic artery and duct are divided and ligated.
The right and left hepatic arteries are divided high in
the porta hepatis to maximize length.
The bile duct is dissected free with a generous
amount of surrounding tissue to minimize
devascularization to this structure.
The ties on the arteries and bile duct are left long to
enable them to be identified easily during the
reconstruction.
The portal vein is dissected free circumferentially but
is not divided until just prior to the hepatectomy.
The region posterior to the bile duct and lateral to the
portal vein is examined for the presence of a replaced
or accessory right hepatic artery (arising from the
superior mesenteric artery), which is encountered in
15% of patients.
Figure 32–3A, B: Recipient hepatectomy—mobilization
of the left lobe and caudate.
The left triangular ligament is divided and the left

lobe retracted to the patient's right (Figure 32–3A).
The gastrohepatic ligament is then divided up to the
diaphragm at the level of the left hepatic vein (Figure
32–3B).
The left phrenic vein may be divided if necessary as it
inserts into the left hepatic vein.
A replaced or accessory left hepatic artery (arising
from the left gastric artery) is encountered in the
gastrohepatic ligament in 10% of patients.
A replaced left hepatic artery is invariably ligated
because it is almost always too small to be a suitable
inflow vessel.
The peritoneal attachments between the caudate lobe
and vena cava are then divided.
The retroperitoneum is divided just to the patient's
left of the vena cava starting the retrocaval plane,
which is later completed from the right side of the
vena cava.
Figure 32–4: Recipient hepatectomy—mobilization of the
right lobe and recipient explant.
Mesenteric attachments to the gallbladder and

retroperitoneal attachments to the inferior border of
the liver are divided.
The right hepatic lobe is then mobilized from the
diaphragm exposing the bare area of the liver.
The right adrenal gland is dissected off the liver and
the adrenal vein is divided.
The mobilization is continued posterior to the vena
cava and the retrocaval plane is completed from right
to left.
The retrocaval plane is extended cephalad and
caudal. There is a posterior phrenic vein at the most
cephalad aspect (behind the hepatic veins) and rarely
a lumbar vein near the position of the adrenal vein.
The suprahepatic and infrahepatic vena cava are
sufficiently dissected to permit vascular clamps to be
placed in these positions.
The portal vein is divided just proximal to the right-
left bifurcation.
The suprahepatic and infrahepatic vena cava clamps
are applied and the liver is dissected a short distance
off the vena cava to facilitate production of adequate
length vascular cuffs for anastomosis.
The vena cava is divided and the liver is removed
from the field.
The retroperitoneum is made hemostatic prior to
reconstruction.
Figure 32–5: Venovenous bypass.
This technique is rarely required with contemporary

liver transplantation techniques.
Venovenous bypass is employed most commonly in
patients without portal hypertension (ie, fulminate
acute liver failure) who experience massive intestinal
swelling with portal vein clamping or, in the other
extreme, if exsanguinating portal hypertensive
bleeding limits the ability to perform the recipient
hepatectomy.
In either case, the goal is to decompress the portal
venous system.
In rare cases, bypass may be necessary to maintain
systemic blood pressure during caval occlusion.
Inflow is provided via the portal vein and the femoral
vein.
Outflow is provided in an upper extremity vein.
The left axilla is typically prepared into the surgical
field specifically for this purpose.
Alternatively, the anesthetist can exchange an
internal jugular line with a bypass cannula for
outflow.
Figure 32–6: Liver transplantation–-suprahepatic and
infrahepatic "bicaval" anastomosis.
The supracaval anastomosis is performed first with a

running 3-0 Prolene suture.
Stay sutures are placed on each side of the vena
cava (recipient to donor) and the back wall is run
(from the inside of the vena cava), followed by the
front wall.
The infrahepatic caval anastomosis is performed next
with a running 4-0 Prolene suture in a similar
fashion.
A small flexible chest tube or red rubber catheter
may be placed through the infrahepatic inferior vena
caval anastomosis at this time and used later for
venting the first-pass circulation through the liver
after reperfusion.
Figure 32–7A-C: Piggyback technique.
Instead of replacing the vena cava with a typical

bicaval approach, the recipient cava is preserved, and
an anastomosis is created between the donor
suprahepatic cava and a cuff of the recipient hepatic
veins.
The infrahepatic donor vena cava is stapled or tied
off.
This technique has the advantages of partial vena
cava return from the lower extremities during liver
transplantation, which minimizes the hemodynamic
changes encountered with complete caval occlusion.
The piggyback technique requires dissection of
segments 6 and 7 and the caudate lobe from the
vena cava with ligation of the venous branches that
drain directly into the vena cava.
The potential disadvantages are the extra time
required to dissect the liver from the vena cava and
typically increased blood loss encountered during this
maneuver.
Figure 32–8: Liver transplantation—portal venous
anastomosis.
The portal venous anastomosis is performed after the

vena cava is reconstructed.
The donor portal vein is shortened such that the
reconstructed portal vein will not have excessive
length.
Care is taken to correctly align the donor and
recipient portal veins to avoid twists or kinks.
The anastomosis is performed in a running fashion
with a 5-0 Prolene suture.
Stay sutures are placed bilaterally and the back wall
is run (from the inside of the portal vein), followed by
the front wall.
A "growth factor" is created before tying the suture
to allow the anastomosis to expand following
reperfusion.
A rule of thumb is to make the growth factor
approximately one-third to one-half the diameter of
the anastomosis.
The liver is then reperfused.
During the portal vein anastomosis, the anesthetist
prepares for reperfusion.
During reperfusion the heart becomes bathed with
potassium-rich, cold perfusate from the donor liver
that contains many metabolic byproducts of liver
preservation. The patient is therefore loaded with
calcium and bicarbonate, and given volume, and a
cardiogenic vasopressor such as epinephrine is
prepared.
The portal venous clamps are released and
approximately 250 mL of first-pass blood is allowed
to "vent" out of the infrahepatic anastomosis
catheter.
This blood is discarded, and the infrahepatic
anastomosis is tied down (or in the case of piggyback
transplantation, the infrahepatic vena cava is
ligated).
The caval clamps are then released and the liver is
reperfused into the systemic circulation.
It is not uncommon for the patient to experience
bradycardia and hypotension or even a short period
of asystole during this phase.
The caval and portal venous anastomoses are
There often is bleeding from the donor portal
structures requiring ligation.
Figure 32–9: Liver transplantation–-hepatic arterial
anastomosis.
After the patient is deemed hemodynamically stable

and the caval and portal venous anastomoses are
made hemostatic, the hepatic arterial anastomosis is
performed.
Alternatively, the arterial anastomosis may be done
prior to reperfusion if time allows.
There are many anatomic approaches to this
anastomosis. Some surgeons prefer a simple end-to-
end anastomosis while others advocate a branch
patch technique.
The recipient branch patch can originate from the
bifurcation of the right and left hepatic arteries, the
gastroduodenal and proper hepatic arteries, or the
common hepatic and splenic arteries (shown as
dotted lines in the figure).
The donor branch patch can similarly arise from any
of these arterial bifurcations.
The anastomosis is performed in a running fashion
with a 6-0 Prolene suture.
The length of the reconstructed hepatic artery should
be either perfect or excessively redundant.
Figure 32–10A, B: Liver transplantation–-biliary
anastomosis.
The basic tenets of the biliary reconstruction are to

create an anastomosis between healthy, viable donor
and recipient bile duct ends (Figure 32–10A) with
good blood supply, and to shorten the donor bile duct
as much as possible.
The bile duct anastomosis is usually performed with
5-0 or 6-0 PDS sutures in either an interrupted or
running fashion.
Placement of a T-tube across the anastomosis has
fallen out of favor because immunosuppressed
patients often do not form a good fibrotic tract
around the transperitoneal portion of the tube.
An internal biliary stent may be placed instead after
blindly dilating the ampulla of Vater via the recipient
common bile duct.
Alternatively, a Roux-en-Y hepaticojejunostomy can
be created (Figure 32–10B) when the recipient bile
duct is ischemic, nonviable, or diseased (ie, primary
biliary sclerosis or primary sclerosing cholangitis),
when a replacement liver transplantation is being
performed, or when there is more than one donor
bile duct.
A 40–60-cm retrocolic limb is fashioned with a
stapled or hand-sewn enteroenterostomy.
The biliary-enteric anastomosis is typically performed
in an interrupted or running fashion with 5-0 or 6-0
PDS suture.
All anastomoses are then reinspected to ensure that they
are hemostatic and lying in an appropriate anatomic
position without twisting, or excessive tension or
redundancy.
The right upper quadrant is irrigated and the

abdominal wall fascia is closed in layers with a
running No. 1 PDS suture.
The skin is closed with staples.
Intraperitoneal drains are not typically employed.
Figure 32–1
Figure 32–2
Figure 32–3A–B
Figure 32–4
Figure 32–5
Figure 32–6
Figure 32–7A–C
Figure 32–8
Figure 32–9
Figure 32–10A–B
Postoperative Care
All patients are admitted to the ICU. The majority of

patients remain intubated with the anticipation of
extubation on postoperative day 1.
Serial laboratory values are obtained (complete blood
count, coagulation function, liver function tests).
Immunosuppression.
Oral medications (especially immunosuppression) are
provided via nasogastric tube.
Infections and other postoperative complications are
treated in a similar manner to all other ill patients (ie, do
not overtreat because the patient has undergone
transplantation).
Adequate nutritional support is of paramount importance
in chronically malnourished patients with liver failure.
Volume overload should be avoided.
Potential complications are numerous.
Acute renal insufficiency is common.

Other specific complications include infections
(bacterial, fungal, and viral), rejection, biliary
complications, bleeding, primary nonfunction, hepatic
artery thrombosis, and portal vein thrombosis.
Pearls and Tips
In the case of acute renal insufficiency, consider lowering

the dose of calcineurin inhibitors or going to a calcineurin-
free regimen in the early postoperative period.
Abdominal ultrasound is to the transplanted liver as a
chest radiograph is to the chest. Obtain an ultrasound
with Doppler flow assessment to rule out hepatic artery
thrombosis in the following situations:
AST/ALT > 5000 within 12–24 hours of reperfusion.

A rise in the AST/ALT values when previously they
had been slowly declining.
To assess for portal vein thrombosis or perihepatic
fluid collections.
In a transplanted graft, the biliary tree typically does not
dilate in the face of obstruction.
Ultrasound is not a good test to evaluate for biliary

obstruction.
MR cholangiopancreatography is only useful if the
patient can hold his or her breath, which most
patients cannot do in the early postoperative period.
Most patients require an endoscopic retrograde
cholangiopancreatogram if a duct-to-duct
anastomosis was performed or a percutaneous
transhepatic cholangiogram if a
choledochojejunostomy was performed.
Suspect bile leak if the patient's general clinical condition
declines.
The serum bilirubin value does not have to be

elevated for a bile leak to be present.
Similarly, sampled ascites may not demonstrate an
elevated bilirubin value as the bile leak or collection
can be localized and loculated.
References
Blumgart LH, Fong Y, eds. Surgery of the Liver and Biliary

Tract, 3rd ed. Philadelphia, PA: WB Saunders; 2000.
Busuttil RW, Klintmalm GB, eds. Transplantation of the Liver,

2nd ed. Philadelphia, PA: Elsevier Saunders; 2005.
Lucey MR, Brown KA, Everson GT, et al. Minimal criteria for
placement of adults on the liver transplant waiting list. Liver
Transplant. 1997;3:628–637.[PubMed: 9404965] [Full Text]
Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for

the treatment of small hepatocellular carcinomas in patients
with cirrhosis. N Engl J Med. 1996;334:693–699.[PubMed:


Current Procedures: Surgery > Chapter 33. Vascular

Access for Dialysis >
Indications
End-stage renal disease; recommendations from the

Kidney Dialysis Outcomes Quality Initiative:
Creatinine clearance < 25 mL/min.

Serum creatinine > 4.0 mg/dL.
Dialysis anticipated within 1 year.
Long-term plasmapheresis.
Contraindications
Ipsilateral proximal venous and arterial occlusion or

stenosis.
Systemic or local infection.
Informed Consent
Expected Benefits
Provides access for dialysis.
Potential Risks
Clotting, narrowing, or scarring of the graft requiring

surgical or radiologic revision.
Infection of the graft requiring surgical excision and
replacement.
Wound infection.
Injury to the neurovascular structures of the arm.
Bleeding.
Failure of the fistula to mature for adequate dialysis
access.
Pain or numbness.
Development of arterial "steal," resulting in decreased
blood flow to the hand.
Equipment
No. 10 or 15 blade scalpel for skin incision.

Electrocautery unit.
Heparinized saline solution.
Prosthetic expanded polytetrafluoroethylene (ePTFE) graft
(frequently tapered 4–7 mm) for forearm loop grafts or
brachial artery to axillary vein arteriovenous grafts if
arteriovenous fistula is not possible.
Tunneling device if needed.
Small vascular clamps or vessel loops.
No. 11 blade scalpel and Micro-Potts scissors.
Double-armed polypropylene suture.
Doppler ultrasound unit.
Patient Preparation
Preoperative History
Specific focus on history of indwelling catheters,

pacemaker, internal automatic cardiac defibrillator, or
extremity trauma.
Dominant extremity should be documented.
Patients with severe congestive heart failure may not
tolerate the additional cardiac output required to circulate
blood through the fistula.
Physical Examination
All pulses should be palpated.

The Allen test should be performed to evaluate perfusion
to the hand.
Blood pressure should be obtained in both arms to
evaluate proximal arterial disease.
Veins of the wrist, forearm, elbow, and upper arm should
be evaluated with or without a tourniquet.
Repetitive hand squeeze may make veins more

prominent.
Visible veins can be considered for access.
Ultrasonography
Doppler: to assess arterial flow.

B-mode: to image and size potential veins.
Vein segments < 2.5 mm may be technically difficult

to use for anastomosis and are associated with
higher rates of failure.
Indications for Venography
Edema in the extremity in which access is planned.

Collateral vein development in the planned access site.
Differential extremity size of the considered limb.
Current or previous central access or transvenous
catheter in the ipsilateral limb.
Previous arm, neck, or chest trauma on the same side as
the planned access site.
Prior failed attempts to establish access in the ipsilateral
extremity.
Patient Positioning
The patient should be supine with the operative arm

extended on an arm board and supinated.
The arm should be prepared circumferentially from the
fingers to the axilla, and the hand covered with a sterile
towel.
Procedure
Figure 33–1: Vascular anatomy of the upper extremity.
The basilic vein courses medially down the arm and is

found in the deeper subcutaneous tissues.
The cephalic vein courses laterally and is very
superficial, running under the skin layer.
The cephalic vein runs posteriorly and laterally,
proximal to the antecubital fossa.
Location of Access
The goal is to provide the greatest surface area available

for cannulation while allowing for the highest flow rates.
The nondominant arm is preferred over the dominant
arm.
A distal location is preferred over a proximal location.
Figure 33–1
Types of Access
Autogenous Radial-Cephalic Direct Wrist Access
Figure 33–2A-D: Autogenous radial-cephalic direct wrist

access is the gold standard in access.
The 3-year patency rate is 64%, with most failures
occurring in the first 12 months.
Approximately 24% of radial-cephalic fistulas do not
mature, failing in the first month.
The procedure may be done with local, regional, or
general anesthesia.
Preoperatively the artery and the vein are located and
marked using ultrasound for guidance.
A single incision may be made between the marked artery
and vein (Figure 33–2A).
The cephalic vein and radial artery are gently dissected
away from the surrounding tissues, ligating and dividing
any small branches.
Proximal and distal control of the radial artery is obtained
with vessel loops in a Potts fashion.
The vessel should not be occluded at this stage

(Figure 33–2B).
The thenar branch of the radial artery, which comes off
laterally, is identified and controlled.
Using ink or a marking pen, the anterior surface of the
vein is marked to avoid kinking or twisting.
The vein is ligated and divided at its most distal aspect.
The vein can later be trimmed to avoid redundancy.
The vein is gently distended with heparinized saline to
evaluate for leaks and assess caliber.
A 3000-unit dose of systemic heparin is administered
before occluding the artery with vessel loops.
Using a No. 11 blade, a small arteriotomy is made on the
anterior surface of the artery.
Care should be taken not to incise the back wall of

the artery with the knife (Figure 33–2C).
Micro-Potts scissors are used to extend the arteriotomy
5–6 mm, in a slightly angled fashion.
The vein is trimmed so that the anastomosis will be
tension free but not redundant.
The anastomosis is completed with a 6-0 polypropylene
suture in an end-to-side fashion.
Following completion of the anastomosis, a palpable thrill
should be felt in the vein.
The wound may be closed with deep dermal interrupted
sutures followed by a running subcuticular absorbable
stitch (Figure 33–2D).
Figure 33–2A–D
Autogenous Brachial-Cephalic Access
Provides superior flow and higher maturation rates than

radial-cephalic access.
Preferable in women, the elderly, and diabetic patients in
whom a radiocephalic fistula may fail to mature.
Associated with a higher incidence of arterial steal than
more distal fistulas.
Basilic Vein Transpositions
Figure 33–3A, B: Basilic vein transposition is preferred

in patients with a sclerotic or small-caliber cephalic vein.
The basilic vein is a deeper vein and thus less amenable
to repeated venipunctures.
Transposition of the basilic vein to an anterior and
superficial location allows for:
Easier dialysis cannulation.

Elimination of the awkward positioning required
during dialysis using posterior arm access.
Brachial-basilic transposition has a 92% maturation rate
with 66% primary patency at 1 year.
Basilic-forearm transposition has a 91% maturation rate
with 84% primary patency at year.
The procedure may be done with regional or general
anesthesia.
Using ultrasound, the basilic vein can be identified
preoperatively anterior to the medial epicondyle of the
humerus.
A longitudinal incision is made along the medial aspect of
the upper arm to the axilla for adequate exposure.
The median cutaneous nerve should be preserved if
possible.
The basilic vein should be gently dissected away from
surrounding tissues and mobilized proximally to the
brachial vein, with small tributaries ligated and divided.
The brachial artery can be exposed though the same
incision.
Distal and proximal control is obtained with vessel loops,
but the vessel should not be occluded at this stage.
Using ink or a marking pen, the anterior surface of the
vein is marked to avoid kinking or twisting.
The vein is ligated and divided at its most distal aspect,
near the antecubital fossa.
The vein can later be trimmed to avoid redundancy.

A small Heifitz clamp can be placed on the proximal
vein to avoid bleeding.
The vein is gently distended with heparinized saline to
evaluate for leaks and to assess the caliber of the vessel.
Using a large Kelly clamp or Bainbridge clamp, a
superficial tunnel is made through the subcutaneous
tissues on the anterior aspect of the upper arm between
the axilla and the antecubital fossa.
The distended vein is pulled gently through the tunnel.

the artery with the knife.
5–6 mm, in a slightly angled fashion.
The vein is trimmed so that the anastomosis will be
tension free but not redundant.
The anastomosis is completed with a 6-0 polypropylene
suture in an end-to-side fashion.
should be felt in the vein.
The wound may be closed in two layers with Vicryl
sutures for the subcutaneous tissues followed by a
running subcuticular absorbable stitch.
Care should be taken not to occlude or impinge flow
through the graft with a tight or strangulated wound
closure.
Figure 33–3A–B
Prosthetic Graft Access
Figure 33–4: PTFE is preferred over Dacron for

prosthetic grafts.
Prosthetic grafts have lower patency rates than those

using autogenous vein, with higher rates of infection;
however, grafts can be accessed within 4 weeks of
creation, eliminating the wait for maturation, and
there are multiple options for sites of insertions.
Inflow can be obtained from the radial artery, antecubital
brachial artery, proximal brachial artery, or axillary artery.
The procedure may be done with regional or general
anesthesia; an interscalene nerve block is also an option.
A curvilinear incision is made over the antecubital fossa.
Careful dissection is performed to isolate and gain control
of the following venous structures in the fossa using
vessel loops:
Cephalic vein.
Basilic vein.
Antecubital vein.
Median antecubital vein.
The median antecubital vein may take off posteriorly and
run deep.
The brachial artery is dissected out, and proximal and
distal control is obtained with vessel loops.
The artery should not be occluded at this stage.

A small horizontal counterincision is made distally on the
anterior surface of the forearm.
Using either a commercial tunneling device or a large
Kelly clamp, a subcutaneous tunnel is made from the
antecubital fossa to the counterincision in a curvilinear
fashion.
The prosthetic graft is gently pulled through the tunnel.
A similar curvilinear-like tunnel is made from the
counterincision back to the antecubital fossa.
The graft is then gently pulled though the tunnel.
The tunneled graft should resemble an oval loop, with the
apex at the counterincision.
The site should be inspected to ensure there are no kinks.

the artery with the knife.
5–6 mm in a slightly angled fashion.
The graft is anastomosed to the artery using a 5-0 ePTFE
suture.
Following the anastomosis, tension is gently released on
the proximal vessel loop to assess arterial flow.
The vessel loops placed earlier around the venous
structures are gently occluded.
The caliber of the laterally running cephalic vein is often
large enough for the venous anastomosis.
A No. 11 blade is used to make a small venotomy, being
careful not to incise the back wall of the vein with the
knife.
Micro-Potts scissors are used to extend the venotomy,
usually to approximately 1.5 cm, depending on the graft
size.
The graft is then anastomosed to the vein using a 6-0
ePTFE suture.
should be felt in the graft and in the proximal vein.
The wounds may be closed with deep dermal interrupted
sutures followed by a running subcuticular absorbable
stitch.
Figure 33–4
Additional Access Strategies
Autogenous posterior radial branch-cephalic access.

