Steven K. Libutti,
Section Editors: A. Alfred Chahine,
MD, FACS
Associate Professor of Surgery and Pediatrics The George Washington University School of Medicine Program Director General Surgery Residency Georgetown University Medical Center Washington, DC
Edward E. Cornwell III,
MD, FACS, FCCM
LaSalle D. Leffall Jr Professor Chairman of Surgery Howard University Hospital Washington, DC
Gerard M. Doherty,
MD, FACS
Chief Tumor Angiogenesis Section Surgery Branch, National Cancer Institute Professor of Surgery Uniformed Services University of the Health Sciences Bethesda, Maryland
M. Blair Marshall,
MD
NW Thompson Professor of Surgery University of Michigan Head Section of General Surgery University of Michigan Health System Ann Arbor, Michigan
Leigh A. Neumayer,
MD
Professor of Surgery Section of Colon and Rectal Surgery Department of Surgery University of Wisconsin School of Medicine and Public Health Madison, Wisconsin MD, MBA
Professor Georgetown University Chief of Transplantation Surgery Vice-Chairman Department of Surgery Georgetown University Hospital Washington, DC
MD
Chief Division of Vascular Surgery Medical Director Non-invasive Vascular Lab Georgetown University Hospital Washington, DC
Shawna C. Willey, Lynt B. Johnson,
MD, MS
Professor of Surgery University of Utah School of Medicine Huntsman Cancer Institute Salt Lake City, Utah
Richard F. Neville, Eugene F. Foley,
MD, FACS
Associate Professor of Surgery Georgetown University School of Medicine Chief Division of Thoracic Surgery Department of Surgery Georgetown University Medical Center Washington, DC
MD, FACS
Associate Professor Georgetown University Director Betty Lou Ourisman Breast Health Center Lombardi Comprehensive Cancer Center Washington, DC
1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899
Surgical pitfalls: prevention and management
ISBN: 978-1-4160-2951-9
Copyright © 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail:
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Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher Library of Congress Cataloging-in-Publication Data Surgical pitfalls : an evidence-based approach to prevention and management / [edited by] Stephen R.T. Evans ; section editors, A. Alfred Chahine . . . [et al.].—1st ed. p. ; cm. Includes bibliographical references. ISBN 978-1-4160-2951-9 1. Surgical errors. I. Evans, Stephen R. T. II. Chahine, A. Alfred. [DNLM: 1. Intraoperative Complications—prevention & control. 2. Evidence-Based Medicine. 3. Medical Errors—prevention & control. 4. Risk Factors. 5. Risk Management. 6. Surgical Procedures, Operative—adverse effects. WO 181 S961 2009] RD27.85.S87 2009 617′.9—dc22 2008034840
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To my loving wife Karen, who every day fuels the fire of love in my heart and makes every moment together pure joy. Stephen Evans,
MD
Contributors Christopher J. Abularrage, MD Fellow in Vascular Surgery, Massachusetts General Hospital, Boston, Massachusetts Infrainguinal Revascularization
Sara A. Bloom, MD Chief Resident, Department of Surgery, Georgetown University Hospital, Washington, DC Axillary Surgery
Reid B. Adams, MD Professor of Surgery, Division Chief, Surgical Oncology, and Chief, Hepatobiliary and Pancreatic Surgery, University of Virginia Health System, Charlottesville, Virginia Enterectomy
Benjamin Braslow, MD Assistant Professor of Surgery, University of Pennsylvania School of Medicine; Director of Emergency Surgical Service, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Damage Control: Abdominal Closures
Mark S. Allen, MD Professor and Chair, Division of General Thoracic Surgery; Consultant, Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota Pneumonectomy
David A. Bruno, MD Chief Resident, Department of Surgery, Georgetown University, Washington, DC Resection and Reconstruction of the Biliary Tract
Stephen L. Altman, Esq, JD Partner, Hamilton Altman Canale & Dillon, LLC, Fairfax, Virginia Legal Considerations
Joseph F. Buell, MD, FACS Professor of Surgery and Director of Transplantation, University of Louisville, Louisville, Kentucky Laparoscopic Liver Resection
Rupen Amin, MD Research Fellow, Georgetown University School of Medicine, Washington, DC Pancreaticoduodenectomy
John Byrne, MB, BCh, BAO, MCh, FRCSI(Gen) Attending, Albany Medical Center Hospital, Albany, New York Aortic Surgery
Andrea Badillo, MD Resident in General Surgery, The George Washington University, Washington, DC Graham Patch Repair
A. Alfred Chahine, MD, FACS Associate Professor of Surgery and Pediatrics, The George Washington University School of Medicine; Program Director, General Surgery Residency, Georgetown University Medical Center, Washington, DC Imperforate Anus and Hirschsprung’s Disease; Congenital Diaphragmatic Hernia
Catherine Bertram, JD Partner, Regan Zambri & Long, PLLC, Washington, DC Legal Considerations Parag Bhanot, MD Assistant Professor of Surgery, Georgetown University Hospital, Washington, DC Open Inguinal Hernia Repair with Plug and Patch Technique; Laparoscopic Incisional Hernia Repair
David C. Chang, PhD, MPH, MBA Assistant Professor of Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland Evaluating Trauma Literature
Joseph A. Blansfield, MD Clinical Assistant Professor of Surgery, Temple University School of Medicine, Philadelphia; Associate, Department of Surgical Oncology, Geisinger Medical Center, Danville, Pennsylvania Isolated Limb Perfusions and Extremity Amputations
Zandra Cheng, MD Breast Surgeon, Anne Arundel Medical Center Breast Center, Annapolis, Maryland Breast Biopsy and Breast-Conserving Surgical Techniques
Kenneth J. Bloom, MD Clinical Professor of Pathology, Keck School of Medicine; Chief Medical Officer, Clarient, Inc., Aliso Viejo, California Image-Guided Breast Biopsy
Mark D. Cipolle, MD, PhD, FACS Medical Director, Trauma Program, and Member of Staff, General Surgery, Christiana Care Health System, Wilmington, Delaware Central Vein Catheterization
viii
CONTRIBUTORS
Bryan M. Clary, MD Associate Professor of Surgery, and Chief, Hepatobiliary Surgery, Duke University Medical Center, Durham, North Carolina Trisectionectomy Edward E. Cornwell III, MD, FACS, FCCM LaSalle D. Leffall Jr Professor and Chairman of Surgery, Howard University Hospital, Washington, DC Management of Thoracic Trauma; Management of Pancreatic and Duodenal Injuries; Traumatic Brain Injury; Managing Injuries to the Spleen Derrick D. Cox, MD Chief Resident, General Surgery, Georgetown University Hospital, Washington, DC Open Inguinal Hernia Repair with Plug and Patch Technique Aimee M. Crago, MD, PhD Fellow, Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York Preoperative Pitfalls; Gastrectomy with Reconstruction Dale A. Dangleben, MD Assistant Program Director, General Surgery Residency, and Member of Staff, General Surgery, and Trauma/ Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pennsylvania Central Vein Catheterization R. Clement Darling III, MD Professor of Surgery, Albany Medical College; Chief, Division of Vascular Surgery, Albany Medical Center Hospital, Albany, New York Aortic Surgery Elizabeth A. David, MD Resident, General Surgery, Georgetown University Hospital, Washington, DC Arterial Catheterization; Laparoscopic Nissen Fundoplication James E. Davies, MD Assistant Professor, Department of Cardiothoracic Surgery, University of Iowa, Iowa City, Iowa Pneumonectomy David Deaton, MD Assistant Professor, Georgetown University; Chief of Endovascular Surgery, Division of Vascular Surgery, Department of Surgery, Georgetown University Hospital, Washington, DC Endovascular Interventions Demetrios Demetriades, MD, PhD Professor of Surgery, University of Southern California School of Medicine; Director of Trauma and Critical Care, Los Angeles County and University of Southern California Medical Center, Los Angeles, California Management of Penetrating Neck Injury
Kiran K. Dhanireddy, MD Transplant Fellow, UCLA Medical Center, Los Angeles, California Distal Pancreatectomy Gerard M. Doherty, MD NW Thompson Professor of Surgery, University of Michigan; Head, Section of General Surgery, University of Michigan Health System, Ann Arbor, Michigan Thyroid Surgery Jessica S. Donington, MD Assistant Professor, Department of Cardiothoracic Surgery, New York University, New York, New York Chest Wall Resections Brian J. Duffy, MD The George Washington University; Research Fellow, Children’s National Medical Center, Washington, DC Pectus Excavatum Quan-Yang Duh, MD Professor of Surgery, University of California, San Francisco; Attending Surgeon, Veterans Affairs Medical Center, San Francisco, California Laparoscopic Inguinal Hernia Repair David T. Efron, MD Assistant Professor of Surgery, Johns Hopkins School of Medicine; Director of Trauma, Division of Acute Care Surgery: Trauma, Critical Care, Emergency and General Surgery, The Johns Hopkins Hospital, Baltimore, Maryland Management of Thoracic Trauma; Management of Pancreatic and Duodenal Injuries Martin R. Eichelberger, MD Professor of Surgery and Pediatrics, The George Washington University; Attending Surgeon, Children’s National Medical Center, Washington, DC Pectus Excavatum Rebecca Evangelista, MD Assistant Professor of Surgery, Georgetown University Medical Center; Staff Surgeon, Veterans Affairs Medical Center, Washington, DC Open Gastrostomy Feeding Tube Placement and Percutaneous Endoscopic Gastrostomy Tube Placement; Open Jejunostomy Tube Placement Stephen R. T. Evans, MD, FACS Robert J. Coffey Professor and Chairman, Department of Surgery, Georgetown University Medical Center, Washington, DC From Error to Perfection: The Process of Surgical Maturation; Teaching Technical Skills—Errors in the Process; Preoperative Pitfalls; Arterial Catheterization; Chest Tube Insertion; Paracentesis; Laparoscopic Nissen Fundoplication; Laparoscopic Esophagomyotomy with Dor Fundoplication; Gastrectomy with Reconstruction
CONTRIBUTORS
Eleanor Faherty, MD Staff Surgeon, and Captain, United States Air Force, Malcolm Grow Medical Center, Andrews Air Force Base, Maryland Open Gastrostomy Feeding Tube Placement and Percutaneous Endoscopic Gastrostomy Tube Placement; Open Jejunostomy Tube Placement; Lateral Pancreaticojejunostomy (Puestow) Procedure; Supraclavicular Lymph Node Biopsy Elizabeth D. Feldman, MD Assistant Professor, Georgetown University, Washington, DC Mastectomy Felix G. Fernandez, MD Cardiothoracic Fellow, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, Missouri Thymectomy and Resection of Mediastinal Masses Richard E. Fine, MD Clinical Associate Professor, Department of Surgery, University of Tennessee College of Medicine— Chattanooga Unit, Chattanooga, Tennessee; Director, Breast Care Continuum Program, Wellstar Kennestone Hospital, Marietta, Georgia Image-Guided Breast Biopsy Thomas M. Fishbein, MD Professor, Department of Surgery, Georgetown University; Director of Small Bowel and Pediatric Liver Transplant Program, Georgetown University Hospital, Washington, DC Distal Pancreatectomy; Resection and Reconstruction of the Biliary Tract James FitzGerald, MD Attending Surgeon, Washington Hospital Center, Washington, DC Ileostomy Eugene F. Foley, MD Professor of Surgery, Section of Colon and Rectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Hemorrhoidectomy; Anal Fistulotomy Hugh M. Foy, MD Professor of Surgery, and Head, Wind River College, University of Washington School of Medicine; Attending Surgeon, Harborview Medical Center, Seattle, Washington Teaching Technical Skills—Errors in the Process Charles M. Friel, MD Associate Professor of Surgery, and Chief, Section of Colon and Rectal Surgery, University of Virginia, Charlottesville, Virginia Low Anterior Resection; Abdominal Perineal Resection with Colostomy
ix
Kelly Garrett, MD Chief Resident, Albany Medical College, Albany, New York Left Colectomy: Open and Laparoscopic Ankur Gosalia, MD Assistant Professor of Anesthesiology, Temple University, Philadelphia; Attending Anesthesiologist, Western Pennsylvania Hospital, Pittsburgh, Pennsylvania Anesthesia for the Surgeon Vicente H. Gracias, MD Associate Professor of Surgery, and Chief, Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Damage Control: Abdominal Closures Jay A. Graham, MD Resident, Department of Surgery, Georgetown University, Washington, DC Laparoscopic Surgery; Right Hepatectomy; Left Hepatectomy Philip C. Guzzetta, Jr., MD Professor of Surgery and Pediatrics, The George Washington University; Pediatric Surgery Chief Resident Program Director, Children’s National Medical Center, Washington, DC Malrotation, Volvulus, and Bowel Obstruction Adil H. Haider, MD, MPH Assistant Professor of Surgery, Division of Trauma/ Critical Care, Johns Hopkins School of Medicine, Baltimore, Maryland Traumatic Brain Injury; Managing Injuries to the Spleen Elliott R. Haut, MD, FACS Assistant Professor of Surgery and Anesthesiology and Critical Care Medicine, Division of Acute Care Surgery: Trauma, Critical Care, Emergency and General Surgery, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine; Director, Trauma / Acute Care Surgery Fellowship, The Johns Hopkins Hospital, Baltimore, Maryland Evaluation and Acute Resuscitation of the Trauma Patient Mary Hawn, MD, MPH Associate Professor of Surgery, and Chief, Section of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, Alabama Open Primary and Mesh Repairs Richard F. Heitmiller, MD Associate Professor of Surgery, Johns Hopkins Medical Institutions; J.M.T. Finney Chairman of Surgery, Union Memorial Hospital, Baltimore, Maryland Esophageal Surgery Earl Hodin, MD Attending Surgeon, Children’s National Medical Center, Washington, DC, and Inova Fairfax Hospital, Falls Church, Virginia Inguinal and Umbilical Hernias
x
CONTRIBUTORS
Arsalla Islam, MD Assistant Instructor, GI Endocrine Surgery Division, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas Adrenal Surgery
James Laredo, MD Assistant Professor, Division of Vascular Surgery, Department of Surgery, Georgetown University; Georgetown University Hospital, Washington, DC Venous Surgical Pitfalls
Kamal M. F. Itani, MD Professor of Surgery, Boston University School of Medicine; Chief of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts Umbilical and Epigastric Hernias
David W. Larson, MD Consultant in Surgery and Assistant Professor of Surgery, Mayo Clinic, Mayo Medical School, Rochester, Minnesota Right Colectomy: Open and Laparoscopic
Patrick G. Jackson, MD Associate Residency Program Director, Georgetown University; Assistant Professor of Surgery, Georgetown University Hospital, Washington, DC Laparoscopic Surgery; Vagotomy and Pyloroplasty; Lateral Pancreaticojejunostomy (Puestow) Procedure; Pancreatic Cyst/Debridement
Edward C. Lee, MD, FACS, FASCRS Associate Professor of Surgery, Chief, Section of GI/ Surgical Oncology, and Vice Chairman for Clinical Affairs, Albany Medical College, Albany, New York Left Colectomy: Open and Laparoscopic
Lynt B. Johnson, MD, MBA Professor, Georgetown University; Chief of Transplantation Surgery, and Vice-Chairman, Department of Surgery, Georgetown University Hospital, Washington, DC Right Hepatectomy; Left Hepatectomy; Pancreaticoduodenectomy; Pancreatic Cyst/Debridement Benjamin Kim, MD Staff Physician, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California Laparoscopic Inguinal Hernia Repair Lawrence T. Kim, MD, FACS Professor, Department of Surgery, University of Arkansas for Medical Sciences; Chief, Surgical Service, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Parathyroid Surgery Daniel Kreisel, MD, PhD Assistant Professor of Surgery, Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri Thymectomy and Resection of Mediastinal Masses John C. Kucharczuk, MD Assistant Professor of Surgery, University of Pennsylvania School of Medicine; Division of Thoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Bronchoscopy: Flexible and Rigid; Esophagoscopy: Flexible and Rigid; Mediastinoscopy; and Anterior Mediastinotomy Paul C. Kuo, MD, MBA Professor of Surgery, and Chief, Division of General Surgery, Duke University Medical Center, Durham, North Carolina Trisectionectomy
Stacy Loeb, MD Resident in Training (Urology), Johns Hopkins Medical Institutions, Baltimore, Maryland Paracentesis Amy D. Lu, MD, MPH, MBA Associate Professor of Surgery, Albert Einstein College of Medicine; Director, Renal Transplant Program, Montefiore Medical Center, Bronx, New York Gallbladder: Cholecystectomy (Laparoscopic vs. Open) Jeffrey Lukish, MD Associate Professor of Surgery and Pediatrics, and Chief, Division of Pediatric Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland Tracheoesophageal Fistula and Esophageal Atresia Repair Robyn A. Macsata, MD Chief, Vascular Surgery, Veterans Affairs Medical Center, Washington, DC Arteriovenous Hemodialysis Access Donna-Marie Manasseh, MD Co-Director of the Women’s Breast Health Center, Stamford Hospital Foundation, New Haven, Connecticut Axillary Surgery Carlos E. Marroquin, MD Assistant Professor of Surgery, Duke University Medical Center, Durham, North Carolina Trisectionectomy M. Blair Marshall, MD, FACS Associate Professor of Surgery, Georgetown University School of Medicine; Chief, Division of Thoracic Surgery, Department of Surgery, Georgetown University Medical Center, Washington, DC Bronchial and Vascular Sleeve Lobectomy
CONTRIBUTORS
Marga F. Massey, MD, FACS Associate, Center for Microsurgical Breast Reconstruction, Charleston/Chicago/Salt Lake City, Charleston, South Carolina Component Separation for Complex Abdominal Wall Reconstruction and Recurrent Ventral Hernia Repair Aarti Mathur, MD Resident in Surgery, Georgetown University, Washington, DC Chest Tube Insertion; Laparoscopic Splenectomy Fabio May da Silva, MD Professor of Clinical Surgery, Universidade do Sul de Santa Catarina; Thoracic Surgeon, Secretaria do Estado de Santa Catarina, Florianopolis, Santa Catarina, Brazil Bronchial and Vascular Sleeve Lobectomy Michael McLeod, MD Associate Professor, Michigan State University, Kalamazoo, Michigan Thyroid Surgery Aziz Merchant, MD Fellow, Minimally Invasive Surgery, Emory University, Atlanta, Georgia Pyloromyotomy Angela M. Mislowsky, MD Chief Resident—Surgery, Union Memorial Hospital, Baltimore, Maryland Esophageal Surgery Bruno Molino, MD Director, Division of Trauma, Liberty Health—Jersey City Medical Center, Jersey City, New Jersey Damage Control: Abdominal Closures Gitonga Munene, MD Chief Resident Physician, Georgetown University Hospital, Washington, DC Gastrectomy with Reconstruction Russell J. Nauta, MD, FACS Professor of Surgery, Harvard Medical School; ViceChairman, Surgery, Beth Israel-Deaconess Medical Center; Chairman of Surgery, Mount Auburn Hospital and Harvard Health Services, Cambridge, Massachusetts General Laparotomy Edward W. Nelson, MD Professor of Surgery and Division Chief of General Surgery, University of Utah School of Medicine, Salt Lake City, Utah Prolene Hernia System—Hernia Repair Richard F. Neville, MD Chief, Division of Vascular Surgery, and Medical Director, Non-invasive Vascular Lab, Georgetown University Hospital, Washington, DC Carotid Endarterectomy; Infrainguinal Revascularization
xi
Kurt D. Newman, MD Professor of Surgery and Pediatrics, The George Washington University School of Medicine; Surgeon in Chief, and Executive Director, Joseph E. Robert, Jr. Center for Surgical Care, Children’s National Medical Center, Washington, DC Pyloromyotomy C. Joe Northup, MD, FACS Assistant Professor, University of Virginia Health System, Charlottesville, Virginia Laparoscopic Appendectomy Fiemu Nwariaku, MD, FACS, FWACS Malcolm O. Perry MD Professor, and Associate Professor and Vice Chair, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas Adrenal Surgery Michael D. Pasquale, MD, FACS, FCCM Associate Professor of Surgery, Penn State College of Medicine, Penn State University, Hershey; Senior Vice Chair, Department of Surgery, Chief, Division of Trauma/Surgical Critical Care, and Member of Staff, General Surgery, and Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pennsylvania Central Vein Catheterization; Pulmonary Artery Catheterization James F. Pingpank, Jr., MD Head, Surgical Metabolism Section, Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Isolated Limb Perfusions and Extremity Amputations Dahlia Plummer, MD Vascular Fellow, Georgetown University, Washington, DC Carotid Endarterectomy Todd A. Ponsky, MD Assistant Professor of Surgery, Case Western Reserve University; Assistant Professor of Surgery, Division of Pediatric Surgery, Rainbow Babies and Children’s Hospital, Cleveland, Ohio Wilms’ Tumor and Neuroblastoma David M. Powell, MD Associate Professor of Surgery and Pediatrics, The George Washington University; Attending Surgeon, Children’s National Medical Center, Washington, DC Pectus Excavatum Brian Reuben, MD Chief Resident, General Surgery, University of Utah, Salt Lake City, Utah Component Separation for Complex Abdominal Wall Reconstruction and Recurrent Ventral Hernia Repair T. A. Rothenbach, MD Staff Surgeon, Pediatric Surgery Inc., The Children’s Hospital at Saint Francis, Tulsa, Oklahoma Congenital Diaphragmatic Hernia
xii
CONTRIBUTORS
Shawn D. Safford, MD Assistant Professor of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland Tracheoesophageal Fistula and Esophageal Atresia Repair Ali Salim, MD Program Director, General Surgery Residency, CedarsSinai Medical Center, Los Angeles, California Management of Penetrating Neck Injury Rovinder S. Sandhu, MD, FACS Clinical Assistant Professor of Surgery, Penn State College of Medicine, Penn State University, Hershey; Medical Director, Adult Transitional Trauma Unit, and Member of Staff, General Surgery, and Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pennsylvania Central Vein Catheterization; Pulmonary Artery Catheterization Babak Sarani, MD Assistant Professor of Surgery, University of Pennsylvania; Attending Surgeon, Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Anesthesia for the Surgeon; Graham Patch Repair John E. Scarborough, MD Assistant Professor of Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina Trisectionectomy Bruce Schirmer, MD Stephen H. Watts Professor of Surgery, University of Virginia Health System, Charlottesville, Virginia Laparoscopic Gastric Bypass Joseph B. Shrager, MD Professor of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford; Chief, Division of Thoracic Surgery, Stanford University Hospital, Stanford; Staff Surgeon, Palo Alto Veterans Affairs Health Care System, Palo Alto, California Cervical Tracheal Resection and Reconstruction
Scott J. Swanson, MD The Eugene W. Friedman Professor of Surgical Oncology, Mount Sinai School of Medicine; Chief, Division of Thoracic Surgery, Mount Sinai Medical Center, New York, New York Lobar Resections Lorraine Tafra, MD Director, The Breast Center, Anne Arundel Medical Center, Annapolis, Maryland Breast Biopsy and Breast-Conserving Surgical Techniques Amit D. Tevar, MD, FACS Assistant Professor, University of Cincinnati, Cincinnati, Ohio Laparoscopic Liver Resection Mark J. Thomas, MD Assistant Professor, University of Cincinnati, Cincinnati, Ohio Laparoscopic Liver Resection Trevor Upham, MD Surgical Resident, Department of Surgery, Georgetown University Hospital, Washington, DC Pancreatic Cyst/Debridement Daniel Vargo, MD Associate Professor of Surgery, Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah Component Separation for Complex Abdominal Wall Reconstruction and Recurrent Ventral Hernia Repair Diana M. Weber, MD Surgeon, Presbyterian Hospital, Albuquerque, New Mexico Laparoscopic Splenectomy; Supraclavicular Lymph Node Biopsy Todd S. Weiser, MD Assistant Professor, Mount Sinai School of Medicine; Attending, Mount Sinai Medical Center, New York, New York Lobar Resections Tamica White, MD Thoracic Surgeon, Surgical Specialists of North Jersey, Englewood, New Jersey Vagotomy and Pyloroplasty
Anton N. Sidawy, MD, MPH Professor of Surgery, Georgetown and George Washington University Schools of Medicine; Chief, Surgical Service, Veterans Affairs Medical Center, Washington, DC Arteriovenous Hemodialysis Access
Shawna C. Willey, MD, FACS Associate Professor, Georgetown University; Director, Betty Lou Ourisman Breast Health Center, Lombardi Comprehensive Cancer Center, Washington, DC Mastectomy
Niten Singh, MD Assistant Professor of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Chief, Endovascular Surgery, Madigan Army Medical Center, Tacoma, Washington Venous Surgical Pitfalls; Endovascular Interventions
Alexander Wohler, MD Fellow in Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York Laparoscopic Esophagomyotomy with Dor Fundoplication
William H. Snyder, MD Professor of Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas Adrenal Surgery
James C. Yang, MD Assistant Professor, Uniformed Services University of the Health Sciences; Senior Investigator, Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Management of Soft Tissue Sarcoma
Preface
It is on our failures that we base a new and different and better success. —Havelock Ellis As a profession, surgeons are exceedingly reluctant to publicize our errors. Whether they are errors in judgment or intraoperative technical errors, they are usually kept to ourselves or become semi-public when presented formally at the usual Morbidity and Mortality conferences held weekly at all hospitals by surgeons throughout the country. It is quite clear, however, that the Morbidity and Mortality conference proves to be the most educationally productive conference for all surgeons because of how much we learn from our own errors as well as the errors of others. Surgical Pitfalls has been a work in progress for many years and is targeted not just at surgeons in training but at surgeons of all levels of expertise. Our hope is that this will lead to significant error prevention and improve and enhance error training through surgical residencies. We have therefore constructed this book to include all of the major specialties in surgery. This book is unique in its intent to identify intraoperative errors that occur at specific steps during both simple and complex operations, but more importantly identifying how to prevent the error, the consequences of the error if they occur, and lastly, how to repair or correct the error once it has happened. The book covers over 80 major operative procedures in addition to discussing common errors, especially errors in preoperative decision making based upon individual organ systems and risk stratification that should be considered in preoperative assessment and evaluation of all patients. Additionally, errors made in teaching technical skills are reviewed, errors in communication that lead to medical legal issues, and lastly an over-
view in the introductory section on the process of surgical maturation. During this first edition we have attempted to be as comprehensive as possible in describing all major published intraoperative complications and intraoperative errors that are made in our decision making. As previously stated, however, surgeons are reluctant not just to talk about our mistakes, but certainly loathe publishing them. In preparation for our second edition we are actively soliciting cases with substantial intraoperative or radiographic confirmation and documentation of the specific errors and complications that have occurred with the intent of making the second edition even more comprehensive and truly an “Encyclopedia of Error” or the “Textbook of Morbidity and Mortality.” I would like to thank all of our extremely talented contributing authors for their tremendous time and effort put in to this first edition. It is certainly much easier to write an operative procedures textbook on how to do an operation; it is far more difficult to write a procedures manual on how NOT to do an operation. I greatly thank our contributors for their patience as we moved through this sometimes arduous process. We have adhered to a template which we hope that the reader will find exceedingly useful and user-friendly. In addition to our contributing authors I would like to extend a heartfelt thanks to our staff at Elsevier, including Scott Scheidt, Sarah Myer, and our publishing director, Judy Fletcher. They have shared the passion, excitement and energy that we all have for this first edition and have made the job all that much easier. Stephen R. T. Evans,
MD, FACS
Introduction
Although the hospital course of a patient is affected profoundly by what happens inside the operating room, many complications can be prevented by adequate preoperative preparation. Rates of postoperative myocardial infarction, congestive heart failure, pneumonia, bleeding, and infection are all affected by identification of a patient’s individual risk factors and medical optimization of the patient’s condition prior to surgery. A clear history and physical examination, reconciliation of a patient’s medication list, and consultation with appropriate specialists are the first steps in ensuring that an operation will go as smoothly as possible, and that hospital length of stay and preoperative morbidity and mortality rates are maintained at a minimum.
Complications The grade of Complications is: Grade 1—Requires medical treatment only, i.e., antibiotics for a urinary tract infection
Grade 2—Requires a procedural intervention, i.e., percutaneous drainage of a pelvic abscess Grade 3—Requires reoperation, but without permanent disability or removal of an organ Grade 4—Leads to a permanent disability, i.e., renal failure requiring dialysis; or reoperation with organ removal Grade 5—Death
Indications The surgeon should complete a mental, if not physical, checklist of preoperative risk factors and appropriate interventions for each patient who is scheduled for the operating room. There are no exceptions to this dictum. Even in emergent situations, knowledge of the patient’s comorbidities should be elucidated as soon as possible to aid in intraoperative and postoperative care.
Section I
GENERAL CONSIDERATIONS Stephen R. T. Evans, MD An error the breadth of a single hair can lead one a thousand miles astray. —Chinese proverb
1
From Error to Perfection: The Process of Surgical Maturation Stephen R. T. Evans, MD Mishaps are like knives that either serve us or cut us, as we grasp them by the blade or the handle.—James Russell Lowell
SURGICAL ERRORS Who Is to Blame? The landmark report, To Err Is Human, from the Institute of Medicine (IOM) published in 19991 spurred enormous attention and focus on patient safety. Initiatives to reduce the number of preventable deaths from medical errors have received widespread awareness, both in the medical literature and in the lay press.1 Five years after the IOM report, Leape and Berwick published a grim account on the lack of progress that the medical community has made in enhancing patient safety.2 These authors urged the medical community to take ownership in the matter and said, “We will not become safe until we chose to become safe.”2 Despite this pessimistic view, a few reports of improvement have been published over the last several years. Brennen3 demonstrated this more optimistic viewpoint. He showed that the rate of injury in medical care in the 1970s was 4.6% in the state of California, but by 1984, New York’s rate declined to 3.7%, and by 1992, Colorado’s and Utah’s rates fell to 2.9%. In addition, he reiterated what has long been known: that major
2
SECTION I: GENERAL CONSIDERATIONS
operative procedures in cardiac surgery and neurosurgery have shown significant reductions in complication rates and overall mortality over the last several decades.3 Although at times met by some degree of animosity, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Agency for Health Care Research and Quality have certainly taken ownership in developing policies to reduce medical errors on a national level. They have mandated error reduction policies in the operating room such as preoperative checklists, surgical marking for “correct side and correct patient,” and the obligatory “timeout” to enhance communication in the operating room. These JCAHO policies are touted to minimize errors by enhancing communication between anesthesia, nursing, and surgical staff.
Taking Ownership At the individual practitioner level, significant room for improvement still exists because we have not uniformly “chosen to become safe.” This is because the surgical approach has historically been more reactive than proactive. Although we, as surgeons, have a strong history of dissecting our own craft, evaluating successes and reviewing flaws in forums such as morbidity and mortality (M&M) conferences, we have not acted cohesively. We all know that the surgical M&M conference—in which surgeons tend to be honest and open about mistakes and propose to learn from those mistakes—has been hailed as the best educational experience for all trainees. However, this forum can be disorganized and happenstance and could become more word of mouth than anything reportable. Indeed, many other fields of medicine do not even participate in a weekly M&M conference. Moreover, even when we know that errors are definable and predictable in given operations, our ability to educate and train in error reduction has fallen short. Passionate discussions that may surface in each hospital’s lecture hall are often forgotten by the next week. Why have we not developed a national registry to report errors that are discovered in these surgical think tanks? Why do we not have a monthly journal dedicated solely to exploring these mistakes to better our field? Many barriers exist to open discussion of surgical errors at a national level, not the least of which is the medicolegal climate. Whereas a unified approach at error reduction seems insurmountable, the current intense focus on patient safety should drive this initiative. We cannot accept anything less than the effort toward perfection. As Deming stated, “if we had to live with 99.9%, we would have: two unsafe plane landings per day at O’Hare, 16,000 pieces of lost mail every hour, 32,000 bank checks deducted from the wrong bank account every hour” (Deming, personal communication, November 1987). Our sophisticated culture demands this effort. It is time for the individual surgeon to take ownership in this matter. This textbook focuses exclusively upon the
individual in an attempt to improve error reduction at both the cognitive and the technical levels. We also hope to affect the future of surgical education by exposing practical ways to teach not just the surgical resident but also more experienced surgeons on the approach to error reduction on a daily basis. We hope that by looking carefully at flaws in cognitive thought processes or technical errors that are preventable, the opportunities for improvement at the practicing physician level will become obvious.
The Paralysis of Fear Leape4 talked about the powerful fear of error (Fig. 1–1). This trilogy is encompassed by (1) the fear of embarrassment by colleagues, (2) the fear of patient reaction to errors, and (3) the fear of litigation. It has seemingly paralyzed our ability to proactively approach error reduction. Moreover, these collective fears are certainly the reasons why we have not uniformly shared and/or published our complications. First, we loathe exposing our ignorance or technical failures to our fellow surgeons and medical colleagues. To become the talk of the surgeon’s lounge over a recent operative failure is our worst nightmare. Second, we face the fear of patient reaction to the mistake we made. It is natural to be uncomfortable talking to patients after mistakes and errors have occurred. Even more distressing is working in an academic health center where resident training is conducted and a mistake occurs. Patients may commonly ask, “What is the resident’s role in my operation and in my care?” And if a mistake occurs, the patient may ask, “Is this is an error caused by the resident?” or “Is this a training error?” Lastly, the prevailing fear of litigation may have become the most dominant stagnating force we face. The
Figure 1–1 Lucian Leape. (Courtesy of Lucian L. Leape, MD.)
1 FROM ERROR TO PERFECTION: THE PROCESS OF SURGICAL MATURATION “MALPRACTICE MACHINE” is on our radar screen daily and has certainly been popularized on the Internet at such sites as “fightingforyou.com.” One can find common headlines such as “Surgical errors are among the most carefully regarded secrets in the medical industry.”
The Paradox Although it is a formidable, some say impossible, task, we cannot be frozen by inaction in an attempt to strive for perfection. Leape described this complex conflict: “the paradox . . . that although the standard of medical practice is perfection—error-free patient care—all physicians recognize that mistakes are inevitable.”2 We know we are all human, but this is not an explanation accepted by the media, the public, the insurance companies, or malpractice lawyers.
THEORIES OF HUMAN PERFORMANCE Knowledge-, Rule-, and Skill-Based Performances To understand how human errors occur, we must first understand the theories behind human performance. Rasmussen and Jensen5 have written extensively on the concepts of human performance, which they divide into three types: (1) knowledge-based, (2) rule-based, and (3) skill-based.5 First, knowledge-based performance occurs when we act on novel thought during new situations (e.g., this is the intern’s life—all operations are new to them and all patient scenarios on the wards are unique to them). Second, ruled-based performance happens when we develop solutions to problems dictated by stored rules—patterns of behavior that occur based upon specific situations (e.g., when we are presented with the unmistakable, discreet areolar plane while mobilizing a right colon, we know our dissection can proceed expediently and safely). Third, skilled-based performance refers to patterns of thought and action that are unconscious or preprogrammed. These are certainly the most common, routine performances that we carry on a daily basis (e.g., driving a car on the same roads daily to work or an experienced surgeon performing his or her 500th inguinal hernia repair).
Errors in Human Performance Reason6 and Rasmussen and Jensen5 have classified errors that can occur in each of these performance categories. Knowledge-based errors happen when there is simply a lack of experience or knowledge or a misinterpretation of the problem. These commonly occur to either the inexperienced surgeon or trainee who is on the steep end of the learning curve and who encounters a novel clinical
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situation. It is these knowledge-based errors that we hope this book will clearly illuminate so that we can all avoid them. Rule-based errors are categorized as misapplied expertise. The wrong rule is chosen during problem solving. This is commonly related to a misperception of the situation or misapplication of a “rule” that is understood but not used correctly. Lastly, skill-based errors are referred to as “slips.” They occur when there is an unusual break in the routine or lack of an additional check (or “time out”) so that we, for example, operate on the wrong leg or on the wrong patient or leave a malleable in the patient after laparotomy. Interestingly, these are more likely to occur with physiologic conditions such as fatigue and psychological interferences such as boredom or frustration. Which errors are the most common? Actually, slips, the skill-based errors, are the most common because most of our daily mental functioning is automatic. However, the rate of error is higher with knowledge-based errors because these typically occur on the steep part of the learning curve.6 This book’s aim is to illuminate and expose pitfalls and errors at all three levels and to change our performance in surgery by focusing training and policy on error reduction.
Perceptual Errors in the Operating Room: Heuristics Understanding the etiology and mechanism for technical errors that occur in operative procedures is a generalized theme throughout this textbook. In a highly referenced and quoted article, Way and coworkers7 studied patients with major bile duct injuries during laparoscopic cholecystectomy in order to determine the cause of the errors. They classified each injury into three different groups: (1) knowledge and decision making errors, (2) a lack of technical skills, and (3) errors of perceptual input or a misperception of the anatomy. The majority of the injuries were of the third type. This variety of error mechanism is based on the principle of heuristics. Heuristics are normal, rapid, subconscious responses that work based upon subjective or illusory contours or shapes. If you look at an example such as the Kanizsa triangle (Fig. 1–2), you may think you are seeing a white triangle surrounded by dark circles. However, a white triangle is NOT actually present, your mind merely constructs it from the backdrop of the circles. The white triangle also appears to be brighter than the surrounding area, but in fact, it is not. As surgeons, we have all encountered heuristics in some way or another. Interestingly, it is inherent in the way our brain functions. Our brain is wired to use the first information that comes to mind in order to understand or comprehend the world. Heuristics are important to recognize, especially in the setting of the operating room. As we proceed through a common operation and visualize globally what the
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• Imagery • The tendency to use the first information that comes to mind • “Fooling” the mind
Figure 1–2 Kanizsa triangle. (From Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries. Ann Surg 2003;237:460–469.)
operative field looks like, we may have a tendency to become complacent about what we see. Humans prefer common patterns and familiarity, especially in the operating room. Therefore, we seek out what we already know from memory. Making a rapid decision based only on misrepresented visual input could get us in trouble. This book will hopefully open our minds to the hidden anatomy that we must all be cognizant of to prevent technical errors. As Reason6 described, “the price we pay for this automatic processing of information is that perceptions, memories, thoughts, and actions have a tendency to err in the direction of the familiar and the expected.”
THE IMPORTANCE OF ERROR RESPONSE So, I Made a Mistake . . . Although it does seem that “to err is human” and much of our abilities to make errors is a constant experience throughout existence, our responses to mistakes are quite individual. First, some of us simply deny that the error even occurred by constantly deflecting the situation and taking no ownership of the error itself. Second, others may be overcome with fear after making an error such that subsequent similar operations are performed with the sole focus on not making a mistake instead of performing the operation correctly. This is a disaster in the setting of oncologic surgery, in which inadequate resections are performed overshadowed by the constant fear of trying to avoid ureteral or vascular injuries. Third, some of us are overcome with passive acceptance. This is the surgeon who believes that mistakes will always occur no matter what we do, and therefore, there is no necessity for change or intervention. Finally, there are those who are deeply analytical. After we make a mistake, we are self-critical, analyze the literature, review videos, and channel all of our energy into self-improvement to minimize the chances of that error occurring again. It turns out that our response to making an error is one of the most important reactions we make in our career.
In residency, we may remember those residents who did not succeed. What was it about them that made them fail? Bosk at the University of Pennsylvania studied this and discovered that failure is related to these responses to making mistakes. Bosk studied the University of Pennsylvania neurosurgery program and found that the failures were residents with passive acceptance, who believe that mistakes will rarely occur or that “bad outcomes [have occurred] due to things outside my control.”8 Conversely, the successful neurosurgery resident was the analytical surgeon who admits that she or he makes terrible mistakes, “plenty of mistakes,” and “is driven to eliminate failure.”
The Resident’s Response to Error Paralleling Bosk’s study, Wu and colleagues9 asked 114 internal medicine residents: How did they handle the most significant mistake they made while training? Ninetynine percent of the mistakes were serious; in fact, 31% of these resulted in death. The mistakes included diagnostic errors (33%), prescribing errors (29%), evaluation errors (21%), and procedural errors (11%). Amazingly enough, only 54% of the residents discussed the mistake with the attending! This remarkably low percentage could be related to a lack of comfort and/or a power imbalance between resident and attending to discuss errors. We argue that there is not an adequate medical culture established to allow a healthy, free-flowing discussion about errors. Interestingly, 88% of the residents discussed the mistake with another physician who was not a supervisor. And only 24% of the residents reported the mistake to the patient or the families—again, the lack of comfort and uneasiness with the young trainee in the position of making an error. Although this chapter does elucidate the true lack of error reporting in residency, it also proves that constructive changes can occur after residents accept responsibility for the mistake and discuss it with the attending physician—not, however, in forums such as M&M. Indeed, 50% of the residents stated that the real issues were never discussed at M&M! As stated by Greenberg and associates,10 “According to both attending and resident surgeons, the most important personality trait for success in a surgical residency is the ability to admit error.” As Hilfiker11 stated, “We see the horror of our own mistakes, yet we are given no permission to deal with their enormous emotional impact. The medical profession simply has no place for its mistakes.”
Is Morbidity and Mortality Conference Enough? It seems obvious that if the most important component of a successful surgeon is, first, the ability to admit error and, second, to deeply ponder the issues surrounding the error, then the M&M conference should be one of the most critical aspects of residency training. Unfortunately, this may not be so.
1 FROM ERROR TO PERFECTION: THE PROCESS OF SURGICAL MATURATION When looking at error response at M&M conferences, a prospective review of 332 M&M conferences in internal medicine (n = 232) and surgery (n = 100) was conducted at an academic medical center.12 Piernissi and coworkers12 showed that M&M conferences may have considerable room for improvement. Only 38% of the errors in medicine and 79% of the errors in surgery were attributed to a particular cause, even though cases were discussed longer in medicine (34.1 min) than in surgery (11.7 min). In addition, fewer internal medicine cases (37%) versus surgical cases (72%) included adverse events. In both medicine and surgery, when errors were discussed specifically as errors, only 40% were discussed explicitly. So what exactly is happening at these conferences? As surgical educators, we are aware of the Accreditation Council for Graduate Medical Education (ACGME) requirements that “All deaths and complications that occur on a weekly basis should be discussed.” Interestingly, not all specialties mandate a weekly complications conference.
HOW DO WE ACHIEVE PERFECTION? THE GIFTED AND TALENTED The Gifted Response to Error Clearly, the success of any surgeon is related to how he or she will respond to errors that will inevitably occur. Going beyond surgery, many believe success in life is linked to our responses to error. Gladwell8 was interested in studying those special people that ultimately achieve colossal success in life (Fig. 1–3). His article, entitled “The Physical Genius,”8 discussed characteristics that link Wayne Gretzky, the brilliant hockey player, YoYo Ma, the gifted
Figure 1–3 Malcolm Gladwell. (Courtesy of www.gladwell.com, Brooke Williams photographer.)
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cellist, and Charlie Wilson, a brilliant neurosurgeon at the University of California at San Francisco (UCSF). Gladwell discovered that one of the most important traits these people all shared was their drive for flawless, error-free performances. Gladwell described the inherent traits of Don Quest, a neurosurgeon at Columbia Presbyterian Hospital in New York, and what makes him so successful. Yes, Quest believes that fine motor skills and swift decision making are important, but are of little value without the right sort of personality. After studying the successful and failing neurosurgery residents, Bosk8 described the “Quest” personality as those with “a practical-minded obsession with the possibility and consequences of failure.” “Physical geniuses are driven to greatness because they have found something so compelling that they cannot put it aside.”8
The Power of Visualization and “Chunking” Not only do these gifted individuals deliberate on the mishaps, but they all have a keen sense of visualization and are able to live in what is almost an extra dimension of reality as well. Gretzky has the capacity to pick up on subtle patterns in the hockey game that others generally miss; he commonly says that he sees the entire rink, not where the puck is, but in fact—where the puck will be. Brilliant surgeons can simultaneously look at tissue planes and look beyond the recognized anatomy to what lies behind the operative field. As Charlie Wilson described in Gladwell’s article,8 “an ability to calculate the diversions and to factor in the interruptions when faced with an internally confusing mass of ‘blood and tissue’ ” is the true description of the gifted and talented surgeon. The ability to visualize has been described in detail by Stephen Kosslyn, who discussed four separate human capacities working in combination.8 The first ability is to generate an image, that is, take something out of longterm memory and reconstruct it. Second, visualization requires image inspection. Take the mental image and draw inferences from it. This clearly requires moving from that image with visualization and making it real and applicable to wherever you are currently working, whether on an operating field, a basketball court, or a hockey rink. Third is image maintenance, the ability to hold the picture steady so that you can actually make real time and actually utilize that visualization for practical purposes doing what you are currently doing right now. Lastly is image transformation, the ability to take the image and manipulate it. This means to look at it from multiple views, rotate it 45°, 90°, or 180°, so that these views will allow you better capacity to utilize it again during your immediate need. Many gifted athletes have discovered that these processes can be learned and practiced during mental training exercises. In addition, the process of visualization in the gifted mind occurs through patternized thought. The concept that enables the mastermind to achieve success
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is called “chunking.” Chunking describes how our mind stores familiar sequences. Bobby Fischer, the brilliant grand master chess player talked about seeing patterns, not individual pieces on the board. Michael Jordan practiced visualization regularly. He would see the basketball court and see multiple patterns of defenses that could be thrown up against him in any given game. He chunked these typical patterns together and would be able to respond to these typical patterns quickly. Master surgeons also chunk together the sequences in operations that they have performed so many times—they can see where they will be in the operation in 10-, 20-, and 30-minute intervals. Chunking patterns together enables these brilliant individuals to respond quickly to error . . . and prevent the mistake before it happens because they have been in this situation so many times before.
THE FUTURE . . . A MEDICAL CULTURAL UPHEAVAL Should We Teach the Reproducible and Predictable Errors We Make? Training must include . . . a consideration of safety issues. These issues include understanding . . . how errors can occur at various stages . . . and instruction in methods for avoidance of errors.4 Our interest in error training arose from an article on a step-by-step approach to the laparoscopic Nissen fundoplication.13 With each defined step, we identified specific pitfalls that could potentially occur at each step. After this article was published, our residents clamored for similar articles or modules for every operative procedure in general surgery, and we began to ask the question, should this be the way we teach surgery: how to, but also how NOT to?
THEORIES OF HOW WE ACQUIRE TECHNICAL SKILLS The Fitts and Posner Model In order to understand the processes and bases of teaching technical skills, we must comprehend, on a theoretical level, how we acquire skills. The concept of skill acquisition is surprisingly constant throughout human experience. Although Reason6 and Rasmussen and Jensen5 set the foundation for understanding these processes, the eloquent and notable treatise, Human Performance, by Fitts and Posner14 outlined the three fundamental phases for acquiring “performance-based skills” (Fig. 1–4). The first is the cognitive phase. During this cerebral phase, we actively intellectualize the skill or procedure. For example, we may outline the specific, detailed steps of an individual procedure and analyze the reasons and rationale for it.
THE FITTS AND POSNER MODEL* Cognitive phase
Autonomous phase
Associative phase
*Human performance, 1969.
Figure 1–4 Fitts and Posner model. (From Fitts P, Posner MI. Human Performance. Belmont, CA: Brooks/Cole Publishing, 1969.)
The second, more active, phase of skill acquisition is the intermediate or associative phase. During this phase, our “old habits which have been learned as individual units during the early phase of skill learning are tried out and new patterns begin to emerge.”14 We link our thought process with action: in our case, utilizing eye-hand coordination. This phase can last for a very short or a very long time, depending on the complexity of the procedure. The associative phase is interesting because here we develop “subroutines” that make up parts of the whole skill. We integrate and compile these subroutines in order to learn the entirety of the skill. In addition, repetition of each subroutine and each skill is important during this phase. Fitts and Posner14 actually studied modes of repetition and showed that too-frequent repetition within a short period of time will “result in a greater depression in performance than the same amount of repetition with more frequent rest” (p. 13). Moreover, if there are components of the skill that are completely independent of each other (e.g., typing different passages with separate hands), it is actually better to practice each component separately (p. 14). The third and final phase of skill acquisition is the autonomous phase. The autonomous phase occurs when we feel we have intrinsically “learned” a task or procedure. The individual processes and subroutines become autonomous, less subject to any cognitive control or any outside interference or environmental distraction. The individual practitioner has become unconsciously competent in performing the task. To reach the autonomous phase requires extensive practice such that the motor skills reach the unconscious mode or become automatic. Much has been written about what are optimal practice patterns, but probably no one has written more than Ericsson15 at Florida State University. Ericsson’s writing on deliberate practice is broad based and covers a variety of fields including sports, music and the arts, and also medicine and surgery. He defined three components of deliberate practice: (1) focus on a defined task to improve a particular aspect of performance (which is measurable), (2) repeated practice, and (3) immediate coaching and feedback in performance.15 Whereas most young trainees hope to achieve
1 FROM ERROR TO PERFECTION: THE PROCESS OF SURGICAL MATURATION the autonomous phase in their growth and development such that they are able to perform what is perceived as a high performance level, there is an interesting twist to automaticity in any defined skill. By Ericsson’s perspective, automaticity actually leads to an arrested phase of growth in one’s personal development of her or his own skills. As an example in the practice of surgery, residents and young surgeons after multiple repetitive operations in the same area finally achieve a phase at which they are comfortable with the operation and are able to, for the most part, perform in an unconsciously competent fashion, meeting the definition of automaticity (or the autonomous phase in the Fitts and Posner model14). This level of competency is the point at which they have reduced most of their obvious gross errors such that they are perceived by their peers as being “an excellent practitioner” and may in fact, in their own mind, now have reached expert status. Again, as Ericsson15 defined it, the failure to attain expert status comes because of complacency with competency. As Ericsson views it, “for aspiring expert performers . . . they must avoid the arrested development associated with automaticity and to acquire cognitive skills to support their continued learning and environment.”15 Or, to restate it more bluntly, “Although everyone in a given domain tends to improve with experience initially, some develop faster than others and continue to improve during ensuing years. These individuals are eventually recognized as experts and masters.” “In contrast, most professionals reach a stable average level of performance within a relatively short timeframe and maintain this mediocre status for the rest of their careers.” This quote from Ericsson is not to suggest that the majority of surgeons practicing are “mediocre” in their practice, but it does emphasize and elucidate the point that reaching a level of competency may work against achieving expert status because of the complacent nature that the individual practitioner views his or her capacity to perform.
Error Training and Cognitive Remodeling in the Fitts and Posner Model Somewhere along the learning curve of any given skill, errors are made and learned. By understanding how we acquire skills and where we learn errors, we can hope not only to unlearn the errors but also to prevent them from being learned. Fitts and Posner14 made a brief reference to the concept of errors when they mentioned where mistakes can occur during skill acquisition, but certainly no attention was given to the process of preventing mistakes during skill acquisition. Thus, we propose an extension to the Fitts and Posner model14 with an interval phase of error training, which enters the three-phase model after the cognitive phase (Fig. 1–5). Introducing error training during skills acquisition allows us to emphasize the errors we inherently
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THE FITTS AND POSNER MODEL* Cognitive phase Cognitive remodeling phase
Autonomous phase
Error training phase
Associative phase
*Human performance, 1969.
Figure 1–5 Fitts and Posner model of error training and cognitive remodeling. (From Fitts P, Posner MI. Human Performance. Belmont, CA: Brooks/Cole Publishing, 1969.)
make while gaining skills. These errors are commonly predictable and, unfortunately, durable. Conversely, while we learn a given skill set, we can preemptively recognize the common errors that will occur for the given skill set so as to NOT learn them. It is crucial that error training occurs prior to the intermediate or associative phase when actions become more innate and intuitive. We may all know that the worst error made is one that is not recognized. In addition, we propose that there is a cyclical way that we learn and perform skills so that cognitive remodeling occurs as we become more knowledgeable and more experienced in the procedure. After a prolonged period of time performing the same procedure, we begin to rethink the procedure and how we carry out the task. We recognize where we can move quickly and where we must move slowly in an operation, we eliminate wasteful movements, and so on. This cognitive remodeling is a desired process as surgeons mature in their approach to a specific procedure. It is this dimension of “error training” that we hope to emphasize in this book. It should be central to how we learn skills and, moreover, is crucial to understand as we train residents and young surgeons in our craft. By recognizing pitfalls while we train, and focusing on the ways to eliminate them, we start to look at the procedure differently, from a more careful perspective. We think about how we do the operation, how to refine it and to establish more efficient and effective steps in the ultimate polished and perfect result. It may not be too far-fetched to argue that a focus on error training may prove to be an extremely useful part not only of the medical educational processes of performance-based skills, but also of the global patient safety initiatives that we hope may change the way we practice medicine. To help answer this question, Rogers and colleagues16 at Southern Illinois University published an elegant but quite simple study to show the impact of error training. Thirty senior medical students were assigned to one of four different training groups to learn two-handed knot tying. The groups included (1) no training, (2) error training only, (3) correct training only, and then (4) error training plus correct training. They then compared all four
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groups. Overall, 11 errors were identified; the 4 most common accounted for 75% of the total errors. Too much right-handed motion accounted for 38% of the errors; failure to maintain consistent tension, 17%; hands too close to the knot, 17%; and failure to cross the hands, 7%. Rogers and colleagues16 showed that common and even predictable error training coupled with correct skills training clearly leads to superior skills acquisition. One could extrapolate from this that, in fact, predictable errors can be identified and delineated from virtually any operation and utilized in global skills training. In Way and coworkers’ article7 outlining common bile duct injuries in laparoscopic cholecystectomies, the errors were not only predictable but in fact also reproducible. Would it improve national outcomes if the resident and practicing surgeon learning the basics of the laparoscopic cholecystectomy also learned the steps that lead to prevention of these described errors? Let us look at this a little differently. Can the ability to detect errors during an operation when observing someone or observing videos have any correlation to skill level? Bann and associates17 took 38 volunteer surgeons and recruited them to undertake three exercises. Two of these were bench-top tasks that were scored using Objective Structural Assessment of Technical Skills (OSATS) global rating techniques. The third was the ability to detect simple errors in 22 synthetic models of common surgical procedures. Those volunteers who were able to detect errors clearly performed with a higher technical ability than those who could not (P < .5). Does this simply mean that those individuals who can detect errors as an external observer are more sophisticated in their ability to carry out the procedure? This study would certainly make that argument, and in fact, understanding errors in skills acquisition is probably an additional level above and beyond what individuals are currently trained to do.
Information Overload The downside of error training is information overload. Just learning how to do a procedure, on both a cognitive and a technical level, can be overwhelming for trainees and young surgeons. The vast majority of textbooks and analysis in surgery are geared toward how to do the operation, not how NOT to do the operation. We may think that we all respond differently to information overload, but Miller18 in the 1960s studied the human response to this excessive input and discovered three broad responses. First, we may work faster and faster, trying to somewhat battle the input, and continue to let errors occur, just hoping to finish the learned task. The second response is to disregard or filter out part of the information that we are trying to learn so as to learn only a part of the whole. The third response to information overload is called queuing, in which our brain places the input messages on hold and asks them to wait in line. The information becomes backed up and then one by one filters back in slowly but methodically.
Unfortunately, in the process of learning a complex operation and simultaneously learning how not to do the operation could lead to a complete disregard or foraging out of part of the information. But we do not think this warning should inhibit us from focusing on teaching technical errors. E. F. Schumacher, a Nobel laureate who wrote Small Is Beautiful and also A Guide for the Perplexed, is quoted in the latter book on how we should approach an issue that is as complex as the issues centered around patient safety, medical mistakes, and resident error training: “Can we rely on it that a ‘turning around’ will be accomplished by enough people quickly enough to save the modern world?” This question is often asked, but whatever answer is given to it will mislead. The answer “yes” would lead to complacency, the answer “no” to despair. It is desirable to leave these perplexities behind us and get down to work.
Error Training The most fruitful lesson is the conquest of one’s own error. Whoever refuses to admit error may be a great scholar but he is not a great learner. Whoever is ashamed of error will struggle against recognizing and admitting it, which means that he struggles against his greatest inward gain.—Johann Wolfgang von Goethe (1749–1832), Maxims and Reflections As we began studying human performance, technical skills acquisition, the gifted and the talented, resident training, and medical mistakes, we realized that we may need a novel approach to how we think about surgery. More importantly for the future, a novel approach to how we teach our craft. We cannot expect that we will all study the Fitts and Posner model14 with error training and cognitive remodeling and hope that this will be a basis to enhance skills performance and to, ultimately, minimize technical errors. Little has been published on surgical errors and error prevention. Anatomic Complications of General Surgery, Skandalakis and coworkers’19 beautiful book published in 1983 (currently no longer in press), is a staple and mainstay for many surgeon’s libraries. Greenfield published his book, Complications in Surgery and Trauma, in 1984.20 It was updated by Mulholland and Doherty as Complications in Surgery in 2006.21 However, the focus has not been on purely cognitive or technical errors. However, something still seems to be missing because we continue to see the same mistakes over and over again. It is quite clear that errors will always occur from the level of the intern all the way to that of the gifted surgeon. The mechanisms of errors are slowly being understood, both from a theoretical perspective and also from an extremely practical perspective. The common mistakes that are made technically and cognitively for each disease and for each operation are now becoming more clearly
1 FROM ERROR TO PERFECTION: THE PROCESS OF SURGICAL MATURATION understood, and these common repetitive errors are predictable and allow an excellent opportunity for error training that is individualized for each procedure and each diagnosis. In addition, responses to error are poorly developed, poorly role-modeled, and poorly implemented— making it difficult for surgical trainees, young surgeons, and experienced surgeons alike. The concept of error training may clearly play an important and significant role in error reduction. This textbook attempts to define specific technical and cognitive errors for a large breadth and depth of operations in surgery with the hope and intent of establishing a comprehensive encyclopedia of pitfalls that can occur in surgery that can be utilized by both young and old surgeons for years to come. Nothing stands out so conspicuously, or remains so firmly fixed in our memory, as something in which we have blundered.—Cicero, De Oratore, I, 129
REFERENCES 1. Institute of Medicine. To Err Is Human. Washington, DC: National Academies Press, 2000. 2. Leape L, Berwick D. Five years after To Err Is Human— what have we learned? JAMA 2005;293:2384–2390. 3. Brennan TA. The Institute of Medicine report on medical errors—could it do harm? N Engl J Med 2000;342:1123– 1125. 4. Leape L. Error in Medicine. JAMA 1994;272:1851–1857. 5. Rasmussen J, Jensen A. Mental procedures in real-life tasks: a case-study of electronic trouble shooting. Ergonomics 1974;17:293–307. 6. Reason J. Human Error. Cambridge, MA: Cambridge University Press, 1992. 7. Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries. Ann Surg 2003;237:460–469.
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8. Gladwell M. The physical genius. The New Yorker, August 2, 1999; pp 57–65. 9. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA 1991;265:2089–2094. 10. Greenburg A, McClure D, Penn N. Personality traits of surgical house officers. Surgery 1982;98:368–372. 11. Hilfiker D. Facing our mistakes. N Engl J Med 1984;310: 118–122. 12. Piernissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA 2003;209:2838–2842. 13. Evans SRT, Jackson P, Czerniach D, et al. A stepwise approach to laparoscopic Nissen fundoplication: avoiding technical pitfalls. Arch Surg 2000;135:723–728. 14. Fitts P, Posner MI. Human Performance. Belmont, CA: Brooks/Cole Publishing, 1969. 15. Ericcson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79(suppl 10):570– 581. 16. Rogers DA, Regehr G, MacDonald J. A role for error training in surgical technical skill instruction and evaluation. Am J Surg 2002;183:242–245. 17. Bann S, Khan M, Datta V, Darzi A. Surgical skill is predicted by the ability to detect errors. Am J Surg 2005;189:412–415. 18. Miller JG. Adjusting to overloads of information. In. Rioch DM, Weinstein EA (eds): Disorders of Communication. Research Publications, Vol 42. New York: Association for Research in Nervous and Mental Diseases, 1964; pp 87–100. 19. Skandalakis JE, Gray SW, Rowe JS. Anatomic Complications in General Surgery. New York: McGraw-Hill, 1983. 20. Greenfield LJ. Complications in Surgery and Trauma. Philadelphia: JB Lippincott, 1984. 21. Mulholland M, Doherty G. Complications in Surgery. Philadelphia: Lippincott Williams & Wilkins, 2006.
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Teaching Technical Skills—Errors in the Process Hugh M. Foy, MD and Stephen R. T. Evans, MD INTRODUCTION The primary duty of a surgical educator is to help instill the knowledge, skill, and attitudes that will help develop the trainee into the very best surgeon possible. Experience tells us that the success of an operation depends on innumerable factors, some controllable, others not. A successful operative procedure is the cumulative sum of thousands of perfectly done steps. It follows logically that our primary responsibility as surgeons is to ensure that our technical input is as perfect as possible, given that much else is subject to chaos, chance, and the attention of others. When teaching surgical technique, it becomes even more important to ensure the quality of our craft by our precise and professional instruction of our residents, while at the same time allowing the necessary “graduated responsibility” that is important for the professional development and maturation of a surgeon.1a Our technical input is, in fact, the only factor that is in our direct control. The other external factors—the patient’s premorbid state, anesthetic care, alteration in normal physiology and unanticipated physiologic deterioration—are far less controllable. All of these conditions continually threaten the surgeon’s best intentions and technical skill. A surgeon’s technique must, therefore, be as perfect as possible in order to tip this precarious balance in the favor of the restoration of the patient’s health. As Bosk remarked in his wellknown sociologic study of surgery training, Forgive and Remember, “Every time a surgeon operates, he is making book on himself. Besides the enormous amount of theoretic and technical expertise that is his cognitive capital, the surgeon carries in his head an odds-book for each procedure.”1 Much attention had been focused on how the principles of aviation safety and training might apply to the practice of medicine in general and, specifically, the training of surgeons.2 Training strategy in both aviation and surgery share some important similarities: (1) They require a body of prerequisite knowledge; (2) They are highly technical; (3) They are done in the setting of unforgiving circumstances; (4) They require quick, precise decision making;
and (5) They require a sequence of subroutines and graduated responsibility. The fundamental inescapable fact in both activities is that human life is held in a precarious position: Our patient’s life is suspended by general anesthesia as the plane and its pilot are suspended in the air by aeronautical engineering. Both medicine and aeronautical engineering are constantly defying unforgivable laws of nature. Ignore either of these basic supports during the endeavor and death is imminent. Both activities are pressed by time, are charged with intensity, and occur in a variable physical environment in which errors can quickly result in morbidity and mortality. Both require training, skill, practice, and quick decisions that are often made with limited data. However, important differences between training surgeons and training pilots limit the application of the aviation model to surgery. Recently, a consulting firm has even proposed to help apply the principles of the highly technical training of fighter pilots to surgical programs and to our professional organizations that seek to improve the training of surgeons. The differences are notably in the setting, engineering parameters, and the resultant simulation equipment. Pilot training in the last several decades has occurred in a very controlled setting. Candidates are selected after extensive examination with batteries of tests grading their intellectual, physical, psychomotor, and emotional abilities. Before any actual flight training begins, they attend months of didactic lectures in “ground school,” learning the principles of aeronautic engineering, meteorology, and finally, the engineering specifics of generic and individual aircraft. The previously described process sounds fairly similar to our medical schools’ curriculum in the basic sciences and clinical clerkships in the various medical specialties. Aviation, however, is much more focused and, by its very nature, precisely defined, described, and quantified by the principles of aeronautical engineering. As a consequence, simulation techniques have been somewhat easier to develop. Equally significant, the threat of war and a substantial military budget helped catapult the field of flight simulation in its inception during the days leading up to World War II.
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SECTION I: GENERAL CONSIDERATIONS
Actual flight training begins in a simulator, safe from the unforgiving reality of gravity. When the student proves proficient, she or he takes to the air in a real plane with an instructor. Obviously, pilots must learn to fly in less threatening, noncombat conditions before they learn the more complicated and dangerous skills of air-to-air combat. Further screening and selection finally distills the pool of aviators to the select group of highly skilled fighter pilots. Here, too, however, training is done in the absence of “live fire” from a real enemy. Ironically, military aviation has not been faced with a real-life, direct lethal threat from a capable enemy force for more than 50 years, other than occasional fire from surface-to-air defensive missiles. The enemy is usually a colleague who chases the trainee through the air or a computerized threat in a highly developed virtual environment. Following the live flight exercise, the scenario is reviewed and dissected in a lengthy “debriefing” often lasting many hours. In stark contrast, surgery training has traditionally been conducted under the live fire of a real patient who may suffer dire consequences from our mistakes. In decades past, the instructor was often a senior resident, with barely more experience than the learner. In addition, a very large portion of surgical education occurs in our large, mostly public-sector, “safety-net” hospitals and trauma centers in which logistic challenges heighten the high stakes of a real-live patient. Ironically, all too often, the number of patients and the serious degree of their illness are inversely proportional to the logistic support and supervision provided to the trainee. Our trauma centers often serve as our major training centers in which precious little time is available to methodically train residents in the aviation paradigm. Fortunately (and ironically), supervision by attendings has improved as a result of considerable pressure and actual laws enacted and strictly enforced by the federal government that require the attending to be physically present in the operating room in order to be paid. Unfortunately, a frequent occurrence in this resourceconstrained environment is for the attending to find himself or herself trying to juggle several overlapping cases with trainees who have little prior experience. It is exactly these constrained resources and variable experience of trainees that may make aviation-based models all the more important and potentially helpful adjuncts to our classic training model of “see one; do one; teach one.” The knowledge of such approaches can help make the surgical instructor more efficient and the resident better educated. Often, the “teaching moment” is effectively the only opportunity for the teacher to cover the various tenets of surgical and technical training, from the assessment of the resident’s prior experience to the review after the case of “what might we have done differently.” Surgical educators, lacking the luxury of hours to accomplish activities like their counterparts in aviation training, must recognize and make effective use of these fleeting “teaching moments” to ensure the safe conduct of the patient’s surgical care.
Our primary objective as surgical educators should be to present to the trainee the most basic, conservative, reliable, and safe techniques. Short cuts that require advanced clinical judgment can be saved for later as the resident matures. First and foremost, the trainer must emphasize attention to detail, adherence to Hallstead’s principles of surgery, and consideration of the emotional needs of the patient and staff. It all boils down to what they know, what they can do with their hands, and what they do with their hearts—otherwise known as the cognitive, psychomotor, and affective domains of learning.
BASIC PRINCIPLES OF SURGICAL TECHNICAL INSTRUCTION AND LEARNING Until recently, little has been written regarding the theory and tenets of teaching and learning in the operating room (OR). The advent of minimally invasive or videoendoscopic surgery heralded by the development of laparoscopic cholecystectomy in the late 1980s and its unforgiving two-dimensional perspective stimulated a renaissance in surgical technical training. From the days of Halstead, certain fundamentals have been espoused but rarely written. Recently, hundreds of articles have been published as attention to skills training has virtually exploded. Consistent with Halstead’s reclusive nature, his principles remain more the oral, rather than the written, tradition of surgery. During the development of the first formal training program for surgeons in this country, Halstead would admonish his trainees to carefully consider the root cause of any technical complication. These principles are best remembered in the order in which they are applied during the normal course of an operation: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Aseptic technique. Adequate exposure. Cutting under tension and countertension. Adequate hemostasis. Gentle handling of tissues. Débridement of devitalized tissue. Obliteration of dead space. Assurance of adequate blood supply. Avoidance of excess tension on the suture line.
The specific conditions and psychomotor training principles have been outlined in various resources and can be helpful in discussing complications that may result from a lack of appreciation and application by the surgical instructor. Learning any motor skill is distinctly different from learning verbal or intellectual skills. Motor skill learning requires application of a “chain of responses,” or ordered, linked tasks, that cannot be accomplished until the preceding task is finished. Like the sign above the confused cartoon character’s bed: “pants first, then shoes.” The precise incision cannot be made until the right amount
2 TEACHING TECHNICAL SKILLS—ERRORS IN THE PROCESS of tension and countertension is applied to the skin. The suture cannot be tied until it is precisely placed in the bowel wall. The artery should not be incised before proximal and distal control are obtained. This succession of tasks has also been described as the “organization of subroutines.”3 Certain conditions make learning a technical skill more likely. Contiguity, or the repeated attempts in close chronological sequence under similar but slightly different conditions, will greatly enhance learning. One cannot learn to ride a bike by trying once today and repeatedly at monthly intervals. Repeated attempts allows for repeated corrective actions. Corrections in one’s technique on repeated trials will oscillate about the mean, which is the desired behavior. Learning a very complex skill like slalom water-skiing is extremely difficult and can be accomplished only by repeated corrections in which the novice first leans too far forward, then too far back, incrementally making smaller adjustments, and finally, on the 10th or 12th attempt stands up, propelled by perfect tension on the rope that transfers the force and speed of the boat. Neither learning to ride a bike nor learning slalom skiing can be achieved while standing still. Both require movement, momentum, and real-time feedback by an instructor. The same is true of operative skill. Analysis of common bile duct injuries in the early years of laparoscopic cholecystectomy revealed that most injuries occurred in the first 12 to 20 attempts at the procedure, implying that a plateau of initial competence was more likely after a dozen or so attempts.4 The intern will never learn more about inguinal herniorrhaphy than when she or he performs three such cases in a single morning. Here, they can finally appreciate the subtle differences in the variable muscular and aponeurotic contributions of the internal oblique muscle, the variance in the size and shape of the hernia sac, and other inherent differences in anatomy and pathology, while the basic steps and repair technique remain constant.
