STEP 3Gastroplasty

A gastroplasty is performed at the site of continuity with the gastric body. This should encircle almost the total circumference of the basis of the tube without compromising its blood supply at the superior aspect of the tube. Circumferential fixation of the rim of the gastroplication is done by anchor sutures to the wall of the tube. Transabdominal pull-through of the tube is done at the left upper abdomen. Opening of the tube and positioning of the mucosal orifice flush with the skin are...

Entering the lesser sac

Lesser Sac

A bilateral subcostal incision is suitable for most patients a midline incision from xiphoid to umbilicus is better for patients with vertically oriented costal arches. Dividing the gastrocolic ligament between hepatic and splenic flexures exposes the lesser sac. The right gastroepiploic artery and vein are ligated and divided to expose the anterior surface of the head and neck of the pancreas. Cephalad retraction of the stomach and caudad retraction of the transverse colon expose the body and...

Preparation of the jejunal loop using the retrocolic route

Retrocolic Gastrojejunostomy

The gastroepiploic vessels are dissected, clamped, divided and ligated starting about 5 cm proximal to the pylorus and moving 6-7cm proximally along the greater curvature of the stomach, so this is completely dissected free from the omentum. The jejunal loop can be brought either anterior to the transverse colon antecolic , or through a window in the transverse mesocolon retrocolic . Although a retrocolic gastrojejunostomy has been considered more prone to obstruction because of its closer...

Prophylactic Drainage

Biliodigestive Anastomose Pancreas

The drain orifice through the skin is created by a penetrating cut with a scalpel A-1 . A Kelly clamp is inserted into the orifice A-2 and penetrates the abdominal wall diagonally A-3 . The hand serves as protection to prevent bowel injury. This technique creates a tunnel that helps to seal the abdominal cavity after drain removal. After clamping the drain tip, the Kelly clamp and drain are pulled through the abdominal wall from inside outwards A-4 . Others prefer to create the tunnel from...

Extended Kocher maneuver

The next maneuver involves an extended Kocher maneuver by mobilizing the entire right colon and the proximal as well as the distal duodenum this allows palpation of the head of the pancreas and, equally important, the wall of the duodenum. Intraoperative ultrasonography is performed in a systematic fashion with a near-field, high-resolution transducer. Small neoplasms within the pancreas are identified by their sonolucent nature compared to the more echo-dense pancreas. Although intraoperative...

STEP 6Removal of gallbladder

Laparoscopic Cholecystectomy

Once cholangiography is completed, the ureteric catheter is removed and the cystic duct is clamped. The gallbladder is then removed from the liver bed using hook diathermy. This is done through a combination of elevating the peritoneum, burning with the hook and pushing so that the gallbladder is removed toward the fundus and finally separated from the liver at the fundus. There is very little place for fundus-first laparoscopic cholecystectomy.

STEP 10Standard procedure isoperistaltic reconstruction

Arcade Riolan

In case of an insufficient vascular supply through the middle colonic artery, the vascular supply can be warranted through the left colonic artery, if a sufficient Riolan's arcade exists. This approach ensures an isoperistaltic reconstruction standard procedure . Care has to be taken not to injure the left colic vessels. Therefore preparation has to be done carefully and closely to the wall of the colon, and transection of the descending colon is always done without extensive dissection of the...

STEP 7Drainage and duodenal fixation

An 18-Fr. closed suction drain is placed alongside the pancreas graft. The cecum is usually pexed or reperitonealized with either running or interrupted polypropylene sutures to avoid later cecal volvulus. Such lateral refixation is not necessary for portomesenteric venous drainage. If a simultaneous kidney transplant is to be done, the same intra-abdominal access can be used to expose the iliac vessels transperitoneally or a separate contralateral retroperitoneal approach is an alternative.

Step 1

Duodenotomy

The biliary tree is intubated to accurately locate the papilla. Access to the biliary tree is gained through a small opening in the cystic duct remnant or, if necessary, the common bile duct the latter access can be avoided if you can confidently locate the ampulla by transduodenal palpation. A 3-Fr. tapered, urethral filiform probe or a small biliary Fogarty catheter is passed through the common bile duct and into the duodenum to locate the papilla. Suspicion of a common bile duct stone may...