Lower extremity venous transposition with the great
saphenous vein.
Lower extremity prosthetic graft insertion.
Axillary artery prosthetic graft insertion.
Postoperative Care
The operation should be performed as an outpatient

procedure.
The patient may remove the dressing after 48 hours.
A sling may be offered for the patient's comfort, although
it is not necessary.
The patient should return for follow-up examination in 4
weeks.
The wound is checked for signs of infection or poor

healing.
The vein is palpated for a thrill.
Distal radial and ulnar pulses are palpated.
Most autogenous fistulas will be ready for use in 8–12
weeks.
The vein is assessed to determine if the caliber is

large enough to accommodate dialysis access.
Prosthetic grafts are usually ready for use in 4 weeks.
Early thrombosis.
Technical error.
Hypercoagulable state.
Low cardiac output.
Poor inflow.
Poor outflow.
Late thrombosis.
Intimal hyperplasia causing progressive outflow

venous stenosis.
Hypotension during hemodialysis.
Worsening inflow stenosis.
Poor puncture technique with excessive pressure.
Arteriovenous access steal syndrome.
Diagnosed by clinical examination and history.

Cool hand.
Diminished distal pulses.
Hand pain.
Confirmed by Doppler finger waveforms and
pressures.
Ischemic monomelic neuropathy.
Acute and potentially irreversible dysfunction of the

radial, median, and ulnar nerves.
Pain, paresthesia, and diminished motor function of
the wrist and hand.
Absence of tissue ischemia.
Preserved distal palpable radial pulse or Doppler
signal.
Presumably caused by alteration in blood flow to the
vasa vasorum of the above-mentioned nerves.
Venous hypertension.
Hand and upper extremity swelling with pain.

Usually secondary to undiagnosed or recently formed
central venous stenosis or occlusion; however, severe
valvular incompetence with retrograde flow can also
produce these symptoms.
Pearls and Tips
Wear surgical loupes while operating.

When inserting a prosthetic graft, perform the arterial
anastomosis first. The arterial graft is more likely to ooze
from needle holes. Place a hemostatic agent around your
suture line and perform the venous anastomosis. This
allows time for hemostasis to be achieved by the
completion of the operation.
When dissecting out the vein, be cognizant of small
venous tributaries that will need to be ligated and divided.
Limit tearing of such veins by careful sharp dissection
with Metzenbaum scissors rather than using
electrocautery for the dissection.
Sewing the back wall of the arterial venous anastomosis
first enables the surgeon to use a forehand approach and
quickly finish the anastomosis on the front wall.
Always dissect out and mobilize more vein than you think
will be needed.
When dissecting out the venous structures in the
antecubital fossa, be mindful of posterior perforating
veins. These will have to be controlled with a vessel loop
in order to perform the anastomosis in a bloodless field.
Before performing the anastomosis, arterial and venous
(although to a lesser degree) spasm can be relieved with
topical application of papaverine. Application of
papaverine can cause vasodilation, allowing for easier
completion of the anastomosis.
References
Bohannon WT, Silva MB. Venous Transpositions in the Creation

of Arteriovenous Access. In: Rutherford R, ed. Rutherford
Vascular Surgery, 6th ed. Philadelphia, PA: Elsevier Saunders;
2005:1677–1683.
NKF-K/DOQI Clinical practice guidelines for vascular access:

Update 2000. Am J Kidney Dis. 2001;37:S137–S181.
Stoney RJ, Effeney DJ. Comprehensive Vascular Exposures.

Philadelphia, PA: Lippincott; 1998:131–144.
Weiswasser JM, Sidawy AN. Strategies of Arteriovenous

Dialysis Access. In: Rutherford R, ed. Rutherford Vascular
Surgery, 6th ed. Philadelphia, PA: Elsevier Saunders;
2005:1669–1676.



Management of Infrarenal Abdominal Aortic
Aneurysm >
Indications
Symptomatic or ruptured abdominal aortic aneurysm

(AAA) of any size.
Asymptomatic AAA 5.5 cm or > 0.8-cm growth in 12
months.
Contraindications
Absolute
None.
Relative
Malignancy with limited life expectancy.

Prohibitive medical comorbidities.
Informed Consent
Infrarenal AAA may be treated by open or endovascular

repair.
Perioperative mortality:
Open repair: 2–5%.

Endovascular repair: 1.2–1.6%.
Repair of ruptured AAA: 50–75%.
Expected Benefits
Exclusion of the aneurysm wall from the systemic

circulation and associated pressure, thereby preventing
its rupture.
Potential Risks
Open Repair
The established treatment option for AAA for > 50

years.
Associated with excellent long-term outcomes and

fewer subsequent aneurysm-related procedures
than endovascular repair.
Limited by comorbidities.
Can treat all aneurysms with no anatomic
restraints.
Involves longer hospital and ICU stays, results in
more postoperative pain, and is associated with a
higher 30-day mortality rate than endovascular
repair.
Complications include but are not limited to:
Surgical site infections and incisional hernias.

Myocardial infarction.
Renal or respiratory failure.
Retrograde ejaculation.
Colonic ischemia.
Embolization of clot to the legs.
Endovascular Repair
Well established for patients who are not surgical

candidates and increasingly being used for all
anatomically favorable aneurysms.
Has specific anatomic requirements.

Rate of aneurysm-related reintervention is higher
than for open repair.
Patients require lifelong follow-up with serial
imaging.
Is associated with a lower 30-day mortality rate
than open repair.
Complications following endovascular repair are similar
to those for open repair, excluding retrograde
ejaculation and incisional hernia. In addition,
approximately 15% of patients treated with an
endovascular approach will need at least one additional
procedure to better seal the aneurysm from an
endoleak or to fix a complication (eg, graft migration,
stent fracture, graft material fatigue).
Equipment
Open Repair
Vascular surgery instrument tray.

Bookwalter or Omni retractor for abdominal exposure.
Graft material (Dacron or polytetrafluoroethylene
[PTFE] of various sizes, 12–36 mm).
Endovascular Repair
Vascular surgery instrument tray.

Sterile angiographic capabilities with a full compliment
of catheters and wires.
A portable C-arm may be used, but a fixed

fluoroscopic unit gives better images.
The procedure should be done in a room with operative
capabilities (eg, suction, electrocautery, good lighting,
etc).
An angiogram table that permits fluoroscopic imaging
of the abdomen is required.
Patient Preparation
The arterial anatomy needs to be defined clearly.
CT angiogram or MR angiogram may provide

sufficient detail for operative planning.
Preoperative stratification with a full history and
physical examination is required.
Eagle criteria or another cardiac risk stratification

algorithm can be used to calculate the patient's
perioperative risk for coronary events and need for
further workup.
All patients should receive optimal medical therapy in
the perioperative period, including:
-Blockers.
Statin therapy, with a goal low-density lipoprotein
(LDL) cholesterol of < 100 mg/dL.
Tight blood glucose control, with a target level <
140 mg/dL (for at least the first 3 days
postoperatively).
Appropriate prophylactic antibiotics are delivered within
30 minutes of skin incision and are redosed as needed
for prolonged procedures (eg, intravenous cefazolin, 1
g preoperatively, then 1 g every 8 hours
intraoperatively).
Invasive hemodynamic monitoring with at least an
arterial line.
Endovascular Repair
Preprocedural imaging (CT or MRI) to determine the

size of the aneurysm.
Aneurysm measurements must be determined

precisely in advance of the operation and the
appropriate size grafts must be available.
Important measurements used to determine the graft
sizes are:
Location and diameter of the aortic aneurysm

neck.
Distance between the lowest renal artery and the
start of the aneurysm (must be > 10–15 mm).
Shape of the neck (a conical-shaped neck is less
desirable for endovascular repair).
Angulation of the neck (> 60 degrees is less
desirable for endovascular repair).
Aneurysm lengths (measured from the lowest
renal artery to the aortic bifurcation [L1], and from
the renal artery to both distal landing zones [L2
and L3]).
Diameter of the iliac arteries and their suitability
as a landing zone (amount of thrombus and
calcium).
Diameter of the femoral arteries and external iliac
arteries for access (> 7 mm is usually required for
most endografts).
Patient Positioning
Open Repair
Anterior approach: the patient should be supine, with a

lumbar roll placed to allow for better aortic exposure
and arms extended on arm boards.
Retroperitoneal approach: the patient should be in left
lateral decubitus position.
Endovascular Repair
The patient should be supine on the angiotable, with

both arms tucked or extended.
Both Procedures
A nasogastric tube is inserted.

A Foley catheter is placed.
Distal pulses are marked.
Two large-bore intravenous lines are placed to provide
for rapid infusion.
A radial arterial line is placed for hemodynamic
monitoring.
Procedure
Open Repair
Epidural anesthesia is administered for intraoperative
and postoperative pain control.
Figure 34–1: Incision and exposure.
A midline incision is made from the xiphoid to

below the umbilicus. Transverse or left lateral
retroperitoneal incisions can also be made.
The abdomen is explored for any additional
pathology. The position of the nasogastric tube in
the stomach is noted.
The small bowel can be packed in the right flank or
eviscerated into a plastic bag to help maximize
exposure of the retroperitoneum. The transverse
colon is reflected cephalad.
The retroperitoneum is exposed from the ligament
of Treitz to the aortic bifurcation using
electrocautery.
Care must be taken to ligate or clip all lymphatics.
Once the aneurysm is exposed, the aortic neck
should be carefully dissected up to the left renal
vein. If the aneurysm is pararenal, both renal
arteries may need to be dissected out and
controlled.
The distal anastomosis site depends on the extent
of the aneurysm (terminal aorta, common iliac,
external iliac, or femoral arteries).
Heparin (100 units x wt [kg]) is administered,
followed by mannitol, 12.5 g. At least 3 minutes
are allowed for appropriate heparin circulation
before clamping the aorta. An activated clotting
time (ACT) > 250 is maintained throughout the
procedure.
Vascular clamps are applied distally first (common
or external iliac or femoral arteries) and then
proximally (aortic neck) to achieve vascular
control.
The aorta is opened longitudinally, using
electrocautery initially followed by surgical
scissors.
Figure 34–2: Control of bleeding vessels.
Aneurysm thrombus and atherosclerotic debris are

removed from the lumen of the aorta.
Backbleeding lumbar arteries and the inferior
mesenteric artery (IMA) are oversewn with 2-0 silk
or 3-0 polypropylene suture.
A backbleeding IMA is ligated from inside the aorta
to preserve any collateral supply from the
hypogastric arteries or superior mesenteric artery
(SMA).
The IMA may be reimplanted as a Carrel patch
onto the graft if there is any question of colonic
ischemia at the end of the procedure.
Figure 34–3: Vascular anastomosis.
Proximally, an end-to-end anastomosis is

performed using a 3-0 Prolene suture and a strip
of felt to reinforce the degenerated aortic wall.
The anastomosis is checked for leaks first by
injecting saline into the distal graft lumen using a
bulb syringe, then by temporarily removing the
proximal clamp.
The proximal clamp is reapplied and, if needed,
repair sutures are placed.
Distally, the graft is pulled to length, then cut.
The distal anastomosis is preformed using 3-0 or
4-0 Prolene.
The proximal clamp is removed thereby testing the
integrity of the distal anastomosis. Any necessary
repair sutures are placed.
The femoral arteries are occluded with manual
pressure in each groin for several cardiac cycles
while the distal clamps are released. This directs
atheroemboli into the pelvis through the internal
iliac vessels and not down the legs.
Sigmoid colon viability is assessed.
Lower extremity pulses and signals are checked.
Once all surgical bleeding is controlled, heparin is
reversed with intravenous administration of
protamine (1 mg per 100 units of heparin).
Figure 34–4: Aneurysm and abdominal wall closure.
After adequate hemostasis, the aortic wall is

closed over the newly placed graft using 3-0
Prolene sutures.
The retroperitoneal tissue is reapproximated over
the aorta using 2-0 Vicryl sutures.
Retractors are removed.
Small and large bowel are replaced into normal
anatomic position.
Standard running abdominal closure of the fascia
is performed using looped PDS or Prolene suture.
Skin closure is accomplished with Monocryl sutures
or skin staples.
Figure 34–1
Figure 34–2
Figure 34–3
Figure 34–4
Endovascular Repair
General anesthesia is preferable, but endovascular

repair may be attempted under epidural, spinal, or
even local anesthesia.
Figures 34–5A-C: Stent graft insertion.
The abdomen and each groin are prepared.

Exposure of both common femoral arteries is
performed with proximal and distal control using
vessel loops in a Potts fashion (double looping the
artery for hemostatic control).
The patient is heparinized with 100 units/kg, and
ACT > 250 is maintained throughout the
procedure.
The ipsilateral (IL) femoral artery (the artery
through which the main body of the graft will be
inserted) is selected preoperatively based on
suitable anatomy.
Both the IL femoral and contralateral (CL) femoral
arteries are cannulated.
Using an 18-gauge needle, the artery is punctured
and a 0.035-inch flexible J guidewire is passed
under fluoroscopic control into the thoracic aorta.
The needle is removed and a 7 French sheath is
placed.
On the IL side, a catheter is inserted over the wire
into the thoracic aorta, and the wire is removed.
Next, a super-stiff guidewire (eg, Lunderquist
wire) is inserted into the catheter and positioned
just below the left subclavian artery.
Using the CL femoral artery, an angio-scaled
catheter (eg, pigtail) is inserted to the level of the
renal arteries (around L1–2) and an aortogram is
preformed. Usually 15 mL/s of iodinated contrast is
injected over 2 seconds (for a total of 30 mL).
The renal arteries and the aortic bifurcation are
marked out.
The main body of the aortic endograft that has
already been selected based on preoperative sizing
is opened on the field.
The graft is prepared on the back table.
Most grafts need to be oriented prior to insertion
so that the radiopaque markers on the CL limb of
the graft are oriented toward the contralateral
artery.
The graft is inserted into the aorta through the IL
femoral artery over the stiff guidewire and
positioned so that the covered portion of the graft
deploys just below the lowest renal artery (Figure
34–5A).
The main body of the graft is deployed and the CL
limb is released.
The CL limb is cannulated from the CL groin. An
angled guide catheter over a glide wire is used.
To make absolutely sure the CL limb is cannulated,
the angle guide catheter is advanced into the main
body of the graft and spun around.
Injection of a small amount of contrast through the
angle guide catheter into the main body of the
graft may also document proper cannulation.
Alternatively, insertion of a balloon catheter over
the wire into the CL limb, and inflation of the
balloon, can confirm proper cannulation.
A stiff guidewire is then inserted into the CL limb
and positioned just under the subclavian artery
(Figure 34–5B).
In the pelvis, the location of the CL hypogastric
artery is marked after injecting contrast through
the CL sheath.
The CL limb of the graft is then inserted and
deployed.
We use a compliant balloon to seat and seal the
graft proximally just below the renal arteries, at
the overlapping segments, and at the distal
attachment sites (Figure 34–5C).
A final angiogram is performed to document
proper placement and the occurrence of
endoleaks, some of which need attention at the
time of primary graft placement (type I and III
endoleaks), while others may be observed (type II
endoleaks).
Figure 34–6: The four types of endoleaks.
Type I: leak from the proximal or distal landing

zones.
Type II: leak from a back-bleeding lumbar or
inferior mesenteric artery into the aneurysm sac
(the most common endoleak).
Type III: leak caused by inadequate graft-to-graft
overlap at the junctions.
Type IV: porosity leak through the graft material
(rare with the current grafts).
The sheaths are pulled followed by the wires.
The femoral arteries are closed with Prolene suture.
The groins are closed in several layers.
Distal pulses and signals are documented.
Figure 34–5A–C
Figure 34–6
Postoperative Care
Open Repair
Patients usually are extubated in the operating room or

within the first 12 hours and out of bed by
postoperative day (POD) 1.
The typical patient requires up to 2 days in the ICU.
During the first 24–48 hours, patients require adequate
fluid resuscitation.
We recommend aggressive diuresis of uncomplicated
patients starting on POD 3 to prevent cardiac and
pulmonary complications.
All central venous lines and arterial catheters should be
removed as early as possible to decrease the risks of
catheter-related infections.
The nasogastric tube may be removed on POD 1 or
according to physician preference.
Most patients who have uncomplicated procedures are
ready for discharge home by POD 7.
Endovascular Repair
Patients are extubated in the operating room.

Patients should be assigned to a telemetry floor bed.
Most patients with uncomplicated procedures are ready
for discharge by POD 1 or 2.
Open Repair
Intraoperative Complications
Injury to the small bowel, colon, ureter, or major

venous structures.
Postoperative Complications
Bleeding.
Infections, including urinary tract or wound
complications.
Pneumonia.
Bowel ischemia (particularly of the descending and
sigmoid colon).
Lower extremity ischemia from distal embolization,
thrombosis, or clamp injuries.
Renal failure.
Endovascular Repair
Intraoperative Complications
Malposition of the graft.

Arterial dissection or rupture.
Avulsion of iliac arteries.
Endoleaks.
Postoperative Complications
Infections, including urinary tract or wound
complications.
Pneumonia.
Bowel ischemia (particularly of the descending and
sigmoid colon).
Lower extremity ischemia from distal embolization,
thrombosis, or clamp injuries.
Renal failure.
Pearls and Tips
In 5% of patients, the renal vein is retroaortic and can

be injured during open para-aortic dissection.
Use care during dissection around the aortic bifurcation
and IMA to prevent sympathetic nerve injuries (the left
side of the aorta), which may result in retrograde
ejaculation in men. Care must also be taken not to
injure the iliac veins (posterior and to the right of the
aorta).
Abdominal pain and loose stools with or without bloody
bowel movements in the initial postoperative period
may indicate ischemic colitis.
Diagnosis is with flexible sigmoidoscopy.

Treatment depends on the degree of ischemia and
can range from broad-spectrum antibiotics to
colectomy with ostomy.
Treat wound cellulitis early to prevent bacterial seeding
of graft.
References
Huber T, Lee A, Ozaki K, Seeger J. Abdominal Aortic

Aneurysms. In: Mulholland MW, Lillemoe KD, Doherty GM,
et al, eds. Greenfield's Surgery: Scientific Principles &
Practice, 4th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2006:1711–1747.
Upchurch GR, et al. Complications of Arterial Surgery. In:

Mulholland MW, Doherty GM, eds. Complications in
Surgery. Philadelphia, PA: Lippincott Williams & Wilkins;
2006:317–335.


Current Procedures: Surgery > Chapter 35. Carotid

Endarterectomy >
Indications
Asymptomatic carotid stenosis > 60% by angiography or

70% by duplex ultrasound.
Symptomatic carotid stenosis (cerebrovascular accident,
transient ischemic attack, or amaurosis fugax) > 50%.
Carotid endarterectomy can be performed safely under
regional anesthesia in patients with severe chronic
obstructive pulmonary disease, coronary artery disease
(CAD), and other comorbidities.
Carotid stenting can be considered in patients with a
history of neck irradiation, modified radical neck
dissection, or reoperative carotid endarterectomy.
Only patients with concurrent symptomatic carotid
stenosis and symptomatic CAD should be considered for
combined carotid endarterectomy and coronary artery
bypass grafting.
Contraindications
There are no absolute contraindications other than distal

internal artery occlusion.
Informed Consent
Expected Benefits
Long-term stroke prevention.
Potential Risks
The risk of perioperative stroke is 1.5% in expert series.