THE OPERATIVE PROCEDURE: SETTING, LOCATION, AND PITFALLS Much attention has been given to the technical or the psychomotor aspect of performing an operation: the actual cutting and sewing of tissues during the procedure. All domains of learning are important contributions to the learning of the trainees and the successful outcome of their patients. Learning theorists maintain that there are three classic domains of learning: cognitive, psychomotor, and affective. Chronologically, the operative learning experience can be said to have three periods: preoperative, intraoperative, and postoperative. In each period, all three domains of learning are important, but one may often predominate. In the preoperative phase, the cognitive domain is predominant. A careful interview of the patient, applying the skills first introduced in medical school, is
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vital to extracting important information regarding the unfolding of the symptom complex in a pattern from which a provisional, clinical diagnosis is made. Inattention to detail, either in the patient’s history or in the review of his or her previous records and diagnostic studies, can have significant deleterious effects on intraoperative decision making and postoperative management. Lack of psychomotor skill in performing a physical examination can also be problematic. Obtaining an informed consent from the patient is one of the most demanding of all affective tasks facing the surgeon. Informed consent is much more than merely having the patient or their representative sign a form. Unfortunately, all too often this task is delegated to a more junior team member, sometimes one not even involved in the actual operation. A properly done informed consent involves several steps: Step 1 Step 2
Step 3 Step 4
Step 5
Step 6
Education of the patient. Description of the differential diagnosis and relative degree of certainty of the working diagnosis based on available information and tests. Explanation of the indications and steps of the proposed procedure. Mention of alternative forms of treatment, their relative success rates and why the proposed procedure is, in the judgment of the surgeon, the preferred alternative. A description of the possible complications, both generic (such as bleeding, infection, and the risk of anesthesia) and also ones more specific to the particular operation. The expected postoperative course and eventual outcome.
PREOPERATIVE PITFALLS— COGNITIVE PHASE OF SKILLS ACQUISITION Most of the work of the preoperative phase involves the cognitive realm of learning and the cognitive phase of skills acquisition. The indications of the operation should be clear, and the intellectual preparation should be accomplished through studying the appropriate educational materials and thoroughly reviewing the patient’s history, examination, and diagnostic studies. However, more subtle tasks need to be attended to: (1) performing a “learning needs assessment (LNA),” (2) defining goals and objectives, and (3) familiarizing oneself with the necessary equipment to be used.
Learning Needs Assessment LNA is the process of determining the previous experience of a learner so that the teacher can better tailor the instructional focus to the individual resident or student. Failure to accurately inquire and appreciate the prior experience
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SECTION I: GENERAL CONSIDERATIONS
and knowledge can result in inefficient and unnecessary frustration for both the attending and the resident and affect patient outcome. Underappreciation of a learner’s capabilities may result in hovering unnecessarily, teaching skills she or he has already mastered, and wasting the time of all involved. This is more likely to be the case early in the academic year. As the year progresses, it is more likely to occur at the beginning of a rotation in a larger program in which the attending may have little or no prior experience or knowledge of the newly arrived resident on the service.
Basic Principle Prior to beginning the procedure, the attendings must obtain knowledge of the operating residents’ prior experience. They must “ask the learner.” The teaching assistant must not assume but must ask the resident what his or her prior experience has been, including (1) factual or cognitive knowledge of the case, (2) prior operative experience, and (3) awareness of common pitfalls and complications. It is critical that the attending establish the level of instruction necessary to avoid either overestimating or underestimating the resident’s ability. Overestimating a resident’s abilities can have disastrous consequences. Conversely, underestimation of technical ability carries the risk of insulting the trainee and wasting precious time. In smaller programs, this is less likely a problem because attendings and residents often spend more time together in longer rotations characterized by more intimate contact in the OR. In larger programs spread across several integrated institutions, this is less likely and a careful LNA is of critical importance. In addition, attendings may overestimate residents’ abilities based on their own prior experience delving into their memory of decades long passed. Often, one hears the admonition, “Why a chief resident should be very capable of doing a routine colectomy with a junior resident.” Such an assumption may be based on the attendings’ memory of their training program in decades past in which direct attending supervision was sparse as best, particularly on emergency cases at night. Surgery has changed dramatically in the last several decades. Most notably, attending presence in the OR has significantly increased. More recently, the 80-hour work week restriction has compounded the insidiously diminished independent responsibility of the resident. We can no longer make assumptions based on the past. Sound practice is to include the LNA in the preoperative checklist in order to avoid potential disastrous complications based on false assumptions, as illustrated in the following scenario. Example: Overestimating a Resident’s Capability A patient is brought to the emergency room with a stab wound in the left third intercostal space in the midclavicular line. The patient is hypotensive with signs of cardiac tamponade. The chief resident, now halfway through her or his final year, is known to be one of the best in the
program, seasoned with 2 extra years in the laboratory and accepted as a good team leader. The attending assumes that she or he has the prerequisite knowledge of cardiac repair and stands by ready to help. After the resident deftly performs an anterolateral thoracotomy, incises the pericardium, and relieves the tamponade, the patient improves. A 1-cm, nonbleeding laceration in the right ventricle is noted and repair is attempted with a running suture using a monofilament suture, which tears the ventricle and results in massive hemorrhage. Fortunately, the attending looking over the resident’s shoulder is finally able to repair the enlarged wound with a generous supply of pledgets and appropriately placed horizontal mattress sutures. If only one could live the last few moments over again and simply ask the resident, “Have you ever sewn a laceration in a beating heart before?” Grade 4 complication Alternative Scenario
Before beginning the thoracotomy, the attending turns to the chief resident and asks if she or he had ever sewn a traumatic laceration in a beating ventricle, making sure to distinguish the technique as uniquely different from closure of the atrium. The resident remarks that she or he has not, and the attending describes the appropriate technique of using horizontal mattress sutures over pledgets to help distribute the tension and avoid further injury. Discussion: Particularly in emergent cases, failure to accomplish an LNA in a timely, precise manner can have dire consequences. A precise and specific inquiry must be made of the learner, because transference from one technique in one anatomic structure cannot necessarily be made to another. As the example illustrates, the technique for closure of the atrium, commonly done in elective surgery after decannulation, is distinctly different from closure of a laceration in a beating ventricle.
Example: Underestimation of a Resident’s Experience On a busy Monday morning, the OR schedule is full. It is the beginning of the year, and the first case is a recurrent inguinal hernia in an obese patient. The chief resident hastily assigns residents to cases. Much to the attending’s chagrin, an intern reports to the OR to scrub on the case. The attending, faced with a busy schedule full of overlapping commitments, is disappointed and visibly agitated, complaining that a more experienced resident has not been assigned to this case, which will require skills in reoperative surgery far beyond the ability of an intern. Irate and upset, the attending lets his or her disappointment show, alienating not only the intern but also the circulating nurse, scrub technician, and anesthesiologist. The air in the room is icy cold, and tension runs high. Halfway through the case, a trauma code is called and the attending becomes further agitated as he or she realizes that the case cannot be left for the intern alone to proceed, even with the more mundane aspects.
2 TEACHING TECHNICAL SKILLS—ERRORS IN THE PROCESS Alternative Scenario
The attending takes a deep breath, holds his or her words of disappointment and gathers the best equanimity he or she can muster, reminding himself or herself that he or she is here, at this hospital, to teach and to teach all, regardless of ability. A flexible approach with the attending doing the more difficult part of the case is outlined as the case is briefly discussed with the resident at the scrub sink. As the case proceeds, the attending is surprised at the technical facility of the intern, particularly with dissection through the scarred tissue. Remarking at the intern’s skill, he or she is reminded that the intern is a transfer to the program, having recently immigrated to the United States after completing 4 years of training in the home country. When the trauma code is announced, the attending pages his or her partner to cover. Discussion: Performing an LNA is accomplished by simply asking the resident about prior experience with any particular procedure. It is best done early, before the procedure begins. A brief inquiry into the resident’s prior knowledge and experience in general and in a particular case helps better set the stage and adjust the attending’s expectations appropriately. Nothing can be more disappointing than false expectations unmet. Emotional control and attitude can prevent a chilling, negative atmosphere in the OR that affects all personnel. Done properly, an LNA sets the stage with realistic expectations and will more likely result in an educational activity characterized by the appropriate and productive levels of anxiety, preparation, and care.
Defined Goals and Objectives Basic Principle Before beginning any operation, it is important to precisely define the goals and objectives of the operation. Much attention has been paid to goals and objectives in clinical education, and most accrediting bodies require that these be put in writing for all rotations, programs, and even individual lectures. Simply stated, goals are what one wishes to accomplish and objectives are the means by which the goal is to be reached. Goals can be multiple, and if so, they must be prioritized. Objectives are the “how and what” of an operation. They can be both assigning appropriate roles for different members of the team and determining strategy for the operation. Sometimes, the goal of the operation is obvious: “Remove the gallbladder” is the goal in an elective cholecystectomy. In an exploratory laparotomy for an unstable trauma patient, the goals may be multiple and more obscure, particularly for the neophyte resident. Restatement of the priorities involved in more complex operations is important; otherwise, trainees may be distracted by less critical tasks at hand. When faced with multiple procedures in a single operation, it is helpful to lead the resident through the list of procedures necessary and assign their relative priority,
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keeping in mind that the most critical procedures must be done first in the event the patient becomes unstable and the operation is aborted or curtailed. In an exploratory laparotomy for trauma, the priorities are assigned along lines akin to the basic principles of resuscitation: (1) stop the bleeding, (2) control contamination, and (3) repair and reconstruct damaged structures if not deemed unwise and unsafe because of the dangerous triad of hypothermia, coagulopathy, and acidosis. In an otherwise stable patient in whom many different reconstructive or reparative procedures are needed, it is important not to burn any bridges nor to perform irreversible steps before other, less definitive intermediate steps are accomplished. The most important task should be accomplished first, such as performing the descending colostomy before reanastamosing the terminal ileum so as to not leave the patient with a blind loop obstruction of the ascending colon with no route of decompression if the case needs to be terminated early. Similarly in any individual procedure, one should not divide the colon before the mesentery is first mobilized and taken down and the vessels ligated. Assigning the precise roles of the members of the surgery team before the operation begins is critical so that each individual’s expectations are clear and appropriate and confusion is subsequently minimized. Typically, only one person can direct the operation as the teaching first assistant, whether it is the attending or the chief resident. If both the attending and the senior resident are scrubbed in to help a junior through the case, then the roles should be defined ahead of time. Often, the attending will act as second assistant, chiming in with tips to help the case move along more smoothly.
Example: Unclear Assignment of Operative Roles An unstable patient is brought expediently to the OR after an ultrasound revealed a large amount of blood in the peritoneal cavity. The 3rd-year resident rotating on the service from another affiliated program missed the orientation session the day before and arrived in the OR eager to do the laparotomy, “get the numbers,” and fulfill her or his operative trauma experience required for completion of residency. She or he was unaware that the trauma service policy was for all unstable patients’ cases to be done by the chief resident until hemorrhage control is established and the case is deemed appropriate for a less experienced resident to be the “primary surgeon”. She or he steps up to the patient’s right side and helps drape the patient, eager to accept the scalpel and begin. The attending arrives, asks her or him to step back so that the chief resident can begin. The visiting resident, visibly disappointed and upset, reluctantly agrees. Over the course of the next several days, she or he is sullen, argumentative, and uncooperative. She or he complains to her or his home program director who calls the chief of trauma to complain.
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SECTION I: GENERAL CONSIDERATIONS
Alternative Scenario
Unable to either turn back the clock or completely orient the visiting 3rd-year resident before the emergent case, the chief resident informs her or him of the policy for the chief resident to perform the case with the attending until the patient’s stability is ensured. The chief resident apologizes and refers the 3rd-year resident to the section in the orientation packet that states the policy and where in the coordinator’s office a copy can be picked up. The chief resident asks that the 3rd-year resident assist if the attending is delayed in arriving to the OR.
Example: Lack of Prioritization of Multiple Operative Tasks The same trauma patient, when explored, is found to have ruptured spleen, extensive mesenteric lacerations, and multiple bowel perforations. All four quadrants are packed off, which appears to control the hemorrhage from the left upper quadrant. The bleeding mesentery is examined and the vessels ligated. The sigmoid colon has deep, fullthickness injuries through the wall with fecal spillage. The residents débride the edges and close the sigmoid injury in two layers. Suddenly, the anesthesiologist announces that the patients’ blood pressure is 50 mm Hg, and the laboratory panel returns with evidence of worsening acidosis and coagulopathy. Still, little or no blood seems to be coming from the left upper quadrant. The patient develops high inspiratory pressures and nearly arrests. The packs are removed from the splenic fossa to reveal that the ruptured spleen has been bleeding into the chest through a 6-cm-long posteromedial tear in the diaphragm. Alternative Scenario
The teaching assistant calmly reiterated the principles and priorities as the abdomen was being opened, helping all involved to understand the priorities involved. After ligation of the bleeding mesentery, the colon injury is quickly stapled off, leaving the repair or diversion for later. The left upper quadrant is reexplored, the spleen mobilized and removed, the diaphragm repaired, and a left chest tube placed. Discussion: Goals and objectives for any learning opportunity need to be clearly stated to all members of the team before proceeding. Preferably, this can be accomplished before the operation: in a preoperative planning conference or at the scrub sink after LNA has been done. In emergency cases, it should occur as the team is assembled and the surgeons are gowning, draping, and making the incision. It takes only a minute. If neglected or omitted, it can have catastrophic results. The teaching moment is often just that long, and the opportunity can be lost just as quickly.
Equipment Familiarization Basic Principle For many generations, most surgical procedures were fairly constant in their design, conduction and equipment.
Since the late 1980s there has been an explosion in the approach, technology, and innovation spurred on by minimally invasive surgery. In the early years of laparoscopic cholecystectomy, many complications occurred owing to lack of appreciation of the lack of depth perception in this new two-dimensional environment, unfamiliarity with newly developed equipment, and hidden liabilities of certain, seemingly innocuous aspects like CO2 insufflation. Technical adaptations of the procedure, anticipation of potential complications, and improvements in instrumentation have overcome many of these challenges. Regardless of these advances, it remains critical for the surgeon to be familiar with whatever equipment may be needed. As new and better instruments are developed, prior familiarization with equipment is ever more important.
Example: Unfamiliarity with Equipment A senior resident is assigned to help a new attending with a laparoscopic colon resection. The attending assumes that the resident has completed the endoscopic stapled anastomosis exercise in the technical skills laboratory. Unfortunately, she or he is in the half of her or his class that was to receive the training in the latter half of the year. The resident rushes to the OR to find that the case has been started with the fellow. The resident scrubs in and, as the case proceeds, is asked to step forward to perform the anastomosis. She or he is given the endoscopic stapler as the attending lines up the bowel for a side-to-side anastomosis. The stapler is threaded into the bowel and the resident attempts to fire it, not realizing that the scrub techncian has failed to remove the safety tab that blocks the instrument’s firing. Not wanting to be seen as incompetent, the resident forcefully closes and fires the stapler, breaking the handle. No other stapler is available that is suitable for the case, and the case requires conversion to an open procedure to complete the anastomosis. Alternative Scenario
A new stapler is proposed to be added to the general surgery inventory. Prior to approval, the manufacturer’s representative demonstrated the device at a regular faculty meeting and the following week to the residents in their weekly technical skills laboratory. Before using it in the OR, the attending asked the resident if she or he was familiar with the instrument and had attended the demonstration session. The resident carefully inserted the stapler into the lumen of the bowel, realized that the safety tab was still in place, removed it, and fired it as she or he announced the specific steps in the procedure out loud to the attending and the rest of the team. Discussion: In an ever-changing surgical environment characterized by constant innovation, it is imperative that new instruments are formally introduced and that all surgeons, trainees, and attendings alike be instructed in their proper use before they are to be utilized in the OR on a live patient. Defined curricula and technical skills laboratories have sprung up in training institutions around the
2 TEACHING TECHNICAL SKILLS—ERRORS IN THE PROCESS country, and formal accreditation protocols have been established to ensure a safe venue for familiarization and practice before the trainee is expected to use new instruments and techniques in the OR. Accreditation of residents in many procedures, both old and new, such as central line insertion, is advocated to make sure that the residents have been properly instructed and proctored through their initial attempts and that their competence is certified before they are allowed to perform the procedures independently.5
INTRAOPERATIVE PITFALLS—THE FIXATIVE AND AUTONOMOUS PHASES OF SKILLS ACQUISITION Basic Principle Technical proficiency in the OR is a continuous process of improvement. Stages of achieving mastery have been described by Dreyfus and Dreyfus,6 proceeding through a logical process of acquiring both awareness and skill: ● ● ● ●
Unconsciously incompetent Consciously incompetent Consciously competent Unconsciously competent
The logical school of epistemology distinguishes between awareness and knowledge. The learner begins both unaware and ignorant. Awareness (consciousness) and competence (technical proficiency) are distinct phenomenon and can be analyzed in a 2 × 2 matrix (Fig. 2–1) or as a linear progression leading to mastery, as listed previously. Regardless of the task, the naïve learner initially has no idea of the complexity of the task, because it looks relatively easy when demonstrated by a master. All
Figure 2–1 The progression to mastery is a logical transition involving both awareness and competence. In order to effectively teach surgical skills, the expert must regress to the “consciously competent” stage.
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of us remember our first attempt at sewing the skin and our nearly ballistic trajectory of the needle once freed from the resistance of the skin. Our lack of appreciation of how to brace our hand and check the movement of the needle quickly converted our naïve confidence and helped take us to the next and essential step of “consciously incompetent” when we realized that sewing the skin was much harder than it looked. With practice, the learner becomes consciously competent. He or she can perform the task but must focus, concentrate, and pay careful attention. After years of experience and hundreds of repetitions, the surgeon may become “unconsciously competent” as her or his body becomes one with the surgical instruments and he or she reaches what has been described as the “autonomous phase” of skills acquisition—like the experienced driver who gets in the car and drives to work, hardly conscious of the thousands of steps taken en route and taken for granted.
Practice Practice, practice, practice is an essential element of achieving mastery. However, practice alone is not enough as espoused by the great football coach Vince Lombardi who stated, “practice does not make perfect. Perfect practice does.”6a Implied in that wisdom is the essence of coaching and teaching. A good instructor not only must be a master but also must appreciate the method and the steps in helping the learner achieve proficiency. The operative teacher must guide the initial attempts, providing feedback in real time to the learner. Often, words cannot describe the exact movement desired. To do so involves a considerable transference of motor knowledge to verbal instructions in terms that the learner can understand. Often, a demonstration is necessary, even at the risk of alienating an overcautious resident who fears he or she will “lose the case.” Done with political sensitivity, a demonstration can be very effective. If “a picture is worth a thousand words,” a demonstration is worth a million. Independent practice is essential in helping the learner progress toward unconscious competence. The repeated practice of a technique in a relatively nonthreatening environment is as important as the real-time feedback that guides the initial attempts of the learner in the consciously incompetent stage. But to progress to a consciously competent level, the trainee must have the opportunity to practice in an environment devoid of the discerning eye and constant critique of the well-meaning but often overvigilant attending, which often results in an excess degree of performance anxiety. Inherently entangled in this quest is the dilemma of how one can achieve a “system of graduated responsibility” and, at the same time, ensure the competence of the learner. The increased presence of attendings required by modern reimbursement and supervision policies creates a constant threat to this critical facet of the surgeon’s training. The challenge requires a very
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SECTION I: GENERAL CONSIDERATIONS
intimate relationship between the teacher and the learner so that direct, observational instruction can gradually fade as the resident becomes more adept. The titration of the teaching surgeon’s involvement is surely a delicate balance that requires careful assessment of not only the learners’ technical ability and judgment but, equally important, their honest self-awareness of their limitations. It is critical that they recognize when they need help and to call for it in a timely fashion. If medicine is indeed an art, then surgical instruction is the distillation of medical education to its absolute essence.
Example: Lack of Autonomous Awareness The chief resident is left in the OR to close with the junior resident after completion of the procedure. The attending goes out to talk with the family. When coming back in, the “counts are correct”: Two days later the patient is found to have vague abdominal pain and a plain X-ray shows a malleable retractor left in the abdominal cavity. Although the chief resident is felt to be “unconsciously competent” at this stage of training, even minor distractions can lead to significant errors. Alternative Scenario
The resident, in accord with hospital policy, requests that an x-ray of the operative field be done before the patient is undraped and awakened. The retractor is recognized. Several fascial sutures are removed and the retractor retrieved. The attending waits until the resident notifies her or him before visiting with the patient’s family in the waiting room. Discussion: Many safeguards have been employed to ensure that the operation is as safe as possible and that such unexplainable misadventures like retained instruments, wrong-side surgery, and transfusion reactions are avoided. Simple methods such as marking the patient’s surgery site with an indelible marker in the preoperative holding area, “time-out” recitation of the operative consent, and positive identification of the patient are simple and effective ways of ensuring that the operation is as safe as possible. New technologic innovations such as radiofrequency chips on laparotomy sponges and routine postoperative x-ray examination of the operative field have become commonplace in many hospitals. Notification of the patients’ family after the operation is extremely important, but this should not be done until one is absolutely sure that the operation is indeed over and the patient is doing well.7–9
usually later in their career, from the overanxious and impatient younger attendings? The masters were able to do anything and they could teach you in a manner that was calm, effective, and enjoyable. They could see things from your perspective. They could appreciate when you could run free and when careful attention was needed. They appreciated parallax, defined as the difference in the appearance of an object when seen from two different vantage points not on a straight line. When operating on many midline structures, the resident surgeon and the attending/instructor typically stand on opposite sides of the table, with the surgical site between. Their vantage points are often 90° different. As a consequence, they often see very different fields. During an open cholecystectomy, the gallbladder, when viewed from the right side of the table, is partially hidden from the resident’s view under the edge of the liver but is in plain view of the teaching assistant on the patient’s left. Failure to appreciate this difference can lead to catastrophic technical errors. Similarly, exposure and retraction must be presented to the resident’s view from the opposite side of the table (Figs. 2–2 and 2–3). Correctly done, this often negates the clear view of the teaching assistant who must have the insight and confidence to allow the resident’s dissection. Failure to show and expose the field adequately and accurately can lead to trouble.
Example: Lack of Appreciation of Parallax A particularly difficult laparoscopic cholecystectomy is converted to an open procedure. The triangle of Calot is densely adherent to the infundibulum of the gallbladder. The resident’s view of the base of the gallbladder is difficult because the patient is obese, the wound is deep, and the distended gallbladder and liver edge partially obstruct the view of the cystic duct. The attending’s view, in contrast, is clearer and affords the view of a thin but discernable plane between the infundibulum and the
TECHNICAL TIPS: BECOMING AN AWARE INSTRUCTOR Parallax We all remember our favorite instructors in the OR and we will never forget those who could turn a simple procedure into a nightmare. What distinguished these masters,
Figure 2–2 Resident’s view of the gallbladder from the patient’s right side. The gallbladder is barely visible and obscured by the wound edge, retractor, and lap pad.
2 TEACHING TECHNICAL SKILLS—ERRORS IN THE PROCESS
Figure 2–3 The attending’s view from the patient’s left side. The gallbladder is obvious and in plain view.
immediately adjacent common duct. Frustrated with the resident’s hesitancy and faint-hearted attempts at dissection, the attending urges the resident to “cut, cut.” Unsure but willing to please, the resident’s Metzenbaum scissors skate off the distended gallbladder and lacerate the common duct. Discussion: The resident’s view of the operative field (see Fig. 2–2) can be drastically different from that of the attending across the table (see Fig. 2–3). Because more biliary surgery is done in the two-dimensional view afforded by a video screen, familiarity with open procedures is rare. In addition, only the most difficult cases default to the open method. Dissection in difficult, deep, and challenging cases can be treacherous, not only for the resident but also for the recently trained attending who likely has minimal experience with open biliary surgery. Anatomic structures in the surgical field that lie underneath the incision and in close proximity to critical structures are particularly dangerous: for example, the common bile duct in cholecystectomy for cholecystitis and the ureter in colon resection in diverticulitis. Appreciation of the principle of parallax and patience with the less experienced resident is of critical importance in achieving a safe outcome.
Bracing Basic Principle Bracing is one of the simplest techniques to help the neophyte achieve a greater deal of proficiency. It is based on the physics of a lever that consists of a long, rigid structure resting on a fulcrum. The lever has two components: the level arm and the moment arm. The placement of the fulcrum, or brace point, close to the object to be dissected helps amplify the strength of the lever and dampen the effects of the movement of the lever arm. The longer the moment arm, the more amplification of the movement of the lever arm. Moving the brace point closer to the target minimizes the moment arm, dampens the
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natural tremor that we all have, and increases the power and control of the instrument. Several trips to the dentist for teeth cleaning can help one better understand the importance of bracing. Dentists and dental hygienists know that a typical molar has 32 different and distinct surfaces. The cleaning, drilling, and filling of a tooth demands precision in fractions of a millimeter. An inexperienced hygienist will typically “skate” off the surface of the tooth and impale the patient’s gums with the instrument. In contrast, the experienced hygienist or dentist never takes the heel (or hypothenar eminence) off the patients chin, carefully bracing and checking each stroke of the instrument. Movements are careful, controlled, and precise because of the focused attention to bracing. In surgery, bracing has both a micro and a macro application. Microbracing is an essential skill in microsurgery, dentistry, and vascular surgery in which the field is small and the tolerances measured in fractions of millimeters. Microbracing requires moving the fulcrum closer to the point of action, minimizing tremor, and affording precise control of the instrument. It helps avoid “past pointing” once the resistance of the tissue is passed. Bracing is facilitated by having the OR table at the correct height, which in most cases should be at the surgeon’s elbow. Adjusted so, it will allow the surgeon to rest the forearm on the patient or the heel of the hand on the edge of the wound. With the wrist locked and a predictable angle of the needle on the needle holder, one simply supinates the forearm to scribe the needle in a controlled, smooth arc through the tissue. The nondominant forearm is held at a right angle to the other, and the forceps is ready to assist the manipulation of the tissue or accept the needle when appropriate (Figs. 2–4 and 2–5). Macrobracing is critical in those maneuvers that take considerable strength to penetrate tissue with marked resistance such as the chest wall when placing a chest tube or the placing of wire sutures through the sternum. The surgeon’s legs are slightly bent at the knees, the upper body is locked in place, “engaging the core,” the elbows are tucked against the torso and/or on the iliac crest, and both hands are held firmly on the instrument. One hand (the dominant) provides the necessary forward force while the other checks the movement of the instrument after the resistance of the tissue is overcome. “One hand is the gas, the other is the brakes.”
Example: Failure to Brace and Control Movement An intern is asked to place a chest tube in a victim of a motorcycle collision, a 250-pound man in acute distress. The chest wall is thick and muscular, making the dissection difficult. Having placed a tube only in a simulator, the intern is unaware of the great degree of force necessary to penetrate the dense intercostal muscles. As the Pean clamp finally penetrates the chest wall, the intern is equally unprepared for checking its forward motion. The clamp continues through the diaphragm and into the spleen.
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Simplifying Movement Simplifying movement, like bracing, is mostly a matter of physics. In performing a controlled and repetitive movement, the fewer muscles and fewer joints that are utilized, the better the control and the less fatigue due to use and overuse of unnecessary muscles. When sewing, the wrist is locked and the only movement necessary is supination of the forearm. The needle scribes a smooth, atraumatic, and predictable arc through the tissue. The needle should remain in place when released as no additional strain or torque is applied during its placement. As a result, the needle’s location, even when obscured by a bloody field, should be predictable and easily retrieved by merely repeating a similar movement aimed just beyond the first.
Figure 2–4 Lack of bracing. The resident’s fulcrum, or brace point, is the scapulothoracic junction.
Example: Lack of Simplifying Movement The morning after a challenging Whipple procedure for severe chronic pancreatitis of the head and uncinate process in a patient with pancreas divisum, your chief resident is unable to open the jar of ointment to apply to the clinic patient’s burn wound owing to extreme soreness and spasm of his or her neck and upper back muscles. The cumulative effect of the repeated movement and static posture of the challenging 10-hour operation have taken their toll owing to their lack of bracing and simplification of movement.
Visualization Visualization, or seeing with the mind’s eye, further facilitates the smooth, careful application of the instrument on the patient’s tissues. Used by athletes who rehearse their complex routines in their mind at the top of the slalom skiing course or at the edge of the gymnastic apparatus, it helps set a mind map of the complex movements to follow. Visualization also helps the surgical trainee develop an awareness of the underlying anatomic structures to be either incorporated (like the submucosa in a Lembert stitch of the bowel) or avoided (like the parotid duct when suturing a facial laceration). A favorite senior resident, who was also a student of martial arts, once remarked: “It is a very Zen thing. Your whole consciousness should ride the tip of the needle as it arcs through the tissue.” Or as Yoda, in the Star Wars trilogy, admonished his student: “See with your mind, Luke, not with your eyes.” Figure 2–5 Maximal bracing. Forearms and hands resting on the field and held at 90°.
Example: Lack of Visualization During a laparoscopic cholecystectomy, the resident fails to appreciate the proximity of the right hepatic duct posterior to the cystic duct/infundibular junction owing to their overlapping nature. Unfamiliar with how movement of the gallbladder with the opposite hand and turning of the 30°-angled scope can help reconstruct a
2 TEACHING TECHNICAL SKILLS—ERRORS IN THE PROCESS
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three-dimensional image, the resident’s attempts to dissect the triangle of Calot results in injury to the right hepatic duct, which lies immediately posterior to the cystic duct.
should always be specific: a particular technical maneuver, action, or omission. It should precisely define your expectations and the manner in which you expect the learner to change.
POSTOPERATIVE PITFALLS—THE AFFECTIVE DOMAIN OF LEARNING
Technical Feedback
Basic Principles Feedback has been described as the “currency” of adult learning. Without providing learners incremental guidance to improve their skill, their practice may result only in the perpetuation of bad habits or the extinction of good ones. It is only with feedback that we can most efficiently guide initial attempts and add encouragement as they demonstrate progress. The basic principles of feedback can be easily remembers with the pneumonic, “TENDS to be both positive and negative”: T E N D S
timing environment nonjudgmental based on direct observation specific information should be both positive and negative
Entire books have been written on how to provide feedback in any educational or supervisory setting. There are many barriers to doing it well. We all want to be liked and are typically uncomfortable in confronting and correcting others. Leveling harsh criticism (often confused with negative feedback) may seem inappropriate at the time because of the presence of others. However, feedback must be given in a timely fashion to be effective. Barring other obstacles, sooner is better than later. Serious negative feedback is best given in private. The OR is always staffed with an entire team, and extremely harsh words can negatively affect all within earshot. One effective technique useful in giving timely but important negative feedback in the OR is to quietly invite a particularly surly or uncooperative resident over to the x-ray board and, while feigning explanation of the film, speak in a very quiet, but firm, unmistakable manner. You can then relate your displeasure with their attitude, lack of skill, or preparation and set definite guidelines for their continued participation in the case. Feedback should be nonjudgmental. It should be about objective behaviors, not based on your opinion of why something was done or character flaws suspected in the learner. It is much better to state that “I am disappointed in your lack of preparation for the case,” rather than calling the resident “lazy.” Likewise, it is best to limit your feedback to those behaviors or actions that you yourself witness rather than relying on hearsay or rumor. As a program director or administrator, it is critical to have on hand any written documentation previously submitted by others during a feedback session. In such formal sessions and in other ad hoc sessions in real time, the feedback
Technical feedback is a bit easier and less emotional in nature and, consequently, easier to impart. As Bosk, in his famous treatise on surgery training, Forgive and Remember1 observed, “technical errors due to lack of experience are the most forgivable of all errors.” In the OR, a little humor to lessen the blow on the resident’s ego can sometimes go a long way. One of my most effective attendings once described my feeble attempts to incise the linea alba as the “Cuisinart technique.” The message was clear, but kind and in good faith. In order to provide effective technical feedback, it is critical for the instructor to be able to “see” the procedure from the learner’s perspective and relate in words the exact movement or technique desired. It is often extremely difficult to describe in precise words our intent. Transference of our motor memory into words that can be understood by the learner can often fall short of its mark and be confusing and subsequently frustrating for both the instructor and the learner. When faced with that frustrating conundrum, we often resort to a demonstration. To be an effective learner and recipient of feedback, residents must be confident enough to receive the help rendered by the demonstration and not fear they are “losing the case.” Such fears are heightened if the demonstration is excessively long. Used sparingly, demonstration of a technique can be extremely helpful. Again, if a picture is worth a thousand words, a demonstration can be worth millions. Feedback on technique must be done in real time and done almost continuously during the conduct of the operation as each movement is performed. A summative or global critique after the operation should emphasize general trends or tendencies that are both positive and negative. The attending should discuss not only areas for improvement but also things that the resident did particularly well. The well-known “sandwich technique,” espoused by Blanchard in his classic primer, The One Minute Manager, is a helpful strategy. The feedback session should begin with a positive comment such as acknowledging the resident’s persistence, followed by citing specific examples of where improvement is needed. Finally, it is best to end with the other “bread of the sandwich,” a positive acknowledgment and encouraging remark to help motivate the resident to persist in her or his efforts to improve. Feedback and Acknowledgment of the Operative Team
Surgery is a team sport that has many members. Most of this discussion has centered on a teaching environment, but regardless of the setting, either in a teaching hospital or in private practice, the other players on the team should be acknowledged. First and foremost is the patient. It is
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often helpful to stand by and reassure, as much as possible, the patient as he or she emerges from anesthesia. It is important to thank the rest of the team, the anesthesiologist, nurses, and technicians, for their help. Any problems that arose should be addressed in a kind and objective but clear manner. If necessary, more serious matters requiring negative feedback can be discussed in private. Feedback is typically sparse in the immediate postoperative period because the patient in the recovery room is affected by the amnesic properties of many of the anesthetic agents and other medications. Writing of the orders and dictation of the operative note are also important to accomplish promptly. As soon as possible, one member of the team, typically the most senior, should speak with the patient’s family. The hours spent in the waiting room while a loved one is undergoing an operation are some of the longest in one’s life. The first words that should come out of your mouth is that the patient is fine or, less frequently, they are in some degree of danger. Until family members hear that the patient is well, they assume the worse. The referring physician or primary care provider should also be promptly notified, updated, and advised of any condition that might complicate the recovery period and should be graciously thanked for allowing you to participate in the care of their patient. Attention to all involved in the operation will help build a sense of teamwork and camaraderie with your colleagues both in and out of the OR and ensure that your next operation will more than likely be as successful as possible.
REFERENCES 1. Bosk CJ. Forgive and Remember: Managing Medical Failure, 2nd ed. Chicago: University of Chicago Press, 2003. 1a. Accreditation Council for Graduate Medical Education (ACGME). Program requirements for graduate medical education in surgery, January 1, 2008. Available at http:// www.acgme.org/acWebsite/downloads/RRC_progReq/ 440_general_surgery_01012008.pdf 2. McGreevy JM. The aviation paradigm and surgical education. J Am Coll Surg 2005;201:110–117. 3. Romfh RF, Cramer FS. Technique in the Use of Surgical Tools, 2nd ed. Norwalk, CT: Appleton & Lange, 1992. 4. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1073–1078 [published correction appears in N Engl J Med 1991;325:1517–1518]. 5. Bell RH. Surgical Council on Resident Education: a new organization devoted to graduate surgical education. J Am Coll Surg 2007;204:341–346. 6. Dreyfus HE, Dreyfus SE. Mind Over Machine. New York: New York Free Press, 1982. 6a. Phillips DT. Run to Win. New York: Macmillan, 2002; p 95. 7. Gibbs VC. Patient safety practices in the operating room: correct-site surgery and nothing left behind. Surg Clin North Am 2005;85:1307–1319. 8. Dagi TF, Berguer R, Moore S, Reines HD. Preventable errors in the operating room—part 2: retained foreign objects, sharps injuries, and wrong site surgery. Curr Probl Surg 2007;44:352–381. 9. Blanchard K, Johnson S. The One-Minute Manager. New York: Harper Collins, 1982.
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Legal Considerations Catherine Bertram, JD and Stephen L. Altman, MD INTRODUCTION As trial lawyers with over 50 years of combined experience we urge you to invest the time it takes to read this chapter. Then, make a commitment to change your practice to consent patients correctly. Top surgeons understand that effective communication with their patients is a skill that needs to be updated and refined over time just like surgical technique. Proper consent does not require more time when you understand the true nature of an adequate consent.
LEGAL PITFALLS IN SURGICAL CARE BEFORE ENTERING THE OPERATING ROOM Let us start by emphasizing the key point of this chapter— informed consent is a process. It is not a hospitalgenerated form. Surgeons make a critical error when they assume that getting a patient to sign the hospital’s consent forms means that they have complied with the requirements of informed consent. This error can be quite costly to your practice and to your reputation. Consent is a process that requires communication between the surgeon and the patient. Usually, it is a twostep process that starts during the office visit and continues at the hospital before surgery. The office visit is your opportunity to take the time to explain the proposed surgery, the risks and alternatives, and the consequences of not proceeding. Thus, patients have time to reflect on all the information you have given them and can really make an informed decision to proceed with the surgery you suggest. The time for having that discussion is not in the hallway of the same-day surgery unit while you are trying to get in the first case of the day. That is not fair to you or to the patient and is certainly not the best use of your time. Patients can feel pressured to agree and will often say they were so worried about the surgery that they did not even listen or that they signed the forms just to get things moving without having time to ask questions or to reflect on the complex decision they were asked to make. In most hospitals, the surgical consent form is executed right before surgery. This is a good practice because it
provides some evidence that the patient consented to surgery. However, in most states, that form alone is not sufficient to establish that you met your duty to your patient. We have both seen surgeons mismanage their relationship with their patient and their family in ways that have led to medical errors, an omission through miscommunication, or claims from patients that the surgeon failed to provide them with sufficient information to make an informed decision about surgery: Here are three ways we have observed: (1) the surgeon acted as an all-knowing being; (2) no office notes were kept about the consent discussion or the refusal of care; (3) the surgeon did not tell the patients about who would assist with their surgery.
Surgeon as All-Knowing Being If you have this aura and express it to your patients, then this is what they will expect. If you tell the patients
what surgery they need and just assure them that “everything will be fine,” then you have taken complete responsibility for the decision making as well as the outcome. No wonder the patient (and the jury) will want to hold you 100% responsible for any negative outcome. Practice Pointer. Communication and decision making are a two-way street. Patients have responsibilities along with their rights. Share these responsibilities with the patient. Make the patient part of your health care team. Here are some ways to do that: ● Have brochures in your office that explain office hours,
after-hours call procedures, what to do in an emergency, and who to call in your office if they are having problems after surgery. Tell them whether they are responsible for bringing their films to the hospital. Also, the brochure can outline their role in follow-up after getting laboratory tests, diagnostic tests, especially from outside providers. Make sure they understand how to get to you if they think they are having a complication and need to be seen. If others will take calls for you, explain how that works. ●
Use American College of Surgeons or other specialized brochures, videos, and computer-
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generated educational materials to supplement your discussion with patients regarding the alternatives, risks, and benefits of the surgery you propose. Also direct them to websites that you think are accurate for basic information, if appropriate. You can provide a fact sheet that explains in detail why the surgery is performed, the alternatives, the risks, and what to expect after surgery. This can be handed out, not as a substitute for discussion, but as a supplement. Your staff can use a checklist to confirm that the patient received the materials. Whereas this is not a substitute for discussion, it certainly helps support your argument that the patient was thoroughly informed about the surgery before the big day! ● If you send a patient for a magnetic resonance imaging (MRI) scan at an outside facility and they need to come back to discuss results, the order for the MRI should include a section that reminds them that it is their responsibility to obtain the film and obtain a follow-up appointment. Many surgeons have the patient sign this acknowledgment. That is a good way to communicate that the patient is sharing responsibility for the implementation of the plan of care.
No Office Notes about the Consent Discussion or the Refusal of Care A surgeon’s note, timed and dated contemporaneously with the event, is the best way to avoid subsequent allegations regarding lack of informed consent. Surgeons often fail to document the most important part of a discussion when a patient refuses care. The key part to document is that you told them the potential consequences of their refusal. A patient cannot make an informed decision about whether to have a surgery or a major diagnostic test without weighing what might happen if they do not have it. Example: “Told the patient that the lump was probably just a cyst but told her to go and have a mammogram.” It is easy to understand if the patient later says, “I trusted Dr. Smith when she said it was just a cyst, so it didn’t seem necessary to have the mammogram.” Practice Pointers. Make sure that you document not only the fact that you had a discussion about the surgery but also that you reviewed the risks, alternatives, and likely outcome if nothing was done. The note should state that the patient understood your explanations and that all questions were answered. ● If the patient has any additional risks or conditions that
make the surgery more risky, you need to document that portion of the discussion more extensively. ● When the patient refuses or seems like she or he is not going to have the surgery, you need to add details about your explanations of the risks of delay and the consequences of no treatment. This is often a good
time for a follow-up letter to the patient, sent by certified mail.
Not Telling Patients about Who Will Assist You with Their Surgery In general, patients will appreciate and understand that you cannot perform the surgery by yourself, but in most circumstances, you have a duty to explain who will be involved and what the assistants will be doing. Patients will also understand that sometimes others, including vendors and technical people, need to be present to assist with device placement. It is your job to make sure the patient agrees to that. Failing to explain these facts can result in claims for fraud or battery. You may also get testimony in a malpractice case that the patient never consented to having a resident do certain portions of the surgery. Practice Pointers ● If you are in a teaching hospital, you must explain what
the resident’s role will be and document that you had this discussion with the patient. ● If you are in a community hospital, you must explain who will be assisting you with surgery and what they will be doing. Document that discussion. ● If vendors or others will be present, the patient has a right to know and needs to consent. ● Some hospital consent forms include general language regarding assistants and others in the operating room, but you are the person that the patient agreed could perform the surgery, not others, so make sure the patient is clear about the role of others. These are fairly simple, straightforward concepts that need to be incorporated into your practice to make certain the patient is provided with all the facts before he or she consents to surgery.
LEGAL PITFALLS IN SURGICAL CARE AFTER THE OPERATING ROOM Murphy’s Law: If anything can go wrong, it will. When Murphy developed his law, he must have been partially thinking about health care providers. What else could explain why doctors and other health care personnel spend countless hours talking with patients about things that might go wrong during treatments and procedures? Why else are entire books like this written about surgical pitfalls if adverse outcomes do not actually occur? Whether a doctor is just finishing a residency program or is getting ready to retire, every doctor should know that you do not need to commit medical malpractice to get sued, you just have to have an unhappy patient—and nothing, we repeat, nothing, can make a patient or family more unhappy than an unexpected surgical complication.
3 LEGAL CONSIDERATIONS Part of the problem and shock can be ameliorated with a good, complete, preprocedure informed-consent discussion. That topic has already been dealt with in this chapter. Unfortunately, even the best informed-consent conversation or document, by itself, may not be enough to prevent a malpractice suit from being filed. You are lucky, however, because when an adverse outcome occurs, you have a second chance to prevent a lawsuit from being filed or, if it is destined to be filed, to improve your chances of prevailing. Although most of these are common sense suggestions, in 30 years of litigating hundreds of medical negligence cases, we have both come to appreciate that common sense does not always rule when a serious injury or death occurs. Thus, a bit of repetition may prove helpful.
DOS AND DON’TS ● Don’t stop seeing or decrease the frequency of visits
with your patient or your patient’s family. When problems occur, this is the time for you to be the most visible. We cannot begin to tell you the number of
depositions we have taken in which the patient or the family complains that Dr. X “never seemed to be around to answer our questions after the surgery” or “I never saw Dr. X for the several days between the surgery and the death of my husband.” Rather than making the heart grow fonder, absence will make the patient or the family think that you do not want to face them and explain what occurred. We have known doctors who have called subsequent treating physicians to simply inquire about how the patient is doing and made note of those conversations in their office charts. ● Do make sure that the family of the patient knows of your concern over what occurred. It is not an admission of liability to express condolences over death or to let a patient know that you are sorry they have suffered a complication. We have even known of surgeons who attended funerals of patients who died after a surgery. To ignore a problem leads the patient or the family to think you do not care. If a patient thinks you do not care about her or his welfare, you are much more likely to be included in any litigation. Remember, the general rule is that people do not sue people they like. The authors are frequently amazed at the number of times potential defendants in malpractice litigation are not sued even though a real question exists about whether their actions were a deviation from the standard of care. This topic is usually explored at deposition only to learn that the patient simply did not want to sue Dr. X because the patient liked him or her. ●
Don’t try to explain what occurred until you are sure of your facts and until your conclusion can be corroborated. Obviously, you are going to be ques-
25
tioned immediately by the patient or the family about what occurred. You will need to describe to them, from a factual standpoint, what you know up to that point. Just refrain from making conclusions as to the cause of problems. In most instances, you would not try to make a diagnosis without adequate data. Why do it now? The admonition not only applies to direct conversations with patients but also to documention. In a recent obstetric case, a baby was transferred to the neonatal intensive care unit (NICU) for a brachial plexus injury postdelivery. The neonatologist, who should have known better, reported that he was dealing with a newborn with an obvious brachial plexus injury caused by excessive traction. Not only was that conclusion shared with the parents in the following days, it was repeated during the pendency of the litigation. In fact, the defendant doctor vigorously denied that excessive traction was used, and had evidence to support that defense. The family and their attorney kept arguing that even the neonatologist concurred that negligence had caused the injuries at birth. It would have been a simple matter for the neonatologist to write “obvious brachial plexus injury, cause unknown at this time.” Similarly, in a recent laparoscopic appendectomy case on a 20-weeks’ pregnant patient, a general surgeon wrote, in a nonperforated appendix procedure, “that upon entering the abdomen, I saw purulent fluid around the appendix.” What he really saw was a whitish exudate and not purulent fluid because there was no source for the purulence in this nonperforated appendix simulation. Weeks later, the patient developed an infection after a spontaneous abortion, and the surgeon was sued for not starting antibiotics in the presence of purulence. The entire lawsuit, over 7 trial days, could possibly have been averted had he simply written that he visualized a white substance around the appendix rather than calling it purulence, especially because he had no information that it was. ● Do make complete records whenever an adverse outcome occurs including as much factual information as you can recall. The plaintiff’s attorney may argue that you are attempting to create a defense, your attorney will counter by arguing that you were attempting to facilitate the investigation or understanding of what occurred by providing the most detail possible. Any entry along these lines should be correctly dated and timed, so that there is no argument that someone was attempting to “alter” their records. ● Don’t ever, ever, alter your records. Even if your alteration, deletion, or addition is perfectly innocent, it will never appear that way. If, after an adverse outcome, you are found to have made a change to an existing record, that patient, their family, and most important, the jury will automatically assume you were attempting to delete a harmful notation and will not believe a word you say. Statistics tell us that approximately 70%
of all medical malpractice cases that go to trial
26
SECTION I: GENERAL CONSIDERATIONS
end up favorably for the health care provider. Clearly, that means that cases are won even in cases in which significant injuries or death occurs. You can talk your way out of a bad outcome. You can never talk your way out of a lie. ● Do carefully read chart entries after an adverse outcome occurs and be sure to properly and timely note any disagreements you might have with the charted information. We know what you are thinking right now. You simply do not have time to read entries that should have been accurately charted by residents, colleagues, or consultants. Take the time. If you make your disagreement known contemporaneously with your review of the note, you can argue that there was a legitimate disagreement. Many of you sign off on notes written by others. A smart plaintiff’s attorney will start by getting you to agree that your countersignature on a note is your statement that you agreed with what was written. As you can see, making your disagreement known 2 years later, when you are in the midst of a malpractice case, will cause you to look like you are manufacturing a defense because you have already agreed that your signature is your statement that you agreed with the note. It will be further argued by your opponent that you now recognize how harmful that fact or comment is to your defense and that any reasonable doctor would have corrected that mistake earlier if, in fact, a disagreement really existed. ● Don’t ignore legitimate requests for medical records by a patient, a family member, or an attorney representing the patient. In many states, the time to respond to
these requests and the amount that can be charged are governed by statute. To ignore this type of request or to take too long to respond will cause the person making the request to question why the records were not sent and will again raise the specter that you are attempting to hide something. The records, in their entirety, should be timely copied and mailed, along with an appropriate letter, inquiring as to whether there is any other way you might be of assistance and again inquiring into the health of the patient or to pass along your sympathies. In another recent general surgery matter involving a failure to timely diagnose and treat a breast mass, the surgeon was accused of withholding information and falsifying his records when his office took months to send out records, did so in a piecemeal fashion, and never sent out all the records. The case, ultimately won by the surgeon, could have been tried in a few days with the central issued being standard of care. Instead, the surgeon’s credibility became the central issue, and days were wasted calling present and past employees about record keeping and responding to record requests. The lists of Dos and Don’ts goes on forever and is far too numerous to cite, in its entirety, here. When you are faced with that inevitable, adverse outcome and you are questioning how you should be handling a particular situation, always ask yourself this question: How would my patient or a jury view my actions? Your choice might just be the thing to keep you from being sued or the exact thing that helps you win.
4
Preoperative Pitfalls Aimee M. Crago, MD, PhD and Stephen R. T. Evans, MD INTRODUCTION Although the hospital course of a patient is affected profoundly by what happens inside the operating room, many complications can be prevented by adequate preoperative preparation. Rates of postoperative myocardial infarction, decomposition of congestive heart failure, pneumonia, bleeding, and infection are all affected by identification of a patient’s individual risk factors and medical optimization of the patient’s condition prior to surgery. A clear history and physical examination, reconciliation of a patient’s medication list, and consultation with appropriate specialists are the first steps in ensuring that an operation will go as smoothly as possible, and that hospital length of stay and preoperative morbidity and mortality rates are maintained at a minimum.
INDICATIONS The surgeon should complete a mental, if not physical, checklist of preoperative risk factors and appropriate interventions for each patient who is scheduled for the operating room. There are no exceptions to this dictum. Even in emergent situations, knowledge of the patient’s comorbidities should be elucidated as soon as possible to aid in intraoperative and postoperative care.
PREOPERATIVE STEPS Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7
Neurologic evaluation and assessment of pain susceptibility Cardiac risk assessment and preoperative optimization Pulmonary risk assessment and preoperative optimization Screening for advanced liver disease Assessment of renal function Assessment of infection risk and wound healing ability Assessment of nutritional status
Assessment of bleeding risk and identification of the hypercoagulable patient Step 9 Identification of endocrine dysfunction Step 10 Documentation of the family history Step 8
PREOPERATIVE EVALUATION Neurologic Evaluation and Assessment of Pain Susceptibility Failure to Recognize Carotid Disease ● Consequence The incidence of ischemic stroke ranges from less than 1% for elective surgery procedures to as much as 10% in post–coronary artery bypass graft (CABG) patients with concurrent carotid disease.1 Grade 4/5 complication ● Intervention Therapy for patients after cerebrovascular accident (CVA) is mainly supportive, centering on blood pressure control and rehabilitation to maximize functional outcomes. More aggressive therapy in the form of intra-arterial thrombolysis may be considered only in the first hours after stroke. Functional outcomes with thrombolysis appear similar to those seen in nonoperative stroke victims. Retrospective studies do, however, show a 25% chance of surgical site bleeding. Mortal complications have been reported with thrombolysis after craniotomy, so this treatment should not be employed in this population.2 ● Prevention The low incidence of stroke in postoperative patients without history of transient ischemic attack (TIA) or CVA means that preoperative screening of the asymptomatic patient is likely unwarranted. However, rates of CVA increase in the general surgery population with symptoms and are noted to range from 3% to 4% in those with a known carotid stenosis or positive history. Similar outcomes are seen in patients undergoing major
28
SECTION I: GENERAL CONSIDERATIONS Table 4–1 Alternative to Intravenous Narcotics in the Postoperative Patient
Prior stroke? Yes
Carotid ultrasound
No
Yes
Symptoms of carotid disease?
Greater than 60% stenosis? Yes
Carotid endarterectomy
Drug
Contraindications/Side Effects
Nonsteroidal anti-inflammatory drugs (e.g., ketorolac)
Renal dysfunction/acute renal failure
Dextromethorphan
Seizure, arrhythmia, brain damage
Cyclo-oxygenase 2 inhibitors
Cardiovascular disease, renal dysfunction/acute renal failure, gastrointestinal bleeding
Acetaminophen
Hepatic dysfunction
Neurontin
Somnolence, dizziness, fatigue
Local anesthetic
Seizure, arrhythmia
Ketamine
Psychotropic effects
Peripheral nerve block • Axillary nerve block • Supraclavicular nerve block • Interscalene nerve block • Paravertebral nerve block • Lumbar plexus block • Femoral nerve block • Sciatic nerve block
Seizure, arrhythmia
Epidural anesthesia
Seizure, arrhythmia, hypotension
No No
OR
Figure 4–1 Algorithm for preoperative evaluation for carotid disease.
vascular surgery.3 It seems prudent, therefore, that carotid endarterectomy (CEA) should, where possible, precede elective general or vascular surgery procedures in patients with known cerebrovascular disease (Fig. 4–1). This recommendation would be concordant with that applied to patients with carotid disease and requiring coronary artery revascularization (CABG). Debate still exists as to the timing of CEA versus CABG, but in the setting of asymptomatic coronary artery disease (CAD), the carotid is addressed first to decrease the rate of CVA at the time of CABG (10%–5.3%). Conversely, risks of comorbid cardiac disease must be considered in the context of asymptomatic carotid disease, because delay of coronary revascularization to allow recovery from CEA leads to an increase in overall mortality (9.4%) despite low rates of stroke.4 The possibility of concurrent CEA and CABG has been explored, but its role is controversial.
Failure to Recognize Low Pain Threshold ● Consequence Tachycardia, pneumonia, and opioid withdrawal are consequences of failure to recognize low pain threshold. Chronic pain patients are often recognized at presentation for elective general surgery procedures. These patients develop tolerance to opioids, and hyperalgesia manifests as increased sensitivity to pain and high analgesia requirements compared with those in opioidnaïve patients. Excessive pain increases the risk of both postoperative pulmonary (owing to splinting and poor mobilization) and cardiac complications. Patients inadequately treated may develop symptoms of nausea, vomiting, and hemodynamic instability consistent with narcotic withdrawal. Grade 1 complication
● Intervention Opioid dosing remains the mainstay of postoperative pain control. However, the use of adjuvant therapies, such as those presented in Table 4–1, has been shown to reduce opioid requirements and may aid in treatment of postoperative pain in patients with chronic pain. Intravenous (IV) narcotics should be used to treat symptoms of opioid withdrawal.5 ● Prevention A patient’s daily dosage of narcotics as well as expectations for postoperative pain should be discussed prior to surgery, and a perioperative pain regimen should be planned between patient, surgeon, and anesthesiologist. Standing doses of preoperative pain regimens should not be stopped pre- or perioperatively. In the case of gastrointestinal (GI) surgeries, oral medications should be substituted with IV equivalents after surgery to prevent withdrawal.5 In addition, patients will require supplemental narcotics, two to four times the doses required by opioid-naïve patients, for adequate pain control.6,7 Narcotics can, in part, be effectively administered by continuous infusion through patientcontrolled analgesia (PCA), which will also provide an efficient means for delivery of supplemental drugs.5 Adjuvant therapies such as those outlined in Table 4–1 have been shown to reduce postoperative opioid requirements in patients with chronic pain. Of note, epidurals should utilize lipophilic narcotics because these are more effective in patients with chronic pain and should not replace IV narcotics because such management could
4 PREOPERATIVE PITFALLS Table 4–2 Commonly Used Narcotics and Their Approximate Conversion Drug
Oral Dose
Intravenous Dose
Hydrocodone
30 mg q3h
—
Hydromorphone
7.5 mg q3h
1.5 mg q3h
Fentanyl
—
0.1 mg q1h
Meperidine
300 mg q3h
100 mg q3h
Morphine
30 mg q3h
10 mg q3h
Oxycodone
30 mg q3h
—
Box 4–1
Sedation Scales
Ramsey Sedation Scale 1 2 3 4 5 6
Anxious, agitated, restless Cooperative, oriented, and tranquil Sedated but responds to commands Asleep; brisk response to glabellar tap or loud auditory stimulus Asleep; sluggish response to light glabellar tap or loud auditory stimulus Asleep; no response to deep painful stimulus
Richmond Agitation-Sedation Scale (RASS) +4 Combative
result in withdrawal. Partial opioid agonists such as buprenorphine or nalbuphine should also be avoided because they too may cause withdrawal.5 Transition to an oral regimen provides another challenge for patient and clinician. The equivalent to the daily postoperative narcotic requirement can be calculated (Table 4–2) and prescribed in part (generally one half the requirement) as long-acting oral opioids such as oxycodone or methadone. Intermittent breakthrough doses of short-acting medications can be prescribed to fulfill the remainder of the daily requirement and can be slowly tapered to return the patient to his or her baseline narcotic regimen over a 2- to 4-week period.5
Failure to Recognize Alcohol Dependence ● Consequence Alcohol withdrawal syndrome (characterized by tremor, insomnia, agitation, hypertension, diaphoresis, fever, nausea, vomiting, and hallucinations) may precede delirium tremens (DT) and result in cognitive change, hallucination, and seizure. Alcohol dependence is common in surgical patients. Patients with cancers of the oropharynx and GI tract often have comorbid alcohol dependence, and more than one third of trauma patients may be alcohol dependent. Less than one quarter of these patients are recognized preoperatively or on admission, resulting in high rates of withdrawal symptoms and requiring admission to the intensive care unit (ICU) for hemodynamic and neurologic monitoring as well as aggressive medical intervention.8 Grade 1/4/5 complication ● Intervention Multiple meta-analyses have looked at the treatment of patients with alcohol withdrawal and DT. Sedativehypnotic drugs, generally benzodiazepenes, appear to be the most effective medications for preventing alcohol withdrawal seizures and related mortality once symptoms of withdrawal occur. The choice of benzodiazepene is based on desired onset and duration of action, with IV dosing providing the most rapid effect, and long-acting medications being associated with fewer breakthrough symptoms but higher rates of oversedation. Intermittent doses of diazepam or lorazepam can
29
+3 Very agitated +2 Agitated +1 Restless
0 Alert and calm −1 Drowsy −2 Light sedation −3 Moderate sedation −4 Deep sedation −5 Unarousable
Overtly combative or violent, immediate danger to staff Pulls on or removes tubes or catheters, aggressive behavior toward staff Frequent nonpurposeful movement or patient-ventilator dyssynchrony Anxious or apprehensive but movements not aggressive or vigorous Not fully alert, sustained (>10 sec) awakening, eye contact to voice Briefly (1 to 1.5L
FEV1 >2L
Yes
FEV1 >40% predicted on split-lung function studies
Yes
Figure 4–4 Algorithm for preoperative pulmonary evaluation in patients with lung disease.
prothrombin time and thrombocytopenia, respectively. Ascites may respond to diuretics. Therapeutic paracentesis provides temporary relief to patient with restrictive lung physiology secondary to ascites. Hyponatremia is treated with free water restriction. Encephalopathy requires prescription of lactulose with or without enteral antibiotics such as neomycin. Hemodynamic instability may require pressor support. Patients with hepatorenal syndrome may be initially treated with fluid resuscitation, although hemodialysis is eventually required in many instances. ● Prevention Initial screening for liver disease comprises a thorough history and physical examination. Risk factors for cirrhosis including infection with hepatitis B or C, history of alcohol abuse, or less commonly genetic diseases such as Wilson’s disease and hematochromatosis should be elucidated. Physical stigmata of cirrhosis include spider angiomata, caput medusa, fluid wave on abdominal examination, palmar erythema, gynecomastia, and jaundice. In the case of risk factors or suspected liver disease, liver function tests (LFTs) and coagulation studies should be ordered. Traditionally, risk stratification in the cirrhotic patient has been assessed using the Child-Pugh classification33 (Table 4–5). Although patients with class A cirrhosis can generally undergo surgery with relative few complications, those with more advanced disease have high rates of complications and death (see Table 4–5). Careful weighing of the benefits of surgery should be made before counseling the patient, and symptoms of liver disease should be controlled by optimal medical management (e.g., cor-
Yes
No
Pre-operative bronchodilators, pulmonary exercise, smoking cessation
Pre-operative bronchodilators, pulmonary exercise, smoking cessation
No Consider exercise tolerance testing versus non-operative management
• OR • Consider local anesthesia (vs. general) and minimally invasive surgical approaches
35
• OR • Consider local anesthesia (vs. general) and minimally invasive surgical approaches
Table 4–5 Child-Pugh Class System Assignment of Points Points
1
2
3
Albumin (g/dl)
>3.5
2.8–3.5
6
Encephalopathy
None
Controlled
Dense
Ascites
None
Controlled
Refractory
Calculation of Class (sum points for individual values) Total Points
Child’s Class
Mortality Rate after Open Abdominal Surgery (%)
5–6
A
10
7–9
B
30
>9
C
80
rection of coagulopathy, treatment of encephalopathy with lactulose) before proceeding to the operating room. More recently, several small series assessed the role of the model for end-stage liver disease (MELD) score in preoperative work-up34 (Eq. 1). The MELD score has the benefit of requiring no objective interpretation by the clinician. MELD score and Child-Pugh class appear to correlate well. To date, specific recommendations regarding risk versus MELD score have been incompletely defined, although a score greater than 15 appears to
36
SECTION I: GENERAL CONSIDERATIONS
predict mortality above 15%, MELD greater than 25 predicts mortality above 25%, and MELD greater than 35 predicts mortality above 50%.35
(Eq. 1)
3.8 × ln(bilirubin [mg/dl]) + 11.2 × ln(International Normalized Ratio [INR]) + 9.6 ln(creatinine [mg/dl])
In patients with an acute abdomen and signs of liver disease, care should be taken to avoid misdiagnosis of spontaneous bacterial peritonitis (SBP). The physical examination in patients with SBP and acute inflammatory processes can be similar, but exploratory laparotomy runs the risk of patient decompensation if the true diagnosis is SBP.
Assessment of Renal Function Failure to Recognize Renal Dysfunction ● Consequence Acute renal failure (ARF) may occur in 4% to 8% of critically ill patients in the ICU, and a significant proportion of these patients will require hemodialysis. The most common causes of ARF in postsurgical patients are prerenal azotemia and acute tubular necrosis (ATN) related to administration of IV contrast or other nephrotoxic agents (Box 4–4). Postrenal causes of ARF are often related to malfunction of indwelling catheters and prostatic hypertrophy.36,37 Grade 1/4/5 complication
Box 4–4 Commonly Used and Encountered Nephrotoxic Agents ● ●
● ● ● ●
● ● ● ● ● ● ●
Iodinated contrast dye Antibiotics ● Vancomycin ● Aminoglycosides ● Rifampin ● Cephalosporins ● Penicillins ● Amphotericin B Furosemide Angiotensin-converting enzyme inhibitors Angiotensin II receptor antagonists Chemotherapeutics ● Cisplatin ● Cyclosporine ● Tacrolimus ● Allopurinol ● Mitomycin Cocaine H2 receptor antagonists Phenytoin Volatile hydrocarbons Myoglobin Calcium Endotoxin
● Intervention Treatment of ARF begins with fluid resuscitation. A central venous pressure of 10 to 12 mm Hg (in the absence of significant cardiac dysfunction) can confirm that intravascular volume is sufficient. A Swan-Ganz catheter may be required for more invasive monitoring if additional clarification about cardiac contribution to renal perfusion is needed. Nephrotoxic agents such as those listed in Box 4–4 should not be prescribed. Supportive care with hemodialysis should not be taken lightly because fluid shifts related to this treatment may induce further damage to the kidney. Unremitting acidosis, hyperkalemia, or uremia in the context of renal failure cannot be definitively treated in any other manner, however. Recent studies examined the role of fenoldopam in preventing progression in patients with early ATN. These studies did not show a consistent improvement in patients receiving the drug, but some subgroups of patients may benefit from its administration. Dopamine has no role in the treatment of ATN.36 ● Prevention Prevention of ARF begins with recognizing the patient at risk for ARF (Box 4–5). Fluid hydration is essential for those receiving nephrotoxic agents.38 N-Acetyl cysteine can improve outcomes in patients with chronic renal insufficiency (CRI) requiring IV contrast agents.39 Bicarbonate given in conjunction with IV contrast agents is believed to act as a scavenger for free radicals related to these agents and appears to provide some degree of renal protection.40 Serum levels of nephrotoxic agents should be routinely measured to prevent supratherapeutic dosing whenever possible (e.g., IV administration of vancomycin, gentamicin, and tobramycin). In all other instances, pharmacologic agents should be prescribed after calculation of the patient’s creatinine clearance as described by Cockroft and Gault41 (Eq. 2). This value is adjusted by a factor of 0.85 in females.
Box 4–5 Risks for Acute Renal Failure in the Surgical Patient ●
Surgical procedure Cardiac surgery ● Aortic cross-clamping ● Liver or renal transplantation Diabetes/preoperative chronic renal failure Underresuscitation Sepsis Burn injury Liver disease Cardiac failure Ureteral injury Nonfunctioning indwelling catheter ●
● ● ● ● ● ● ● ●
4 PREOPERATIVE PITFALLS (Eq. 2) (140 − age [in yr]) × (weight [in kg]/0.81) × (serum creatinine [in μmol/L])
Assessment of Infection Risk and Wound Healing Ability Failure to Administer Preoperative Antibiotics ● Consequence Rates of wound infection are related to the type of procedure and range from 1.5% in clean cases (those in which there is no associated inflammation and no entry into the alimentary, respiratory, or genitourinary tracts during surgery) to 40% in dirty cases (those with frank contamination related to infection or foreign body). Risk factors for development of wound infection include the length of procedure (>75th percentile compared with similar cases), age, diabetes, poor nutritional status, obesity, and an ASA score of 3, 4, or 5. Immunosuppresive medications including steroids can further increase rates of poor wound healing and surgical site infection.42 Grade 1–5 complication ● Intervention Treatment of surgical infections revolves around drainage of abscess collection. This can be accomplished by opening the skin incision when infections involve the subcutaneous tissues. Abscess cavities within the surgical site may require reoperation for drainage or the placement of a percutaneous drain. Cultures should be obtained, and antibiotics started empirically at the time of diagnosis should be tailored based on culture results. For superficial infections with likely pathogens being Staphylococcus and Streptococcus, first-generation cephalosporins or penicillin derivatives are adequate coverage except when methicillin-resistant Staphlyococcus aureus (MRSA) is suspected, necessitating treatment with linezolid or vancomycin. For infections related to pathogens of the respiratory or alimentary tract, combination therapy aimed at anaerobic organisms and
37
gram-negative bacteria should be employed. Metronidazole with fluoroquinolones, piperacillin-tazobactam combinations, second-generation cephalosporins, and carbepenams are frequently used combinations. ● Prevention Prevention of wound infection relies on the administration of preoperative antibiotics (Table 4–6). Studies indicate that the proper timing of antibiotic administration is half an hour before incision, corresponding with induction of anesthesia. If surgery lasts longer than 2 half-lives of an antibiotic, additional dosing should be considered. Dilution related to high-volume transfusion should also prompt readministration.42 Although clean cases were historically not believed to warrant preoperative antibiotics, this is still debated; benefits have been suggested in numerous studies, especially in instances in which clean cases involve placement of a prosthetic mesh as in herniorrhaphy.43,44 Antimicrobials acting against staphylococcal and streptococcal species should be administered preoperatively in these instances. Broader-spectrum drugs or combination regimens such as those discussed previously are more appropriate as prophylaxis for surgeries involving the bowel and the respiratory and genitourinary tracts. A significant decrease in rates of infection after surgery on the bowel was initially reported when a preoperative bowel regimen with both mechanical and antimicrobial preparations was used to decrease the quantity of intraluminal bacteria. Although several randomized trials questioned this practice,45 the standard of care among surgeons remains mechanical bowel preparation with or without oral neomycin and erythromycin prior to elective procedures.46
Incomplete Tobacco Use History ● Consequence Complications related to an incomplete tobacco use history include poor wound healing, dehiscence, wound
Table 4–6 Perioperative Wound Infections and Prevention Rate of Infection (%)
Definition
Preoperative Antibiotics
Clean
1.5
• No inflammation • No entry into GI, GU, or respiratory tract
• First-generation cephalosporin • Vancomycin
Clean-contaminated
7.7
• Minor break in technique • Entry into GI, GU, or respiratory tract with no spillage
• Metronidazole with fluoroquinolones • Piperacillin-tazobactam • Second-generation cephalosporins • Carbepenams
Contaminated
15.2
• Major break in technique • Entry into GI, GU, or respiratory tract with spillage • Traumatic wound
Dirty
40
• Gross purulence • Fecal contamination • Traumatic wound with delay in treatment
GI, gastrointestinal; GU, genitourinary.