STEP 3Caval anastomosis

Satinsky Side Biting Clamp

A segment of 8mm externally reinforced polytetrafluoroethylene PTFE graft is used for the portacaval shunt. The graft is 3cm long from toe to toe and 1.5cm from heel to heel. The bevels of the graft are oriented at 90degrees to each other because the portal vein is not parallel to but rather oriented approximately 60 degrees to the inferior vena cava. The graft is placed in heparinized saline and negative pressure is applied in order to remove any air bubbles. A side-biting Satinsky clamp is...

STEP 1Access exposure exploration and dissection of the hepatoduodenal ligament

Duodeno Hepatic Ligament

After a bisubcostal incision, the round and falciform ligaments are divided. Care must be taken to avoid injury of large collaterals or a repermeabilized umbilical vein, which may be present in the umbilical ligament due to portal hypertension. A retractor e.g., Thompson is installed followed by a careful mobilization of the left and right hemiliver. The left and right triangular and coronary ligaments are divided as for a left and right hemihepatectomy and the hepatogastric ligament is...

Of the pancreas

Pancreas Hepatic Artery Dissection

The middle colic vein is followed downward to localize the superior mesenteric vein. The superior mesenteric vein should be freed below the edge of the pancreas and followed beneath the neck of the pancreas this maneuver ensures easy division of the neck of the gland later. The peritoneum along the inferior border of the pancreas is incised the body tail of the pancreas is elevated by gentle sharp dissection behind the gland.

Intraoperative Chemical Splanchnicectomy

Splanchnicectomy

Intraoperative chemical splanchnicectomy can be useful, especially in patients who are found at the time of exploration for resection to have unresectable pancreatic cancer. Rather than having these patients undergo percutaneous or endoscopic chemical splanchnicectomy postoperatively, an intraoperative approach is easy, effective, and warranted. The celiac plexus contains visceral afferent pain nerves from the stomach, pancreas, hepatobiliary tree, kidneys, and mid gut. There are one to five...

STEP 1Exposure and entry into the lesser sac pancreatic and peripancreatic necrosectomy

Necrosectomy Pancreatitis

In any surgical approach to necrotizing pancreatitis, the goal is to remove the necrotic tissue and to minimize accumulation of exudative fluid and extravasated pancreatic exocrine secretions. Reoperation in this setting can be difficult and can lead to increased morbidity. The principle of necrosectomy and closed packing is to perform a single operation, with thorough debridement and removal of necrotic and infected tissue, while minimizing the need for reoperation or subsequent pancreatic...

Radiofrequency Ablation of Liver Tumors

Ious Liver

Indications Unresectable malignant tumors of the liver e.g., hepatocellular carcinoma, colorectal metastases, neuroendocrine tumors, selected other types of metastases Tumors lt 5 cm in size most effective for lesions lt 3 cm Palliative treatment of symptomatic tumors e. g., neuroendocrine metastases Bridge to liver transplantation hepatocellular carcinoma - In combination with resection - When resection is planned, but unresectability is found at time of laparotomy - In difficult locations or...

STEP 9Sidetoside portacaval anastomosis

Portacaval Anastomosis

A Satinsky clamp is placed obliquely across a 5-cm segment of the anteromedial wall of the IVC in a direction parallel to the course of the overlying portal vein and the IVC is elevated toward the portal vein A-1 . A 5-cm segment of the portal vein is isolated between two angled vascular clamps and the portal vein is depressed toward the IVC, bringing the two vessels into apposition. A 2.0- to 2.5-cm-long strip of the IVC and a 2.0- to 2.5-cm-long strip of the portal vein are excised with...

Dissection of the porta hepatis

Replaced Common Hepatic Artery

Expose the common hepatic artery CHA by removing the lymph node that lies directly anterior to the CHA proximal to the right gastric artery and the GDA the portal vein PV lies posterior to the inferior border of the CHA just proximal to the GDA origin. Ligate and divide the right gastric artery and the GDA. If the tumor extends to within a few millimeters of the GDA origin, do not attempt bluntly to dissect the origin of the GDA instead, obtain proximal control of the CHA and distal control of...

