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...

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 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 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...

Anatomical Resection of Segment

Incision For Peripherial Artery Excision

Access to Sg7 is gained through a straight thoracoabdominal incision via the 8th intercostal space left semilateral position , or through a right subcostal incision. An overview of the important anatomical structures is shown in the Figure. STEP 1 Identification of the intersegmental plane and ligation The intersegmental plane between segments 7 and 6 is identified by injecting the die into P6 a counterstaining technique . A crushing method is applied using Pringle's maneuver A . When a...

Modifications of the EnBloc Liver Pancreas Procurement

Image Celiac Trunk Divisions

Pancreas Removal for Islet Transplantation For islet procurement, the pancreas is removed together with the liver and the duodenum is simply removed from the pancreatic head. Procurement of Intestine for Transplantation After initial preparation of the superior mesenteric artery and the celiac trunk, the intestine is repositioned adequately in the abdominal cavity. The first jejunal loop is transected about 10 cm distal to the ligament of Treitz using a GIA stapler . The transected jejunal loop...

STEP 3Preparation of neoduodenum A1 A2

Treitz Ligament

Using a harmonic scalpel, the mesenteric vascular attachments to the proximal jejunum are divided the jejunum is divided with a stapler 6-8cm distal to the ligament of Treitz. The avascular portion of the transverse mesocolon is opened just to the left of the middle colic vein. The defect in the ligament of Treitz is closed to avoid internal hernia. An intraoperative fluoroscopic pancreatogram of the pancreatic remnant is obtained if this area of the duct was not visualized by preoperative...

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

Liver Segments Right Left

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...

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

Portal Vein Hepatic Vein

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 1Positioning and installations

Patient Positioning

The patient is placed in the supine position. The surgeon stands between the legs of the patient, the first assistant on the left, the second assistant on the right side of the patient. The scrub nurse is positioned on the right or left hand side of the surgeon A . Installation of pneumoperitoneum and inspection of abdominal cavity Pneumoperitoneum is installed at the site of the umbilicus. In obese patients, the umbilicus is located more caudally in these patients the first trocar may be...

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 Bile Duct Ligation

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

Anatomy Gastroduodenal Artery

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...

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

Ligamentum Teres Ultrasound

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

Common Hepatic Duct Transection

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...

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...

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...