38
SECTION I: GENERAL CONSIDERATIONS
infection, pneumonia, failed vascular reconstruction, increased ventilator dependence, anastomotic leaks, and death.47 Grade 1–5 complication ● Intervention Treatment of smoking-related complications is mainly supportive. Aggressive pulmonary toilet including incentive spirometry, early ambulation, and suctioning may aid in recovery from pneumonia and improve respiratory function. Wound infections should be treated with antibiotics and drainage and dehiscence with operative repair. ● Prevention Although aggressive pulmonary toilet may help to prevent pneumonia and respiratory failure in smokers postoperatively, an overall reduction in surgery-related complications may be improved by smoking cessation before surgery.47 An 8-week window is believed to improve pulmonary function and decrease pulmonary secretions that predispose patients to pneumonia and COPD exacerbation.48 Recent studies suggest that patients who enter a preoperative smoking-cessation program may reduce rates of wound as well as pulmonary complications. These reports vary in their degree of significance, and no clear duration of abstinence has been defined to be required for observations of these benefits.49,50
Patient with pre-operative weight loss or albumin ⬍2.5
Enteral supplementation failed? Yes
One week parenteral nutrition for supplementation • OR • Consider placement of enteral feeding tube if anticipate persistant failure to feed orally or anticipate prolonged postoperative fast.
Pre-operative TPN? No
Failed enteral feeding anticipated to continue to two weeks?
Assessment of Nutritional Status Failure to Assess Patient Nutritional Status Many patients referred for surgery have chronic GI dysfunction or anorexia related to cytokine production and associated with malignancy. Severely malnourished patients are generally defined as those with albumin levels less than 2.5 g/dl and those with preoperative weight loss greater than 20%.51 ● Consequence Common consequences of failure to assess a patient’s nutritional status include dehiscence of the surgical wound and anastomotic breakdown. Wound healing is more significantly compromised in those defects that are not treated by primary reanastomosis, but instead heal by secondary intention. Infection may progress to multiple organ system failure (MOSF) and death.52 Grade 1–5 complication ● Repair Repair is directed toward treatment of associated complications. Wound dehiscence requires reoperation. Anastomotic breakdown dictates prolonged fasting with total parenteral nutrition (TPN) for nutritional support. Antibiotics should be prescribed for associated infections and ICU support prescribed for MOSF.
No
Yes
Yes
Continue parenteral supplementation until enteral feedings adequate to meeting nutritional requirements
Initiate TPN
Figure 4–5 Management of the malnourished surgical patient.
● Intervention A protocol for identifying and treating the malnourished surgical patient is presented in Figure 4–5. History or laboratory values consistent with severe malnutrition are an indication for preoperative TPN. Calculation of nitrogen balance, as described in Eqs. 3, 4, and 5, can confirm whether a patient is catabolic (negative balance) or anabolic (positive balance). (Eq. 3)
Nitrogenin = protein (in g/day)/6.25
(Eq. 4)
Nitrogenout = urinary nitrogen (in g/day) + insensible losses (2–8 g/day)
(Eq. 5)
Nitrogen balance = nitrogenin − nitrogenout
The Veterans Administration Total Parenteral Nutrition Cooperation study53 stratified patients according to degree of malnutrition as evidenced by preoperative weight loss and hypoalbuminemia and randomized patients to treat-
4 PREOPERATIVE PITFALLS ment with preoperative TPN or to a control group. In severely malnourished patients, the risk of noninfectious complications (e.g., anastomotic leaks, bronchopleural fistulae, MOSF) with a 7-day course of preoperative TPN was reduced from 43% to 5%. Increased rates of infectious complications did not appear to justify the use of TPN in mild to moderately malnourished populations, however. These findings have been borne out by multiple subsequent trials and have resulted in the adoption of preoperative TPN as the standard of care in severely malnourished patients. Treatment appears to be of no benefit when prescribed for less than 1 week. Postoperatively, patients should continue TPN started preoperatively until enteral feeds can be initiated. The question of postoperative TPN in patients without indications for preoperative therapy was addressed by a randomized study published by Sandstrom and associates,54 which noted increased rates of postoperative complications in those patients unable to tolerate oral feeds after GI surgery and receiving only IV fluids for longer than 14 days. In patients without contraindications, early enteral feedings (administered as early as 6 hours postoperatively in some series of esophagectomy patients) are clearly superior to postoperative TPN, reducing rates of postoperative infectious complications and length of ICU and hospital stays.55,56 No clear evidence relating mortality to mode of feeding has been published.
Assessment of Bleeding Risk and Identification of the Hypercoagulable Patient Failure to Identify the Patient at Risk of Bleeding ● Consequence Inherited and acquired coagulopathies place patients at risk for surgical bleeding. Special attention should also be placed on the significant proportion of older surgical patients who are maintained on antiplatelet and anticoagulant medications for treatment and prevention of cardiovascular conditions. End-stage renal disease (ESRD) and liver disease (ESLD) are comorbid conditions associated with significant risk of bleeding diathesis. Grade 1–5 complication ● Intervention Platelet dysfunction as seen in renal disease can be treated with 1-deamino(8-D-arginine) vasopressin (DDAVP) and platelet transfusion should excessive bleeding occur. Transfusion of platelets alone should be used for treatment of thrombocytopenia and consumptive coagulopathies and in patients receiving massive transfusion of packed red blood cells. Fresh frozen plasma can be used for treatment of bleeding associated with deficiency of most factors in the clotting cascade, and transfusion with concentrated recombinant factors can be used for von Willebrand disease, as well as for factor VIII and IX deficiencies. Local
39
control can be achieved with fibrin sealants or collagenenriched matrices. Activated factor VII can be administered in patients with ongoing bleeding in whom standard transfusion therapies have failed to improve the clinical condition.57 ● Prevention Coagulation disorders can be elucidated on history by inquiring about previous episodes of unusual bleeding. Recurrent GI bleeding, epistaxis, hematuria, menorrhagia, or hemarthroses suggest a bleeding disorder. History of ESRD is associated with platelet dysfunction, and stigmata of ESLD are worrying for coagulopathy and thrombocytopenia. Collagen vascular diseases including lupus and Ehlers-Danlos are risks for intraoperative bleeding. Poor diet is associated with vitamin K deficiency and deficits in clotting factors. Organomegaly warrants further work-up to rule out liver or hematologic disorders.58 In the absence of any of the previously cited risk factors, no evidence has been found to indicate that further work-up is necessary before elective surgery to exclude bleeding disorders. In fact, in a population of low-risk patients, the partial thromboplastin time (PTT) was found to have no predictive value as related to postoperative hemorrhage.59 Preoperative preparation with known coagulation defects are described in Table 4–7.60 Patients on oral anticoagulation or antiplatelet regimens require special care. Recovery of adequate platelet function requires at least 2 to 4 days after stopping aspirin. Similar results affect management of patients on clopidogrel and ticlopidine, irreversible inhibitors of platelet function. Complete recovery of platelet function takes 7 days, and patients should be instructed to cease taking antiplatelet agents 5 to 7 days before elective surgery. If the risk of acute thrombus is high as in patients with recently placed coronary artery stents, elective surgery should be postponed. Emergent surgery can be performed on patients taking aspirin or novel antiplatelet drugs because postoperative bleeding risk is generally limited to wound hematoma. More severe bleeding risk is present, however, when patients are on both aspirin and clopidogrel because these drugs act synergistically and perioperative morbidity is great in this population.61 Management of coumadin in the perioperative setting is based on the indication for which it is prescribed (Fig. 4–6). The complications of thromboembolic events require perioperative bridging with unfractionated heparin or low-molecular-weight heparin in patients with mechanical heart valves. Recent venous embolic disease (within 1 mo) similarly indicates the need for perioperative heparin derivatives.62–64
Failure to Treat for Hypercoagulable State ● Consequence The incidence of deep venous thrombosis (DVT) was historically quoted as ranging from 15% to 30% in
40
SECTION I: GENERAL CONSIDERATIONS
Table 4–7 Treatment of Coagulation Factor Disorders Bleeding Disorder
Target Factor Level
Plasma Product
Hemophilia A Minor surgery
>30% for 3–4 days
Major surgery
>80%–100% for 4 days, then >50% for 3–7 days
Cardiovascular, prostate, and neurosurgery
>100% for 3 days, then 80%–100% for 7–10 days
Recombinant or plasma-derived monoclonal factor VIII concentrates
Hemophilia B Minor surgery
>30% for 3–4 days
Major surgery
>80%–100% for 4 days, then >50% for 3–7 days
Cardiovascular, prostate, and neurosurgery
>100% for 3 days, then 80%–100% for 7–10 days
Recombinant or monoclonal plasmaderived factor IX concentrates
von Willebrand Disease Minor surgery
>50% for 1–3 days
Major surgery
Keep 50%–100% for 7–10 days
DDAVP or vWF-containing factor VIII concentrates
Factor XI Deficiency Minor surgery
>30% for 3–4 days
Major surgery
>45% for 7–10 days
FFP
Factor VII Deficiency Minor surgery
>15%
Major surgery
>25%
FFP or recombinant human factor VIIa
Factor X Deficiency Minor surgery
>15%
Major surgery
>50% perioperatively, then >30%
FFP or prothrombin complex concentrates
Factor V Deficiency Minor surgery
>25%
Major surgery
>50% perioperatively, then >25%
FFP
Minor surgery
20%–40%
FFP or prothrombin complex concentrates
Major surgery
20%–40%
Prothrombin Deficiency
A- or Hypofibrinogenemia Minor surgery
>50–100 mg/dl for 1–3 days
Major surgery
>50–100 mg/dl for 2–3 wk
Cryoprecipitate
Factor XIII Deficiency Minor surgery
>5%
Major surgery
>5%
FFP or cryoprecipitate
DDAVP, 1-Desamino-8-D-arginine vasopressin; FFP, fresh frozen plasma; vWF, von Willebrand factor. From Streiff MB. Abnormal operative and postoperative bleeding. In Cameron J (ed): Current Surgical Therapy, 8th ed. Philadelphia: Elsevier Mosby, 2001; p 1124, Table 4.
4 PREOPERATIVE PITFALLS
41
Stop coumadin 4 days pre-operative
Low risk for thromboembolism (atrial fibrillation or DVT ⬎3 months before procedure)
Post-operative DVT prophylaxis with LMWH or heparin
Restart coumadin on POD 0
Figure 4–6 Perioperative management of the patient on coumadin. LMWH, low molecular weight heparin.
postsurgical patients before the institution of prophylactic measures. Pulmonary embolism caused death in 0.2% to 0.9% of patients.65,66 In fact, as many as 29% of postoperative deaths occurring in the first 30 days after a procedure and in prophylaxis may have resulted from pulmonary embolism (PE) according to some autopsy studies.67 Grade 1/4/5 complication ● Intervention Although surveillance for postoperative DVT is rarely indicated, symptoms of unilateral lower extremity pain, color change, or edema should prompt emergent imaging, duplex ultrasonography (DUS), of the deep veins. In cases in which a high clinical suspicion for DVT is present, yet DUS is negative, pelvic computed tomography (CT) or venography may be useful to delineate the presence of a pelvic clot. Unexplained respiratory distress and an elevated arterial-alveolar gradient requires spiral CT scan of the chest, ventilation˙ ) scanning, or pulmonary angiography perfusion (V˙/Q to rule out PE. After diagnosis of a DVT or PE, patients should be immediately started on therapeutic anticoagulation. A high index of suspicion and respiratory distress is indicated for empirical treatment. High-dose unfractionated heparin should be administered intravenously to obtain an activated PTT between 60 and 80 seconds. Recently, lowmolecular-weight heparins such as enoxaparin have been employed, and this drug, given subcutaneously in doses of 1 mg/kg twice daily (once daily in renal failure patients), has been shown to be equally effective in preventing clin-
Intermediate risk
Prophylactic heparin or LMWH starting two days pre-operatively, continuing postoperatively
Resume coumadin on POD 0
High risk (mechanical valve, DVT within 1 month)
Admit for therapeuticic heparin 2 days pre-operatively
Therapeutic LMWH starting 2 days pre-operatively
D/C 4–6 hours pre-operatively and restart 12 hours post-op
D/C 12 hours preoperatively and restart 12 hours post-op
Resume coumadin on POD 0, stop heparin or LMWH after therapeutic INR
ical sequelae of DVT and PE.68 In the case of severely compromised oxygenation ability, thrombolysis may be essential, but the risk of postoperative bleeding should be recognized. In patients at risk for bleeding and who have a contraindication to anticoagulation, or in those who develop DVT or PE despite medical therapy, an inferior vena cava (IVC) filter can be placed in the setting of DVT to prevent migration of the clot to the lungs.69 Long-term consequences of DVT including venous stasis are not addressed by this mode of therapy; however, and multiple complications are associated with IVC filter placement including recurrent DVT, filter migration, insertion site injury, and IVC occlusion. Recently, removable IVC filters have been approved for use in the U.S. market, aiming to prevent these complications by filter retrieval after the risk of PE decreases.70 Results related to these filters are incompletely characterized. They do appear to prevent PE, but almost 50% are unable to be removed owing to ongoing contraindications to anticoagulation or to large emboli wedged in the filter.71 ● Prevention Surgery itself is a risk factor for development of DVT and PE, but as in the prevention of most postoperative complications, a thorough history and physical examination should be completed to assess a patient’s risk for coagulation disorders. The conditions most commonly associated with elevated risk of postoperative DVT and PE are age, obesity, previous DVT or PE, genetic predisposition, and cancer.70 It should be noted that orthopedic procedures (major joint surgery) and
42
SECTION I: GENERAL CONSIDERATIONS
Table 4–8 Thromboembolism Risk in Surgical Patients DVT (%) Level of Risk
Calf
PE (%)
Proximal
Clinical
0.4
0.2
Low risk Minor surgery in patients 60 yr, or age 40–60 with additional risk factors (prior VTE, cancer, molecular hypercoagulability)
20–40
4–8
Highest risk Surgery in patients with multiple risk factors (age >40 yr, cancer, prior VTE) Hip or knee arthroplasty, HFS Major trauma; SCI
40–80
10–20
Fatal
Successful Prevention Strategies
3400 U daily), or IPC
0.2–5
LMWH (>3400 U daily), fondaparinux, oral VKAs (INR, 2– 3), or IPC/GCS + LDUH/LMWH
4–10
GCS, glucocorticosteroid; INR, International Normalized Ratio; IPC, intermittant pneumatic compression; LDUH, low dose unfractionated heparin; LMWH, low-molecular-weight heparin; SCI, spinal cord injury; VKAs, vitamin K antagonists; VTE, venous thromboembolism. From Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism—the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(suppl):338–400, Table 5.
therapy for trauma carry high risks of venous thromboembolic disease (VTED). Risks after colorectal surgery are somewhat higher than those following other general surgery procedures. Recommendations for prevention of postoperative VTED are based on a consensus statement by the American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy.72 Prescription of postoperative graded compression stockings, low-dose unfractionated heparin, low-molecular-weight heparin, or vitamin K inhibitors (e.g., coumadin) is based on the type of surgery the patient has undergone and the number of risk factors a patient is known to have. Table 4–8 summarizes these recommendations, which are based on currently available randomized, controlled trials and meta-analyses.72 The role of IVC filters in the prevention of PE in surgical patients is poorly defined. Although clinicians have resisted this indication in an attempt to prevent long-term complications of the filters, the possibility of removable filters has encouraged reexamination of this therapy. Obesity and trauma surgery are the first fields likely to adopt routine prophylactic IVC filter placement owing to the high rate of VTED in respective patient populations.70 Patients with known DVT and surgical disease are also considered for prophylactic IVC filter placement.
Identification of Endocrine Dysfunction Failure to Treat and Prevent Hyperglycemia ● Consequence Multiple studies have demonstrated that patients with poor blood sugar control have higher rates of wound
infections.73–75 ICU patients with hyperglycemia are prone to septicemia and resultant MSOF.76 Complications of diabetes such as gastroparesis and neuropathy place patients at risk of aspiration and autonomic instability, respectively, and indicate that both anesthesiologists and surgeons must be aware not only of the immediate effect of hyperglycemia on postoperative healing but also of the derangements associated with chronic physiologic changes related to diabetes.77,78 Grade 1/4/5 complication ● Intervention In patients with persistent hyperglycemia, aggressive control to maintain blood sugar below 120, as discussed later, is essential. Treatment of infections is mainly supportive, with IV antibiotics tailored to the microorganism, débridement or drainage as necessary, and ventilatory or dialysis support as required for MSOF. ● Prevention Preventing the postoperative complications related to diabetes begins before the induction of anesthesia (Box 4–6). Patients should be directed to stop taking oral antihyperglycemics the day before surgery to prevent interactions with anesthesia that may result in lactic acidosis and arrhythmia. Long-acting insulin medications should be taken through the day of surgery, but after initiation of the fast, injection with short-acting analogues should stop to prevent hypoglycemic reactions. The fast should be broken before the start of surgery by administration of IV dextrose. This appears to minimize the insulin resistance observed postoperatively. When possible, epidural anesthesia should be
4 PREOPERATIVE PITFALLS
Box 4–6 ● ● ● ● ● ●
Perioperative Management of Diabetes
Hold short-acting insulin and oral medications with onset of fast. Continue long-acting insulin analogues (L-glargine) on day of surgery Break fast immediately preoperatively with dextrosecontaining IV fluid Low threshold for insulin drip intra- and postoperatively Floor patients with goal blood sugar 24 hr old) Massive trauma Spinal cord transection (>48 hr) Acute renal failure Stroke Massive trauma/crush injury Prolonged immobility (>7 days) Guillain-Barré syndrome Severe Parkinson disease Acute tetanus exacerbation Acidosis with hypovolemia Profound sepsis Severe intra-abdominal sepsis Congenital muscle diseases
5 ANESTHESIA FOR THE SURGEON Table 5–5 Complications of Malignant Hyperthermia Sign
Physiologic Effect
Muscle rigidity/spasm
Inability to ventilate, hyperkalemia
Hyperkalemia
Cardiac dysrhythmia
Rhabdomyolysis, myoglobinuria
Renal failure
Increase metabolism, acidosis
Cardiovascular collapse due to extreme tachycardia or severe acidosis, hypoxemia
Fever (late sign)
Seizures, cerebral edema, brain anoxia
59
hypovolemia resulting from severe pyrexia. Severe hyperkalemia should be treated with insulin/glucose, bicarbonate, fluid resuscitation, and/or dialysis as indicated by the patient’s electrocardiogram and hemodynamic status.35
● Prevention Nondepolarizing muscle relaxants should be used in this patient population to avoid potential hyperkalemia.
● Prevention The most effective way to prevent MH is to recognize its risk factors, most notably family history, and avoid the use of volatile anesthetics and succinylcholine in these patients. The syndrome is inherited as an autosomal dominant trait. Furthermore, the surgeon and anesthesia provider must be familiar with signs of MH. Of note, fever is a very late sign. The earliest sign of MH is a sudden increase in the partial pressure of exhaled carbon dioxide and masseter muscle spasm. Patients who may have experienced MH should be referred to the national registry for MH (1-800-MHHYPER) for proper evaluation and counseling.
Malignant Hyperthermia Patients with musculodystrophy, central cord disease, osteogenesis imperfecta, and those with a family history of malignant hyperthermia (MH) are at risk for developing this syndrome.
Patients with Parkinson Disease Patients with Parkinson disease must continue their medications throughout the perioperative period. Furthermore, specific medications may worsen muscle rigidity and should be avoided.
● Consequence MH is a rare (1 : 15,000) life-threatening condition that can develop as a result of volatile anesthetic or succinylcholine administration. It is characterized by an acute hypermetabolic state occurring up to 24 hours after administration of a volatile general anesthetic or succinylcholine. The consequences of this syndrome are listed in Table 5–5. Life-threatening complications can include muscle rigidity, which can prevent adequate ventilation; severe hyperkalemia and cardiac dysrhythmia; myoglobinuria and acute renal failure; severe hyperthermia, leading to seizures and brain anoxia or cerebral edema; and metabolic acidosis and cardiovascular collapse.34,35 Grade 1/4/5 complication
● Consequence Patients with Parkinson disease should continue their medications because abrupt withdrawal may lead to difficulty with intubation and ventilation owing to worsened muscle rigidity. Grade 1 complication
ride, intravenous insulin and dextrose 50%, sodium bicarbonate, and hyperventilation.
● Repair If MH occurs intraoperatively, then surgery must be aborted as expediently as possible. Dantrolene is the only approved medication for the treatment of MH. Its mechanism of action involves stabilization of the sarcoplasmic reticulum to prevent further release of calcium from the skeletal muscle stores and ongoing muscle contraction. The dose is 2.5 mg/kg every 5 minutes until symptoms abate or until a maximum dosage of 10 mg/kg is reached, and then 1 mg/kg every 6 hours for 24 to 48 hours. All patients should be cooled aggressively with ice packs and intubated with 100% oxygen with hyperventilation to meet their high oxygen and metabolic demands during the crisis phase. Massive fluid resuscitation may be needed to prevent renal failure owing to myoglobinuria and
● Repair and Prevention Phenothiazines, butyrophenones, and metoclopramide should not be given to patients with Parkinson disease because these agents can exacerbate symptoms as a consequence of their antidopaminergic activity.36
Cardiovascular Pitfalls Preoperative Evaluation and Clearance The most common reason for delay in elective surgery is inadequate cardiac work-up and optimization of medical therapy in the setting of ischemic heart disease. Specific criteria related to preoperative evaluation and medical clearance for surgery are discussed elsewhere. Patients with Aortic and Mitral Stenosis ● Consequence Severe aortic stenosis poses a great perioperative risk for noncardiac surgery. If stenosis is moderate (aortic valve orifice area of 0.7–0.9 cm2 and aortic valve index of 0.5 cm2/m2) with symptomatic impairment or stenosis is critical (aortic valve orifice area of 5 L), some reports have suggested a risk of triggering an acute reduction in intravascular volume or electrolyte abnormalities. ● Consequence In 18 patients undergoing large-volume paracentesis, Kao and coworkers15 found no significant difference in pre- and postprocedure sodium, blood urea nitrogen, hematocrit, or postural systolic blood pressure.15 Pinto and associates4 measured plasma volume using a dilution method involving 125I-labeled human serum albumin in 12 patients undergoing large-volume paracentesis. They did not find any difference in the mean plasma volume, serum sodium, creatinine, or blood urea nitrogen at 24 and 48 hours after the procedure as compared with preparacentesis levels. Nevertheless, in large hepatology services, overaggressive paracentesis has led to severe hypotension and death (personal communication, 2007). Grade 1–5 complication ● Repair Aggressive fluid resuscitation; monitor and replete electrolytes.
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SECTION II: BEDSIDE PROCEDURES
● Prevention Simple steps for prevention are to establish a good fluid and electrolyte balance prior to performing the paracentesis. Furthermore, the paracentesis should be limited to removing enough fluid for symptomatic relief and diagnostic purposes, without being overzealous. Albumin may also be useful with paracentesis in some cases, taking into account factors such as the presence or absence of peripheral edema and the volume of fluid removed.6
Ascitic Fluid Leak In a series of 52 patients undergoing 73 large-volume paracenteses, Wilcox and colleagues6 reported that the most common complication was ascitic fluid leak in 5 procedures (7%). In all cases, the leak was self-limited. Nevertheless, in 2 patients the drainage persisted for a few days. ● Consequence All cases of ascitic fluid leak in the literature have been self-limited. Grade 1 complication ● Repair Although in most paracenteses, a sterile 4 × 4 dressing is sufficient to cover the puncture site, in the presence of a leak, additional dressings may be needed. Wilcox and colleagues6 recommended placing an ostomy bag over the site until the drainage ceases. ● Prevention It is possible that the use of peritoneal dialysis catheters led to the increased rate of ascitic fluid leakage in the series of Wilcox and colleagues6 and that there is less risk with smaller-bore needles. However, it is also possible that other authors simply did not report this as a complication. Another suggestion for prevention is to position the patient opposite to the paracentesis site for a period of time after the procedure.6
Other Complications In a prospective series of 229 abdominal paracenteses performed on 125 patients, Runyon1 reported 1 abdominal wall hematoma requiring transfusion and 2 that did not require transfusion. Additional morbidities that have been reported in association with paracentesis include scrotal edema (grade 1) and retained catheter fragments left in abdomen9 (grade 2).
CONCLUSIONS/CLINICAL PEARLS ● Use sterile technique. ● Include routine use of ultrasound for localization.
● Make careful needle selection. ● Avoid anatomic obstacles (e.g., surgical scars, varices). ● Monitor fluid and electrolyte status both before and
after the procedure.
REFERENCES 1. Runyon BA. Paracentesis of ascitic fluid. A safe procedure. Arch Intern Med 1986;146:2259–2261. 2. Pare P, Talbot J, Hoefs JC. Serum-ascites albumin concentration gradient: a physiologic approach to the differential diagnosis of ascites. Gastroenterology 1983;85: 240–244. 3. Angueira CE, Kadakia SC. Effects of large-volume paracentesis on pulmonary function in patients with tense cirrhotic ascites. Hepatology 1994;20(4 pt 1):825–828. 4. Pinto PC, Amerian J, Reynolds TB. Large-volume paracentesis in nonedematous patients with tense ascites: its effect on intravascular volume. Hepatology 1988;8: 207–210. 5. Gines P, Arroyo V, Quintero E, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987;93:234–241. 6. Wilcox CM, Woods BL, Mixon HT. Prospective evaluation of a peritoneal dialysis catheter system for large volume paracentesis. Am J Gastroenterol 1992;87:1443– 1446. 7. Lawson JD, Weissbein AS. [The puddle sign; an aid in the diagnosis of minimal ascites.] N Engl J Med 1959;260: 652–654. 8. Shaheen NJ, Grimm IS. Comparison of the Caldwell needle/cannula with Angiocath needle in large volume paracentesis. Am J Gastroenterol 1996;91:1731–1733. 9. Mallory A, Schaefer JW. Complications of diagnostic paracentesis in patients with liver disease. JAMA 1978; 239:628–630. 10. Runyon BA. Patient selection is important in studying the impact of large-volume paracentesis on intravascular volume. Am J Gastroenterol 1997;92:371–373. 11. Runyon BA, Antillon MR, Montano AA. Effect of diuresis versus therapeutic paracentesis on ascitic fluid opsonic activity and serum complement. Gastroenterology 1989; 97:158–162. 12. Martinet O, Reis ED, Mosimann F. Delayed hemoperitoneum following large-volume paracentesis in a patient with cirrhosis and ascites. Dig Dis Sci 2000;45:357– 358. 13. Pache I, Bilodeau M. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther 2005;21:525–529. 14. McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991;31:164– 171. 15. Kao HW, Rakov NE, Savage E, Reynolds TB. The effect of large volume paracentesis on plasma volume—a cause of hypovolemia? Hepatology 1985;5:403–407.
Section III
GASTROINTESTINAL SURGERY Stephen R. T. Evans, MD Reason and free inquiry are the only effectual agents against error. —Thomas Jefferson
STOMACH, DUODENUM AND SMALL BOWEL 13
Open Gastrostomy Feeding Tube Placement and Percutaneous Endoscopic Gastrostomy Tube Placement Rebecca Evangelista, MD and Eleanor Faherty, MD INTRODUCTION Gastric tube placement is a common procedure for the delivery of supplemental or total enteral nutrition and for drainage in cases of distal obstructing masses. A number of approaches are available depending on the patient’s previous surgical history, comorbidities, and reason for requiring tube placement. Open gastrostomy placement by Stamm and Janeway techniques as well as percutaneous endoscopic gastrostomy (PEG) tube placement are
addressed in this chapter. Most retrospective studies have shown little or no statistical difference in the complication rates between these procedures. The most serious complication reported is tube dislodgement, with all other complications falling into the minor category.1 Reported overall complication rates range from 9% to 46%, in which a vast majority are minor complications.1–5 Most steps discussed in this chapter are related to reducing risk of tube dislodgement in the early and late postoperative periods and reduction in risk of visceral injury during each
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SECTION III: GASTROINTESTINAL SURGERY
procedure. Choosing to perform a Janeway gastrostomy with gastric stoma maturation can be the best choice in those cases in which early tube dislodgement is more likely, in cases of significant mental status changes, essentially avoiding all related and subsequent complications.
INDICATIONS ● ● ● ● ●
Functional dysphagia or other risks for aspiration Gastric outlet obstruction Distal obstructing masses Proximal obstructing masses Other poor nutritional states
Open Gastrostomy Tube Placement OPERATIVE STEPS OPEN STAMM GASTROSTOMY TUBE Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8
Upper midline incision Mobilization of the stomach Placement of the pursestring suture in the anterior stomach Gastrostomy Placement of the gastrostomy tube into the stomach through the abdominal wall Suturing the anterior stomach to the peritoneum around the tube tract and insertion site Closure of the midline incision External suturing of the tube to the anterior abdominal wall
OPEN JANEWAY GASTROSTOMY TUBE Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7
Upper midline incision Mobilization of the stomach Creation of the gastric tube along the anterior stomach Creation of the tract through the anterior abdominal wall for the gastric tube Maturation of the gastric stoma Insertion of the gastrostomy tube through the stoma Closure of the midline incision
OPERATIVE PROCEDURE OPEN STAMM GASTROSTOMY Upper Laparotomy Intra-Abdominal Injuries with Midline Incision To obtain access to and adequate exposure of the stomach, an upper midline is the standard incision of choice for
an open gastrostomy tube placement. Occasionally, a left subcostal incision can be used. Complications related to laparotomy incisions are discussed in Section I, Chapter 7, Laparoscopic Surgery.
Mobilization of the Stomach and Lysis of Adhesions Bowel Perforation ● Consequence Leak from the injured stomach, small bowel, or transverse colon, leading to postoperative peritonitis. A minority of patients will have dense adhesions from previous surgery or a partially or completely intrathoracic stomach owing to paraesophageal hernia. The stomach will require adequate mobilization to allow the anterior portion along the greater curvature to approximate the anterior abdominal wall two fingerbreadths below the left costal margin without undue tension. Grade 3/4 complication ● Repair Two-layer suture repair of all full-thickness injuries. Single-layer suture repair of all serosal tears. ● Prevention The position of the stomach must be fully visualized through an adequate fascial incision and any degree of herniation directly visualized. Sharp dissection should be used for lysis of adhesions and cautery avoided to reduce the risk of delayed thermal perforation.
Placement of the Pursestring Suture in the Anterior Stomach Inadequate Suture Thickness ● Consequence Tear of the gastric wall with pull-through of the suture. This can result in an immediate or delayed perforation in the stomach, allowing for potential leak if not repaired adequately. Suture that is visible through the serosal surface layer is too shallow, has a higher risk of tear, and should be replaced. Grade 3 complication ● Repair Two-layer repair and repositioning of the pursestring suture for a separate site of intended tube insertion. ● Prevention Sutures should be placed to a seromuscular thickness by fully pronating the wrist and driving the needle perpendicular with an almost immediate supination of the wrist. If a seromuscular placement cannot be ensured, a full-thickness bite is adequate.
13 GASTROSTOMY TUBE PLACEMENT
Gastrostomy in the Center of the Pursestring Injury to the Posterior Wall of the Stomach ● Consequence Immediate or delayed intra-abdominal leak through the posterior wall. Grade 3/4 complication ● Repair Two-layer suture repair from the posterior surface of the stomach requires exposure of the posterior stomach through a window into the lesser sac through the gastrocolic ligament. ● Prevention Retract the anterior stomach wall with atraumatic forceps or Babcocks while creating the gastrostomy. The gastrostomy can also be made by opening the individual layers of the gastric wall, sequentially retracting each subsequent deeper layer. Avoid prolonged application of the cautery and using pressure on the tip of the cautery to create tension while making the gastrostomy.
Placement of the Gastrostomy Tube into the Stomach through the Anterior Abdominal Wall Tube Damage/Inadequate Closure of Pursestring Sutures ● Consequence Immediate or delayed failure of the balloon to retain inflation. Immediate or delayed leak from or around the tube. An early consequence of deflation of a balloon, if used, is bleeding from the gastrotomy owing to lack of tamponade. Leak from the tube early through a hole in the tube can result in extravasation of tube contents into the abdomen or along the abdominal wall tract leading to peritonitis or localized fasciitis, respectively. Grade 1/2 complication ● Repair After passing the tube through the tract in the abdominal wall, test a balloon, if used, or flush the tube with saline and look for a leak. A dilute solution of methylene blue can also be used if damage to the tube is suspected but unclear with saline flush. ● Prevention After the tract in the anterior abdominal wall is made with a tonsil clamp use a broader Kelly clamp to pull the tube through the tract. Also clamp the entire tube rather than feeding the lumen of the tube onto one tine of the clamp to avoid damage to the tube as it is being pulled through the layers of the abdominal wall.
149
Suturing the Anterior Stomach to the Peritoneum around the Tube Tract and Insertion Site Tension and Tearing of Stomach around Gastrostomy Site/Loss of Tube Tract ● Consequence Leak around the tube insertion site. Slippage of stomach away from the anterior abdominal wall or tube from within the stomach. Early, this can lead to free intraabdominal leak of gastric contents and inability to replace the tube by fluoroscopic guidance. Grade 3 complication ● Repair Fluoroscopic guidance to replace a slipped tube may be possible 3 to 5 days after placement. Seldinger technique can be used to identify the tract and determine whether access to the stomach is present. If access to the stomach cannot be verified, open exploration and replacement of the tube or repair of the original gastrotomy will be necessary. ● Prevention Place multiple interrupted sutures of nonabsorbable material around the tube site. Be sure that the sutures are placed seromuscular or full thickness in the stomach and obtain adequate purchase of each suture on the peritoneum. Ensure that the balloon is deflated during this step and inflated before closing the abdomen.
Closure of the Midline Incision Injury to Intra-Abdominal Structures/Dehiscence See Section I, Chapter 7, Laparoscopic Surgery.
External Suturing of the Tube to the Anterior Abdominal Wall Tube Dislodgement ● Consequence Slippage of stomach from the anterior abdominal wall with subsequent leak and loss of percutaneous access to the stomach. Grade 3 complication ● Repair See “Suturing the Anterior Stomach to the Peritoneum around the Tube Tract and Insertion Site,” earlier. Replace any sutures that have pulled through the skin or been inadvertently cut. ● Prevention Place several permanent interrupted sutures around the tube and/or external bumper to the skin. Air knots
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SECTION III: GASTROINTESTINAL SURGERY
may keep the skin from necrosis, but skin sutures should be full thickness to avoid tearing through. Abdominal binders can also be placed for the first week to minimize access to the tube before the tract becomes epithelialized.
OPEN JANEWAY GASTROSTOMY For upper midline incision and mobilization of the stomach, see “Open Stamm Gastrostomy,” earlier.
● Repair Lengthen the gastric tube to allow for tension-free passage and reduce torque through the abdominal wall. Enlarge the diameter of the fascial opening. ● Prevention Complete the creation of the gastric tube prior to making the tract through the abdominal wall to allow for more accurate placement of the tract. The tract should be straight through the abdominal wall up from the base of the gastric tube and should be at least 2 to 3 cm below the left costal margin.
Creation of the Gastric Tube along the Anterior Stomach Wall
Maturation of the Gastric Stoma
Inadequate Length or Width of Gastric Tube/Inadequate Blood Supply to Gastric Tube
● Consequence Leak of gastric or tube contents into abdominal wall owing to slippage of the gastric tube end below the skin surface. Inability to pass tube into the stomach. Grade 3 complication
● Consequence Inability to evert a stoma at the skin surface or undue tension on the gastric tube to evert the stoma. If the tube is not developed from the midanterior stomach toward the greater curvature, there may be too much tension on the gastric tube through the abdominal wall or poor blood supply along the staple line. Grade 1 complication ● Repair If the tube appears dusky or cannot deliver completely with 1 cm above the skin, a new tube needs to be created or extended toward the greater curvature. ● Prevention Start the creation of the gastric tube in the midportion of the anterior gastric wall and remain parallel to the greater curvature. Based on the thickness of the abdominal wall, estimate the length needed to ensure a 1-cm extension above the skin. Maintain a tube diameter of approximately 1.5 cm for the full length.
Creation of the Tract through the Anterior Abdominal Wall for the Gastric Tube Inadequate Position/Inadequate Diameter of Tract ● Consequence Inability to place a tube of adequate diameter through the gastric tube into the stomach, undue tension on the base of the gastric tube, or impingement of tube through too narrow a tract. Grade 3 complication
Inadequate Eversion of Gastric Tube
● Repair Increase the length of the gastric tube and resuture the circumference of the gastric tube. ● Prevention Place interrupted sutures from the gastric tube end, seromuscular through the gastric tube 1 cm deep to the end and finally through deep dermis. This will ensure complete eversion of the end of the gastric tube.
Insertion of the Gastrostomy Tube through the Stoma Inadequate Positioning below the Level of the Abdominal Wall ● Consequence Leak and inadequate nutrition delivery. Grade 2 complication ● Repair Release any balloon at the end of the tube, remove, and replace after lubricating the tip. A contrast study can be done if there is any question about complete tube advancement into the stomach below the level of the posterior fascia. ● Prevention A contrast study can be done if there is any question about complete tube advancement into the stomach below the level of the posterior fascia.
Closure of the Midline Incision See “Open Stamm Gastrostomy,” earlier.
13 GASTROSTOMY TUBE PLACEMENT
Percutaneous Gastrostomy Tube Placement OPERATIVE STEPS Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8
Insertion of endoscope through the esophagus into the stomach Insufflation of the stomach Identification of the “one-to-one” position on the abdominal wall Percutaneous insertion of the angiocatheter into the stomach Endoscopic capture of the guidewire and removal Pull-through of PEG tube from the oral cavity into the stomach via guidewire Placement of external bumper and external anchoring suture Repeat endoscopy
OPERATIVE PROCEDURE Insertion of the Endoscope into the Stomach Perforation ● Consequence Anywhere along the path of the endoscope, a visceral tear and perforation can occur. Leak from an esophageal tear can be into the thorax or the abdomen depending on the location of the perforation. Perforation of the stomach is rare but possible. Although rare, it can be fatal.6 Grade 3/4 complication ● Repair If found early after endoscopy, exploration and repair of the perforation may be necessary by either open surgical repair or esophageal stent placement.7 If diagnosed late, many esophageal perforations can be treated with a course of total parenteral nutrition and nothing by mouth. ● Prevention Maintain the view of the lumen in the center of the scope at all times. Recognize the appearance of bright white, signifying the end of the scope up against the visceral wall. Use of small amounts of insufflation will also help open the lumen ahead of the scope, allowing for maintaining the proper view during scope advancement.
151
Insufflation of the Stomach Inadequate Distention of the Stomach ● Consequence Inability to find the best one-to-one position and/ or pass the angiocatheter percutaneously into the stomach. Grade 1 complication ● Repair Close all nonworking ports and cover the insufflation button on the scope. Watch as the rugae of the stomach flatten as an indicator of the proper amount of insufflation. Insufflate until the stomach grossly distends the anterior abdominal wall. If one-to-one position cannot be well defined, convert to an open gastrostomy. ● Prevention Prior to the start of the endoscopy, ensure that all systems for the scope are in proper working order including the insufflation. Look over the head of the scope and ensure that all instrument ports are capped or closed while not in use.
Identification of One-to-One Position on the Abdominal Wall Colonic or Small Bowel Injury/Placement of PEG Tube through Bowel ● Consequence Peritonitis from leak, sepsis, bowel obstruction. Grade 3 complication ● Repair Exploratory laparotomy and resection of involved bowel with possible temporary colostomy. ● Prevention Look for the one-to-one position where minimal compression on the anterior abdominal wall shows obvious depression of the stomach on endoscopy. In addition, transilluminating can show the end of the scope clearly through the anterior abdominal wall indicating minimal tissue between the scope and the skin and proper location for tube placement (Fig. 13–1).
Percutaneous Insertion of the Angiocatheter into the Stomach Laceration of Short Gastric Vessels/Injury to Bowel ● Consequence Ongoing intra-abdominal bleeding. Grade 2/3/4 complication
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Colon
Rib
Liver
Small intestine
A
Stomach
Endoscope Gastrostomy tube secured
Colon
Rib
Liver
Small intestine
C
Stomach
B
Figure 13–1 A, Poor “one-to-one” with a wide gastric indentation may indicate the presence of transverse colon, omentum, or small bowel between the abdominal wall and the anterior gastric wall. B, Example of poor one-to-one palpation with a wide gastric indentation (arrow). C, Example of percutaneous endoscopic gastrostomy (PEG) placement through intervening tissue if good oneto-one palpation is not identified.
● Repair Exploratory laparotomy and suture ligation of bleeding vessels.
guidewire. Laceration of the tongue will result in local pain and bleeding. Grade 1 complication
● Prevention Establish proper one-to-one position and do not go below two fingerbreadths under the costal margin, increasing the risk of needle insertion at the greater curvature rather than on the anterior surface of the stomach. Do not attempt multiple passes of the angiocatheter. If good one-to-one position cannot be established or two passes of the angiocatheter are unsuccessful, convert the procedure to an open gastrostomy placement.
● Repair Repeat placement of the endoscope to locate the end of the guidewire to recapture. If the end is not seen or it is not possible to safely grasp the end within the esophagus, pull the wire back into the stomach under direct visualization, reinsufflate, and regrasp the guidewire. A tongue laceration from this step will very rarely require any specific treatment other than direct pressure and suctioning of the mouth until the bleeding ceases.
Endoscopic Capture of the Guidewire and Removal through the Mouth Loss of Guidewire/Laceration of Tongue ● Consequence Inability to attach and pull the PEG tube into place, requiring repeat endoscopy to locate the end of the
● Prevention When grasping the wire, be sure to allow sufficient guidewire through the loop of the grasper. Assign a single person to maintain a tight grasp on the guidewire until it is retrieved from the grasper after pulling the entire scope and grasper from the mouth. To avoid tongue laceration, minimize the amount of movement of the guidewire after pulling through the mouth (Fig. 13–2).
13 GASTROSTOMY TUBE PLACEMENT
Figure 13–2 Grasp the guidewire well beyond the end to avoid loss of the wire during delivery through the esophagus and oropharynx.
Pull-through of the PEG Tube into the Stomach and through the Abdominal Wall via the Guidewire Laceration of Tongue/Loss of PEG from Guidewire For laceration of the tongue, see “Endoscopic Capture of the Guidewire and Removal through the Mouth,” earlier. ● Consequence Loss of the tract as the guidewire is pulled through the abdominal wall without the PEG tube. Grade 1 complication ● Repair Restart the procedure from Step 1, “Insertion of the Endoscope through the Esophagus into the Stomach.” ● Prevention Prior to pulling the PEG through the esophagus and stomach, ensure that the guidewire is securely attached to the PEG tube and manually guide them as a unit into the posterior oropharynx before pulling into the stomach and through the abdominal wall. Also ensure that the stab incision in the abdominal skin is long enough to accommodate the diameter of the PEG tube to avoid undue resistance while pulling through the abdominal wall.
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Figure 13–3 Repeat endoscopy is done to ensure adequate approximation of the PEG button to the gastric wall and good hemostasis.
Placement of the External Bumper and the External Anchoring Suture Abdominal Wall Necrosis/Bleeding/Accidental Loss of PEG Tube ● Consequence Tight placement of the bumper can lead to abdominal wall abscess and/or necrotizing fasciitis around the tube site. Loose placement can allow for bleeding around the tube insertion site from the gastric mucosa. Grade 2/3 complication ● Repair Loosen the bumper at the bedside as soon as tight placement is recognized. Local wound care may be all that is necessary. However, with worsening necrosis, operative wide débridement may be necessary. If ongoing blood loss is suspected and a loose position is recognized, the bumper can be tightened at the bedside. Endoscopy can confirm this problem and guide tightening to a point of tamponade. ● Prevention In most patients, the bumper position should be around 3 cm on the tube at the exit point from the abdominal wall. Repeating the endoscopy after tube securing can confirm adequate tamponade.
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Repeat Endoscopy This is done primarily to ensure proper tension of the PEG tube on the gastric wall to promote hemostasis and evaluate for any injury (Fig. 13–3). See “Insertion of the Endoscope into the Stomach,” earlier.
4.
5.
REFERENCES 1. MacLean AA, Alverez NR, Davies JD, et al. Complications of percutaneous endoscopic and fluoroscopic gastrostomy tube insertion procedures in 378 patients. Gastroenterol Nurs 2007;30:337–341. 2. Möller P, Lindberg CG, Zilling T. Gastrostomy by various techniques: evaluation of indications, outcome, and complications. Scand J Gastroenterol 1999;34:1050–1054. 3. Bankhead RR, Fisher CA, Rolandelli RH. Gastrostomy tube placement outcomes: comparison of surgical, endo-
6.
7.
scopic, and laparoscopic methods. Nutr Clin Pract 2005; 20:607–612. Hoffman MS, Cardosi RJ, Lemert R, Drake JG. Stamm gastrostomy for postoperative gastric decompression in gynecologic oncology patients. Gynecol Oncol 2001;82: 360–363. Rustom IK, Jebreel A, Tayyab M, et al. Percutaneous endoscopic, radiological and surgical gastrostomy tubes: a comparison study in head and neck cancer patients. J Laryngol Otol 2006;120:463–466. Freeman RK, Van Woerkom JM, Ascioti AJ. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation. Ann Thorac Surg 2007;83:2003–2007; discussion 2007–2008. Panos MZ, Reilly H, Moran A, et al. Percutaneous endoscopic gastrostomy in a general hospital: prospective evaluation of indications, outcome, and randomised comparison of two tube designs. Gut 1994;35:1551– 1556.
14
Open Jejunostomy Tube Placement Eleanor Faherty, MD and Rebecca Evangelista, MD INTRODUCTION
Step 5
Enteral nutrition is the preferred method of feeding patients who are unable to meet their caloric needs through the conventional oral route. Feeds are most commonly initiated via the stomach, but the jejunum is an acceptable alternative. Jejunal feeding tubes are often placed in patients who are at increased risk of aspiration of gastric contents. It is also an option when the stomach is not suitable for a gastrostomy tube because of previous surgery, distal obstruction, or disease. Jejunostomy tubes are also often placed during extensive enteric reconstructions in which delayed oral intake is anticipated. Such tubes provide distal access for enteral nutrition and help to avoid the need for parenteral nutrition and prolonged vascular access.1
Step 6 Step 7 Step 8
Placement of jejunostomy tube into jejunum through abdominal wall* Suturing of jejunal wall to anterior abdominal wall around tube insertion site Close midline incision External suturing of tube to anterior abdominal wall
OPERATIVE PROCEDURE Upper Midline Incision Intra-Abdominal Injuries with Midline Incision To obtain access and adequate exposure of the jejunum for an open jejunostomy tube placement, an upper midline incision is the standard choice. Care should be taken if the patient has had prior laparotomies and, thus, has resultant scar tissue. Complications related to laparotomy incisions are discussed in Section I, Chapter 7, Laparoscopic Surgery.
INDICATIONS ● ● ● ● ● ●
High risk for aspiration Gastric outlet obstruction Gastric dysmotility (i.e., gastroparesis) Previous gastric resection or gastric bypass Status after esophagogastrectomy Inability to place percutaneous endoscopic gastrostomy (PEG) tube ● Enteral access needed after extensive surgical procedure ● Long-term enteral access for chemotherapy patients2,3
OPERATIVE STEPS 2 Step 1 Step 2 Step 3 Step 4
Upper midline incision Identification of the jejunum approximately 20 cm distal to ligament of Treitz Placement of pursestring suture in antimesenteric side of jejunum Jejunostomy
Identification of the Jejunum Incorrect Identification of the Ligament of Treitz If the ligament of Treitz is not identified or is incorrectly identified, the placement of the jejunostomy tube may not be in the correct location in the jejunum. Ideal placement is considered to be approximately 20 to 30 cm distal to the ligament of Treitz. ● Consequence Malabsorption may result if the tube is placed too distally. If the tube is too proximal, it is possible that enteral feeds could reflux via the duodenum into the stomach and possibly cause aspiration. Grade 2/3 complication
*Some surgeons add a step here to additionally secure tube via the Witzel technique. To do this, place seromuscular sutures on either side of feeding tube to wrap about 5 cm of tube proximally with jejunal wall. Potential pitfalls with this technique are intestinal obstruction owing to excessive imbrication of the bowel wall circumference.
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● Repair If incorrect placement of the tube is noticed intraoperatively, the tube may be removed and the jejunostomy closed primarily. If proximal or distal placement is suspected from clinical factors, a contrast study may be performed to confirm tube location. If the study confirms either proximal or distal placement and the patient is not tolerating enteral feeding, a new tube should be placed. ● Prevention Correct identification of the ligament of Treitz will aid in proper tube placement. Locating the ligament is most easily accomplished by reflecting the transverse colon and omentum superiorly and following the transverse colon mesentery to its posterior origin. The ligament of Trietz should be visualized and palpated just to the left of midline in its posterior location.
Placement of the Pursestring Suture in the Antimesentric Jejunum Inadequate Suture Thickness ● Consequence Tear of the jejunal wall with pull through of the suture. This can result in an immediate or delayed fullthickness tear in the jejunal wall, allowing for potential leak. Grade 2/3 complication ● Repair Primary repair of any jejunal injury and repositioning of the pursestring suture for tube placement. ● Prevention Pursestring sutures should be anchored in the seromuscular layer of the jejunum for adequate strength. Sutures can be placed by fully pronating the wrist and driving the needle perpendicular to the tissue with an almost immediate supination of the wrist. Suture that is visible through the serosal surface is likely too shallow and has a higher risk of pulling through the tissue and, thus, should be replaced.
Jejunostomy in the Center of the Pursestring Suture
injury. Avoid prolonged application of the cautery or using significant pressure on the tip of the cautery or knife when making the jejunostomy.
Mesenteric Hematoma if the Jejunostomy Is Made Too Close to the Mesentery ● Consequence Bowel ischemia at the associated small bowel, resulting in bowel necrosis and/or intra-abdominal leak. Grade 3 complication ● Repair If the hematoma is small and detected intraoperatively, direct pressure may be sufficient or a small suture ligature to the mesentery may be needed. If the hematoma is large, or if there are signs of ischemia or stricture of the jejunum, a resection with primary anastomosis may be necessary. ● Prevention Careful placement of jejunostomy on the antimesenteric side of the jejunum.
Placement of the Jejunostomy Tube into the Jejunum through the Anterior Abdominal Wall Failure of the Pursestring to Secure the Jejunostomy Tube ● Consequence Tube dislodgement and possible intra-abdominal leak. Grade 2/3 complication ● Repair If recognized intraoperatively, a new pursestring suture may be placed to secure the tube. If recognition is delayed, a repeat laparotomy would be needed for jejunal repair and new tube placement. ● Prevention Ensure that the pursestring suture is placed in the seromuscular layer (see earlier). When tying the suture around the tube, maintain tension to avoid placement of an air knot.
Injury to the Posterior Wall of the Jejunum
Injury to the Epigastric Vessels
● Consequence Immediate or delayed leak through the posterior wall. Grade 3 complication
● Consequence Abdominal wall hematoma and, rarely, pseudoaneurysm of the epigastric artery. Grade 1/2/3 complication
● Repair Primary repair of the posterior wall injury. ● Prevention Retraction of the antimesenteric side of the jejunum with atraumatic forceps will help avoid a posterior wall
● Repair Evacuation of hematoma and oversewing of vessels if active bleeding is still apparent. Surgical excision of the pseudoaneurysm may be necessary to relieve pain at the site.
14 OPEN JEJUNOSTOMY TUBE PLACEMENT ● Prevention Knowledge of the normal and variant anatomy of the superior and inferior epigastric vessels is essential to avoiding injury. Placement of the jejunostomy tube at least 8 cm lateral to the midline should avoid vessel injury. Also direct visualization of the tube and instrument entry into the abdomen from the peritoneal side of the abdominal wall will allow identification of the epigastric vessel course and avoidance of injury.
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Closure of the Midline Incision See Section I, Chapter 7, Laparoscopic Surgery.
External Suturing of the Tube to the Anterior Abdominal Wall Tube not Adequately Secured to the External Abdominal Wall
Suturing of the Jejunal Wall to the Anterior Abdominal Wall around the Tube Insertion Site
● Consequence Tube dislodgement. Grade 2/3 complication
Inadequate Anchoring of the Jejunum to the Anterior Abdominal Wall Owing to a high risk of obstruction, most surgeons do not use tubes with distal balloons in the jejunum. The tubes are not routinely fixed to the small bowel other than to secure the pursestring sutures. This differs from the procedure for gastrostomy tubes in that the anchoring sutures to the anterior abdominal wall are significant in jejunostomy tube placement.
● Repair If this occurs early (48 hr old No indices of systemic sepsis present No diffuse peritonitis Documentation with contrast radiography that the perforation has sealed Significant comorbid conditions rendering the patient American Society of Anesthesiologists’ Class 4–5, if all of the above conditions are also present
From Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan. Arch Surg 1998;133:1166–1171; Jamieson GG. Current status of indications for surgery in peptic ulcer disease. World J Surg 2000;24:256–258; Berne T, Donovan A. Nonoperative treatment of perforated duodenal ulcer. Arch Surg 1989;124:830–832; and Taylor H. Peptic ulcer perforation treated without operation. Lancet 1946;2:441–444.
ulation of inflamed tissues to re-create a seal over the defect and may increase the postoperative leak rate. Grade 2 complication ● Repair See later steps for how to proceed with a Graham patch repair. ● Prevention Tissues that appear to be adherent to the duodenum in cases in which no perforation is seen should not be manipulated. Rather, air or liquid can be gently injected into the duodenum by nasogastric tube to test the integrity of the existing seal.
Placement of Sutures across the Perforation Enlargement of the Perforation
Step 7 Step 8
Secure sutures over the omentum Close fascia and skin. Remove trocars.
OPERATIVE PROCEDURE Midline Incision Injury to Visceral Organs A standard laparotomy incision beginning just caudad to the xyphoid and ending several centimeters above the umbilicus is most often used. A transverse incision can also be used based on the patient’s previous surgical history or surgeon preference. Many, though not all, studies suggest that transverse incisions may be associated with a lower postoperative hernia rate.24–26 Complications related to midline incision and fascial closure are discussed separately in Section I, Chapter 5, Anesthesia for the Surgeon.
● Consequence An increase in the size of the perforation can amplify the difficulty of repair, with a possible increase in the postoperative leak rate. Grade 1 complication ● Repair A slight increase in the size of the perforation does not require a change in operative technique. A giant duodenal defect (>3 cm) may not be amenable to Graham patch repair.27 In this circumstance, other procedures such as vagotomy/pyloroplasty, pyloric exclusion with proximal gastric diversion, or side-to-side duodenojejunostomy may be necessary. However, the latter procedure is very rarely needed in the majority of patients undergoing surgery for PPUD, even with iatrogenic enlargement of the perforation. Pitfalls related to anastomoses involving the duodenum are discussed elsewhere.
Exposure of the Area of Perforation and Irrigation of Surrounding Spaces
● Prevention Three to four interrupted 3-0 silk sutures are placed across the perforation. The sutures are inserted approximately 1 cm away from the edge of the perforation to accommodate the tendency of the suture to pull through the friable, inflamed duodenum. Ideally, all sutures should be placed through normal intestine, away from the area of inflammation. The needle should be retrieved and reintroduced from within the perforation during suture placement so as to place the suture using two passes of the needle (Figs. 15–1 and 15–2). This minimizes torque or undue force on the duodenum itself and helps prevent inadvertent worsening of the perforation.
Opening of a Sealed Perforation
Stenosis of the Duodenal Lumen
● Consequence At the time of surgery, tissues in the area have sealed the duodenal perforation in 50% of cases.12 Disruption of this closure results in the need for additional manip-
● Consequence Stenosis of the duodenum may result in small bowel obstruction postoperatively. Grade 2/3 complication
Trocar Insertion Injuries (Laparoscopic Approach) Trocar placement varies based on surgeon preference and experience. One approach utilizes a Hassan trocar in the infraumbilical position, an 11-mm trocar in the left midclavicular line approximately just above the level of the umbilicus, and a 5-mm trocar in the right midclavicular line just above the umbilicus. Complications of trocar insertion are discussed separately in Section I, Chapter 7.
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O
m
en
tum
15 GRAHAM PATCH REPAIR
er ss Le
Perforated duodenal ulcer
MC
er
Om e
ntu m
Figure 15–1 Incorrect placement of sutures across the perforation. Passage of the needle across the perforation in one pass can result in undue force and tension, resulting in tearing of the indurated tissue. The suture should be placed across the perforation using two passes of the needle.
ss Le
Perforated duodenal ulcer
A
B
C Figure 15–2 Correct placement of sutures across the perforation. Placement of the suture and needle across the perforation using two passes of the needle (A and B) minimizes undue tension across the site and decreases trauma to the indurated tissue. C shows the correct placement of sutures across the defect.
● Repair Sutures that are noted to narrow the lumen of the bowel or that may have apposed the posterior and anterior walls of the duodenum should be removed and replaced. ● Prevention Utilizing two passes of the needle as described previously decreases the possibility of suturing the posterior and anterior walls of the duodenum.
Mobilization of the Tongue of the Greater Omentum Necrosis of the Omental Tongue ● Consequence Necrosis of the tongue of the omentum used to fashion a repair can manifest as a postoperative leak with subsequent peritonitis and sepsis. This significantly
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Mobilized pedicle of greater omentum Securing greater omentum over ulcer
Figure 15–3 Mobilization of the omentum to the perforation. A wide pedicle must be mobilized to prevent ischemia of the omentum.
Figure 15–4 Securing the omentum across the perforation. The sutures should be tied to keep the omentum in place. Excessively tight knots will result in ischemia and necrosis of the omentum and disruption of the repair.
increases the morbidity and mortality associated with PPUD.28 Grade 3 complication ● Repair Necrosis of the omental tongue is rarely noted intraoperatively because of the operative time associated with repair of DUD. However, if noted intraoperatively, a separate, better-vascularized portion of the omentum should be used and the ischemic flap should be resected. ● Prevention Creating a wide, well-vascularized pedicle on the greater omentum and placing the omentum over the perforation in a tension-free manner best prevents this complication (Fig. 15–3). Similarly, there is no need to push the omentum into the perforation because this can strangulate the omentum in a mechanism similar to that of an incarcerated, strangulated hernia.
Placement of the Omentum over the Perforation and Securing of Sutures Strangulation of the Omentum The original Graham patch describes using the previously placed sutures to hold the omental tongue in place, as opposed to using them to formally close the perforation itself (Figs. 15–4 to 15–6). However, care must be taken not to strangulate the omentum when securing it in place. ● Consequence As noted previously, strangulation of the omentum can lead to an increase in the postoperative leak rate and a significant increase in the morbidity and mortality associated with PPUD.28 Grade 3 complication
Figure 15–5 Securing the omentum across the perforation. The sutures should be tied to keep the omentum in place. Excessively tight knots will result in ischemia and necrosis of the omentum and disruption of the repair.
● Repair Sutures tied too tightly may cause omental necrosis and should be removed and replaced. ● Prevention Sutures should be tied to prevent displacement of the omentum without compromising vascular flow.
Lack of Omentum ● Consequence Some patients may not have sufficient omentum to allow for a Graham patch repair. However, other tissues can be used in place of an omental patch, and the same
15 GRAHAM PATCH REPAIR
163
Greater omental pedicle Duodenum
Omental plug inside of perforated ulcer
Figure 15–6 Cross-sectional view of the omentum secured across the perforation. The intent of the omentum is to plug the defect, as opposed to closing the defect primarily and buttressing the repair with the omentum.
principles as that of the Graham patch can be employed for fashioning a tissue repair Grade 1 complication ● Repair The perforation can be suture-repaired primarily without further reinforcement,29 though there are no studies comparing differences in outcome in those patients undergoing suture repair alone with those undergoing Graham patch repair. There are also case reports on the use of fibrin glue both to reinforce suture closure of the duodenum and also as a sole modality to seal a perforation.30,31 However, there are no controlled studies evaluating the safety and efficacy of fibrin glue as the only modality to seal a perforation, and its use as the sole method of ulcer repair is not advised. Finally, another option involves creating a “serosal” patch by suturing the serosal surface of a loop of jejunum over the perforation. ● Prevention This situation is not preventable because it is often due to previous surgery or omentectomy. Previous abdominal surgery should raise a surgeon’s index of suspicion, and arrangements should be made for other types of repairs should the patient be found to have insufficient omentum.
Fascial and Skin Closure Postoperative Drainage of the Dissection Bed Routine drainage of the dissection bed postoperatively has no role.32 Although there are no studies evaluating the role of nasogastric decompression after duodenal ulcer repair, most surgeons leave a nasogastric tube to continuous suction for 24 to 48 hours after repair.
Stomach
● Consequence Postoperative drainage of the area of repair is rarely required and has been reported to increase the risk for infection.23,32 Grade 1 complication ● Prevention Drains should not be placed in the operative site.
Skin Closure ● Consequence Closure of skin after a delayed perforation can lead to an increase in the wound infection rate. Wound infection has been shown to increase hospital stay, cost, and the incidence of incisional hernia.33 Grade 1 complication ● Repair Wounds that become infected after closure should be opened at the bedside and allowed to heal by secondary intent. ● Prevention Although there are no studies evaluating the time at which skin closure becomes prohibitive, skin should not be closed if the perforation is greater than 12 hours old. In such instances, delayed primary closure can be performed in 2 to 3 days if the wound remains clean.
Other Complications Treatment for Helicobacter pylori Definitive acid-reducing operation may not be necessary until H. pylori infection is addressed. It is well established that the overwhelming majority of duodenal ulcers are
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Box 15–2 Risk Factors for Reperforation in the Early Postoperative Period ● ● ● ● ● ●
Admission heart rate >110 beats per minute Systolic blood pressure 60), division of the jejunum at a point over 50 cm distal to the ligament of Treitz will provide greater mobility of the Roux-en-Y limb and should be strongly considered. It is always wise to prevent this complication rather than to have to deal with it later in the operation.
Misidentification of the Roux-en-Y Limb Versus the Biliopancreatic Limb ● Consequence This occurs when the gastric pouch is made first, then the jejunum is divided and brought up to do the gas-
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trojejunostomy first, prior to the enteroenterostomy.14 If the biliopancreatic limb is mistakenly identified as the Roux-en-Y limb and anastomosed to the proximal gastric pouch, the surgeon then realizes when going to create the enteroenterostomy, that this has occurred. Great unhappiness results in the operating room when it is realized the infamous Roux-en-O has been created. If the anastomosis is left this way, food would go from the proximal gastric pouch to the distal gastric pouch. The proximal anastomosis must be taken down and redone, and the biliopancreatic limb must have the anastomosis point resected. Not only is excessive time spent doing this, but the proximal anastomosis, being revised, is now much more prone to leak. Grade 1–5 complication ● Repair If this complication does occur, the gastrojejunostomy should be taken down by dividing the biliopancreatic limb just distal to the anastomosis and resecting as little as possible of the proximal gastric pouch to remove the old anastomosis. It is preferable to resect the anastomosis, if the gastric pouch is large enough to allow a stapler to be placed above the anastomosis. Then that staple line must be tested for integrity. A new, stapled anastomosis is made between the correct end of the Rouxen-Y limb and the more proximal part of the gastric pouch. This new anastomosis should be treated as a redo anastomosis; a drain is placed adjacent to it, as well as a gastrostomy in the lower stomach. The biliopancreatic limb is correctly repositioned for appropriate placement and creation of the enteroenterostomy. ● Prevention Creation of the enteroenterostomy usually precludes this potential complication. To be absolutely certain it does not occur, once the proximal jejunum is divided to create the Roux-en-Y limb, a Penrose drain is sutured to the proximal end of the Roux-en-Y limb, for ease in later passage as well as for positive identification. The Roux-en-Y limb must be constantly viewed with the camera from time of division to attachment of the drain to prevent misidentification.
Enteroenterostomy Misalignment of the Bowel to Create the Twisted Mesentery of the Roux-en-Y Limb ● Consequence Creation of the enteroenterostomy is performed by aligning a portion of the Roux-en-Y limb, usually from 75 to 150 cm distal to the end of the Roux-en-Y limb, with the distal end of the biliopancreatic limb. The alignment must position the Roux-en-Y limb such that the proximal end is pointed upward toward the head, so that when it is passed to the proximal stomach the bowel is straight. Observing from the patient’s feet, the
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left side of the Roux-en-Y limb is the side to which the anastomosis must be made to conform to keep it straightly aligned. If during the alignment of the bowel segments, the end of the Roux-en-Y limb is allowed to slide down toward the feet and the portion of the Roux-en-Y limb is twisted such that the right side of the limb is now aligned next to the biliopancreatic limb, creating the enteroenterostomy with the bowel in this position will cause a twist in the Roux-en-Y limb mesentery as it passes back up toward the stomach. This is not acceptable, and the anastomosis must be totally revised. Once again, excessive operating room time is used, a segment of the biliopancreatic limb and the Roux-en-Y limb are lost, and there are two stapled anastomoses instead of one, multiplying the danger of leakage. Although harder to imagine, if the anastomosis were so incorrectly created and the twist in the Rouxen-Y limb not recognized, ischemia of the Roux-en-Y limb postoperatively could result, along with subsequent bowel infarction, peritonitis, sepsis, and death. Grade 1–5 complication ● Repair Once recognized, the anastomosis must be resected and revised. The biliopancreatic limb is divided just proximal to the anastomosis. There is enough length of it to create a new anastomosis, given that the usual length of division of the jejunum is at 30 cm or greater beyond the ligament of Treitz. It is best to resect the length of the Roux-en-Y limb involved in the anastomosis, and then perform an enteroenterostomy of the Roux-en-Y limb to reconstitute it. The new enteroenterostomy to the biliopancreatic limb is made a safe distance beyond this anastomosis. Mesenteric defects of both anastomoses must be closed at the time of their creation. ● Prevention When measuring the Roux-en-Y limb for length, and to determine the place for creation of the enteroenterostomy, the Roux-en-Y limb must always be passed upward and toward the left upper quadrant while being measured. This prevents the end from falling toward the feet. It is mandatory that this stage of the operation be carefully and constantly viewed by the camera operator and that the surgeon and first assistant work together to effect a safe measurement of the Roux-enY limb while uniformly passing it in this direction. Once the locations of the two segments of bowel (Roux-en-Y limb and biliopancreatic limb) are determined, they are sutured together with a stay suture on the antimesenteric side. Before the anastomosis is created, a final check to prevent this complication is mandatory to be certain that the Roux-en-Y limb is not twisted underneath this suture and coming back through the opening of the area below the bowel segments.
Misfiring of the Stapler ● Consequence Misfiring of the stapler may occur at any time during the operation. However, in creation of the enteroenterostomy, it carries particular potential morbidity. Injury to the bowel tissue, an incorrectly formed anastomosis, hemorrhage from the bowel edge if cut but not stapled, stenosis of the anastomosis from refiring over the area again, and leakage of the anastomosis owing to tissue weakening from two overlapping staple lines are all potential complications of this problem. Postoperative hemorrhage, bowel obstruction, and anastomotic leakage are potential resulting complications, all of which can be life-threatening. Grade 1–5 complication ● Repair The repair needed is based on what results after the misfiring. If few staples were fired and no tissue divided (when the cartridge essentially falls off because it was misloaded), little damage is done and a new firing of the stapler is performed. It is essential to remove all unfired staples that may be in the way of the new staple line. Retrieval of the cartridge is, of course, necessary. If the stapler has divided tissue but the staples are incompletely fired, the damaged bowel must be suturerepaired to prevent leakage and hemorrhage. If the staples have fired only partially, the loose staples are removed, a new load is fired to create the anastomosis, and the new anastomosis is both carefully inspected for integrity of staple line and, if possible, checked for leakage afterward by milking the bowel contents through the anastomosis and observing for signs of any leakage. Reinforcing sutures are always helpful to prevent leakage after a staple misfire at an anastomosis. Confirmation that the newly created anastomosis is adequate is also necessary before closing the stapler defect. ● Prevention Fully trained scrub nurses and surgeons who handle the staplers are the first and most important prevention. Loading the stapler correctly and positioning and firing it correctly are usually the steps violated when stapler misfire occurs. However, there is no question that a stapler may be defective and misfire. All experienced surgeons have had this occur. The incidence of it is kept to a minimum by avoiding the human operator errors noted.
Perforation of the Bowel with the Stapler ● Consequence The surgeon may insert one jaw of the stapler too forcefully into the lumen, causing a perforation of the bowel. This most commonly occurs when the bowel segments are not appropriately aligned and one segment
19 LAPAROSCOPIC GASTRIC BYPASS of bowel is kinked at an angle, allowing the side of the bowel to be encountered by the advancing jaw of the stapler. Zeal of the surgeon to make sure the stapler is inserted to its full length while not observing the bowel near the tip of the stapler can lead to this complication. If recognized, it must be repaired; the patient is at risk for leak from the perforation site. If unrecognized, it will result in postoperative leak, peritonitis, sepsis, and potentially, death. Grade 1–5 complication ● Repair The perforation is repaired using sutures in most cases. If a major tear has occurred in the biliopancreatic limb and sufficient length is available to resect this area and still have adequate biliopancreatic limb for an anastomosis, resection of the injured section of the biliopancreatic limb is best. The repair must be carefully performed and the damaged area securely closed. ● Prevention This complication is easily prevented by having the surgeon constantly being able to visualize the stapler jaws in their entirety. The enterotomies made for the stapler jaws should be of adequate size to prevent difficulty in inserting the jaws. The bowel segments must be aligned side by side without kinking so that the stapler jaws can be advanced smoothly into the two lumens of the bowel (Fig. 19–2). The process requires good cooperation on the part of the first assistant and camera person to optimally assist the surgeon during insertion.