STEP 15Gastric or duodenal reconstruction

Witzel Jejunostomy

The gastrojejunostomy is placed antecolic and is hand-sewn in two layers A . When the pylorus is preserved, the duodenojejunostomy is created in an end-to-side fashion with a single layer, hand-sewn technique using monofilament absorbable sutures B . The distance between the biliary and gastric duodenal anastomoses is 50 cm to prevent reflux of gastric content. A 10-Fr. feeding jejunostomy tube for postoperative enteral feeding is placed distal to the gastrojejunostomy using the Witzel...

Extended Right Hemihepatectomy Right Trisectionectomy

Right Hemihepatectomy

The extended right hemihepatectomy also called right trisectionectomy includes resection of segments 4-8. For cholangiocarcinoma of the liver hilum Klatskin's tumor or carcinoma of the gallbladder, an en-bloc resection including segments 1 and 9 is usually performed. This procedure should only be performed if the remnant liver segments 2 and 3 provides sufficient liver function. Therefore, preoperative assessment of liver function, a volumetric assessment of the expected remnant liver volume,...

For Benign Non Parasitic Liver Cysts

Hepatic Dome Cyst

Nagorney Hepatic cysts are classified according to the presence or absence of a parasitic etiology. They seldom lead to hepatic dysfunction and are mostly asymptomatic. The treatment is always individualized according to the origin and presence of symptoms. The choice between unroofing versus resection is dictated by site, number of cysts, malignant potential cystadenoma cystadenocarcinoma , and parasitic infection see next chapter . Malignant potential is rare and...

Dissecting Sealer Tissue Link

Tissuelink

The TissueLink dissecting sealer uses proprietary technology to coagulate and seal tissue to provide hemostasis before and after transection. It delivers radiofrequency RF energy through a conductive fluid saline to coagulate and seal tissue A-1, A-2 . The saline couples the RF energy into tissue and cools the tissue so that the temperature never exceeds 100 C. The result is hemostasis via collagen shrinking without the tissue desiccation, smoking, arcing, and char of conventional...

Operation for Paraesophageal Hernia

Hiatal Hernia Left Upper Quadrant

Jean-Marie Michel, Lukas Kr henb hl Postempski first reported the repair of a wound of the diaphragm in 1889. Ackerlund described different types of paraesophageal hernia in 1926, and the first hiatal hernia repair fundoplication was reported by Nissen in 1955. Since then, Nissen fundoplica-tion has gained wide acceptance and is now recognized as the operation of choice for antireflux surgery and, although technically challenging, laparoscopic paraesophageal hernia repair. The goal of a...

Three Field Lymphadenectomy for Esophageal Cancer

Two Field Lymphadenectomy

Masamichi Baba, Shoji Natsugoe, Takashi Aikou Lymphatic drainage from the upper two-thirds of the thoracic esophagus occurs mainly towards the neck and upper mediastinum, although there is also some drainage to the nodes along the left gastric artery. In 1981, the first reported study of three-field lymphadenectomy in Japan noted that 10 of 36 patients with esophagectomy had skip metastases to the neck or abdominal lymph nodes in the absence of associated intrathoracic spread. In this chapter,...

Extended Left Hemihepatectomy Left Trisectionectomy

Staple Ligation Right Hepatic Vein

The extended left hemihepatectomy includes resection of segments 2,3,4,5 and 8. This procedure should only be performed if the remnant liver segments 1 9 6 7 provides sufficient liver function. Preoperative assessment of liver function, volumetric evaluation of the expected remnant liver volume and exclusion of liver fibrosis or even cirrhosis are essential. Depending on the vascular anatomy, two different approaches can be used for the anatomic resection of segments 5 and 8 in addition to the...

STEP 1Exposure of central part of pancreas

Optimal access is via a midline incision The pancreas is exposed by detaching the greater omentum from the transverse colon and freeing the superior aspect of the middle colic vessels until the anterior aspect of the pancreas is exposed completely stomach is retracted rostrally. The superior mesenteric vein is identified, and its anterior surface cleared below the neck of the pancreas care must be taken not to injure venous tributaries occasionally a middle colic branch of the superior...