The risk of a clinically significant cranial nerve injury is
similarly small in experienced hands and includes:
Injury to the hypoglossal nerve with tongue deviation

toward the operative side.
Injury to the vagus nerve or a nonrecurrent laryngeal
nerve (which may result in ipsilateral vocal cord
paralysis).
Superior laryngeal nerve injury (which may result in
difficulty speaking at high pitch).
A retraction injury to the marginal mandibular branch
of the facial nerve (which may result in a lower facial
droop).
Glossopharyngeal nerve injury (a concern in exposures
approaching the skull base).
Spinal accessory nerve injury (a risk only if dissection

is not conducted anterior to the internal jugular
vein).
Other complications include myocardial infarction,
postoperative bleeding requiring reexploration,
wound infection, local sensory loss, and restenosis.
It should be emphasized that regular postoperative
surveillance by duplex ultrasound is required to monitor
for restenosis.
Equipment

A small, self-retaining retractor such as the "mini"
Omnitract may be helpful, particularly if high exposure is
necessary.
We prefer to control the distal internal carotid artery with
an atraumatic clip (eg, Schwartz, Yasargil, or Heifetz).
Patient Preparation
Duplex ultrasound is highly sensitive and specific and is

the only preoperative imaging required in most cases.
Arteriography (conventional or CT) is generally reserved
for cases involving restenosis, a history of radiation or
prior neck dissection, or atypical findings on duplex
ultrasonography.
Patient Positioning
The patient should be in a semi-seated position with a

small roll across the shoulder blades.
This allows for gentle extension and external rotation

of the head to the contralateral side.
The ipsilateral arm is tucked, padding the elbow and
wrist.
Care should be taken not to over-rotate or extend the
head to avoid kinking of the vertebral arteries or
contralateral carotid artery.
Landmarks such as the ear lobe, angle of the mandible,
mastoid process, sternal notch, and clavicle must be
included in the prepared area.
Procedure
Carotid endarterectomy can be performed under regional

anesthesia, general anesthesia with routine shunting, or
general anesthesia with selective shunting based on
adjuncts such as intraoperative EEG monitoring or stump
pressures.
Figure 35–1: Most surgeons prefer an oblique incision
along the anterior border of the sternocleidomastoid
(SCM) muscle.
A transverse incision is cosmetically superior and

technically feasible for all patients except those with
the highest lesions.
Electrocautery is used to divide the platysma and
dissect along the medial border of the SCM muscle
from its tendon superiorly to the level of the
omohyoid muscle inferiorly.
The medial edge of the internal jugular vein (IJV) is
identified by sharp dissection.
Ligation and division of the common facial and the
middle thyroid vein inferiorly and any hypoglossal
veins superiorly, allows for lateral retraction of the
SCM and IJV.
Figure 35–2: Great care must be taken to identify the
cranial nerves of interest.
The vagus nerve usually lies posterolateral to the

carotid arteries but can be located anteriorly, placing
it at risk of injury early in the dissection.
The ansa cervicalis can be divided near its origin and
followed in a cephalad direction to the hypoglossal
nerve.
Dissection of the superior thyroid artery should be
kept to its origin to avoid injury to the external
branch of the superior laryngeal nerve.
Figure 35–3: The common (CCA), external (ECA), and
internal carotid (ICA) arteries are circumferentially
dissected and encircled with vascular loops.
The superior thyroid artery can be looped with a 2-0

silk ligature.
The distal ICA can be controlled with a Schwartz clip.
A long plaque or high carotid bifurcation necessitates
additional distal exposure of the ICA; this requires
division of the digastric muscle and any underlying
crossing veins.
Cephalad mobilization of the hypoglossal nerve is
achieved through ligation and division of the occipital
artery and the sternocleidomastoid artery.
Figure 35–4: A longitudinal arteriotomy is made and a
shunt of the surgeon's choice is used, if indicated.
The atheroma is bluntly dissected and elevated in a

medial plane.
The proximal plaque in a relatively healthy portion of
the CCA is sharply cut and the plaque dissected in a
cephalad direction toward a finely feathered
endpoint.
Eversion endarterectomy of the ECA is required.
The bed should be irrigated vigorously with
heparinized saline and any remaining loose bits of
media removed with fine forceps.
If a satisfactory endpoint is not found, the remaining
distal plaque can be secured to the vessel with
interrupted, full-thickness 7-0 sutures tied on the
adventitial surface.
Figure 35–5: Once the endarterectomy is complete, a
patch of the desired material (Dacron or bovine
pericardium) is cut to fit the length and shape of the
arteriotomy.
Prior to completion of the patch angioplasty the shunt

is removed, the ICA is allowed to back-bleed, and the
atheroma bed is irrigated with heparinized saline.
Upon completion of the circumferential and
continuous suture line, flow is established into the
ECA prior to establishing antegrade flow into the ICA.
Figure 35–6: The transection plane for eversion carotid
endarterectomy is determined by the location of the bulk
of the plaque.
A type I transection (severe oblique, ICA only) is

performed when the bulk of the lesion is located in
the ICA.
A type II transection (gentle oblique, across the CCA
3 mm below the flow divider) is performed when the
bulk of the disease lies within the distal CCA and
most proximal portion of the ICA.
Lesions extending beyond the proximal 2–3 cm of the
ICA are best treated with patch angioplasty rather
than eversion.
Figure 35–7: Eversion endarterectomy (type I depicted)
is performed by bluntly developing a circumferential
medial plane and continuing it in a cephalad direction
while gently pulling back the adventitia with atraumatic
forceps.
The arteriotomy is extended in a caudad direction on

the lateral CCA and in a cephalad direction on the
medial ICA to allow for an even wider, circumferential
anastomosis.
Figure 35–8: Once the ICA portion of the eversion
endarterectomy is complete a shunt may be placed, as
indicated.
The primary anastomosis is quite wide, necessitating

use of synthetic patch material.
If the ICA is redundant in length it may be cut
shorter or implanted more proximally on the CCA,
making eversion endarterectomy ideal for patients
with ICA stenosis in the setting of concurrent ICA
elongation.
Figure 35–1
Figure 35–2
Figure 35–3
Figure 35–4
Figure 35–5
Figure 35–6
Figure 35–7
Figure 35–8
Postoperative Care
Closed suction drain overnight, depending on surgeon

preference.
Strict postoperative management of blood pressure,
avoiding hypertension to reduce the risk of hyperperfusion
syndrome.
Discharge following overnight observation and monitoring
(possibly 8 hours postoperatively if uncomplicated and
with satisfactory blood pressure).
Cranial nerve injury.

Stroke.
Carotid restenosis.
Pearls and Tips
Do not hesitate to expose the distal ICA early in the

procedure by the techniques discussed.
This is much more difficult to do once the ICA is

clipped and an arteriotomy has been made.
In eversion cases, the ICA can be transposed anterior
to the hypoglossal nerve to facilitate distal exposure
and anastomosis.
In rare cases when the ICA must be exposed at the level
of C1 or above, a retrojugular approach is preferable.
This is more likely in reoperative surgery or if

preoperative imaging reveals an extremely long
lesion or unusually high bifurcation.
Nasotracheal intubation and mandibular subluxation
are useful adjuncts for this approach.
A "nonrecurrent" laryngeal nerve may cross the carotid
artery as it courses from the vagus nerve. If not
recognized, it can be mistaken for a branch of the ansa
cervicalis and damaged or ligated, resulting in ipsilateral
vocal cord paralysis.
References
Ballotta E, Da Giau G, Baracchini C, Manara R. Carotid

eversion endarterectomy: perioperative outcome and
restenosis incidence. Ann Vasc Surg. 2002;16:422–429.
Chiesa R, Melissano G, Castellano R, et al. Carotid

endarterectomy: experience in 5425 cases. Ann Vasc Surg.
2004;18:527–534.[PubMed: 15534731] [Full Text]
Green RM, Greenberg R, Illig K, et al. Eversion

endarterectomy of the carotid artery: technical considerations
and recurrent stenosis. J Vasc Surg. 2000;32:1052–1061.



Management of Aortoiliac Occlusive Disease >
Indications
Significant chronic lower extremity ischemia.
Lifestyle-limiting claudication, tissue loss, and rest

pain.
Risk factor modification partially helpful.
Acute lower extremity ischemia.
Thrombosed aortoiliac system.

Infected aortic graft (prior abdominal aortic graft for
aneurysmal or occlusive disease).
Abdominal aortic aneurysm with iliac disease (occlusive
or aneurysmal).
Contraindications
Absolute
Chronic ischemia: none.

Acute ischemia: nonsurvivable acidosis.
Relative
Prior abdominal surgery.
If significant comorbidities exist, extra-anatomic bypass
(axillary-femoral bypass) is preferred.
Informed Consent
Expected Benefits
Restoration of adequate blood flow to the pelvis and

lower extremities to prevent tissue loss and improve
claudication symptoms.
Potential Risks
Cardiac compromise is common, as more than one

third of patients have significant coronary artery
disease.
Respiratory compromise can occur with abdominal
approaches.
Renal dysfunction can occur due to perioperative
hemodynamic variation, preoperative intravenous
contrast dye administration, and suprarenal aortic
cross-clamping.
Although rare, significant morbidity can occur with graft
infections, which can appear late (months to years
postoperatively).
Equipment
An Omni rectractor is preferred.

Polytetrafluoroethylene (PTFE) or Dacron bifurcated
aortic grafts for aortobifemoral bypass or a ringed PTFE
graft for axillary (bi)femoral bypass.
Vascular clamps and instruments.
Tunneling device if axillary-femoral bypass is to be
performed.
Doppler ultrasonography is useful to document lower
extremity pulses before and after bypass.
Patient Preparation
Thorough preoperative workup is essential before

recommending aortic surgery.
Claudication or rest pain symptoms need to be

distinguished from other causes of lower extremity
pain.
Likewise, tissue loss must be attributable to
ischemia, at least in part.
Screening for peripheral occlusive disease should
include ankle-brachial indices (ABIs).
Diabetic patients may have calcified vessels,

resulting in inaccurate ABIs.
The gold standard for diagnosis is aortography with
evaluation of runoff vessels in the lower extremities.
CT angiography of the aorta and lower extremity
arteries is now frequently used to evaluate aortic and
iliac occlusive and aneurysmal disease.
MR angiography is preferred in patients with renal
dysfunction but can overestimate occlusive disease.
Patient selection is based on preoperative
cardiopulmonary testing.
Significant cardiac disease can be present in up to

50% of patients.
Appropriate cardiac testing, including stress
testing, echocardiography, and cardiac
catheterization, should be considered in
appropriate patients.
Patient Positioning
The patient should be supine and prepared from mid

chest to the feet.
The abdomen is entered through a midline

incision.
Groin incisions can be transverse but more often
are longitudinal.
Procedure
Aortobifemoral Bypass
Figure 36–1: Exposure of the retroperitoneum and

aorta.
After a midline laparotomy, the small bowel is

retracted to the patient's right side and the
transverse colon is lifted superiorly, exposing the
ligament of Treitz.
The ligament of Treitz is taken down sharply and
the duodenum retracted to the right.
The retroperitoneum is opened over the aorta,
taking care to avoid injuring the duodenum and
preserving enough retroperitoneum for later
closure.
Figure 36–2: Control of the proximal aorta.
The left renal vein is identified crossing the aorta.
A noncalcified, minimally diseased region of the
aorta suitable for clamping is identified.
The infrarenal aorta is dissected free from the
surrounding structures.
Large lumbar vessels are controlled, preserving
collateral vessels, while smaller lumbar vessels can
be ligated.
The types of vascular clamps used will determine
the length of aorta needed; generally this is 3–4
cm.
Figure 36–3: Bilateral femoral artery exposure.
Vertical incisions are made over the femoral pulse

(artery) at the level of the inguinal ligament.
Subcutaneous fat is opened vertically.
The femoral sheath is opened sharply, exposing
the underlying femoral artery lateral to the femoral
vein.
The common, superficial, and deep (profunda)
femoral arteries are isolated with vessel loops.
Circumflex branches are controlled and preserved.
Figure 36–4: Creation of the retroperitoneal tunnel.
The proximal common femoral artery is bluntly

dissected from the posterior inguinal ligament,
taking care to avoid injuring a commonly crossing
circumflex vein, and continued onto the anterior
external iliac artery.
From the abdomen, blunt dissection along the
anterior common iliac artery is performed with the
contralateral hand lifting the colon and ureter away
from the iliac vessels.
The dissection is continued bluntly until the
contralateral fingers meet.
Moving both fingers in a continuous circular motion
aids in completion of this tunnel.
The tunnel is maintained with a ringed forceps or
umbilical tape.
Figure 36–5A, B: Aortic cross-clamping and
aortotomy.
After adequate heparinization (typically 100

units/kg), the proximal and distal aorta are
clamped.
Before opening the aorta, the surgeon must
ensure that no pulse is present in the clamped
aorta and that the clamp is secure.
End-to-end anastomosis is performed with a single
proximal clamp and transection of the aorta for
cases of distal aortic occlusions (Figure 36–5A).
End-to-side anastomosis, performed using a
Satinsky side-biting clamp with anterior aortotomy,
is useful for preserving collateral vessels from the
aorta (Figure 36–5B).
The aortic anastomosis is best performed close to
the renal vessels.
Figure 36–6A, B: Performing the proximal
anastomosis.
PTFE or Dacron-woven bifurcated grafts are chosen

to match the distal vessel size.
End-to-end anastomosis is performed with a
running 3-0 polypropylene or PTFE suture starting
with the back wall and running to the anterior wall
(Figure 36–6A).
End-to-side anastomosis is performed with a
running 3-0 or 4-0 polypropylene or PTFE suture,
starting at the heel.
Important sutures are the "heel" and "toe" stitches
(Figure 36–6B).
The clamp is released and anastomosis tested.
Figure 36–7: Femoral anastomosis.
The graft limbs are tunneled into the femoral

wounds.
In general, spatulation of the anastomosis onto the
profunda femoris is preferred.
An arteriotomy is preformed with a No. 11 blade
after the common, superficial, and deep femoral
arteries are clamped.
The graft is fashioned to length.
An end-to-side anastomosis is performed, starting
at the heel with a running 5-0 polypropylene
suture.
The femoral vessels and graft are flushed to
remove debris.
The anastomosis is completed and flow
reestablished.
Figure 36–8: Closure of the retroperitoneum.
After ensuring improved distal flow, heparinization

is reversed with protamine.
The retroperitoneum is closed with 2-0 or 3-0
absorbable suture covering the graft from the
abdomen.
The abdominal contents are replaced and the
fascia and skin closed.
The femoral incisions are closed with a deep 2-0
absorbable suture covering the graft and femoral
artery.
Superficial tissue is closed with a running 3-0
absorbable suture.
Skin is closed in a subcuticular fashion.
Figure 36–1
Figure 36–2
Figure 36–3
Figure 36–4
Figure 36–5A–B
Figure 36–6A–B
Figure 36–7
Figure 36–8
Axillary-Femoral Bypass
Figure 36–9: Infraclavicular incision.

The side of inflow is chosen (if the thoracic aorta
needs to be accessed in future, axillary-femoral
bypass should be performed on the right side).
The incision is made 2 fingerbreadths below the
clavicle.
The pectoralis major muscle is split and the
pectoralis minor insertion is divided.
The axillary fat pad is dissected.
Figure 36–10: Exposure of the axillary artery.
The axillary vein lies anterior to the artery from

this exposure, requiring isolation of the vein and
inferior (or occasionally superior) retraction to
allow access to the axillary artery.
Branch vessels are isolated and controlled.
A 3–4-cm length of artery is isolated with vessels
loops.
Figure 36–11A, B: Axillary and femoral tunneling.
After femoral exposure is performed (see Figure

36–3), a Gore tunneler is used to create a
subcutaneous tunnel anterior to the midaxillary
line, lateral to the nipple, and above the abdominal
fascia from the axillary incision to the femoral
incision (Figure 36–11A).
A femoral-femoral tunnel is created superior to the
pubic bone (Figure 36–11B).
The bifurcated ringed PTFE graft is passed from
the ipsilateral groin incision to the axillary incision
and contralateral femoral incision.
Tunneling is preferred prior to heparinization to
minimize bleeding.
Figure 36–12: Axillary anastomosis.
After heparinization, the axillary artery is clamped

proximally and distally with angled ductus clamps.
A longitudinal arteriotomy is performed.
The graft is fashioned and a running end-to-side
anastomosis is performed.
The femoral anastomoses are performed (see
Figure 36–7).
Prior to completion of the anastomoses, femoral
arteries and grafts are flushed.
Flow is reestablished.
After ensuring improved distal flow, heparinization
is reversed.
The axillary incision is closed with a deep 2-0
absorbable suture, a superficial 3-0 absorbable
suture, and subcuticular layer.
Figure 36–9
Figure 36–10
Figure 36–11A–B
Figure 36–12
Postoperative Care
Arterial line, central line, and pulmonary artery

catheter for hemodynamic monitoring.
Nothing by mouth.
A nasogastric tube is needed for decompression for 12–
24 hours in cases of abdominal entry.
Respiratory failure.
Renal failure.
Pearls and Tips
Perioperative hemodynamic monitoring is essential to

good outcomes.
Communication between surgeon and anesthesiologist
during aortic clamping and unclamping will minimize
hemodynamic fluctuations.
Early graft thrombosis or pseudoaneurysm is a sign of
early graft infection.
References
Ernst C, Stanley JC, eds. Current Vascular Surgery. St

Louis, MO: Mosby; 2001.
Rutherford RB, ed. Vascular Surgery. Philadelphia, PA: WB

Saunders; 2005.


Current Procedures: Surgery > Chapter 37. Surgical

Revascularization of Infrainguinal Arterial Occlusive
Disease >
Indications
Disabling claudication.
Critical limb ischemia, defined as rest pain or tissue loss.
Contraindications
Absolute
Debilitated patient with severe comorbidities.

Unaddressed inflow disease.
Lack of an appropriate distal target for revascularization.
Relative
Nondisabling claudication.
Nonambulatory patient.
Severe joint contractures.
Informed Consent
Expected Benefits
Restoration of adequate blood flow to the lower extremity,

thereby relieving ischemic pain, preventing gangrene, and
maintaining ambulation.
Potential Risks
The 30-day mortality and morbidity rates are 2% and

26%, respectively. Morbidity includes:

Renal and respiratory failure.
Vein graft patency overall is reported to be 73% at 5
years versus 49% for a polytetrafluoroethylene (PTFE)
graft.
Primary and secondary vein graft patency at 5 years

is reported to be 50% and 70%, respectively, with a
limb salvage rate of 73%.
Equipment
No special equipment is needed other than a standard

vascular instrument tray.
Patient Preparation
Ankle-brachial indices (ABIs) or segmental pressures.

The arterial anatomy must be defined clearly.
A lower extremity angiogram, CT angiogram, or MR

angiogram may provide sufficient detail for operative
planning.
Preoperative stratification with a full history and physical
examination.
Eagle criteria, American Heart Association guidelines

for perioperative cardiovascular evaluation for
noncardiac surgery, or another cardiac risk
stratification algorithm can be used to calculate the
patient's perioperative risk for coronary events and
need for further workup.
All patients should receive optimal medical therapy in the
perioperative period, including:
Daily aspirin.
-Blockers to titrate the heart rate to < 70 beats/min.
Statin therapy to achieve a goal low-density
lipoprotein level < 100 mg/dL.
Tight blood glucose control with a target level < 140
mg/dL (for at least the first 3 days postoperatively).
Appropriate prophylactic antibiotics are delivered within
30 minutes of skin incision and are redosed as needed for
prolonged cases (eg, intravenous cefazolin, 1 g
preoperatively, then 1 g every 8 hours intraoperatively).
Patient Positioning
The patient should be supine with both arms extended;

procedure-specific positioning is indicated later.
A Foley catheter is inserted.
A radial arterial line is placed.
Procedure
Principles of Open Infrainguinal Revascularization

Inflow
The artery from which the bypass will originate must have
an adequate pressure and allow suturing. Significant
vascular calcification can present challenges.
Outflow
The vessel should be the least diseased vessel with

dominant blood flow to the foot.
Conduit
The great saphenous vein (GSV) has superior long-term

patency rates for all infrainguinal bypasses.
In the absence of an ipsilateral GSV, the contralateral vein
may be used.
Alternatively basilic, cephalic, or lesser saphenous veins
may be used as a composite graft.
The GSV may be used in situ, reversed, or nonreversed
transposed with equivalent long-term patency results,
depending on the surgeon's experience.
Although prosthetic grafts have mediocre long-term
patency rates in infrainguinal bypasses, they can be used
if no other conduit is available.
Anatomy, Exposure, and Preparation of Proximal and Distal

Targets
Figure 37–1: Anatomy of the target site.
The mnemonic NAVEL aids in recollection of the

anatomy; from lateral to medial, the Nerve, Artery,
Vein, Empty space, and Lymphatics will be
encountered—the latter is where a femoral hernia
may occur.
The GSV joins the femoral vein at the saphenofemoral
junction.
The common femoral artery (CFA) begins at the inguinal
ligament as a continuation of the external iliac artery.
The femoral artery bifurcates approximately 5 cm distal to
the inguinal ligament into the superficial femoral artery
(SFA) and the deep femoral artery, also known as the
profunda femoris (PF), the latter traveling laterally and
posteriorly.
Figure 37–1
Common Femoral Artery

Figure 37–2: Exposure and preparation for bypass.
A vertical incision 3–5 cm in length is made proximal

to the inguinal ligament and continued for about 3–4
cm distally over the femoral pulse.
If the pulse is absent, the incision should be made 1–
2 cm lateral to the pubic tubercle where the femoral
artery is usually located.
A calcified artery may be pulseless but is easily
palpated.
The femoral artery should be exposed longitudinally
to avoid lymphatic disruption and the lymphatics
dissected laterally; we ligate or clip larger lymphatics
when present.
A Weitlaner or cerebellar retractor is used to help
expose the vessel.
The CFA, SFA, and PF artery are dissected and
isolated with vessel loops.
The lateral circumflex femoral vein is located between
the origins of the SFA and PF. During dissection of the
femoral artery bifurcation, this vein tends to be
injured and bleed if not sought out and carefully
mobilized.
We have found that the proximal CFA is best clamped
using a Satinsky or a Dara clamp. The external iliac
artery may be mobilized, instead, if it is a better
vessel to clamp; this sometimes entails dividing the
inguinal ligament, which is repaired at the end of the
operation.
A severely diseased CFA may require an
endarterectomy with patch angioplasty in order to
make it suitable for bypass grafting.
Caution must be undertaken with this maneuver as
suitable end points after endarterectomy are rare.
Figure 37–2
Popliteal Artery
Figures 37–3 and 37–4: Exposure and preparation for

bypass.
Proximal popliteal artery (see Figure 37–3).
The knee is flexed and a roll is placed under the

thigh.
The skin incision is made in the lower thigh at the
superior edge of the sartorius muscle and below the
muscle belly of the vastus medialis.
If the ipsilateral GSV is used for conduit, then one
incision may be used for both harvesting the vein and
dissecting out the popliteal artery.
Cutting the superficial fascia allows entry into the
sheath of the sartorius muscle; this muscle is isolated
and reflected posteriorly along with the
semitendinosus and gracilis muscles.
The popliteal fat space is exposed.
The dissection is performed close to the femur,
retracting the great adductor muscle anteriorly and
exposing the adductor hiatus.
The popliteal artery is found by palpation.
Doppler localization is helpful in patients with larger
legs and small nonpalpable arteries.
Distal popliteal artery (see Figure 37–4).
A roll is placed under the distal thigh.