Inadequate Closure of the Stapler Defect ● Consequence The defect left by the linear stapler after creating the enteroenterostomy must be closed securely to prevent
Figure 19–2 Inserting the stapler the second time, from right to left, to perform the double-stapling technique.
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postoperative leakage of intestinal contents. If not closed securely, such leakage may result in localized abscess, potential scarring and obstruction, free leakage with peritonitis, sepsis, and death. Grade 3–5 complication ● Repair Suture closure of the enteroenterostomy stapler defect has been performed at our center with excellent results. Some surgeons advocate the “double-stapling technique” in which the linear stapler is fired both proximally and distally at the enteroenterostomy site (see Fig. 19–2), the stapler defect can then be closed with another firing of the stapler.15 This will work if the stapled edges are both held together and totally placed within the jaws of the closing stapler. We prefer to sew this defect closed, because the accuracy of suturing seems more appropriate to this step of the procedure. No data exist to show whether stapling or suturing is best. Should any leakage in the stapled or sutured closure be detected, suture repair is indicated. ● Prevention Careful suturing or stapling techniques to confirm that a secure and complete closure of the defect made by the stapler is the only prevention. It is difficult to do a leak test of this anastomosis, as is commonly performed for the gastrojejunostomy.
Stenosis of the Enteroenterostomy at Creation ● Consequence Stenosis of the enteroenterostomy, if severe, can lead to distention of the biliopancreatic limb and the distal stomach. Because this portion of the stomach has no “pop-off” valve, it cannot be decompressed without intervention. Failure to intervene quickly enough can result in rupture of the distal gastric staple line with peritonitis, sepsis, and death.16 Stenosis of the enteroenterostomy can also cause postoperative vomiting, which can lead to dehydration, fluid and electrolyte imbalances and acute thiamine deficiency if prolonged, and places stress on the proximal anastomosis. Emergent operative treatment is usually indicated. Grade 3–5 complication ● Repair It is most important for the surgeon to recognize the problem early in its symptomatic development. We have found the major value of the postoperative day 1 Gastrografin swallow is to alert us to the potential for this complication. Whereas percutaneous distal gastrostomy placement has been advocated by some as a means of acutely treating the distal gastric distention,17 we recommend emergent reoperation. This is usually accomplished in as rapid a time frame and allows for distal gastric decompression with an operatively placed gastrostomy as well as revision of the enteroenteros-
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tomy. We have found, through experience, that revision of the anastomosis is advisable unless a clear alternative mechanical reason, such as a kink in the distal jejunum just beyond the enteroenterostomy or another cause of obstruction, is found. Creating a new enteroenterostomy between the segment of Roux-en-Y limb just proximal to the existing anastomosis and the segment of distal jejunum just distal to the anastomosis, in a side-to-side fashion, is recommended. After the anastomosis is stapled, but before closure of the stapler defect, an instrument is inserted into the lumen of the jejunum to be certain there is still an adequate opening into the biliopancreatic limb for drainage. The operation can be accomplished laparoscopically, provided the distal stomach is not so distended as to preclude this approach. Also, placing the gastrostomy tube laparoscopically is quite feasible, but controlling any spillage of gastric contents as the tube is inserted can be a technical challenge without losing the pneumoperitoneum and visualization of the operation. ● Prevention We advocate using a double-staple technique for creation of the enteroenterostomy and closing the stapler defect with sutures. Beginning the suture closure at the alimentary tract side of the defect will minimize the risk of a suture catching the back wall of the intestine and causing narrowing (Fig. 19–3). We believe this approach minimizes the risk for postoperative distal anastomotic obstruction. Mesenteric closure prevents kinking of the jejunum just distal to the anastomosis (the “Brolin stitch” of open gastric bypass).18
Obstruction of the Anastomosis from Edema, Hemorrhage, or Technical Error ● Consequence This complication is identical to the one just described, except the lumen is totally obstructed and the etiolo-
gies may be from technical error, edema, or hemorrhage with intraluminal hematoma causing obstruction. The potential complications are identical. Grade 3–5 complication ● Repair The principles of repair are identical to those listed previously (see “Stenosis of the Enteroenterostomy at Creation”). However, in some cases in which edema is suspected to be the cause (swallow study shows minimal passage initially past the anastomosis), careful monitoring of the patient and conservative treatment can be justified only if the patient is clinically doing well and radiographic studies are done that definitively rule out a dilated distal stomach. Intraluminal hemorrhage will require the additional operative steps of evacuating the hematoma from the anastomosis, being sure the distal jejunum is not similarly obstructed with hematoma, and directly visualizing the anastomosis staple line to confirm whether the hemorrhage has stopped. If hemorrhage is still ongoing, suture ligature to control it is indicated. An enterotomy adjacent to the area of the anastomosis is often the best way to do this. If a new enteroenterostomy is planned, this may be done with the stapler insertion site serving as the enterotomy. ● Prevention Prevention is similar to the prevention of stenosis of the anastomosis listed previously. Hemorrhage at the time of initial operation that is seen from the lumen of the bowel must of course be sutured to arrest the hemorrhage from the anastomotic staple line. Vomiting blood postoperatively must alert the surgeon to the potential for this complication, which needs attention, as does the hemorrhage itself, which could arise from either the enteroenterostomy staple line or the gastrojejunostomy staple line.
Closure of the Mesenteric Defect Hemorrhage from the Mesentery ● Consequence Suturing the mesenteric defect closed is mandatory to prevent postoperative internal hernia. Sutures placed too deeply into the mesentery may cause hemorrhage or hematoma. Hemorrhage is rarely of significant volume but can require energy or sutures to repair if it is significant. These sutures or the compression of a hematoma may impair blood supply to the jejunum of the enteroenterostomy, causing it to become ischemic. The entire anastomosis must then be redone, with resection of the ischemic area and two new enteroenterostomies performed. Grade 1–3 complication
Figure 19–3 Closing the stapler defect with sutures.
● Repair Repair of the bleeding is done initially with direct pressure. If this is insufficient, use of a suture is more likely
19 LAPAROSCOPIC GASTRIC BYPASS to achieve hemostasis. If the bleeding point is very superficial and easily identified, the harmonic scalpel may be applied with good effect. If ischemia of the jejunum occurs, the ischemic portion must be resected. Treatment is identical to that described in the section on “Misalignment of the Bowel to Create the Twisted Mesentery of the Roux-en-Y Limb” in that a portion of the Roux-en-Y limb must be resected, the biliopancreatic limb cut back, and two new anastomoses created. ● Prevention Careful suturing technique to take a very superficial, although lengthy, bite of peritoneum when closing the mesenteric defect is essential to preventing this complication. Observation to avoid visible vessels in the mesentery with the superficial sutures is also essential.
Ischemia of the Anastomosis ● Consequence The ischemia that may result from a hematoma from bleeding can also result from sutures placed too deeply into the mesentery during closure of the mesenteric defect. The resulting ischemia has the same consequence. Grade 1–3 complication ● Repair Repair is as described in the section on “Misalignment of the Bowel to Create the Twisted Mesentery of the Roux-en-Y Limb.” ● Prevention As with prevention of hemorrhage, prevention of ischemia also requires that the bite of tissue taken is a superficial one, including just the peritoneum. The needle must be placed just under the peritoneum and passed parallel to it to include a sufficiently long length of peritoneum to have strength to hold the suture line together.
Failure to Close the Mesentery ● Consequence Failure to close the mesenteric defect after a bowel anastomosis leaves the patient at risk for an internal hernia. This can cause a closed-loop bowel obstruction with ischemia and gangrene of a significant portion of the small bowel. This is life-threatening. The frequency of this complication has increased since a laparoscopic approach to RYGB was instituted.19 This is because few intra-abdominal adhesions form postoperatively, and the bowel is more mobile to slide into tissue crevices like the mesenteric defect. In addition, that defect is less likely to scar down on its own after a laparoscopic than after an open operation. Grade 1–5 complication
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● Repair Closure of the mesenteric defect is performed with permanent suture placed carefully, to prevent bleeding or ischemia but to close the peritoneal edges of the cut mesentery together. Either a running or an interrupted technique may be used. Exposure of the edges is often difficult, and this can be a technically challenging portion of the operation. ● Prevention Prevention is by performing closure with adequate technique.
Creation of the Gastric Pouch Hemorrhage along the Lesser Curvature ● Consequence Dissection along the lesser curvature to create an opening for the stapler jaws to divide the stomach can be met with hemorrhage. This is usually easily controlled but can, if dissection is misplaced or technically incorrectly performed, result in significant hemorrhage from the left gastric artery or its main branches along the lesser curvature. If hemorrhage is not easily controlled, this may lead to conversion to an open incision, significant blood loss requiring transfusion, and hypotensive shock. Grade 1–4 complication ● Repair An experienced laparoscopic surgeon will usually control this hemorrhage with a combination of compression, application of the harmonic scalpel, and a suture ligature or an Endo loop. ● Prevention Careful dissection in an area just adjacent to the lesser curvature surface of the stomach is required to create an opening for the stapler. The harmonic scalpel is used for division of smaller vessels along or just superficial to the gastric surface. Careful spreading dissection from the right upper quadrant trocar (at the surgeon’s left hand) creates the opening in the appropriate orientation such that the instrument breaks through the peritoneum into the lesser sac. Avoiding dissection too far off the stomach surface and too high up on the lesser curvature minimizes the risk for severe hemorrhage. Careful retraction of the mesentery is also necessary to avoid tearing the vessels.
Division of the Stomach Too Proximal ● Consequence Division of the stomach too close to the gastroesophageal junction leaves inadequate room for a technically easy gastrojejunostomy. The subsequent difficulty in
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creating an anastomosis close to the esophagus increases the risk for postoperative leak. Grade 1–5 complication ● Repair No repair for this problem once it is created. However, the anastomosis must be done to the very proximal stomach or, perhaps, almost directly to the esophagus. Only a highly proficient laparoscopic surgeon should perform this anastomosis, because it is difficult. Hand suturing is probably the best option for the anastomosis, but an end-to-end anastomosis stapler could conceivably be used, with the anvil passed through the esophagus. A linear stapler will not work owing to inadequate length of the gastric pouch. ● Prevention Careful assessment of the stapler placement before firing the initial load of staples to start gastric division is important. The stapler jaws should be approximately 3 cm or more, preferably 4 cm, from the gastroesophageal junction along the lesser curvature. They can be placed even further distally, especially if there is concern that the Roux-en-Y limb may have difficulty reaching the proximal gastric pouch. By having the pouch longer yet still very small in terms of its diameter, we have not seen any difference in weight loss between those individuals who had slightly longer-length gastric pouches versus those with standard shorter ones. However, these data are observational impressions only.
Creation of Too Large a Pouch ● Consequence Creation of too large a proximal gastric pouch is not a major complication in and of itself. However, it will decrease the effectiveness of the operation, allowing the patient to eat more and potentially lose less weight. It also will allow for an increased incidence of both marginal ulcer and recurrent gastroesophageal reflux disease long-term. Grade 1–4 complication ● Repair The pouch can be cut down in size if this complication is recognized intraoperatively. This is much more easily done before the creation of the gastrojejunostomy. The surgeon should assess the pouch, and if she or he believes it is clearly too large, it should be resected further to a more appropriate size. If this results in intersecting staple lines, suture reinforcement at that point and testing for pouch integrity (leak test) are advised intraoperatively prior to performing the gastrojejunostomy. ● Prevention Careful assessment of pouch size as the staple loads are being fired to divide the stomach is crucial. Some surgeons use a bougie, a lavage tube, or a Baker tube to
Figure 19–4 Creating the gastric pouch but taking care to exclude the fundus. It is best if the Ewald tube can be seen as it makes a distortion of the proximal gastric pouch.
help size the pouch. Others pass a flexible endoscope. We use a Ewald or gastric lavage tube, placed by the anesthesiologist under laparoscopic vision and adjusted to lie along the upper lesser curvature of the stomach. The tube serves as a guide for pouch size. When stapling near the gastroesophageal junction to divide the stomach, the surgeon must be careful to exclude as much of the fundus as possible, because this part of the stomach is much more distensible and should not compose a significant percentage of the pouch (Fig. 19–4).
Stapling across the Tube in the Stomach ● Consequence This unfortunate complication results in a tube that is stapled and usually divided. The portions of the tube must be removed from each staple line by resecting back those sections of the staple line. This allows the proximal tube to be withdrawn and the distal tube segment to be removed. Both staple lines, even if repaired, are now at increased risk for leakage, with the already defined risks of staple line leakage. Grade 1–5 complication ● Repair One hopes this complication is always realized intraoperatively, and not postoperatively when the nasogastric tube is attempted to be removed. Reoperation is required in the latter case. Repair of this problem intraoperatively involves resecting enough of each staple line, usually with a laparoscopic scissors, to allow the tube segments to be freed up. This is usually less than a 1-cm length of staples. The defect is then sutured closed, preferably with a two-layer closure to encompass some of each side of the staple line. A leak test of the proximal pouch must then be performed. Strong consideration should be given to placing a laparoscopic gastrostomy in the distal stomach.
19 LAPAROSCOPIC GASTRIC BYPASS ● Prevention This complication is preventable if the surgeon ascertains from the anesthesiologist that the tubes are withdrawn from the stomach (including nasogastric tubes as well as temperature probes) before the first stapler load is fired. If a tube is used to help size and create the gastric pouch, the surgeon must be certain the tube position remains where intended and it is not allowed to shift or be withdrawn slightly and then pushed back in. This can result in the tube being caught in the stapler. Direct verbal communication every time with the anesthesiologist must be done at this step of the operation. We use a plastic and, hence, see-through upper drape during our LRYGB procedures, which visually confirms the act of removing the tubes.
Stapler Misfire ● Consequence Stapler misfiring during creation of the proximal gastric pouch carries the potential that the area of divided stomach during the misfire is incompletely and insecurely stapled. This can lead to postoperative staple line leak and its already stated sequelae. If the stapler knife cuts and staples are not fired, the gastrotomy created is a risk for bleeding and leakage and must be repaired. Grade 1–5 complication ● Repair Repair is based on the injury. If a staple line is unstable or insecure, it must be sutured to prevent leakage. If there is hemorrhage, it must also be sutured to arrest it. Any defects in either the gastric pouch or the distal stomach staple lines must be repaired, reinforced, and tested (proximal is possible, distal is not). Distal gastrostomy may also be needed if there is concern about the staple line. ● Prevention As mentioned previously for the jejunojejunostomy, most stapler misfires involve operator error. Either the stapler is misloaded or the amount of tissue attempted to be divided may be too thick or have preexisting staples in it that prevent clean firing. These operator errors are best prevented by training in loading the stapler as well as in firing and using it. Because staple misfires do occur, there is no absolute way to prevent this complication.
Hemorrhage from the Staple Line ● Consequence Minor immediate and recognized hemorrhage is easily treated intraoperatively, with no consequence. Major intraoperative hemorrhage is rare but is usually also controlled without the need for transfusion or conversion to an open procedure. Postoperative hemorrhage
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can be significant in volume and can, if sufficient, subject the patient to hypovolemic shock and its sequelae. Transfusions may be needed. Reoperation, endoscopy, and angiography may all potentially be needed to arrest the hemorrhage, depending on its site and severity. Intraluminal hematoma from the stomach that passes to the area of the enteroenterostomy can cause alimentary tract obstruction and vomiting. If the distal stomach is the site, it may distend to the point at which staple lines rupture; massive contamination, peritonitis, and a high likelihood of death may follow. Grade 1–5 complication ● Repair Bleeding that occurs during operation and is identified can be treated with suture ligature or, for smaller amounts of hemorrhage, a brief application of the harmonic scalpel to the vessel lumen site. The most common site for this occurrence is at the edge of the lesser curvature during the first stapler firing. Inspection of the staple line after creation may demonstrate small bleeding sites as well. These are similarly treated. If a patient presents with postoperative tachycardia, decrease in hematocrit, and a radiographic picture of distal gastric distention (on computed tomography scan) or obstruction at the enteroenterostomy (swallow study), the site of bleeding must be presumed to be the distal stomach staple line. Treatment is emergent operative decompression of the distal stomach with a gastrostomy tube. We recommend this be done operatively, although success has been reported with percutaneous techniques (but for air not hematoma distention). Oversewing the distal gastric staple line, evacuating the distal stomach hematoma, and placement of a distal stomach gastrostomy are indicated. Hemorrhage from the proximal gastric pouch staple line will usually manifest itself with hematemesis as the primary symptom, even before hemodynamic changes occur. Upper endoscopy and direct endoscopic injection of the bleeding site is the treatment of choice.20 At the sign of hemorrhage of any type postoperatively, the patient’s deep vein thrombosis prophylaxis must be stopped and a coagulation panel checked to be certain that no element of coagulopathy is contributing to the problem. ● Prevention The incidence of postoperative significant hemorrhage after LRYGB is under 3% and includes all types and sources of hemorrhage.21 Measures to prevent gastric staple line hemorrhage include a careful intraoperative inspection of these staple lines and avoiding overdosing any postoperative anticoagulation medication (including using any combinations that may be synergistic such as coumadin and low-molecular-weight heparin, given in therapeutic doses simultaneously). Aggressive management of hemorrhage can minimize the complications.
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Leak from the Staple Line ● Consequence Gastric staple line leakage postoperatively can result in massive peritonitis, sepsis, and death. Smaller, more contained leakages may result in intra-abdominal abscesses, often in the left subphrenic region. Grade 3–5 complication ● Repair Distal gastric staple line leaks. Recognition of the problem is the major obstacle to appropriate and timely care. The diagnosis of a distal gastric staple line leak is made more difficult by the fact that an oral gastrografin swallow study, considered the standard test for leaks from the gastrojejunostomy or proximal gastric pouch, will be normal in this setting. A high index of suspicion and any untoward signs such as unexplained tachycardia, tachypnea, excessive abdominal pain, fever, and persistent oliguria are all tips to the potential presence of this problem.22 Distal gastric distention from biliopancreatic intestinal limb obstruction and distention must raise the immediate suspicion of this problem existing or potentially occurring. Repair of distal gastric distention is via immediate operation, usually open but laparoscopic can be appropriate in some settings, with closure of the staple line, thorough lavage and elimination of contaminating fluids in the abdomen, and placement of a gastrostomy tube in the distal stomach. Leakage from the proximal gastric staple line is treated identically as leakage from the gastrojejunostomy, described later. ● Prevention There is, unfortunately, no guaranteed method of preventing this complication entirely. Major series of LRYGB report leaks, which would include this site, at from 1% to 5%.23 Careful intraoperative attention to successful and complete division and closure of the stomach is the most important step. If staple misfire, staple line bleeding, or other problems arise to suggest that the staple line could be compromised, our approach is to be as certain as possible that excellent closure of the staple line has occurred intraoperatively (including testing the proximal pouch if indicated) and consideration of placement of a drain in the area as well as a distal gastrostomy, depending on the concern for the staple line integrity. Although the drain and gastrostomy may not prevent the leak, they can be useful in its management.24
Inadequate Division of the Stomach ● Consequence Inadequate division of the stomach leaves an isthmus of intact stomach, always at the area of the greater curvature near the angle of His. This passageway allows
for decompression and, hence, defeat of the process of proximal gastric restriction of intake of food. It also is a pathway for distal gastric juice, causing a high incidence of marginal ulcer when present. Grade 1–4 complication ● Repair The situation in which this usually occurs is in the very superobese patient undergoing LRYGB, in whom visualization of the area of the angle of His is difficult. BMI alone may not be an accurate reflection of this difficulty: men with central obesity and a BMI of 50 may be more difficult than a woman with a hips-and-buttocks fat distribution pattern and a BMI in excess of 70. Once recognized, treatment depends on the resultant symptoms from the remaining gastric communication. If weight loss is suboptimal or if a marginal ulcer develops, reoperation to complete division of the stomach is indicated. ● Prevention The best means of preventing this complication is to ensure the surgeon and the whole operating team see the two sides of the completely divided stomach at the area of the angle of His. If liver retraction prevents this, a second liver retractor should be placed. If telescope position is not optimal, an additional port should be placed to allow good visualization of the area. If these measures fail, conversion to an open incision may be necessary to accomplish this task, although the exposure and visualization using that approach are often less optimal than the laparoscopic approach, in this author’s experience.
Ischemia of the Proximal Gastric Pouch ● Consequence Fortunately, the stomach is very vascular, and this complication is rarely seen or reported. If it occurs, the surgeon must have ligated the left gastric artery near its takeoff. If recognized, resection of the remaining stomach and esophagojejunostomy is indicated. This is an operation with at least a five times higher leak rate for the anastomosis.25 If unrecognized, the ischemic gastric pouch will break down and a postoperative anastomotic leak, with its potentially lethal result, will occur. Grade 2–5 complication ● Repair The repair is hopefully done during the original operation when the condition is recognized. Reports of this are so scarce as to make it an extremely unlikely complication. If it occurs, the gastric pouch must be resected back to viable tissue, likely the distal esophagus, and an esophagojejunostomy performed. This anastomosis, because of its high potential for leak, should be treated
19 LAPAROSCOPIC GASTRIC BYPASS by placement of a perianastomotic drain and a distal gastrostomy tube. Conversion to an open operation may be needed to accomplish all these tasks. ● Prevention Avoiding hemorrhage from the upper lesser curvature of the stomach during dissection for initiating the creation of the proximal gastric pouch is the key preventive step. Only if the left gastric artery and its main feeding vessels to the proximal stomach are totally ligated would this result occur. This is unlikely, but avoidance during mesenteric dissection is key.
Passage of the Roux-en-Y Limb Injury to Colon ● Consequence If recognized and repaired successfully, there is minimal consequence. If unrecognized or inadequately repaired, colonic contents leaking postoperatively will cause fecal peritonitis, sepsis, and potentially, death. Grade 1–5 complication ● Repair Recognizing that this has occurred is key. In the retrogastric passage of the Roux-en-Y limb, this is unlikely unless there is difficulty, the gastrocolic ligament is opened to visualize the lesser sac, and the opening is made too close to the colon and causes injury. In the antegastric approach, usually the omentum is divided. At the base of that division, extending it too far can cause colon injury. Once recognized, the injury is usually small enough that two-layer suture repair is appropriate and satisfactory. ● Prevention Using the retrocolic approach, keeping the mesenteric opening at the base of the mesentery, and being careful to avoid opening the gastrocolic ligament very far from the greater curvature of the stomach (the ideal location is just beyond the gastroepiploic vascular arcade) will prevent this injury. Using the antecolic approach, halting omental division before the surface of the colon is encountered is imperative.
Injury to the Stomach ● Consequence Injury to the stomach, from the harmonic scalpel or traction injury, can potentially result in postoperative gastric necrosis and leak. The same consequences as for anastomotic leak would follow. Grade 1–5 complication ● Repair Repair of any gastric injury should be by immediate suturing, usually with an imbricating suture, to buttress
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the injury site and avoid postoperative perforation and leakage. The incidence of this injury is extremely low. ● Prevention Prevention of injury to the stomach is by clearly visualizing any use of an energy source in the creation of a mesenteric opening to the lesser sac. Avoiding touching the stomach with the energy source will prevent this complication. Similarly, avoiding excessive traction on the stomach that could result in an injury to its wall is also imperative.
Hemorrhage ● Consequence During retrocolic advancement of the Roux-en-Y limb, an opening is made in the mesentery of the transverse colon. If that opening is made through a major vessel of the colon mesentery, significant hemorrhage may occur. This can lead to the need for further surgical maneuvers to stop it, at best, or conversion to an open operation and significant blood loss with consequent hemodynamic shock, at worst. Grade 1–5 complication ● Repair If hemorrhage from the colonic mesentery is encountered, it must be controlled with direct pressure and grasping. Then either use of the harmonic scalpel (for a vein or smaller artery) or clips or sutures (for larger arteries) will affect an adequate control of the bleeding. If the bleeding has caused hemodynamic changes, appropriate fluid resuscitation and transfusion should be performed as indicated. ● Prevention Creating a defect in the transverse colon mesentery that will minimize the risk of bleeding can be done if the defect is made just to the patient’s left of the ligament of Treitz and relatively low on the surface of the underside of the transverse colon mesentery. Staying to the patient’s left of the ligament of Treitz usually prevents injury to the middle colic vessels. Keeping the mesenteric defect relatively low on the transverse colon mesentery avoids the often-present large crossing vessel in the upper portions of the colon mesentery (marginal artery of Drummond or other crossing vessels that may exist and be unnamed).
Inadequate Length of the Roux-en-Y Limb ● Consequence If the Roux-en-Y limb will not stretch up to meet the proximal gastric pouch, the operation is already in trouble. Because the proximal gastric pouch is likely already created, it cannot be revised to make it longer. The mesentery of the jejunum must be
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further undercut to mobilize the Roux-en-Y limb further, and this presents the potential for bleeding and ischemia. Finally, once the anastomosis is created, it may be under tension, increasing the risk for leakage postoperatively. Grade 1–5 complication ● Repair If the Roux-en-Y limb is not long enough to reach the proximal gastric pouch, it must be further mobilized. If the distal anastomosis has already been performed, this task becomes very difficult. The mesenteric closure must be taken down. The mesentery then must be further divided to allow enough mobilization of the Roux-en-Y limb to reach the proximal gastric pouch. This can be a difficult technical maneuver, fraught with the potential for hemorrhage or ischemia to the existing Roux-en-Y limb or biliopancreatic limb. ● Prevention Adequate mobilization and length of the Roux-en-Y limb must be ascertained early in the operation when this maneuver is performed. Experience will usually allow the surgeon to visually assess whether the bowel will reach the proximal stomach. If any doubt exists, simply attempting to bring the bowel up to the proximal stomach immediately after creating the Roux-en-Y limb will confirm adequate length. We have found that in patients with high BMI, the bowel mesentery can be short and the distance to the stomach longer. In these patients, we construct the gastric pouch longer, starting just above the incisura, to decrease the distance the Roux-en-Y limb must reach. The pouch can be cut back if the limb is long enough to reach higher.
Twist of the Roux-en-Y Limb Mesentery ● Consequence The Roux-en-Y limb must be passed upward to the proximal gastric pouch with no twists in it or its mesentery. Such undetected twists may result in postoperative ischemia, gangrene, necrosis, leakage of intestinal contents, peritonitis, sepsis, and death.26 Twists may also cause partial to complete bowel obstruction. Ischemic stenosis may occur over a longer time frame if none of the these manifest themselves first. Grade 1–5 complication ● Repair If the twist is discovered prior to creation of the gastrojejunostomy, the Roux-en-Y limb is simply untwisted. If it is discovered at surgery after creating the anastomosis, the anastomosis must be taken down and revised after untwisting the Roux-en-Y limb. In our experience, this usually requires conversion to an open incision and puts the revised gastrojejunostomy at higher risk for leakage.
Figure 19–5 Passing the Roux-en-Y limb with emphasis on being sure the mesentery is downward.
● Prevention During passage of the Roux-en-Y limb, the entire surgical team must focus on the fact that the mesentery of the limb is straight and not twisted. Imaging the mesentery during passage is important to confirm this. Using a retrocolic approach, which we do for LRYGB, the passage of the end of the Roux-en-Y limb into the lesser sac is carefully done to maintain the mesentery location straight downward (Fig. 19–5). Once the Roux-en-Y limb is passed up after dividing the stomach, the orientation of the limb must be identical to that which it had previously: the mesentery down, the staple line pointing toward the patient’s right side as it is brought up to just clear the distal stomach. If this is not true, the gastrocolic ligament must be opened to clearly visualize the entire Roux-enY limb and its mesentery, and the area at which the Roux-en-Y limb passes through the transverse colon mesentery must also be visualized to confirm appropriate orientation.
Roux-en-Y Limb Obstruction at the Colonic Mesentery ● Consequence This complication occurs only with the retrocolic route of the Roux-en-Y limb. The mesenteric opening may be too tight or, more likely, later postoperatively develop scarring at the opening that kinks or narrows the Roux-en-Y limb. Partial to complete bowel obstruction can occur, with the need for reoperation to revise this area. Grade 2–4 complication ● Repair The opening in the transverse colon mesentery must be adequately large to allow the Roux-en-Y limb to pass
19 LAPAROSCOPIC GASTRIC BYPASS through it without constriction. If scar tissue has developed to form a constricting ring about the opening, it must be divided to alleviate the obstruction. If the surgeon used a running permanent suture to close the mesenteric opening, it can result in stenosis at the mesenteric opening. This suture must be divided and the resultant scar released. If the Roux-en-Y limb was not appropriately sutured to the mesentery at surgery, partial herniation of the limb into the retrogastric space can mimic the same types of obstructive symptoms as can scarring at the mesenteric opening. Reduction and resuturing of the bowel is indicated. ● Prevention Creating an adequate mesenteric opening, then suturing the bowel to it appropriately with interrupted permanent sutures will prevent this complication.
Gastrojejunostomy Stapler Misfire ● Consequence Staple misfiring to create the gastrojejunostomy carries the same potential problems as it does for the jejunojejunostomy. In addition, it is particularly hard to correct this problem at the gastrojejunostomy site because only a small amount of gastric tissue is available for a new staple firing. A new stapled or a revised handsewn anastomosis must be created after the misfiring. This may involve conversion to an open procedure. Increased chance for postoperative leakage exists, the consequences of which were well defined previously (see “Creation of the Gastric Pouch, Stapler Misfire”). Grade 1–5 complication ● Repair The repair required is based on the tissue injury caused by the misfire. If it is minimal, a new staple load may be fired carefully, ensuring good tissue apposition and visually inspecting the anastomosis for competence and security. A postoperative leak test is indicated after closing the stapler defect. More severe injury to the tissues could require resecting back a portion of the gastric pouch or Roux-en-Y limb or both and creating a new anastomosis. If not enough gastric tissue is available and an opening exists in the gastric pouch, a handsutured gastrojejunostomy is the best option for constructing the anastomosis. Placement of a perianastomotic drain and a distal gastrostomy should be considered if the revised anastomosis is considered high risk for leakage. ● Prevention Prevention is similar to that for stapler misfirings, described previously for the jejunojejunostomy. There is no absolute prevention.
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Leak from the Anastomosis ● Consequence Postoperative leaks from the gastrojejunostomy represent the most frequent site for leaks after LRYGB.27,28 Leaks here pose the same risks to the patient’s health as in the other areas described previously (jejunojejunostomy and gastric staple line). Leaks may persist for months despite reoperation and closure. Grade 1–5 complication ● Repair The signs and symptoms of a leak are the same as that of leakage from the gastric staple line described previously. A high index of suspicion must be maintained by the surgeon for any patient with any such symptoms. Aggressive evaluation includes an emergent swallow test, which even if negative does not rule out the chance for a leak because these are known to be inaccurate in a significant percentage of cases. Persistence of any untoward signs suggesting a leak is indication for emergent reoperation. If a leak is found, oversewing, buttressing the repair with tissue such as omentum, thorough drainage of the area, and placement of a distal gastrostomy are indicated. The surgeon must be prepared to care for a potentially very sick patient postoperatively, and all available intensive care facilities and consultants should be appropriately used as indicated. Persistent fistulas may require many weeks to close, and drains should be monitored until no further output is seen. Then a swallow test should be conducted to confirm no further leak before oral intake is restarted. Enteral feeding via gastrostomy during the recovery is indicated. Recent evidence suggests leaks from the gastrojejunostomy may be treated with a high rate of success using an endoscopically placed stent. Stent migration is the major complication when such an approach is used.29,30 ● Prevention Use of good technique to create the anastomosis is the best prevention (Fig. 19–6). Having no tension on the
Figure 19–6 Creating the proximal stapled anastomosis with the linear stapler. The stapler is in place, ready to fire.
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anastomosis, having a cleanly fired stapler to create it, and careful oversewing of the staple defect are all necessary. Good blood supply to both the stomach and the Roux-en-Y limb is important. An intraoperative leak test is highly recommended. Despite these measures used by surgeons, the leak rate after LRYGB is at or over 1% in most series, indicating that even these measures do not guarantee that this complication cannot occur. However, because it is the leading cause for postoperative legal action against bariatric surgeons, the surgeon is wise to follow all precautions. In addition, maintaining a high index of suspicion for a leak postoperatively will improve the likelihood it is promptly diagnosed and treated, and thus minimize complications from it.
Tension on the Anastomosis ● Consequence Finding that the anastomosis is under some tension at the time of its creation poses the risk for a higher incidence of postoperative leakage. This leakage can result in peritonitis, sepsis, and death, as described in the section “Leak from the Anastomosis.” Tension on the anastomosis may also result in postoperative stenosis of the anastomosis from chronic ischemic stricture. This typically presents 6 to 12 weeks postoperatively with symptoms of vomiting and food intolerance.31 Grade 1–5 complication ● Repair The repair is based on the degree of tension. If only a very small amount exists, we suture the Roux-en-Y limb to the side of the proximal gastric pouch (done in all cases), and that process provides us with further feedback on the tension, if any, present. If after creating this suture line, the tension issue seems resolved, we proceed with anastomosis. If the tension seems too severe before creating the anastomosis, we proceed to lengthen the Roux-en-Y limb as described previously under “Inadequate Length of the Roux-en-Y Limb.” A leak test is always done. ● Prevention Prevention involves recognition of tension and alleviating the situation. The same measures indicated for preventing an inadequate length of the Roux-en-Y limb, described previously, should be followed here as well.
Hemorrhage from the Anastomosis ● Consequence Hemorrhage from the gastrojejunostomy during surgery requires suture ligature repair or harmonic scalpel energy to stop the hemorrhage. Care must be
taken to avoid tissue necrosis or stenosis of the anastomosis during this process. Hemorrhage postoperatively can result in hematemesis, aspiration, need for hospitalization and transfusion, hypovolemic shock, and need for endoscopic or even operative measures to arrest the hemorrhage. Hemorrhage can be life-threatening. Grade 1–5 complication ● Repair Repair involves stabilization of the patient, assessment for amount of blood loss, resuscitation with intravenous fluids and blood products as indicated, ruling out any coagulopathy, and aggressive use of upper endoscopy to assess the bleeding site and perform epinephrine injection to arrest the bleeding.20 Other endoscopic measures such as heater probe or bicap cautery may be used but are less advisable because of a higher likelihood of tissue injury leading to perforation. Operative suturing of the anastomosis is indicated if endoscopic measures fail. ● Prevention There is no absolute prevention for this problem, as noted previously for hemorrhage from the gastric staple line. Oversewing or use of suture line buttress materials to perform the anastomosis has not been shown to totally eliminate this complication. The incidence of this complication is fortunately low, probably in the 1% range.23 Noting and treating intraoperative suture line bleeding is important to prevent postoperative problems from large amounts of blood loss.
Stenosis of the Anastomosis ● Consequence Stenosis of the gastrojejunostomy may present very early after surgery (postoperative days 1–2) from edema or technical error in creating too small an anastomosis. Subsequent stenosis usually presents at 6 to 12 weeks postoperatively, but later presentation is possible associated more with concurrent marginal ulcer and the edema and scarring from it.31 Stenosis causes nausea, vomiting, food intolerance, dehydration, electrolyte disturbances, acute thiamine deficiency, and even renal injury if dehydration persists too long. Thiamine deficiency can produce permanent neurologic deficits such as Wernicke’s encephalopathy picture if not appropriately treated.32 Endoscopic, fluoroscopic, and operative procedures may be needed to treat this problem. Protein calorie malnutrition may also evolve if stenosis is chronic and untreated. Grade 1–5 complication ● Repair Usually, the problem is suggested by the patient’s symptoms. If highly suspected, we recommend an upper endoscopy to both diagnose and treat the problem. Endoscopic balloon dilation is indicated for
19 LAPAROSCOPIC GASTRIC BYPASS any anastomosis with a diameter less than 10 mm, essentially one that does not allow the scope to pass through. Usually one or two dilations will suffice to treat the stenosis, but further dilations may sometimes be needed. A fluoroscopic dilation may be indicated if more than one endoscopic dilation has failed, because the radiologist can use a larger-diameter balloon than can the endoscopist. Reoperation is rare; in our experience, it is limited to those few patients with associated marginal ulcers that failed to heal without severe stenosis.31 Any patient who presents postoperatively after a bariatic operation, including LRYGB, should be given intravenous thiamine and B vitamins (similar to treatment for alcoholism) before the administration of intravenous glucose. Fluid resuscitation, electrolyte replacement, and even short-term parenteral nutrition may be indicated depending on the severity of dehydration and malnutrition seen. ● Prevention The incidence of gastrojejunostomy stenosis after LRYGB can be minimized by several measures. The type of stapler used to create the anastomosis has been related to the incidence of stenosis.33 The linear stapler is associated with an exceedingly low incidence of this problem (4–6 hr) Multiple blood transfusions Chronic obstructive pulmonary disease Peritonitis Bowel obstruction Use of corticosteroids Radiation Based on references 18 and 57–61.
Special care should be taken when constructing an anastomosis between the esophagus and the jejunum after total gastrectomy. The anastomosis is particularly difficult because a layer of fatty tissue between the mucosa and the submucosa causes frequent retraction of the mucosa on the cut end of the esophagus. It is essential that this layer
20 GASTRECTOMY WITH RECONSTRUCTION
Billroth 1881
A
Billroth 1881
B
C
v. Haberer, 1922 Finney, 1923
F
Kocher 1890
D
Winkelbauer 1927
G
Kutscha-Lissberg 1925
v. Haberer 1920
E
Schoemaker 1911
H
229
Harkins, Nyhus 1960
I
Figure 20–6 Billroth I reconstructions. (Reproduced with permission from Sieivert JR, Bumm R. Distal gastrectomy with Billroth I, Billroth II or Roux-en-Y reconstruction. In Fischer JE, Bland KI, Callery MP, et al. [eds]: Mastery of Surgery, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007.)
be incorporated in a full-thickness stitch used to create the hand-sewn esophagojejunostomy in a Roux-en-Y reconstruction after total gastrectomy. No benefit of stapled versus hand-sewn anastomosis has been consistently demonstrated,23,24 and when choosing to create this anastomosis with a circular stapler, a tight pursestring suture through the esophageal wall and around the anvil helps to ensure a sturdy anastomosis. After the stapler is fired, two complete rings of tissue, one obtained from each limb, should be visualized. Incomplete tissue rings serve to identify potential defects in construction. A second technical point, uniquely applicable to the Billroth I reconstruction, is the importance of addressing the “angle of sorrow” or Jammerecke. This area defines the junction of the gastroduodenostomy and the stapled end of the stomach. A triple seromuscular suture placed outside to in on the anterior wall of the stomach, inside to out on the duodenum, and inside to out on the posterior stomach can be used to secure this region.
● Repair Anastomotic bleeding normally resolves spontaneously postoperatively and can be treated with correction of coagulopathy and limited transfusion. Upper endoscopy can identify the site of bleeding and allow for placement of clips or electrocautery. Rarely does anastomotic bleeding require operative intervention that involves gastrostomy and direct control of hemorrhage. ● Prevention Although some surgeons consider rates of anastomotic bleeding to be higher in stapled versus sutured anastomoses, large series in postgastrectomy patients do not consistently show this to be the case.25 Regardless, a two-layered hand-sewn anastomosis with one layer being full-thickness with absorbable sutures results in good hemostasis. Careful inspection and oversewing of exposed staple lines can prevent some episodes of staple line bleeding.
Anastomotic Bleeding ● Consequence Hemorrhage and increased transfusion requirement. Grade 2/3 complication
Postgastrectomy Syndromes Numerous chronic complications related to gastrectomy with reconstruction are discussed in references 26 to 28.
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Afferent Loop Syndrome Afferent loop syndrome is an uncommon complication most often associated with Billroth II reconstruction in which the afferent loop becomes obstructed owing to stasis, adhesions, volvulus, or herniation. ● Consequence This complication can occur in the immediate postoperative period and present as unrelenting epigastric pain, which reflects a closed-loop obstruction. This may result in duodenal stump dehiscence. Late presentation of afferent loop syndrome is characterized by postprandial fullness, nausea, and eventually, projectile, bilious vomiting followed by relief of symptoms. Patients may have jaundice owing to biliary outflow obstruction, pancreatitis, and postprandial epigastric mass. Definitive diagnosis can be made by CT scan, upper gastrointestinal series, or endoscopy. Grade 3 complication ● Repair Lysis or adhesions, reduction of internal hernia, shortening of the afferent loop, or bowel resection treating the underlying cause of obstruction may correct the problem. In emergent procedures, in which markedly dilated loops of bowel are present, enteroenterostomy between the afferent and the efferent loops of the gastrojejunostomy is an option. In the chronic syndrome, shortening of the afferent loop (to 10–15 cm) or conversion to either Billroth I or Roux-en-Y gastrojejunostomy will treat the condition. ● Prevention Afferent loop syndrome is associated with long afferent loops (generally >30 cm in length), which can also present with diarrhea, marginal ulcer, or malabsorption. Antecolic reconstruction, antiperistaltic gastrojejunostomy, and poor positioning of the gastrojejunostomy along the greater curve of the stomach are also risk factors in development of the syndrome and should be considered when deciding the appropriate reconstruction for a given patient. Closure of the retroanastomotic opening by tacking the anastomosis to the transverse mesocolon can reduce the risk of retroanastomotic hernia.
Efferent Loop Syndrome Efferent loop syndrome is associated primarily with internal hernia but may also reflect adhesive disease or jejunogastric or jejunojejunal intussusceptions. ● Consequence Efferent loop syndrome presents in a manner similar to small bowel obstruction with colicky abdominal pain, nausea, and vomiting. Grade 3 complication
● Repair Repair centers on correction of the underlying problem, that is, hernia reduction and repair or lysis of adhesions. ● Prevention Proper closure of mesocolic defects and anchoring the jejunum to the mesocolon are the most effective ways of preventing internal herniation.
Anastomotic Stricture Anastomotic stricture is seen in 1.5% to 13% of patients after gastric resections.24,29 It can occur in the acute postoperative period or many years after the initial operation. The etiology of anastomotic stricture or stenosis can be anastomotic edema, extraluminal adhesion or compression,30 cancer recurrence, or long-term fibrosis and scarring. Chronic changes that result in strictures may occur owing to ulceration, inadequate perfusion at the anastomosis, or poor technique. The diagnostic work-up of stricture should begin with a contrast study to evaluate the etiology of the obstruction. Recurrent tumor at the gastrojejunal anastomosis may be seen as plaquelike, ulcerative, or polypoid lesions at or near the anastomosis on upper gastrointestinal series. In esophagogastric anastomosis, strictures resulting from anastomotic technique typically appear as short, ringlike areas of narrowing, whereas strictures from alkaline reflux esophagitis appear as long segments of smooth, tapered narrowing in the distal esophagus. Eccentric anastomotic narrowing would suggest recurrent tumor.31 ● Consequence Patients present with dysphagia when related to esophagogastrostomy stricture or with gastric outlet obstruction after gastric to small bowel anastomosis. Grade 2/3 complication ● Repair After a contrast study is performed, an esophagogastroduodenoscopy should be performed as a diagnostic and potentially therapeutic intervention. Benign anastomotic strictures can be treated successfully with either endoscopic balloon dilation or fluoroscopy-guided balloon dilation.32 For complete resolution of the stricture, multiple dilations may have to be performed, risking perforation.33 There have been several reports of benign strictures being treated successfully with selfexpandable stents, but long-term data are still forthcoming.34 The operation of choice for recalcitrant stricture is anastomotic revision. If structuring is due to recurrent tumors, the patient should be restaged, and if resection is possible, surgical intervention should include lymphadenectomy and completion gastrectomy with reconstruction. In those patients with unresectable disease, palliation with metallic stents should be considered.35
20 GASTRECTOMY WITH RECONSTRUCTION ● Prevention Risk factors for anastomotic stricture include inadequate blood supply at the anastomosis, alkaline reflux, ulcer formation, anastomotic dehiscence, and smallerdiameter stapled anastomosis. The surgeon should be conscious of the blood supply preserved during resection, and the largest possible end-to-end anastomosis stapler should be used to create the esophagogastrectomy.36 These principles are particularly important in laparoscopic resection because there have been reports of increased anastomotic stricture (≤40%) after these procedures compared with open gastrectomy.37
Roux Stasis Syndrome Roux stasis syndrome presents in 30% of patients with Roux-en-Y gastrojejunostomy. ● Consequence Early satiety, postprandial vomiting, and epigastric pain.38 The etiology of this dysmotility is believed to be related to disconnection of the transected Roux limb from the duodenal pacemaker,39 but it may also be related to gastric dysmotility or to anastomotic stricture. Grade 2/3 complication ● Repair Patients are initially treated with promotility agents such as metoclopramide or erythromycin.40 Endoscopy may be useful for dilating anastomotic strictures. Failure to improve with medical and endoscopic management indicates the need for surgical intervention. Standard therapy consists of subtotal gastrectomy with reconstruction. This is essential if evidence of severe gastric dysmotility is observed. More recently, conversion to an “uncut” Roux-en-Y gastrojejunostomy, as described later, has been shown to improve symptoms associated with Roux stasis syndrome.41 ● Prevention The Roux stasis syndrome can be prevented by performing the uncut Roux-en-Y as initial reconstruction (Fig. 20–7).38,41 Studies have also noted that longer length of the Roux limb was associated with higher rates of Roux syndrome, but as noted previously, this must be balanced against the risk of afferent loop syndrome.
Bile Reflux Gastritis Bile reflux gastritis is most commonly seen after Billroth II reconstruction as a consequence of a defective pyloric channel and results from exposure of the gastric mucosa to bile, pancreatic secretions, and duodenal contents. ● Consequence Symptoms result in only 3% to 30% of patients with endoscopic evidence of bile reflux,42 and include burning epigastric pain, bilious emesis, oral aversion,
231
Gastric enteric stream Bilious enteric stream Propagation of enteric pacesollar potantlias Staple line
Figure 20–7 Conversion to an “uncut” Roux-en-Y gastrojejunostomy is believed to restore the physiologic flow of enteric contents, improving dysmotility of the small bowel and relieving symptoms related to Roux stasis syndrome. (From Collen JJ, Kelly KA: Gastric motor physiology and pathophysiology. Surg Clin North Am 1993;71:1145–1160.)
and weight loss. Pain is unrelieved by acid suppression and is aggravated by both oral intake and the recumbent position. Bile reflux gastritis is a diagnosis of exclusion owing to the low specificity of endoscopic findings and histologic findings (intestinalization of gastric glands with inflammation). Zollinger-Ellison syndrome and other postgastrectomy syndromes should be ruled out prior to operative repair aimed at correction of this condition. Grade 2–4 complication ● Repair Medical management of bile reflux gastritis includes prokinetic agents, antispasmodic therapy, cholestyramine, and dietary modification. The aim of reoperative surgery in this setting is to divert duodenal contents away from the gastric remnant and may be accomplished by any of several procedures: ● Conversion to Roux-en-Y gastrojejunostomy with a
Roux limb of at least 40 cm is associated with symptomatic relief in up to 85% of patients.42 ● Distal Braun enterostomy (see Fig. 20–5) has been shown to improve symptoms of bile reflux gastritis in 53% of patients.43 ● The Henley procedure is a gastrojejunoduodenostomy constructed with an interposition of a jejunal segment approximately 40 cm in length between the gastric remnant and the duodenum (Fig. 20–8).44 Symptomatic relief is seen in 70% of patients undergoing this procedure.
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SECTION III: GASTROINTESTINAL SURGERY ● Repair Most patients will respond to medical management of dumping syndrome. Low-carbohydrate, high-protein meals and fiber supplementation have been shown to reduce dumping symptoms. If symptoms persist despite dietary modification, the long-acting somatostatin analogue, octreotide, can be administered with good effect or the alpha-glucosidase inhibitor acarbose may prevent absorption of the carbohydrate load, treating late dumping symptoms.47–49 Surgical therapy is rarely necessary and historically centered on reconstruction of the pylorus whether by direct repair after pyloromyotomy or by creation of an antiperistaltic jejunal interposition limb anastomosed between the stomach and the duodenum. Use of jejunal interposition has been largely abandoned owing to high rates of postoperative obstruction and gastric stasis. The most commonly employed revision procedure to treat dumping syndrome is currently the Roux-en-Y gastrojejunostomy, which results in near-complete symptom resolution in 86% of patients.50
Figure 20–8 The Henley procedure creates a gastrojejunoduodenostomy with interposition of a 40-cm jejunal segment between the gastric remnant and the duodenum. (From Aranow JS, Matthews JB, Garcia-Aguilar J, et al. Isoperistaltic jejunal interposition for intractable postgastrectomy alkaline reflux gastritis. J Am Coll Surg 1995;180:648–653.) ● Biliary diversion using Roux-en-Y hepaticojejunos-
tomy can be performed by converting the gastric anastomosis to a gastroduodenostomy and performing choledochojejunostomy. ● Prevention Rates of bile reflux are lowest in the Roux-en-Y gastrojejunostomy, although the possibility of Roux stasis syndrome should be weighed against this benefit when choosing reconstruction.
Dumping Syndrome Dumping is a well-recognized complication of distal gastrectomy, occurring in as many as 25% of patients owing to alteration in the pyloric outflow mechanism.45,46 ● Consequence Early dumping results from a hyperosomotic load delivered to the small bowel and causes abdominal cramping and diarrhea. Late dumping is less common, is related to hyperinsulinemia, and presents with hypoglycemic symptoms that are relieved with carbohydrate administration. Grade 2/3 complication
● Prevention No clear measures are known to prevent dumping when Billroth I or Billroth II reconstruction is planned, and complications specific for Roux-en-Y gastrojejunostomy should be weighed when choosing this as a means to prevent dumping.
Delayed Gastric Emptying Delayed gastric emptying occurs owing to either mechanical outflow obstruction or dysmotility related to alteration in vagal innervation of the stomach or the gastric pacemaker owing to surgery. ● Consequence Delayed gastric emptying can occur in the immediate postoperative period, presenting as inability to tolerate an oral diet. In the chronic setting, it is associated with abdominal pain and bloating, nausea, vomiting, weight loss, and malnutrition. Diagnosis is made by gastric emptying studies that demonstrate delayed emptying of solids. Endoscopy will show evidence of retained food and, potentially, bezoar formation. Grade 2–4 complication ● Repair Anastomotic strictures should be treated with endoscopic dilation, if possible, and adhesive disease should be treated with reoperation. As in Roux stasis syndrome, promotility agents are the first-line therapy when no evidence of mechanical obstruction is found. Metoclopramide, doperamide, and cisapride may provide some symptomatic relief.40,51,52 In refractory cases, patients may require a subtotal or complete gastrectomy with Roux-en-Y reconstruction.53,54 Place-
20 GASTRECTOMY WITH RECONSTRUCTION ment of implantable pacemakers have been of some use in severe gastroparesis after bariatric surgery and may provide relief for some patients after gastrectomy.55 ● Prevention Careful dissection around the esophageal hiatus to preserve vagal innervation should minimize damage to the autonomic innervation of the gastric remnant. Maintenance of as much residual stomach as possible will prevent inadvertent resection of the gastric pacer. In patients undergoing Roux-en-Y reconstruction after distal gastrectomy, higher rates of gastric stasis were seen in patients who underwent more extensive lymph node dissection.56 Risk factors associated with postoperative delayed gastric emptying include diabetes and gastric outlet obstruction. In patients with these conditions, consideration should be given to placement of gastrostomy and feeding jejunostomy tube placements at the time of operation. Preoperative nasogastric decompression may provide some improvement in outcomes.27
4.
5.
6.
7. 8.
9.
10.
Other Complications Nutritional deficits after gastrectomy can result in anemia, neuropathy, and osteoporosis. Attention to adequate vitamin replacement therapy must continue throughout the patient’s lifespan and address malabsorption of iron, vitamin B12, folate, vitamin D, and calcium. Stump carcinoma is most common with Billroth II reconstruction, occurring several decades after operation, and should be considered in the differential diagnosis of patients presenting with vague abdominal complaints or weight loss. No definitive recommendations for screening have been published, but low threshold for endoscopy is appropriate. Gastroesophageal reflux disease is a common complication of gastric surgery and may result from damage to the lower esophageal sphincter, gastric dysmotility, or bile reflux. Medical management with metoclopramide or domperidone and histamine receptor or proton pump inhibitors should be attempted. Fundoplication (if possible) or revision surgery, as discussed previously and aimed at addressing gastric dysmotility or bile reflux, may be required.
11.
12.
13.
14.
15.
16.
17.
18.
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22. Lee BI, Choi KY, Kang HJ, et al. Sealing an extensive anastomotic leak after esophagojejunostomy with an antimigration-modified covered self-expanding metal stent. Gastrointest Endosc 2006;64:1024–1026. 23. Seufert RM, Schmidt-Matthiesen A, Beyer A. Total gastrectomy and oesophagojejunostomy—a prospective randomized trial of hand-sutured versus mechanically stapled anastomoses. Br J Surg 1990;77:50–52. 24. Takeyoshi I, Ohwada S, Ogawa T, et al. Esophageal anastamosis following gastrectomy for gastric cancer: a comparison of hand-sewn and stapling technique. Hepatogastroenterology 2000;47:1026–1029. 25. Hori S, Ochiai T, Gunji Y, et al. A prospective, randomized trial of hand-sutured versus mechanically stapled anastomosis for gastroduodenostomy after distal gastrectomy. Gastric Cancer 2004;7:24–30. 26. Dempsey DT. Reoperative gastric surgery and postgastrectomy syndromes. In Yeo C, Zuidema GD (eds): Shackleford’s Surgery of the Alimentary Tract, Vol 2. Philadelphia: WB Saunders, 2001; pp 161–177. 27. Jaffe BM, Florman SS. Postgastrectomy and postvagotomy syndromes. In Fischer JE (ed): Mastery of Surgery, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007; pp 938–954. 28. Sawyers JL. Management of postgastrectomy syndromes. Am J Surg 1990;159:8–14. 29. Date RS, Panesar KJ. D2 gastrectomy—a safe operation in experienced hands. Int J Clin Pract 2005;59:672– 674. 30. Takahashi T, Yamashiro M, Hashimoto H, et al. Stomal stenosis following gastrectomy in the elderly. Nippon Ronen Igakkai Zasshi 1992;29:758–764. 31. Woodfield CA, Levine MS. The postoperative stomach. Eur J Radiol 2005;53:341–352. 32. Inagake M, Yamane T, Kitao Y, et al. Balloon dilatation for anastomotic stricture after upper gastrointestinal surgery. World J Surg 1992;16:541–544. 33. Carrodeguas L, Szomstein S, Zundel N, et al. Gastrojejejunal anastomotic stricture following laparoscopic Rouxen-Y gastric bypass: analysis of 1291 patients. Surg Obes Relat Dis 2006;2:92–97. 34. Ustündag Y, Köseglu T, Cetin F, et al. Self-expandable metallic stent therapy of esophagojejunal stricture in a stapled anastomosis: a case report and review of the literature. Dig Surg 2001;18:211–213. 35. Sugimoto K, Hiroto S, Imanaka K, et al. Application of self expanding metallic stents to malignant stricture following mechanically stapled esophagojejunostomy: report of two cases. Radiat Med 2000;18:133–137. 36. Wong J, Cheung H, Lui R, et al. Esophagogastric anastomosis performed with a stapler: the occurrence of leakage and stricture. Surgery 1987;101:408–415. 37. Varela JE, Hiyasha M, Nguyen T, et al. Comparison of laparoscopic and open gastrectomy for gastric cancer. Am J Surg 2006;192:837–842. 38. Gustavsson S, Ilstrup DM, Morrison P, Kelly KA. Rouxen-Y stasis syndrome after gastrectomy. Am J Surg 1988; 155:490–494. 39. Tu BN, Kelly KA. Elimination of the roux stasis syndrome using a new type of “uncut Roux” limb. Am J Surg 1995; 170:381–386.
40. Petrakis J, Vassilakis JS, Karkavitasas N, et al. Enhancement of gastric emptying of solids by erythromycin in patients with Roux-en-Y gastrojejunostomy. Arch Surg 1998;133:709–714. 41. Noh SM. Improvement of the Roux limb function using a new type of “uncut Roux” limb. Am J Surg 2000;180: 37–40. 42. Zobolas B, Sakorafas GH, Kouroukli I, et al. Alkaline reflux gastritis: early and late results of surgery. World J Surg 2006;30:1043–1049. 43. Vogel SB, Drane WE, Woodward ER. Clinical and radionucleotide evaluation of bile diversion by Braun enteroenterostomy: prevention and treatment of alkaline reflux gastritis. An alternative to Roux-en-Y diversion. Ann Surg 1994;219:458–465. 44. Aranow JS, Matthews JB, Garcia-Aguilar J, et al. Isoperistaltic jejunal interposition for intractable postgastrectomy alkaline reflux gastritis. J Am Coll Surg 1995;180:648– 653. 45. Carvajal SH, Mulvihill SJ. Postgastrectomy syndromes: dumping and diarrhea. Gastrointest Clin North Am 1994; 23:261–279. 46. Mix CL. “Dumping stomach” following gastrojejunostomy. Surg Clin North Am 1922;2:617–622. 47. Gerard J, Luyckx AS, Lefebvre PJ. Acarbose in reactive hypoglycemia: a double-blind study. Int J Clin Pharmacol Toxicol 1984;22:25–31. 48. Gray JL, Debas HT, Mulvihill SJ. Control of dumping symptoms by somatostatin analogue in patients after gastric surgery. Arch Surg 1991;126:1231–1235. 49. Hasegawa T, Yoneda M, Nakamura K, et al. Long-term effect of alpha-glucoside inhibitor on later dumping syndrome. J Gastroenterol Hepatol 1998;13:1201– 1206. 50. Vogel SB, Hocking MP, Woodward ER. Clinical and radionucleotide evaluation of Roux-Y diversion for postgastrectomy dumping. Am J Surg 1988;155:57–62. 51. Ramirez B, Eaker EY, Drane WE, et al. Erythromycin enhances gastric emptying in patients with gastroparesis after vagotomy and antrectomy. Dig Dis Sci 1994;39: 2295–2300. 52. Tomita R, Ikeda T, Fujisaki S, et al. Effects of mosapride, citrate on patients after vagal nerve preserving distal gastrectomy reconstructed by interposition of a jejunal J pouch with a jejunal conduit for early gastric cancer. World J Surg 2006;30:205–212. 53. Eckhause FE, Conrad M, Knol JA, et al. Safety and longterm durability of completion gastrectomy in 81 patients with postsurgical gastroparesis syndrome. Am Surg 1998; 64:711–716. 54. McCallum RW, Polepalle SC, Schirmen B. Completion gastrectomy for refractory gastroparesis following surgery for peptic ulcer disease. Long-term follow-up with subjective paramenters. Dig Dis Sci 1991;36:1156–1161. 55. Salameh JR, Schmeig RE, Runnels JM, Abell TL. Refractory gastroparesis after roux-en-Y gastric bypass: surgical treatment with implantable pacemaker. J Gastrointest Surg. 2007;11:1669–1672. 56. Hirao M, Fujitani K, Tsujinaka T. Delayed gastric emptying after distal gastrectomy for gastric cancer. Hepatogastreoenterology 2005;52:305–309.
20 GASTRECTOMY WITH RECONSTRUCTION 57. Makela JT, Kiviniemi H, Laitinen S. Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastamosis. Dis Colon Rect 2003;46:653– 660. 58. Sorenson LT, Jørgensen T, Kirkeby LT, et al. Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg 1999;86:927– 931. 59. Golub R, Golub RW, Cantu R Jr, Stein HD. A multivaried analysis of factors contributing to leakage of
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intestinal anastomosis. J Am Coll Surg 1997;184:364– 372. 60. Walker KG, Bell SW, Rickard MJ, et al. Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer. Ann Surg 2004; 240:255–259. 61. Kudsk KA, Tolley EA, DeWitt RC, et al. Preoperative albumin and surgical site identify surgical risk of major preoperative complications. J Parenter Enter Nutr 2003; 27:1–9.
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Enterectomy Reid B. Adams, MD INTRODUCTION Enterectomy is a common procedure used primarily for resection of small bowel or in combination with other gastrointestinal procedures. Enterectomy also is used in conjunction with reconstructive procedures for replacement of the gastrointestinal or urologic tract. This discussion focuses on primary enterectomy for treatment of small bowel conditions. The complications discussed here are common to those procedures requiring small bowel resection for other reasons. Enterectomy has been part of the abdominal surgeons’ repertoire for much of the history of surgery, yet the risks and complications associated with this procedure have remained constant over its recent history. Whereas we may understand the pathophysiology and predisposing factors for their development, complications persist and all abdominal surgeons should be familiar with their development, consequences, repair, and prevention. This chapter focuses on these issues related to enterectomy. The reported leak rates for intestinal anastomosis range from 1% to 8%.1–6 Specific leak rates for enterectomy are more difficult to find in the literature. One review reported a 1.1% leak rate in 798 patients undergoing enterectomy.7 The primary aspects necessary for construction of a successful anastomosis include careful approximation of well-vascularized bowel wall in a tension-free manner. Clearly, a technically inadequate anastomosis will lead to anastomotic failure.8 However, despite a technically suitable anastomosis, complications such as anastomotic failure can occur. Significant efforts have focused on understanding the nontechnical factors that contribute to anastomotic failure. Poor nutrition, hypoalbuminemia, infection, smoking, diabetes, obesity, and many others have been implicated in various studies.1–4,7,9–11 Despite extensive investigation, study results are conflicting and no consensus on predisposing factors has been reached. In Pickleman and coworkers’ review,7 the only factor predicting anastomotic leak after enterectomy was hypertension. How this contributed to anastomotic failure was unclear from this study. No differences were seen in stapled versus sewn anastomoses or between different types of anastomoses. Overall, their findings reinforced
the concept that a clear set of factors predisposing to anastomotic leak have not been delineated.
INDICATIONS ● ● ● ● ● ● ●
Small bowel obstruction Small bowel neoplasm Small bowel inflammatory disease (e.g., Crohn’s disease) Small bowel herniation with vascular compromise Enterocutaneous fistula Small bowel intussusception Mesenteric tumors when resection leads to small bowel ischemia ● Traumatic injury to the small bowel
OPERATIVE STEPS Incision Evaluation of small bowel from ligament of Treitz to ileocecal valve 3 Identification of transection sites proximal and distal to diseased segment 4 Creation of anastomosis Creating a mesenteric defect Transection of bowel Ligation and division of small bowel mesentery Small bowel anastomosis Inspection of anastomosis for bleeding Closure of enterotomy resulting from small bowel anastomosis 5 Assessment of anastomosis patency by palpation 6 Suture closure of mesenteric defect 7 Closure of incision
Step 1 Step 2 Step Step ● ● ● ● ● ●
Step Step Step
OPERATIVE PROCEDURE Incision Injuries upon Entry into the Peritoneal Cavity All grades of injuries can occur during this step. This is primarily the case during reoperative surgery or during a
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primary procedure when the bowel is grossly dilated. Careful dissection and controlled entry into the peritoneal cavity under these conditions are required to avoid entry complications, as discussed in Section I, Chapters 6 and 7.
Evaluation of the Small Bowel Missed Lesions Many small bowel conditions (neoplasia, ischemia, strictures, or obstruction) requiring enterectomy can be multifocal. Identification of all diseased segments is important to facilitate complete treatment. ● Consequence Persistent neoplasm with development of obstruction or metastasis. Residual ischemia leading to stricture, obstruction, or perforation with peritonitis. Grade 3/4/5 complication ● Repair Repeat operation for resection of residual tumor, ischemia, stricture, or obstruction. ● Prevention A thorough evaluation of the entire small bowel and its mesentery is important to rule out additional lesions, particularly if the procedure is being done for small bowel neoplasm or ischemia. Identification of mass lesions, strictures, or injuries is accomplished by “milking” the bowel between the index and the middle fingers (Fig. 21–1) and visually examining both sides of the bowel during this process. This allows identification of small lesions. Similarly, the mesentery in the area of a small bowel neoplasm is palpated for lymphadenopathy and tumor involvement. When assessing for ischemia, fluorescein staining or Doppler studies may aid in distinguishing viable from ischemic segments when determining the extent of enterectomy. One ampule of fluorescein is given, and the small bowel is examined under a Wood lamp. Nonviable segments of bowel will be demarcated by this method. When areas are indeterminate for ischemia at the initial laparotomy, a planned repeat laparotomy 24 hours later will allow assessment of the questionable areas of ischemia. Additional enterectomy may be required at the second operation.
Identification of Transection Sites Proximal and Distal to the Diseased Segment Missed or Recurrent Disease The site chosen for transection of the small bowel is dependent upon the disease process being treated. Historically, a distance of 5 to 10 cm away from the lesion being resected has been advocated to ensure an adequate resection margin when treating a neoplasm. However, there does not appear to be literature providing solid evidence to support a specific transection distance. The
Figure 21–1 Lesions within the bowel can be identified by “milking” the bowel between the index and the middle fingers. This allows small lesions to be palpated, preventing missed pathologic findings. In addition, enteric contents can be milked away from the site of an enterotomy, minimizing the risk of operative site contamination by enteric contents.
transection site of the bowel is partly dictated by the amount of mesenteric resection necessary to encompass the lymphatic drainage in the area of the neoplasm. Transection for ischemic disease should be at sites that are well vascularized. Transection for inflammatory disease, such as Crohn’s disease, is done just outside the area of grossly involved bowel. The consequences, repair, and prevention of this complication are similar to those in the prior section.
Creation of the Anastomosis Several techniques are described for enterectomy with anastomosis. Currently, the most commonly practiced is a stapled side-to-side, functional end-to-end anastomosis. In some circumstances, this anastomosis is not technically feasible and a sewn anastomosis is required. The stapled anastomosis is used for illustrative purposes for this discussion, because the general complications for enterectomy with anastomosis are similar in both the stapled and the sewn techniques.
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Figure 21–2 Backlighting the mesentery (transillumination) allows identification of the vascular arcade (arrows). This permits precise identification of the bowel’s edge (arrowhead) and the vessels (arrows). As a result, careful ligation can be done, preventing injury to the bowel or the vascular arcade.
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Figure 21–3 Wound contamination is minimized by covering the wound edges with a saline-moistened towel. This and the strategies shown in Figures 21–1 and 21–4 limit enteric spillage and contamination.
Injuries during Creation of a Mesenteric Defect Injury to the small bowel or the adjacent mesentery can occur during this step. ● Consequence Leakage of enteric contents, wound contamination, and increased postoperative infection risk. Mesenteric injury with bleeding, hematoma, or compromise of the blood supply to the remaining small bowel. Any of these injuries may lead to the unintended resection of additional normal small bowel. Grade 1/2 complication ● Repair The injured small bowel can be incorporated into the stapled transection line or the resection specimen. The mesenteric injury can be oversewn and/or incorporated into the resection specimen. ● Prevention Transillumination of the mesentery (Fig. 21–2) will allow identification of the small mesenteric vessels and the edge of the bowel, thereby avoiding these injuries. Removing the lights from the operative field followed by direct light on the back side of the mesentery will allow the surgeon to identify these structures. The avascular window is then marked with cautery or punctured with a tonsil clamp to mark its position. Prevention of infection is facilitated by covering the wound with a moist towel to keep the enteric contents from contaminating the edges (Fig. 21–3). The bowel involved in the anastomosis also can be surrounded by moist towels to contain any spillage of enteric contents. Milking enteric contents away from the transection sites (see Fig. 21–1) and occluding the bowel proximally and distally with a noncrushing bowel clamp (Fig. 21–4) will minimize enteric contents in the enterectomy site. Placement of the occluding clamp should be done in a fashion that does not include the mesentery. Finally, administra-
Figure 21–4 After the enteric contents are milked away from the enterectomy site, noncrushing bowel clamps can be used to occlude the lumen proximally and distally from the resection site, preventing reflux into the operative field. The clamps are placed to the edges of the bowel, but not onto the adjacent mesentery (arrows).
tion of perioperative antibiotics, covering gram-negative bacilli and anaerobes, will minimize the risk of perioperative infections.
Difficulties during Bowel Transection Complications at this step usually are the result of device malfunction. ● Consequence Spillage of enteric contents, intra-abdominal abscess formation, or wound infection. Additional loss of healthy bowel can result if further intestinal resection is required to repair the misfire site. An inadequate staple line can lead to anastomotic leak, as discussed later. Grade 1/2/3 complication
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● Repair The site of malfunction typically results in an open or injured piece of small intestine. Reapplication of the stapler at an adjacent site of healthy bowel will treat this complication. ● Prevention Stapler malfunctions are uncommon.8 Experienced surgeons frequently know whether the stapler has not operated correctly. Occluding the bowel adjacent to the stapler to prevent spillage of enteric contents can be done while the stapler is removed and the staple line inspected. If the bowel is not intact or is injured, the stapler can be reapplied adjacent to the occluding bowel clamp. Anticipating/recognizing a misfiring will minimize opportunities for enteric spillage. Stapler malfunctions can result from educational deficiencies or the introduction of new equipment or models. Adequate staff and surgeon training regarding the use and reloading of the devices will minimize these errors. Finally, multiuse staplers should be fired according to the manufacturer’s specifications. Firing the stapler more times than recommended may lead to malfunction.