Total Vascular Exclusion

Total Hepatic Vascular Exclusion

Before total vascular exclusion can be performed, the liver needs to be completely mobilized as for a liver transplantation see chapter Orthotopic Liver Transplantation . The hepatoduodenal ligament is dissected and the tourniquet is placed around it without closing, as described for inflow occlusion. The infrahepatic vena cava is prepared on its right and left side for 2-3cm. The right adrenal vein needs to be identified and transected through ligatures A . A finger is passed under the cava...

Transsection of the liver parenchyma

Liver Hanging Maneuver

The technique of bipolar forceps and Kelly clamp is shown B . A band can be placed between the cava and the liver, which allows lifting and better exposure see also the chapterHanging Maneuver for Right Hepatectomy . As an alternative, the left hand of the surgeon can be placed between the liver and the cava. Each identified bile duct or vessel gt 3mm is ligated on the left side and divided. In the hilum, the right bile duct is divided away from the main confluence above the caudate process.

Laparoscopic Nissen Fundoplication

Gastrosplenic Nissen

It can be argued that total 360 fundoplication is generally not performed in patients with severe esophageal dysmotility. STEP 1 Operating room and patient setup The patient is placed supine with the legs abducted on straight leg boards no flexion of the hips or knees . An orogastric tube is placed. The operating room personnel and equipment are arranged with the surgeon between the patient's legs, the assistant surgeon on the patient's right, and the camera...

Portal vein hepatic artery and bile duct anastomoses

Extended Right Hemihepatectomy

Implantation of the Right Graft After Splitting for Two Adult Grafts or After Right Living Donor Procurement Implantation of the left graft when the liver is split for two adult recipients is described in the chapter on left living donor transplantation. In the situation of living donor procurement or split liver procedure for two adult recipients, the cava remains in the donor or with the left graft, respectively. Therefore, the venous outflow is reconstructed by anastomosing the donor's...

STEP 7Liver resection

Pringle Maneuver

After transection of the right hepatic duct, tissue from both the left and right ductal margins is sent for frozen section analysis. The entire gallbladder bed including segments 4b and 5 is then resected along the dotted lines shown. The portal veins and hepatic arteries are protected under direct vision. Liver parenchymal transaction is as described in Sect. 3, chapters Liver Resections and Left Hemihepatectomy, usually with inflow occlusion by the Pringle maneuver, and with central venous...

Choledochojejunostomy and Cholecystojejunostomy

Mobilization Ligament Treitz

Stockmann, Johannes J. Jeekel For any patient with a life expectancy of greater than 6months, surgical biliary bypass can provide durable palliation for jaundice. The preferred surgical method for palliative treatment of biliary obstruction is a side-to-side anastomosis, because it allows the possibility of making a large anastomosis, and of draining the intrahepatic bile duct as well as the part of the bile duct distal to the anastomosis. If local anatomy does not allow a...

Resection of the Mid Common Bile Duct

Common Hepatic Duct Transection

Chandrajit P.Raut, Jean-Nicolas Vauthey True mid bile duct tumors are very rare. Most patients with mid bile duct obstruction should be considered to have gallbladder cancer until proven otherwise. Mid bile duct resections are usually performed for the rare mid duct cholangiocarcinomas or for patients with early gallbladder cancer and tumor at the cystic duct margin. Diagnosis of biliary strictures without confirmed malignancy Diagnosis of suspected benign disease Confirmed malignant disease...

Selective Hepatic Intraarterial Chemotherapy

Hepatic Artery Infusion Pump

Chari Hepatic intra-arterial infusion pump HAIP placement provides hepatic specific continuous infusion of chemotherapeutic agents. The chemotherapeutic agents selected for use with HAIP should exhibit a high degree of first pass kinetics in order to minimize systemic toxicity. Agents used include cisplatin, fluodeoxyuridine FUDR , mitomycin C, and Adriamycin. Unresectable hepatic metastatic colorectal carcinoma Liver specific adjuvant chemotherapy following...