The incision starts 1 cm behind the medial tibial
condyle, runs for 1–2 cm behind the posterior edge
of the tibia, and then courses down the upper third of
the leg; we extend it proximally or distally as needed.
The medial head of the gastrocnemius is retracted
posteriorly using a Weitlaner or an Adson retractor.
A Beckman retractor is placed, lifting the soleus
muscle up and the gastrocnemius muscle down.
The popliteal artery is surrounded by two veins, and
the tibial nerve lies posterior to it.
Careful sharp dissection is carried out using
Metzenbaum scissors.
The popliteal artery gives off the anterior tibial artery
and the tibioperoneal trunk 2–7 cm before diving into
the soleus muscle.
To expose the tibioperoneal trunk, follow the popliteal
artery caudally, dividing the soleus muscle with
cautery.
The anterior tibial artery is isolated with vessel loops
at its origin at the proximal end of the soleus muscle.
Figure 37–3
Figure 37–4
Posterior Tibial and Peroneal Arteries
Patient positioning.
The patient should be supine with the thigh rotated

30–50 degrees.
A bump is placed below the thigh to help exposure.
A tourniquet or microvascular Heifitz clips may be
used for homeostasis at the time of bypass.
Figures 37–5 and 37–6: Exposure and preparation for
bypass.
Upper and middle leg: the incision is placed 1–2 cm

behind the posterior edge of the tibia midway in the
leg. This incision usually overlies the GSV.
The fascia is cut and the gastrocnemius muscle is
freed and retracted posteriorly while the insertion of
the soleus muscle is taken down from the posterior
aspect of the tibial bone, exposing the deep posterior
compartment of the calf.
Both the posterior tibial artery and, a little deeper to
it, the peroneal artery lie inside this compartment.
With the use of a tourniquet, only the anterior and
lateral aspects of the vessels need to be exposed,
and there is no need for circumferential exposure or
vessel loops.
Figure 37–5
Figure 37–6
Anterior Tibial Artery
Patient positioning.
The leg is maintained at 30 degrees of flexion and a

roll is placed under the thigh.
Exposure and preparation for bypass.
The skin and fascia are incised over the space

between the anterior tibial muscle and the long
extensor of the toes.
The anterior tibial artery runs with the deep peroneal
nerve on top of the interosseous membrane.
In the lower third of the leg the muscles are more
tendinous and the anterior tibial artery runs behind
the anterior tibial muscle and the extensor hallucis
longus.
The Doppler probe can aide in identifying the location
of both the dorsalis pedis and posterior tibial arteries.
Preparing the Conduit
Vein Harvest
The GSV is harvested through a separate skin incision

medial to the CFA incision.
Cephalic, basilic, or lesser saphenous veins may also

be harvested.
Once the vein is removed, it should be placed in a
solution containing heparin.
The vein is distended gently and any leaks are

addressed.
Tributaries are ligated with 4-0 silk ties.
In-Situ Bypass
Here the vein is not mobilized from its bed except at the
proximal and distal ends.
As the vein is exposed, tributaries are tied off with

silk ties.
The proximal GSV is mobilized, excising the first
valve under direct vision.
Then the GSV is spatulated and anastomosed to the
CFA.
Once the clamps are released, the first competent valve
will hold up; valve lysis is then performed using one of a
variety of valvulotomes.
It is essential to preserve the vein side branches to
allow passage of the valvulotome.
Routes for Bypass and Creating the Tunnel
Figure 37–7A, B: The graft is tunneled before

heparinization.
Popliteal route.
The graft is tunneled beneath the sartorius muscle

but superficial to the adductor magnus tendon
(Figure 37–7A).
If the distal anastomosis target is the below-knee
popliteal artery, then the graft should be further
tunneled in an anatomic position (Figure 37–7B).
Posterior tibial artery route.
The GSV is mobilized for approximately 10 cm.

The aponeurosis of the leg should be incised high
enough to avoid angulation of the vein.
In reversed bypasses, either a subcutaneous or an
anatomic route may be used.
The anatomic route follows the posterior edge of the
sartorius, enters the popliteal fossa between the two
heads of the gastrocnemius, and passes anterior to
the soleus muscle to the posterior tibial artery.
This route is used preferentially for reversed
saphenous vein graft and prosthetics; it is less
susceptible to the risk of superficial infections and is
not subject to kinking when the knee is flexed.
When using a subcutaneous route, a tunnel is made
that runs along the anterior medial surface of the
thigh and continues on the medial side of the knee
and leg.
The diameter of the tunneling instrument must be
sufficient to create a tunnel wide enough to prevent
compression.
Peroneal artery route.
When accessed through the medial approach, the

trajectory is the same as for the posterior tibial
artery.
Anterior tibial artery route.
In-situ bypasses: the lower part of the popliteal fossa

is divided, and the interosseous membrane is freed
and then incised longitudinally for 2–3 cm.
A blunt instrument is passed from the anterior
compartment to the popliteal fossa.
The distal anastomosis should be performed far
enough from the point where the vein graft crosses
the interosseous space so that the vein is parallel to
the artery.
The path for a reversed GSV may follow the anatomic
route behind the sartorius, between the heads of the
gastrocnemius, before joining the anterior
compartment.
Figure 37–7
Performing the Bypass
Before occluding the inflow, the patient is given an initial

heparin bolus of 100 units/kg; the activated clotting time
(ACT) is kept above 250 seconds.
Figures 37–8 and 37–9: The arteriography is made
using a No. 11 blade and then extended with Potts
scissors.
The graft is spatulated and a polypropylene suture (eg,
Prolene) is used to create the proximal anastomosis.
We usually use 5-0 Prolene suture for the CFA and 6-

0 Prolene suture for the distal target vessels.
After completing the proximal anastomosis, the inflow is
released and the graft is distended and then marked for
orientation.
The graft is passed through the tunnel carefully

making sure there are no twists.
For the leg vessels a tourniquet may be used to ensure a
bloodless field (see Figure 37–8).
An arteriotomy is made in the distal vessels with a No. 11
blade, and a 1.5–2.5-mm coronary dilator is carefully
passed to ensure patency.
The graft is cut to size with the leg extended, and the
end is spatulated. The anastomosis is created (see
Figure 37–9).
Before completion of the anastomosis the artery is back-
bled and the graft is flushed.
Some centers perform completion angiograms; we use
intraoperative duplex ultrasonography to scan the inflow
anastomosis, the outflow anastomosis, and the graft for
any abnormalities.
In cases of a threefold increase in flow velocities or a

velocity above 300 cm/s, close evaluation is needed
to identify technical errors, flaps, or retained valves.
The groin wound is closed in at least three layers of 3-0
Vicryl, obliterating all the potential space.
The leg wounds are closed by approximating the fascia
only.
The skin is closed with staples, interrupted nylon, or
subcuticular stitches.
Figure 37–8
Figure 37–9
Postoperative Care
Doppler ultrasound signals should be checked frequently

to monitor graft patency.
Patients are maintained on a -blocker, an antiplatelet
agent, and a statin unless contraindicated.
Antibiotics are stopped 24 hours after surgery unless
there is an active infection (eg, an infected ulcer or toe).
Epidural injection or patient-controlled analgesia may be
used for postoperative pain management.
Venous thromboembolic prophylaxis is started on
postoperative day 1 using unfractionated heparin
administered subcutaneously.
Patients with significant edema and pedal wounds are
treated with an Ace wrap and leg elevation.
Sutures in the foot are removed only when the wounds
are solidly healed, and not before 4 weeks.
Local wound infections.

Hematoma.
Lymph leaks.
Graft thrombosis.
Pearls and Tips
Vessel exposure in previously operated groins requires

patience and care.
Doppler insonation is useful for locating difficult-to-

palpate arteries and grafts.
Sharp knife dissection is also helpful in groins that
are very scarred.
Patients should continue to take aspirin preoperatively as
this improves graft patency. However, clopidogrel is
associated with excessive bleeding, and we recommend
stopping this drug 7 days before the operation.
Perioperative antibiotics, excellent homeostasis, and good
incision closure technique are essential to decrease
postoperative problems.
If there are no distal targets, amputation may be
required.
The level of amputation may be determined based on

segmental pressures and the angiogram.
A below-the-knee amputation should heal if the
popliteal pressure is > 50 mm Hg or there is a patent
PF artery.
References
Branchereau A, Berguer R. Vascular Surgical Approaches.

New York, NY: Futura; 1999.
Zelenock G. Mastery of Vascular and Endovascular Surgery.




of Lower Extremity Venous Insufficiency >
Indications
Swelling.
Leg heaviness.
Aching.
Cramping.
Skin discoloration.
Venous ulcers.
Contraindications
Acute deep venous thrombosis.

Malformation of the deep venous system.
Active infection.
Symptomatic peripheral arterial disease.
Cardiopulmonary comorbidities (relative).
Informed Consent
Expected Benefits
Removal of varicose veins of the lower extremity.
Potential Risks
Phlebectomy.
Bleeding or hematoma formation at the operative

site.
Superficial surgical site infection.
Paresthesias.
Recurrent varicose veins.
Endovenous laser or radiofrequency ablation.
Recanalization.
Thromboembolism.
Burning pain.
Swelling.
Bruising.
Scarring.
Equipment
Stab Phlebectomy
No. 11 blade scalpel.

Mosquito clamps.
Vein hooks of several sizes.
Endovenous Laser Ablation

Micropuncture kit.
Endovenous laser generator, laser catheter.
Ultrasonographic equipment.
Tumescent anesthesia (infused by hand or Klein pump):
lidocaine 1% with epinephrine, 50 mL; sodium
bicarbonate 1 mEq/mL, 30 mL; saline 0.9%, 1000 mL.
Endovenous Radiofrequency Ablation

Micropuncture kit.
Radiofrequency generator, catheter.
Ultrasonographic equipment.
Tumescent anesthesia (as discussed earlier).
TriVex Transilluminated Power Phlebectomy

Power phlebectomy unit and handpiece.
Tumescent anesthesia.
Patient Preparation
Nothing by mouth after midnight on the evening before

the procedure.
Ultrasound mapping.
Veins should be marked in the preoperative area while the
patient is standing upright to distend affected veins.
Antimicrobial prophylaxis: cefazolin, 1 g intravenous, if
phlebectomy is indicated (not needed for ablation only) or
if skin changes indicative of chronic venous insufficiency
are present.
Deep vein thrombosis prophylaxis as appropriate for risk
factors, using unfractionated or low-molecular-weight
heparin.
Patient Positioning
The patient is usually placed in the supine position

initially, with exposure of the entire affected extremity.
The leg should be prepared circumferentially from the
inguinal ligament to the foot.
If necessary, the patient may be repositioned prone.
This is especially helpful when access to posterior

perforators or the small saphenous vein is necessary.
Procedure
The patient may receive either general or regional (spinal)

anesthesia.
Figure 38–1A: The anatomy of the superficial veins of
the lower extremity, showing the location of the great
saphenous vein (GSV) and small saphenous vein (SSV) as
well as the tributaries to the GSV near the
saphenofemoral junction.
Ablation of the GSV and SSV reduces venous

hypertension transmitted to the varicose veins.
Figure 38–1B: The saphenofemoral junction.
The tributaries that join the GSV near the

saphenofemoral junction are shown in greater detail.
Formal stripping requires identification and division of
these branches.
Figure 38–2A: A 3-cm incision is made in the medial
thigh, below the inguinal ligament, lateral to the femoral
arterial pulse.
Figure 38–2B: The tributaries to the saphenofemoral
junction are identified, ligated, and divided.
The GSV is traced distally from the saphenofemoral

junction, then doubly ligated and divided 1 cm distal
to the junction.
Figure 38–3A-D: Stab avulsion.
Small (< 1 cm) incisions are made directly over the

varicosities marked preoperatively.
The vein segments are then pulled to the surface
using small hemostatic clamps or small specially
modified crochet hooks.
Figure 38–4: The SSV courses in close proximity to the
sural nerve.
Figure 38–5: Essentials of endovenous ablation (laser
and radiofrequency).
Using ultrasonographic guidance, the GSV is accessed

and a guidewire is introduced, followed by a sheath
and the catheter containing the laser fiber or
radiofrequency probe.
With the catheter in place, tumescent anesthesia is
introduced into the perivascular space.
Placement of the catheter 2 cm distal to the
saphenofemoral junction is confirmed.
A laser catheter is activated and withdrawn at a rate
of 1 mm/s for 100 seconds, and then 2.5 mm/s until
the laser tip is 1 cm from the skin surface.
A radiofrequency catheter is heated to a temperature
of 120°C and withdrawn in steps.
The catheter is activated at each 7-cm segment and
activated at each station until pulled back to its
insertion site.
Figure 38–6: Transilluminated powered phlebectomy.
The area of varicosities is marked preoperatively.

In the operating room, first-stage tumescent
anesthesia is instilled using the irrigated illuminator,
causing hydrodissection.
The resector is then introduced and passed alongside
and underneath the vein clusters of interest.
The resector disrupts the vein, and then the vein
segment is removed with high suction.
Second-stage tumescent anesthesia is instilled with
the illuminator.
Third-stage tumescent anesthesia is used to remove
blood from the incisions.
Figure 38–1A–B
Figure 38–2A–B
Figure 38–3A–D
Figure 38–4
Figure 38–5
Figure 38–6
Postoperative Care
A short stretch bandage is applied in the operating room,

and covered with an elastic bandage.
For the first night, patients are allowed to walk and are
instructed to elevate the leg when resting.
Patients are encouraged to ambulate on postoperative day
1 and to return to normal activity by 48 hours, keeping
the leg elevated when resting.
The dressing may be removed after 48 hours; the leg
should be kept clean and dry.
Compression stockings or wraps should be worn
thereafter, with the patient continuing to elevate the legs
when possible.

Deep venous thrombosis.
Leg swelling.
Pearls and Tips
It is best to mark varicosities in the preoperative area

with the patient standing. If this is not done, a tourniquet
can be applied in the operating room, but this is less
effective than marking varicosities while the patient is
standing.
In ablation (laser or radiofrequency), tumescent
anesthesia is critical for reducing superficial discomfort
and burns.
Postoperative care is an essential part of this operation.
Compression must be applied in the operating room and
maintained for the first 48 hours postoperatively.
Following removal of the bandages, patients should use
compression stockings or wraps and elevate the legs
when possible.
References
Caggiati A, Bergan JJ, Gloviczki P, et al. International

Interdisciplinary Consensus Committee on Venous Anatomical
Terminology. Nomenclature of the veins of the lower limb:
extensions, refinements, and clinical application. J Vasc Surg.
2005;41:719–724.[PubMed: 15874941] [Full Text]
Knipp BS, Blackburn SA, Bloom JR, et al. Michigan Venous

Study Group. Endovenous laser ablation: venous outcomes
and thrombotic complications are independent of the
presence of deep venous insufficiency. J Vasc Surg.
2008;48:1538–1545.[PubMed: 18829223] [Full Text]
Pfeifer JR, Engle JS. Surgical Management of Varicose Veins

by Saphenous and Perforator Ligation with Sparing of the
Saphenous Vein. In: Zelenock GB, Huber TS, Messina LM, et
al, eds. Mastery of Vascular and Endovascular Surgery.
Spitz GA. Transilluminated Powered Phlebectomy (Trivex): An

Illustrated Guide. Andover, MA: Smith and Nephew; 2000.


Current Procedures: Surgery > Chapter 39. Below- and

Above-the-Knee Amputation >
Indications
Below-the-Knee Amputation (BKA)
Nonsalvageable lower extremity infection.

Chronic nonhealing lower extremity wounds.
Acute lower extremity infection.
Trauma with vascular or neurologic injury; open tibia
fracture with posterior tibial nerve disruption or warm
ischemia > 6 hours.
Above-the-Knee Amputation (AKA)
Severe peripheral vascular disease not amenable to

bypass graft with popliteal pressures inadequate to heal
BKA.
Chronic nonhealing BKA wound.
Nonreconstructible traumatic injury to the lower extremity
involving the knee joint or proximal tibia.
Contraindications
Below-the-Knee Amputation
Cardiopulmonary disease and inability to tolerate surgery

(relative contraindications).
Fixed knee contracture that would cause pressure on the
distal stump after amputation (AKA is indicated in these
cases).
Nonfunctional limbs (an indication for AKA).
Paraplegia (relative contraindication).
Infection that extends above the knee.
Inadequate blood flow to heal a BKA (popliteal artery
pressures < 50 mm Hg).
Above-the-Knee Amputation
Aortoiliac occlusive disease with inadequate femoral

artery flow to heal an AKA wound.
Osteomyelitis of the proximal femur, femoral head, or
acetabulum.
Cardiopulmonary disease and inability to tolerate surgery
(relative contraindications).
Informed Consent
Potential Risks
Nonhealing wound.
Phantom pain.
Chronic pain.
Neuroma.
Persistent infection.
Need for higher amputation.
Loss of mobility.
Bleeding requiring transfusion.
Complications related to general medical condition,
including heart attack, stroke, venous thromboembolism,
or death.
Equipment
Tourniquet.
Electrocautery and surgical ties for hemostatic control.
Bone-cutting saw (either a powered oscillating saw or
Gigli saw).
Bone rasp.
Amputation knife.
Standard vascular and soft tissue instruments.
Patient Preparation
Ankle-brachial index studies (if applicable) and segmental

arterial pressures of the lower limb.
Popliteal artery pressure of 50 mm Hg is generally

considered adequate to heal a BKA.
Full vascular evaluation for possible salvage procedures,
including angioplasty, stenting, or vascular bypass (see
Figure 39–1).
Full medical evaluation (given the high incidence of
cardiac disease among patients).
Consider cardiac optimization with aspirin, a statin,

and a -blocker as tolerated.
Preoperative Physical Medicine and Rehabilitation
Amputee service consultation.
Preoperative anesthesia consultation for spinal or regional
block.
Discussion among orthopedic, vascular, and plastic
surgery services regarding limb viability in patients with
traumatic injury.
Preoperative type and crossmatch, as appropriate.
Figure 39–1
Patient Positioning
For either BKA or AKA, the patient should be supine.
Procedure
Figure 39–1: Vascular anatomy of the lower extremity,

showing locations for skin incision and femoral and tibial
transection.
Below-the-Knee Amputation
General, epidural, or long-acting spinal anesthesia may be

used.
The entire leg is prepared circumferentially to the level of
the proximal thigh; open wounds should be prepared with
povidone-iodine.
A sterile thigh tourniquet is applied.
Caveat: a tourniquet should not be used in patients

with severe vascular occlusive disease.
The distal foot is covered with stockinette or Ioban
antimicrobial drape to further exclude it from the
operative field.
Ideally, 10 cm of tibia distal to the tibial tuberosity is
maintained; this can be measured with a ruler or using
the width of the surgeon's hand.
The planned skin incision is marked 1–2 cm distal to the
planned site of tibial transaction to allow for soft tissue
coverage.
Figure 39–2: Marking of the incision site.
The planned incision is marked to proceed around the

anterior two thirds of the lower extremity
circumference.
The posterior flap is then marked by measuring one
third of the lower extremity circumference with slight
tapering at the distal end; this measurement can be
made with a suture or umbilical tape cut to the
circumference of the lower extremity at the site of
amputation.
A slight beveling of the incision proximally at the
corner can allow for better closure at the end of the
case.
The marked incisions are then made and carried
down through the skin, subcutaneous fat, and fascia.
Care is taken to identify and ligate the great
saphenous vein.
Figure 39–3: Cross-sectional anatomy of the calf.
With electrocautery, the musculature of the anterior

and lateral compartments is divided down to the
periosteum of the tibia and fibula.
Special care is taken when dissecting through the
muscle bellies to achieve hemostasis.
The anterior tibial vessels are identified and ligated.
Figure 39–4A: Using a rake retractor, the subcutaneous
tissues are retracted proximally over the tibia to expose
the planned site of transection.
The periosteum is divided around the tibia and a
periosteal elevator is used to separate the proximal
periosteum from the tibia.
Figure 39–4B: Either a reciprocating saw or a Gigli saw
is used to transect the tibia.
To avoid causing a pressure point under the

prosthesis, the anterior edge of the tibia is then
beveled at a 45-degree angle using either the
reciprocating saw or a bone rasp.
Attention is next turned to the fibula; the periosteum
is again divided and a periosteal elevator is used to
strip the proximal periosteum from the fibula.
Figure 39–4C: The fibula is then transected 1 cm
proximal to the location of the tibial transection in order
to prevent the fibula from becoming a pressure point.
This can be done with a reciprocating saw, Gigli saw,

or bone cutter.
Next, an amputation knife is used to transect the
posterior soft tissues.
The initial knife cut is perpendicular to the limb axis

in a posterior direction to divide the deep posterior
compartment.
The knife is then turned in a coronal plane to develop
a posterior flap consisting of skin, subcutaneous fat,
and the muscles of the superficial posterior
compartment.
Care must be taken to keep the knife within the
previous lateral incisions made at the start of the
operation to maintain an adequate skin for flap
closure.
At the distal aspect of the incisions, the gastrocnemius
and soleus tendons are cut and the amputated specimen
is handed off for pathologic examination.
If a tourniquet is not used, pressure is held on the
remaining tissue to control hemorrhage mainly from the
transected popliteal trunk.
Hemostasis is achieved with specific attention paid to
identification and ligation of the posterior vasculature
using electrocautery or suture ligatures.
The transected nerves are sharply cut as proximal as
possible and allowed to retract up into the soft tissue.
Rough edges of bone are rasped smooth.
After irrigation, the posterior flap is rotated anteriorly.
Figure 39–5A-C: The deep fascia of the superficial
posterior compartment may be sutured to the anterior
periosteum of the tibia with absorbable sutures to secure
muscle coverage over the tibia, although not all surgeons
perform this step.
Deep dermal sutures are then placed followed by skin
staples or nylon sutures; the final stump has the
appearance of Figure 39–5.
Based on the clinical situation, a Penrose drain may be
left under the flap and brought out through a corner of
the incision.
A soft, gently compressive dressing is placed.
Figure 39–2
Figure 39–3
Figure 39–4
Figure 39–5
Above-the-Knee Amputation
As in BKA, general, epidural, or a long-acting spinal

anesthetic is administered.
The operative leg is circumferentially prepared and an
extremity drape is applied.
A sterile tourniquet can be placed high on the thigh but
may not be necessary in the patient with severe vascular
disease.
A fish-mouth incision is designed with equal anterior and
posterior flaps that end just proximal to the knee,
maximizing the length of the amputated thigh (see Figure
39–2).
Figure 39–6: Cross-sectional anatomy of the thigh.
If a tourniquet is used, the leg should be

exsanguinated by either elevation or compression
with an Ace or Esmarch bandage.
The tourniquet is then insufflated to 250 mm Hg.
The skin incision is made with a No. 10 blade.
Dissection is continued straight down to the femur
through the subcutaneous fat, rectus femoris, and
vastus musculature anteriorly using electrocautery.
Figure 39–7A: In patients with severe vascular disease,
some surgeons prefer the entire dissection to be
performed sharply with a No. 10 blade followed by
focused hemostasis using suture ligature to minimize
thermal tissue trauma.
Figure 39–7B: On the medial side of the leg, the great
saphenous vein is clamped between hemostats, divided
sharply, and ligated with 2-0 silk ties.
Figure 39–7C: Dissection continues through the
hamstring and adductor muscles of the medial and
posterior thigh until the femoral artery and vein are
located.
The artery and vein are isolated and suture-ligated.