Inadequate Ligation and Division of the Small Bowel Mesentery ● Consequence Bleeding or hematoma formation. Imprecise ligation can cause small bowel ischemia, leading to unnecessary resection of healthy intestine. Unrecognized, inadequate ligation can result in immediate or delayed major intra-abdominal hemorrhage. Grade 1/3/4 complication ● Repair Bleeding sites can be transfixed with a suture ligature or reclamped and ligated to achieve hemostasis. Care should be taken to prevent occlusion of adjacent major vessels and subsequent ischemic injury. Expanding hematomas can be treated with a suture ligature to achieve hemostasis of a retracted mesenteric vessel. Although rarely required, opening of the hematoma may be necessary to ensure accurate and complete ligation of the bleeding site. Ligation resulting in ischemic intestine requires additional resection of intestine back to adequately perfused bowel. Delayed hemorrhage typically requires reoperation and ligation of the bleeding site. This may result in intestinal ischemia, requiring re-resection of the small intestine including the site of the anastomosis. Alternatively, interventional angiography may allow identification and embolization of the bleeding site if it can be selectively cannulated. ● Prevention Transillumination of the mesentery (see Fig. 21–2) will allow determination of the exact location of the mesenteric vessels. This ensures accurate and adequate liga-
tion. Occasionally, a fatty mesentery prevents accurate location of the vessels or an adequate purchase for a tie. A suture ligature used in this instance will prevent dislodgement of the tie. Good communication between the surgeon and the assistant will prevent premature removal of the clamp before the suture is secured.
Difficulties during the Anastomosis A number of complications can occur during this step as a result of equipment malfunction or operator error. Attention to the technical details of this and the following steps will minimize complications during this part of the procedure. ● Consequences Failure to accurately line up the proximal and distal ends of the bowel can result in a distorted, torqued, and dysfunctional anastomosis with a stricture or obstruction. Stapler malfunction can occur, as described previously. However, loss of this staple line results in a much greater loss of healthy intestine because both the proximal and the distal bowel ends will require resection back to healthy bowel. Alternatively, suture repair of the injury may suffice. Perforation of the bowel with the end of the stapler can occur if both limbs are not adequately seen during stapler insertion. Again, this will require repair or resection of healthy bowel. Enteric spillage during this step can lead to infection, as discussed previously. Bleeding from the staple line can result in immediate or delayed hemorrhage. Delayed hemorrhage can result in obstruction at the anastomosis or disruption of the anastomosis owing to distention, which can result in an anastomotic leak. An inadequate or disrupted staple line can lead to anastomotic leak, as discussed later. Grade 1/2/3/4/5 complication ● Repair Mechanical problems resulting in a strictured or obstructed anastomosis may require resection of the anastomosis and construction of a new one. Similar treatment is used for stapler malfunctions that result in an inadequate staple line or anastomosis. Bleeding at the anastomosis can be treated with a transfixing suture. ● Prevention Careful approximation of the proximal and distal limbs of the bowel involved in the anastomosis will prevent misalignment complications (Fig. 21–5). A traction suture placed at the cut ends of the bowel will help ensure that the two pieces are pulled equally onto the stapler jaws (Fig. 21–6). Rotation of the bowel so the antimesenteric edges are in approximation will ensure a technically precise anastomosis (Fig. 21–7). Adequate inspection and palpation during stapler placement will prevent perforation injuries (Fig. 21–8).
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Enteric spillage can be prevented, as described previously. Opening of the stapler jaws completely, prior to removing the stapler, will prevent traction injuries, including bleeding, once the stapler is fired. Retraction of the edges of the enterotomy and direct inspection of the staple line will allow identification and oversewing of any bleeding sites and will prevent delayed hemorrhage complications (Fig. 21–9).
A
Failure at the Enterotomy Closure Site ● Consequence Strictured anastomosis. An inadequate staple line can lead to anastomotic leak, as discussed later. Grade 1/2/3/4 complication
B
● Repair Reapplication of the stapler or oversewing of the inadequately closed enterotomy. Narrowing/stricture requires construction of a new anastomosis.
Figure 21–5 A, The proximal and distal ends of the bowel are aligned by traction sutures (arrowheads). Careful approximation prevents misalignment complications, such as kinking or twisting of the bowel limbs. B, To anastomose the proximal and distal bowel limbs, an enterotomy is made in the antimesenteric border of each limb. The proximal traction suture (not seen, behind the stapler) is then used to pull the bowel ends up onto the stapler arms, bringing them into appropriate alignment (arrows).
● Prevention Care to include the entire length of the enterotomy is required to prevent this problem. At each corner of the enterotomy, an Allis clamp is placed with one jaw into the lumen of the anastomosis (Fig. 21–10). The Allis is partially closed while withdrawing the clamp, thereby grabbing the mucosa to ensure that full-thickness bowel is included in the enterotomy closure. This prevents inadequate closure at the corners of the enterotomy. Alternatively, a suture through each corner of the anastomosis and a suture in the middle of the anastomosis, all of which include the full thickness of the bowel, can be used to hold the bowel edges in apposition to allow precise closure. The staple lines are offset slightly from
A B Figure 21–6 A, The proximal traction sutures (arrows) help pull the bowel ends onto the stapler arms. This suture ensures that the bowel ends are aligned (arrowheads). B, Inspection of the posterior part of the staple line ensures that the entire anastomosis is appropriately aligned.
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B
Figure 21–7 Once the stapler jaws are closed, proper alignment of the bowel limbs includes the ends at the enterotomy sites (arrowheads) and the small bowel mesentery (arrow), which is held out directly opposite (180°) from the anastomosis. The surgeon’s fingers are placed behind the bowel as shown to insure no other structures are caught in the staple line.
Figure 21–8 A, The distal end of the staple line requires inspection as the stapler arms are inserted into the bowel lumen. This prevents a through-and-through bowel injury from the tip of the stapler (arrows) coming out the bowel wall. B, This is particularly true when an anastomosis is done deep in the abdominal cavity and the distal end of the anastomosis is difficult to see.
each other (see Fig. 21–10) and the two edges of bowel between the corner clamps are held in approximation with additional Allis clamps (Fig. 21–11). Application of the linear non-cutting stapler just below the Allis clamps will prevent narrowing of the anastomosis and subsequent stricture formation (Fig. 21–12). A buttressing suture placed at the end of the staple line will prevent tension at this portion of the anastomosis (Fig. 21–13). Assessment of the patency of the anastomosis is done by palpation of the lumen (Fig. 21–14). In addition, intraluminal air can be milked into the anastomosis to distend it and ensure an airtight seal. Likewise, passage of succus through the anastomosis ensures an adequate size of the opening.
Anastomotic Failure Anastomotic disruption and leakage are dreaded and potentially fatal complications of enterectomy. Although
Figure 21–9 The staple line (arrow) can be inspected directly to ensure hemostasis. Bleeding along the staple line can be suture-ligated to prevent delayed anastomotic bleeding resulting in obstruction or disruption.
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these fears are warranted, the incidence of anastomotic failure for enterectomy is low, 1.1% in one series, resulting in a mortality of 0.4%.7 ● Consequence Anastomotic leak, intra-abdominal abscess, enterocutaneous fistula, peritonitis, and death. Grade 2/3/4/5 complication
Figure 21–10 An Allis clamp is placed at each corner of the enterotomy. One side of the clamp is placed into the lumen, partially closing it and pulling outward to include the mucosa (arrows) within the closed clamp. This insures that full-thickness bowel and the entire corners are included in the enterotomy closure. The initial (gastrointestinal anastomosis) staple lines are offset (arrowheads) during closure of the enterotomy to avoid multiple overlapping staple lines.
● Repair Contained leaks without generalized peritonitis can be treated with supportive care, antibiotics, and percutaneous drainage. Failure of this treatment, a free leak or generalized peritonitis requires laparotomy for repair. In these circumstances, drainage alone is associated with increased mortality. Repair of the anastomosis can be done, but most authors favor construction of a new anastomosis. Either way, a proximal diverting ostomy is recommended by some authors as part of the procedure.7 ● Prevention All authors believe that attention to the technical details during construction is critical. In addition, all adhere to the primary tenets of this and any other anastomosis that the minimum requirements for a successful anastomosis are adequate approximation of wellvascularized tissue in a tension-free manner. Despite a technically excellent anastomosis, leaks still occur. As noted earlier, although significant efforts have been devoted to detecting risk factors for anastomotic failure, the results from these studies have been mixed and variable. Consequently, no consistent risks have been identified that might be optimized preoperatively to minimize the nontechnical risks of anastomotic failure.
Inadequate Closure or Injury during Closure of the Mesenteric Defect
Figure 21–11 Allis or Babcock clamps are used to approximate the bowel edges to insure complete closure of the enterotomy site.
● Consequence Internal herniation, bleeding, hematoma, and anastomotic failure. Grade 1/2/3/4/5 complication ● Repair Internal herniation requires laparotomy to reduce the hernia. Ischemic injury may require resection and reconstruction of the ischemic bowel. Injury typically results in bleeding or hematoma, requiring suture ligation of the bleeding site.
Figure 21–12 The linear non-cutting stapler is placed just beneath the clamps, allowing complete closure of the enterotomy without narrowing the anastomosis.
● Prevention When closing the mesenteric defect include small bites of the peritoneum only (Fig. 21–15). Deeper bites into the mesenteric adipose tissue result in vascular injury. Avoid placing sutures at sites where the sutures used to ligate the mesentery during mesenteric division are present. Vessels extend to the edge of the mesentery at these sites and are more easily injured with the superficial bites of the closing sutures. Inspection after
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A
B
Figure 21–13 A, The “corner” of the staple line (arrow). B, A suture is placed adjacent to the linear staple line (arrow) to prevent tension at this site. This is the “buttressing” suture.
Figure 21–14 The lumen of the anastomosis (indicated by the bracket) can be palpated between the thumb and the index finger to ensure that it is patent.
closure insures adequate approximation to prevent subsequent herniation.
Closure Injury during Closure of the Incision All grades of injury can occur at this step. Careful fascial approximation will avoid these complications, as discussed in Section I, Chapters 6 and 7.
Figure 21–15 During closure of the mesenteric defect (edge indicated by small arrowheads), small superficial bites of the peritoneum (see the needle) are obtained to avoid injury to the mesenteric vessels. Care is used to avoid the mesentery ligation sites (arrows), where vessels come to the cut edge of the mesentery and, therefore, are easily injured.
Other Complications Short Bowel Syndrome Grade 4 complication Although not a technical complication of enterectomy, short bowel syndrome is a consequence of massive intestinal resection. Symptoms can be avoided if more than 150 cm of small bowel remain intact. A minimum of
21 ENTERECTOMY 50 cm of small bowel in the absence of any colon is required to allow adaptation.12,13 Jejunal resection is tolerated better than ileal resection, because the ileum adapts better than the jejunum.13 Maintaining the ileocecal valve and as much colon as possible also diminishes the onset and severity of symptoms from massive enterectomy. Finally, stricturoplasty and other techniques to maintain length in patients with small bowel disease, such as Crohn’s disease, will prevent short bowel syndrome in those patients in whom even minimal resections may lead to symptoms owing to their diseased bowel.
Nutritional Deficiencies Grade 1 complication Resection of significant ileum can lead to nutritional deficiencies, most notably vitamin B12. Patients with extensive ileal resection should have B12 supplementation. Malabsorption of fat, fat-soluble vitamins, and bile salts also occurs with extensive ileal resection. Fat malabsorption may require supplementation for fat-soluble vitamins A, D, and E.14 It also can lead to nephrolithiasis.15 Bile salt malabsorption can lead to diarrhea and cholelithiasis. Ileus Grade 1 complication A common feature of abdominal surgery, ileus prolongs hospital stay and increases patient discomfort. Although not unique to enterectomy, ileus may be decreased by a number of interventions including the use of thoracic epidural catheters, avoidance of systemic opioid analgesics, administration of new pharmacologic agents, and the use of laparoscopic techniques, all feasible in enterectomy.16,17 In addition, the effects of postoperative ileus may be minimized by a number of strategies. Numerous studies demonstrate no benefit in the routine use of nasogastric tubes postoperatively.18 Likewise, early postoperative feeding has become standard, because only 10% to 20% of patients fail the early initiation of a diet.19 Together, these strategies minimize the effects of an ileus, lessening patient discomfort and shortening the length of stay. Postoperative Bowel Obstruction Grade 1/3/4 complication Early or late bowel obstruction can occur after enterectomy. Like an ileus, this is not a technical error in the conduct of the operation, but a consequence of laparotomy. Early obstruction can mimic ileus, and distinguishing the two may be difficult.20 Ileus usually resolves after 3 to 5 days. Lack of bowel activity or progressive distention after this time typically represents an early small bowel obstruction. The risk of occurrence is reported to be 0.7% at 4 weeks after operation,21 although Fazio and associates22 reported that 30% of all bowel obstructions in their series occurred within 30 days of the operation. Resolution with conservative therapy occurs in approxi-
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mately 90% of patients by 10 to 14 days. The risk of strangulation obstruction is reported to be extremely small, allowing prolonged conservative therapy in this group of patients. Late postoperative bowel obstruction most commonly occurs as a result of adhesions. Up to 90% of patients will develop adhesions postoperatively.23 However, a smaller percentage, approximately 3% to 30%, will develop a small bowel obstruction as a result of adhesions.22,24–28 Whereas significant research has been devoted to minimizing postoperative adhesions and subsequent bowel obstruction, reliable means for doing so have been elusive. Recently, adhesion-prevention products have proved successful in decreasing the risk of adhesive small bowel obstruction based on randomized, controlled trials.22
REFERENCES 1. Jex RK, van Heerden JA, Wolff BG, et al. Gastrointestinal anastomoses. Factors affecting early complications. Ann Surg 1987;206:138–141. 2. Carty NJ, Keating J, Campbell J, et al. Prospective audit of an extramucosal technique for intestinal anastomosis [see comment]. Br J Surg 1991;78:1439–1441. 3. Golub R, Golub RW, Cantu R Jr, Stein HD. A multivariate analysis of factors contributing to leakage of intestinal anastomoses. J Am Coll Surg 1997;184:364–372. 4. Max E, Sweeney WB, Bailey HR, et al. Results of 1,000 single-layer continuous polypropylene intestinal anastomoses. Am J Surg 1991;162:461–467. 5. Kaidar-Person O, Person B, Wexner SD. Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg 2005;201:759–773. 6. Hautmann RE, de Petriconi R, Gottfried HW, et al. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 1999;161: 422–427; discussion 427–428. 7. Pickleman J, Watson W, Cunningham J, et al. The failed gastrointestinal anastomosis: an inevitable catastrophe? J Am Coll Surg 1999;188:473–482. 8. Baker RS, Foote J, Kemmeter P, et al. The science of stapling and leaks. Obes Surg 2004;14:1290–1298. 9. Irvin TT, Goligher JC. Aetiology of disruption of intestinal anastomoses. Br J Surg 1973;60:461–464. 10. Pruett TL, Simmons RL. Failure of Gastrointestinal Anastomosis. Chicago: Year Book Medical, 1984. 11. Resegotti A, Astegiano M, Farina EC, et al. Side-to-side stapled anastomosis strongly reduces anastomotic leak rates in Crohn’s disease surgery. Dis Colon Rectum 2005;48:464–468. 12. Sax HC. Specific nutrients in intestinal failure: one size fits no one. Gastroenterology 2006;130(2 suppl 1): S91–S92. 13. Tappenden KA. Mechanisms of enteral nutrient–enhanced intestinal adaptation. Gastroenterology 2006;130(2 suppl 1):S93–S99. 14. Jeejeebhoy KN. Management of short bowel syndrome: avoidance of total parenteral nutrition. Gastroenterology 2006;130(2 suppl 1):S60–S66.
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15. Buchman AL. Etiology and initial management of short bowel syndrome. Gastroenterology 2006;130(2 Suppl 1): S5-S15. 16. Saclarides TJ. Current choices—good or bad—for the proactive management of postoperative ileus: a surgeon’s view. J Perianesth Nurs 2006;21(2A suppl):S7–S15. 17. Wolff BG, Michelassi F, Gerkin TM, et al. Alvimopan, a novel, peripherally acting mu opioid antagonist: results of a multicenter, randomized, double-blind, placebocontrolled, phase III trial of major abdominal surgery and postoperative ileus. Ann Surg 2004;240:728–734; discussion 734–735. 18. Vermeulen H, Storm-Versloot MN, Busch OR, Ubbink DT. Nasogastric intubation after abdominal surgery: a meta-analysis of recent literature. Arch Surg 2006;141: 307–314. 19. Behrns KE, Kircher AP, Galanko JA, et al. Prospective randomized trial of early initiation and hospital discharge on a liquid diet following elective intestinal surgery. J Gastrointest Surg 2000;4:217–221. 20. Sajja SB, Schein M. Early postoperative small bowel obstruction. Br J Surg 2004;91:683–691. 21. Stewart RM, Page CP, Brender J, et al. The incidence and risk of early postoperative small bowel obstruction. A cohort study. Am J Surg 1987;154:643–647. 22. Fazio VW, Cohen Z, Fleshman JW, et al. Reduction in adhesive small-bowel obstruction by Seprafilm adhesion
23.
24.
25.
26.
27.
28.
barrier after intestinal resection. Dis Colon Rectum 2006; 49:1–11. Menzies D, Ellis H. Intestinal obstruction from adhesions—how big is the problem? Ann R Coll Surg Engl 1990;72:60–63. Parker MC, Ellis H, Moran BJ, et al. Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum 2001;44: 822–829; discussion 829–830. Nieuwenhuijzen M, Reijnen MM, Kuijpers JH, van Goor H. Small bowel obstruction after total or subtotal colectomy: a 10-year retrospective review. Br J Surg 1998; 85:1242–1245. Ellis H, Moran BJ, Thompson JN, et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study.[see comment]. Lancet 1999; 353:1476–1480. Beck DE, Opelka FG, Bailey HR, et al. Incidence of small-bowel obstruction and adhesiolysis after open colorectal and general surgery [erratum appears in Dis Colon Rectum 1999;42:578]. Dis Colon Rectum 1999; 42:241–248. Matter I, Khalemsky L, Abrahamson J, et al. Does the index operation influence the course and outcome of adhesive intestinal obstruction? Eur J Surg 1997;163: 767–772.
22
Ileostomy James FitzGerald, MD INTRODUCTION Proper construction of an ileostomy is a fundamental and essential skill for all surgeons operating in the abdomen. It can be performed either as a separate operation or as a part of a larger procedure and can be created using a traditional open incision or laparoscopic techniques.1 Depending upon the indication, an ileostomy may be constructed in a variety of ways. Because both ends of the small bowel are accessible on the surface of the skin, loop ileostomies are generally easier to close and intended to be temporary stomas. However, a recent study of patients undergoing surgery for rectal cancer showed that approximately 19% of these “temporary” stomas will never be reversed.2 End ileostomies may be either permanent or temporary depending upon the remaining bowel anatomy, but generally require a laparotomy to restore bowel continuity. An “end-loop” ileostomy is generally used when there is difficulty reaching through the abdominal wall (Fig. 22–1). Ileostomies have a significant impact on the quality of life of patients, with up to 80% experiencing some change in their lifestyle after the creation of a stoma.3 The degree of social impact appears to be related to the number of stoma care problems.4 Regardless of the indication for the procedure or the technique used, surgeons must adhere to several basic principles in order to minimize postoperative stoma-related complications.
INDICATIONS ● After surgical resection of the colon and rectum ● Protection of a high-risk anastomosis ● Temporary fecal diversion for perineal infections
OPERATIVE STEPS Step Step Step Step Step
1 2 3 4 5
Site selection Selection and preparation of bowel segment Alignment of layers of abdominal wall Skin and subcutaneous tissue incision Anterior rectus sheath fascial incision
Step Step Step Step
6 7 8 9
Separation of rectus muscle fibers Posterior rectus sheath fascial incision Passing bowel through abdominal wall Placing the bridge and maturing the stoma
OPERATIVE PROCEDURE Site Selection Poorly Fitting or Leaking Stoma Appliance ● Consequence Breakdown of the skin surrounding the ileostomy. Approximately 28% of patients with an ileostomy would prefer the stoma to be relocated, and the percentage is higher in patients undergoing an emergency procedure (37%) than in those undergoing elective surgery (23%).3 Thirty percent to 61% of patients experience excoriation of the skin around the stoma, and 22% to 57% of patients experience leakage4–6 (Fig. 22–2). Grade 1 complication ● Repair Patient education and changing the type of appliance may be effective. In extreme cases, laparotomy with stoma relocation may be necessary. ● Prevention Ideally, the stoma should be placed through the rectus muscle centered on a flat area or on the crest of a fat roll away from scars, creases, or bony prominences. The site should be chosen prior to the operation after examining the patient in the supine and sitting positions. Marking the patient preoperatively in the proper site can significantly reduce skin problems in the immediate postoperative period.7
Selection of the Bowel Segment and Preparation of the Bowel High-Output Stoma ● Consequence Electrolyte imbalances or dehydration potentially leading to acute renal failure. A prospective analysis of
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A
Figure 22–1 An end-loop ileostomy. The mesentery to the bowel is not divided, enabling the bowel to be brought through a thick abdominal wall without the risk of ischemia. (Adapted from Wu JS. Ileostomy. Oper Tech Gen Surg 2003;5:257–263.)
60 patients undergoing restorative colectomy with a defunctioning ileostomy showed that ileostomy output peaked at postoperative day 4 and that the critical period for acute dehydration was from 3 to 8 days after the operation. During this time, ileostomy output is increasing, but oral intake is still limited.8 Overall, dehydration occurs in 5% to 20% of patients with ileostomies.6,9 Grade 1 complication ● Repair Replacement fluids should be given while monitoring standard parameters of resuscitation. Serum electrolytes should be checked and replaced as needed. Loperamide has been shown to decrease ileostomy output by 22%.10 Bismuth subgallate, lomotil, tincture of opium, and codeine sulfate have also been shown to reduce ileostomy output.11 ● Prevention During surgery, every effort should be made to preserve the distal small bowel and use the most distal portion of the small bowel for the ileostomy. Postoperatively, ileostomy output should be carefully measured and recorded. On discharge, patients should be instructed and taught to continue to track the stoma output.
B Figure 22–2 The site for this ileostomy was not marked prior to the operation. In the operating room, it looks to be in good position. However, postoperatively, when the patient is seated the ileostomy is low, making care difficult.
Stoma Retraction ● Consequence Leakage around the stoma, leading to peristomal skin irritation. Retraction of a loop ileostomy can result in incomplete defunctionalization of the distal bowel.6,12 Stoma retraction occurs in up to 17% of ileostomy patients followed for 20 years.13 Grade 3 complication
22 ILEOSTOMY
249
Figure 22–3 To determine the depth of ischemia or necrosis of a stoma, a test tube is gently inserted into the stoma opening. A penlight is used to help visualize the mucosa. If the ischemia extends below the fascial level, an urgent laparotomy is required.
● Repair Stoma revision may be accomplished by a local procedure at the ileostomy site, but the majority of cases will require a laparotomy. ● Prevention Stoma retraction is caused by tension on the bowel or loss of the distal stoma from necrosis. Retraction often is associated with a high body mass index.14 In obese patients, an end-loop ileostomy should be considered. Some data indicate a higher rate of retraction in contaminated stoma cases, although this is not specific for ileostomies.15
Necrotic/Ischemic Stoma ● Consequence Superficial necrosis of the stoma, resulting in stenosis or retraction of the stoma. If the ischemic segment extends below the fascia, peritonitis can result. A simple bedside test can be performed to assess the depth of necrosis (Fig. 22–3). Grade 2/3 complication ● Repair Superficial necrosis can be observed. If it results in stenosis or difficulty fitting the appliance, the stoma will need to be revised. If the ischemic segment extends below the fascia, an emergent laparotomy is required. ● Prevention Mesenteric tension or excessive trimming of the mesentery may result in an ischemic stoma. The last vascular arcade of the small bowel mesentery should be preserved. Again, consideration should be given to constructing an end-loop ileostomy, especially in obese patients.
Figure 22–4 Ischemia at the distal end of the ileostomy or tension on the mesentery of the bowel can lead to stenosis. This will make it difficult for the patient to properly fit the appliance.
Stoma Stenosis ● Consequence Difficulty fitting the appliance, stoma leakage, and noise while passing flatus (Fig. 22–4). Grade 2/3 complication ● Repair If the stenosis is at the skin level, local repair is possible. In cases resulting from ischemia or Crohn’s disease, a formal laparotomy is usually required. ● Prevention Stenosis is believed to be secondary to ischemia of the distal bowel or to result from tension at the mesentery. See comments for “Prevention” in the section on “Necrotic/Ischemic Stoma,” earlier.
Skin and Subcutaneous Tissue Incision Mucocutaneous Separation ● Consequence Difficulty fitting the appliance, leading to breakdown of the skin around the stoma. Grade 2/3 complication ● Repair Local revision is possible in simple cases. V-Y flaps have been used to decrease the size of the incision.16 In extreme cases, laparotomy and resitting of the stoma may be necessary. ● Prevention Proper assessment of the diameter of the bowel to be used for the stoma. It is generally advisable to start small and increase the size as needed.
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Alignment of the Layers of the Abdominal Wall and Incision of the Anterior Rectus Fascia Peristomal Hernia ● Consequence Difficulty fitting the appliance, bowel obstruction, and strangulation leading to bowel ischemia. Loop ileostomies are associated with a 1% to 3% incidence of peristomal hernia. For end ileostomies, the rate is between 6% and 7%. The cumulative probability after 20 years of developing a peristomal hernia is 16% (Figs. 22–5 and 22–6). Grade 3 complication ● Repair Local tissue repairs overall have poor results, with recurrence rates ranging from 40% to 100%. Stoma relocation fares slightly better, with recurrence rates ranging from 0% to 76%. Mesh repairs have the lowest reported recurrence rate (0%–33%), but carry the risk of infection in a contaminated field.17 ● Prevention The fascial incision should be just large enough to allow passage of the limb of bowel, generally 2.5 cm. Whereas it is generally believed that placing the stoma through the rectus muscle reduces the incidence of a peristomal hernia, the data are mixed18,19 (Fig. 22–7).
Stoma Prolapse ● Consequence Difficulty fitting the appliance and irritation of the bowel. In extreme cases, incarceration of the prolapsed
bowel may occur, leading to strangulation. The cumulative risk of prolapse over a 20-year period is approximately 11%.13 Grade 2/3 complication ● Repair Local revision of the stoma with excision of the prolapsed bowel is generally required. In cases of incarceration, application of sugar on the edematous bowel will act as an osmotic agent and may reduce the bowel. Strangulated bowel requires an emergent laparotomy and stoma revision. ● Prevention See comments for “Prevention,” in the section on “Parastomal Hernia,” previously.
Separation of the Rectus Fibers Injury to the Inferior Epigastric Vessels ● Consequence Excessive bleeding. Grade 1 complication ● Repair Ligation of the vessel. ● Prevention Careful separation of the rectus fibers by spreading in a longitudinal direction may reduce the risk of injury to this vessel (Figs. 22–8 and 22–9).
Incision of the Posterior Rectus Fascia and Peritoneum Parastomal Hernia and Prolapse See the section on “Alignment of the Layers of the Abdominal Wall and Incision of the Anterior Rectus Fascia,” earlier.
Injury to the Underlying Bowel ● Consequence Enterotomy, possible peritonitis postoperatively if not identified at the time of injury. Grade 2/3 complication ● Repair Primary repair or resection as required. Figure 22–5 Although there are no specific data regarding the exact size of the stoma opening, either too large or too small an opening can lead to complications. In general, the stoma incision should be two fingerbreadths for a loop ileostomy and slightly smaller for an end ileostomy.
● Prevention The assistant should place a laparotomy pad under the peritoneum and lift up the undersurface of the abdominal wall (Fig. 22–10).
22 ILEOSTOMY Lateral edge of rectus muscle
251
Medial edge of rectus muscle Fascial edge
Skin
A Stoma opening
Skin Fat
Clamps
Ructus muscle
B
Fascia
Figure 22–6 Hidden anatomy. A, In patients with thick abdominal walls, the fascia tends to retract laterally relative to the midline skin incision. If proper alignment is not restored, the stoma opening will be made tangential to the muscular wall of the abdomen. The opening in the fascia for the stoma will be too close to the midline incision. This can lead to difficulty closing the midline incision and could result in kinking of the bowel as it traverses the abdominal wall. B, By placing a clamp on the fascia and on the dermal layer of the midline incision, proper alignment can be restored.
Passing the Bowel through the Stoma Opening
pressure should be exerted from the abdominal side to deliver the bowel segment onto the skin surface.
Tearing the Bowel ● Consequence Enterotomy, contamination of field, and possibly peritonitis if not identified at the time of injury. Grade 2/3 complication ● Repair Use the enterotomy site as the stoma opening if possible; otherwise, primary repair or resection is required. ● Prevention The bowel should be guided through the abdominal wall from the skin side, but not pulled. Rather, gentle
Twisting of the Bowel ● Consequence Bowel obstruction, ischemia, and maturing wrong end of a loop ileostomy. Grade 2/3 complication ● Repair Rotate bowel for proper alignment if noted intraoperatively; otherwise reoperation is required. ● Prevention For an end ileostomy, following the divided mesentery of the right colon up to the underside of the
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Figure 22–9 A clamp is passed through the stoma opening. When the surgeon grasps the tip of the clamp, the abdominal wall can be closely inspected for signs of bleeding. The inferior epigastric artery lies just below the rectus muscle.
Figure 22–7 At the base of this stoma incision, the fibers of the external oblique muscles can be visualized. Most surgeons believe that placing a stoma in this location increases the possibility of hernia formation.
Figure 22–8 To reduce the chance of injury to the inferior epigastric vessel, the rectus muscle should be separated in the direction of its fibers. (Adapted from Wu JS. Ileostomy. Oper Tech Gen Surg 2003;5:257–263.)
Figure 22–10 Proper alignment of the skin and fascial layers is crucial to ensure that the bowel passes perpendicular to the abdominal wall. A Kocher clamp is placed on the rectus fascia and a second on the dermal layer. A folded lap pad is placed under the stoma site. The assistant holds the two clamps and presses up on the underside of the abdominal wall.
22 ILEOSTOMY
Figure 22–11 Once the bowel has been passed through the abdominal wall, it is essential to be certain that it is not rotated. Placing a seromuscular suture through one side of a loop ileostomy can help maintain proper orientation.
abdominal wall will ensure proper alignment. For a loop ileostomy, marking one side with a seromuscular suture is helpful, but careful attention to detail is essential (Fig. 22–11).
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Figure 22–12 Skin implants at the mucocutaneous junction are the result of passing a suture through the epidermal skin layer. Ideally, the suture should be placed at the dermal level. (Reprinted with permission from Wu JS. Ileostomy. Oper Tech Gen Surg 2003;5:257–263.)
Placing the Bridge and Maturing the Stoma Enterocutaneous Fistula ● Consequence Poor-fitting appliance and peristomal irritation. Fistulas develop in 7% to 11% of ileostomy patients with Crohn’s disease.20 Grade 2/3 complication ● Repair Simple fistulas may be amenable to local revision of the stoma. In patients with Crohn’s disease, laparotomy with resection of the distal bowel and peristomal skin and revision of the stoma are frequently required.21 ● Prevention Fistulas arise either from a technical error maturing the ileostomy, Crohn’s disease, or pressure necrosis from the appliance on the side of the ileostomy (Fig. 22–12). When the end of the ileostomy is being everted, the first bite should be full thickness through the distal cut edge of the bowel. The second should be a seromuscular bite approximately 5 cm proximal to the cut edge. A full-thickness bite at this level has the potential to develop into a fistula. Finally, the last bite should be of the dermis at the edge of the ileostomy incision. Placing the suture full thickness through the skin can lead to mucosal implants around the stoma (Fig. 22–13). Care should be taken to avoid pressure from the stoma wafer on the ileostomy.
Figure 22–13 The appliance has irritated the side of the ileostomy. If this is not corrected, it can result in fistula formation.
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Other Complications Diversion Colitis Grade 1 complication Segments of the colon excluded from the fecal stream can develop inflammatory changes. Up to 50% of patients experience symptoms, commonly mucous discharge, abdominal pain, or low-grade fevers. The endoscopic appearance of the diverted segment can be normal or inflamed. Diversion colitis is believed to be caused by the absence of luminal short chain fatty acids, which are used as an energy source for colonic mucosal cells. Symptoms generally resolve with closure of the ileostomy.22 In cases in which this is not possible, short chain fatty acid enemas may be useful.23,24 Pyoderma Gangrenosum Grade 1 complication Pyoderma gangrenosum is a chronic, painful ulceration of the skin associated with inflammatory bowel disease. Although it usually affects the lower extremity, several cases of peristomal pyoderma gangrenosum have been described. The painful ulcerations around the stoma create difficulty fitting the appliance. Meticulous care of the stoma is essential. Injection of corticosteroids, infliximab, antibiotics, and systemic steroids have all been tried with limited success.25 Carcinoma Grade 3/4/5 complication Forty-four cases of primary adenocarcinoma of an ileostomy have been reported in the literature. The average time from creation of the ileostomy to appearance of the adenocarcinoma is 24 years. The pathologic features suggest a transition from ileal mucosa to colonic mucosa to colonic dysplasia to adenocarcinoma. Chronic irritation of the stoma may predispose the ileal mucosa to these changes. Patients with ileostomies older than 15 years should be followed closely for this complication.26 Stomal excision is advised for any dysplastic changes, and segmental excision is recommended for adenocarcinoma.27 Stomal Varices Grade 3/4/5 complication Patients with portal hypertension may develop varices at the mucocutaneous junction. Local control measures and revision of the mucocutaneous junction may provide local control. Portal decompression or liver transplantation offers a more permanent solution.28
3. 4.
5.
6. 7.
8. 9.
10.
11. 12.
13.
14.
15.
16.
17. 18.
19.
20. 21.
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with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol 2007;8:278–279. Nugent KP, Daniels P, Stewart B, et al. Quality of life in stoma patients. Dis Colon Rectum 1999;42:1569–1574. Gooszen AW, Gelkerken RH, Hermans J, et al. Quality of life with a temporary stoma: ileostomy vs. colostomy. Dis Colon Rectum 2000;43:650–655. Robertson I, Leung E, Hughes D, et al. Prospective analysis of stoma-related complications. Colorectal Dis 2005;7:279–285. Feinberg SM, McLeod RS, Cohen Z. Complications of loop ileostomy. Am J Surg 1987;153:102–107. Bass EM, Del Pino A, Tan A, et al. Does preoperative stoma marking and education by the enterostomal therapist affect outcome? Dis Colon Rectum 1997;40: 440–442. Tang CL, Yunos A, Leong APK, et al. Ileostomy output in the early postoperative period. Br J Surg 1995;82:607. Wexner SD, Taranow DA, Johansen OB, et al. Loop ileostomy is a safe option for fecal diversion. Dis Colon Rectum 1993;36:349–354. Tytgat GN, Huibregtse K, Meuwissen SG. Loperamide in chronic diarrhea and after ileostomy: a placebo-controlled double-blind cross-over study. Arch Chir Neerl 1976;28: 13–20. Kramer P. Effect of antidiarrheal and antimotility drugs on ileal excreta. Am J Dig Dis 1977;22:327–332. Winslet MC, Drolc Z, Allan A, Keighley MRB. Assessment of the defunctioning efficiency of the loop ileostomy. Dis Colon Rectum 1991;34:699–703. Leong APK, Londono-Schimmer EE, Phillips RKS. Lifetable analysis of stomal complications following ileostomy. Br J Surg 1994;81:727–729. Arumugam PJ, Bevan L, Macdonald L, et al. A prospective audit of stomas—analysis of risk factors and complications and their management. Colorectal Dis 2003;5:49– 52. Leenen LPH, Kuypers JHC. Some factors influencing the outcome of stoma surgery. Dis Colon Rectum 1989;32: 500–504. Edington HD, Lorze MT. V-Y closure for abdominal wall stomal reduction. Surg Gynecol Obstet 1987;164:381– 382. Carne PWG, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg 2003;90:784–793. Sjodahl R, Anderberg B, Bolin T. Parastomal hernia in relation to site of the abdominal stoma. Br J Surg 1988; 75:339–340. Williams JG, Etherington R, Hayward MWJ, Hughes LE. Paraileostomy hernia: a clinical and radiological study. Br J Surg 1990;77:135–137. Shellito PC. Complications of abdominal stoma surgery. Dis Colon Rectum 1998;41:1562–1572. Greenstein AJ, Dicker A, Meyers S, Aufses AH. Periileostomy fistulae in Crohn’s disease. Ann Surg 1983;197:179– 182. Giardiello FM, Lazenby AJ. The atypical colitides. Gastroenterol Clin North Am 1999;28:479–490. Harig JM, Soergel KH, Komorowski RA, et al. Treatment of diversion colitis with short chain fatty acids irrigation. N Engl J Med 1989;320:23–28.
22 ILEOSTOMY 24. Kiely EM, Ajayi NA, Wheeler RA, Malone M. Diversion procto-colitis: response to treatment with short-chain fatty acids. J Pediatr Surg 2001;36:1514–1517. 25. Kiran RP, O’Brien-Ermlich B, Achkar JP, et al. Management of peristomal pyoderma gangrenosum. Dis Colon Rectum 2005;48:1397–1403. 26. Quah HM, Samad A, Maw A. Ileostoma carcinomas a review: the latent risk after colectomy for ulcerative colitis and familial adenomatous polyposis. Colorectal Dis 2005; 7:538–544.
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27. Gadacz TR, McFadden DW, Gabrielson EW, et al. Adenocarcinoma of the ileostomy: the latent risk of cancer after colectomy for ulcerative colitis and familial polyposis. Surgery 1990;107:698–703. 28. Roberts PL, Martin FM, Schoetz DJ, et al. Bleeding stomal varices: the role of local treatment. Dis Colon Rectum 1990;33:547–549.
COLON, RECTUM AND ANUS Eugene F. Foley, MD 23
Right Colectomy: Open and Laparoscopic David W. Larson, MD INTRODUCTION The operative choices available for right colectomy expanded in May of 2004. With the publication of Clinical Outcomes Surgical Therapy (COST),1 laparoscopic or minimally invasive surgery (MIS) for the treatment of malignant disease had the evidence needed to ethically offer it to patients with cancer. Since the early 1990s, laparoscopic colectomy for benign and, more importantly, malignant disease suffered from poor adoption. The reasons for this are many, including technical difficulty, poor instrumentation, and concerns over the oncologic impact of laparoscopic surgery. These important factors and concerns crystallized the importance of open right colectomy as the standard by which MIS is judged. Despite the slow growth of MIS, the evidence supplied by trials like COST, Conventional vs. Laparoscopic Assisted Surgery in Colorectal Cancer (CLASICC), and Colon Cancer Laparoscopic or Open Resection (COLOR)1–3 have allowed for the dramatic increase in the use of this technique. Right colectomy remains a classic and standard operation that results in outstanding outcomes with relatively few lasting complications. However, even well-known and successful operations have pitfalls. These potential problems can be avoided by careful planning and meticulous technique. The best data to date would suggest that morbidity associated with this procedure is around 20% with 2% to 4% of these occurring intraoperatively.1,3 Most complications from this operation involve two areas: those common to all operations of the right colon and those important to cancer specifically. The complications common to all operations of the right colon include trocar complications ( 20%) because the amount of time required for adequate compensatory hypertrophy of the anticipated remnant liver would be excessive in light of the relative urgency of proceeding from an oncologic perspective. The use of portal venous embolization combined with preoperative biliary drainage in patients with obstructive jaundice has been shown to expand the surgical options for patients needing extensive hepatic resection. In a retrospective study of 79 patients undergoing major hepatic resection for hilar cholangiocarcinoma, preoperative biliary drainage was performed in 65 patients who had obstructive jaundice and in 41 of 51 patients undergoing extended right hepatectomy. The in-hospital mortality rate for the patients in this series was only 1.3%, and the incidence of postoperative hepatic failure was zero.67 The combination of portal venous embolization and preoperative biliary drainage for patients with obstructive jaundice has enabled the safe performance of trisectionectomy with minimal postoperative mortality and hepatic failure in other recent series as well and should, therefore, be considered in any patient needing major hepatic resection who has preoperative evidence of obstructive jaundice and borderline hepatic function.6
REFERENCES 1. Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative outcomes after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 2002;236:397–407. 2. Melendez J, Ferri E, Zwillman M, et al. Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality. J Am Coll Surg 2001;192:47– 53. 3. Nishio H, Hidalgo E, Hamady Z, et al. Left hepatic trisectionectomy for hepatobiliary malignancy: results and an appraisal of its current role. Ann Surg 2005;242:267– 275. 4. Seyama Y, Kubota K, Sano K, et al. Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate. Ann Surg 2003; 238:73–83. 5. Rui JA, Wang SB, Chen SG, Zhou L. Right trisectionectomy for primary liver cancer. World J Gastroenterol 2003;9:706–709.
6. Fong Y, Blumgart LH. Hepatic resection. In ACS Surgery: Principles and Practice. Available at http://www. acssurgery.com (accessed May 10, 2006). 7. Pinson CW, Drougas JG, Lalikos JL. Optimal exposure for hepatobiliary operations using the Bookwalter self-retaining retractor. Ann Surg 1995;61:178– 181. 8. Nagano Y, Togo S, Tanaka K, et al. The role of median sternotomy in resection for large hepatocellular carcinomas. Surgery 2005;137:104–108. 9. Tanaka S, Kubo S, Tsukamoto T, et al. Risk factors for intractable pleural effusion after liver resection. Osaka City Med J 2004;50:9–18. 10. Kwon AH, Matsui Y, Satoi S, et al. Prevention of pleural effusion following hepatectomy using argon beam coagulation. Br J Surg 2003;90:302–305. 11. Yan JJ, Zhang XH, Chu KJ, et al. Preservation and management of pleural effusions following hepatectomy in primary liver cancer. Hepatobiliary Pancreat Dis Int 2005; 4:375–378. 12. Nanashima A, Yamaguchi H, Shibasaki S, et al. Comparative analysis of postoperative morbidity according to type and extent of hepatectomy. Hepatogastroenterology 2005; 52:844–848. 13. Matsumata T, Kanematsu T, Okudaira Y, et al. Postoperative mechanical ventilation preventing the occurrence of pleural effusion after hepatectomy. Surgery 1987;102:493–497. 14. Uetsuji S, Komada Y, Kwon AH, et al. Prevention of pleural effusion after hepatectomy using fibrin sealant. Int Surg 1994;79:135–137. 15. Kise Y, Takayama T, Yamamoto J, et al. Comparison between thoracoabdominal and abdominal approaches in occurrence of pleural effusion after liver cancer surgery. Hepatogastroenterol 1997;44:1397–1400. 16. Tanabe G, Kawaida K, Hamanoue M, et al. Treatment for accidental occlusion of the hepatic artery after hepatic resection: report of two cases. Surg Today 1999;29:268– 272. 17. Shimada H, Endo I, Sugita M, et al. Hepatic resection combined with portal vein or hepatic artery reconstruction for advanced carcinoma of the hilar bile duct and gallbladder. World J Surg 2003;27:1137–1142. 18. Iseki J, Tamaki N, Touyama K, et al. Mesenteric arterioportal shunt after interruption. Surg Today 1998;123:58– 66. 19. Sahani D, Mehta A, Blake M, et al. Preoperative hepatic vascular evaluation with CT and MR angiography: implications for surgery. RadioGraphics 2004;24:1367– 1380. 20. Skandalakis JE, Skandalakis LJ, Skandalakis PN, Mirilas P. Hepatic surgical anatomy. Surg Clin North Am 2004;84: 413–435. 21. Imamura H, Makuuchi M, Sakamoto Y, et al. Anatomical keys and pitfalls in living donor liver transplantation. J Hepatobiliary Pancreat Surg 2000;7:380–394. 22. Machado MA, Herman P, Makdissi FF, et al. Anatomic left hepatic trisegmentectomy. Am J Surg 2005;190:114– 117. 23. Makuuchi M, Yamamoto J, Takayama T, et al. Extrahepatic division of the right hepatic vein in hepatectomy. Hepatogastroenterology 1991;38:176–179.
33 TRISECTIONECTOMY 24. Smyrniotis V, Farantos C, Kostopanagiotu G, Arkadopoulos N. Vascular control during hepatectomy: review of methods and results. World J Surg 2005;29:1384–1396. 25. Gozzetti G, Mazziotti A, Grazi GL, et al. Liver resection without blood transfusion. Br J Surg 1995;82:1105–1110. 26. Belghiti J, Hiramatsu K, Benoist S, et al. Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection. J Am Coll Surg 2000;191:38–46. 27. Kooby DA, Stockman J, Ben-Porat L, et al. Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg 2003;237:860–870. 28. Matsumata T, Yanaga K, Shimada M, et al. Occurrence of intraperitoneal septic complications after hepatic resection between 1985 and 1990. Surg Today 1995;25:49–54. 29. Poon RT, Fan ST, Irene OL, Wong J. Significance of resection margin in hepatectomy for hepatocellular carcinomas: a critical reappraisal. Ann Surg 2000;231:544– 551. 30. Pringle JH. Notes on the arrest of hepatic haemorrhage due to trauma. Ann Surg 1909;48:541–549. 31. Abdalla EK, Noun R, Belghiti J. Hepatic vascular occlusion: which technique? Surg Clin North Am 2004;84: 563–585. 32. Huguet C, Gavelli A, Chieco PA, et al. Liver ischemia for hepatic resection: where is the limit? Surgery 1992;111: 251–259. 33. Elias D, Desruennes E, Lasser P. Prolonged intermittent clamping of the portal triad during hepatectomy. Br J Surg 1991;78:42–44. 34. Clavien PA, Yadav S, Sindram D, Bentley RC. Protective effects of ischemic preconditioning for liver resection performed under inflow occlusion in humans. Ann Surg 2000;232:155–162. 35. Belghiti J, Noun R, Zante E, et al. Portal triad clamping or hepatic vascular exclusion for major liver resection: a controlled study. Ann Surg 1996;224:155–161. 36. Makuuchi M, Mori T, Gunven P, et al. Safety of hemihepatic vascular occlusion during resection of the liver. Surg Gynecol Obstet 1987;164:155–158. 37. Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg 1998;85:1058–1060. 38. Chen H, Merchant NB, Didolkar MS. Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anesthesia improves morbidity and mortality. J Gastrointest Surg 2000;4:162–167. 39. Lesurtel M, Selzner M, Petrowsky H, et al. How should transection be performed?: a prospective randomized study in 100 consecutive patients comparing four different transection strategies. Ann Surg 2005;242:814–823. 40. Takayama T, Makuuchi M, Kubota K, et al. Randomized comparison of ultrasonic versus clamp transection of the liver. Arch Surg 2001;136:922–928. 41. Ray HG, Wichmann MW, Schinkel S, et al. Surgical techniques in hepatic resections: ultrasonic aspirator versus Jet-Cutter. A prospective randomized clinical trial. Zentralbl Chir 2001;126:586–590. 42. Reed DN, Vitale GC, Wrightson WR, et al. Decreasing mortality of bile leaks after elective hepatic surgery. Am J Surg 2003;185:316–318.
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43. Lo CM, Fan ST, Liu CL, et al. Biliary complications after hepatic resection: risk factors, management, and outcome. Arch Surg 1998;133:156–161. 44. Yanaga K, Kanematsu T, Takenaka K, Sugimachi K. Intraperitoneal septic complications after hepatectomy. Ann Surg 1986;203:148–152. 45. Yamashita Y, Hamatsu T, Rikimaru T, et al. Bile leakage after hepatic resection. Ann Surg 2001;233:45–50. 46. Bhattacharyja S, Puleston J, Davidson B. Hepatic resection: early endoscopic drainage in bile leak management. Gastrointest Endosc 2003;57:526–530. 47. Tanaka S, Hirohashi K, Tanaka H, et al. Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors. J Am Coll Surg 2002;195:484– 489. 48. Kyokane T, Nagino M, Sano T, Nimura Y. Ethanol ablation for segmental bile duct leakage after hepatobiliary resection. Surgery 2002;131:111–113. 49. Lam CM, Lo CM, Liu CL, Fan ST. Biliary complications during liver resection. World J Surg 2001;25:1273–1276. 50. Ijichi M, Takayama T, Toyoda H, et al. Randomized trial of usefulness of bile leakage test during hepatic resection. Arch Surg 2000;135:1395–1400. 51. Kraus TW, Mehrabi A, Schemmer P, et al. Scientific evidence for application of topical hemostats, tissue glues, and sealants in hepatobiliary surgery. J Am Coll Surg 2005;200:418–427. 52. Eder F, Meyer F, Nestler G, et al. Sealing of the hepatic resection area using fibrin glue reduces significant amount of postoperative drain fluid. World J Gastroenterol 2005; 11:5984–5987. 53. Kohno H, Nagasue N, Chang Y, et al. Comparison of topical hemostatic agent in elective hepatic resection: a clinical prospective randomized trial. World J Surg 1992; 16:966–970. 54. Imamura H, Seyama Y, Kokudo N, et al. One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg 2003;138:1198–1206. 55. Nagino M, Kamiya J, Uesaka K, et al. Complications of hepatectomy for hilar cholangiocarcinoma. World J Surg 2001;25:1277–1283. 56. Povoski SP, Fong Y, Blumgart LH. Extended left hepatectomy. World J Surg 1999;23:1289–1293. 57. Stone MD, Benotti PN. Liver resection: preoperative and postoperative care. Surg Clin North Am 1989;69:383– 391. 58. Mullin EJ, Metcalfe MS, Maddern GJ. How much liver resection is too much? Am J Surg 2005;120:87–97. 59. Lau H, Man K, Fan ST, et al. Evaluation of preoperative hepatic function in patients with hepatocellular carcinoma undergoing hepatectomy. Br J Surg 1997;84:1255– 1259. 60. Fan ST, Lai EC, Lo CM, et al. Hospital mortality of major hepatectomy for hepatocellular carcinoma associated with cirrhosis. Arch Surg 1995;130:198–203. 61. Kubota K, Makuuchi M, Kusaka K, et al. Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology 1997;26:1176–1181. 62. Ercolani G, Grazi GL, Calliva R, et al. The lidocaine (MEGX) test as an index of hepatic function: its clinical usefulness in liver surgery. Surgery 2000;127:464–471.
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63. Huang YS, Chiang JH, Wu JC, et al. Risk of hepatic failure after transcatheter arterial chemoembolization for hepatocellular carcinoma: predictive value of monoethylglycineexylidide test. Am J Gastroenterol 2002;97:1223– 1227. 64. Shoup M, Gonen M, D’Angelica M, et al. Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection. J Gastrointest Surg 2003;7:325– 330. 65. Makucchi M, Thai BL, Takayasu K, et al. Preop portal embolization to increase safety of major hepatectomy for
hilar bile duct carcinoma: a preliminary report. Surgery 1990;107:521–527. 66. Takayama T, Makuuchi M. Preoperative portal vein embolization: is it useful? J Hepatobiliary Surg 2004;11: 17–20. 67. Kawasaki S, Imamura H, Kobayashi A, et al. Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization. Ann Surg 2003;238:84–92.
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Laparoscopic Liver Resection Amit D. Tevar, MD, Mark J. Thomas, MD, and Joseph F. Buell, MD INTRODUCTION The rapid evolution of technology and experience with laparoscopic surgery has led to the feasibility of safe minimally invasive hepatic resection. The first laparoscopic liver resection was reported by Gagner and coworkers in 1992.1 Ferzli and colleagues2 subsequently reported an additional hepatic resection in 1995. Azagra and associates3 were the first to perform a segmental resection, describing a left lateral segmentectomy in 1996. Since these initial reports, multiple institutional series and a few multicenter groups have reported segmental and nonsegmental resection for benign and malignant disease.4–24 The application of laparoscopic techniques for liver resection has demonstrated equivalent morbidity and mortality rates to those of open techniques. In addition, the laparoscopic approach has resulted in decreased blood loss, shorter postoperative stay, and reduced postoperative analgesic requirement for pain.18,25,26 Although technologic advancement and surgeon experience have rapidly advanced the extent and safety of laparoscopic liver resection, concern remains regarding the oncologic integrity of laparoscopic resection for malignant disease and of multiple potential complications. These complications include those that are possible with any liver resection—including functional synthetic reserve in a cirrhotic liver, tumor recurrence, bleeding, biliary leak—and those that are unique to laparoscopic liver resection, such as CO2 embolism and port site metastasis.
INDICATIONS The indications for laparoscopic liver resection are similar to those for open procedure in regard to patient and lesion characteristics. No liver resection should be performed using a laparoscopic technique that would not be indicated using an open technique. Special consideration should be given to preoperative imaging and the proximity of the lesions with the hepatic vein confluence and the portal bifurcation. The most common benign lesions and
indications that would be considered for liver resection include ● Hemangioma ● Severe symptoms ● Hemorrhage ● Focal nodular hyperplasia ● Severe symptoms ● Growth on serial imaging ● Uncertain diagnosis ● Liver cell adenoma ● Simple liver cysts ● Severe symptoms The most common malignant lesions that would be considered for liver section include ● Hepatocellular carcinoma ● Noncirrhotic patients ● Child’s A cirrhotic patients with lesion smaller than
5 cm ● Metastatic colon adenocarcinoma ● Metastatic lesions noncolonic ● Include gastrointestinal stromal tumor (GIST),
melanoma, renal cell carcinoma, and others, only if no extrahepatic metastatic lesions and primary has been controlled
OPERATIVE STEPS Step Step Step Step Step Step
1 2 3 4 5 6
Patient positioning Port placement Liver mobilization Laparoscopic intraoperative hepatic ultrasound Parenchymal division Closure
OPERATIVE PROCEDURE Patient Positioning Patient positioning is paramount to a successful laparoscopic liver resection. Left lateral, left median segment,
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12 mm 5 mm lap disk
Surgeon
12 mm
First assistant
Figure 34–1 Surgeon, laparoscopic and hand port placement for left hepatic laparoscopic resection.
Figure 34–2 Operative table in full flexion for decubitus positioning of patients for right sided laparoscopic liver resection.
and caudate lesions are best performed with the patient in a supine position with the arms out6,7 (Fig. 34–1). This allows for uncomplicated and safe division of the left triangular and coronary, falciform, and gastrohepatic ligaments. Lesions involving the right lobe (segments 5, 6, 7, and 8) are best laparoscopically approached with the patient in a left decubitus position with the operative bed in full flexion (Fig. 34–2).
Port Placement All laparoscopic liver resections at the University of Cincinnati are performed with a hand-assist device (Lap-Disc; Ethicon, Cincinnati, OH) in combination with low-profile balloon ports. The hand-assist technique allows for tactile feedback, which is an important tool in the armamentarium for obtaining adequate margins in the malignant hepatic resection (Fig. 34–3). The hand-assist also allows for
Figure 34–3 Laparoscopic hand port placement.
digital compression of parenchymal or vascular bleeding, preventing unnecessary blood loss or CO2 air embolism. As with any laparoscopic surgery, appropriate port and surgeon placement greatly facilitates the operative technique, allowing for a safer and shorter case. The primary surgeon leads the case by placement of his or her hand in the hand port. In the case of left-sided lesions, the primary surgeon resides on the patient’s right side in order to place his or her right hand intracorporeally through a hand port placed on the right to guide mobilization and parenchymal division. Resection of the right lobe of the liver involves the primary surgeon on the patient’s left side with his or her assistant directly opposite. The primary surgeon’s left hand is placed through a right-sided hand port to facilitate dissection, mobilization, and resection. Some groups have placed the hand port in the midline with success. The low-profile balloon port is used, and the initial port is placed using an open Hasson technique. In the cirrhotic patient, the initial 12-mm balloon port is placed infraumbilically in order to avoid the large recannulized umbilical vein circuit. If a varix is encountered, hemostasis should be obtained with direct suture ligation. In the noncirrhotic patient, the initial port is placed supraumbilically, again using an open technique. The remaining ports are placed under direct visualization after pneumoperitoneum is obtained. Right-sided lesions require placement of two additional subcostal 12-mm ports. These should be placed under direct visualization, and great care should be taken to avoid cephalad or caudal placement of these ports. Working ports placed too high will result in difficulty opening the jaws of a laparoscopic vascular staple owing to the proximity to the liver. Working ports placed too low will lead to inability of instrument to reach the right and middle hepatic veins. The hand port is placed in the right upper quadrant, just above and lateral to the supraumbilical port. It is recommended that the hand port be placed more cephalad for right-sided lesions to allow for hand retraction of the liver for dissection of the hepatic veins and the bare area. Left-sided lesions require two
34 LAPAROSCOPIC LIVER RESECTION
12 mm lap disk
First assistant
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● Prevention All patients with end-stage liver disease should be identified preoperatively by laboratory values. Even with normal liver function tests and coagulation studies and no evidence of ascites or encephalopathy, all patients should be carefully examined after general anesthesia is obtained for evidence of a caput medusae. The presence of other physical examination findings classically seen in portal hypertension suggest that periumbilical varices may have developed, even if they are not readily visible on visual examination. Port placement for patients with end-stage liver disease should begin with an infraumbilical 12-mm port using an open Hasson technique. This generally will avoid disruption of any periumbilical varices.
12 mm
12 mm
Surgeon
Figure 34–4 Surgeon, laparoscopic and hand port placement for right hepatic laparoscopic resection.
additional left subcostal ports, placed in a similar fashion. Our group routinely places the hand port in the right side for left-sided resections, and it may be placed more caudally than for right-sided lesions (Fig. 34–4).
Trocar Insertion Hollow Viscus Injury This is an unnecessary complication that deserves special consideration because the patient population undergoing laparoscopic liver resection has often undergone previous surgery or may have end-stage liver disease. The standard trocar insertion is described previously, and the initial port should be placed using an open technique. See Section I, Chapter 7, Laparoscopic Surgery. Trocar Insertion Bleeding The patient population undergoing laparoscopic liver surgery often has end-stage liver failure with impressive superficial periumbilical vein circuits originating from a recannulized umbilical vein. ● Consequence Variceal bleeding can be somewhat problematic because of the large-volume, low-pressure, and thin-walled veins. In addition, the variceal veins will often retract into the subcutaneous fat and, when working through a small 12-mm port skin incision, a significant volume of blood may be lost before the vein is visualized. ● Repair Direct digital pressure should be applied to the area in order to minimize a potentially large volume of blood loss. Blind electrocautery into the area of the bleeding is usually ineffective. Visualization is key in controlling this bleeding. Retraction with Army-Navy retractors or extension of the skin incision may facilitate this. Identification and direct ligation of both ends of the varix with suture is the appropriate way to treat this bleeding.
Liver Mobilization Mobilization is performed in a manner similar to that of the traditional open technique. The left lobe is mobilized by having the primary surgeon retract the left lateral segment in an inferior and posterior position. The laparoscopic ultrasonic cutting and coagulation device (Harmonic Scalpel; Ethicon Endo-Surgery, Inc.) is then used to divide the coronary and triangular ligament. The dissection is taken to circumferentially clear the left and middle hepatic veins. Great care should be taken at this time to avoid injury to the phrenic vein. Injury to this should be managed with digital compression and clip or ultrasonic ligation. The left lateral segment is now retracted in an anterior fashion, and the gastrohepatic ligament is divided with the ultrasonic shears. In case an accessory left hepatic artery is encountered, it should be divided using the ultrasonic shears or ligated with clips and divided. After complete mobilization of the left lateral segment, the caudate lobe can also be mobilized for resection. The peritoneum overlying the inferior vena cava is first divided with the ultrasonic shears. The posterior aspect of the left hepatic vein is then fully mobilized, followed by the superior aspect of the caudate lobe. Once the small caudate veins are ligated and divided, the main caudate vein is circumferentially dissected and can be taken with a reloadable laparoscopic articulating vascular stapler (Endo GIA Roticulator; Autosuture, Tyco, Norwalk, CT). Caudate portal vein branches may also be taken if needed. The right lobe is mobilized by retracting the lobe medially and caudally with the primary surgeon’s hand through the hand port. Ligament attachments are then divided with the ultrasonic shears (Fig. 34–5). A combination of blunt and sharp dissection is used to fully mobilize the right lobe to the right hepatic vein. The inferior vena cava ligament may be divided to facilitate visualization of the right hepatic vein. The right hepatic and middle hepatic veins are circumferentially dissected. The lateral attachments of the inferior vena cava are divided using the ultrasonic shears. Small branches from the vena cava to the liver may be taken with the laparoscopic vessel sealant device (LigaSure Lap; Valleylab, Boulder, CO) or with clip ligation and laparoscopic shear division.
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Figure 34–6 Laparoscopic liver ultrasound. Figure 34–5 Mobilization of lateral attachments of the right lobe using a laparoscopic ultrasonic cutting device.
Pneumothorax Mobilization of the right lobe often requires ultrasonic dissection. This thermal heat can lead to a diaphragm injury and a spontaneous pneumothorax. This is extremely vexing when the working space becomes compromised with the mobile diaphragm. ● Consequence Airway pressures suddenly rise while the working space becomes inhibited. Each pulmonary excursion results in a billowing of the diaphragm, making continued operating difficult. ● Repair Repair can be performed through open operative conversion or a laparoscopic approach. In our practice, we have elected to utilize continuous suction during suture repair of the diaphragm. First, the diaphragm injury is identified. Either a figure-of-eight or an interrupted suture repair is performed around the injury. This can be done with a suture passer device or free-hand suturing with intracorporeal knot tying. Once this is repaired, an endoscopic suction device is placed in the thoracic cavity. Aspiration of the free air is accomplished, and a forced inspiration is performed to minimize the free space. At that juncture, the suture is secured and the suction device removed. ● Prevention This is achieved though meticulous placement of the ultrasonic device. Pass pointing and adjacent thermal injuries can be avoided by either conservative or meticulous placement of these devices.
Laparoscopic Intraoperative Hepatic Ultrasound The ultrasound examination remains a crucial aspect of any liver operation, and surgeons performing laparoscopic
hepatectomy should be familiar with the equipment and well versed in assessment of the obtained images. The laparoscopic ultrasound probe (8666 probe; B-K Medical, Denmark) is used to methodically evaluate all segments of the liver, looking for additional lesions, boundaries of known lesions, and the relationship with the vascular anatomy (Fig. 34–6). If the patient is still a candidate for resection, a 2-cm margin around the lesion is marked with the argon beam coagulator.
Inadequate Intrusion Laparoscopic hepatic resection is dependent on adequate working space. When there is insufficient space to deploy or articulate instrumentation, this operative procedure becomes impossible. ● Consequence Inadequate working space incapacitates most forms of technology that are critical to the performance of these operations. ● Repair Unfortunately, there are few remedies for the lack of intrusion. The most widespread or universally accepted procedure is the technique of laprolift. In this scenario, the abdominal wall is elevated by the technique of laprolift.
Parenchymal Division Our group has avoided routine employment of the Pringle maneuver. If brisk bleeding is encountered, direct compression of the porta with the primary surgeon’s hand can be performed while a laparoscopic vascular clamp is put into position. Parenchymal transection begins with division of the Glisson capsule using the ultrasound shears at a line marked with the laparoscopic ultrasound (Figs. 34–7 and 34–8). The technique used by our group involves liberal use of 60-mm-long, 2.5-mm staple loads. The staple load
34 LAPAROSCOPIC LIVER RESECTION
Figure 34–7 Division of Glisson’s capsule along an argon beam marking line using a laparoscopic ultrasonic cutting device.
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Figure 34–8 Division of Glisson’s capsule using a laparoscopic ultrasonic cutting device.
Figure 34–9 Hepatic parenchymal resection using a reticulating laparoscopic vascular staple.
is guided into position using the intracorporeal hand. The thin blade is guided into the liver parenchyma and then fired. The staples ligate any hepatic vessels or bile ducts. As the cutting blade distance is shorter that the staple length, partial division of large vessels remains hemostatic
(Fig. 34–9). Alternative methods to parenchymal division include a saline infusion, radiofrequency ablation device (TissueLink floating ball; TissueLink, Dover, NH) (Fig. 34–10), with selective stapling or clip placement of large vascular or biliary structures.
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SECTION IV: HEPATOBILIARY SURGERY ● Consequence The resulting blood loss can be quite significant and result in hemodynamic compromise if not recognized and treated effectively in a timely manner. If not controlled quickly, this blood loss will invariably result in conversion to an open procedure or reexploration for continued bleeding.
Figure 34–10 Hepatic parenchymal resection using a saline infusion, radiofrequency ablation device.
Figure 34–11 ulation device.
Cut surface hemostasis with an argon beam coag-
Upon completion of the resection, cut surface liver parenchymal bleeding can be controlled by argon beam coagulation of the cut surface (Fig. 34–11). Bile leakage or focused arterial bleeding is controlled with free-hand suturing or clip application. A hemostatic matrix of collagen and topical thrombin (Floseal; Baxter, Deerfield, IL) is then applied to the cut surface. After hemostasis and absence of bile leak is appropriately assessed, the specimen is removed through the hand port. The port itself acts as a wound protector and prevents tumor seeding of the wound.
Venous and Arterial Bleeding Hepatic arterial or venous bleeding can become a significant problem in the confined space of a laparoscopic procedure. This results from disruption of the small or large portal or hepatic veins resting in the liver parenchyma. Intraparenchymal hepatic arterial bleeding is another potential source of bleeding when the liver parenchyma is divided. This may be further complicated by a baseline coagulopathy of the cirrhotic patient.
● Repair Intraoperatively, all patients should have their coagulopathies corrected with fresh frozen plasma, cryoprecipitate, and/or platelets before proceeding with hepatic resection. Central venous pressure should be continuously measured through a central venous line and be kept below 6 mm Hg. Again, recognition is paramount in successfully controlling the bleeding. Our group does not perform a Pringle maneuver before beginning parenchymal division, which allows for early identification of bleeding. The first maneuver in controlling bleeding is direct compression with the primary surgeon’s intra-abdominal hand. This keeps blood loss to a minimum and prevents the possibility of CO2 embolism if large hepatic veins are divided. In addition, it safely allows for the remainder of the hepatic resection to be completed so that the entire cut surface can be visualized, greatly simplifying direct permanent control of bleeding vessels. Laparoscopic suturing or clip application in the crevice of a partially completed resection is extremely difficult and does not allow for direct visualization. In almost all cases, direct pressure with the intraabdominal hand and a laparotomy sponge will maintain hemostasis until the surgeons are ready to perform more permanent hemostatic maneuvers. In the case of a cirrhotic liver in which direct compression of the liver does not always adequately stop bleedings, the surgeon’s hand can be used to compress the portal structures. Visible venous or arterial vessels on the cut surface should be permanently ligated with clip application, direct laparoscopic suture ligation, or a laparoscopic vascular stapler. Avoid argon beam coagulation of large vessels because this does not provide permanent hemostasis and can lead to gas embolization. After major vessels have been ligated, the cut surface parenchyma may be cauterized with the argon beam coagulator. We often spread a collagen and thrombin hemostatic matrix over the cut surface before closing. ● Prevention Among the different techniques available for parenchymal division, our group employs liberal use of 60-mm length, 2.5-mm staple loads. The staple load is guided into position using the intracorporeal hand. The thin blade is guided into the liver parenchyma and then fired. The staples ligate any hepatic vessels or bile ducts. This results in a very hemostatic cut surface. When using the Tissuelink device, it is important to identify vessels and staple or clip them directly to avoid bleed-
34 LAPAROSCOPIC LIVER RESECTION ing. Vigilant attention should also be given toward correction of the patient’s coagulopathy and maintenance of adequate body temperature and central venous pressure throughout the procedure.
Bile Leak Biliary leakage remains a significant problem in major open hepatic resection. Reports from recent series have shown the rate of biliary complications to range from 3% to 10%, with mortality from major leaks to be as high as 40% to 50%.27,28 ● Consequence The cut surface of the liver with associated cut bile duct is a significant source of bile leak. Many leaks are small and will resolve without intervention. Larger leaks can result in abdominal pain, bile peritonitis, abscess, or abdominal sepsis. The large symptomatic leaks can be high as 40% to 50%. ● Repair Intraoperative recognition and repair of bile leaks is paramount to avoiding postoperative complications. This involves thorough investigation for bile leak on the cut surface prior to closure. This can be done through direct visualization with the laparoscope or by placing a clean laparotomy sponge on the cut surface and looking for bile staining. We do not perform routine cholangiogram on open or laparoscopic liver resections to search for bile leaks. Once a bile leak is discovered, it is repaired in the same fashion as that for open hepatic resection, with free-hand suture ligation or clip application. Again, intraoperative recognition and repair of bile leaks are important. If leaks are discovered postoperatively, they should be treated aggressively with early endoscopic retrograde cholangiography and stent placement. If fluid collections are not adequately resolved by operatively placed drains, computed tomography scan should be obtained and interventional radiology percutaneous drains should be placed. ● Prevention Meticulous attention and focused search and repair of bile leaks intraoperatively will invariably result in fewer biliary complications.