STEP 3Handassisted technique

A McBurney incision is made in the right lower quadrant using a muscle-splitting technique the size of the incision 4-5 cm should fit snugly around the surgeon's wrist. The surgeon's hand is introduced into the peritoneum by sliding between the abdominal muscles, keeping a tight fit with the skin around the wrist to prevent leakage of gas commercially available seals may facilitate this maneuver. The abdomen is then explored manually. The hand further dissects the body tail bluntly, then grasps...

Laparoscopic Liver Resection

Hand Port Device

Unroofing of symptomatic simple liver cysts was the first laparoscopic liver procedure to be performed followed by resection of superficial, small-sized benign tumors. The first laparoscopic anatomical liver resection, a left lateral sectionectomy, was reported in 1996. More recently, larger hepatectomies and liver resections for malignant tumors have been described. Today, about 15-20 of liver resections might be considered for a laparoscopic approach. Indications The indications for...

Venovenous Bypass Optional

Hepatic Vein Cannulation

Depending on the center, a venovenous bypass will be used systematically, occasionally, or never. When venovenous bypass is used during the anhepatic stage, this usually includes drainage of a the portal vein and b the lower part of the body via the left greater saphenous vein into the left axilliary, brachial or internal jugular vein. An alternative for direct cannulation of the portal vein stump is cannulation of the inferior mesenteric vein. The centripetal Biopump with heparin-coated, armed...

Right Paramedian Sector

Right Anterior Sectionectomy

Terminology Committee of the International Hepato-Pancreato-Biliary Association SM Strasberg USA , J Belghiti France , P-A Clavien Switzerland , E Gadzijev Slovenia , JO Garden UK , W-Y Lau China , M Makuuchi Japan , and RW Strong Australia . The Brisbane 2000 Terminology of Liver Anatomy and Resections. HPB 2 333-339,2000 Anatomical Couinaud segments Term referred to Right Hemihepatectomy stipulate -segment 1 Left Hemihepatectomy stipulate -segment 1 Right Hemihepatectomy stipulate -segment 1...

STEP 11Anisoperistaltic reconstruction not standard

Arcada Riolan

Preparation of an anisoperistaltic not standard colonic segment begins with incision of the peritoneum far from the colon and stepwise preparation of the mesocolon maintaining the paracolic arcades and the middle and left colic vessels. A vascular clamp is provisionally applied across the left colic artery and the sigmoid artery across the provisional colonic transection plane to prove a sufficient arcade of Riolan. If no ischemia occurs after 3min, the colon interposition can be performed.

STEP 3Removal of the native liver

Piggyback Technique

Before completion of the recipient hepatectomy, hemostasis of the retroperitoneal bare areas is performed using an argon beam coagulator. The bare areas are not routinely oversewn in order to keep the available space for the allograft to the maximum. The Classical Technique with Resection of the IVC Ligate and divide the portal vein as high up into the hilum as possible A-1 . Place vascular clamps on the suprahepatic and infrahepatic IVC and transsect it A-2 . The Cava-Sparing or Piggyback...

Bile Duct Resection

Replaced Right Hepatic Artery Anatomy

Resection of tumors at the bifurcation of the left and right hepatic duct requires one of the most difficult operations. The surgical procedure requires not only a portal lymphadenectomy and bile duct resection, but almost always a liver resection. The goals of this operation are 1 resection of the primary tumor, 2 resection of the lymphatic drainage of the liver and 3 reestablishment of biliary continuity. Indications Primary malignancies e.g., intrahepatic cholangiocarcinoma involving the...

STEP 4Removal of central pancreas

Distal Pancreatectomy Main Duct Ligation

Transection of pancreas Stay sutures are placed on the superior and inferior pancreatic margins just to the right and left of the proximal and distal lines of division to occlude the superior and inferior pancreatic vessels running transversely in the parenchyma. The pancreas is divided by scalpel using a V-shaped incision on the right side of the tumor to facilitate closure in a fish-mouth fashion the pancreas is transected 1 cm to the left of the tumor with suture ligation of the larger...