Near the femoral artery and vein, the sciatic nerve is
identified.
Proximal resection of the nerve is essential to
minimize chance of palpable neuroma.
The nerve is placed on tension and cut sharply to
allow the proximal end to retract up the thigh within
the posterior musculature.
Figure 39–8A: Transection of the femur.
A periosteal elevator is used to expose the femur 2–3

cm proximal to the deep corner of the fish-mouth
incision.
Alternatively, the femur can be transected before the
posterior musculature and soft tissues are
transected.
Figure 39–8B: A powered oscillating saw or Gigli saw is
used to cut the bone.
No bevel is needed because of the thickness of the

muscle bellies in the thigh.
If a tourniquet was used, the pressure is released and
hemostasis is achieved with a combination of
electrocautery and suture ligature.
The wound is copiously irrigated and the viability of the
anterior and posterior muscle flaps is assessed.
A 10 French closed suction drain, if clinically indicated, is
placed in the subfascial space through a separate stab
incision on the lateral aspect of the leg.
Figure 39–8C, D: The wound is closed in layered
fashion.
First, the fascia is closed with interrupted figure-of-eight
2-0 Vicryl sutures over the drain.
Next, the skin is closed with deep dermal 3-0 Vicryl

sutures followed by either staples or vertical mattress
3-0 nylon sutures.
The wound is dressed with nonadherent iodinated
petrolatum gauze dressing and soft gauze wrap.
Figure 39–6
Figure 39–7A-C
Figure 39–8A-D
Postoperative Care
Wound Care
Most surgeons keep the initial dressing in place for 2 days

before examining the wound.
For both AKA and BKA, the lower extremity stump must
be kept strictly elevated at all times to reduce edema.
Medical Management
A patient-controlled analgesia pump is often used for

postoperative pain.
Perioperative tight glucose control is essential to decrease
the risk of wound infection and optimize healing.
Due to concomitant cardiovascular disease in many
patients undergoing amputation, perioperative aspirin,
statins, and -blockers should be continued.
Patients should be closely monitored for symptoms of
cardiac ischemia.
Rehabilitation
Early physical therapy consultation is required to initiate

teaching of transfers and one-legged mobility.
If not consulted preoperatively, the Physical Medicine and
Rehabilitation service should be consulted after
amputation is completed.
With BKA, the patient should be monitored closely for any
evidence of flexion contracture at the knee.
If contracture is developing, a posterior splint can be

used to keep the knee straight.
Some surgeons prefer to use a rigid removal cast dressing
in the initial postoperative period to protect the stump
and help prevent flexion contracture.
The patient should remain non-weight bearing on the
amputated extremity for a minimum of 3 months.
A prosthesis may be fit at 6 weeks but should not be used
until all wounds have completely healed.
Delayed wound healing.
May occur during the first few postoperative weeks

secondary to persistent infection or poor vascular
inflow.
Often managed with antibiotics when indicated and
local wound care but can require surgical
debridement, revision, or higher amputation
Hematomas.
Should be drained to prevent future infection.

Joint contractures of the knee.
Contracture after BKA is often difficult to correct;

early intervention with physical therapy can be
helpful, including splinting of the knee in an extended
position.
With an AKA, contractures can occur at the hip joint;
prevention involves having the patient lie in a prone
position and aggressive physical therapy.
Neuromas.
Can occur at sites of transected nerves from

overactive axonal regeneration.
If close to the skin, these sensitive nodules cause
shooting pain with contact and may limit fitting of a
prosthetic limb.
Occurrence is minimized by dividing the nerve as
proximally as possible and then burying the nerve
stump under the muscle.
Phantom limb sensations.
Occur in most amputations and can be quite disabling

and difficult to treat.
Early desensitization therapy and involvement of an
amputee specialist can decrease the risk of this
disabling complication.
Medicines for neuropathic pain (eg, pregabalin or
gabapentin) may also be effective to prevent
phantom sensations.
Cardiovascular events, including heart attack, stroke,
venous thromboembolism, or death.
These are significant risks given the frequent

comorbidities in amputation patients and significant
physiologic stress of the amputation procedure.
Preoperative optimization and close postoperative
monitoring are the best interventions to decrease this
risk.
Pearls and Tips
In cases of wet gangrene, uncontrolled lymphedema, or

critical illness, a guillotine amputation (either above or
below the knee) may be performed to remove the
infected tissue. Formal amputation is planned once the
patient is physiologically stable and the infection has been
controlled with systemic antibiotics and local wound care.
With any amputation, preoperative optimization is
necessary to decrease the risk of morbidity and mortality.
Thorough knowledge of the cross-sectional anatomy of
the thigh or calf will facilitate quick and easy identification
of major vessels and nerves.
In BKA, dissection of the posterior flap with the
amputation knife can be tricky; it is best to have too
much flap and trim to fit rather than not have enough and
be forced to shorten the amputation.
The posterior flap is most commonly used because the
vascular supply to the gastrocnemius musculocutaneous
flap is from the sural artery, which arises above the knee;
alternatively, sagittally based flaps or anterior-posterior
fish-mouth flaps can be used if clinically necessary.
Division of any nerves should be performed on tension to
allow the nerve to retract up the leg, minimizing the
chance of neuroma development.
References
Giglia J, Jarboe MD. Lower Extremity Amputation. In:

1334.
Rapp JH, MacTaggart J. Arteries. In: Doherty GM, ed. Current

Diagnosis and Treatment: Surgery. New York, NY: McGraw-
Hill; 2010:753–787.


Current Procedures: Surgery > Chapter 40. Inguinal

Hernia Repair >
Indications
Recent literature suggests that patients who are

asymptomatic or "minimally symptomatic" may be
managed without surgical intervention.
All symptomatic inguinal hernias (pain, neurologic
symptoms) should be repaired unless a specific
contraindication exists.
Inguinal hernias that are incarcerated and are reduced in
a timely fashion should be repaired on an urgent basis.
Hernias that are unable to be reduced should be treated
as a surgical emergency and repaired expeditiously.
Contraindications
There are no absolute contraindications.

In the event the patient cannot undergo general or spinal
anesthetic, the repair can be performed under local
anesthetic with sedation.
Informed Consent
Potential Risks
Bleeding.
Infection (potentially requiring reoperation to remove
infected mesh).
Damage to nerves resulting in loss of inner thigh skin
sensation.
Damage to the vas deferens or testicular vessels
potentially leading to decreased fertility.
Recurrence.
Neuralgia.
Patient Preparation
Nothing by mouth for 6 hours before surgery.

Blood thinners should be discontinued with adequate time
for normalization of coagulation.
Foley catheter insertion is required for laparoscopic
procedures only.
Patient Positioning
Procedure
Open Inguinal Hernia Repair
The operation may be performed under spinal, local, or

general anesthesia.
Figure 40–1: Inguinal hernia locations.
Figure 40–2A: Landmarks for skin incision are the
anterior superior iliac spine and pubic tubercle.
The incision should be superior to the inguinal
ligament and, if possible, hidden in a natural skin
crease.
Figure 40–2B: The subcutaneous tissue should be
divided until the external oblique fascia is encountered.
A regional local anesthetic block may be placed at

this time (10 mL of 0.5% bupivacaine infiltrated
subfascially into the deep muscular layers and
retroperitoneum along the iliac fossa region 2 cm
medial and cephalad to the anterior superior iliac
spine).
The external oblique fascia is then divided sharply to
expose the underlying cord and hernia.
Figure 40–3: The hernia sac is dissected free from the
associated cord structures.
Care should be taken to identify the ilioinguinal nerve

and retract it away from the area of dissection to
avoid injury.
Indirect hernias originate from the internal ring and
are located anteromedial to the cord structures.
Direct hernias come directly through the floor and
push the cord structure superficially.
Sliding hernias arise lateral to the cord.
Figure 40–4: The hernia sac is opened and the contents
are visualized to ensure that no incarcerated bowel is
present. The sac is then amputated and ligated with a
suture ligature.
If the internal ring is widely dilated, sutures may be

placed to tighten it medially, laterally, or in both
directions.
A large direct hernia may be navigated by sutures in
the inguinal floor.
Figure 40–5: A piece of polypropylene mesh is then cut
to a keyhole shape and sewn medially to the pubic
tubercle with a 2-cm overlap on the tubercle, inferiorly to
the shelving edge of the inguinal ligament, and superiorly
to the internal oblique fascia.
The internal ring is recreated by sewing together the

two tails of the mesh lateral to the cord.
The tails then extend laterally beneath the external
oblique fascia.
Figure 40–6: After the mesh is secured, the external
oblique fascia is closed using a running stitch in a medial
to lateral direction. The medial closure will form the new
external inguinal ring.
Figure 40–1
Figure 40–2A-B
Figure 40–3
Figure 40–4
Figure 40–5
Figure 40–6
Laparoscopic Total Extraperitoneal Inguinal Hernia Repair
The operation is performed under general anesthesia for

laparoscopic hernia repair.
Figure 40–7A, B: A 10-mm port is placed at the
umbilicus (Figure 40–7A).
Care is taken to insert a balloon dilator between the

rectus muscle and posterior sheath fascia.
By advancing the dilator toward the pubis, the
preperitoneal space is entered.
The balloon is inflated and held in place for 5 minutes
to ensure hemostasis of small vessels avulsed on
entry (Figure 40–7B).
The preperitoneal space is then insufflated.
Two 5-mm ports are placed in the midline between
the umbilicus and pubis into the preperitoneal space
(see Figure 40–7A).
Figure 40–8A: The pubic tubercle and Cooper's ligament
are identified medially (this view is of the right groin).
The space lateral to the hernia and cord structures is

then developed bluntly.
The hernia is identified and the sac dissected free
from the cord structures. It is then pulled out of the
internal ring for an indirect hernia using a hand-over-
hand technique.
Great care should be taken to avoid creating a hole in
the hernia sac or peritoneum during this dissection as
this leads to development of a pneumoperitoneum,
which collapses the preperitoneal working space.
A direct hernia may also be reduced using a hand-
over-hand technique if necessary, although often
insufflation of the preperitoneal space alone will
reduce a direct inguinal hernia.
Figure 40–8B: Once the hernia sac has been swept clear
of the cord structures and anterior abdominal wall, a
piece of preformed mesh is placed through the 10-mm
port and positioned using graspers.
The mesh is positioned to cover the entire

myopectineal orifice and then tacked medially to the
pubis or Cooper's ligament, or both.
Direct, indirect, and femoral hernia defects are
covered by the mesh, as shown.
Figure 40–7A-B
Figure 40–8A
Figure 40–8B
Postoperative Care
Uncomplicated open or laparoscopic hernia repair is

performed on an outpatient basis.
Postoperative pain control is achieved with anti-
inflammatory medications and narcotics for severe pain.
Bleeding can range from a subcutaneous hematoma to

hemoscrotum.
This rarely requires reoperation, but patients must be

informed about potential groin or scrotal bruising.
Life-threatening hemorrhage is exceedingly rare but may
occur if an unrecognized retroperitoneal arterial injury
occurs.
Typical manifestations are hypotension, decreased

urine output, and possibly flank bruising.
Damage to the ilioinguinal or genitofemoral nerves may
result in paraesthesia to the inner thigh or scrotum, or
both.
This complication is often temporary when caused by

traction but may be permanent if caused by
transection.
Chronic groin pain is believed to be caused by nerve
entrapment during repair. Occasionally, the pain is
debilitating enough to require reexploration.
Some surgeons electively transect the ilioinguinal

nerve when it is encountered to avoid this
complication, although this has not been proven to be
effective.
Pearls and Tips
In open repair, take care to identify the ilioinguinal nerve

and retract it away from the repair to avoid entrapment.
Entrapment most often occurs when sewing the mesh
superiorly to the internal oblique fascia and when closing
the external oblique fascia.
During laparoscopic repair, avoid overly aggressive blunt
dissection in the region inferior and medial to the hernia
and cord to avoid damage to the femoral vessels. To avoid
injury to blood vessels and nerves, do not place tacks
inferior to the inguinal ring.
Avoid tearing of the peritoneum during laparoscopic repair
as this will cause pneumoperitoneum, decreasing the
preperitoneal working space. If this does occur, a Veress
needle can be inserted in the periumbilical region to
decompress the peritoneum.
To prevent recurrence after laparoscopic repair, ensure
that the mesh used is large enough to cover the entire
myopectineal orifice.
The most common site of recurrence following
laparoscopic repair is posteriorly. This is likely the result
of failure to adequately reduce the posterior peritoneum
(hernia sac) far enough cephalad.
References
Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, et al. Watchful

waiting vs. repair of inguinal hernia in minimally symptomatic
men. JAMA. 2006;295:285–292.[PubMed: 16418463] [Full
Text]
Franz MG. Complications of Abdominal Wall and Hernia

Operations. In: Mulholland MW, Doherty GM, eds.
Complications in Surgery. Philadelphia, PA: Lippincott


Current Procedures: Surgery > Chapter 41. Ventral

Hernia Repair >
Indications
Incarceration.
Strangulation.
Bowel obstruction.
Functional or cosmetic deformity.
Threatened overlying skin.
Pain.
Contraindications
Absolute
Inability to tolerate general anesthetic (cardiopulmonary

risk).
Absence of tissue for reconstruction (myofascia or skin).
Massive loss of peritoneal domain.
Relative
Infection.
Moderate loss of peritoneal domain.
Morbid obesity.
Malnutrition.
Tobacco use.
Bleeding diathesis.
Ascites.
Informed Consent
Expected Benefits
Restoration of the structure and therefore function of the

abdominal wall by reestablishing myofascial continuity
and preventing evisceration.
Potential Risks
Recurrence rates are as high as 50% depending on the

type of repair (primary vs mesh, open vs laparoscopic).
Complications include:

Mesh-associated infection and fistulization.
Bleeding.
Seroma formation.
Damage to adjacent structures.
Hernia recurrence.
Risks related to any major operation (myocardial
infarction, pneumonia, and venous
thromboembolism).
Equipment
No special equipment is required for an open repair.
Laparoscopic repair utilizes standard laparoscopic
equipment, including camera (30 degree), monitor, and
appropriately sized ports (5 or 10 mm) with associated
trocars.
Mesh selection is complex and should be based on an
understanding of mesh material properties and their
effect on wound healing.
Meshes may be made of permanent synthetic

plastics, rapidly absorbed polymers, or biologic
extracellular matrices.
Patient Preparation
The number of previous attempts at hernia repair should

be elicited, including whether or not mesh was used.
If the patient smokes or is overweight, lifestyle changes
should be recommended prior to the operation.
Nutrition should be optimized and medications adjusted
as necessary (eg, discontinuing methotrexate and
steroids) to decrease the likelihood of wound healing
problems.
Visual inspection should include looking for existing
abdominal scars that may influence the operative plan.
The fascial defect should be palpated to determine if the
contents of the hernia sac are reducible.
CT imaging is helpful for outlining the exact size and
location of the fascial defect, which is often larger than it
may appear on clinical examination.
CT imaging also reveals the contents of the hernia sac,
condition of the abdominal wall musculature for
reconstruction, and the presence of other hernias.
Patient Positioning
The patient should be supine for the most common

midline incisional hernias.
Modified decubitus positions are used for flank incisional
hernia repairs, with appropriate pressure points padded.
Limited hip flexion can help relax the abdominal wall
musculature.
Tilting the head of the operating table up or down, left or
right, aids in gravity-assisted retraction of the abdominal
viscera and reduction of the hernia sac contents.
Procedure
Figure 41–1: Sharp dissection is carried down through

the skin and subcutaneous tissue to the underlying fascia.
The hernia sac (blue) can sometimes be difficult to

expose, especially if its contents are already reduced
secondary to proper patient positioning.
If present, the thin layer of overlying fascia is
delicately teased off the hernia sac and dissected
back to fascia with sufficient bulk and robust blood
supply to hold suture material.
The thickened, fibroplastic "hernia ring" should be
fully exposed.
The hernia sac is opened, being cognizant that loops
of bowel may be adherent to the posterior peritoneal
surface.
Under direct visualization, the contents of the hernia
sac are definitively reduced.
The excess peritoneum (hernia sac) is then excised.
Figure 41–2: The fascial defect is clearly outlined by
removing fat and other devitalized tissue from the fascial
edges.
It is important to allow at least 5 cm of clearance in

all directions before closure is attempted.
This is easily accomplished by a careful finger sweep
in the subfascial layer to release any further adherent
intra-abdominal contents from the posterior
peritoneal surface.
Figure 41–3A, B: Primary repair is reserved for small,
uncomplicated hernias (<3 cm).
It can be performed in either an interrupted (Figure

41–3A) or a continuous running (Figure 41–3B)
fashion using either resorbable or nonresorbable
monofilament suture, depending on the perceived
degree of wound healing or tissue defect.
During a continuous suture repair, it is important to
take bites that are at least 1 cm back from the
normal fascial edge, with 1 cm of spacing in between
bites to allow for a suture-to-wound length ratio of
4:1.
Figure 41–4: There are various mesh placement
techniques, including the onlay, inlay, retrorectus, and
intraperitoneal underlay (intraperitoneal onlay of mesh).
The figure shows retrorectus placement, in which the

mesh is placed between the rectus abdominis muscle
and posterior rectus sheath above the arcuate line
and in the preperitoneal space below the arcuate line.
This technique allows for preservation of the hernia
sac and thus maintains a barrier between the mesh
and underlying bowel.
Again, at least 5 cm of overlap between the mesh
and fascia should be allowed to promote optimum
fibrous tissue ingrowth; tacking sutures are placed 3
cm from the fascial edge.
Figure 41–5: The components separation technique is a
useful alternative for large midline abdominal defects.
Fibrotic stiffness of the external oblique muscle layer

plays a key role in the development of these hernias
and hinders successful closure.
Release of this muscle 1–2 cm lateral to its insertion
into the anterior rectus sheath allows medial
advancement of the remaining trimuscle complex
composed of the rectus abdominis, internal oblique,
and transverse abdominis muscles.
The neurovascular bundle is preserved because it
travels in the layer between the internal oblique and
transverse abdominis muscles.
Typical mobility includes 5 cm of unilateral
advancement in the epigastric region, 10 cm at the
umbilicus, and 3 cm in the suprapubic region.
This technique minimizes the use of foreign material
implants and preserves the innate dynamic nature of
the abdominal wall musculature. Fibrotic lateral
oblique stiffness is also released.
Figure 41–6: Newer modifications to the components
separation technique include preservation of the umbilical
perforators.
This modification allows for better blood supply to the

periumbilical watershed area and can decrease the
risk of infection and wound healing problems.
Figure 41–7: If laparoscopic repair is preferred, the first
trocar may be placed in the midline superior or inferior to
the hernia defect.
A Veress needle technique can often be safely used in
the left upper quadrant, where complicating
adhesions are less common.
Once pneumoperitoneum is established, insertion of
the laparoscope (30 degree) aids in proper placement
of the remaining trocars.
Additional trocars should be placed on either side, as
far lateral as possible.
A 10-mm port assists with mesh placement into the
peritoneum; otherwise, smaller operating ports are
effective.
An additional 5-mm port can be placed on the
patient's opposite side to help with dissection and
mesh fixation.
Figure 41–8: At least 5 cm of overlap should be allowed
between the fascia and mesh to promote good fibrous
tissue ingrowth.
The mesh is secured in place by either tacking or

through-and-through sutures. Most surgeons prefer a
combination of both to optimize early mesh fixation.
Figure 41–1
Figure 41–2
Figure 41–3A-B
Figure 41–4
Figure 41–5
Figure 41–6
Figure 41–7
Figure 41–8
Postoperative Care
Bowel rest until ileus resolves.

Drains to prevent seroma formation if large flaps are
raised.
Binder for comfort (except after the components
separation technique, in which compression may
compromise blood flow to the abdominal wall skin flaps).
Recurrence.
Early (within 1 month): usually related to technical

issues.
Late (after 1 year): most often due to patient factors
leading to wound healing problems. The best clinical
and preclinical evidence now supports the idea that
the majority of incisional hernias are the result of
very early laparotomy defects.
Mesh (wound) infection or mesh extrusion.
Bowel or bladder injury.
Hematoma and seroma.
Pain.
Pearls and Tips
Avoid mesh-on-bowel contact.

Select the appropriate mesh material based on the
surgical circumstances.
Allow at least 5 cm of overlap between the fascia and
mesh to promote good fibrous tissue ingrowth.
Avoid large gaps between sutures to prevent bowel
interposition (Richter's hernia).
Optimize mesh fixation.
Repair all questionable deserosalizations to prevent
missed enterotomy.
References
Burger JW, Luijendijk RW, Hop WC, et al. Long term follow-up
of a randomized controlled trial of suture versus mesh repair
of incisional hernia. Ann Surg. 2004;240:578–585.[PubMed:
15383785] [Full Text]
Grevious MA, Cohen M, Jean-Pierre F, et al. The use of

prosthesis in abdominal wall reconstruction. Clin Plastic Surg.
2006;33:181–197.[PubMed: 16638462] [Full Text]
Korenkov M, Paul A, Sauerland S, et al. Classification and

surgical treatment of incisional hernia: Results of an experts'
meeting. Langenbecks Archiv Surg. 2001;386:65–73.
Nguyen V, Shestak KC. Separation of anatomic components

method of abdominal wall reconstruction: clinical outcome
analysis and an update of surgical modifications using the
technique. Clin Plastic Surg. 2006;33:247–257.[PubMed:
16638467] [Full Text]
Ramirez OM, Ruas E, Dellon L. "Components separation"

method for closure of abdominal-wall defects: an anatomic
and clinical study. Plastic Reconstruct Surg. 1990;86:519–


Current Procedures: Surgery > Chapter 42. Wound Closure

Techniques >
Indications
Surgical wounds.
Traumatic wounds.
Contraindications
Absolute

Active infection.
Foreign body (except surgical implants).
Active bleeding.
Relative
Impaired healing (corticosteroids, malnutrition, radiation, chronic

disease).
Informed Consent
Usually implied with consent for major procedure, must obtain

consent otherwise.
Potential Risks
Scarring (normal and abnormal).