Closure Particular attention should be given to closure of all port incisions because early herniation is an unnecessary complication in laparoscopy. Also, because patients with endstage liver disease may have large-volume ascites with diminished healing capacity, attention should be given to meticulous technique to avoid closure breakdown in this subgroup of patients. Our technique involves a 1-0 permanent suture twolayer closure for the hand port incision. The 12-mm port sites should be closed using the laparoscopic fascial closure device or an open technique.
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Other Complications Intraoperative Hypotension Pneumoperitoneum often leads to unexpected hypotension, as a result of patient intravascular volume depletion and subsequent susceptibility to pneumoperitoneal pressures. In laparoscopic liver resection, the patient is often placed in a reverse Trendelenburg position, which worsens central venous return. Subsequently, the blood pressure is extremely sensitive to patient positioning. ● Consequence Often transient but significant and dramatic hypotension can occur. Associated with this hypotension is bradycardia rather than the expected tachycardia resulting from hypotension. ● Repair Hypotension and bradycardia are responsive to atropine and/or fluid resuscitation utilizing normal saline or 5% albumin. In more extreme cases, immediate release of the pneumoperitoneum or repositioning of the patient until adequate central volume resuscitation is achieved is required. ● Prevention Adequate resuscitation of the patient is critical. The goal of central venous pressure is 6 to 8 mm Hg. However, excessive volume depletion is inappropriate and dangerous. Management of these patients with a central venous line to monitor pressures is very helpful in monitoring volume status.
Major Air Embolism A potentially fatal complication of minimally invasive hepatic resection is major air embolism. Significant disruption of the hepatic venous system in the face of CO2 pneumoperitoneum may result in air embolism to the central venous system. Subsequent air lock hypotension and fatal arrhythmia may follow. This is the most feared complication of hepatic transection performed under positive pressure. ● Consequence Air embolism is a known complication of hepatic resection. This rare complication is the result of air entering a vessel and becoming trapped within the atrium. The most susceptible patients to fatal complications are those with patent foramen ovale. This allows for trapp-ing of air in the right ventricle outflow tract, resulting in air lock with resultant hypotension or even cardiac arrest. ● Repair Procedure-related hypotension should be monitored closely. In the event of a significant drop in end-tidal CO2 along with decreases in oxygen saturation and/or hypotension, the pneumoperitoneum should be
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released and the patient hand-ventilated. The most sensitive test for air embolism remains transesophageal echocardiography, which can detect less than 0.02 ml/ kg of air. Treatment should be instituted immediately on suspicion of air embolism. The patient should immediately be placed in a Trendelenburg and left lateral decubitus position. Administration of 100% oxygen should begin immediately because it may decrease bubble size. Pulmonary artery or central venous catheters should be advanced into the heart and aspirated, in hopes of aspirating trapped air. In the case of circulatory collapse, advanced cardiac life support protocol should be instituted with cardiopulmonary resuscitation because this may break bubbles and advance air into pulmonary vessels and out of the heart.
11. 12.
13.
14.
15.
● Prevention Several authors have advocated the elimination of pneumoperitoneum and the use of a laprolift.29,30 Others advocate use of low pneumoperitoneum. Several air embolisms have been documented in the performance of laparoscopic hepatic resection. One reported fatality resulted from air embolism after an argon beam use in the liver.31 Avoidance of direct gas instillation in an open hepatic vein is critical to preventing this complication. In our practice, the use of high pneumoperitoneal (15–18 mm Hg) pressures is common. Another consideration is avoidance of nitrous oxide anesthetic because it will cause expansion of any air embolus. Despite these elevated pressures, we have not experienced an increased incidence of air embolism.
16.
REFERENCES
23.
1. Gagner MRM, Dubuc JE. Laparoscopic partial hepatectomy for liver tumor. Surg Endosc 1992;6:99. 2. Ferzli G, David A, Kiel T. Laparoscopic resection of a large hepatic tumor. Surg Endosc 1995;9:733–735. 3. Azagra JS, Georgen M, Gilbart E, Jacobs D. Laparoscopic anatomical (hepatic) left lateral segmentectomy—technical aspects. Surg Endosc 1996;10:758–761. 4. Antonetti MC, Killelea B, Orlando R 3rd. Hand-assisted laparoscopic liver surgery. Arch Surg 2002;137:407–411; discussion 412. 5. Are C, Fong Y, Geller DA. Laparoscopic liver resections. Review. Adv Surg 2005;39:57–75. 6. Buell JF, Koffron AJ, Thomas MJ, et al. Laparoscopic liver resection. J Am Coll Surg 2005;200:472–480. 7. Buell JF, Thomas MJ, Doty TC, et al. An initial experience and evolution of laparoscopic hepatic resectional surgery. Surgery 2004;136:804–811. 8. Descottes B, Glineur D, Lachachi F, et al. Laparoscopic liver resection of benign liver tumors. Surg Endosc 2003; 17:23–30 [erratum appears in Surg Endosc 2003;17:668]. 9. Gigot JF, Glineur D, Azagra JS, et al. Laparoscopic liver resection for malignant liver tumors: preliminary results of a multicenter European study. Ann Surg 2002;236:90–97. 10. Huang M, Lee W, Wag W, et al. Hand-assisted laparoscopic hepatectomy for solid tumor in the posterior
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portion of the right lobe. Ann Surg 2003;238:674– 679. Kaneko H, Otsuka Y, Takagi S, et al. Hepatic resection using stapling devices. Am J Surg 2004;187:280–284. Kaneko H, Takagi S, Otsuka Y, et al. Laparoscopic liver resection of hepatocellular carcinoma. Am J Surg 2005;189:190–194. Kurokawa T, Inagaki H, Sakamoto J, et al. Hand-assisted laparoscopic anatomical left lobectomy using hemihepatic vascular control technique. Surg Endosc 2002;16:1637– 1638. Linden BC, Humar A, Sielaff TD. Laparoscopic stapled left lateral segment liver resection–technique and results. J Gastrointest Surg 2003;7:777–782. Laurent A, Cherqui D, Lesurtel M, et al. Laparoscopic liver resection for subcapsular hepatocellular carcinoma complicating chronic liver disease. Arch Surg 2003;138:763–769. Lesurtel M, Cherqui D, Laurent A, et al. Laparoscopic versus open left lateral hepatic lobectomy: a case-control study. J Am Coll Surg 2003;196:236–242. Mala T, Rosseland AR, Gladhaug I, et al. Laparoscopic liver resection: experience of 53 procedures at a single center. J Hepatobiliary Pancreat Surg 2005;12:298–303. Morino M, Morra I, Rosso E, et al. Laparoscopic vs open hepatic resection: a comparative study. Review. Surg Endosc 2003;17:1914–1918. O’Rourke N, Fielding G. Laparoscopic right hepatectomy: surgical technique. J Gastrointest Surg 2004;8:213–216. Takagi S, Kaneko H, Ishii A. Laparoscopic hepatectomy for extrahepatic growing tumor. Surg Endosc 2002;16: 1573–1578. Tang CN, Li MK. Laparoscopic-assisted liver resection. J Hepatobiliary Pancreat Surg 2002;9:105–110. Teramoto K, Kawamura T, Sanada T, et al. Hand-assisted laparoscopic hepatic resection. Surg Endosc 2002;16:1363. Teramoto K, Kawamura T, Takamatsu S, et al. Laparoscopic and thoracoscopic approaches for the treatment of hepatocellular carcinoma. Am J Surg 2005;189:474–478. Vibert E, Perniceni T, Levard H, et al. Laparoscopic liver resection. Br J Surg 2006;93:67–72. Rau H, Buttler E, Meyer G, et al. Laparoscopic liver resection compared with conventional partial hepatectomy—a prospective analysis. Hepatogastroenterology 1998;45:2333–2338. Cherqui D, Husson E, Hammond R, et al. Laparoscopic liver resections: a feasibility study in 30 patients. Ann Surg 2000;232:753–762. Nakai T, Kawabe T, Shiraishi O, Shiozaki H. Prevention of bile leak after major hepatectomy. Hepatogastroenterology 2004;51:1286–1288. Pol B, Campan P, Hardwigsen J, et al. Morbidity of major hepatic resections: a 100-case prospective study. Eur J Surg 1999;165:446–453. Intra M, Viani MP, Ballarini C, et al. Gasless laparoscopic resection of hepatocellular carcinoma (HCC) in cirrhosis. J Laparoendosc Surg 1996;6:263–270. Gutt CN, Kim ZG, Schmandra T, et al. Carbon dioxide pneumoperitoneum is associated with increased liver metastases in a rat model. Surgery 2000;127:566–570. Fatal gas embolism caused by overpressurization during laparoscopic use of argon enhanced coagulation. Health Devices 1994;23:257–259.
35
Pancreaticoduodenectomy Lynt B. Johnson, MD and Rupen Amin, MD INTRODUCTION A pancreaticoduodenectomy (PD) or Whipple procedure is one of the most complex general surgical operations. Owing to the complexity of this procedure, pitfalls that lead to major complications can occur. In this operation, experience of the surgeon is paramount to successful outcomes. This operation is most commonly performed to remove benign and malignant tumors that involve the head of the pancreas, duodenum, periampullary region, or distal common bile duct (CBD). The classic technique of PD consists of the en-bloc removal of the distal segment of the stomach (antrum), the first and second portions of the duodenum, the head of the pancreas, the distal CBD, and the gallbladder. Another approach to this procedure is known as a pylorus-sparing PD. In this approach, a small segment of duodenum is left in situ with the entire stomach to preserve the pylorus and prevent post–gastrectomyrelated symptoms and complications. The classic Whipple and pylorus-preserving operations are associated with comparable operation times, blood loss, hospital stays, mortality, morbidity, and incidence of delayed gastric emptying. The overall long-term and disease-free survival is comparable in both groups. Both surgical procedures are equally effective for the treatment of pancreatic and periampullary carcinoma.1 Although the mortality associated with this procedure has remained low, around 2% at major surgical centers,1 significant morbidity of 20% to 50% still occurs after this operation.1,2 Several series have demonstrated that results are improved when the procedure is performed by highvolume surgeons, defined as those surgeons that perform more than 24 procedures per year.3 Common complications after PD are postoperative pancreatic fistula (POPF), gastroparesis, wound infection, hemorrhage, and pancreatitis.1,4 Complications of the procedure generally result in prolonged hospital stay, delayed adjuvant therapy, diminished quality of life, or death. The most common complication after PD is POPF. The occurrence of POPF with release of autolytic digestion enzymes in the peritoneal cavity is an underlying source of other complications such as peripancreatic collections, abscess, and hemorrhage.5 Many series have demonstrated fistula rates ranging from 1% to 20%.6,7 The wide range of this reported com-
plication is likely a result of varying definitions of POPF as well as some patient and surgeon factors. Currently, the International Study Group Pancreatic Fistula (ISGPF) definition of POPF remains the most useful for diagnosis.8 This definition includes any amount of drainage fluid that has an amylase level greater than three times the normal limit of serum amylase. The definition further classifies POPF into subcategories based on the clinical consequences of the fistula.6 Risk factors for the development of POPF after PD include patients with soft texture of the gland, small pancreatic ducts, and low preoperative albumin and prealbumin.5 In pancreatic adenocarcinoma and chronic pancreatitis, the pancreas has a more fibrotic consistency and is more likely to maintain anastomotic integrity. In patients with duodenal, neuroendocrine, or small bile duct tumors, the duct remains small and the gland maintains a soft normal gland consistency.5 Small duct size has also been shown to result in a higher incidence of POPF. However, duct size may be a surrogate for gland consistency because small ducts are more often seen in patients with soft glands.
INDICATIONS ● ● ● ● ● ●
Carcinoma of head of the pancreas Carcinoma of ampulla of Vater Chronic pancreatitis Duodenal cancer Distal bile duct cancer (cholangiocarcinoma) Cystic tumors of pancreas
OPERATIVE STEPS Step Step Step Step Step Step
1 2 3 4 5 6
Step 7
Laparotomy and exploration Kocher’s maneuver Cholecystectomy and transection of CBD Division of gastroduodenal artery Ligation of gastrocolic ligament Identification and dissection of superior mesenteric vein (SMV) Division of duodenum or stomach
368 Step 8 Step 9 Step 10 Step 11 Step 12 Step 13 Step 14
SECTION IV: HEPATOBILIARY SURGERY Division of ligament or Treitz and division of jejunum Division of neck of pancreas Dissection of portal vein branches from uncinate process Division and ligation of branches from superior mesenteric artery (SMA) to uncinate process Pancreaticojejunostomy Hepaticojejunostomy Duodenojejunostomy or gastrojejunostomy
OPERATIVE PROCEDURE Kocher’s Maneuver Damage to the Inferior Vena Cava or the Left Renal Vein The peritoneum overlying the second and third portions of the duodenum is divided to mobilize the duodenum. The inferior vena cava (IVC) lies directly posterior to the pancreatic head and thus can be inadvertently injured if the dissection does not occur in the correct plane. ● Consequence Excessive bleeding with injury to the anterior wall of the IVC. Venous bleeding is often more difficult to control because the venous walls will collapse when incised. Grade 3 complication ● Repair The first thing to do when faced with IVC bleeding is to remain calm. The second objective is to accurately visualize the injury before attempting repair. A good technique is to apply digital pressure for control initially and then compress the IVC with two sponge sticks above and below the injury. The IVC wall is often fragile so one should refrain from attempts to clamp the injured walls because this can result in an extension of the injury. Once the injury is visualized, closure with simple oversewing with monofilament suture will repair the injury. ● Prevention Knowledge of the anatomic position of the IVC with respect to the duodenum and pancreas is critical. The relationship is constant. Once the peritoneum is divided, the index finger of the right hand can be used to guide the dissection through the loose areolar tissue behind the duodenum and anterior to the IVC.
Cholecystectomy and Transection of the CBD Injury to the Right Hepatic Artery (Normal or Replaced) In the normal course, the proper hepatic artery bifurcates to the left of the CBD and the right hepatic artery courses behind the common hepatic duct to reach the right hepatic lobe. In almost 20% of patients, the right hepatic artery
will be replaced from the SMA. The replaced right branch reaches the right hepatic lobe by running parallel and adjacent to the right side of the CBD in the hilum. The aberrant replaced right hepatic artery is particularly prone to injury if not expected. ● Consequence Either excessive bleeding or arterial compromise to the right hepatic lobe and right intrahepatic biliary tree. On most occasions, the hepatic ischemia will be limited and not catastrophic. However, long-term strictures or necrosis of the right-sided intrahepatic biliary radicles may occur, resulting in inadequate intrahepatic biliary drainage or intrahepatic abscesses (Fig. 35–1). Grade 3 complication ● Repair End-to-end anastomosis with interrupted fine monofilament suture (7-0 or 8-0) should be carried out under loupe or microscope magnification. ● Prevention Aberrant anatomy to the liver occurs in upward of 30% of patients. Surgeons should always open the gastrohepatic ligament and manually palpate the hilar vessels to gain an understanding of the arterial supply to the liver. Knowledge of the course of a replaced hepatic artery is essential and should guide palpation to the lateral posterior area of the bile duct to ascertain whether there is a replaced right hepatic artery. Extreme care is taken to gently dissect the right hepatic artery away from the wall of the bile duct prior to transection of the CBD. The replaced right hepatic artery is then dissected proximally to separate it from the areolar tissue holding it close to the pancreatic head or the injury may recur when dividing the uncinate process.
Identification and Dissection of the SMV Injury to the SMV The SMV is identified at the inferior border of the pancreas. Injury to the SMV at this location can be catastrophic if it occurs behind the neck of the pancreas. ● Consequence Excessive bleeding. Grade 3 complication ● Repair Gently lifting the inferior border of the neck of the pancreas with a vein retractor may expose the injury so that repair with oversewing of the injury with fine monofilament suture can occur (Fig. 35–2). If the injury occurs at the middle of the neck of the pancreas, packing the injury with hemostatic sponge or gauze and proceeding with division of the neck of the pancreas may then allow for better exposure to repair the injury.
35 PANCREATICODUODENECTOMY
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Pancreas
Superior mesenteric vein
Figure 35–2 The inferior border of the neck of the pancreas is lifted to visualize the superior mesenteric vein and portal vein. This maneuver is more easily accomplished with benign tumors.
● Prevention Typically, no branches from the SMV are exactly anterior to the vein. During the dissection, it is paramount to stay in this orientation and not deviate to either side. Lifting on the inferior border of the neck of the pancreas with a vein retractor will provide some additional visualization, but inevitably, a portion of the dissection will be performed without direct visualization to completely mobilize the neck of the pancreas from the portal vein and SMV.
Dissection of the Portal Vein Branches from the Uncinate Process Portal Vein Injury Injury to the portal vein most often occurs when the tumor is closely abutting or adherent to the portal vein. ● Consequence Excessive bleeding or narrowing of the portal vein leading to portal vein thrombosis. Grade 3 complication
Figure 35–1 Hepatic infarcts after Whipple resection. Contrastenhanced axial computed tomography (CT) images demonstrate peripheral geographic areas of diminished attenuation in the liver, most prominent in segment 1. The main portal vein and hepatic artery are patent.
● Repair The initial goal when bleeding from the portal vein occurs is to control the bleeding site to visualize the injury and prepare for repair. Lifting of the head of the pancreas and vein by placing a hand in the retroperitoneal space behind the duodenum will often control the bleeding. If the injury can be easily visualized, repair with simple oversewing can be performed. However, often the specimen prevents adequate visualization. Thus, if the specimen can be removed while controlling the bleeding site with digital pressure, this may allow for better visualization of the injury and a more satisfactory repair (Fig. 35–3). The goal of repair of the portal vein is to prevent narrowing at the closure site. If the vein cannot be repaired with primary closure, mobiliza-
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Transected pancreas
Uncinate process
Portal vein
Figure 35–3 Short branches from the portal vein to the uncinate process must be carefully dissected and secured. Malignant neoplasms, especially in the uncinate process, can make this dissection difficult. In this situation, obtaining control of the portal vein, superior mesenteric vein, and splenic vein will allow control of hemorrhage in the event of branch avulsion.
tion of the portal vein by dividing the peritoneal attachments of the hepatic flexure as well as dissecting distally to free the vein of perihepatic lymphatic and areolar tissue may allow for repair by complete transection followed by an end-to-end anastomosis of the portal vein. The authors, however, prefer to perform a vein patch angioplasty at the injury site. Typically, the saphenous vein is harvested from the groin to create a repair with a vein patch angioplasty. ● Prevention Branches from the portal vein and SMV are fragile in nature and are easily torn. Gentle retraction and dissection of the areolar tissue between the portal vein and the uncinate process is necessary to prevent injury. If the tumor is adherent, an early decision to excise part of the lateral wall of the portal vein and repair with saphenous vein patch angioplasty will prevent foolhardy attempts to dissect the tumor away from the portal vein. If the surgeon anticipates a difficult dissection, control of the portal vein, SMV, and splenic vein with vessel loops prior to dissecting the uncinate process away from the portal vein may allow for rapid control and minimize blood loss owing to an inadvertent injury of the portal vein.
Division and Ligation of Branches from the SMA to the Uncinate Process SMA Injury During the final portion of dissection, the specimen is freed in the region of the uncinate process. Small branches for the SMA course through the soft tissue in this area. Knowledge of these branches and the course of the SMA is paramount to prevent injury. With large and bulky
● Consequence Excessive blood loss may occur from avulsion of a side branch of the SMA or direct injury to the SMA itself. Ligation or clamping of the main SMA will result in intestinal ischemia with a disastrous outcome if not easily recognized and repaired. Grade 3 complication ● Repair The critical maneuver is to lift the SMA with the specimen attached so manual control of the bleeding can occur. If the injury site is visualized, simple oversewing of the vessel with monofilament suture can be used for repair. Often, the specimen itself prevents adequate visualization for repair. In this instance, the remainder of the specimen dissection will be unnecessary while maintaining digital or clamp control of the bleeding site. Often, proximal and distal control with clamps applied to the SMA is necessary to prevent catastrophic hemorrhage. Once the specimen is removed, repair of the vessel can be performed under better visualization.
Pancreaticojejunostomy Pancreatic Leak or Postoperative Pancreatic Fistula POPF is the most feared complication after a PD procedure. In this situation, amylase-rich fluid escapes from the pancreatic duct owing to a loss of the integrity of the pancreatic to jejunal or gastric anastomosis. The release of autodigestive enzymes in the peritoneal cavity can lead to other secondary complications. Some series have reported that intra-abdominal abscess has been related to POPF in 50% to 60% of cases.5,9–12 ● Consequence POPF can result in abscess, sepsis, and mortality in its severest form. However, if handled properly, POPF does not necessarily present serious clinical consequences. Recently, the ISGPF devised a classification system for POPF. The complication is graded as A, B, or C, depending on the consequences of the POPF— grade A: biochemical fistula without clinical sequelae; grade B: fistula requiring any therapeutic intervention; and grade C: fistula with severe clinical sequelae.13 Grade A fistulas occurred 15% of the time; grade B, 12%; and grade C, 3%.14 Grade 3 complication ● Repair Reoperation for POPF is generally unnecessary unless an undrained fluid collection is unattainable by percutaneous drainage. If reoperation is necessary, controlling the fistula with a closed-suction drain is typically
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all that is necessary. A few buttress repair sutures can be placed if the site of the leak is obvious, but dedicated attempts to locate the fistula site with aggressive dissection is unnecessary and often will result in further damage or disruption. Patients with the clinical diagnosis of pancreatic fistula usually undergo a computed tomography (CT) scan to assess for associated abscess formation, but approximately 80% of fistulas heal with conservative management.4 Ten percent to 15% of patients with pancreatic fistulas require percutaneous drainage, whereas only 5% require repeat surgery.4 ● Prevention Numerous strategies have been employed to prevent POPF. Accurate suture placement by an experienced pancreatic surgeon is warranted. Whether one chooses a duct-to-mucosa two-layered anastomosis or a singlelayered dunking technique does not seem to differ in the occurrence of POPF. Other strategies have included the use of octreotide, although the effect has been variable in different reported series. In addition, it appears that a standardized approach to the pancreatic anastomosis and a consistent practice of a single technique can help to reduce the incidence of complications after PD.15
Figure 35–4 Pseudoaneurysm of hepatic artery jump graft after Whipple resection. Immediate postoperative contrast-enhanced axial CT image shows peripancreatic inflammation.
Other Complications Foregut Ischemia due to Ligation of the Gastroduodenal Artery in Patients with Celiac Artery Stenosis or Occlusion An unusual but potentially devastating complication can occur in patients who undergo a Whipple procedure who have celiac artery stenosis or occlusion. This can occur in patients with atherosclerotic disease or arcuate ligament syndrome. In this situation, the blood supply to the liver and pancreas will be supplied by retrograde flow through the gastroduodenal artery via collaterals from the SMA. If unrecognized, division of the gastroduodenal artery will result in foregut ischemia. ● Consequence Liver, pancreatic, and stomach ischemia. Grade 4/5 complication
Figure 35–5 Pseudoaneurysm of hepatic artery jump graft after Whipple resection. Follow-up CT 3 weeks later shows complex fluid in the lesser sac, consistent with blood products.
● Repair Aorta to hepatic artery bypass graft with saphenous vein is necessary in most cases. If the stenosis is recognized preoperatively, endovascular dilation and stenting may prevent the need for bypass and ischemic insult to the aforementioned organs. If a bypass graft is necessary, strong consideration should be given to performing a completion pancreatectomy to prevent the need for a tenuous pancreaticojejunostomy. In this situation, the risk of leak from the pancreatic anastomosis can lead to devastating complications of abscess, sepsis, or pseudoaneurysm owing to disruption of the pancreatic enteric anastomosis (Figs. 35–4 to 35–7).
● Prevention A thorough review of the visceral vessel anatomy with preoperative imaging can demonstrate significant narrowing of the celiac axis.
Delayed Gastric Emptying Delayed gastric emptying is defined as the persistent need for a nasogastric tube for longer than 10 days and is seen in 11% to 29% of patients.16–18 This is one of the most common complications after PD. Most cases occur owing to edema at the anastomosis or dysmotility after partial gastrectomy and loss of the duodenal pacemaker. The classic Whipple and pylorus-sparing operations are
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SECTION IV: HEPATOBILIARY SURGERY embolization if the site can be identified. Post-PD pancreatitis is rarer, occurring in fewer than 5% of patients.17,18
OVERALL MORBIDITY AND MORTALITY
Figure 35–6 Pseudoaneurysm of hepatic artery jump graft after Whipple resection. On a more inferior image, a pseudoaneurysm of the hepatic artery is seen as a new finding.
Many questions remain regarding the morbidity and mortality associated with the two different approaches to this complicated procedure. Several studies clearly demonstrated no statistical difference in morbidity between the two types of procedures. Further, the overall mortality of this procedure remains steady at approximately 3%, but no difference in mortality has been described between the two different approaches to this procedure. Therefore, pylorus-preserving PD is an acceptable alternative to the classic Whipple procedure in the treatment of periampullary cancer. Long-term survival and type of recurrence are not influenced by selection of surgical procedures.22–25
REFERENCES
Figure 35–7 Pseudoaneurysm of hepatic artery jump graft after Whipple resection. A multiplanar reformatted image demonstrates the pseudoaneurysm of the hepatic artery and associated hematoma.
associated with comparable operation times, blood loss, hospital stays, mortality, morbidity, and more importantly, incidence of delayed gastric emptying.1,19 The incidence of delayed gastric emptying can possibly be reduced by shortening the operative time and using antecolic duodenojejunostomy.20
Hemorrhage Hemorrhage in the postoperative period occurs in approximately 7% of patients. Endoluminal hemorrhage generally requires endoscopic evaluation or arteriography with embolization.21 Early intraperitoneal hemorrhage generally requires urgent surgical exploration. Delayed hemorrhage is often best managed with arteriography and
1. Tran KT, Smeenk HG, van Eijck CH, et al. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 2004;240:738–745. 2. Crist DW, Sitzmann JV, Cameron JL. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg 1987;206:358–365. 3. Urbach DR, Bell CM, Austin PC. Differences in operative mortality between high- and low-volume hospitals in Ontario for 5 major surgical procedures: estimating the number of lives potentially saved through regionalization. CMAJ 2003;168:1409–1414. 4. Gervais DA, Fernandez-del Castillo C, O’Neill MJ, et al. Complications after pancreatoduodenectomy: imaging and imaging-guided interventional procedures. Radiographics 2001;21:673–690. 5. Crippa S, Bassi C, Salvia R, et al. Enucleation of pancreatic neoplasms. Br J Surg 2007;94:1254–1259. 6. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an International Study Group Pancreatic Fistula (ISGPF) definition. Surgery 2005;138:8–13. 7. Kazanjian KK, Hines OJ, Eibl G, et al. Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients. Arch Surg 2005;140:849– 854; discussion 54–56. 8. Liang TB, Bai XL, Zheng SS. Pancreatic fistula after pancreaticoduodenectomy: diagnosed according to International Study Group Pancreatic Fistula (ISGPF) definition. Pancreatology 2007;7:325–331. 9. Li-Ling J, Irving M. Somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of enterocutaneous pancreatic fistulas: a systematic review of randomized controlled trials. Br J Surg 2001;88:190–199. 10. Popiela T, Kedra B, Sierzega M, et al. Risk factors of pancreatic fistula following pancreaticoduodenectomy for
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periampullary cancer. Hepatogastroenterology 2004;51:1484–1488. Buchler MW, Friess H, Wagner M, et al. Pancreatic fistula after pancreatic head resection. Br J Surg 2000;87:883– 889. Balsam JH, Ratter DW, Warsaw AL, et al. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001;136:391–398. Pratt W, Maithili SK, Vanounou T, et al. Postoperative pancreatic fistulas are not equivalent after proximal, distal, and central pancreatectomy. J Gastrointest Surg 2006;10:1264–1278; discussion 1278–1279. Pratt WB, Maithel SK, Vanounou T, et al. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007;245:443–451. Shrikhande SV, Barreto G, Shukla PJ. Pancreatic fistula after pancreaticoduodenectomy: the impact of a standardized technique of pancreaticojejunostomy. Langenbecks Arch Surg 2008;393:87–91. Fernandez-del Castillo C, Rattner DW, Warshaw AL. Standards for pancreatic resection in the 1990s. Arch Surg 1995;130:295–299; discussion 299–300. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226:248–257; discussion 257–260.
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18. Barens SA, Lillemoe KD, Kaufman HS, et al. Pancreaticoduodenectomy for benign disease. Am J Surg 1996;171: 131–134; discussion 134–135. 19. van Berge Henegouwen MI, van Gulik TM, DeWit LT, et al. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. J Am Coll Surg 1997;185:373–379. 20. Gao HQ, Yang YM, Zhuang Y, et al. [Influencing factor analysis of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy]. Zhonghua Wai Ke Za Zhi 2007;45:1048–1051. 21. Rumstadt B, Schwab M, Korth P, et al. Hemorrhage after pancreatoduodenectomy. Ann Surg 1998;227:236– 241. 22. Pellegrini CA, Heck CF, Raper S, et al. An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy. Arch Surg 1989;124:778–781. 23. Itani KM, Coleman RE, Meyers WC, et al. Pyloruspreserving pancreatoduodenectomy. A clinical and physiologic appraisal. Ann Surg 1986;204:655–664. 24. Takao S, Aikou T, Shinchi H, et al. Comparison of relapse and long-term survival between pylorus-preserving and Whipple pancreaticoduodenectomy in periampullary cancer. Am J Surg 1998;176:467–470. 25. Grace PA, Pitt HA, Tompkins RK, et al. Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg 1986;151:141–149.
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Distal Pancreatectomy Kiran K. Dhanireddy, MD and Thomas M. Fishbein, MD INTRODUCTION Distal pancreatectomy is performed for a variety of benign and malignant indications. The tail of the pancreas can be resected for lesions that are to the left of the superior mesenteric vessels. The procedure can be performed with or without splenic preservation, depending on the initial indication and intraoperative findings. Pancreatic malignancy generally requires splenectomy, whereas benign indications for distal pancreatectomy allow for splenic preservation. Although the ultimate outcome of the procedure depends on the underlying disease process, the complications associated with distal pancreatectomy are readily avoided through an intimate knowledge of pancreatic anatomy and meticulous surgical technique. The most discussed complication of pancreatic surgery is pancreatic leak and fistula1–3; however, several additional pitfalls to be avoided in the course of executing distal pancreatectomy will also limit postoperative morbidity and mortality. Whereas laparoscopic distal pancreatectomy with or without splenic preservation is currently possible, specific discussion of the laparoscopic aspects of this operation are beyond the scope of this chapter.4–7
INDICATIONS ● ● ● ● ● ● ● ●
Pancreatic adenocarcinoma Benign cystadenoma Cystadenocarcinoma Neuroendocrine tumor Traumatic pancreatic duct disruption Pancreatic pseudocyst Chronic pancreatitis Acute pancreatic necrosis
OPERATIVE STEPS Step 1 Step 2 Step 3
Incision Entry into lesser sac and exposure of pancreas Dissection of inferior border of pancreatic tail
Distal Pancreatectomy with Splenectomy Step 4a Splenic mobilization Step 5a Medial rotation of spleen pancreas Step 6a Ligation of splenic vessels
and
tail
of
Splenic Preservation Vascular control of splenic vessels medial to lesion Step 5b Ligation of perforating branches of splenic vein and artery Step 7a/6b Pancreatic division Step 8a/7b Drain placement and closure of abdomen Step 4b
OPERATIVE PROCEDURE Incision The patient should be in the supine position on the operative table in slight reverse Trendelenburg. Either an upper midline or a left subcostal incision may be used because both provide excellent exposure of the pancreas. The midline incision may be preferable when the patient has a narrow costal arch, whereas the subcostal incision is superior in patients in whom the costal arch is wide.
Entry into the Lesser Sac and Exposure of the Pancreas To enter the lesser sac, the gastrocolic ligament is divided in a relatively avascular area. The anterior surface of the pancreas is then fully exposed. Occasionally, the inferior short gastric vessels must be ligated to facilitate full exposure of the tip of the pancreatic tail. This has no implication for splenic function if the spleen is preserved.
Hemorrhage from the Veins Communicating between the Right Gastroepiploic Vessels and the Middle Colic Vein Occasionally, a branch of the right gastroepiploic vessels will communicate with the middle colic vessels inferior to the pylorus. In the process of elevating the stomach, this vein may be torn.
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● Consequence Unnecessary blood loss can obscure the operative field and prolong the course of the operation. Grade 1 complication
splenorenal, and splenogastric ligaments, must be fully mobilized.
● Repair Ligation of the torn ends of the vessel.
● Consequence The spleen has a rich blood supply from both the splenic artery and the short gastric vessels. Injury to the splenic capsule or failure to recognize all the short gastric vessels can result in bothersome bleeding. Grade 1 complication
● Prevention Prior to elevating the antrum and pylorus of the stomach, all vascular attachments should be identified and ligated using silk or Vicryl ties of the appropriate caliber. Entering through the gastrocolic omentum in the correct avascular plane and continuing toward the short gastric vessels to the spleen will help avoid this complication.
Dissection of the Inferior Border of the Pancreatic Tail After the pancreas has been fully exposed, the peritoneum overlying the inferior margin of the pancreatic tail is incised. This maneuver allows for superior reflection of the pancreas and exposure of the splenic vessels.
Injury to the Middle Colic Vein or the Inferior Mesenteric Vein The middle colic vein runs in the transverse mesocolon in close proximity to the inferior border of the pancreas. This vein may be encountered during the medial portion of the dissection. Similarly, the inferior mesenteric vein may be encountered more laterally as it drains into the splenic vein. ● Consequence Unnecessary blood loss and increased operative time are the consequences of unrecognized middle colic and inferior mesenteric vein injury. Grade 1 complication
Bleeding from the Spleen
● Repair Meticulous ligation of the short gastric vessels will control bleeding from these vessels. ● Prevention Ligation of the splenic artery at the hilum of the spleen early in the course of mobilization will limit blood loss if splenic injury occurs. Argon beam coagulation or other local measures can temporarily halt splenic capsular or ligamentous bleeding.
Medial Reflection of the Spleen and the Tail of the Pancreas After the splenic attachments have been released, the spleen and tail of the pancreas may be rotated medially. The attachments of the pancreatic tail to the retroperitoneum are avascular and can therefore be freed using a combination of gentle blunt and sharp dissection. The splenic vessels are included in the mobilization.
Injury to the Left Renal Vein or the Adrenal Vein The left renal vein lays posterior to the inferior margin of the tail of the pancreas (Fig. 36–1). The left adrenal vein enters the superior surface of the renal vein, and the adrenal gland can sometimes be adherent to the posterior
● Repair The middle colic and inferior mesenteric veins may be ligated if they are injured because there is a rich network of collateral venous drainage for the large intestine.
Adrenal
● Prevention During the course of dissection, these vessels should be identified and spared injury. Dissection of the pancreatic tail should proceed from distally (near the spleen) toward the body. Identification of the splenic vein along the inferior margin of the pancreas allows one to directly identify where these veins will potentially enter, avoiding injury.
Splenic Mobilization If the spleen is not to be preserved during the conduct of the operation, the attachments, including the leinocolic,
Spleen
IVC
Renal vein
Kidney
Pancreas
Figure 36–1 Hidden anatomy – relationship of left renal vein/left adrenal vein to tail of pancreas.
36 DISTAL PANCREATECTOMY capsule of the pancreas, making this mobilization of the pancreas more difficult. During the course of medial reflection, the left renal vein, adrenal gland, or adrenal vein may be inadvertently injured. ● Consequence Renal vein injury can result in brisk bleeding and significant blood loss. Based on the severity of the laceration, a significant prolongation of the operative procedure may result. If a branch of the renal vein is inadvertently ligated and unrecognized, venous congestion and subsequent loss of renal function may result. The left adrenal gland may be controlled with electrocautery, and the vein may be ligated without consequence. Grade 1/2 complication ● Repair The left renal vein should be repaired primarily using a nonabsorbable monofilament suture such as Prolene. This requires vascular control of the vein proximally and distally. This may be facilitated by ligation of the left gonadal vein and retroperitoneal collateral vein from the left renal vein in order to gain mobility for repair with good visualization. ● Prevention Knowledge of the relationship between the left renal vein and the tail of the pancreas along with careful dissection during the course of medial reflection will prevent this complication.
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supply to the tail of the pancreas consists of multiple perforating vessels directly from the splenic vessels.
Bleeding from the Pancreatic Branches of the Splenic Vessels These vessels must be carefully dissected and ligated with small clips, suture ligature, or harmonic scalpel. If an unsecured vessel is transected, the vessel may retract out of the operative field and cause bleeding that is difficult to control. ● Consequence Unnecessary blood loss and prolonged operative time will result from bleeding branches of the splenic vessels. Grade 1 complication ● Repair Identification and ligation of the bleeding vessels halts blood loss. The pancreatic side is best controlled with fine monofilament suture, whereas the splenic vein side may be tied or sutured if it tears. ● Prevention Early vascular control of the splenic vessels proximal to the site of proposed pancreatic transection allows for minimization of any bleeding from the perforating vessels. The use of suture ligation of these very short branches with fine Prolene may speed the conduct of the operation.
Pancreatic Division Ligation of the Perforating Branches of the Splenic Vein and Artery If the spleen is to be preserved during the conduct of the operation, the splenic artery and vein must be separated from the tail of the pancreas (Fig. 36–2). The blood
Spleen
Pancreas
The pancreatic parenchyma can be divided using a gastrointestinal anastomosis (GIA) stapler with a vascular load or using nonabsorbable horizontal mattress sutures. Data suggest that the incidence of complications is lower in stapled transections.8
Pancreatic Leak/Fistula Pancreatic fistula after distal pancreatectomy is reported to occur in approximately 25% of patients.9,10 This complication adds significant morbidity and mortality to the operation. ● Consequences Pancreatic fistula infrequently necessitates reoperation but does add significantly to length of hospital stay, the need for parenteral nutrition, and overall costs.7 Grade 4 complication
Figure 36–2 Small vessels directly from splenic vessels to tail of pancreas. Note added branches from splenic vein.
● Repair Few would advocate direct repair of the pancreatic stump for management of a pancreatic fistula. Current strategies include drainage and the use of parenteral nutrition to prevent pancreatic stimulation by enteral diet. The use of a somatostatin analogue has been examined as a means to decrease the production of
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pancreatic enzymes.11 Low-volume leaks usually seal with drainage alone, whereas those fistulas with highvolume output are likely to seal with a period of prolonged parenteral nutrition in the absence of oral intake. ● Prevention There have been numerous reports of strategies to reduce the risk of pancreatic leak after distal pancreatectomy. Most of these techniques have been unsuccessful. For example, the use of fibrin glue had been advocated but has recently been shown to not significantly change the rate of fistula development.12 Another technique that might alter the rate of fistula development is direct ligation of the pancreatic duct, even if a stapler is used for transecting the pancreatic tissue.13 The mainstay of treatment is closed-suction drainage of the pancreatic bed after surgery, the institution of a low-fat diet, and the judicious use of antibiotics to treat superinfection when it occurs.
REFERENCES 1. Rodriguez JR, Germes SS, Pandharipande PV, et al. Implications and cost of pancreatic leak following distal pancreatic resection. Arch Surg 2006;141:361–365. 2. Kuroki T, Tajima Y, Kanematsu T. Surgical management for the prevention of pancreatic fistula following distal pancreatectomy. J Hepatobiliary Pancreat Surg 2005;12: 283–285. 3. Knaebel HP, Diener MK, Wente MN, et al. Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy. Br J Surg 2005;92:539–546. 4. Toniato A, Meduri F, Foletto M, et al. Laparoscopic treatment of benign insulinomas localized in the body and tail
5.
6.
7.
8.
9.
10.
11.
12.
13.
of the pancreas: a single-center experience. World J Surg 2006;30:1916–1919. Palanivelu C, Shetty R, Jani K, et al. Laparoscopic distal pancreatectomy: results of a prospective non-randomized study from a tertiary center. Surg Endosc 2007;4:250– 254. Aluka KJ, Long C, Rickford MS, et al. Laparoscopic distal pancreatectomy with splenic preservation for serous cystadenoma: a case report and literature review. Surg Innov 2006;13:94–101. Pierce RA, Spitler JA, Hawkins WG, et al. Outcomes analysis of laparoscopic resection of pancreatic neoplasms. Surg Endosc 2007;4:579–586. Takeuchi K, Tsuzuki Y, Ando T, et al. Distal pancreatectomy: is staple closure beneficial? Aust N Z J Surg 2003; 73:922–925. Fahy BN, Frey CF, Ho HS, et al. Morbidity, mortality, and technical factors of distal pancreatectomy. Am J Surg 2002;183:237–241. Pannegeon V, Pessaux P, Sauvanet A, et al. Pancreatic fistula after distal pancreatectomy: predictive risk factors and value of conservative treatment. Arch Surg 2006;141: 1071–1076. Suc B, Msika S, Piccinini M, et al, and the French Associations for Surgical Research. Octreotide in the prevention of intra-abdominal complications following elective pancreatic resection: a prospective, multicenter randomized controlled trial. Arch Surg 2004;139:288– 294. Suc B, Msika S, Fingerhut A, et al, and the French Associations for Surgical Research. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Ann Surg 2003;237:57– 65. Bilimoria MM, Cormier JN, Mun Y, et al. Pancreatic leak after left pancreatectomy is reduced following main pancreatic duct ligation. Br J Surg 2003;90:190–196.
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Lateral Pancreaticojejunostomy (Puestow) Procedure Eleanor Faherty, MD and Patrick G. Jackson, MD INTRODUCTION
OPERATIVE STEPS
Surgical approaches to chronic pancreatitis are indicated in the setting of intractable pain or anatomic complications of the disease process, such as symptomatic obstruction of the common bile duct, pancreatic duct, or duodenum. From a conceptual standpoint, the surgical procedures offered for chronic pancreatitis can be segregated into resection procedures, drainage procedures, or combinations of the two. The specific approach to surgical management must be individualized because there is a wide variability in symptomatology, gland pathology, and anatomic manifestation.1 Ductal drainage procedures are used for patients with dilated pancreatic ductal systems, under the theory that the pancreatic duct has a symptomatic and functional obstruction. With a limitation to enzyme secretion into the duodenum, there is a lack of inhibitory feedback, thus allowing an increase in cholecystokinin, which induces further enzyme secretion into a functionally obstructed duct. The increased ductal distention then causes pain.2 No clear consensus exists regarding the definition of a dilated ductal system. Whereas most would agree that pancreatic ducts greater than 1 cm (Fig. 37–1) constitute sufficient dilation, greater controversy exists regarding ducts between 5 mm and 1 cm.1,3 Although no prospective study exists correlating greater ductal size with superior long-term outcome, increased ductal dilation does facilitate a number of the steps in the procedure. Surgical management of chronic pancreatitis and ductal drainage is technically challenging, requiring a comprehensive and coherent surgical approach to avoid common pitfalls.
Step 1 Step 2
INDICATIONS ● Intractable abdominal pain and/or back pain ● Symptomatic duodenal obstruction ● Symptomatic common bile duct obstruction
Skin incision Exploration of peritoneal contents for additional pathology Step 3 Enter lesser sac to expose anterior pancreas Step 4 Wide Kocher maneuver Step 5 Location of pancreatic duct with palpation and needle aspiration Step 6 Unroofing of pancreatic duct from duodenum to splenic hilum Step 7 Ensure adequate pancreatic drainage Step 8 Construction of Roux-en-Y jejunal loop of approximately 60 cm Step 9 Anastomosis of Roux-en-Y loop in retrocolic, two-layer, side-to-side pancreaticojejunostomy Step 10 Fixation of Roux-en-Y jejunal loop to transverse mesocolon Step 11 Closure4,5
OPERATIVE PROCEDURE Exploration of Peritoneal Contents for Additional Pathology Unexpected Intraoperative Findings ● Consequence Change in operative strategy. Grade 1/2 complication ● Repair Appropriate surgical management of another disease process such as pancreatic cancer. ● Prevention Preoperative planning in the management of chronic pancreatitis is critical to success. Noninvasive imaging with high-quality dynamic bolus-enhanced computed tomography (CT) with thin cuts to evaluate the pancreas helps avoid errors in the management algorithm. Pancreatic cancers will generally appear as
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Figure 37–1 calcifications.
Dilated
pancreatic
duct
with
parenchymal
hypodense lesions. Preoperative CT scans can also delineate biliary ductal dilation, pseudocysts, and pancreatic duct size.1 Endoscopic retrograde cholangiopancreatography (ERCP) can provide valuable information about intraductal pathology and should be used when the diagnosis of chronic pancreatitis is in doubt, to evaluate possible ampullary lesions, or to assess duct size if CT cannot provide adequate information. Endoscopic ultrasound (EUS), a newer diagnostic technique, is the most sensitive modality for the diagnosis of pancreatic carcinoma, and although it is invasive, it poses fewer risks than ERCP.4 With its ability to assess the pancreatic parenchyma and determine duct size and an increased sensitivity for mass lesions, EUS is becoming a valuable tool in the preoperative planning of chronic pancreatitis management.
Figure 37–2
Needle aspiration of dilated duct system.
The posterior wall of the stomach may be densely adhered to the pancreas and will require meticulous dissection in the avascular place for separation. Critical in this step is exposure of the entire anterior surface of the pancreas, with careful preservation of the gastroepiploic vessels.6
Location of the Pancreatic Duct with Palpation and Needle Aspiration and Unroofing of the Pancreatic Duct from the Duodenum to the Splenic Hilum Inability to Identify the Pancreatic Duct
Enter the Lesser Sac to Expose the Anterior Pancreas and Perform a Wide Kocher Maneuver Inadequate Exposure ● Consequence Technical inability to complete the procedure. Grade 2/3 complication ● Repair Appropriate exposure of the abdomen and the anterior surface of the entire pancreas. ● Prevention A generous midline incision is employed for the procedure, and the entire abdomen is explored. A wide Kocher maneuver helps in the exposure of the head of the pancreas. The gastrocolic ligament is divided to enter the lesser sac with subsequent mobilization of the stomach superiorly and the transverse colon inferiorly.
● Consequence Bleeding or inadvertent injury to the pancreatic parenchyma. Grade 2/3/4 complication ● Repair Hemostasis and wide postoperative drainage. ● Prevention The pancreatic duct can usually be palpated as a soft compressible area in the body of the gland. Intraoperative ultrasound should be used liberally to confirm the identification of the duct and thus avoid unwarranted pancreatotomy. Accessory or side branch ducts may also be dilated, so aspiration of clear secretions does not confirm location of the main duct (Fig. 37–2). With intraoperative ultrasound, a needle can be easily placed into the pancreatic duct by aspiration, with the syringe then removed, leaving the needle in the duct to serve as a guide.
37 LATERAL PANCREATICOJEJUNOSTOMY (PUESTOW) PROCEDURE
Aggressive Attempts to Identify and Open the Duct ● Consequence Injury to the superior mesenteric vein/portal vein. Grade 2/3/4 complication ● Repair Meticulous hemostasis using fine sutures. ● Prevention Clear and careful identification of the superior mesenteric vein during exposure of the pancreas will help avoid this potentially disastrous event. In addition, the duct should be entered using electrocautery through its anterior surface at the midbody, thus avoiding the splenoportal confluence.6
Ensure Adequate Pancreatic Drainage Insufficient Decompression ● Consequence Anastomotic stricture, reduced likelihood of symptomatic relief. Grade 2/3/4 complication
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intraductal concretions must be removed.4 The entire duct from tail to head should be opened to allow sufficient drainage of the entire pancreatic parenchyma (Fig. 37–4). Studies suggest that a pancreaticojejunostomy less than 6 cm in length has a higher risk of stricture and therefore inadequate drainage.7 Although this is factually correct, focusing too heavily on the minimum requirement fails to emphasize the goal of adequate decompression of the entire pancreas because the minimum requirement becomes the definition of adequacy. Therefore, unroofing of the entire duct from tail to head with subsequent longitudinal pancreaticojejunostomy will provide sufficient drainage.
Anastomosis of the Roux-en-Y Loop in a Retrocolic, Two-Layer, Side-to-Side Pancreaticojejunostomy Inadequate Orientation of the Roux-en-Y Limb ● Consequence Difficulty in subsequent biliary decompression. Grade 2/3 complication ● Repair Additional biliary enteric bypass limb.
● Prevention Using the needle as a guide, the pancreatic duct is opened. Once the pancreatotomy is sufficient to allow passage of a fine right-angle clamp or probe, the course of the duct can be determined (Fig. 37–3). This allows incision of the overlying pancreatic parenchyma. All
● Prevention The blind end of the Roux-en-Y limb used for pancreaticojejunostomy should be oriented toward the splenic hilum (Fig. 37–5). Orientation in the opposite direction will not allow for decompression of the biliary tree, should this prove necessary later. With orientation of the blind end toward the spleen, additional length of this limb can be drawn through the rent in the transverse mesocolon for creation of a tension-free biliary enteric anastomosis if necessary.1
Figure 37–3 incision.
Figure 37–4 Exposure of entire length of pancreatic duct.
● Repair Further endoscopic or surgical procedures to decompress the ductal system.
Right angle clamp used to extend pancreatic duct
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REFERENCES Figure 37–5 Construction of pancreaticojejunostomy.
Leak from the Pancreaticojejunostomy ● Consequence Intra-abdominal autodestruction from activated pancreatic enzymes. Grade 2/3 complication ● Repair Wide drainage with prolonged bowel rest. ● Prevention Given the fibrotic parenchymal changes from chronic pancreatitis, leak from this anastomosis should be
1. Prinz R. Pancreatic duct drainage. In Pancreas. p 829. 2. Owyang C. Control of exocrine pancreatic secretion. Regul Pept 1989;1:107. 3. Prinz RA. Surgical options in chronic pancreatitis. Int J Pancreatol 1993;14:97–105. 4. Nakeeb A, Lillemoe K, Cameron JL. Procedures for benign and malignant pancreatic disease. In Souba WS (ed): ACS Surgery: Principles and Practice. Hamilton, Ontario: BC Decker, 2008. 5. Sakorafas GH, Sarr MG. Tricks in the technique of lateral pancreaticojejunostomy. Eur J Surg 2000;166:498–500. 6. Nealon WH, Thompson JC. Progressive loss of pancreatic function in chronic pancreatitis is delayed by main pancreatic duct decompression. A longitudinal analysis of the modified Puestow. Ann Surg 1993;217:458–468.
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Pancreatic Cyst/Debridement Lynt B. Johnson, MD, Patrick G. Jackson, MD, and Trevor Upham, MD Inflammatory Pancreatic Cyst Drainage Lynt B. Johnson INTRODUCTION Cysts of the pancreas are typically inflammatory in nature or neoplastic. Pancreatic pseudocysts generally occur as a consequence of acute or chronic pancreatitis. Unlike pseudocysts of the pancreas due to chronic pancreatitis, pseudocysts that occur as a result of acute pancreatitis more often can spontaneously resolve over time; however, some of these cysts persist and require intervention. Distinction should be made between a pancreatic pseudocyst with a low viscous liquid fluid and other peripancreatic collections that include phlegmons and tissue necrosis, which are more semisolid or solid in consistency. The consistency of the material encountered greatly influences the appropriate treatment options. Typically for noninfected collections, it is prudent to wait 6 weeks from the inflammatory incident to allow time for the cyst to resolve or for the cyst wall to mature. During this 6-week period, the consistency of the fluid can change dramatically from a toothpaste consistency to pure liquid. The diagnosis of the pseudocyst is typically identified through abdominal imaging. Computed tomography, magnetic resonance imaging, or ultrasound can be used to confirm the diagnosis. One must be cautious to not misdiagnose a cystic neoplasm as a pseudocyst. Suspicion of the diagnosis should occur if there has not been a precedent history of pancreatitis. Clinical signs of infection such as fevers and gas within the collection often warrant early intervention. Although studies utilizing percutaneous drainage as well as endoscopic drainage have reported some success, the selection of the appropriate patient for these treatments is paramount. In general, patients with semisolid or solid components in the collection should be managed with
operative drainage. The choices for operative drainage include internal drainage by cystenterostomy or external drainage. Internal drainage is preferred when the cyst is not infected and has low-viscosity fluid. For giant pseudocysts, the author prefers a Roux-en-Y cystgastrostomy performed through the transverse mesocolon. This allows for complete resolution of the cyst through dependent drainage. Although cystgastrostomy is regarded as a mainstay for internal drainage cases, stasis and retroperitoneal sepsis have occurred, especially in large pseudocysts, owing to lack of adequate dependent drainage. External drainage can also be accomplished through a transverse mesocolon approach for patients with phlegmons or infected pseudocysts to allow for manual débridement of the necrotic tissue and placement of large-caliber drains.
Cystgastrostomy or Endoscopic Drainage INDICATIONS ● Small, less than 5 cm persistent pseudocyst located pos-
terior to stomach ● Low viscosity of cyst fluid
OPERATIVE STEPS Step Step Step Step
1 2 3 4
Anterior gastrotomy Creation of posterior gastrotomy Cyst wall and posterior stomach anastomosis Closure of anterior gastrotomy
OPERATIVE PROCEDURE Anterior Gastrotomy Anterior Gastrotomy Bleeding Typically, a transverse incision using electrocautery directly overlying the cyst should be made. The gastric wall is very vascular, and thus, bleeding can occur if other nonhemostatic incisions are made in the stomach wall.
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● Consequence Bleeding can occur and obscure adequate vision. Grade 1 complication
verse mesocolon, one can identify the pseudocyst bulging through the mesocolon. If not, apply the same maneuvers as listed previously.
● Repair Oversewing of the gastrotomy edges typically will control the bleeding.
Injury to the Mesocolon Vessels
● Prevention Alternatively, the gastrotomy can be performed with a dividing stapling device.
Creation of the Posterior Cystgastrostomy Inability to Locate the Cyst The cyst can typically be felt by palpation or visualized owing to an impression on the posterior gastric wall. ● Consequence Creation of a gastrotomy not in continuity with the pseudocyst. Grade 1 complication ● Repair Closure of the aberrant opening and reassessment. ● Prevention The cyst cavity can be detected by aspiration with a 22-gauge needle through the posterior gastric wall. Alternatively, intraoperative ultrasound can be used to localize the cyst.
Roux-en-Y Cystjejunostomy INDICATIONS ● Large, greater than 5 cm persistent pseudocyst.
OPERATIVE STEPS Step 1 Step 2
Identification and opening of pseudocyst wall through transverse mesocolon Creation of Roux-en-Y cystjejunostomy
● Consequence Hemorrhage. Grade 1 complication ● Repair Oversewing of the bleeding vessel should control the bleeding. If it occurs from the pancreatic bed, oversewing of the vessel or topical coagulation should be attempted. If these maneuvers are not effective, packing of the cavity and immediate angiographic embolization of the bleeding vessel may be warranted. ● Prevention Great caution should be used when creating the opening to perform this through an avascular plane in the mesocolon. Aspirating with a small-gauge needle may provide some safety before making the opening. One should avoid carrying the opening too medial to avoid injury to the middle colic vessels. Typically, the opening should be to the left of the ligament of Treitz to avoid this complication.
Creation of the Roux-en-Y Cystjejunostomy Anastomotic Leak ● Consequence Undrained fluid collection or abscess, sepsis. Grade 1 complication ● Repair Percutaneous drainage of the fluid collection to try to create a controlled fistula is paramount. If the fluid is amylase rich, the patient should be started on octreotide. Once the drain has been left for 6 weeks, a drain study can be performed. If there is no collection, the drain can be removed and the epithelialized tract will generally seal. ● Prevention Closed-suction drains should be left above and below the anastomosis. These drains should be left in place until there is certainty that no leak has occurred.
OPERATIVE PROCEDURE Identification and Opening of the Pseudocyst Wall through the Transverse Mesocolon
External Drainage
Inability to Locate the Cyst See the section on “Inability to Locate the Cyst,” under “Cystgastrostomy,” earlier. Typically by lifting the trans-
INDICATIONS ● Infected pseudocyst or phlegmon.
38 PANCREATIC CYST/DEBRIDEMENT
OPERATIVE STEPS Step 1 Step 2 Step 3
Identification and opening of pseudocyst wall through transverse mesocolon Débridement of necrotic or infected tissue Placement of large-bore sump drains
OPERATIVE PROCEDURE Identification and Opening of the Pseudocyst Wall through the Transverse Mesocolon Same pitfalls as in the sections on “Inability to Locate the Cyst,” and “Injury to the Mesocolon Vessels,” under “Roux-en-Y Cystjejunostomy,” earlier.
Débridement of Necrotic or Infected Tissue The fluid and tissue within the phlegmon is typically of a semisolid consistency much like that of toothpaste. As the first step, the author prefers to manually dislodge and remove this tissue through the opening created. The tissue separates fairly easily from the underlying viable pancreatic tissue. Russian forceps can then be used to extricate the hard-to-reach areas. Irrigation with a red rubber catheter can also be employed to remove dislodged particles.
Pancreatic Bed Hemorrhage Overaggressive débridement can result in hemorrhage from the pancreatic bed. Minor bleeding can occur from surface branches. More substantial bleeding can occur from the pancreatoduodenal vessels or dorsal pancreatic vessels. ● Consequence Major hemorrhage during or after the procedure can lead to disastrous consequences. Grade 3 complication ● Repair When hemorrhage is recognized during the procedure, suture ligation should be attempted. If this fails, packing the opening and quickly transporting the patient for angiographic embolization is the indicated treatment. ● Prevention The necrotic tissue is generally of a different consistency than the underlying parenchyma and should elevate quite easily. Densely adherent tissue that does not easily elevate with manual débridement or irrigation should be left behind.
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Placement of Large-Bore Sump Drains Large-bore sump drains should be placed in the pancreatic bed and brought external. These drains should have an opening of sufficient size such that particulate material can be drained adequately. A drain in the style of a Waterman sump is one variation. Alternatively, some surgeons use stuffed Penrose drains as packing, with sequential removal once they stop draining.
Surgical Management of Pancreatic Necrosis Patrick G. Jackson and Trevor Upham INTRODUCTION Pancreatic necrosis occurs as a sequela of approximately 15% to 30% of the 185,000 cases of acute pancreatitis in the United States every year.1 Pancreatic necrosis exists as a continuum from sterile pancreatic necrosis to infected pancreatic necrosis (Fig. 38–1). Bacteria infect the sterile necrotic pancreas, probably via translocation from the colon, in a time-dependent manner from the onset of pancreatitis. The infection rate of the sterile pancreatic bed ranges from approximately 24% within 1 week to 71% within 3 weeks in the absence of treatment.2 If untreated, infected pancreatic necrosis can progress to a dense walled-off collection of pus and liquefied necrosis. To prevent the associated systemic complications, early recognition of infection and proper treatment, medically or surgically, are critical. In the setting of known infected pancreatic necrosis or worsening clinical presentation indicative of infection, pancreatic débridement is necessary to prevent the lethal systemic inflammatory response syndrome (SIRS) and possible multiple organ system failure. Surgical treatment of a necrotic pancreas requires careful approach, débridement, and postoperative management to resuscitate the critical organ. Surgeons select the appropriate surgical protocol from the three primary methods that exist for surgical débridement and packing: (1) open débridement with closed packing, (2) open débridement with closed lavage, and (3) open débridement with open packing. Open débridement consists of gentle blunt finger dissection to carefully identify all necrotic tissue and finger abrasion with sponges covering the fingertips to remove the necrotic tissue. Because the necrotic tissue may be very poorly demarcated, a preoperative computed tomography (CT) scan can be used as a guide to identify and débride all necrotic areas of the pancreas and any necrotic attachment to local structures. Generous interoperative lavage is encouraged.
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Closed packing involves placement of ¾-inch Penrose drains or an Abramson drain in conjunction with several Jackson-Pratt (JP) drains. Closed lavage consists of placement of single- and double-lumen catheters in the cavity. The drains on the left traverse from the cavity posterior to the large bowel, inferior to the spleen, and anterior to the kidney through separate skin stab wounds. On the right, the drains traverse from the cavity through the foramen of Winslow to separate skin stab wounds. The gastrocolic ligament and transverse mesocolon are closed with sutures to create a confined space for concentrated lavage. Hyperosmolar potassium-free dialysis fluid is used postoperatively to lavage the cavity at a rate of 2 L/hr until the effluent lacks necrotic tissue and does not contain amylase. Open packing involves an approach through a horizontal incision. The cavity is packed with moist gauze. Redébridement with lavage is performed first after 48 to 72 hours and then every 48 hours until the cavity is clean with healthy granulation tissue at the base. The cavity is then managed with surgical drains. Choosing between these strategies must be done in the scope of the clinical details of the necrotizing process as well as the available surgical expertise and ancillary support staff. In that all strategies have equivalent outcomes, the choice of approach is largely surgeon dependent. Regardless of the chosen surgical protocol, minimizing surgical complications while optimally preserving the remaining pancreatic function proves a delicate task that favors foresight to prevent surgical management pitfalls. Although all operative strategies have equivalent outcomes, open débridement with close packing is preferred. To avoid the following pitfalls, carefully planned surgical management of pancreatic necrosis is mandated in the setting of known infected pancreatic necrosis or worsening clinical presentation indicative of infection. Surgical outcomes can be maximized with complete débridement
Figure 38–1 Retroperitoneal air with infected necrosis.
of the necrotic tissue and management of the residual cavity with carefully chosen closed packing, closed lavage, or open packing.
INDICATIONS ● Infected pancreatic necrosis ● Worsening clinical symptomatology of infection in
setting of pancreatic necrosis
OPERATIVE STEPS Step Step Step Step Step Step
1 2 3 4 5 6
Skin incision Entrance into lesser sac to expose pancreas Débridement of necrotic pancreas Surgical drainage Closed packing Abdominal closure
Skin Incision Delayed Pancreatic Débridement ● Consequence SIRS and possible multiple organ system failure. Grade 3/4 complication ● Repair Surgical débridement. ● Prevention Surgical débridement is indicated in the setting of (1) infection, (2) increasing toxicity in the absence of infection, (3) failure to improve clinically despite continued support over 3 to 4 weeks, or (4) an acute abdominal catastrophe.3 A commonly used and helpful means of identifying infection in pancreatic necrosis is the liberal use of cross-sectional imaging, with the identification of retroperitoneal gas from gas-forming bacteria. Extensive studies have failed to define a universally concrete time point to operate in the setting of sterile pancreatic necrosis. Sterile pancreatic necrosis requires careful consideration for surgical débridement on a case-by-case basis. In the setting of true sterile pancreatic necrosis, conservative management without surgery is warranted. Patients must be closely monitored for signs of organ failure or SIRS including tachycardia, tachypnea, leukocytosis, fever, or hypoxia. Concurrently, imipenem/cilastin may be used to reduce the progression to pancreatic necrosis.4 Fluoroquinolones also provide broad coverage and good pancreatic penetration. Cautionary use of antibiotics in this setting is advised because progression to pancreatic infection by typical enteric pathogens may be supplanted by fungal or gram-positive nosocomial infections.5 In addition to antibiotics, fine-needle aspiration may be used, and repeated, whenever sterile necrosis is
38 PANCREATIC CYST/DEBRIDEMENT
Transverse mesocolon
Middle colic artery
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ligament or through the transverse mesocolon (Fig. 38–2). A local inflammatory response often makes the gastrocolic ligament access difficult enough to warrant access via the mesocolon. The middle colic vessels must be carefully identified to avoid ligation. If the middle colic vessels are the sole blood supply to areas of the colon, ligation of this sole blood supply will lead to an ischemic bowel, requiring resection. Thus, access to the lesser sac via the mesocolon should be carefully made on either side, or on both sides, of the middle colic vessels.1 Ligation of the middle colic vessels is reserved only for necessary surgical access to the pancreas when other approaches are not possible.
Débridement of the Necrotic Pancreas Damage to Peripancreatic Critical Vascular Structures Figure 38–2 Infra-mesocolic exposure of pancreatic bed.
clinically ambiguous. In the absence of retroperitoneal gas, repeat CT imaging is an unreliable marker of progression to infection. In addition, repeat images are advised when surgical débridement would be seriously considered—following the second week after initial pancreatitis presentation, unless the clinical picture mandates otherwise. Again, the assumption of sterile pancreatic necrosis must always be questioned. Surgical débridement must be considered in the setting of unresolving or significant new signs of SIRS that warrant surgical intervention.6,7 If pancreatic necrosis is known to be infected, surgical intervention is required. If pancreatic necrosis has progressed to a welldeveloped, uncomplicated true pancreatic abscess, primary treatment with concurrent culture-sensitive antibiotics and percutaneous drainage or endoscopic drainage of the abscess cavity through the posterior wall of the stomach may prevent surgical necessity. Before this treatment is begun, the diagnosis of a true pancreatic abscess must be questioned and obscured necrotizing processes ruled out.
Entrance into the Lesser Sac to Expose the Pancreas Ligation of the Middle Colic Vessels ● Consequence Possible large bowel ischemia. Grade 2/3/4 complication ● Repair Bowel resection. ● Prevention Surgical access to the lesser sac for surgical débridement of the pancreas can be approached via the gastrocolic
● Consequence Operative blood loss secondary to inferior vena cava, splenic, or portal vein damage. Grade 3/4 complication ● Repair Surgical repair of the vasculature. ● Prevention Extensive necrotic involvement may attach to local structures. Excessive débridement may leave the portal vein near the head of the pancreas and the splenic vein near the tail of the pancreas vulnerable to avoidable damage. Extensive retroperitoneal involvement may compromise the structure of the vena cava. Although demarcation of necrotic borders may not be present, only semisolid necrotic tissue must be gently débrided without unnecessarily disrupting the vasculature.
Endocrine or Exocrine Insufficiency ● Consequence Diabetes mellitus results from lack of endocrine function of the pancreas. Malabsorption, steatorrhea, and associated abdominal symptomatology result from insufficient exocrine secretions. Grade 2 complication ● Repair Medical management of glucose control and supplementation of pancreatic enzymes. ● Prevention Maximal preservation of healthy pancreatic endocrine tissue is ideal. Exocrine and endocrine deficiencies do not result from débridement because the majority of débrided tissue is peripancreatic inflammatory soft tissue, and débridement removes only the alreadydemarcated necrotic tissue, rather than viable pancreas.
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Rather, exocrine and endocrine deficiencies result from the inflammatory insult of necrotizing pancreatitis to the islets of Langerhans and exocrine glands. In order to maximize pancreatic function in the setting of necrotizing pancreatitis, physicians must be diligent with the treatment of sterile pancreatic necrosis and carefully monitor for surgical indication.
Surgical Drainage
Limited Surgical Drainage
Pancreaticocutaneous Fistula ● Consequence Leakage of pancreatic amylase and proteins onto the skin may induce inflammatory mediators and potential hypercholeraemic or normal anion gap metabolic acidosis. Grade 2/3 complication ● Repair Suppression of pancreatic enzymes with octreotide, catheter manipulation or replacement, and possible surgical correction. ● Prevention Recognition of patients with a high risk of pancreaticocutaneous fistula formation and carefully coordinated surgical drainage of the surgical cavity are the best methods to avoid the occurrence and complications of a pancreaticocutaneous fistula. The more severely the pancreatic parenchyma is disrupted by disease, the more likely a pancreaticocutaneous fistula will occur. Consequently, severe pancreatitis and, possibly, pancreatitis of biliary cause are most likely to result in a pancreaticocutaneous fistula.8 Percutaneous drainage, either used alone or postoperatively, must be monitored daily in critically ill patients
Jp
in order to determine necessary (1) changes in nutrition or antibiotic treatment, (2) catheter flushing, manipulation, or replacement, and (3) indication for surgical intervention. Prophylactic octreotide9,10 may also be used when a high likelihood of pancreaticocutaneous fistula exists, such as in severe pancreatitis.
Jp Jp
Jp
Figure 38–3 Extensive drainage of pancreatic infection.
● Consequence Persistent infection. Grade 2/3/4 complication ● Repair Redébridement. ● Prevention The large residual cavity following pancreatic débridement must be carefully managed to prevent further infection, visceral communication, and erosion of blood vessels. The Penrose or Abramson drain must be removed before JP drains to prevent pancreatic ascites or a pancreatocutaneous fistula (Fig. 38–3). If Penrose drains are used, sequential removal, one drain per day, 7 to 10 days postoperatively, carefully allows the cavity to collapse in a stepwise fashion.