The Ligamentum Teres Approach and Other Approaches to the Intrahepatic Ducts for Palliative Bypass

Ligamentum Venosum And Left Hepatectomy

When the hilus of the liver is not accessible for decompression of obstructive jaundice, use of intrahepatic ducts for surgical bypass is a safe and effective technique as originally described by Bismuth and Corlette in 1975 and later by Blumgart and Kelly in 1984. The general principle is to identify intrahepatic healthy bile duct mucosa proximal to a point of biliary obstruction and to create a mucosa-to-mucosa anastomosis to a long Roux-en-y loop of jejunum. Anastomosis should provide...

Intrahepatic Biliodigestive Anastomosis Without Indwelling Stent

Biliodigestive Anastomose

The technique for reestablishing continuity of the extrahepatic bile ducts to the intestinal tract is described. Multiple biliary lumen may be encountered even with minor dissection into the hepatic parenchyma. All lumens should either be anastomosed or ligated with permanent sutures. Indications Reconstitution of biliary-enteric continuity after bile duct resection or combined hepatic and biliary resection for malignancy involving the proximal bile duct -typically hilar cholangiocarcinoma or...

Types of Drain

Blake Drain

Drains can be divided into passive and active drains. Passive drains, such as the Penrose A-1 and Easy Flow A-2 devices, serve to evacuate fluid passively by providing a route of access secondary to the natural pressure gradients, such as gravity flow, muscle contraction, and overflow. The opening in the abdominal wall for these drains should be made large enough, because passive drains are potentially collapsible. Easy Flow drains have intraluminal corrugations to prevent complete collapse...

Therapeutic Drainage

Omental Sac

Infected collections, such as abscesses or infected bilomas, are known complications after upper abdominal surgery and require drainage by operative or radiologically guided drain placement. The right subphrenic space 1 , left subphrenic space 2 , Morison's pouch 3 , left subhepatic space 4 , and omental sac 5 are anatomic spaces that predispose to abscess development. The majority of postoperative collections in the upper abdomen are manageable by means of percutaneous drainage by...

Subtotal Esophagectomy Transhiatal Approach

Para Aortic Lymphadenectomy

Yekebas, Jakob R. Izbicki The surgical trauma of the transhiatal approach is less pronounced as compared to a transthoracic approach. On the other hand, the lymphatic clearance is less radical, at least for the mid and upper mediastinum. This is the reason why some surgeons are in favor of the transthoracic approach even for distal adenocarcinoma. Subtotal transhiatal esophagectomy is indicated for benign conditions and for distal carcinoma. Intraepithelial squamous...

Left Thoracoabdominal Approach for Carcinoma of the Lower Esophagus and Gastric Cardia

Kocher Maneuver

Shoji Natsugoe, Masamichi Baba, Takashi Aikou Tumors located aborally to the carina, i.e., Barrett's carcinoma or carcinoma of the esophagogastric junction, may be removed by a left-sided thoracotomy instead of the more usual right-sided access combined with an abdominal approach. The extent of lymphadenectomy is limited to the middle and lower mediastinum. Indications Tumors of the infracarinal esophagus Tumors of the esophagogastric junction Contraindications See chapter on Subtotal...

Subtotal En Bloc Esophagectomy Abdominothoracic Approach

Suture Ligation Artery

Hosch, Asad Kutup, Jakob R. Izbicki The goal of this operation is to remove an esophageal cancer with the widest possible lymphatic clearance two-field lymphadenectomy , which comprises upper abdominal lymphadenectomy and lymphatic clearance of the posterior and mid mediastinum. Reconstruction is accomplished by either gastric tube or colonic interposition. Indications Thoracic esophageal carcinoma Benign stricture, if transhiatal resection is ill-advised e.g., adherence to trachea...

Types of Mechanical Staplers

Tia Stapler

There are currently three major types of mechanical stapling devices in clinical use for open and laparoscopic surgery. As described in Tables 1 and 2, the principles and prerequisites of mechanical stapling remain largely unchanged. Tablel. Principles of mechanical stapling Tissue stapling using metallic wire as staples Configuration of the closed staples in B-shape Staggered positioning of the staple lines Preserving adequate tissue vascularization Preventing tension of adapting tissues...