Bleeding (may require reoperation or transfusion).
Infection (may require antibiotics or reoperation).
Failure of operation or need for secondary intention healing.
Need for revision.
Equipment
Instruments
Appropriate instruments vary by wound type but include at a

minimum a needle driver and tissue handling forceps.
Sutures
Consist of both a needle and suture material, each with multiple

subtypes and characteristics.
The needle and suture material may vary widely based on different
types of wounds in different locations.
Needle
Table 42–1: Point characteristics.

Swage: the method of attaching the suture material to the needle.
Channel swage: a channel is crimped over suture material

(swage diameter > body diameter).
Drill swage: suture material is placed in the drill hole at the rear
of needle, which is then crimped (swage diameter < body
diameter).
Nonswaged: eyed needle (similar to sewing needle). Closed-eye
needles require suture material to be passed through the eye
each time it is threaded. French eye needles have a posterior
slit allowing suture to be placed in the eye without direct
threading; this causes more tissue trauma and reduced suture
integrity (eye > body diameter).
Pop-off: swage is designed to allow suture material to be gently
removed from the needle with traction.
Table 42–2: Needle body characteristics.
Designed to transmit the penetrating force to the point.

Varied alloy characteristics can make a needle soft or firm
(ductility).
Diameter: gauge or thickness of needle.
Table 42–1. Needle characteristics—point.
Category Type Description Tissue Use

Triangular point that
changes to a flattened
Conventional body with one cutting Skin and

cutting edge on the concave tendon
surface of the needle
(surface seeking)
Cutting edge on convex Dense tissue,
curvature of the needle including
Reverse
(depth-seeking) skin, oral
cutting
Stronger than mucosa, and
conventional cutting tendon
Flat with 2 cutting edge
Side-cutting to reduce tissue injury Ocular
Cutting
(spatula) and improve depth tissues
control
Stretches tissue without Easily
direct cutting action to penetrated
Taper-point minimize tearing tissues,
(round Sharpness increases including
needle) with taper ratio (slope)abdominal
(8–12:1) and decrease viscera,
with tip angle (20–35 dura, and
degrees) peritoneum
Friable
tissue,
Dissects through tissue
Blunt Blunt including
rather than cutting it
kidney and
liver
Table 42–2. Needle Characteristics—body.
Type Notes
Used in easily accessible tissue
Straight Tissue is manipulated to allow passage of needle
(eg, Keith needle)
Chord length: linear
Most common distance between tip and
swage (bite width)
Needle follows
predicable path Needle length: distance
through tissue with between tip and swage
Curved
even tension along curvature of needle
distribution
Radius: distance form
center of arc of rotation of

needle to needle itself—
determines bite depth
Compound curved: variable radius
Compound Used in ophthalmologic and microsurgical
procedures
Patient Preparation
Nothing by mouth the evening before surgery if the patient will be

undergoing general anesthesia.
Preoperative antibiotics per institutional policy and based on wound
characteristics.
Anesthesia
Under general anesthesia, no additional preparation is necessary.

In a conscious patient, local anesthetic (lidocaine, bupivacaine, etc)
must be used.
Wound Preparation
Wound must be clean.

Clean wounds may need no specific preparation prior to closure.
Highly contaminated wounds should be irrigated (bulb, pulse-
lavage, etc).
Lacerations.
May use a prefabricated syringe-mounted ocular flushing

system.
A saline bottle with 5–10 needle punctures provides a low-cost,
effective irrigator in the acute setting.
Skin edge.
Complex lacerations and damaged skin edges should be

resected to healthy tissue where possible.
"Freshen" skin edges to allow more accurate apposition of
wound margins.
Hair is generally removed to fully expose wounds and reduce
infection.
Patient Positioning
The wound should be fully exposed and at comfortable working

distance from the surgeon.
A light source is often necessary in the emergency department
setting.
Procedure
Suture Closure Techniques
Figure 42–1: Running continuous stitch.
Widely used technique to close many wounds varying from

lacerations to midline laparotomy wounds.
Depth of bite and layers of tissue incorporated are dependent
on site and tissue characteristics.
Advantages of running technique.
Allows expeditious wound closure.

Closure is completed with one continuous length of suture
material.
Achieves approximation of wound margins.
Disadvantages of running technique.
Less reliable than interrupted closure.

Wound edge eversion is difficult and there is greater potential
for misalignment of wound edges, particularly if the tissue is
pliable and the wound is long.
Figure 42–2: Simple interrupted suture.
Most common and basic suturing technique.
Depth of bite and layers of tissue incorporated are dependent
on site and tissue characteristics.
Advantages of interrupted technique.
Closure is completed suture by suture.

The depth of bite, layers of tissue incorporated, and tension on
the closure can be carefully adjusted for each individual stitch.
Achieves accurate approximation of wound margins with
optimal control.
More reliable closure than continuous stitch.
Disadvantages of interrupted technique.
Time consuming.
Multiple knots may contribute to foreign body response and
additional scarring.
Additional suture material may contribute to infections in the
wound (suture abscess).
Mattress suture: interrupted suturing technique in which the needle
is passed through tissue multiple times.
Figure 42–3: Horizontal mattress technique.
The initial simple suture is placed perpendicular to the wound.

Instead of tying the suture, the needle is advanced parallel to
the wound margin and passed back through the tissue at an
equal bite depth to a point on the initial wound edge equidistant
to the length of advance on the opposite wound edge.
The suture is tied and now lies parallel to the wound edge.
Figure 42–4: Vertical mattress technique.
The initial simple suture is placed perpendicular to the wound

using a large bite depth.
Instead of tying the suture, the needle is returned to the side of
the initial bite at a smaller bite depth and without any
advancement down the length of the wound.
The suture is tied and now lies perpendicular to the wound
edge.
Figure 42–5: Half-buried horizontal mattress technique.
Similar to the horizontal mattress technique, but the suture

does not pass out of the tissue on the edge opposite the initial
bite.
The suture remains buried.
Advantages of mattress suture techniques.
Tissue eversion is easily controlled.

Wound tension is distributed in friable tissue to prevent the
suture from tearing through the tissue.
Strong closure.
Disadvantages of mattress suture techniques.
Can create ischemic tissue either directly under the suture

(vertical mattress) or constrict tissue within the confines of
each suture leading to tissue ischemia (horizontal mattress).
Figure 42–6: Purse-string suture.
Used to close wounds by circumferential constriction of the

wound edge.
Commonly used in closing the end of a hollow viscus such as
bowel or appendiceal stumps, around a catheter, or in
reconstructive and cosmetic surgery.
Uses a running suture technique.
The suture is passed in and out of tissue around the
circumference of the wound without entering the lumen of the
viscera.
As the suture reaches the origin, it can be tightened to reduce
the circumference of the initial wound in a manner similar to
the leather strings on a pliable "purse."
If the technique is executed properly, the viscera can be
reduced into the wound as the suture is tightened, creating a
seal.
Advantages of purse-string technique.
Provides equal wound tension distribution around the

circumference of the wound.
Rapid closure.
Disadvantages of purse-string technique.
Creates pleating, which may lead to a poor seal, unfavorable

scarring, or both.
When used on skin, may lead to scar-widening as tissue
stretches.
Figure 42–7: Subcuticular suture.
Used to close superficial skin edges to achieve accurate wound

margin approximation.
Sutures are not placed through the epidermis, thus avoiding
potential scarring related to suture placement.
The suture is introduced through normal skin and brought out
of the deep tissue into the epidermal-dermal junction.
The suture is then passed back into tissue and out of tissue at
this same level, alternating edges of the wound (the suture
should not penetrate epidermis).
The suture exits deep tissue through the epidermis just distal to
the wound.
The tails are trimmed so they may be accessed to pull the
suture out after several days (some prefer to tie or bury the
suture).
Advantages of subcuticular technique.
Excellent control of wound margins increases the likelihood of a

cosmetically pleasing outcome.
May help avoid transverse "railroad track" scarring since
sutures do not pass through the epidermis.
Suture can be pulled out of the wound to reduce inflammatory
response or suture erosion through the skin (spitting).
Disadvantages of subcuticular technique.
Closure is more time consuming than either staples or tissue

glue.
Figure 42–1
Figure 42–2
Figure 42–3
Figure 42–4
Figure 42–5
Figure 42–6
Figure 42–7
Nonsuture Closure Techniques
Figure 42–8: Stapled closure.
Used to close superficial skin edges.

Skin edges are held up and everted using tissue forceps.
A staple is deployed at this site.
The process is repeated down the length of the wound.
Advantages of stapled closure.
Rapid skin edge closure.

Individual staples can be removed in the event of wound
infection.
Disadvantages of stapled closure.
May contribute to transverse hatching of the scar in a "railroad

track" pattern.
Staple removal can be uncomfortable.
Tissue glue.
Used to close superficial skin edges to achieve close edge

approximation.
Skin edges are approximated manually or with pull-out sutures.
The wound is cleaned of necrotic debris, foreign material, and
dried blood.
A bed of glue is applied down the length of the wound, typically
in one pass.
Advantages of tissue glue.
Rapid skin edge closure.

Minimal tissue handling.
Disadvantages of tissue glue.
Glue cannot be removed easily if need be (eg, opening an

infected wound).
Expensive.
Figure 42–8
Postoperative Care
Wound edges should remain clean.

Sutures should be removed several days (typical in face) or weeks
following repair, depending on the location of the wound and
characteristics of the tissue.
Pain control with analgesics is appropriate.
Antibiotics are not necessary for most wounds but may be
recommended in contaminated wounds following closure.
Wound infection.
Infected wounds, particularly those involving deep spaces, are

typically opened to prevent systemic spread.
Unfavorable scarring.
Some scarring is expected, but hypertrophic scars, keloids, or

wound contraction leading to functional limitation may occur,
often without a known cause.
Some wounds with unfavorable scarring may require scar
revision.
Figure 42–9: Standing cutaneous deformities ("dog ears") may be
a result of individual wound length differences leading to excess
tissue on one side of the wound, or occur in cases in which tissue
rearrangement is necessary to achieve closure.
These cutaneous deformities may persist and can often be

addressed at primary closure.
To remove a standing cutaneous deformity, the tissue leading to
the deformity can be lifted away from the plane of tissue and
resected in an elliptical fashion.
If executed properly, the dimensions of the newly created
ellipse will allow primary closure without a standing cutaneous
deformity.
Figure 42–9
Pearls and Tips
Remember that not all wounds require or are well-managed by

primary closure.
To prevent injury to yourself and others, never handle needles
directly.
Returning suture by grasping the suture material instead of the
needle will reduce the risk of the needle ejecting out of the needle
holder.
Use instruments appropriate for both the needle and the tissue you
are suturing.
References
Aston SJ, Beasley RW, Thorne CH, et al. Grabb and Smith's Plastic
Surgery, 5th ed. Philadelphia, PA: Lippincott-Raven Publishers; 1997.
Baker SR, Swanson NA. Local Flaps in Facial Reconstruction. St Louis,
MO: Mosby-Year Book; 1995.
Evans GRD. Operative Plastic Surgery. Stamford, CT: Appleton & Lange;
2000.
Johnson & Johnson. Ethicon Wound Closure Manual, 2001. Available at:
http://www.orthonurse.org/portals/0/wound%20closure%20manual.pdf.
Accessed August 12, 2008.
McGregor IA. Fundamental Techniques of Plastic Surgery and Their

Surgical Applications, 10th ed. Edinburgh, New York: Churchill
Livingstone; 2000.
Sanders RJ. Subcuticular skin closure—description of technique.

Dermatol Surg. 1975;1:61–64.[PubMed: 770536] [Full Text]


Current Procedures: Surgery > Chapter 43. Central

Venous Access >
Indications
Intravenous hemodynamic monitoring.

Central venous sampling.
Parenteral nutrition.
Hemodialysis.
Transvenous pacing.
Placement of pulmonary artery catheters.
Contraindications
Significant coagulopathy, especially with platelet counts <

50,000/ L.
Informed Consent
Potential Risks
Infection.
Pneumothorax.
Dysrhythmia.
Arterial puncture.
Guidewire loss.
Pseudoaneurysm.
Thrombosis.
Retroperitoneal dissection.
Arteriovenous fistula.
Equipment
Chlorhexidine skin preparation solution.

Sterile gown, gloves, and drapes.
Hat and mask.
1% lidocaine.
Sterile gauze pads.
22-gauge finder needle.
18-gauge introducer needle.
J-tip guidewire.
Transduction tubing.
Tissue dilator.
Sterile saline for flushing the line.
Catheter.
2-0 silk sutures.
Sterile dressing.
Patient Preparation
Short-acting antianxiety or pain medications as needed in

consultation with the patient's nurse.
Patient Positioning
The patient should be supine, in Trendelenburg (head-

down) position for subclavian and internal jugular lines,
and in reverse Trendelenburg (head-up) position for
femoral lines.
For infraclavicular subclavian vein access in larger
patients, and those in whom the clavicle is difficult to
palpate, a rolled towel can be placed between the
shoulder blades to facilitate access.
For femoral lines the patient should be placed supine with
the leg slightly abducted and externally rotated.
The patient should be placed on continuous monitoring.
The area chosen should be widely exposed and all
necessary hair trimmed.
The area is prepared with a chlorhexidine-based skin
solution and sterile drapes are applied.
Procedure
Femoral Vein Access
Figure 43–1: Landmarks used for placement are the

anterior iliac spine and the symphysis pubis.
The vein is found halfway between these landmarks

just below the inguinal ligament, lateral to the artery
and medial to the nerve.
One hand is placed over the femoral pulse, and the
syringe is held in the other with the needle at a 30–40-
degree angle to the skin and the bevel up.
The needle typically encounters the vein within 2–4 cm
but may be hubbed before encountering the vein in an
obese patient.
If there is no return of blood, the needle should be
withdrawn slowly as the vein may be entered on
withdrawal.
The needle should be moved medially to laterally in a
systematic manner until the vein is encountered.
Figure 43–1
Subclavian Vein Access
Figure 43–2A, B: The axillary vein continues as the

subclavian vein at the lateral border of the first rib.
It arches superiorly behind the medial clavicle and

then joins the internal jugular vein to become the
brachiocephalic vein posterior to the sternoclavicular
joint.
The subclavian artery runs with the vein, separated
by the anterior scalene muscle, in a superior and
posterior position (Figure 43–2A).
The apex of the lung can rise above the level of the
first rib on the left but is usually situated more
inferiorly on the right. It lies deep and inferior to the
subclavian vein.
The subclavian vein can be accessed along the length of
the clavicle, but the midpoint approach is the most
common (Figure 43–2B).
The needle is inserted at the midpoint, approximately

1 cm lateral to the bend and 2–3 cm inferior to the
clavicle.
The needle is held at an angle that would allow it to
skim just beneath the clavicle and is aimed toward
the suprasternal notch.
If the clavicle is encountered, the needle should be
marched down until it skims just beneath.
Alternatively, a more lateral approach can be used.
The clavicle is thinner lateral to the midclavicular line,

so the needle is held parallel to the floor, still aiming
toward the suprasternal notch (Figure 43–2B, inset).
The subclavian vein can also be approached more
medially at the convergence of the great veins.
To access this site, the needle must be held at a

much more perpendicular angle, still aiming toward
the suprasternal notch.
The medial clavicle is much thicker, and this approach
also must pass through the costoclavicular ligament.
The subclavian vein can also be accessed from above the
clavicle, although this is much less commonly done.
This approach enters the vein near its junction with

the internal jugular vein.
The most important surface landmark for this
approach is the posterior (clavicular) head of the
sternocleidomastoid (SCM) muscle.
The patient's head is turned to the contralateral side
in order to delineate the muscle.
The needle is inserted approximately 1 cm superior
to the clavicle and 1 cm posterior to the clavicular
head of the SCM muscle.
The needle is oriented at an angle to slip just behind
the medial clavicle and toward the contralateral
nipple.
The vein is encountered within 1–2 cm.
Figure 43–2A-B
Internal Jugular Vein Access
Figures 43–3 and 43–4: The internal jugular vein runs

within the carotid sheath along with the internal and
common carotid arteries.
The vein becomes anterolateral to the artery as they

pass beneath the SCM.
The vein runs just beneath the SCM before it
emerges between the sternal and clavicular heads; at
this point it lies 1–1.5 cm beneath the skin.
Internal jugular localization is initially done with a finder
needle to minimize damage to the carotid artery in case
of an inadvertent puncture.
The finder needle is left in place and the introducer needle
is inserted alongside it, following the same trajectory.
There are three main approaches to catheterization of the
internal jugular vein: central, posterior, and anterior.
The central approach is most commonly used, and utilizes
the triangle made by the two bellies of the SCM and the
clavicle as the external landmark.
The needle is inserted at the apex of the triangle,

approximately 5 cm superior to the clavicle, just
lateral to the carotid pulsation at an angle of 30–45
degrees.
The needle is directed toward the ipsilateral nipple
and should enter the vein within 2.5 cm.
To access the internal jugular vein from the posterior
approach, the patient's head is turned to the contralateral
side to accentuate the landmarks of the SCM.
The needle is inserted between the middle and lower

thirds of the SCM, along the posterior border.
This point can also be identified by the external
jugular vein, which often crosses at this point.
The needle is directed toward the sternal notch and
held at an angle to slide just beneath the SCM.
The internal jugular vein can also be accessed anterior to
the sternal head of the SCM.
The carotid pulsations are palpated with one hand,

and the needle is inserted at the midpoint of the
anterior border of the SCM, about 5 cm above the
clavicle.
The needle should follow a trajectory aimed at the
ipsilateral nipple.
Figure 43–3
Figure 43–4
Seldinger Technique
Figure 43–5A—E: The vein is first accessed using a

small needle, typically 21 or 22 gauge.
Once the vein is located, an 18-gauge introducer needle is
used for guidewire placement.
The skin is punctured with the needle held at 45 degrees,
and the bevel of the needle is oriented to allow guidewire
placement into the vena cava.
For subclavian lines the bevel is caudally oriented.

For internal jugular approaches the bevel is medially
oriented.
The needle is inserted slowly in the same trajectory as it
entered the skin, while aspirating continuously.
Once beneath the skin, the needle should only move
forward and backward, never side to side as this can
lacerate the vein.
Dark, nonpulsatile blood return indicates intraluminal
venous position, but a blood gas sample or an arterial line
transducer can be used to confirm the position as well.
When intraluminal position is confirmed, the syringe is
removed and a guidewire is inserted through the needle.
Once the wire is advanced, the needle is removed.
A scalpel is used to make a small incision over the wire to
allow passage of the dilator.
The dilator is inserted over the wire to the depth of the
vessel with a steady twisting motion, and then removed
leaving the wire in place.
The catheter is advanced over the wire to the desired
depth.
The wire is removed through the distal port.
Blood is then back through all ports to confirm all are in
working order and the catheter is then sutured into place.
A sterile dressing is applied.
Figure 43–5A-E
Postoperative Care
Placement of internal jugular and subclavian central

venous catheters is confirmed with a chest radiograph; no
radiographs are required for femoral line placement.
In general, it is recommended that the catheter tip lie
within the superior vena cava, outside of the right atrium
and above the pericardial reflection. On chest
radiographs, therefore, the tip should lie above the level
of the carina.
A sterile dressing is applied to the central line, which is
changed weekly.
Current guidelines indicate that catheters should only be
replaced if there is evidence of sepsis or localized
infection, and that routine replacement is not indicated.
Topical antibiotic ointment at the insertion site does not
reduce infection rates and should not be used.
Central venous catheters should be removed as soon as
possible.
Each year 250,000 central venous catheter-related

infections occur in the United States, with an associated
mortality of 12–25% and a cost of $25,000 per infection.
Femoral venous catheters have higher rates of infection
and iliofemoral thrombosis in comparison with subclavian
and internal jugular sites.
When the femoral technique is used in patients during
cardiac arrest, misplacement in the retroperitoneum,
femoral artery, or elsewhere occurs in up to 30% of
cases.
Pneumothorax may occur with both internal jugular and
subclavian vein access approaches.
Review of the literature reveals no difference in the rates
of major complications, including pneumothorax, between
subclavian and internal jugular vein catheters.
If a patient might require dialysis in the future, an
internal jugular approach is preferred to a subclavian
approach to prevent the possible complication of
subclavian vein stenosis, which would limit arteriovenous
dialysis access options.
Malposition of the catheter.
Dysrhythmia, often caused by advancing the wire into the
right atrium.
Arterial puncture.
Guidewire loss.
Venous thrombosis and stenosis.
Retroperitoneal dissection.
Arteriovenous fistula, a late complication.
Pearls and Tips
If an internal jugular or subclavian approach has been

chosen, prepare the area widely enough so that the other
ipsilateral site may be used without changing drapes if
placement at the first site is unsuccessful.
If unsuccessful in placing either an internal jugular or
subclavian line on one side, obtain a chest radiograph to
rule out the presence of a pneumothorax before
attempting line placement on the contralateral side.
To ascertain intravenous position, a pressure transducer
or manometer tubing can be used. The needle can be
connected directly to a pressure line and transduced as
would be done with an arterial line. The pressure and
waveform can then be visualized on the monitor.
Alternatively, a saline-filled length of single-lumen tubing
can be connected to the needle. The tubing is then raised
to a vertical position; variation with respirations will be
seen with venous blood, and pulsations will be seen with
arterial placement.
For subclavian lines, orienting the J-tip of the guidewire
caudally facilitates placement into the superior vena cava.
Manually occluding the ipsilateral jugular vein will also
decrease the chance of malposition of the guidewire into
the internal jugular vein.
Having the patient turn his or her head to the
contralateral side against resistance can help identify the
triangle formed by the sternal and clavicular heads of the
SCM.
For most patients, the right internal jugular vein is chosen
as an access site over the left. This is due to its larger
caliber, the lower apex of the right lung, and the technical
ease for the right-handed surgeon. The left internal
jugular vein is significantly smaller than the right in about
one third of patients.
Placing downward traction on the arm during subclavian
line placement increases the amount of overlap between
the artery and vein and improves cannulation success; 5
cm below neutral has been shown to be the optimal
position.
The clavicular periosteum should be included in the local
anesthetic field when placing a subclavian line.
References
Ambesh SP, Dubey PK, Matreja P, et al. Manual occlusion of

the internal jugular vein during subclavian vein
catheterization: a maneuver to prevent misplacement of
catheter into internal jugular vein. Anesthesiology.
2002;97:528–529.[PubMed: 12151957] [Full Text]
Emerman CL, Bellon EM, Lukens TW, et al. A prospective

study of femoral versus subclavian vein catheterization during
cardiac arrest. Ann Emerg Med. 1990;19:26–30.[PubMed:
Fortune JB, Feustel P. Effect of patient position on size and

location of the subclavian vein for percutaneous puncture.
Arch Surg. 2003;138:996–1000.[PubMed: 12963658] [Full
Text]
McGee DC, Gould MK. Preventing complications of central

venous catheterization. N Engl J Med. 2003;348:1123–1133.
Mumtaz H, Williams V, Hauer-Jensen M, et al. Central venous

catheter placement in patients with disorders of hemostasis.
Am J Surg. 2000;180:503–505.[PubMed: 11182407] [Full
Text]
Polderman KH, Girbes AJ. Central venous catheter use. Part