Pancreatic Ascites and Pancreatic Pleural Effusion ● Consequence Fistula formation and erosion of peripancreatic structures by exocrine secretions. Grade 2/3/4 complication ● Repair Conservative treatment consists of gastrointestinal rest, nasogastric suction, octreotide, and total parenteral nutrition. Treatment of the fistula is fostered by repeat paracentesis and thoracocentesis as well as chest tube drainage. Surgical intervention is indicated when there is no clinical improvement from conservative measures. Endoscopic placement of a pancreatic duct stent may also be useful. ● Prevention Although clinical symptoms of pancreatic ascites and effusions are very similar to those of other pancreatic disease, any patient clinically suspected to have pancreatic ascites or pleural effusion should have the appropriate bodily fluids sampled for amylase and albumin via paracentesis or thoracocentesis. If pancreatic ascites has occurred, the amylase level will always be markedly elevated (>1000 Somogyi units/100 ml), and in the absence of hypoalbuminemia, the albumin level will be greater than 3 g/100 ml. If conservative management
38 PANCREATIC CYST/DEBRIDEMENT of the pancreatic ascites or pleural effusion fails to reverse the course of disease, surgical correction is warranted based upon the pancreatic duct anatomy and the extent of damage from the ascites.11
Abdominal Closure Intra-Abdominal Swelling with Challenging Abdominal Wall Closure ● Consequence Dehiscence, wound infection, or abdominal hernia. Grade 2/3 complication ● Repair Antibiotics. Possible surgical correction of the incision or hernia. ● Prevention Two types of incisions—horizontal and vertical—may be made to gain access to the pancreas. Horizontal transverse or subcostal “chevron” incisions leave the incision more difficult to approximate and often require mesh fortification. The preferable vertical midline incision allows better approximation and rarely involves mesh placement. Properly placed retention sutures are used to best close the abdominal wall.
REFERENCES 1. Jackson PG, Rattner DW. Pancreatic abscess. In Cameron JL (ed): Current Surgical Therapy, 7th ed. St. Louis: Mosby, 2001; pp 539–543.
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2. Rau B, Pralle V, Uhl W, et al. Management of sterile necrosis in instances of severe acute pancreatitis. J Am Coll Surg 1995;181:279–288. 3. Bouvet M, Moossa AR. Pancreatic abscess. In Cameron JL (ed): Current Surgical Therapy, 8th ed. Philadelphia: Mosby, 2004; pp 476–479. 4. Bassi C, Falconi M, Talamini G, et al. Controlled clinical trial of perfloxacin versus imipenem in severe acute pancreatitis. Gastroenterology 1998;115:1513– 1517. 5. Buchler M, Malfertheiner P, Friess H, et al. Human pancreatic tissue concentration of bactericidal antibiotics. Gastroenterology 1992;103:1902–1908. 6. Buchler MW, Gloor B, Muller CA, et al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000;232:619–626. 7. Warshaw AL. Pancreatic necrosis: to débride or not to débride?—That is the question. Ann Surg 2000;232:627– 629. 8. Fotoohi M, D’Agostino HB, Wollman B, et al. Persistent pancreatocutaneous fistula after percutaneous drainage of pancreatic fluid collections: role of cause and severity of pancreatitis. Radiology 1999;213:573–578. 9. Rosenberg L, MacNeil P, Turcotte L. Economic evaluation of the use of octreotide for prevention of complications following pancreatic resection. J Gastrointest Surg 1999;3:225–232. 10. Yeo CJ. Does prophylactic octreotide benefit patients undergoing elective pancreatic resection? J Gastrointest Surg 1999;3:223–224. 11. Kaman L, Behera A, Singh R, Katira RN. Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management. Aust N Z J Surg 2001;71:221–225.
39
Resection and Reconstruction of the Biliary Tract David A. Bruno, MD and Thomas M. Fishbein, MD INTRODUCTION
OPERATIVE STEPS
In 1891, in Dresden, Germany, Oskar Sprengel published the first report of a choledochoenterostomy. In this patient, after a successful cholecystectomy, Dr. Sprengel was unable to clear the distal common bile duct of stones. A choledochotomy was made, and the common bile duct was anastomosed to the duodenum. Although the first patient survived, subsequent attempts resulted in several deaths, presumably from bile peritonitis followed by sepsis.1,2 Not until a successful series of cases in the early 20th century was the operation accepted as standard of care.3 Many years later, it was recognized that hepatic ducts could also be resected and reconstructed with attention to two simple principles: The anastomosis must be performed free of tension and with direct mucosal apposition to facilitate proper healing. These principles still maintain today. Safe and effective biliary reconstruction requires intimate knowledge of normal anatomy as well as commonly recognized variations in biliary and vascular anatomy of the liver and porta hepatis. Proper exposure allowing careful dissection in this region is of paramount importance. Resection and reconstruction, performed to establish biliary continuity with the small bowel, is the usual goal, regardless of the specific pathology. When malignancy is the indication for surgery, anatomic planes are frequently altered owing to inflammation, desmoplastic reaction, and sometimes, tumor mass, increasing the complexity of the procedure. All procedures involving the biliary tract involve several operative steps: exposure, dissection, and establishment of biliary continuity.
Step Step Step Step Step Step
1 2 3 4 5 6
Incision Exposure of hepatoduodenal ligament Dissection of common bile duct Duct division Duct resection or closure Reestablishment of biliary continuity
OPERATIVE PROCEDURE Resection and restoration of biliary continuity above or below the hepatic bifurcation.
Operative Incision This is reviewed in Section IV, Chapter 32, Right Hepatectomy. Briefly, this can be optimally accomplished through a right subcostal incision, a midline incision, or a bilateral subcostal incision. Prior operations may dictate which of these is chosen, whereas in patients with no prior operations, a right or bilateral subcostal incision is preferred.
Bile Duct Isolation Extrahepatic Bile Duct—Blood Supply The blood supply to the extrahepatic bile duct is derived from vessels on the medial and lateral walls of the duct, sometimes referred to as “9 o’clock and 3 o’clock position”4 (Fig. 39–1). Blood flow derives both from intrahepatic arteriobiliary collateral circulation downward and upward from the gastroduodenal artery.
Bleeding from Peribiliary Vessels
INDICATIONS ● Bile duct obstruction ● Biliary injury—trauma ● Biliary fistula
● Consequence Failure to avoid or ligate these vessels and adequately control hemorrhage can lead to three possible complications. First, poor visualization may increase the likelihood of injury to other vital structures, most
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Right hepatic artery Common hepatic artery
3 o’clock vessels
9 o’clock vessels Common bile duct
Figure 39–1 Bile duct lateral vessels. Note the right hepatic artery courses posterior to the common bile duct.
commonly, the right hepatic artery. Second, postoperative bleeding from the anastomosis may occur. Third, injury and extensive coagulation may lead to ischemia of the duct, leading to late stricture formation at the anastomosis. Grade 3 complication ● Repair Careful ligation of larger peribiliary vessels at the point of transaction of the duct should be undertaken, usually with fine monofilament suture. Smaller vessels may be controlled with electrocautery. Care must be taken when using electrocautery because thermal damage to the biliary tree may result in late stricture.5 ● Prevention Preoperative understanding of the normal and variant anatomy of the biliary tree and its surrounding vessels is essential. In normal anatomy, the common bile duct is derived from one left and one right hepatic duct joining at the hepatic hilum. The right hepatic artery branches from the proper hepatic artery medial to the duct, giving off small branches to the bile duct. Additional branches may be derived from the right hepatic artery lateral in the porta hepatis once it has passed posterior to the duct. The right hepatic artery bifurcates into anterior and posterior sectoral branches lateral to the duct. A replaced right hepatic artery sometimes courses lateral to the portal vein and gives off branches to the bile duct.
Common Hepatic Artery Injury ● Consequence Hepatic artery anatomy can sometimes be obscured by pathology and variations in anatomy.6–12 As the duct is
dissected and prepared for division or resection, identification of the common hepatic artery origin should be noted. Inadvertent injury to the hepatic artery will result in brisk hemorrhage. Complete ligation and division may result in ischemia of the right hepatic lobe of the liver. This can result in hepatic parenchymal damage postoperatively, sometimes leading to intrahepatic biliary necrosis, biloma formation, or abscess. Grade 3 complication ● Repair Incomplete transection of the proper hepatic artery should immediately be recognized. Control of the proximal and distal segments with vascular clamps should immediately be obtained. The artery itself should be repaired with an appropriately sized monofilament suture. Repair should be made in a transverse fashion in order to avoid narrowing of the artery. If the artery has suffered injury that makes a clean complete primary repair impossible, the authors recommend completing transection of the artery at the site of the injury and direct end-to-end anastomosis.13,14 ● Prevention Never transect the common bile duct until the hepatic artery has been positively identified at the level of planned transection. Encircle only the bile duct if possible.
Proper Hepatic Artery Injury ● Consequence Variations in both the right and the left hepatic arteries are common.15 Division of the proximal common bile duct without identification of arterial supply in the porta should be avoided (Fig. 39–2). Early proper hepatic arterial injury can lead to hemorrhage and hepatic parenchymal ischemia. Unrecognized division of these arteries has been associated with strictures and the formation of bilomas late after surgery.16–18 Grade 4 complication ● Repair Inadvertent transection of the right or left hepatic artery should be repaired with an end-to-end anastomosis after proximal and distal control is established.19–22 Nonabsorbable monofilament sutures are appropriate for repair. In the patient in whom an accessory hepatic artery branch exists and either it or the proper branch is injured, an injury of one may not require repair. The proximal stump of the injured vessel may be examined for backbleeding, which if it is judged to be pulsatile and sufficient, implies adequate intraparenchymal collateral circulation. Such an accessory branch may be ligated. High injuries of right hepatic artery branches may not allow distal control, thus requiring direct suture repair or closure.
39 RESECTION AND RECONSTRUCTION OF THE BILIARY TRACT
393
Figure 39–3 Right hepatic artery (RHA) is shown coursing anterior to a fusiform choledochal cyst (CDC) and entering the hilum anteriorly. Blue loop identifies the common bile duct, which usually is anterior to the RHA. CBD, common bile duct; CHA, common hepatic artery; LHA, left hepatic artery. Atrophic left lobe with no portal vein seen
Figure 39–2 Replaced right hepatic artery. This usually runs posterior to the portal vein, but may then course anteriorly to lie just behind the bile duct above the cystic duct.
● Prevention Proper hepatic artery injury prevention begins with an intimate knowledge of variations before entering the operating room. Potentially hazardous variations of hepatic artery anatomy include an early trifurcation branching into (1) right and (2) left hepatic artery branches and the (3) gastroduodenal artery low in the porta hepatis, the right hepatic artery deriving from the superior mesenteric artery posterior to the portal vein, the right hepatic artery passing anterior to the common bile duct, and the entire proper hepatic artery arising from the gastroduodenal artery (Fig. 39–3).4 Early identification of the proper hepatic artery by palpation medial to the bile duct low in the porta hepatis is advantageous.
Portal Vein Injury ● Consequence Inflammatory reactions, secondary to benign or malignant disease, may result in a proximal common bile duct or hepatic ducts that are adherent to the portal vein. These may occur in the setting of pancreatitis, chronic biliary infections, biliary fistula, and cholangiocarcinoma. Excessive dissection can cause disruption of the sometimes-attenuated anterior wall of the portal vein. Hilar cholangiocarcinoma frequently directly invades the vein or small portal branches, such as branches draining the left caudate (Fig. 39–4). This vascular invasion must be recognized to avoid injury. Grade 3 complication
Figure 39–4 Computed tomography (CT) scan shows hilar cholangiocarcinoma invading the left portal vein.
● Repair The portal vein can be manually compressed and then occluded with a Pringle maneuver proximal to the disruption in order to allow sufficient exposure during bleeding. A vascular clamp is then placed on the vein, and primary repair with nonabsorbable monofilament suture can be undertaken.23–25 The vein wall should be directly visualized and transverse repair performed to avoid narrowing the vein, which can lead to late portal thrombosis. Freeing a length of the vein, when possible, allows tension-free repair. This sometimes requires the ligation of a small pancreatic branch on the right anterior portal vein wall. Division of the gastroduodenal artery allows easy visualization of the proximal portal vein. ● Prevention Recognition of a portal vein that is densely adherent to the common bile duct is the first step in prevention of
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this injury. In such cases, circumferential control of the bile duct may not be required. Instead, in the case of benign disease or unresectable malignancy, the duct may be incised anteriorly, leaving the adherent posterior wall intact. Anastomosis to the intestine may be accomplished safely by placing sutures into the intact posterior wall after suturing the distal portion of the duct closed. Alternatively, if the bile duct can be transected, minimal dissection proximally up to the liver may be performed to allow suture placement without injuring the anterior portal vein wall. Placing the posterior wall sutures on the inside of the anastomosis decreases the potential for injury in patients in whom the duct is adherent to the portal vein.
Excision Distal Stump Leak ● Consequence Failure to ligate the distal remnant of the common bile duct in procedures that call for complete common bile duct resection can result in a retrograde reflux from the duodenum. This may result in peritonitis and abscess formation from refluxed enteric contents. Grade 2 complication ● Repair This complication sometimes presents in the late postoperative period. Endoscopic stent placement via endoscopic retrograde cholangiopancreatography (ERCP) to decrease intrabiliary pressure and allow duodenal drainage can result in closure of the leak.18,26–30 ● Prevention Closure of the distal ductal remnant with suture or tying is critical to prevent this injury. One must ensure that all lumens seen at the point of division of the duct are closed adequately. Recognition of aberrant biliary anatomy, including a low insertion of the right posterior sectoral bile duct or an accessory right bile duct running parallel to the common bile duct prior to entry, may leave a lateral opening in the common bile duct wall that may leak. A low insertion of the cystic duct below the level of transection likewise may lead to the same complication (Fig. 39–5).
Biliary Stricture ● Consequence Hepatic duct and common bile duct blood supplies run axially along the length of the ducts (see Fig. 39–1). Excessive dissection of the duct beyond the area of excision may lead to ischemia, which in turn may lead to either early bile leak or late stricture formation.31 Grade 2/3 complication ● Repair When anastomotic disruption due to ischemia, tension, or late stricture occurs, two repair options exist. Early
LHA
RHA
Figure 39–5 Normal level of insertion of cystic duct (CD) and cystic artery (CA) in Calot’s triangle. LHA, left hepatic artery; RHA, right hepatic artery.
leak may be managed by early reoperation in the absence of systemic sepsis and if diagnosed promptly. Late diagnosis of leak may be best managed with conservative measures of drainage and delayed repair if stricture ensues. Stricture late after anastomosis may be managed utilizing decompression (transhepatic access is usually preferable) and either balloon dilation or definitive surgical repair.28,32–35 In patients in whom access cannot be obtained via the transhepatic approach, a transjejunal approach can occasionally be used for dilation of the stricture.36–39 ● Prevention Adequate blood supply at the point of transection of the bile duct is critical to ensure prevention of complications. This is generally ensured by observation of good bleeding from the cut edge of the transected duct. This usually requires direct suture ligation of the bleeding vessels. Dissection of the duct near the area to be transected should be lateral to the ductal tissue, leaving periadventitial tissue undisturbed. The area should not be skeletonized in the manner of vascular dissection. If there is any indication that the duct has been devascularized, further resection to bleeding tissue is required prior to anastomosis. Vessels running along the duct should be directly ligated with fine monofilament suture.
Reconstruction and Reestablishment of Biliary Continuity Anastomotic Leak ● Consequence Irrespective of the method for reestablishing biliary continuity, tension on the biliary-enteric anastomosis may result in a bile leak. This may result in sterile
39 RESECTION AND RECONSTRUCTION OF THE BILIARY TRACT
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biloma, which can be drained, or uncontrolled peritonitis. Grade 2/3 complication ● Repair Anastomotic tension should be recognized immediately. A primary choledochocholedochostomy should be performed only if the duct is freshly cut, with no loss of bile duct length, as with a direct division during another procedure. If duct edges are not cleanly divided or there is any tension, a Roux-en-Y choledochojejunostomy should be performed. A drain is generally placed in the pouch of Morrison, the most dependent portion of the abdomen, near the anastomosis. This will usually control bile leakage if it occurs. ● Prevention Any sign of anastomotic tension will result in an anastomosis that is prone to leakage. Such an anastomosis should not be completed, with or without an internal stent such as a T-tube. We recommend a Roux-en-Y anastomosis that is retrocolic and approximately 40 cm long. Mobilization of an adequate length of intestinal mesentery will alleviate tension on the intestinal loop utilized for anastomosis.
Hepatic Duct Leak ● Consequence Resections above the biliary bifurcation may result in three or more hepatic ducts requiring reconstruction. When a smaller stump is not recognized, it may not be included in the hepaticojejunostomy. In this case, bile will freely drain into the peritoneum and a biliary leak will occur. As previously discussed, uncontrolled biliary fistula will result in bile peritonitis. Grade 3 complication ● Repair Early recognition of all proximal extrahepatic ducts and subsequent inclusion into the anastomosis will prevent this complication. Smaller ducts such as those draining the caudate lobe can be oversewn without loss of significant hepatic parenchymal function. Those draining larger areas of functional liver, such as anterior and posterior sectoral ducts, may be joined together using an intact back wall to provide a single larger anastomosis. Repair of a missed duct postoperatively usually requires reoperation and revision with construction of an additional anastomosis. ● Prevention Preoperative imaging of the biliary tree above the site of resection helps to prevent this by identifying the intrahepatic anatomy. This is best accomplished with percutaneous transhepatic cholangiography for totally obstructing lesions but may sometimes be accomplished
Figure 39–6 Completed hepaticojejunostomy with an aberrant right hepatic artery anterior to a Roux-en-Y loop of jejunum performed tension free with mucosal apposition.
with imaging from below in cases in which dye will pass through the area requiring repair. Magnetic resonance cholangiography is increasingly used for this purpose. Cholangiitis should be prevented by treating with systemic antibiotics during these imaging studies, and imaging from below should be accompanied by a drainage procedure (stent placement). Intraoperative recognition of each duct transected as identified by imaging will help prevent this complication. One must also recognize that little bile may be produced by liver segments that have been chronically obstructed at the time of transaction, later to be followed by improved bile flow after surgery. Thus, orifices encountered that appear consistent with biliary radicals should be tagged and reconstructed despite the lack of good bile flow intraoperatively. Probing what appear to be very small ducts with a lacrimal probe will often demonstrate direct access into a major lobe of the liver, making clear the requirement for drainage (Fig. 39–6).
REFERENCES 1. Sprengel O. Uber eienen fall von exstirpation der gallenblase mit anlegung einer kommunikation zwischen dudenum und ductus choledochus. Zentralbl Chir 1891; 18:121–122. 2. Horgan E. Reconstruction of the biliary tract: a review of all the methods that have been employed. New York: Macmillan, 1932. 3. Sasse F. Uber choledochoduodenostomie. Zentralbl Chir 1913;40:942–943. 4. Northover JM, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg 1979;66:379–384.
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5. Hochstadetr H, Bekavac-Beslin M, Doko M, et al. Functional liver damage during laparoscopic cholecystectomy as the sign of the late common bile duct stricture development. Hepatogastroenterology 2003;50:676– 679. 6. Abdullah SS, Mabrut JY, Garbit V, et al. Anatomical variations of the hepatic artery: study of 932 cases in liver transplantation. Surg Radiol Anat 2006;28:468–473. 7. Chaib E, Ribeiro MA Jr, Saad WA, Gama-Rodrigues J. The main hepatic anatomic variations for the purpose of split-liver transplantation. Transplant Proc 2005;37:1063– 1066. 8. Chen CY, Lee RC, Tseng HS, et al. Normal and variant anatomy of hepatic arteries: angiographic experience. Chin Med J (Free China ed) 1998;61:17–23. 9. Koops A, Wojciechowski B, Broering DC, et al. Anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies. Surg Radiol Anat 2004;26:239–244. 10. Mlakar B, Gadzijev E, Ravnik D, et al. Anatomical variations of the arterial pattern in the left hemiliver. Eur J Morphol 2002;40:115–120. 11. Mlakar B, Gadzijev EM, Ravnik D, Hribernik M. Anatomical variations of the arterial pattern in the right hemiliver. Eur J Morphol 2002;40:267–273. 12. Mlakar B, Gadzijev EM, Ravnik D, Hribernik M. Congruence between the courses of the biliary ductal and the hepatic arterial systems. Eur J Morphol 2005;42:135– 141. 13. Mathisen O, Soreide O, Bergan A. Laparoscopic cholecystectomy: bile duct and vascular injuries: management and outcome. Scand J Gastroenterol 2002;37:476–481. 14. Doctor N, Dooley JS, Dick R, et al. Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy. Br J Surg 1998;85:627–632. 15. Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg 1994;220:50–52. 16. Krotovskii GS, Shcherbiuk AN, Gerasimov VB. [Intraoperative injury to the hepatic artery proper]. Khirurgiia (Sofiia) 1983;5:105–106. 17. Sankot J. [Injury of the hepatic artery]. Rozhl Chir 1998; 77:121–122. 18. Gupta N, Solomon H, Fairchild R, Kaminski DL. Management and outcome of patients with combined bile duct and hepatic artery injuries. Arch Surg 1998;133:176– 181. 19. Schmidt SC, Langrehr JM, Raakow R, et al. Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases. Langenbecks Arch Surg 2002;387:183–187. 20. Schmidt SC, Langrehr JM, Settmacher U, Neuhaus P. [Surgical treatment of bile duct injuries following laparoscopic cholecystectomy. Does the concomitant hepatic arterial injury influence the long-term outcome?]. Zentralbl Chir 2004;129:487–492. 21. Schmidt SC, Settmacher U, Langrehr JM, Neuhaus P. Management and outcome of patients with combined bile
22.
23. 24. 25. 26.
27.
28.
29.
30.
31.
32.
33.
34. 35.
36.
37.
38.
39.
duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 2004;135:613–618. Shiraishi M, Hiroyasu S, Kusano T, Muto Y. Vascular reconstruction for intraoperative major vascular injuries. Int Surg 1997;82:141–145. Snyder CJ. Injuries to the portal triad. Am J Surg 1993; 166:318. Jurkovich GJ, Hoyt DB, Moore FA, et al. Portal triad injuries. J Trauma 1995;39:426–434. Dawson DL, Johansen KH, Jurkovich GJ. Injuries to the portal triad. Am J Surg 1991;161:545–551. Binmoeller KF, Katon RM, Shneidman R. Endoscopic management of postoperative biliary leaks: review of 77 cases and report of two cases with biloma formation. Am J Gastroenterol 1991;86:227–231. Familiari L, Scaffidi M, Familiari P, et al. An endoscopic approach to the management of surgical bile duct injuries: nine years’ experience. Dig Liver Dis 2003;35:493–497. Katsinelos P, Kountouras J, Paroutoglou G, et al. The role of endoscopic treatment in postoperative bile leaks. Hepatogastroenterology 2006;53:166–170. Katsinelos P, Paroutoglou G, Beltsis A, et al. Endobiliary endoprosthesis without sphincterotomy for the treatment of biliary leakage. Surg Endosc 2004;18:165–166. Sandha GS, Bourke MJ, Haber GB, Kortan PP. Endoscopic therapy for bile leak based on a new classification: results in 207 patients. Gastrointest Endosc 2004;60:567– 574. Sawaya DE Jr, Johnson LW, Sittig K, et al. Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multiinstitutional review. Am Surg 2001;67:473–477. Hillis TM, Westbrook KC, Caldwell FT, Read RC. Surgical injury of the common bile duct. Am J Surg 1977; 134:712–716. Sava P, Camelot G, Kahn J, Gillet M. [Operative trauma of the common bile duct. Report of eight cases (author’s transl)]. J Chir 1978;115:663–671. Michelassi F, Ranson JH. Bile duct disruption by blunt trauma. J Trauma 1985;25:454–457. Mergener K, Strobel JC, Suhocki P, et al. The role of ERCP in diagnosis and management of accessory bile duct leaks after cholecystectomy. Gastroint Endosc 1999;50: 527–531. Sugiyama M, Izumisato Y, Ubukata N, et al. Peroral jejunoscopy for treating stenosis of hepaticojejunostomy after pancreatoduodenectomy. Hepatogastroenterology 2001;48:681–683. Severini A, Cozzi G, Salvetti M, et al. Management of complications from hepatobiliary surgery using the percutaneous transjejunal approach. Tumori 1997;83:912– 917. Ruiz J, Torres R. Translaparoscopic jejunal approach for benign stricture of Roux-en-Y hepaticojejunostomy. Surg Endosc 2001;15:518. McPherson SJ, Gibson RN, Collier NA, et al. Percutaneous transjejunal biliary intervention: 10-year experience with access via Roux-en-Y loops. Radiology 1998;206: 665–672.
Section V
ENDOCRINE SURGERY Gerard M. Doherty, MD A life spent making mistakes is not only more honorable but more useful than a life spent doing nothing.—George Bernard Shaw
40
Thyroid Surgery Michael McLeod, MD and Gerard M. Doherty, MD
INTRODUCTION
● Local symptoms due to mass effects of enlarged
gland Thyroid operations are usually safe procedures with rare life-threatening complications. Complications common to any operation, such as bleeding, infection, and anesthetic reactions, are all quite unusual. Almost never is sufficient blood lost during the operation to require transfusion. After the procedure, bleeding can cause dangerous local effects but only rarely requires blood replacement. The neck is a privileged site for wound healing that can withstand substantial contamination without clinical infection. These procedures are typically performed as ambulatory or overnight hospitalizations, with short (1–3 hr) general or regional anesthetic techniques, which limit the risk of anesthetic or pulmonary complications and deep venous thrombotic events. However, thyroid surgery is considered a delicate area of clinical practice. Significant technical complications can occur that can create permanent changes for the patient. The most common of these are hypoparathyroidism and nerve injury. Other less-frequent complications include cervical hematoma and aerodigestive tract damage.
OPERATIVE STEPS (UNILATERAL LOBECTOMY) Step 1 Step 2
Step 3 Step 4
Step 5 Step 6 Step 7
INDICATIONS Step 8 ● Hyperthyroidism ● Malignancy or suspicion of malignancy
Induce general anesthesia and secure airway Transverse incision along skin lines inferior to thyroid isthmus through platymus, raising subplatysmal flaps Separate strap muscles in midline, exposing thyroid gland Expose upper pole vessels by dissecting between cricothyroid muscle and thyroid gland and lateral to thyroid gland Divide upper pole vessels Reflect thyroid medially and dissect lateral aspect of gland Identify inferior thyroid artery, recurrent laryngeal nerves (RLNs), and parathyroid glands in tracheoesophageal groove Divide inferior thyroid artery branches, thyroid attachment to trachea anterior to RLN insertion, and inferior pole vessels
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Divide thyroid isthmus. For bilateral procedures, isthmus is usually left intact, and same steps are followed for contralateral lobe Step 10 Obtain hemostasis and close wound in layers Step 9
OPERATIVE PROCEDURE The potential complications of thyroid operations include the immediate complication of cervical hematoma, as well as the more chronic complications of hypoparathyroidism, nerve injury, and injuries to the aerodigestive tract. Finally, chronic problems can arise from iatrogenic hyper- or hypothyroidism.
Securing the Airway At the outset of the operation, for most patients, general anesthesia is induced and an endotracheal tube is placed. For most patients, this is a routine and uneventful portion of the procedure; however, this can be the most dangerous portion of the procedure for a patient with a large goiter or tumor (Fig. 40–1).
Airway Management ● Consequence Because the thyroid lies directly anterior to the trachea, enlargement of the thyroid or direct invasion of the trachea by tumor can cause airway compromise that can become critical during the induction of anesthesia.1–4
Compression of the trachea can cause loss of airway patency in the supine patient under anesthesia. Once the negative intrathoracic pressure needed to lift the thyroid and keep the trachea patent is lost, it may be difficult or impossible to ventilate the patient with positive pressure. This can be avoided by using awake intubation to maintain airway patency. Grade 2/3 complication ● Prevention Compression of the trachea in the neck can narrow the lumen substantially and require placement of a smaller endotracheal tube at intubation. However, the more difficult management issue can be significant lateral deviation of the trachea. Although these patients can usually be ventilated by positive-pressure mask ventilation, the shift of the larynx can make it difficult or impossible to access the vocal cords for placement of an endotracheal tube. Intubation over a fiberoptic laryngobronchoscope can be helpful in most patients. However, some patients cannot be intubated in spite of all attempts, who require tracheostomy at the outset of the thyroidectomy in order to safely perform the operation. Anticipation of the difficulties that may be faced, the assembly of a team expert in airway management, and the readiness of an experienced surgeon prepared to access the airway operatively are critical to the safe outcome of these occasionally extremely challenging and dangerous situations.
Dissection and Identification of Cervical Structures After exposure of the thyroid gland (Fig. 40–2), the upper pole vessels are divided (Fig. 40–3). The thyroid lobe is
78 mm
45 mm
Thyroid
Trachea
Upper pole
Left thyroid lobe
Figure 40–1 Tomographic reconstruction of a substernal goiter with airway compromise. The compression and shift of the trachea in patients such as this can be particularly dangerous during the induction of anesthesia. Intubation can be difficult, and the airway can be lost with induction.
Figure 40–2 Exposure of the left lobe of the thyroid gland. The sternohyoid and sternothyroid muscles are held by the retractor.
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Upper parathyroid gland
Upper pole vessels Ligament of Berry
Left thyroid lobe
Figure 40–3 Division of the left upper pole vessels. These vessels can be divided using a number of techniques, including division between ligatures or clips or using powered hemostasis equipment, as illustrated here.
Left upper parathyroid Thyroid lobe
Recurrent laryngeal nerve Nerve stimulator probe
Figure 40–4 Demonstration of the tracheoesophageal groove dissection. The nerve is carefully exposed and may be confirmed using intraoperative nerve monitoring, as demonstrated here. The upper parathyroid is typically posterior to the recurrent nerve position and superior to the inferior artery, as in this patient.
reflected anteriorly in order to expose the tracheoesophageal groove (Fig. 40–4). The dissection is carried down along the medial surface of the carotid artery to the prevertebral fascia. The inferior thyroid artery can be identified passing deep to the carotid in its course toward the
Recurrent laryngeal nerve
Figure 40–5 The posterior attachment of the thyroid to the trachea anterior to the recurrent laryngeal nerve (ligament of Berry) is divided with careful avoidance of the recurrent nerve.
lower pole of the thyroid. Careful dissection is performed around the inferior thyroid artery to identify the RLN as it passes underneath or, less commonly, anterior to the artery. If the RLN is not visible, it can usually be identified caudally (in previously undissected areas) as it ascends in the tracheoesophageal groove. The cephalad course of the nerve is defined, taking care to preserve branches that arise proximal to its disappearance under the caudal border of the cricothyroid muscle. The right RLN arises more laterally in the chest than the left, leading to a more oblique course. The superior and inferior parathyroid glands may be preserved by dissecting them away from the posterior capsule of the thyroid gland with their vascular pedicles. The superior glands are most commonly located on the dorsal surface of the thyroid lobe at the level of the upper two thirds of the gland (see Fig. 40–4). Although their location is more variable, the lower glands usually lie caudal to the inferior thyroid artery. With the course of the RLN directly visualized, the branches of the inferior thyroid artery are divided adjacent to their entrance into the thyroid gland to preserve the parathyroid blood supply. The inferior pole is then dissected. A variable number of inferior thyroid veins and, in some cases, a thyroid ima artery are divided. The RLN is also vulnerable to injury in this area. With its upper and lower poles free, the thyroid lobe remains fixed to the trachea by the ligament of Berry. The thyroid gland is rolled medially, and with the RLN separated from the thyroid gland and in clear view, the ligament is encircled, ligated, and divided (Figs. 40–5 and 40–6). During this active dissection, most complications of thyroidectomy can occur.
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Thyroid isthmus
Cricothyroid muscle Ligament of Left upper Berry ligature parathyroid gland
Left thyroid lobe
Trachea
Recurrent laryngeal nerve
Figure 40–6 Completed dissection of the left lobe of the thyroid gland. With the ligament of Berry divided, the thyroid lobe is attached only by the isthmus, and the trachea returns to its natural position. Careful hemostasis must be ensured.
Hypoparathyroidism ● Consequence The parathyroid glands are delicate structures that share a blood supply with the thyroid gland. Their diminutive size (normally 30–60 mg) and fragile nature make them particularly prone to damage during thyroidectomy. Patients who have markedly diminished or absent parathyroid function after thyroidectomy have severe hypocalcemia that requires replacement. If permanent, this complication can be palliated by calcium and vitamin D supplements, but this requires multiple doses each day, and uncomfortable symptoms occur if doses are late or missed. In addition, there is cumulative bone damage over time. The symptoms of hypoparathyroidism are those of severe hypocalcemia. Patients have numbness and tingling in the distal extremities and around the mouth or tongue in the earliest phases. With more severe hypocalcemia, patients develop muscle cramping at rest or, especially, with use. The anxiety that often accompanies these symptoms exacerbates them because the patient hyperventilates. The consequent respiratory alkalosis shifts more calcium intracellularly, lowering the serum level of calcium and worsening the symptoms. Severe tetany can result. Patients can then be limited in their ability to help themselves resolve the episode with calcium supplements because their hands and forearms are often severely affected by the muscle spasms. The classic signs of hypocalcemia are Chvostek’s sign and Trousseau’s sign. Chvostek’s sign is generated by tapping gently over the facial nerve in the lateral cheek to demonstrate facial muscle contraction due to increased nerve irritability. This sign is present in a minority of people with a normal serum level of calcium and so is not entirely reliable in the diagnosis of hypocalcemia.
Trousseau’s sign is elicited by placing a sphygmomanometer cuff on the upper arm and inflating to systolic pressure. Within a few minutes, the patient develops severe carpal spasm, with flexion of the wrist and fingers, and abduction of the thumb. This sign is very uncomfortable for the patient and should not be used clinically. In general, the symptoms of hypocalcemia are much more reliable and useful than the signs for patient assessment. Grade 1/2 complication ● Repair The acute management of hypocalcemia in the postoperative patient depends upon the severity of the hypocalcemia and symptoms. Total serum calcium levels correlate roughly with symptoms but are quite variable between individuals. Some patients can have extremely low total serum levels of calcium with no symptoms, whereas others can have severe symptoms and signs, with nearly normal calcium levels. Ionized calcium measurements correlate better than total serum calcium levels, but there is still variability. Replacement is generally guided by symptoms. For mild hypocalcemia with tingling, oral calcium supplements (calcium carbonate, 500–1500 mg by mouth, two to four times a day) are often sufficient to resolve the hypocalcemia. Daily doses of calcium above 3000 mg provide little incremental benefit, however, because of the limits of gastrointestinal absorption of calcium. If supplementation beyond this level is necessary, the addition of supplemental vitamin D (calcitriol 0.25–1.0 mcg daily) will increase the gastrointestinal absorption of calcium. Vitamin D requires 48 to 72 hours to have its effect, however, so intravenous calcium supplementation may be needed until then. Anticipation of the need for vitamin D can smooth patient management considerably by starting it early. Hypocalcemia not controlled by oral supplements, or accompanied by severe symptoms such as muscle cramping, is best managed by intravenous calcium administration. Intravenous calcium gluconate is the only option for calcium supplementation. Calcium chloride can cause severe tissue damage if accidental tissue infiltration occurs and should be used only for the acute, life-threatening cardiac emergency. Bolus administration of calcium gluconate (supplied in 1000-mg ampules containing 90 mEq calcium) corrects serum levels of calcium rapidly and safely, although the effect is short lived. A preferable alternative is to use a calcium gluconate solution (6 ampules calcium gluconate = 6 g calcium gluconate = 540 mEq calcium in 500 ml D5W) infused at 1 ml/kg/hr. This provides a steady calcium supplement and can be adjusted to maintain the calcium in the normal range while oral supplements are absorbed. Temporary hypocalcemia occurs in about 10% of patients after total thyroidectomy, and permanent hypocalcemia occurs in about 1% (Table 40–1).5–11 The temporary hypocalcemia can be severe and requires intravenous and oral
40 THYROID SURGERY
401
Table 40–1 Incidence of Complications after Total Thyroidectomy Authors, Yr Thompson, 19786
Farrar, 19805
Schroder, 19867
Clark, 19888
Ley, 19939
Tartaglia, 200310
Rosato, 200411
No. of Patients
165
29
56
160
124
1636
9599
Transient nerve paresis, N (%)
NR
NR
1 (2%)
4 (2.5%)
1 (0.8%)
31 (1.9%)
195 (2%)
Permanent nerve paresis, N (%)
0
1 (3%)
0
3 (2%)*
1 (0.8%)
15 (0.9%)
94 (1%)
Transient hypoparathyroidism, N (%)
NR
2 (7%)
9 (17%)
NR
13 (10%)
NR
797 (8.3%)
Permanent hypoparathyroidism, N (%)
4cm Elevated aldo-renin ratio Elevated plasma and/or urinary metanephrines.
+
Adrenalectomy
Interval growth or hyperfunction
− Non-enhanced CT
10H
Delayed enhanced CT or chemical shift MRI
>50% contrast washout (15min) OR signal drop on out-of-phase MRI
6–8 cm). ● Malignant tumors, particularly with evidence of invasion. ● Conversion to open procedure during a laparoscopic approach.21 ● Primary or metastatic invasive adrenal malignancies because extensive en-bloc excision and node dissection may be necessary. ● Previous extensive upper abdominal surgery in the area of adrenal dissection (e.g., nephrectomy, partial hepatectomy, or splenectomy). ● Intracranial hypertension (may be exacerbated by CO2 insufflation). ● Diaphragmatic hernias. ● Cardiovascular and respiratory diseases that preclude laparoscopic surgery.
Advantages ● Better en-bloc resection and lymphatic clearance for malignant tumors. Disadvantages ● More postoperative ileus compared with laparoscopic approach.
Retroperitoneal Adrenalectomy—Posterior Approach Advantages ● Reduced operative time for bilateral adrenalectomy. ● Fewer wound complications than with the open retroperitoneal approach. Disadvantages ● Limited operative space. ● Poor organ and tissue landmarks. ● Requires specific experience.
Open Posterior Adrenalectomy Advantages ● Bilateral adrenalectomy without the need to reposition the patient. ● Less postoperative ileus. ● Fewer wound complications. Disadvantages ● Less visualization and control of potential hemorrhage. ● Difficult dissection with larger tumors (>7 cm). ● The adrenal vein is identified at a later phase in dissection. Therefore, pheochromocytomas are a relative contraindication because early ligation of the adrenal vein may prevent excessive intra-operative hemodynamic instability. ● Subcostal nerve injury.
Thoracoabdominal Adrenalectomy Indications ● Tumors greater than 12 cm. ● Tumors adherent to the diaphragm, liver, and extraadrenal structures. Advantages ● Excellent exposure for large tumors. Disadvantages ● Postoperative pulmonary dysfunction. Division of the diaphragm peripherally, 2 cm from its insertion into the chest wall, may reduce postoperative pulmonary dysfunction. ● Postoperative pain.
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Dissection of inferior pole of adrenal gland and superior pole of kidney Removal of adrenal gland and desufflation Closure of trocar sites
Laparoscopic Anterior Transperitoneal Adrenalectomy
Step 7
OPERATIVE STEPS (Table 42–1)
Figure 42–8 shows the positioning for the laparoscopic anterior transperitoneal approach during right adrenalectomy.
Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
Positioning Trocar insertion and CO2 insufflation Liver mobilization (spleen and pancreas for left adrenal gland) Dissection of inferior vena cava (IVC) Identification and ligation of adrenal vein Dissection of arterial supply (medial) of adrenal gland
Table 42–1 Steps for Laparoscopic Anterior Transperitoneal Adrenalectomy Step
Description
Position of the patient
Full left lateral decubitus position, lower leg flexed, cushion under left flank, table flexed to open the space between the inferior costal margin and the anterior superior iliac spine.
Trocar placement
Usually three or four trocars (one 12 mm and three 5 mm) and a 30° laparoscope are required.
Liver retraction
An atraumatic liver retractor is used to gently retract the liver superiorly and medially.
Mobilization of the liver (spleen and pancreas for left adrenal)
Using electrocautery hook, scissors, or ultrasonic shears, the subhepatic peritoneum is incised lateral to the inferior vena cava. Complete mobilization of the liver to include dissection of the right triangular ligament.
Identification of the inferior vena cava and the renal vein
Lateral border of the inferior vena cava is dissected superiorly to the level of the right crus of the diaphragm and can be dissected inferiorly to visualize the renal vein.
Identification of the main and accessory adrenal veins
Main adrenal vein is divided between surgical clips. An accessory adrenal vein may be present inferiorly.
Dissection of the arteries
Multiple adrenal arteries supply the adrenal gland from the aorta and the phrenic and renal arteries. These can usually be controlled by electrocautery or with ultrasonic shears.
Extraction of the gland
Attachments between the inferior aspect of the gland and the upper pole of the kidney are dissected. The gland is grasped with an atraumatic grasper and introduced into an extraction bag. The port site may be slightly enlarged depending on the size of the gland. Figure 42–7 shows placement of adrenal gland in an endobag.
Postoperative care
Liquid diet and ambulation on the day of surgery. Discharge home in 1 or 2 days.
Step 8 Step 9
Positioning
Nerve Injuries; Brachial Plexus, Peroneal Nerve Injury ● Consequence Transient or permanent neuropathy with disability. Grade 1/3 complication ● Repair No specific repair. Physical therapy and rehabilitation may improve function. ● Prevention Padding of all bony prominences, especially the dependent lower extremity. Correct placement of axillary roll
Figure 42–7 Placement of the adrenal gland in an Endobag.
Figure 42–8 Position for the laparoscopic right adrenalectomy— transperitoneal approach.
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prior to laparoscopic adrenalectomy. Avoidance of excessive shoulder stretching. The lower leg is slightly flexed to provide stability and the upper leg extended. A pillow placed between the legs should support the upper leg and prevent stress on the knee joint.
Skeletal Fractures May Occur with Patients with Severe Osteoporosis from Cushing’s Syndrome ● Consequence Inability to ambulate. Grade 4 complication
● Repair Intraoperative repair when possible. Control of bleeding with energy sources (electrocautery, argon beam coagulator) or hemostatic agents. May require open conversion. ● Prevention Careful dissection, leaving a peritoneal flap during splenic or liver dissection.
Dissection of the IVC and Adrenal Vein Vascular Injury (IVC, Renal or Adrenal Vein)
● Repair Open reduction and internal fixation. ● Prevention Padding of all bony prominences and preventing excessive torsion on joints.
Trocar Insertion and CO2 Insufflation Figure 42–9 shows port placement from above.
Bowel and Vascular Injuries Grade 3 complication Bowel and vascular injuries during entry into the abdomen may occur during laparoscopic procedures. Their consequences and steps for prevention are detailed in Section I, Chapter 7, Laparoscopic Surgery.
Liver Mobilization (Spleen and Pancreas for Left Adrenal Gland) Solid Organ Injury ● Consequence Bleeding (intraoperative and postoperative). May require open conversion and splenorrhaphy or splenectomy. Pancreatic fistula and intra-abdominal abscess formation. Grade 3 complication
● Consequence Intraoperative bleeding and hypotension. ischemia or infarction with possible renal loss. Grade 3 complication
Renal
● Repair Small tears may be controlled with surgical clips. Larger tears will require open conversion and suture repair. Direct gentle caval compression may be attempted with an endoscopic Kittner dissector during a laparoscopic procedure to control blood loss. Conversion to open adrenalectomy should be performed early if there is difficulty maintaining hemostasis. ● Prevention Careful dissection with minimal tension on the adrenal gland or adrenal vein. Clear visualization of the space between the IVC and the right adrenal gland. The right adrenal vein drains directly into the right hepatic vein in 4% of patients.22 An accessory right adrenal vein can also drain into the inferior phrenic vein, and rarely, the main adrenal vein can divide into two branches, each entering the IVC separately.
Identification and Ligation of the Adrenal Vein Adrenal Vein Injury ● Consequence Same as for “Vascular Injury (IVC, Renal or Adrenal Vein),” earlier. An example of adrenal hemorrhage from possible adrenal vein injury during adrenal vein sampling is shown in Figure 42–10. Grade 3 complication Figures 42–11 and 42–12 show adrenal vein and its relation to inferior vena cava.
Dissection of the Arterial Supply (Medial) to the Adrenal Gland Bleeding from Adrenal Arteries Figure 42–9 Trochar placement for adrenalectomy–transperitoneal approach.
laparoscopic
right
● Consequence Intraoperative or postoperative hemorrhage. Grade 3 complication
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Figure 42–13 Partial diaphragmatic injury. Figure 42–10 Adrenal hemorrhage.
IVC
● Repair Control of small adrenal arteries can usually be accomplished with surgical clips. The use of a suction irrigator device as a retractor is helpful to keep the operative field dry. ● Prevention Careful use of ultrasonic shears or electrocautery to coagulate small arteries prior to dividing them.
Adrenal vein
Injury to the Diaphragm or Stomach (Left Adrenalectomy) Figure 42–11 Adrenal vein going into the inferior vena cava (IVC).
● Consequence Postoperative bleeding. Postoperative abdominal abscess. Gastrocutaneous fistula. Diaphragmatic hernia. Figure 42–13 shows diaphragmatic injury during laparoscopic right adrenalectomy. Grade 3 complication ● Repair Laparoscopic or open suture repair of the stomach or diaphragm. ● Prevention Sharp dissection under direct vision.
Clips on adrenal vein
IVC
Dissection of the Inferior Pole of the Adrenal Gland and the Superior Pole of the Kidney Renal Vascular Injury
Figure 42–12 Clipped adrenal vein—right adrenalectomy.
● Consequence, Repair, and Prevention Similar to those of “Vascular Injury (IVC, Renal or Adrenal Vein),” earlier. Grade 3 complication
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Removal of the Adrenal Gland Hollow Viscus or Solid Organ Injury ● Consequence and Repair Same as for “Bowel and Vascular Injuries,” and “Solid Organ Injury,” under “Liver Mobilization (Spleen and Pancreas for Left Adrenal Gland),” earlier. Grade 3 complication ● Prevention Direct visualization of the bag during extraction from the abdominal cavity will prevent the bowel being pulled up and injured during removal of the adrenal gland.
Closure of Trocar Sites Similar to that for other laparoscopic procedures. Entrapped bowel and postoperative hernias may occur; therefore, closure of trocar sites should be performed under direct vision (laparoscopically or anteriorly).
Open (Right) Anterior Adrenalectomy OPERATIVE STEPS Step Step Step Step Step
1 2 3 4 5
Step 6 Step 7
Entering abdomen Mobilizing liver Dissection of IVC Identification and ligation of adrenal vein Dissection of arterial supply (medial) of adrenal gland Dissection of inferior pole of adrenal gland and superior pole of kidney Removal of adrenal gland
Duodenal Injury ● Consequence Duodenal fistula. Abscess formation. Grade 3 complication ● Repair Two-layer suture repair and drainage. ● Prevention Dissecting the IVC cephalad to the duodenum.
Colonic Injury (Hepatic Flexure) ● Consequence, Repair, and Prevention This is rare during right adrenalectomy; however, the consequences and repair are similar to those of “Bowel and Vascular Injuries” under “Laparoscopic Anterior Transperitoneal Adrenalectomy,” earlier. Figures 42–14 and 42–15 show the laparoscopic dissection for a right adrenalectomy. Figure 42–16 shows the mobilization of the liver in an open approach. Grade 3 complication
Open (Left) Anterior Adrenalectomy OPERATIVE STEPS Step Step Step Step
1 2 3 4
Step 5 Step 6
Entering abdomen Entering lesser sac and mobilizing pancreas Identification and ligation of adrenal vein Dissection of arterial supply (medial) of adrenal gland Dissection of inferior pole of adrenal gland Removal of adrenal gland
Abdominal Entry Small Bowel Injury
Abdominal Entry
● Consequence, Repair, and Prevention Similar to consequences during “Laparoscopic Anterior Transperitoneal Adrenalectomy,” earlier. In the presence of adhesions, sharp dissection under direct vision may reduce the risk of bowel injury. Grade 3 complication
Bowel Injury
Hepatic Flexure Injury
Entering the Lesser Sac and Mobilizing the Pancreas
● Consequence, Repair, and Prevention Similar to those of “Bowel and Vascular Injuries” under “Laparoscopic Anterior Transperitoneal Adrenalectomy,” earlier. Grade 3 complication
● Consequence, Repair, and Prevention Same as those of “Bowel and Vascular Injuries” under “Laparoscopic Anterior Transperitoneal Adrenalectomy,” earlier. Grade 3 complication
Stomach Injury Same as those of “Bowel and Vascular Injuries” under “Laparoscopic Anterior Transperitoneal Adrenalectomy,” earlier.
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Liver
A
Figure 42–15
Dissection—right adrenalectomy.
Adrenal
Kidney
B
Figure 42–16 adrenalectomy.
Mobilization
of
the
liver
for
a
right
● Prevention Gentle upward retraction of the pancreas with blunt retractors.
Colonic Injury (Splenic Flexure)
C Figure 42–14
Dissection—right adrenalectomy.
● Consequence, Repair, and Prevention Similar to those of “Bowel and Vascular Injuries” under “Laparoscopic Anterior Transperitoneal Adrenalectomy,” earlier. Grade 3 complication
Splenic Injury Pancreatic Injury ● Consequence Pancreatic fistula or abscess. Pancreatitis. Grade 3 complication ● Repair No repair for small injuries. However, larger injuries may require distal pancreatectomy. All injuries should be drained to create a controlled pancreatic fistula.
● Consequence Intraoperative or postoperative hemorrhage requiring splenorrhaphy or splenectomy. Postsplenectomy infection. Grade 4 complication ● Repair Electrocautery, argon beam coagulator, hemostatic agents, splenorrhaphy. or splenectomy.
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● Prevention Sharp dissection of splenocolic and splenophrenic ligaments under direct vision and leaving a flap of peritoneum attached to the spleen during dissection. This flap can be used to retract the spleen without avulsing the splenic capsule.
Step 3 Step 4 Step 5 Step 6 Step 7 Step 8
Retroperitoneal entry Dissection of upper pole of kidney Dissection of arterial supply (medial) of adrenal gland Ligation of adrenal vein Removal of adrenal gland Wound closure
Identification and Ligation of the Adrenal Vein Discussed under “Laparoscopic Anterior Transperitoneal Adrenalectomy” under “Dissection of the IVC & Adrenal Vein.”
Patient Positioning Patient is placed prone with arms extended. There is a risk of brachial plexus injury from stretching, especially in prolonged cases.
Dissection of the Arterial Supply (Medial) of the Adrenal Gland
Incision Placement and Muscle Dissection
Injury to thoracic duct or intestinal lymphatics around the left crus may occur.
The classic Young curvilinear (hockey-stick) incision or a 12th rib incision (parallel to the 12th rib) may be used.
Injury to the Lymphatics
Rib Resection and Pleural Reflection
● Consequence Chylous fistulas. Grade 3 complication ● Repair Initial therapy is pharmacologic. Etilefrine chlorhydrate is an α-adrenergic agonist that acts on the muscular fibers of the thoracic duct. Patients can also be placed on a medium chain triglyceride diet. Persistent chylous fistulas may require reoperation. ● Prevention Dilated lymphatic connections should be individually ligated.
Dissection of the Inferior Pole of the Adrenal Gland Complications and pitfalls are similar to those of laparoscopic anterior transperitoneal adrenalectomy under “Dissection of the Inferior Pole of the Adrenal Gland and Superior Pole of the Kidney.”
Injury to the Intercostal Blood Vessels and the Subcostal Nerve ● Consequence Intraoperative or postoperative hemorrhage. Retroperitoneal hemorrhage. Postoperative abdominal wall hypesthesia and muscle laxity. Grade 2 complication ● Repair Suture ligation of intercostal blood vessels. No repair for nerve injury. ● Prevention Subperiosteal dissection prior to rib resection ensures that only the rib is resected.
Injury to the Pleura ● Consequence Pneumothorax. Lung injury. Grade 3 complication
Removal of the Adrenal Gland
● Repair Suture repair and thoracostomy tube drainage.
Complications and pitfalls are as discussed under “Removal of the Adrenal Gland” under “Laparoscopic Anterior Transperitoneal Adrenalectomy.”
● Prevention Subperiosteal dissection.
Open Posterior Adrenalectomy OPERATIVE STEPS Step 1 Step 2
Patient positioning Incision placement and muscle dissection
Dissection of the Upper Pole of the Kidney Injury to the Kidney, Hemorrhage ● Consequence Intraoperative or postoperative hemorrhage. Grade 3 complication ● Repair Hemostasis with ligatures and electrocautery.
42 ADRENAL SURGERY
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Fascial edge
Phrenic vein
Lumbar hernia
Lumbar hernia
Adrenal vein
Figure 42–18 adrenalectomy.
Bilateral lumbar hernias after an open posterior
● Prevention Use of the kidney for retraction and avoidance of excessive traction on the adrenal vein.
Wound Closure Figure 42–17 Left adrenal—dissection showing the confluence of adrenal and phrenic veins.
Lumbar Hernias (Fig. 42–18)
● Prevention Sharp dissection under direct vision.
● Consequence Pain and discomfort. Grade 3 complication
Dissection of the Arterial Supply (Medial) to the Adrenal Gland Complications are similar to those of “Dissection of the Arterial Supply (Medial) to the Adrenal Gland” under “Laparoscopic Anterior Transperitoneal Adrenalectomy,” earlier.
Ligation of the Adrenal Vein
● Repair Operative hernia repair. ● Prevention Multilayer closure with nonabsorbable or delayed absorbable sutures.
Complications are similar to those of “Dissection of the Arterial Supply (Medial) to the Adrenal Gland” under “Laparoscopic Anterior Transperitoneal Adrenalectomy,” earlier.
Retroperitoneoscopic (Posterior) Adrenalectomy
Injury to the Vena Cava or the Renal Vein Figure 42–17 shows the left adrenal vein and the phrenic vein.
OPERATIVE STEPS
● Consequence Intraoperative or postoperative hemorrhage. Renal injury. Grade 3 complication
Step Step Step Step Step
● Repair Suture repair suture.
Step 6 Step 7 Step 8
with
monofilament
nonabsorbable
1 2 3 4 5
Patient positioning Incision placement and muscle dissection Retroperitoneal entry Dissection of upper pole of kidney Dissection of arterial supply (medial) of adrenal gland Ligation of adrenal vein Removal of adrenal gland Wound closure
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Figure 42–19 Stapler for partial adrenalectomy.
The complications of this approach are similar to those that occur after “Open Posterior Adrenalectomy.” However, the incidence of wound complications is lower.23,24 Partial adrenalectomy may be necessary in situations in which preservation of adrenal function is desirable in a patient with no contralateral adrenal gland. The challenge of partial adrenalectomy is parenchymal bleeding and remnant devascularization. However, these can be minimized using careful dissection, bipolar electrocautery, and topical hemostatic agents. Stapling devices can also be used for partial resections (Fig. 42–19).
REFERENCES 1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992;327:1033. 1a. Brunt LM. Current approach to the adrenal incidentaloma. In Problems in General Surgery. Philadelphia: Lippincott, 1984; pp 81–91. 2. Suzuki H. Laparoscopic adrenalectomy for adrenal carcinoma and metastases. Curr Opin Urol 2006;16:47– 53. 3. Caoili EM, Korobkin M, Francis IR, et al. Delayed enhanced CT of lipid-poor adrenal adenomas. AJR Am J Roentgenol 2000;175:1411–1415.
4. Boland GW, Hahn PF, Pena C, et al. Adrenal masses: characterization with delayed contrast-enhanced CT. Radiology 1997;202:693–696. 5. Anca M, Avram LMF, Gross MD. Adrenal gland scintigraphy. Semin Nucl Med 2006;36:212–227. 6. Favia G, Lumachi F, Basso S, et al. Management of incidentally discovered adrenal masses and risk of malignancy. Surgery 2000;128:918–924. 7. Korobkin M, Dunnick NR. Characterization of adrenal masses. AJR Am J Roentgenol 1995;164:643–644. 8. Outwater EK, Siegelman ES, Radecki PD, et al. Distinction between benign and malignant adrenal masses: value of T1-weighted chemical-shift MR imaging. AJR Am J Roentgenol 1995;165:579–583. 9. NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”). NIH Consens State Sci Statements 2002;19:1–25. 10. Small M, Lowe GDO, Forbes CD, et al. Thromboembolic complications in Cushing’s syndrome. Clin Endocrinol 1983;19:503–511. 11. Bonjer HJ, Bruning HA. Endoscopic retroperitoneal— flank approach. Oper Tech Gen Surg 2002;4:322–330. 12. Hanssen WE, Kuhry E, Casseres YA, et al. Safety and efficacy of endoscopic retroperitoneal adrenalectomy. Br J Surg 2006;93:715–719. 13. Berends FJ, Harst EVD, Giraudo G, et al. Safe retroperitoneal endoscopic resection of pheochromocytomas. World J Surg 2002;26:527–531. 14. Berber E, Siperstein AE. Laparoscopic retroperitoneal adrenalectomy—posterior approach. Oper Tech Gen Surg 2002;4:331–337. 15. Brunt LM, Doherty GM, Norton JA, et al. Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms. J Am Coll Surg 1996;183:1–10. 16. Saunders BD, Doherty GM. Laparoscopic adrenalectomy for malignant disease. Lancet Oncol 2004;5:718–726. 17. Shen W, Sturgeon C, Clark OH, et al. Should pheochromocytoma size influence surgical approach? A comparison of 90 malignant and 60 benign pheochromocytomas. Surgery 2004;136:1129–1136. 18. Gagner M. Laparoscopic adrenalectomy. Surg Clin North Am 1996;76:523–537. 19. Gagner M, Pomp A, Heniford BT, et al. Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures. Ann Surg 1997;226:238–246; discussion 246–247. 20. Fazeli-Matin S, Gill IS, Hsu THS, et al. Laparoscopic renal and adrenal surgery in obese patients: comparison to open surgery. J Urol 1999;162:665–669. 21. Shen W, Kebebew E, Clark O. Reasons for conversion from laparoscopic to open or hand-assisted adrenalectomy: review of 261 laparoscopic adrenalectomies from 1993 to 2003. World J Surg 2004;28:1176–1179. 22. Proye CAG, Lokey JS. Thoracoabdominal adrenalectomy for malignancy. Oper Tech Gen Surg 2002;4:338–345. 23. Walz MK, Alesina PF, Wenger FA, et al. Laparoscopic and retroperitoneoscopic treatment of pheochromocytomas and retroperitoneal paragangliomas: results of 161 tumors in 126 patients. World J Surg 2006;30:899–908. 24. Walz MK, Petersenn S, Koch JA, et al. Endoscopic treatment of large primary adrenal tumours. Br J Surg 2005;92:719–723.
Section VI
BREAST SURGERY Shawna C. Willey, MD It is on our own failures that we base a new and different and better success. —Havelock Ellis
43
Image-Guided Breast Biopsy Richard E. Fine, MD and Kenneth J. Bloom, MD
INTRODUCTION Increased utilization of mammography screening is believed to have resulted in a relative increase in breast abnormalities of sufficient risk to warrant a biopsy. It is estimated that approximately 1.5 million breast biopsies are performed each year in the United States. Many of these biopsies are for nonpalpable lesions and, therefore, require some type of image guidance. A significant number of these biopsies will be performed for benign disease because the average positive predictive value for mammography is only 20% (range 15%–35%).1–4 If traditional methods for histologic confirmation were utilized, all women with nonpalpable breast lesions would proceed to the operating room after a wire localization procedure was performed in the radiology suite. Percutaneous imageguided breast biopsy has become an effective minimally invasive alternative to open surgical breast biopsy for the diagnosis of both palpable and nonpalpable imagedetected abnormalities.5–7 Although the risk of bleeding and infection may be comparable with those of open surgical breast biopsy, some potential difficulties are unique to image-guided breast biopsy.8 With the early introduction by the Karalinski Institute in 1989 of stereotactic-guided fine-needle aspiration cytology of nonpalpable breast abnormalities,9 imageguided percutaneous breast biopsy has been shown to provide a secondary level of screening in a less-invasive,
cost-effective manner to obtain a histologic diagnosis without sacrificing accuracy.5–7,10 The evolution of the biopsy tools used with image guidance (stereotaxic, ultrasound, and recently, magnetic resonance imaging [MRI]) has added to the accuracy of minimally invasive imageguided breast biopsy,11,12 keeping a greater portion of women with probably benign disease out of the operating room for a diagnostic procedure. However, advancement in technology has also added to the potential procedural risks.13
INDICATIONS Almost any palpable or nonpalpable, indeterminate breast abnormality, which is visualized with imaging modalities (ultrasound, mammography, MRI), can be evaluated with image-guided breast biopsy. The lesions will fall into the following categories established by the American College of Radiology (ACR) lexicon14: ● BI-RADS 3 (probably benign, short-interval follow-up
[6 mo], 30–45 min) will cause a decrease in blood flow and result in skin necrosis at the entrance site. Local anesthesia with epinephrine (1 : 100,000) is commonly used with the deeper injection into the breast parenchyma. Grade 1 complication ● Repair The area of necrosis is usually limited to the size of the skin wheal. Local wound care is sufficient and rarely requires surgical excision of the necrotic skin.
43 IMAGE-GUIDED BREAST BIOPSY
Injecting Too Much Local Anesthetic ● Consequence Too much local anesthetic injected into the biopsy site can also pose potential problems. The injection is not performed in real time as is done with ultrasoundguided procedures and, therefore, can cause inadvertent lesion movement, and faint, noncalcified lesions can become difficult if not impossible to see on additional imaging. Grade 2 complication ● Repair If the injection is too large, a quantity of local anesthetic results in the movement of the lesion such that adequate sampling may be altered; in this situation, it will be necessary to remove the biopsy device from the breast and retarget the lesion. If the lesion is faint and/or noncalcified, correction is more difficult. Occasionally, waiting a few minutes for reabsorption or dilution of the local anesthetic is sufficient. Sometimes, a review of the stereo digital images taken for initial targeting can help judge the correct position of the lesion by comparing the surrounding breast architecture. A last resort would be postponing the procedure and rescheduling. ● Prevention Physicians have employed different techniques for providing the patient with adequate anesthesia and avoiding the difficulties outlined. One technique utilizes a skin wheal followed by injection of deep local anesthetic at the four quarters of the clock (12, 3, 6, 9 o’clock positions) positioned at the lateral aspect of the skin wheal. The 1½ inch needle is inserted to the hub and the local anesthetic is injected gently as the needle is withdrawn. This technique disperses the local anesthetic evenly and provides a region of anesthesia where tissue sampling will occur. Another technique involves placing local anesthetic directly at the biopsy site only after a skin wheal has been raised. A spinal needle can be directed with stereotactic guidance to the correct x-, y-, and z-axis (depth) coordinates, and 1 or 2 ml of local anesthetic is directed in a limited fashion to the biopsy site. However, the most accurate prevention starts with recognition of which lesions will be difficult to visualize when larger amounts of local anesthetic are injected (faint asymmetrical densities and microcalcifications). Prior to injecting larger quantities of local anesthetic, deploying a metallic clip in the lesion will eliminate nonvisualization. In addition, allowing injection of deep local anesthesia only after the biopsy device is in position and visually aligned with the target lesion will usually accomplish the goal.
Insertion of the Biopsy Device The physician inserts the biopsy device into the breast to the depth determined by the system software.
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Failure to Recognize Specific Insertion Depths for Different Devices ● Consequence Certain devices require placement at a depth less than that calculated by the system software. The “pullback” is calculated by the individual manufacturers because of the device mechanics such as the forward motion or throw with the amount of “dead space” at the front of the needle along with the length of the sampling portion of the needle. If the required pullback in depth is ignored for a particular device, the device may be too deep or not aligned correctly with the lesion and adequate tissue sampling will not occur. Grade 1 complication ● Prevention It is crucial not only to be familiar with the biopsy mechanism of the device but also to know the specifications from the manufacturers for stereotactic targeting, including the pullback depth. The Fischer MammoTest table allows the specifications for all the biopsy devices physicians will use to be programmed into the system. The Lorad Multi-Care table requires calibration of each device to the system on each patient (z-axis = zero), and the physician manually sets the depth.
Inability to Avoid a Negative Stroke Margin ● Consequence If a negative stroke margin cannot be prevented by changing the positioning or approach to the breast or utilizing any of the other previously discussed options, the negative stroke margin must be recognized and manipulated to prevent injury to the patient or the equipment. Grade 1 complication ● Repair The most commonly employed correction method is pulling back the prefire position of the biopsy needle a determined number of millimeters until the calculated stroke margin is adequate. Care must be taken not to pull back the biopsy device to a distance that places the sampling notch or biopsy mechanism too far in front of the lesion such that the lesion will be missed.
Assess Appropriate Alignment between the Lesion and the Biopsy Device on Prebiopsy and/or Postbiopsy Alignment Stereo Digital Images Failure to Recognize Targeting Errors ● Consequence Interpretation of the stereotactic digital images allows the physician to determine whether the breast-imaged abnormality is within the range required by the device for adequate sampling. Correct targeting demonstrates
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Vertical error 12
9
3
6
Probe is above
12
9
3
6
Probe is below
Figure 43–6 Y or vertical axis targeting error: The device is visualized above or below the lesion. The directed sampling is illustrated by the shaded areas on the clock.
symmetrical alignment of the lesion and the biopsy portion of the device in each stereo image. There are three types of targeting errors that can occur: x-, y-, and z-axis targeting errors. X-axis deviation occurs when the lesion is pushed to the right or the left of the biopsy needle. Y-axis errors represent movement of the lesion above or below the needle/probe. Z-axis error occurs when the sampling notch or biopsy mechanism is too proximal or too distal to the depth of the breast abnormality. Grade 1 complication ● Repair Fortunately, most x- and y-axis targeting errors that present a problem with stereotactic needle-core biopsy have a limited effect on the success of a stereotactic biopsy performed with either a VAB or a large-intake sample device because these devices can be directed for specific sampling (Fig. 43–6). However, if the deviation from the target is significant enough to risk a poor biopsy, the lesion must be retargeted. After the device is removed from the breast, it is redirected and inserted with new coordinates. ● Prevention To avoid missing a lesion because of an incorrect depth (z-axis) coordinate caused by forward motion of the lesion because of the “plowing” effect as the biopsy device is inserted; targets can be placed on the lesion in each of the new stereo images and the resultant zaxis depth compared with the original z-axis depth. The
position of the target in each stereo image can also be helpful in preventing lesion movement and improve the probability of being able to easily visualize a very small lesion once the biopsy needle/probe is fully inserted into the breast. By targeting beneath the lesion, some of the plowing effect is dispersed, and because the lesion will be elevated above the device, even a very small lesion will not be hidden and its position will be easily assessed.
Adequately Sample the Lesion for Diagnosis and/or Potential Therapeutic Removal Failure to Choose the Correct Biopsy Device ● Consequence The tools for specimen acquisition have evolved from fine-needle aspiration, automated Tru-Cut core needle, VAB devices to large-intact sampling instruments, and the technologic advancements have closely paralleled the acceptance of image-guided breast biopsy.19 Fineneedle aspiration has long been recognized to have several potential pitfalls. This includes insufficient sampling, as high as 38% in some series, with sensitivity ranges between 68% and 93% and specificity between 88% and 100%.18,19 Cytology rarely provides a specific benign diagnosis and cannot distinguish between invasive and in situ carcinoma. The automated Tru-Cut core needle has a lower false-negative rate compared with that of fine-needle aspiration.5–7 Standard use of the 14-gauge needle essentially eliminated the issue of insufficient sampling.
43 IMAGE-GUIDED BREAST BIOPSY Several different gauge needles have been evaluated for Tru-Cut biopsy. The lower rate of insufficient sampling and increased sensitivity, without increased complications, has led to a minimum size of 14-gauge as a standard.5,19 The issue of how many cores are needed was addressed by Dr. Laura Lieberman from Sloan-Kettering in New York.20 In this study, 145 lesions were biopsied: 92 were nodular densities, and 53 were microcalcifications. Five cores with a 14-gauge automated Tru-Cut needle yielded a diagnosis in 99% of biopsies for breast masses. Five cores yielded a diagnosis in only 87% of the microcalcification cases, and more than six cores yielded a diagnosis in 92% of the cases. The accuracy of needle-core biopsy of microcalcifications came into question. Studies demonstrated upgrading to carcinoma from 48% to 52% of atypical hyperplasia identified on stereotactic core biopsy.21–23 Not surprisingly, atypical hyperplasia diagnosed at stereotactic core biopsy has become an indication for open biopsy. Grade 2 complication ● Repair The VAB device was developed to satisfy the requirement of increasing the size of the core sample and the contiguous nature of the sampling as a proposed solution to the upgrading issue.24,25 The VAB system was ideal for performing an image-guided biopsy of calcifications under stereotactic guidance. The spring-loaded mechanism to advance the biopsy probe could eliminate the potential z-axis targeting error by rapidly penetrating the tissue and avoiding the plowing effect of pushing the lesion forward. But the ability to manually insert the device without having to utilize the firing mechanism could help deal with the small breast and potential stroke margin issues. The vacuum applied to the sampling portion of the device eliminates the pinpoint accuracy required with automated Tru-Cut biopsy needles by pulling the lesion toward the sampling chamber, and the ability of the VAB sampling to be directional is helpful in dealing successfully with mild x-axis and y-axis targeting errors.18,24 The improved accuracy with the directional VAB device lowered the upgrading of diagnosis compared with that of needlecore biopsy technology.11,12
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large intact sample devices. Fortunately, the vacuum associated with these devices will continue to pull blood from the biopsy site and allow the inherent biopsy mechanism the opportunity to continue to obtain tissue samples. Therefore, from personal experience, the most important step in dealing with bleeding during a stereotactic breast biopsy is to continue to take core samples with appropriate rapidity. The injection of additional local anesthesia with 1 : 100,000 epinephrine can be helpful. ● Prevention During the imaging phase of the procedure, it should be determined whether there are vessels near the lesion that may be in the pathway of the biopsy device. This is accomplished by placing a target on the vessel in each stereo image to check whether the depth is the same as the lesion. If the lesion and the vessel are at the same depth, the patient should be repositioned to try to manipulate the breast so the approach to the lesion avoids the vessel.