1: mechanical complications. Intensive Care Med. 2002;28:1–
Ruesch S, Walder B, Tramer MR. Complications of central

venous catheters: internal jugular versus subclavian access—
a systematic review. Crit Care Med. 2002;30:454–460.
Sanchez R, Halck S, Walther-Larsen S, et al. Misplacement of

subclavian venous catheters: importance of head position and
choice of puncture site. Br J Anaesth. 1990;64:632–633.
Schuster M, Nave H, Piepenbrock S, et al. The carina as a

landmark in central venous catheter placement. Br J Anaesth.
2000;85:192–194.[PubMed: 10992822] [Full Text]
Stone MB, Price DD, Anderson BS. Ultrasonographic

investigation of the effect of reverse Trendelenburg on the
cross-sectional area of the femoral vein. J Emerg Med.
2006;30:211–213.[PubMed: 16567260] [Full Text]
Tanner J, Khan D. Surgical site infection, preoperative body

washing and hair removal. J Perioper Pract.
2008;18:232,237–243.
Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the
guidewire, in Seldinger technique, is a significant factor in
misplacement of subclavian vein catheter: a randomized,
controlled study. Anesth Analg. 2005;100:21–24.[PubMed:
15616046] [Full Text]


Current Procedures: Surgery > Chapter 44. Tube

Thoracostomy >
Indications
Pneumothorax.
Hemothorax.
Chylothorax.
Empyema.
Pleural effusion (persistent).
Thoracic trauma or surgery.
Contraindications
Absolute
None.
Relative
Coagulopathy.
Overlying skin infection.
Overlying chest wall malignancy.
Intrapleural adhesions.
Loculated pleural collection.
Informed Consent
Potential Risks
Bleeding.
Infection.
Skin and subcutaneous infection.

Empyema.
Risk of anesthetic if used.
Death.
Possible injury and need for repair of surrounding
structures.
Intercostal neurovascular injury.

Great vessel injury.
Pulmonary parenchymal injury.
Diaphragmatic injury.
Cardiac injury.
Splenic injury on left side.
Hepatic injury on right side.
Persistent air leak.
Need for emergent thoracotomy or future additional
procedures.
Equipment
Sterile gown and gloves, cap, mask, eye protection.

Povidone-iodine or chlorhexidine preparation, sterile
towels.
Local anesthesia.
Chest tube (varied sizes, depending on indication and size
of patient).
Chest tube management system.
Scalpel, Kelly clamp, needle driver, scissors,
nonabsorbable suture, Xeroform or petroleum gauze,
sterile gauze, foam tape.
Patient Preparation
The patient does not need to have an empty stomach

although this is preferable if conscious sedation is used in
the nonemergent setting.
Preoperative antibiotics are not required.
Patient Positioning
The patient should be supine with the ipsilateral arm

positioned over the head to facilitate adequate exposure
of the anterolateral thoracic wall.
Procedure
Local anesthesia with or without conscious sedation may

be used.
When local anesthesia is used, infiltration of the skin,

subcutaneous tissue, muscle, and parietal pleura
provides the best anesthesia.
Figure 44–1: A transverse skin incision parallel to the
intercostal space is planned, usually at approximately the
fourth or fifth intercostal space at the midaxillary or
anterior axillary line.
The goal of this placement is to avoid the diaphragm,
intra-abdominal organs, and breast tissue (in
women), and to allow for placement anterior enough
that the patient does not lie on the tube after
placement.
Figure 44–2A—C: The skin incision is made using a
scalpel at one intercostal level below the planned entry
site of the chest tube into the pleural space.
The subcutaneous tissue and intercostal muscles are

dissected bluntly in a transverse direction using a
hemostat or Kelly clamp until the parietal pleura is
reached.
Figure 44–3: During dissection of the subcutaneous
tissue and muscles, the Kelly clamp should be directed
cranially toward the rib above and the tips should be
pointed toward the superior aspect of this rib to avoid the
course of the intercostal neurovascular bundle inferior to
each rib.
Figure 44–4: Using a Kelly clamp, the pleural space is
entered parallel to the ribs in a controlled fashion with the
tips of the instrument closed.
Once the pleural space is penetrated, the clamp

should be opened to allow egress of air or fluid.
A finger should be placed in the pleural space and
swept to check for adhesions prior to tube placement.
Figure 44–5: Once the pleural space is entered and freed
of any adhesions, the chest tube is clamped at its
fenestrated end with a Kelly clamp and, using finger
guidance, the tube is advanced into the pleural space in
the posterosuperior direction of the apex to the desired
tip location.
The tube is advanced to various lengths depending
on the patient; however, all fenestrations should be
intrapleural to create a closed system.
Figure 44–6: Once the chest tube is in place, it is
connected and secured to a chest tube management
system and placed on suction, typically at 20 cm H20
negative pressure.
The chest tube is secured in place by a

nonabsorbable U-stitch through the skin with ends
wrapped and tied around the tube.
Xeroform or petroleum gauze is placed around the
tube opening and gauze and foam tape are applied.
Figure 44–1
Figure 44–2A–C
Figure 44–3
Figure 44–4
Figure 44–5
Figure 44–6
Postoperative Care
A chest radiograph should be obtained at the conclusion

of the procedure to assess placement.
The patient's hemodynamic status should be monitored
for signs of cardiopulmonary distress.
The chest tube output should be recorded; if there is
considerable blood loss a thoracotomy should be
considered.
Each time the patient is evaluated, assessment of the
nature of the output and presence of an air leak should be
noted.
Typically, when the patient has clinically improved, the
output is decreased (values vary based on surgeon
preference), and an air leak has resolved the chest tube is
transitioned from suction to water seal in anticipation of
removal.
To remove a chest tube, great care must be taken to
prevent introduction of air into the pleural space.
An assistant should hold pressure with petroleum

gauze and dry gauze over the tract as the tube is
rapidly removed at the end of an inspiration.
The previously placed U-stitch may be tied to close
the skin opening (see Figure 44–6); however, this is
optional.
A chest radiograph should be obtained to assess for
interval development of a pneumothorax.
Bleeding: intercostal neurovascular or great vessel injury.
May present with hemorrhage.

Treatment includes resuscitation, hemostatic control
through possible thoracotomy, and consultation with
a cardiovascular surgeon.
Solid organ injury: pulmonary parenchymal injury,
diaphragmatic injury, cardiac injury, splenic injury on the
left side, or hepatic injury on the right side.
May present with bleeding or dysfunction of the

involved organ.
Treatment is directed at the affected organ system.
Persistent air leak.
May manifest if a bronchopleural fistula is present or
pulmonary parenchymal injury has occurred.
Treatment would require surgical management by a
thoracic surgeon.
Pearls and Tips
Infiltration of the parietal pleura prior to the procedure

provides the best anesthesia.
Although the fourth or fifth intercostal space is typically
used for tube thoracostomy, any variety of intercostal
locations can be used if pathologic findings preclude
standard placement.
To avoid loss of the pleural opening, spread the Kelly
clamp widely after entering the pleural space and do not
remove the clamp before a finger is placed into the
pleural space.
Sweep a finger in the pleural space before placing the
chest tube to avoid parenchymal injury.
Use nonabsorbable suture to secure the chest tube; the
area is often moist from chest tube output and bleeding
and an absorbable suture might dissolve.
References
Rozycki GS, McNeil J, Thal ER. Diagnostic Procedures Used to

Establish Priorities. In: Thal ER, Weigelt JA, Carrico J, eds.
Operative Trauma Management: An Atlas. New York, NY:
McGraw-Hill; 2002:20–34.



Tracheostomy and Emergency Cricothyroidotomy >
Indications
Tracheostomy
Supralaryngeal obstruction.
Secure airway access.
Prolonged intubation and mechanical ventilation.
Inability to control secretions.
Emergency Cricothyroidotomy
Inability to obtain an oral or nasopharyngeal airway in a

patient who requires emergent intubation.
Severe facial or head and neck trauma.
Acute loss of the airway due to supralaryngeal obstruction
secondary to tumor, anaphylaxis, foreign body, trauma, or
burn injury.
Contraindications
Tracheostomy
Significant coagulopathy can be considered a relative
contraindication because bleeding into the airway can be
catastrophic.
Emergency Cricothyroidotomy
There are few contraindications to cricothyroidotomy in

the emergent setting with a patient in extremis.
Informed Consent
The emergent circumstances under which

cricothyroidotomy are considered typically preclude
informed consent.
Expected Benefits (Tracheostomy)
Provision of a secure airway and prevention of

complications of prolonged oral or nasal intubation.
Potential Risks (Both Procedures)

Bleeding.
Tracheal stenosis (1.6–6%).
Vocal cord injury.
Subglottic stenosis.
Tracheoesophageal fistula formation.
Rates of complications and vocal cord injury are higher for
emergent cricothyroidotomy as compared with elective
tracheostomy.
Equipment
No special equipment is required, although a

bronchoscope can be useful in some instances.
Small self-retaining retractors are useful for exposing the
operative field.
Patient Preparation and Positioning
If possible, patient preparation should include the use of a

folded sheet, sandbag, or other supporting device placed
transversely under the shoulders; this helps in extending
the neck and exposing the operative area.
Endotracheal intubation is also extremely useful to
maintain the airway during the procedure.
In emergent situations when the patient is in respiratory
distress, there may not be any time for such preparations.
Procedure
Anatomic Landmarks
Figure 45–1: The anatomy of the neck with pertinent

landmarks.
The location of the thyroid cartilage in relation to the

cricoid cartilage and the trachea is shown.
Incision for the tracheostomy is made either
transversely or vertically, approximately 2
fingerbreadths above the sternal notch.
An emergency cricothyroidotomy is performed
between the thyroid cartilage and the cricoid
cartilage.
A vertical incision is preferred for emergency
cricothyroidotomy to minimize bleeding secondary to
venous laceration. Additionally, if the initial incision is
off target, it is easier to extend a vertical incision
rather than make another transverse incision.
Open Tracheostomy
Figure 45–2: After incision (shown here as a transverse

incision), dissection is carried down through the
subcutaneous tissues.
Often there is an anterior jugular vein crossing the

field which may be tied off and divided.
A small self-retaining retractor is useful to hold the
incision open.
Once the strap muscles are identified, they are divided
vertically in the midline to expose the trachea.
Often, the thyroid isthmus can be seen in the superior
portion of the dissection; it may need to be divided for
exposure.
It is preferable to ligate the lateral aspects of the

thyroid isthmus prior to division in the midline.
Bleeding from thyroid tissue can be troublesome to
control once initiated.
Figure 45–3A-C: Once the trachea is exposed, two
polypropylene sutures are placed around the third or
fourth tracheal ring.
These are placed well laterally so as not to be divided

when the trachea is opened, and care should be
taken not to suture the balloon of the endotracheal
tube if it is present.
The balloon on the endotracheal tube can be deflated
temporarily during suture placement to avoid
inadvertent puncture.
If the patient is intubated and oxygenation permits,
the inspired Fio2 should be decreased to 50% to
minimize the possibility of endotracheal fire should
cautery be required to control bleeding after tracheal
opening.
The trachea is then typically entered with a vertical
incision through the third and fourth rings.
Care must be taken not to cut the posterior wall of
the trachea so as to avoid injury to the underlying
esophagus.
Several different methods exist for creation of lateral
tracheal flaps to facilitate insertion of the
endotracheal tube: T-shaped incision (Figure 45–3A),
H-shaped incision (Figure 45–3B), and trapdoor-type
incision (Figure 45–3C).
Figure 45–4A, B: Once the tracheal flaps have been
created, a tracheal spreader is used to dilate the opening
in preparation for tube placement.
The polypropylene sutures can be used to help

retract the tracheal flaps laterally to facilitate
placement of the tracheostomy tube into the trachea,
but care must be taken not to pull the sutures
through the delicate tracheal tissues (Figure 45–4A).
Once in place, the balloon is inflated and the
tracheostomy tube is connected to the ventilator.
At this point, confirmation of proper placement of the
tube into the trachea is of paramount importance.
The detection of end-tidal CO2 confirms appropriate
tube placement in the trachea.
Once the ability to ventilate the patient is confirmed,
the incision is closed loosely with nylon sutures and
the cuff of the tracheostomy tube is sutured in place
with four nylon sutures (Figure 45–4B).
The tracheostomy tube should also be secured with
straps around the neck.
The polypropylene sutures in the tracheal flaps are
left in place for several days in case replacement of
the tracheostomy tube is needed.
Figure 45–1
Figure 45–2
Figure 45–3A-C
Figure 45–4A-B
Emergent Cricothyroidotomy
Figure 45–5: Emergency cricothyroidotomy is performed

using a vertical skin or stab incision to reduce bleeding.
The scalpel is stabbed through the skin and cricoid

membrane between the thyroid cartilage and cricoid
cartilage.
Figure 45–6: Once the airway is entered, a hemostat or
the knife handle (if no hemostat is available) is passed
into the airway and spread or twisted to dilate the
opening in the cricothyroid membrane.
If a hemostat is used, it can be left in place to hold

open the incision while an endotracheal tube is
passed into the airway.
Figure 45–7A, B: It can be useful to use a finger to
guide the endotracheal tube as blood may obscure the
field.
Once the emergency airway is secured, the patient is

typically taken to the operating room where
conversion to a formal tracheostomy can be
performed, although this can be delayed for several
days if the patient is unstable.
Figure 45–5
Figure 45–6
Figure 45–7A-B
Postoperative Care
A replacement tracheostomy tube should be available at

the patient's bedside at all times, and close monitoring is
necessary in the first several days after tracheostomy.
The inhaled air should be humidified since the upper
airway is bypassed.
Frequent endotracheal suctioning is often required to
clear secretions.
In the comatose patient, continuous pulse oximetry and
frequent arterial blood gas monitoring may be needed.
Delayed bleeding in the wound can often be difficult to
visualize because the tracheostomy tube hinders
exposure.
In such situations, packing of the wound with a long
piece of hemostatic material (eg, Surgicel) may
control the bleeding.
Packing with small pieces should be avoided to
prevent aspiration into the airway.
The initial tracheostomy tube is usually left in place for a
minimum of 5–7 days, after which it may be removed and
replaced.
The polypropylene sutures in the tracheal flaps can be cut
and removed at the time of the first tracheostomy tube
change if the change goes smoothly.
Tracheal stenosis.
Subglottic stenosis.
Tracheoesophageal fistula.
Bleeding.
Pearls and Tips
Staying in the midline will facilitate a more bloodless

dissection.
A bronchoscope can be used to visualize the airway from
inside the trachea if needed.
References
Hemmila M, Wahl W. Management of the Injured Patient. In:

Doherty GM, ed. Current Diagnosis and Treatment: Surgery,
13th ed. New York, NY: McGraw-Hill; 2010:176–209.


Management of Pyloric Stenosis: Pyloromyotomy >
Indications
Projectile nonbilious emesis in an infant.

Palpable "olive" on physical examination.
"String sign" on an upper gastrointestinal series.
Pyloric muscle wall thickness 4 mm and pyloric
channel length 16 mm on ultrasound examination.
Contraindications
Severe hypochloremic, hypokalemic metabolic

alkalosis.
Severe dehydration.
Informed Consent
The procedure is successful in nearly 100% of cases.
Expected Benefits
Elimination of the mechanical gastric outlet obstruction

caused by a hypertrophic pylorus.
Potential Risks
Incomplete myotomy (usually gastric).

Mucosal perforation (usually duodenal).
Wound infection.
Postoperative bleeding.
Fascial dehiscence.
Equipment
Open pyloromyotomy: pyloric spreader (Benson).

Laparoscopic pyloromyotomy.
Veress needle and sheath.

5-mm umbilical port.
3-mm instruments, including laparoscopic pyloric
spreader.
Patient Preparation
Pyloric stenosis is not a surgical emergency; the goal of

preoperative evaluation is to confirm the diagnosis and
to correct metabolic derangements caused by
persistent vomiting.
Diagnosis is based on a thorough history and physical
examination and is usually confirmed by radiographic
findings.
A history of projectile nonbilious vomiting between

ages 4 and 6 weeks and a palpable "olive" is
sufficient for diagnosis.
If the diagnosis is unclear, ultrasound examination
of the pylorus is the radiologic procedure of choice.
Criteria for ultrasound diagnosis are pyloric muscle wall
thickness 4 mm and pyloric channel length 16 mm.
Once the diagnosis is suspected, the patient should not
ingest anything orally.
Preoperative nasogastric decompression is not required
and may exacerbate the metabolic alkalosis.
The most common metabolic abnormality is
hypochloremic, hypokalemic metabolic alkalosis (HCO3
30 mEq/L) and overall volume deficit.
The patient should be rehydrated with 20 mL/kg
boluses of normal saline until urinating and then given
D51/2 normal saline (10–20 mEq KCl/L if indicated) at a
maintenance rate of 1.5. Lactated Ringer solution is
contraindicated because it may exacerbate the
metabolic alkalosis.
Patient Positioning
Figure 46–1A: For both open and laparoscopic

procedures, the infant should be supine on the
operating table.
Laparoscopic procedure.
The infant is positioned supine at the end of the

operating table with appropriate padding.
The lower extremities are secured to the operating
table in a frog leg position.
Figure 46–1A-C
Procedure
Before induction of anesthesia, nasogastric

decompression should be performed.
Figure 46–1B: A longitudinal incision is made in the
umbilicus and a Veress needle and trocar sheath are
inserted.
A CO2 pneumoperitoneum is established to a level

of 10–12 mm Hg, and a 5-mm port is inserted.
Under direct vision, a No. 11 blade is used to make
two 3-mm stab incisions in the upper abdominal
wall.
Figure 46–1C: An open pyloromyotomy is performed
using a right upper quadrant or umbilical skin incision.
Right upper quadrant incision: a transverse
incision is made directly over the right rectus
muscle midway between the xiphoid and
umbilicus. The rectus muscle may be divided
transversely or the rectus fascia divided
longitudinally to facilitate splitting of the rectus
muscle.
Umbilical incision: a supraumbilical curvilinear skin
incision is made. The subcutaneous tissue is
dissected until the midline fascia is exposed. The
fascia is incised longitudinally and extended as far
cephalad as required to locate the pylorus.
Figure 46–2: Cross-sectional view through a
hypertrophic pylorus. The hypertrophic pylorus is
readily apparent laparoscopically.
In the open procedure, mobilization of the pylorus out
of the wound requires grasping the greater curvature of
the stomach with a gauze sponge and gently "rocking"
the pylorus outside the abdominal wall.
Figure 46–3A, B: Pyloromyotomy.
Laparoscopic procedure: 3-mm instruments are

used to grasp the duodenum and elevate the
pylorus into view. Using a guarded Bovie tip, the
serosa is cauterized in a linear fashion in an
avascular area 2 mm proximal to the
pyloroduodenal junction (noted by color and
texture change and the Mayo vein) and extending
to the antrum (Figure 46–3A). The cold "guarded"
Bovie tip is used to extend the incision through the
muscular layer. In the midportion of the incision,
the Bovie tip is twisted to separate the pyloric
musculature.
Open procedure: cautery is not typically used.
Using a scalpel, an incision is made in an avascular
region of the pylorus, 2 mm proximal to the
pyloroduodenal junction and extending to the
antrum (Figure 46–3B). The back of the scalpel
handle is placed in the midportion of the incision
and then twisted to separate the pyloric
musculature.
Figure 46–4A, B: Splitting the pyloric musculature.
Laparoscopic procedure: a laparoscopic spreader is

used to slowly spread the hypertrophied muscle
fibers until the submucosa bulges out (Figure 46–
4A).
Open procedure: a Benson spreader is placed in
the incision and used to slowly spread the
hypertrophied muscle until the submucosa bulges
out (Figure 46–4B).
Figure 46–5A, B: Laparoscopic or open
pyloromyotomy is complete when the two halves of the
pyloric muscle appear askew, move independently, and
normal antral muscle fibers are visualized proximally.
Bleeding is venous and self-limited and should never be
cauterized due to potential mucosal injury.
At the conclusion of the procedure, the proximal
duodenum is gently compressed and 60 mL of air is
injected through a nasogastric tube to rule out mucosal
perforation.
Figure 46–2
Figure 46–3A-B
Figure 46–4A-B
Figure 46–5A-B
Postoperative Care
Maintenance intravenous fluids are given until the
infant is able to tolerate oral feedings.
Nothing by mouth for 6 hours followed by feeding
every 3 hours:
For the first feeding, give 30 mL of full-strength

formula; for the second feeding, give 60 mL of
formula, and then increase amount as tolerated.
If the infant vomits, hold feeding and repeat the last
tolerated volume in 3 hours.
Mucosal perforation.
Incomplete myotomy.
Wound infection.
Pearls and Tips
Preoperatively, ensure correction of electrolyte

abnormalities, adequate hydration, and HCO3 30
mEq/L.
Preoperative nasogastric decompression is
contraindicated because gastric secretions are tolerated
and metabolic alkalosis may be exacerbated with
persistent loss of gastric acid.
Intraoperatively, test for intestinal perforation by
administering 60 mL of air via the nasogastric tube and
looking for bubbles or bile staining.
References
Barksdale EM. Pyloric Stenosis. In: Ziegler MM, Azizkhan

RG, Weber TR, eds. Operative Pediatric Surgery. New York,
NY: McGraw-Hill; 2003:583–588.
Dillon PW, Cilley RE. Lesions of the Stomach. In: Ashcraft

KW, Murphy JP, Sharp RJ, et al, eds. Pediatric Surgery.
Philadelphia, PA: WB Saunders; 2000:391–406.
Lobe TE. Pyloromyotomy. In: Spitz L, Coran AG, eds. Rob &
Smith's Operative Surgery: Pediatric Surgery. London,
England: Chapman & Hall; 1995:320–328.
Miniati DN, Albanese CT. Pyloric Stenosis. Operative

Techniques in General Surgery. 2004;6:296–306.


Current Procedures: Surgery > Chapter 47. Pediatric

Vascular Access >
Indications
Need for acute resuscitation.
Trauma.
Critical care monitoring.
Need for long-term central venous access.
Total parenteral nutrition.

Chemotherapy.
Hemodialysis.
Long-term antibiotic therapy.
Limited peripheral access in ill child.
Contraindications
Absolute
None.
Relative
Coagulopathy.
Severe thrombocytopenia.
Informed Consent
Expected Benefits
Stable vascular access in infants and children to aid a

variety of therapeutic interventions.
Potential Risks
Bleeding.
Pneumothorax.
Hemothorax.
Catheter infection.
Line sepsis.
Catheter malfunction or thrombosis.
Venous thrombosis.
Equipment
Cutdown central venous lines in premature infants and

neonates require very fine vascular pickups and small
right-angle clamps. It is best to assemble a sterile
neonatal cutdown tray to have available at all times.
A portable ultrasound machine is helpful for internal
jugular venous punctures.
All lines inserted in the operating room should be placed
using live fluoroscopy on an appropriate radiolucent table.
A wide range of catheter types and sizes should be
available at all times.
For both acute and long-term hemodialysis catheters,
it is best to develop a weight-based catheter size
chart in conjunction with pediatric nephrologists to
ensure that the catheter placed has the capacity to
provide adequate flow for dialysis or hemofiltration.
Patient Preparation
Preoperative blood work should include hematocrit,

platelet count, and coagulation studies.
If the child has had previous central lines, a duplex
Doppler vascular ultrasound of the neck and upper
extremity vessels should be performed to identify
potential preoperative thromboses.
If multiple thromboses are seen, a magnetic

resonance venogram is useful for preoperative
planning.
Patient Positioning
The patient is most often positioned supine with a

shoulder roll in place.
If a saphenous vein cutdown or femoral vein
catheterization is planned, the leg should be straight and
abducted away from the midline.
Procedure
Figure 47–1: Saphenous vein cutdown.
This procedure is used most often for premature

infants and neonates and can be performed at the
bedside.
The location of the femoral artery is identified by
palpation.
After infiltration of the area with local anesthesia, a
short transverse incision is made 1 cm below the
groin crease and medial to the femoral artery.
The saphenous vein is identified, ligated distally, and
encircled proximally.
A 5-mm stab wound is made on the medial thigh just
above the knee.
A Broviac catheter is tunneled from the distal incision
to the venous cutdown site until the Dacron cuff is
midway between the two incisions.
The catheter is measured to lie in the
subdiaphragmatic superior vena cava (SVC) and is
cut on a very acute angle to the appropriate length.
Using a No. 11 blade, an anterior venotomy is
performed and the catheter placed bevel down into
the vein.
Once in place, the catheter is secured in the vein with
the previously placed suture.
The catheter is then checked to ensure that blood can
be withdrawn and the catheter flushes easily.
The catheter is secured at the skin exit site with a
nylon suture and the wound closed with either a
running nylon or absorbable suture.
Figure 47–2A, B: Subclavian vein puncture.
This procedure is safe and effective in both infants

and children.
The patient should be in Trendelenburg position with
a small horizontal shoulder roll.
The needle is attached to an empty 5-mL syringe and
inserted just lateral to the midportion of the clavicle,
at a depth of approximately 5 mm below the clavicle.
The needle is advanced medially toward the
suprasternal notch while aspirating continuously.
Placing a finger in the suprasternal notch may help
guide the angle of advancement (Figure 47–2A).
In smaller children and infants, the needle should be
angled more superiorly to a spot 1 cm above the
suprasternal notch (Figure 47–2B).
Free return of venous blood during aspiration signals
successful venipuncture.
The needle is then carefully stabilized as the syringe
is removed and a flexible J-tipped guidewire passed
through the needle and into the vein.
Fluoroscopy is essential at this point to confirm
proper position of the wire in the right atrium.
This wire will then be used to place either a
temporary central venous catheter or the introducer
and sheath required for a tunneled catheter.
Figure 47–3: Internal jugular vein puncture.
This procedure is also safe and effective in both

infants and children and can be facilitated by the use
of intraoperative portable ultrasound.
The right internal jugular vein provides direct access
to the right atrium and is the preferred route for
placing dialysis catheters.
The patient should be in Trendelenburg position with
a shoulder roll in place and the head turned to the
left.
The needle is attached to an empty 5-mL syringe and
inserted between the two heads of the
sternocleidomastoid muscle at the level of the cricoid
cartilage.
This puncture site is just above the apex of the
triangle formed by the two muscle heads and lateral
to the carotid artery.
The needle is directed inferiorly and laterally toward
the ipsilateral nipple at an angle of 15–30 degrees to
the skin.
Free return of venous blood during aspiration signals
successful venipuncture.
If the artery is accidentally punctured, the needle is
removed and direct pressure applied for 5 minutes.
The needle is then carefully stabilized as the syringe
is removed and a flexible J-tipped guidewire passed
through the needle and into the vein.
Fluoroscopy is essential at this point to confirm
proper position of the wire in the right atrium.
This wire is then used to place either a temporary
central venous catheter or the introducer and sheath
required for a tunneled catheter.
Figure 47–4A-C: Radial artery cutdown.
This technique is most commonly used in neonates

when the percutaneous route is unsuccessful.
The hand is taped to an armboard and a small gauze
roll is placed under the supinated, extended wrist
(Figure 47–4A).
A 1-cm transverse incision is made over the area of
the radial artery just proximal to the wrist.
The artery is often deeper than expected and usually
located directly over the head of the radius.
A suture is placed distally around the artery for
traction.
Cannulation is via standard puncture of the vessel by
an over-the-needle catheter device.
Choice of catheter size depends on the child: 24-
gauge is best for neonates, 22-gauge for large
infants and toddlers, and 20-gauge for older children.
The catheter is introduced directly into the artery at a
30-degree angle and the needle is removed (Figure
47–4B).
The catheter is advanced only if brisk blood return is
noted. Otherwise, the catheter is withdrawn until
blood returns, then carefully advanced into the
artery.
The catheter hub is sutured in place with nylon
sutures and the skin incision is closed around the
catheter.
Arterial catheters require continuous perfusion with
0.5–1.0 mL/h of heparinized saline solution to
maintain patency.
Figure 47–4C outlines the anatomy of the upper
extremity arterial system.
Figure 47–5: Placement of tunneled catheters.
Initial central venous access is obtained via the

subclavian or internal jugular route as outlined
earlier.
A small 5-mm incision is made transversely along the
wire at the wire insertion site using a No. 11 blade.
A second incision is made on the anterior chest wall,
taking into consideration the presence of future
breast tissue in girls.
This incision can be made superior to the breast
region or in the midline over the sternum.
A tendon passer is then tunneled from the wire
insertion site, passing lateral to the venous access
site before turning and traveling to the skin exit site.
The tunnel is anesthetized with 0.25% bupivacaine;
the proximal end of the catheter is then grasped by
the tendon passer and pulled through the tunnel.
The Dacron cuff should be placed in the tunnel 2 cm
proximal to the exit site.
The catheter is measured to the appropriate length
using fluoroscopic guidance and cut on a slight angle.
The dilator and associated peel-away sheath are
placed over the wire and advanced under fluoroscopic
guidance only as far as the SVC.
The wire and dilator are then removed together, the
tunneled catheter is inserted into the sheath, and the
sheath is peeled away.
Catheter position is confirmed by fluoroscopy, and
catheter function is assured by easy bidirectional flow
of blood and saline.
The venous access site is closed with a single 5-0
absorbable subcuticular suture and the catheter
secured in place at the skin exit site with a nylon
suture.
The catheter is then flushed with heparinized saline
(10 units/mL concentration) unless it is a
hemodialysis catheter.
Figure 47–1
Figure 47–2A-B
Figure 47–3
Figure 47–4A-C
Figure 47–5
Postoperative Care
All lines except radial arterial lines require a post-

procedure radiograph to confirm catheter position and
look for complications.
These films may pick up a subtle pneumothorax not

seen by fluoroscopy during catheter placement.
Meticulous aseptic technique must be used for routine
catheter care and every time the catheter is accessed for
infusion or blood draw.
Acute
Pneumothorax.
Hemothorax.
Catheter malposition.
Pericardial tamponade.
Chronic
Catheter infection.
Bacteremia and line sepsis.
Catheter thrombosis.
Vessel thrombosis.
Septic emboli.
SVC syndrome.
Pearls and Tips
For standard central venous access indications, premature

infants usually require a 2.7 French catheter, while full-
term infants will tolerate a 4.2 French line. Larger
catheters (ie, 7 French) required in urgent settings should
be placed in the right internal jugular vein.
Percutaneous access in infants and smaller children is
best obtained using a 21-gauge needle. Older children
may be accessed using the standard 18-gauge needle.
After securing any Broviac catheter in place and closing
the venous access site, always flush the catheter again
and ensure easy blood withdrawal as sometimes the
securing sutures are placed too tightly and partially
occlude the catheter.
It is best to use a concentration of 10 units of heparin per
milliliter of saline as the standard solution for line flushes
in children in the pediatric operating room.
Small accidental flushes of a more concentrated

solution can fully heparinize an infant and increase
bleeding complications.
Higher concentrations of heparinized saline (100–
1000 units/mL) required for hemodialysis catheters
should be specifically requested during those cases.
References
Coran AG, Hirschl RB. Cardiovascular Considerations. In:

O'Neill JA, Grosfeld JL, Fonkalsrud EW, et al, eds. Principles of
Pediatric Surgery, 2nd ed. St Louis, MO: Mosby; 2004:437–
442.
Janik JE, Conlon SJ, Janik JS. Percutaneous central access in

patients younger than 5 years: size does matter. J Pediatr
Johnson EM, Saltzman DA, Suh G, et al. Complications and

risks of central venous catheter placement in children.
Surgery. 1998;124:911–916.[PubMed: 9823406] [Full Text]


Current Procedures: Surgery > Chapter 48. Pediatric

Inguinal Hernia >
Indications
Presence of a hernia (elective).

Incarceration or strangulation (emergent).
Contraindications
Absolute
Coagulopathy.
Thrombocytopenia.
Relative
Extreme prematurity.
Immunosuppression.
Informed Consent
Expected Benefits
The most important goal is to eliminate the risk of
incarceration and strangulation.
Repair can also provide relief from discomfort
associated with the hernia.
Potential Risks
Risks include:
Bleeding.
Wound infection.
Injury to the vas deferens.
Injury to the testicular vessels.
Injury to the ilioinguinal nerve.
Parents should also be informed that the procedure is
performed under general anesthesia.
Equipment
A basic pediatric soft tissue tray should provide the

various small retractors (Davis, U.S. Army retractors)
needed for the surgery.
Peritoneoscopy equipment.
2.7-mm, 70-degree angled laparoscope.

Small, blunt-tipped metal 3-mm trocar.
Laparoscopy equipment (light cord, camera cord,
and a single video monitor).
Patient Preparation
No special preparation is required other than a

thorough preoperative examination with attention to
both inguinal regions.
The side of the symptomatic hernia should be marked
by the surgeon on the patient on the day of surgery
with the parent or guardian present.
Patient Positioning

Following induction of general anesthesia, the patient
may be turned on his or her side for placement of a
caudal block if appropriate.
Procedure
The following steps describe the procedure for a male

patient. The procedure is performed under general
anesthesia with or without the addition of a caudal
block.
The entire lower abdomen, perineum, and upper thighs
are scrubbed, prepared with povidone-iodine, and
draped in the standard sterile fashion.
Figure 48–1: A 1–2-cm transverse skin incision is
made along the lowest inguinal skin crease
approximately 1 cm superior and lateral to the pubic
tubercle.
The subcutaneous fat is separated to expose

Scarpa's fascia, which is incised with either
Metzenbaum scissors or electrocautery.
Figure 48–2: The opening in Scarpa's fascia is then
explored using a hemostat to expose the external
oblique aponeurosis below. This allows for placement of
small Davis retractors into the wound.
A key maneuver at this point is to dissect laterally

to fully expose the groove between the abdominal
wall and the lateral border of the external oblique
fascia.
This groove is then followed inferiorly to the
external ring, where the spermatic cord and
associated hernia sac exit the inguinal canal.
A hemostat is placed in the external ring and a
small nick is made in the ring using a knife.
The hemostat is briefly removed to allow the
ilioinguinal nerve to fall away and is then replaced
in the external ring.
The external oblique fascia is incised from along its
fibers for a distance of 1–2 cm.
The edges of the opened external oblique fascia
are grasped with atraumatic forceps and the
undersurface of each leaf is gently brushed clear of
the underlying cord structures to protect the nerve
and facilitate later closure.
The ilioinguinal nerve should then be visualized
and gently dissected free.
Figure 48–3: Using atraumatic tissue forceps, the
cremasteric fibers are grasped and separated to
identify the underlying hernia sac.
The sac lies anteromedial to the cord structures

and has a glistening, whitish appearance.
The sac is grasped with one forceps while the
other is used to sweep the muscular fibers down
toward the floor of the inguinal canal.
The sac is then retracted medially with two
atraumatic forceps by the assistant, while the
surgeon dissects the spermatic vessels and vas
deferens off the sac.
Of note, the spermatic vessels are the first
structures encountered on the lateral edge of the
sac. If the vas is seen first, the orientation of the
sac must be evaluated.
The vas and vessels must never be directly
grasped or held with forceps as this can cause
significant damage.
Figure 48–4: After the cord structures have been
separated from the sac, the sac is inspected to ensure
that no abdominal viscera are trapped within.
Unless the sac is blind-ending, it is divided

between hemostats.
The proximal end of the sac is lifted vertically and
the cord structures are dissected free down to the
level of the internal ring, where properitoneal fat is
identified.
To facilitate this dissection, the assistant should
place gentle downward traction on the spermatic
cord structures.
At this point, peritoneoscopy may be performed if the
clinical situation warrants and the sac appears sturdy.
To perform peritoneoscopy, the sac is opened and

secured with hemostats.
A 3-mm blunt metal trocar is inserted directly into
the sac and secured with a heavy silk tie.
The abdomen is insufflated with CO2 (8–12 mm
Hg), and a 2.7-mm, 70-degree scope is inserted
with the lens facing the opposite inguinal region.
The vas deferens and spermatic vessels on the
opposite side are identified and the region is
inspected for a patent processus vaginalis on the
contralateral side.
The scope and trocar are removed, and
desufflation is ensured by placing a tissue forceps
into the sac and observing for release of air and
abdominal decompression.
Figure 48–5: High ligation of the proximal sac is then
performed by twisting the sac and placing two 3-0 or
4-0 Vicryl suture ligatures at the base.
Care must be taken to avoid incorporating the cord

structures in these sutures as twisting the sac may
alter the anatomy at the internal ring.
Following ligation, the excess sac is removed with
scissors.
The distal end of the sac heading toward the
scrotum may be opened widely along its anterior
surface.
If a noncommunicating hydrocele also exists, it
should be opened widely and a portion of this sac
excised.
If the testicle is visualized, any associated
appendix testes should be excised or cauterized.
The testicle must be placed back in the scrotum
prior to closure.
Figure 48–6: Once hemostasis is ensured, the
external oblique fascia is closed using interrupted Vicryl
sutures, taking care to identify and protect the
ilioinguinal nerve.
If a preoperative caudal block was not used, an

ilioinguinal nerve block can be placed under direct
visualization at this juncture.
Scarpa's fascia is then reapproximated using
buried, interrupted Vicryl sutures.
The skin is closed with a running 5-0 Monocryl
suture. The wound may be dressed using an
adhesive (Collodion, Dermabond, Indermil) in
children who are still in diapers, or Steri-Strips
with Benzoin in older children.
Figure 48–1
Figure 48–2
Figure 48–3
Figure 48–4
Figure 48–5
Figure 48–6
Postoperative Care
Analgesia using acetaminophen, ibuprofen, and

narcotics as needed.
Heavy lifting and high-contact sports in older children
and adolescents should be limited for 4–6 weeks
postoperatively.
Acute
Bleeding.
Wound infection.
Injury to spermatic vessels.
Injury to vas deferens.
Postoperative hydrocele.
Damage or entrapment of ilioinguinal nerve.
Chronic
Testicular atrophy.
Recurrence.
Iatrogenic undescended testicle.
Pearls and Tips
To avoid getting lost in a pediatric hernia and thereby

risking injury to the bladder or the floor of the inguinal
canal, always clearly identify and dissect out the groove
along the lateral edge of the external oblique fascia
early in the operation.
In the newborn, the internal ring lies almost directly
below the external ring so it may not be necessary to
incise the external oblique aponeurosis to obtain
adequate exposure and perform a high ligation of the
sac.
The initial surgical approach to the inguinal canal in
girls is the same as in boys. However, in girls the round
ligament may be divided.
The hernia sac should be opened and inspected in

all cases, as many inguinal hernias in girls contain
a sliding component.
The ovary, fallopian tube, and mesosalpinx can be
present either in the hernia sac or within the wall
of the sac. Care must be taken to avoid injury to
these structures.
If the fallopian tube lies within the wall of the sac,
a purse-string closure of the sac may be
performed followed by inversion of the sac and
separate closure of the internal ring.
References
Ein SH, Njere I, Ein A. Six thousand three hundred sixty-

one pediatric inguinal hernias: a 35-year review. J Pediatr
Fonkalsrud EW, Stolar CJ. Disorders of the Inguinal Canal.

In: O'Neill JA, Grosfeld JL, Fonkalsrud EW, et al, eds.
Principles of Pediatric Surgery, 2nd ed. St Louis, MO:
Mosby; 2004:437–442.
Manoharan S, Samarakkody U, Kulkarni M, et al. Evidence-

based change of practice in the management of unilateral
inguinal hernia. J Pediatr Surg. 2006;40:1163–1166.

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Brett A. Almond, MD, PhD

Ramon Berguer, MD, PhD

Michael Bernstein, MD, PhD

Dan G. Blazer, III, MD

Kimberly McCrudden Erickson, MD

Emily V.A. Finlayson, MD

Awori J. Hayanga, MD, MPH

Sean C. Kumer, MD, PhD

Constance M. Mobley, MD, PhD

Arden M. Morris, MD, MPH

Michael W. Mulholland, MD, PhD

Erika Adams Newman, MD

Barry L. Rosenberg, MD, MBA

Gilbert R. Upchurch, Jr, MD

Jennifer Waljee, MD, MPH, MSc

Stewart C. Wang, MD, PhD

Theodore H. Welling, III, MD

Copyright © The McGraw-Hill Companies. All rights reserved.

Current Surgical Procedures is a new book intended to

Copyright © The McGraw-Hill Companies. All rights reserved.

Note: Large images and tables on this page may

Current Procedures: Surgery > Chapter 1.

Unilateral toxic nodule.

Locally advanced head and neck carcinoma demonstrated

Absolute (Neck Dissection)

Randomly scattered dermal metastases precluding a full-

Relative (Neck Dissection)

Tumor fixation to the internal carotid artery.

Curative resection for actual or potential malignancy.

Bleeding that may cause airway compression and require

Modified Radical Neck Dissection

Clearance of primary tumor and locally advanced

Damage to vital adjacent structures, including spinal

No special equipment is required.

Nothing by mouth the evening before surgery.

The patient should be supine.

Figure 1–1: A curvilinear incision is made in the neck a

Additionally, a suitable skin crease in the lower neck

A plane is established between the sternohyoid and

The cricothyroid space is entered along the medial

If a neck dissection is needed, the incision is extended

The goal is to provide exposure of the anterolateral

The specimen is dissected from lateral to medial with

A drain is placed through a separate stab incision in

For benign thyroid disease, thyroid hormone replacement

Nerve injury: spinal accessory nerve; recurrent laryngeal

Pearls and Tips

Perform neck dissection with careful attention to the

Doherty GM. Complications of Thyroid and Parathyroid

Gauger PG. Thyroid Gland. In: Mulholland MW, Lillemoe KD,

Copyright © The McGraw-Hill Companies. All rights reserved.

Note: Large images and tables on this page may

Current Procedures: Surgery > Chapter 2.

Fractures (especially vertebral compression fractures).

Markedly elevated serum calcium (> 1.0 mg/dL above

Pregnancy (first trimester).

Treatment of symptomatic hypercalcemia.

Bleeding requiring reoperation.