Place a Postprocedure Marker and Obtain Postprocedure/Clip Placement Stereo Images Postprocedure digital images are required to document removal of the microcalcifications and, at the same time, to verify the presence of residual calcifications. If the postprocedure images are taken after clip placement, it is important to verify accurate and successful clip deployment. In addition, accuracy is improved when calcifications are documented within the core samples on a digital specimen radiograph.26,27 Even in open biopsy surgical literature, pathologic assessment has identified atypical hyperplasia and ductal carcinoma in situ (DCIS) at a “distance” from the targeted calcifications.28
Clip Placement and Migration
● Consequence During the course of any image-guided breast biopsy procedure, bleeding can occur. An excessive amount of intraprocedural bleeding can potentially interfere with sampling and, as a result, an accurate biopsy. Grade 2 complication
● Consequence At the conclusion of a stereotactic breast biopsy, the placement of a marker has become standard. The marker has two purposes. The first and foremost is to be able to localize a stereotactic biopsy site when all image evidence of the target lesion has been removed, and second, to track the site on future mammograms. The initial clip (Micromark; Ethicon Endosurgery) was developed as an adjunct to the Mammotome VAB device to mark the complete removal of calcifications where pathology resulted in the need for follow-up surgery.29 Clip migration was a reported event.30 The result would be a failure to accurately localize a biopsy site. Grade 1 complication
● Repair When performing a stereotactic breast biopsy, the most common biopsy devices used include VAB devices and
● Prevention The prevention of clip migration involved careful technique, including pulling the device back to position the
Failure to Appropriately Manage Intraprocedural Bleeding
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ramping up of the clip into the center of the biopsy cavity, applying active suction to pull the tissue in the breast toward the clip applier, and rotating and closing the device away from the clip position (to avoid accidental removal). Postprocedure mammograms could accurately ensure good clip placement. The issue of clip migration has also been avoided by the use of clips or markers that do not require attachment to the breast tissue. The newer markers include a metallic component along with an absorbable component such as Vicryl or collagen that can be visualized by ultrasound. These newer markers are simply deposited into the biopsy cavity. As the biopsy site heals, the cavity contracts and the clip is trapped at the biopsy site.
Obtain a Specimen Radiograph Postprocedure digital images and specimen radiographs of calcifications and the relationship to diagnostic upgrading have been addressed earlier. Additional sampling to remove a greater portion of the targeted lesion can easily be accomplished if inadequate calcifications are visualized on postprocedure images.
Obtain Adequate Hemostasis and Apply Appropriate Dressing and/or Wrap Techniques to avoid hematomas are discussed in the section on “Image-Guided Breast Biopsy with Ultrasound Guidance,” later.
Check Pathology for Concordance with Radiologic Impression This topic is addressed in the section on “Pathologic Pitfalls in Image-Guided Breast Biopsy,” later.
Image-Guided Breast Biopsy with Ultrasound Guidance
Adequately sample lesion for diagnosis and/or potential therapeutic removal Step 8 Place postprocedure marker and obtain postprocedure/clip placement mammogram Step 9 Obtain adequate hemostasis and apply appropriate dressing and/or wrap Step 10 Check pathology for concordance with radiologic impression Step 11 Obtain follow-up imaging Step 7
Evaluate the Ultrasound Failure to Recognize a Possible Cystic Lesion ● Consequence The ultrasound characteristics of a complex cyst frequently mimic those of a solid lesion. If the complex cystic lesion is not recognized and the physician moves forward with an image-guided biopsy of a presumed solid lesion, the physician may waste a more costly disposable biopsy device instead of a simple syringe or a needle that would be adequate for a cyst aspiration. By evaluating the ultrasound images and appreciating the depth (superficial or deep) of the lesion or its relationship to an implant, the patient can be better positioned (see the section on “Position the Patient and Equipment [Ultrasound and Biopsy System], later) and the optimal biopsy device chosen. To be discussed further in the section on “Sample the Lesion for Diagnosis and/or Potential Therapeutic Removal,” later, certain biopsy instruments are more ideally suited for a very deep or very superficial lesion. Grade 1 complication ● Prevention Careful evaluation of the diagnostic ultrasound performed at an outside institution can sometimes eliminate the unnecessary wasting of an expensive disposable biopsy tool for a lesion that may actually turn out not to be solid and can be aspirated. Any suggestion of posterior enhancement or other characteristics of a possible complex cyst should first lead to an attempt at aspiration, even with a larger-gauge needle. Occasionally, duct ectasia may be associated with cystic fluid that requires a needle as large as 14-gauge to aspirate the contents.
OPERATIVE STEPS Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
Evaluate ultrasound Position patient and equipment (ultrasound and biopsy system) Identify lesion with ultrasound and optimize image Anesthetize skin and make skin incision after appropriate antiseptic skin preparation Insert biopsy device Confirmation scan for alignment of lesion with biopsy device
Position the Patient and Equipment (Ultrasound and Biopsy System) Poor Positioning of the Patient and Equipment ● Consequence/Prevention Regardless of the imaging modality, the most significant error in image-guided breast biopsy is of course missing the lesion or a failure to accurately sample the breast abnormality and providing the patient a false sense of security. With ultrasound intervention, the ability to perform a successful procedure starts with
43 IMAGE-GUIDED BREAST BIOPSY comfort for the patient and the physician. Positioning of the physician, the patient, and the ultrasound equipment will greatly facilitate the required alignment of the biopsy device with the lesion. Standing opposite to the ultrasound unit will eliminate the physician from turning his or her head away from the biopsy field to see the ultrasound monitor. The optimal setup to provide the best visualization of the advancing biopsy device is a straight line between the physician’s vision and the physician’s arm down the length of the biopsy device, along the long axis of the ultrasound transducer, and up to the ultrasound monitor. Grade 1 complication
Identify the Lesion with Ultrasound and Optimize the Image Inappropriate Gain and Focal Zone Setting ● Consequence/Repair Optimal scanning is achieved by adjusting the time gain compensation slope to provide a uniform gray scale. An altered overall gain setting may change the appearance of the internal echo pattern and limit the ability to distinguish solid from cystic lesions. To achieve the optimal lateral resolution, the sonographer must align the focal zone with the target lesion as illustrated in Figure 43–7. This will better demonstrate the retrotumoral characteristics such as posterior enhancement. Grade 1 complication
Poor Optimization of the Lesion Position for Biopsy ● Consequence If the ultrasound transducer is not positioned so that the greatest diameter of the lesion is within the ultrasound plane, the needle-core biopsy device may miss the lesion by veering off the edge of a solid mass. If the lesion is not positioned correctly on the ultrasound
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monitor, the shortest skin-to-lesion distance will not be achieved. Grade 2 complication ● Prevention Two scanning techniques are crucial for identifying the area of greatest lesion diameter and positioning the lesion on the ultrasound monitor to limit the skin-tolesion distance. Movement of the transducer perpendicular to the long axis of the transducer allows the scanner to visualize the lesion from end to end and find the widest portion of the lesion. Sliding the transducer in the direction parallel with the long axis will change the position of the lesion on the ultrasound monitor.
Prepare the Breast: Skin Preparation, Local Anesthesia, and Skin Incision Failure to Judiciously Administer Local Anesthetic ● Consequence Too much local anesthetic injected into the breast parenchyma carries the risk of the inability to visualize a smaller target lesion. In addition, the injection of too much local anesthetic in one area can create a false lesion that mimics a cyst. This can be especially frustrating when the target lesion is cystic. Grade 2 complication ● Repair If the visibility of the target lesion has been hindered by the local anesthetic administration, few alternatives are available to continue the biopsy. A very skilled sonographer could use an aspiration needle to aspirate any collections of local anesthetic that are interfering with the biopsy. However, the usual course of action would be to wait until the local anesthetic has been reabsorbed. Attempting to perform the biopsy without optimal visualization of the lesion could result only in
Figure 43–7 Alternating the focal zone, as seen with this breast phantom, will alter the lateral resolution. The ideal lateral resolution occurs when the focal zone is aligned with the target.
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an inadequate sampling of the lesion and a diagnosis that may falsely reassure the patient. ● Prevention After a sterile or “clean” preparation of the skin and the ultrasound transducer, local anesthetic (usually 1% lidocaine) is injected at the proximal end of the ultrasound transducer. Once a skin wheal is made, intraparenchymal injection of local anesthetic is performed under direct ultrasound visualization. By monitoring the injection with ultrasound, adequate anesthesia is obtained without compromising visibility. The technique of injection under direct visualization is discussed further with prevention of inadvertent biopsy of the skin and prevention of pneumothorax below.
Insert the Biopsy Device Failure to Visualize the Advancing Biopsy Device Tip ● Consequence Pneumothorax, hemothorax, and biopsy of pectoral muscle (with associated increased bleeding and pain) are among the potential problems associated with the inability to confirm the position of the advancing biopsy device. Grade 2 complication ● Repair The details of treatment of a rare pneumothorax or hemothorax, and the placement and management of chest tubes are not discussed in this section. Management of “Bleeding and Hematoma” are discussed later. ● Prevention To avoid potential advancement of the device into the pectoral muscle or lung, multiple issues are addressed. The key to visualizing the advancing tip of any device resides in both maintaining alignment of the device with the ultrasound scan plane and keeping the advancing device as parallel with the face of the ultrasound transducer as possible. To achieve parallel positioning with the transducer, regardless of the lesion depth, will require that the patient be positioned in lateral decubitus with a pillow behind the shoulder. In addition, the ultrasound transducer can be gently tilted into the breast away from the advancing device. Local anesthesia can also be injected under direct ultrasound visualization; by directing the needle beneath the lesion, it can be raised off or away from the pectoral muscle. Another way to avoid inadvertent pneumothorax is to use a nonfiring device. The VAB as well as the large intact sample devices are positioned below a lesion without a spring-loaded firing mechanism and the acquisition of tissue is directed superiorly.
Confirmation Scans for Alignment of the Lesion with the Biopsy Device Failure to Align the Lesion with the Biopsy Device ● Consequence Failure to confirm with ultrasound imaging that the biopsy device tip or its sampling area is aligned correctly with the lesion will of course lead to inadequate biopsy of the lesion and potentially falsely reassuring a patient of a benign diagnosis. Grade 2 complication ● Prevention To avoid missing significant portions of the lesion with ultrasound-guided needle core biopsy, by the forward movement of the inner and outer cannula, the needle tip is brought just to the front edge of the lesion and does not penetrate into the lesion prior to firing. When performing a needle-core biopsy, in which it is crucial to know whether the needle has penetrated the lesion, a confirmation scan is needed to avoid a false image created by the overlap of the narrow ultrasound scan plane with the needle just at the edge of the lesion (image averaging). The physician may view the ultrasound image and interpret it as a successful biopsy although the needle has not actually penetrated the lesion (Fig. 43–8). By moving the ultrasound transducer perpendicular to its long axis, the lesion can be visualized from one end through its middle to the other end of the lesion. It is necessary to see a portion of the lesion without the needle, followed by the needle with the lesion, and then continuing the scan in the same direction to again visualize the lesion without the needle. This will confirm that the needle is in the lesion. The success of ultrasound-guided VAB or large intact biopsy is enhanced by careful attention to the technical aspect of the procedure. Patient positioning (lateral decubitus), injection of local anesthetic posterior to the lesion for a lifting effect, and torquing down of the biopsy device handle as the probe approaches the underside of the lesion all serve to provide a shallow angle of insertion and easier access underneath the lesion, especially when the lesion is deep within the breast parenchyma. When the biopsy device is in position for a biopsy, ensuring an adequate sampling requires a confirmation scan to assess the relationship of the device and the lesion. VAB devices and one of the large intact sample devices (Rubicor Medical, Halo, Redwood City, CA) are positioned below the lesion. If these are not positioned beneath the breast target lesion, the artifact created by the device would eliminate visualization of any portion of the lesion below the biopsy probe. To confirm that the device is centered beneath the lesion, the ultrasound transducer is rotated 90°. The device is then visualized in crosssection, and it becomes obvious whether it is centered underneath the lesion, also seen in cross-section.
43 IMAGE-GUIDED BREAST BIOPSY
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Figure 43–8 When the biopsy needle and the edge of a lesion are both within the ultrasound scan plane, image averaging occurs and creates the perception that the needle is in the lesion.
Sample the Lesion for Diagnosis and/or Potential Therapeutic Removal Failure to Choose the Appropriate Biopsy Device for Ideal Sampling ● Consequence Cytologic or histologic confirmation of malignancy is the minimum requirement for ultrasound-guided biopsy of “indeterminate” or suspicious solid lesions. Fine-needle aspiration biopsy is a quick, inexpensive technique to delineate benign from malignant solid breast masses. However, the same issues surrounding the use of fine-needle aspiration in stereotactic imageguided breast biopsy apply to ultrasound-guided procedures. Grade 2 complication ● Prevention Ultrasound fine-needle aspiration is ideally suited to evaluate lesions in areas such as the axilla where more invasive biopsy devices may be difficult or dangerous. The diagnosis of lymph node metastasis by fine-needle aspiration can assist with preoperative staging in consideration of neoadjuvant chemotherapy or eliminating sentinel lymph node biopsy by confirming positive cytology in clinically suspicious lymph nodes. The use of automated Tru-Cut needle-core biopsy eliminates the same problems with fine-needle aspiration that are seen with stereotactic breast biopsy such as insufficient sampling and the inability to provide the histologic type and grade of a diagnosed cancer. VAB and large intact sample technology are also available with ultrasound guidance. The indications for an ultrasound-guided VAB are similar to those for needlecore biopsy, including any indeterminate, ultrasoundvisible, palpable or nonpalpable solid masses. If the physician is interested in the potential therapy of probably benign breast abnormalities, VAB devices or large intact sampling devices would be required. Both of these device categories have successfully demonstrated their ability to
Figure 43–9 A postprocedure hematoma after a vacuum-assisted biopsy. No surgical intervention was required.
remove image evidence and especially palpability of probably benign solid masses.31
Place a Postprocedure Marker and Obtain Postprocedure/Clip Placement Mammogram Clip placement and potential pitfalls have been addressed previously.
Obtain Adequate Hemostasis and Apply Appropriate Dressing and/or Wrap Bleeding and Hematoma ● Consequence The incidence of hematoma with image-guided breast biopsy is reported to be 2% to 8% (Fig. 43–9). It is extremely rare for bleeding or hematoma to result in any post–image-guided surgical procedures. This author’s experience is that no patient has required operative intervention. Bruising and small hematoma
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formation are common, especially near the biopsy insertion site. The size of the hematoma will, of course, contribute to the level of pain and discomfort. Grade 1 complication ● Prevention/Repair Manual compression is the mainstay for achieving hemostasis in image-guided breast biopsy and preventing hematomas. It is important for the pressure to be applied across the biopsy track created by the device. When a VAB or large intact sample device has been used to remove the image evidence of the lesion, a larger biopsy cavity is created and there is a greater risk of bleeding/hematoma. It is important that the manual pressure and the pressure dressing, in particular, be applied to the site of the lesion and not only at the incision. Prevention of a hematoma can also be influenced by placing the patient in a chest wrap. Conservative management with ice and pressure wraps is sufficient.
Check Pathology for Concordance with Radiologic Impression This topic is addressed in the section on “Pathologic Pitfalls in Image-Guided Breast Biopsy.”
PATHOLOGIC PITFALLS IN IMAGE-GUIDED BREAST BIOPSY Not Performing a Further Procedure with a Diagnosis of Benign Papillary Lesion on Core Biopsy ● Consequence The pathologist is confronted with the following decision points when presented with a papillary lesion: 1. Distinguishing benign, atypical, and malignant papillary lesions with limited material. 2. Establishing a diagnosis with the realization that the sample may not contain the most worrisome histology present in the lesion. 3. Distinguishing invasive carcinoma from a fragmented and distorted sclerosing papillary lesion. Papillary lesions of the breast can be divided into benign and malignant categories. Benign lesions include solitary intraductal papilloma, multiple papillomas, and atypical hyperplasia within a papilloma. If a diagnosis of atypia is mentioned, further surgical excision needs to be performed. What is less clear is whether or not complete surgical excision is required for a diagnosis of benign intraductal papilloma. Solitary intraductal papilloma usually presents as a well-defined mass, whereas multiple intraductal papillomas typically present as a nodular mass or with microcalcifications.32 In both instances, a cystic component may be identified on ultrasound examination.
The significance of either diagnosis is an increased risk of developing breast cancer. Based on a review of 372 solitary papillomas and 41 multiple papillomas published from the Mayo clinic, there is an approximately twofold increased risk in the case of solitary papilloma and a threefold increase in the case of multiple papillomas.33 Atypia, when present, is more often associated with multiple papillomas than with solitary central papillomas.34 The atypia in papillary lesions is frequently unevenly distributed and is usually present in less than 50% of the papilloma.35 The relative risk of developing carcinoma when atypia is present versus when atypia is not identified is a 7.5-fold increase.36 In addition, that risk is in the ipsilateral breast as opposed to a more generalized risk associated with atypical intraductal hyperplasia (AIDH). Studies have demonstrated the presence of atypia and/ or malignancy in 0% to 44% of excision specimens when a diagnosis of benign papillary lesion is rendered on a core biopsy.37–46 In general, a relationship exists between the presence of atypia and/or malignancy in excisional specimens and the amount of residual lesion remaining after core biopsy. This is not surprising given the focal nature of atypia, when present. Because of the possibility of missing the most worrisome histology and the fact that papilloma with atypia is a precursor lesion, most experts recommend complete radiographic excision of the imaging abnormality if a diagnosis of benign papillary lesion is rendered by the pathologist. When sclerosing papillary lesions are removed in small fragments, they can be difficult to distinguish from radial sclerosing lesions and invasive carcinomas. The sclerosis can entrap benign epithelial elements, simulating an invasive carcinoma. The use of immunostains can effectively demonstrate the presence or absence of a myoepithelial cell layer to aid in the differential diagnosis of an invasive cancer but cannot help to distinguish a radial sclerosing lesion. It should be noted, however, that most malignant papillary lesions behave in a relatively indolent manner.47 Whereas they occasionally metastasize to lymph nodes, distant metastasis is rare. ● Prevention Complete removal of the imaging abnormality should be performed.41,42,45,46,48 The biopsy device chosen by the surgeon may dictate further procedures. For example, if a lesion, highly suspicious for a papilloma, is sampled with a 14-gauge spring-loaded biopsy device, a second procedure will need to be performed even if a diagnosis of a benign papillary lesion is rendered. Limited sampling of a papillary lesion may miss atypia, which is usually present only focally, and atypia is believed to be a precursor lesion. Therefore, when the probability of a papillary lesion, such as a welldefined subareolar mass, is high, a large-core biopsy device or whole intact excisional biopsy device should be used.
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Figure 43–10 Low-power hematoxylin and eosin (H&E) microscopic image of a completely resected intraductal papilloma. The biopsy was obtained using a whole intact biopsy device, preserving the architecture and eliminating the need for further surgery.
A second factor in selecting a biopsy device is preservation of tissue architecture. Biopsy devices can be thought of as providing puzzle pieces to the pathologist. The larger the pieces, the less the architecture is distorted and the easier it is for a pathologist to establish a diagnosis. In addition to deciding how much tissue should be sampled, the radiologist or surgeon must also decide whether to remove the lesion in one piece (whole intact), to optimally preserve the architecture, or in pieces. If the lesion is to be sampled in pieces, the size of the pieces must be determined. Because architecture is critical in differentiating a sclerosing papillary lesion from other lesions, larger pieces allow the pathologist to obtain a better overall assessment of the architecture. Removing all imaging evidence of a potential papillary lesion will greatly reduce the need for further surgery if a diagnosis of benign papillary lesion is rendered (Fig. 43–10).
Obtaining a HER-2 Result on a Core Biopsy Specimen ● Consequence HER-2 is an oncogenic protein that may be overexpressed in up to 20% of high- and intermediate-grade invasive breast carcinomas. It is rarely overexpressed in low-grade ductal or classic invasive lobular carcinomas.49 Patients with HER-2 overexpression benefit from targeted anti–HER-2 therapies, such as trastuzumab, in both the adjuvant and the metastatic settings.50–52 The assessment of HER-2 overexpression is most commonly performed by immunohistochemistry, and patients whose tumor cells show 3+ overexpression have the greatest likelihood of response to anti–HER-2 therapy.
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The ability of a pathologist to accurately assess a HER2 immunostain can be compromised by four major artifacts: tissue crush, tissue retraction, thermal injury, and edge artifact. These artifacts can cause the HER-2 antibody to diffuse unevenly, causing the tumor cells in the area of artifact to see a higher concentration of antibody than expected. Tissue crush is caused when a thin needle is forced into tissue and the cells along the edge are crushed. The cytoplasm becomes streamed and distorted. Tissue retraction is defined as the separation of breast epithelial cells, benign or malignant, from stromal elements, creating a cleftlike space. The use of VAB devices can accentuate this artifact, but it may also occur as part of routine tissue processing. Thermal injury is caused by the use of cautery. It causes the cells to take on a windswept appearance and increases nuclear chromasia. Edge artifact is seen in all tissues and is caused by antibody pooling along the edge of a specimen, affecting tissue located within 1 mm of the edge. Thus, a core biopsy measuring 2 mm in diameter is mostly edge artifact, with the exception of the exact middle of the core. Core biopsies with a small diameter, such as a 14-gauge springloaded core, are virtually all edge artifact. Fluorescence in situ hybridization (FISH) is a method that allows detection of the HER-2 gene.53 The technique involves exposing the tumor nuclei via digestion of the cell membrane and cytoplasm, heating the DNA until it uncoils, flooding the sample with a fluorescently tagged complementary sequence to the HER-2 gene, and then cooling the DNA allowing it to recoil with the HER-2 gene now fluorescently tagged. The number of HER-2 genes in each tumor nucleus can then be enumerated. Because two HER-2 genes are present in all normal cells, one from mom and one from dad, it is essential that only tumor nuclei be assessed. The key to counting only the tumor nuclei is preservation of tissue architecture. It has been noted that approximately 18% of breast tumors scored as 3+ by HER-2 immunohistochemistry and 12% of breast tumors assessed as having gene amplification do not show overexpression or gene amplification when repeated in a central reference laboratory.54,55 This high rate of error has resulted in the American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP) issuing joint guidelines in an effort to improve HER-2 assessment in breast cancer.56 ● Prevention The artifacts caused by core biopsy all lead to potential overstaining by immunohistochemistry. Thus, tumors assessed as 3+ may be truly 3+ or may be falsely positive as a result of an artifact. If the diameter of the biopsy core is less than 2 mm, cores assessed as 3+ should be confirmed with FISH testing or be repeated on the lumpectomy specimen, because the majority of the core is edge artifact. Even if large-core biopsy devices are used, care must be taken to avoid scoring artifacts because these will still be present in the biopsy.
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Figure 43–11 Low-power HER-2 immunostained slide shows apparent strong expression of the protein. However, the staining cannot be clearly visualized on the membrane and is the result of both edge and crush artifact typical of a core biopsy specimen.
Before relying on the results of a FISH test, you must be assured that the correct cells were examined. Because only tumors can show amplification of the HER-2 gene, if gene amplification is detected, tumor cells must have been examined. The only possibility for error is if in situ and invasive carcinoma are both present and only the in situ carcinoma shows amplification of the HER-2 gene. Although this does occur, it is unusual. More problematic is when FISH testing does not show amplification of the HER-2 gene. In this circumstance, one must always question whether tumor cells were observed. It can be difficult to distinguish tumor cells from normal cells on fluorescence microscopy, especially when the tumor is limited and intermixed with benign pathology such as adenosis. The pathologist relies on architecture and comparison with an adjacent hematoxylin and eosin (H&E)–stained section to select the tumor cells. As a general rule, if the pathologist is struggling to establish the diagnosis on the H&E slide, it will be difficult to identify the tumor cells by fluorescence. The larger the core biopsy, the better the preservation of tissue architecture, and the more reliable the FISH result (Fig. 43–11).
Not Obtaining an Estrogen Receptor Immunostain on a Core Biopsy Specimen ● Consequence The determination of estrogen receptor (ER) should be performed on all breast carcinomas. The accurate determination of ER status is largely dependent on the amount of tumor assessed, tissue fixation, and the assay used. Currently, ER status is usually assessed by immunohistochemistry. Unlike HER-2, which is a membrane protein, ER is a nuclear stain and is not affected by the artifacts such as edge artifact, tissue crush, tissue retraction, or cautery artifact.
Studies have shown that ER status is an excellent predictor of response to antiestrogen therapy.57,58 The initial studies were performed by ligand-binding assay. This assay requires a large amount of fresh tissue, which is ground up and assessed quantitatively. Assessment of ER on formalin-fixed paraffin-embedded tissue was found to be even more predictive of response to antiestrogen therapy when using a specific immunohistochemical assay with a specific scoring system.58 This is not surprising because the tissue included in the ligand-binding assay usually included a mixture of tumor cells, stroma, and often, benign breast epithelial cells. Unfortunately, in current practice, many different immunohistochemical assays and scoring systems are used to assess ER status, leading to significant errors in ER testing results. These errors can be broken down into several problems including tissue fixation, tissue processing, antigen retrieval methods, antibody clones, amount of tissue assessed, scoring system, and cutoff levels. With respect to core biopsies, tissue fixation and the amount of tissue examined are of most concern. ER determination is greatly affected by tissue fixation. Underfixation of breast tissue can cause a marked decrease in the ability of immunohistochemistry to detect ER.59 Because core biopsies tend to be significantly smaller than excisional specimens, they fix more rapidly, which is optimal for ER assessment. It is not unusual to see weak expression of ER on a core biopsy while no expression is noted on the excision specimen. ● Prevention ER determination should be performed on all core biopsies because of more optimal tissue fixation.60 If no expression of ER is noted, ER status should be reassessed on the excisional specimen. Expression in as little as 1% of the invasive tumor cells is associated with significantly greater responsiveness to antiestrogen therapy than those tumors showing no expression. Because the amount of tissue examined in a core biopsy is typically less than the amount examined in an excisional specimen, lack of expression in a core biopsy may be the result of incomplete sampling.
Not Performing a Further Procedure with a Diagnosis of AIDH on Core Biopsy ● Consequence The diagnosis and significance of AIDH are defined based on the follow-up of patients who underwent excisional biopsy. When AIDH is found on a core biopsy, the question is whether it is representative of the entire lesion or whether it is indicative of a more worrisome pathology. On a molecular level, AIDH and low-grade intraductal carcinoma are undistinguishable.61–63 The two lesions are sometimes difficult for the pathologist to separate, even on excisional specimens, let alone on core biopsy samples in which more limited tissue is available. Even when a definitive diagnosis of
43 IMAGE-GUIDED BREAST BIOPSY AIDH can be rendered on core biopsy, it is frequently associated with low-grade DCIS. When diagnosed on core biopsy, AIDH is frequently upgraded to DCIS or invasive carcinoma once the lesion is excised.21,64–68 In general, the more tissue removed at core biopsy, the smaller the percentage of cases that will be diagnosed as carcinoma on excision. Approximately 40% of core biopsies diagnosed as AIDH using a 14-gauge biopsy device will show carcinoma on excision whereas only about 20% will show carcinoma when AIDH is diagnosed with an 11-gauge VAB device.69 Recently, it has been suggested that it may be important to note the number of foci of AIDH on core biopsy and that the number of foci may be predictive of the presence of carcinoma on the excisional biopsy.70 When AIDH was limited to only one or two foci, carcinoma was not seen on the subsequent excisional biopsy specimen; the incidence of carcinoma was 50% when three foci of AIDH were identified and 87% when four or more foci were identified. I believe this approach is too simplistic and that attention should be paid to the type and extent of the mammographic lesion. If the lesion presents as microcalcifications, carcinoma is more often detected if the mammographic lesion is not completely removed. However, even if the mammographic microcalcifications are completely removed, carcinoma may still be found at excision. If the mammographic lesion presents as a mass, there is only a 5% incidence of carcinoma at excision.71 It has been noted that when a micropapillary pattern is identified, most excisional specimens will contain a micropaillary DCIS.70 ● Prevention Whereas there continues to be much interest in defining a subset of AIDH patients who do not require subsequent excision, no such category can be defined reliably. AIDH has similar molecular alterations to those seen in low-grade DCIS and should be treated. It is frequently found at the periphery of DCIS, and thus, a concurrent carcinoma can be truly excluded only if the surrounding tissue is examined and no carcinoma is seen.66 AIDH is a significant risk factor for the development of invasive breast cancer, conferring a relative risk of four to five times and is about equal in both breasts.72,73
Not Performing a Further Procedure with a Diagnosis of Angiolymphoid Hyperplasia/Lobular Carcinoma In Situ on Core Biopsy ● Consequence When angiolymphoid hyperplasia (ALH) or lobular carcinoma in situ (LCIS) is found on excisional biopsy, no further surgery is performed because the lesions are believed to be markers of a generalized increased risk of developing invasive breast carcinoma that occurs
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with equal frequency in both breasts.74–80 LCIS/ALH is not typically associated with a mammographic or ultrasound abnormality and, thus, is usually an incidental finding rather than the pathology that led to the core biopsy. It has an incidence of less than 2% in most core biopsy studies.42,79,81–84 Because of its low incidence, our knowledge of ALH/LCIS on core biopsy is mostly derived from retrospective trials. Pooling these studies, approximately 19% of excisional biopsies after a diagnosis of ALH/LCIS show carcinoma.85 Approximately 55% of these show invasive carcinoma (30% invasive lobular), and 45% show intraductal carcinoma. Liberman and coworkers84 put forth criteria strongly recommending surgical excision if there is radiologicpathologic discordance, if another lesion requiring excisional biopsy (such as atypical ductal hyperplasia [ADH]) is also present, or if the histologic features of the ALH/ LCIS cannot be easily distinguished from DCIS.84 ● Prevention Because ALH/LCIS is not associated with a radiographic abnormality, there is likely to be radiologicpathologic discordance. Although concern has been raised that these studies might be biased because not all patients who were diagnosed with ALH/LCIS on core biopsy underwent excisional biopsy, until further studies are available, excisional biopsy seems prudent.
Not Performing a Further Procedure with a Diagnosis of Flat Epithelial Atypia (Atypical Columnar Cell Alteration) on Core Biopsy ● Consequence Columnar cell lesions are the most common cause of pleomorphic microcalcifications seen on core biopsy. These lesions have been described under a number of different names ranging from “blunt duct adenosis” on the benign side to “clinging carcinoma” on the malignant side. The significance of columnar cell lesions is the company they keep. Atypical columnar cell lesions (flat epithelial atypia) have been associated with lowgrade in situ and invasive ductal and/or lobular carcinomas.86 In one review, 95% of cases of pure tubular carcinoma were associated with atypical columnar cell lesions.87 On a molecular level, columnar cell lesions frequently show loss on chromosome 16 similar to those seen in low-grade carcinomas.88 For years, these lesions were largely ignored when identified in excisional biopsy specimens and the association with lowgrade carcinomas was not appreciated. Retrospective studies looking at benign breast biopsies containing overlooked atypical columnar cell lesions did not show a subsequent invasive carcinoma. When columnar cell alterations were present without an associated carcinoma, the lesions did not appear to confer an increased risk of malignancy.
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Figure 43–12 H&E-stained microscopic slide shows flat epithelial atypia. The nuclei in the lining cells are more vesicular with visible nucleoli. They have lost their polarity and have a much more uniform and focally rounded appearance.
● Prevention Columnar cell alterations are commonly seen because of their frequent association with pleomorphic microcalcifications. If a dedicated breast pathologist is not available at your institution, it is worth asking your pathologists if they are aware of this entity and the current histologic criteria. It is essential that the pathologist be familiar with the terminology and criteria. If atypia is present, complete surgical excision of the lesion is advised because of the possible association with an in situ or invasive carcinoma. If no associations are found, the probability of developing into an invasive carcinoma is exceedingly low (Fig. 43–12).
Pathology Does not Correlate with Imaging Findings?/No Calcifications Found on Pathology When Calcifications Were Identified on Your Imaging Study (Tissue Processing in General) ● Consequence Although they are not encountered very often, the inability to demonstrate microcalcifications on histologic examination can be problematic. If calcifications cannot be demonstrated, and the lack of microcalcifications cannot be explained, complete excision of the lesion should be performed, assuming microcalcifications are still remaining in the breast. When performing an image-guided biopsy for microcalcifications, large-core or whole intact biopsy devices should be utilized. Studies have shown that larger biopsy samples and more cores will remove more of the calcifications and require few excisional biopsies owing to radiographic-pathologic discrepancies.89–91 ● Prevention This is definitely the case in which an ounce of prevention is worth a pound of cure. The radiologist/surgeon
should radiograph all of the removed cores as well as obtain a postbiopsy film to ensure that the calcifications have been removed and a specimen radiogram to ensure that they are present in the core biopsy specimens. Once documented, the cores containing the microcalcifications should be submitted separately from the cores that do not show radiographic evidence of calcifications. This will allow the pathologist to concentrate on the more suspicious cores and potentially examine more levels on sections thought to contain calcifications. If microcalcifications are not identified by the pathologist, several steps should be taken. The first step is for the pathologist to polarize the H&E slides. Calcifications composed of calcium oxylate are not easily demonstrated on the H&E stain but are easily demonstrated on polarization.92,93 This type of calcification is most commonly seen associated with apocrine metaplasia. Assuming that calcifications are still not identified, the next step should be to x-ray the tissue block. If no calcifications are identified within the block, but preprocessing radiographs demonstrated the microcalcifications, it can be assumed that the calcifications dissolved in processing. This happens very rarely. If calcifications are still demonstrated in the paraffin-embedded block, deeper sections should be obtained. The sections should be cut on a fresh microtome blade, if possible. Occasionally, microcalcifications cannot be cut by a microtome blade and the calcifications are launched as small projectiles rather than being cut. These can be detected as holes in the tissue that represent remnants of where the microcalcifications used to reside.
Lack of Radiographic and Pathologic Correlation, Whatever the Cause, Requires Complete Surgical Excision Not Performing a Further Procedure with a Diagnosis of Radial Scar on Core Biopsy ● Consequence Most radial scars are incidental findings measuring approximately 4 mm in size. Based on data from the Nurses’ Health Study, women with radial scars demonstrate a twofold increase in risk of invasive breast cancer; this risk increases with the size of the radial scar.94 The risk is believed to be bilateral, but larger radial scars may be associated with DCIS and invasive carcinomas. Carcinomas arising in association with radial scars are frequently located at the periphery of the lesion, causing them to be missed if the center of the lesion is targeted. It is important to note whether a radial scar is an incidental finding or whether it is the targeted lesion. There is a significantly higher association of carcinoma and AIDH in lesions identified mammographically than those lesions found incidentally. There does not appear to be any distinguishing mammographic feature that allows
43 IMAGE-GUIDED BREAST BIOPSY
7.
8.
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10.
11.
Figure 43–13 Triple immunostaining for P63, cytokeratin 5/6, and cytokeratin 18 in the same radial sclerosing lesion as seen on the H&E stain. P63 and cytokeratin 5/6 highlight cells with myoepithelial/basal differentiation. Both antibodies are visualized with diaminobenzidine (DAB) (brown). P63 is a nuclear, and cytokeratin 5/6 is a cytoplasmic. Cytokeratin 18, a cytoplasmic stain, is visualized with fast red. The presence of two cell types confirms the proliferation as benign.
radiographic separation of radial scars harboring carcinomas from those that do not harbor such foci.95 ● Prevention All mammographically detected radial scars and all radial scars measuring 6 mm or larger should undergo excision. Sloane and Meyers96 reported a 30% incidence of carcinoma when the radial scar measures 6 mm or larger and an incidence of only 2.6% with smaller radial scars. Given the small number of radial scar studies and the low incidence of radial scars in general, it seems prudent to recommend excision for all mammographically detected radial scars and certainly all radial scars measuring larger than 6 mm (Fig. 43–13).
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25. Berg WA, Kerbs TL, Campassi C, et al. Evaluation of 14and 11-gauge directional vacuum-assisted biopsy probes and 14-gauge biopsy guns in a breast parenchymal model. Radiology 1997;205:203–208. 26. Liberman LL, Evans WP, Dershaw DD, et al. Radiography of microcalcifications in stereotaxic mammary core biopsy specimens. Radiology 1994;190:223–225. 27. Meyer JE, Lester SC, Grenna TH, White FV. Occult breast calcifications sampled with large-core biopsy: confirmation with radiography of the specimen. Radiology 1993;188:581–582. 28. Tocino I, Gaargia B, Carter D. Surgical biopsy findings in patients with atypical hyperplasia diagnosed by stereotactic core needle biopsy. Ann Surg Oncol 1996;3:482–488. 29. Burbank F, Forcier N. Tissue marking clip for stereotactic breast biopsy: initial placement accuracy, long-term stability and usefulness as a guide for wire localization. Radiology 1997;205:407–415. 30. Kass R, Kumar G, Klimberg VS, et al. Clip migration. Am J Surg 2002;184:325–331. 31. Fine R, Whitworth P, Kim J, et al. Low risk palpable breast masses removed using a vacuum-assisted hand-held device. Am J Surg 2003;186:362–367. 32. Pellettiere EV 2nd. The clinical and pathologic aspects of papillomatous disease of the breast: a follow-up study of 97 patients treated by local excision. Am J Clin Pathol 1971;55:740–748. 33. Lewis JT, Hartmann LC, Vierkant RA, et al. An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol 2006;30:665– 672. 34. Ohuchi N, Abe R, Kasai M. Possible cancerous change of intraductal papillomas of the breast. A 3-D reconstruction study of 25 cases. Cancer 1984;54:605–611. 35. Raju U, Vertes D. Breast papillomas with atypical ductal hyperplasia: a clinicopathologic study. Hum Pathol 1996;27:1231–1238. 36. Page DL, Salhany KE, Jensen RA, et al. Subsequent breast carcinoma risk after biopsy with atypia in a breast papilloma. Cancer 1996;78:258–266. 37. Agoff SN, Lawton TJ. Papillary lesions of the breast with and without atypical ductal hyperplasia: can we accurately predict benign behavior from core needle biopsy? Am J Clin Pathol 2004;122:440–443. 38. Irfan K, Brem RF. Surgical and mammographic follow-up of papillary lesions and atypical lobular hyperplasia diagnosed with stereotactic vacuum-assisted biopsy. Breast J 2002;8:230–233. 39. Ivan D, Selinko V, Sahin AA, et al. Accuracy of core needle biopsy diagnosis in assessing papillary breast lesions: histologic predictors of malignancy. Mod Pathol 2004;17:165–171. 40. Liberman L, Tornos C, Huzjan R, et al. Is surgical excision warranted after benign, concordant diagnosis of papilloma at percutaneous breast biopsy? AJR Am J Roentgenol 2006;186:1328–1334. 41. Mercado CL, Hamele-Bena D, Oken SM, et al. Papillary lesions of the breast at percutaneous core-needle biopsy. Radiology 2006;238:801–808. 42. Philpotts LE, Shaheen NA, Jain KS, et al. Uncommon high-risk lesions of the breast diagnosed at stereotactic
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core-needle biopsy: clinical importance. Radiology 2000;216:831–837. Puglisi F, Zuiani C, Bazzocchi M, et al. Role of mammography, ultrasound and large core biopsy in the diagnostic evaluation of papillary breast lesions. Oncology 2003;65:311–315. Renshaw AA, Tizol-Blanco DM, Gould EW, et al. Papillomas and atypical papillomas in breast core needle biopsy specimens: risk of carcinoma in subsequent excision. Am J Clin Pathol 2004;122:217–221. Rosen EL, Bentley RC, Baker JA, et al. Imaging-guided core needle biopsy of papillary lesions of the breast. AJR Am J Roentgenol 2002;179:1185–1192. Valdes E, Tarttler PI, Genelus-Dominique E, et al. Significance of papillary lesions at percutaneous breast biopsy. Ann Surg Oncol 2006;13:480–482. Nassar H, Qureshi H, Volkan-Adsay N, et al. Clinicopathologic analysis of solid papillary carcinoma of the breast and associated invasive carcinomas. Am J Surg Pathol 2006;30:501–507. Liberman L, Bracero N, Vuolo MA, et al. Percutaneous large-core biopsy of papillary breast lesions. AJR Am J Roentgenol 1999;172:331–337. Hoff ER, Tubbs RR, Myles JL, et al. HER2/neu amplification in breast cancer: stratification by tumor type and grade. Am J Clin Pathol 2002;117:916– 921. Piccart-Gebhart MJ, Procter M, Leyland-Jones B, et al. Trastuzumab after adjuvant chemotherapy in HER2positive breast cancer. N Engl J Med 2005;353:1659– 1672. Romond EH, Perez EA, Bryant J, et al. Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer. N Engl J Med 2005;353:1673–1684. Slamon DJ, Leyland-Jones B, Shak S, et al. Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2. N Engl J Med 2001;344:783–792. Hicks DG, Tubbs RR. Assessment of the HER2 status in breast cancer by fluorescence in situ hybridization: a technical review with interpretive guidelines. Hum Pathol 2005;36:250–261. Paik S, Bryant J, Tan-Chiu E, et al. Real-world performance of HER2 testing—National Surgical Adjuvant Breast and Bowel Project experience. J Natl Cancer Inst 2002;94:852–854. Roche PC, Suman VJ, Jenkins RB, et al. Concordance between local and central laboratory HER2 testing in the breast intergroup trial N9831. J Natl Cancer Inst 2002; 94:855–857. Wolff AC, Hammond MEH, Schwartz JN, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol 2007;25:118–145. Elledge RM, Green S, Pugh R, et al. Estrogen receptor (ER) and progesterone receptor (PgR), by ligand-binding assay compared with ER, PgR and pS2, by immunohistochemistry in predicting response to tamoxifen in metastatic breast cancer: a Southwest Oncology Group Study. Int J Cancer 2000;89:111–117.
43 IMAGE-GUIDED BREAST BIOPSY 58. Harvey JM, Clark GM, Osborne CK, et al. Estrogen receptor status by immunohistochemistry is superior to the ligand-binding assay for predicting response to adjuvant endocrine therapy in breast cancer. J Clin Oncol 1999;17:1474–1481. 59. Goldstein NS, Ferkowicz M, Odish E, et al. Minimum formalin fixation time for consistent estrogen receptor immunohistochemical staining of invasive breast carcinoma. Am J Clin Pathol 2003;120:86–92. 60. Mann GB, Fahey VD, Feleppa F, et al. Reliance on hormone receptor assays of surgical specimens may compromise outcome in patients with breast cancer. J Clin Oncol 2005;23:5148–5154. 61. Boecker W, Buerger H, Schmitz K, et al. Ductal epithelial proliferations of the breast: a biological continuum? Comparative genomic hybridization and high-molecularweight cytokeratin expression patterns. J Pathol 2001; 195:415–421. 62. Buerger H, Mommers EC, Littmann R, et al. Correlation of morphologic and cytogenetic parameters of genetic instability with chromosomal alterations in in situ carcinomas of the breast. Am J Clin Pathol 2000;114:854–859. 63. Buerger H, Mommers EC, Littmann R, et al. Different genetic pathways in the evolution of invasive breast cancer are associated with distinct morphological subtypes. J Pathol 1999;189:521–526. 64. Dahlstrom JE, Sutton S, Jain S. Histological precision of stereotactic core biopsy in diagnosis of malignant and premalignant breast lesions. Histopathology 1996;28:537– 541. 65. Jackman RJ, Nowels KW, Rodriguez-Soto J, et al. Stereotactic, automated, large-core needle biopsy of nonpalpable breast lesions: false-negative and histologic underestimation rates after long-term follow-up. Radiology 1999;210:799–805. 66. Lennington WJ, Jensen RA, Dalton LW, et al. Ductal carcinoma in situ of the breast. Heterogeneity of individual lesions. Cancer 1994;73:118–124. 67. Liberman L, Dershaw DD, Glassman JR, et al. Analysis of cancers not diagnosed at stereotactic core breast biopsy. Radiology 1997;203:151–157. 68. Moore MM, Hargett CW, Hanks JB, et al. Association of breast cancer with the finding of atypical ductal hyperplasia at core breast biopsy. Ann Surg 1997;225:726–731; discussion 731–733. 69. Reynolds HE. Core needle biopsy of challenging benign breast conditions: a comprehensive literature review. AJR Am J Roentgenol 2000;174:1245–1250. 70. Ely KA, Carter BA, Jensen RA, et al. Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting. Am J Surg Pathol 2001;25:1017– 1021. 71. Liberman L, Dershaw DD, Rosen PP, et al. Percutaneous removal of malignant mammographic lesions at stereotactic vacuum-assisted biopsy. Radiology 1998;206:711– 715. 72. Dupont WD, Page DL. Risk factors for breast cancer in women with proliferative breast disease. N Engl J Med 1985;312:146–151. 73. McDivitt RW, Stevens JA, Lee NC, et al. Histologic types of benign breast disease and the risk for breast cancer. The
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Cancer and Steroid Hormone Study Group. Cancer 1992;69:1408–1414. Andersen JA. Lobular carcinoma in situ of the breast. An approach to rational treatment. Cancer 1977;39:2597– 2602. Bodian CA, Perzin KH, Lattes R. Lobular neoplasia. Long-term risk of breast cancer and relation to other factors. Cancer 1996;78:1024–1034. Ottesen GL, Graversen HP, Blichert-Toft M, et al. Lobular carcinoma in situ of the female breast. Short-term results of a prospective nationwide study. The Danish Breast Cancer Cooperative Group. Am J Surg Pathol 1993;17:14–21. Page DL, Kidd TE Jr, Dupont WD, et al. Lobular neoplasia of the breast: higher risk for subsequent invasive cancer predicted by more extensive disease. Hum Pathol 1991;22:1232–1239. Rosen PP, Kosloff C, Lieberman PH, et al. Lobular carcinoma in situ of the breast. Detailed analysis of 99 patients with average follow-up of 24 years. Am J Surg Pathol 1978;2:225–251. Shin SJ, Rosen PP. Excisional biopsy should be performed if lobular carcinoma in situ is seen on needle core biopsy. Arch Pathol Lab Med 2002;126:697–701. Wheeler JE, Enterline HT, Roseman JM, et al. Lobular carcinoma in situ of the breast. Long-term followup. Cancer 1974;34:554–563. Berg WA, Mrose HE, Ioffe OB. Atypical lobular hyperplasia or lobular carcinoma in situ at core-needle breast biopsy. Radiology 2001;218:503–509. Burak WE Jr, Owens KE, Tighe MB, et al. Vacuumassisted stereotactic breast biopsy: histologic underestimation of malignant lesions. Arch Surg 2000;135:700– 703. Elsheikh TM, Silverman JF. Follow-up surgical excision is indicated when breast core needle biopsies show atypical lobular hyperplasia or lobular carcinoma in situ: a correlative study of 33 patients with review of the literature. Am J Surg Pathol 2005;29:534–543. Liberman L, Sama M, Susnik B, et al. Lobular carcinoma in situ at percutaneous breast biopsy: surgical biopsy findings. AJR Am J Roentgenol 1999;173:291–299. Jacobs TW, Connolly JL, Schnitt SJ. Nonmalignant lesions in breast core needle biopsies: to excise or not to excise? Am J Surg Pathol 2002;26:1095–1110. Rosen PP. Columnar cell hyperplasia is associated with lobular carcinoma in situ and tubular carcinoma. Am J Surg Pathol 1999;23:1561. Abdel-Fatah TM, Powe DG, Hodi Z, et al. High frequency of coexistence of columnar cell lesions, lobular neoplasia, and low grade ductal carcinoma in situ with invasive tubular carcinoma and invasive lobular carcinoma. Am J Surg Pathol 2007;31:417–426. Simpson PT, Gale T, Reis-Filho JS, et al. Columnar cell lesions of the breast: the missing link in breast cancer progression? A morphological and molecular analysis. Am J Surg Pathol 2005;29:734–746. Dahlstrom JE, Sutton S, Jain S. Histologic-radiologic correlation of mammographically detected microcalcification in stereotactic core biopsies. Am J Surg Pathol 1998; 22:256–259.
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90. Meyer JE, Smith DN, DiPiro PJ, et al. Stereotactic breast biopsy of clustered microcalcifications with a directional, vacuum-assisted device. Radiology 1997;204:575–576. 91. Reynolds HE, Poon CM, Goulet RJ, et al. Biopsy of breast microcalcifications using an 11-gauge directional vacuum-assisted device. AJR Am J Roentgenol 1998; 171:611–613. 92. Tornos C, Tornas C, Silva E, et al. Calcium oxalate crystals in breast biopsies. The missing microcalcifications. Am J Surg Pathol 1990;14:961–968. 93. Truong LD, Cartwright J Jr, Alpert L. Calcium oxalate in breast lesions biopsied for calcification detected in
screening mammography: incidence and clinical significance. Mod Pathol 1992;5:146–152. 94. Jacobs TW, Byrne C, Colditz G, et al. Radial scars in benign breast-biopsy specimens and the risk of breast cancer. N Engl J Med 1999;340:430–436. 95. Frouge C, Tristant H, Guinebretiere JM, et al. Mammographic lesions suggestive of radial scars: microscopic findings in 40 cases. Radiology 1995;195:623–625. 96. Sloane JP, Mayers MM. Carcinoma and atypical hyperplasia in radial scars and complex sclerosing lesions: importance of lesion size and patient age. Histopathology 1993;23:225–231.
44
Breast Biopsy and Breast-Conserving Surgical Techniques Lorraine Tafra, MD and Zandra Cheng, MD INTRODUCTION Surgical procedures of the breast have changed significantly since the late 1990s. With improved imaging techniques, the detection of radiologic abnormalities is increasing and the size of detected malignancies is decreasing. These factors have led to a shift in management strategies toward more precise and aesthetic surgical approaches. Just as the surgical management has changed, so have other subspecialty management strategies such that the multidisciplinary aspect of breast cancer has become more complex. Comprehensive care, therefore, involves surgical strategies and decisions with input from a team of multidisciplinary specialists. The operating surgeon’s first and crucial step to avoid surgical pitfalls with the breast patient is to ensure easy and frequent communication with the other specialists. A strategy used by many centers to ensure this communication is the multidisciplinary tumor board. A significant change in breast surgery was the shift from open surgical biopsy to image-guided needle-core biopsy (for the diagnosis of breast abnormalities). The current literature supports the superiority of an image-guided needle biopsy over an open surgical biopsy for the vast majority of patients with a breast abnormality.1–7 This technology has decreased the frequency of operative procedures, allowed for tailored care of proven malignancies, and improved the accuracy of definitive surgical management of breast cancer. It is also convenient for the patient and expedites the diagnosis. A very small group of patients remain who present with a palpable abnormality, with no imaging correlate, who will still require an open surgical biopsy for a definitive diagnosis. The vast majority of patients who do need to go to the operating room for a diagnosis (1) are being evaluated for a nonpalpable, image-detected lesion for which the core biopsy pathology result is equivocal or (2) were constrained by the limitations of the image-guided techniques (e.g., thin breast, very faint microcalcifications).
Partial mastectomy, which is also commonly referred to as lumpectomy, is the breast-conserving surgical procedure performed for a breast cancer. Although many of the steps of a lumpectomy are similar to those of a biopsy, the goals of each are very different and are considered separately.
Breast Biopsy INDICATIONS ● Patient with a defined mass on palpation but no
evidence of abnormality on mammography or ultrasound ● Patient with an image-detected abnormality who, on core biopsy, has insufficient tissue for a definitive diagnosis, or the benign pathology results are not concordant with imaging findings ● Patient with a benign diagnosis on core biopsy but who exhibits growth or other concerning symptomatic or physiologic behavior over time ● Patient with an image-detected abnormality who is not a candidate for image-guided biopsy (presence of implants, thin breasts, needle phobias, obese [stereotactic tables have a weight limit of about 350 lbs], or bleeding disorders)
OPERATIVE STEPS Step 1 Step 2 Step 3 Step 4 Step 5
Mark palpable lesion in preoperative area Ensure adequate localization if lesion is nonpalpable Mark incision on breast Resect Palpate lesion resection, perform a specimen radiograph as indicated, and close
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OPERATIVE PROCEDURE Marking the Lesion Failure to Remove the Correct Area of Concern ● Consequence Occasionally, the patient will have a subtle abnormality; something the patient can feel well, but for the surgeon, the abnormality is not well defined. Removing the wrong area may warrant a return to the operating room. Besides avoiding the dreaded scenario of doing a breast biopsy on the wrong breast, marking the site of the lesion and obtaining consensus on its location ensure the precise removal of the area of concern. Grade 3 complication ● Prevention Preoperative discussion of the area, marking and finding the lesion, and reaching consensus between the surgeon and the patient on the site of the abnormality.
Adequate Localization Failure to Remove the Correct Area of Concern ● Consequence Lesions that are not palpable require some form of localization. This is an active area of investigation because this scenario continues to increase in frequency.8 Wire localization has been the standard procedure for localizing a lesion for the surgeon since its introduction in the 1980s,9–11 but there is much room for improvement. Standard wire localization is frequently imprecise. In addition, when addressing a malignancy, it does not assist with obtaining negative margins and is not very convenient for the patient who must endure an additional procedure prior to the initial surgery. It has typically been performed outside of the operating room by the radiologist, but fortunately with increasing use of ultrasound by surgeons, a shift is occurring, allowing the patient to be localized in the operating room. Intraoperative localization has many advantages: it avoids the time delays that come with coordination of a second department; scheduling is simplified; patient satisfaction is maximized; staff inconvenience is minimized; and finally, the accuracy is probably better when the physician localizing the lesion is also removing it. The precision and accuracy of the localization of the lesion are far more important than who performs it. The worst consequence of inadequate localization is missing the lesion and having to return the patient to the operating room for a second attempt at excision. This is obviously disconcerting to the patient, but it also delays the diagnosis and potential treatment. In addition, because cosmesis is related to the amount of tissue removed, a second trip to the operating room to remove more tissue
could negatively affect cosmesis, patient satisfaction, and future imaging. Grade 3 complication ● Prevention The localization procedure needs to adhere to the following basic principles, whether performed by the radiologist or the surgeon: 1. Ensure that the correct area has been targeted, and if a clip is the target, that the clip has, in fact, remained at the area of interest since the time of needle biopsy. 2. Ensure that the site of the wire entering the skin has been marked with a marker visible in the postlocalization films (if the localization is done by someone other than the surgeon) and that another point of reference on the breast (most commonly, the nipple) is also marked so that the surgeon can determine how far the lesion is from the entry of the wire through the skin and within the breast tissue. 3. Ensure that the location of the wire is within 2 to 3 mm of the clip (if a clip is targeted). 4. Ensure that two views (both the craniocaudal [CC] and the mediolateral [ML]) have been obtained and sent with the patient to confirm that the locations of the lesion, the clip, and the wire can be determined by the surgeon. Once this has been established, it is the surgeon’s goal to remove the area of concern. If the target is a clip or calcifications or if the lesion remains nonpalpable even with dissection down to the area, a specimen radiograph is needed. If there has been clip migration or if the localization is not where the surgeon believes the original lesion is, it is imperative that good communication occurs between the radiologist and the surgeon prior to the procedure. In these cases, retrieval of the clip on specimen radiograph may not be necessary. If the lesion becomes palpable with dissection, a specimen radiograph need not be performed if the operating surgeon is confident the lesion has been obtained. Caution should be exercised with this approach, however, because a palpable hematoma from the prior core biopsy may masquerade as the lesion. Once the best determination of the site of the lesion is made based upon direct review intraoperatively of the mammographic or ultrasound images, the lesion is marked and the incision is placed directly over the abnormality. Occasionally, the more cosmetic periareolar incision is used, especially if the lesion is in close proximity to the nipple-areolar complex. Dissection then proceeds toward the wire. The wire is then delivered into the wound. Palpation of the tissue surrounding the wire will ensure an adequate removal of the tissue that needs further assessment. It is worth emphasizing that the incision usually is not placed at the site of the entrance of the wire to the skin. If the lesion is localized by the surgeon in the operating room, the surgeon must have prior, precise knowledge of the lesion’s location. It is best if the surgeon retains
44 BREAST BIOPSY AND BREAST-CONSERVING SURGICAL TECHNIQUES a copy of the ultrasound or mammogram for reference in the operating room. The use of intraoperative ultrasound is justifiably increasing. If a lesion is visible on ultrasound and the surgeon has ultrasound skills, localization in the operating room is easier and safer, requires less time, and is more convenient for the patient and surgeon. With experience, localizing a lesion in the operating room is usually straightforward, but it can be challenging with small lesions. If the lesion is small (70 yr) and obese (BMI > 30) with large breasts (mean weight of resected tissue 1015 g) needed to undergo a fish-tail plasty in their study. This technique did not prolong hospitalization. Similarly, Gibbs and Kent52 described their technique for creating a lateral V-Y advancement flap by retracting
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B
A
C
D
E Figure 46–7 Modified V-Y advancement technique for mastectomy closure. A, Standard incision for mastectomy. B, The lateral apex is retracted for marking the superior and inferior flaps. C, The superior and inferior flaps are excised along the dotted line. D, The lateral apex is retracted medially and secured to the superior and inferior skin edges. E, The closure as it appears after completion. (From Gibbs ER, Kent RB 3rd. Modified V-Y advancement technique for mastectomy closure. J Am Coll Surg 1998;187:632–633.)
the lateral apex medially and securing it to the approximated transverse incision about one third of the way medial in the incision (Fig. 46–7). The incision is closed with a newly created Y configuration. Other techniques include extending the ellipse (by further lengthening of the wound) and excising excess tissue. The scar may eventually extend around the back and further diminish the cosmetic result. Flap length discrepancy is a key factor in the creation of dog ears. Gold53 described a technique similar to the one we use at our institution whereby skin length of both the superior and the inferior flaps is measured with a silk suture to avoid length asymmetry between both limbs of the ellipse (Fig. 46–8). The technique was applied to over 250 patients and was especially effective in patients with small breasts and relatively large tumors situated large distances from the NAC.
Suture-Associated Issues ● Consequence Suture removal may provoke patient anxiety and result in suture tracks. It also requires an additional follow-up visit. Grade 1 complication ● Repair Use of tissue adhesive as an alternative to sutures. ● Prevention Gennari and colleagues54 conducted a prospective, randomized trial comparing skin closure with the tissue adhesive 2-octylcyanoacrylate (OCA) with subcuticular monofilament suture and then blindly assessed cosmetic and economic outcome at various time points. They found that tissue adhesive skin closure was faster
46 MASTECTOMY
B A
A B
A
B
C
D
E
Figure 46–8 Measurement with silk sutures for flap length. A, Marking the long and short axes of the intended skin incision. B, A snugly clamped suture to mark the superior skin incision. C, A second suture placed to mark the inferior skin incision, leaving the superior suture undisturbed. D, The intended ellipse is traced with a skin marker. E, The wound after a cosmetic closure along the long axis. F, Photographic depiction of the technique.
F
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Lateral pectoral n. Pectoralis major m.
Pectoralis minor m. Medial pectoral n.
Figure 46–9 An artistic rendition of the anatomy of the lateral and medial pectoral nerves as they relate to the pectoralis minor muscle. The lateral pectoral nerve courses along the undersurface of the pectoralis minor muscle, and the medial pectoral nerve courses through the pectoralis minor muscle in 62% and exits around the lateral aspect of the muscle in the remaining 38%.
than the suture closure, the OCA patients developed less tissue reaction, and the total cost in the OCA group was significantly lower (P < .001). The cost saving was mostly due to reduced physician and ancillary services and reduced equipment needs. However, there is a learning curve in applying the OCA in that hemostasis must be meticulous because the adhesive polymerizes upon contact with blood and fluid. If polymerization occurs too rapidly, the adhesive can form an unsightly plastic mass on top of the wound. In addition, subcutaneous sutures must be placed to minimize dead space, maximize skin eversion, avoid depressed scarring, and improve cosmetic outcome. Lastly, the preference of staples over sutures for wound closure in mastectomy is not directly addressed in the literature in terms of cosmetic outcome or infectious complications. At our institution, we use subcuticular sutures to approximate the skin edges in mastectomy patients because the psychological impact of staple removal and the skin imprinting from the staples can be devastating to the patient.
Postoperative Concerns Postoperative Muscle Atrophy/Limitation of Shoulder Movement ● Consequence Injury to the lateral pectoral nerve by accidental division, cautery injury, or avulsion produces variable postoperative atrophy, fibrosis, and shortening of the lower third of the pectoralis major muscle (PMM). This limits
shoulder motion and changes the cosmetic contour of the pectoral region of the chest. Grade 3 complication ● Repair Reconstruction with skin-muscle flaps, as opposed to breast implants or tissue expansion, to correct the infraclavicular depression followed with breast implants. ● Prevention Awareness of the anatomic distribution and course of the medial and lateral pectoral nerves is essential to the preservation of the PMM and its function. The upper part of the PMM is innervated by the medial pectoral nerve, whereas the lateral pectoral nerve supplies the lower third of the muscle.55 The lateral pectoral nerve courses along the undersurface of the PMM and may be compromised during division and retraction of removal of the pectoralis minor muscle (Fig. 46–9). In 100 cadaver dissections, Moosman55 demonstrated that the medial pectoral nerve coursed through the pectoralis minor muscle in 62% of the specimens, whereas it exited around the lateral aspect of the muscle in the remaining 38% (see Fig. 46–9). Hoffman and Elliot56 had similar findings and suggested that dissection between the PMM and the pectoralis minor muscle is more likely to result in disruption of a significant portion of the innervation to the PMM. In addition, capsule formation around breast implants has been implicated as causing compression of the medial and lateral pectoral nerves under the PMM.
46 MASTECTOMY
Phantom Breast Phenomena ● Consequence Psychological consequences as well as need for pain management. Phantom breast syndrome (PBS) refers to both painful and painless sensations of persistence of the entire breast or parts of it despite its absence. Onset may be immediately after mastectomy or more than 1 year after mastectomy58 and may persist for years. The incidence of PBS is reported to vary from 17% to 64%.59,60 Grade 1 complication ● Prevention PBS sensation may be the nonpainful variety: numbness, tension, twinging, pressuring, pounding, itching, pricking, and bothering as described by Rothemund and associates.61 The authors also addressed the painful variant, which included sensations such as twinging, tearing, tense, cutting, sharp, convulsive, pressing, and cramplike. Whereas Rothemund and associates61 found no relation of PBS to age, Staps and coworkers62 reported that in their study of 89 women surveyed, those with PBS tended to be younger (5 cm in diameter), and depth of involvement (superficial or deep to fascia). Nodal involvement is rarely a consideration in the presentation of STS (but is a poor prognostic factor when present). The dominant prognostic parameter is the histologic grade, based on its microscopic appearance. An experienced pathologist will use characteristics such as pleomorphism, cellularity, mitotic rate, and necrosis to assign a grade to a tumor; this drives the clinical staging system. The ability of different pathologists to do this accurately varies widely,2 and here, the surgeon is at the mercy of the anatomic pathologist. The latest American Joint Committee on Cancer (AJCC) staging system is presented in Table 47–1, and the prognosis of these stages is shown in Figure 47–1.3 Thus, it is evident that misidentification and mistakes in staging of STS can be some of the earliest and most detrimental pitfalls for those treating this disease, because these errors will lead to mistreatment. Therefore, the biopsy is critical to sarcoma management.
PROPER APPROACH TO PREOPERATIVE BIOPSY TO AVOID LOCAL RECURRENCE For uncomplicated, superficial masses less than 3 cm, simple excision is the indicated biopsy. This has the advantages of complete histologic sampling and definitive treatment if malignancy is not found. Major errors in this area can occur if the lesion proves to be a sarcoma. The exci-
Table 47–1 Staging of Adult Soft Tissue Sarcomas Stage
Primary Tumor
Metastases*
Grade
Size
Depth
I
Low
Any
Any
No
II
High
≤5 cm
Any
No
High
>5 cm
Superficial
No
III
High
>5 cm
Deep
No
IV
Any
Any
Any
Yes
*Nodal or distant. From Fleming ID, Cooper JS, Henson DE, et al (eds): AJCC Cancer Staging Manual, 5th ed. Philadelphia: Lippincott-Raven, 1997.
Probability of metastasis-free survival
490
1.0
Stage I
.9 .8
Stage II
.7 .6 .5
Stage III
.4 .3 .2 .1 0
0 12 24 36 48 60 72 84 96 108120132144156168180 Months from diagnosis
Figure 47–1 Metastasis-free survival by the American Joint Committee on Cancer (AJCC) stage (minimal differences from current staging) for localized adult soft tissue sarcomas. Low-grade lesions (stage I) have a very low risk of metastasis, even with prolonged follow-up. (From Wunder JS, Healey JH, Davis AM, Brennan MF. A comparison of staging systems for localized extremity soft tissue sarcoma. Cancer 2000;88:2721–2730.)
sion scar should be longitudinal on the limb to facilitate wide reexcision, and drains should be avoided if at all possible or, when necessary, placed immediately adjacent to the wound. Hemostasis is of the highest priority because many sarcomas can be quite vascular, and hematoma can carry malignant cells throughout tissue planes within a limb, leading to an otherwise avoidable amputation. For larger or more complex lesions, a diagnostic biopsy is indicated. This can often be accomplished adequately by core needle biopsy, depending on the experience of the facility and pathologist. Some institutions advocate fineneedle assessment, but in our hands, this is often inadequate for complete staging and occasionally incorrect (owing to sampling error) when compared with the ultimate resection specimen.4 A bruit, thrill, or pulsation should alert one to the possibility of a vascular sarcoma and the potential for major bleeding from a biopsy. Hematuria, abdominal mass, or associated bony destruction should raise the possibility of a bony metastasis from renal
47 MANAGEMENT OF SOFT TISSUE SARCOMA cancer with a soft tissue component masquerading as a sarcoma because these are particularly prone to hemorrhage after biopsy. Very large or fixed lesions should have imaging performed prior to biopsy to identify areas of solid tumor versus liquefaction and to evaluate the structures that may need to be sacrificed in future operations. For instance, when an amputation is a possibility for a large, deep, proximal thigh lesion, consideration should be given to preserving the appropriate anterior or posterior hemipelvectomy flap and not compromise it with a biopsy site. Prebiopsy imaging suggesting bone or major neurovascular involvement would particularly raise such a concern. Conversely, if an unequivocal diagnosis of lowgrade (grade I) sarcoma is made from a biopsy, a lesser, nonablative surgical option may be entertained. In such a situation, the surgeon relies heavily on the pathologist to accurately “predict” the biologic behavior of the tumor based on histology. A relatively small number of experienced sarcoma pathologists have seen sufficient cases and have an adequate clinical database to assess and refine their own reliability. For most experts, designating a sarcoma as “grade I” indicates that there is less than a 10% chance (and in most cases, 5% or less) that this lesion will ever show metastatic behavior. Even large grade I lesions, when correctly identified, are typically limb-threatening rather than life-threatening malignancies, and the options for local therapy are perhaps more flexible. Although the causal link between local recurrence and metastatic disease has come under major scrutiny based on animal data as well as prospective, randomized clinical studies, the surgeon undoubtedly feels more comfortable considering a function-sparing procedure with a higher risk of local recurrence if he or she knows he or she is dealing with a lesion with minimal metastatic potential. In a published
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experience from our institution, none of 67 patients with a diagnosis of low-grade (grade I) sarcoma of the extremities required an amputation at their initial presentation.5 The metastasis-related mortality in this group was only 4%, with a maximum follow-up extending beyond 10 years. Therefore, limb-sparing and function-sparing operations within this group of patients with low-grade sarcomas are the rule, and the major pitfall in their care is not adequately considering these options. If the biopsy reveals an unequivocal high-grade lesion, the appropriate definitive procedure can be planned without further disturbing tissue planes.
PROPER APPROACH TO PREOPERATIVE IMAGING Imaging of extremity sarcomas is also a point of some controversy. Plain radiographs have little utility, and the main competing modalities are computed tomography (CT) scanning and magnetic resonance imaging (MRI). Because the radiodensity and vascularity of some sarcomas differ minimally from surrounding tissues, they can be difficult to delineate on CT (Fig. 47–2). Conversely, the effects that very large compressive masses can have on surrounding tissue vis-à-vis inflammation, edema, and ischemia can exaggerate the apparent size of the malignancy on MRI. This can lead to procuring excess margins at a high functional cost. As an example, a patient with a large high-grade sarcoma was evaluated by MRI (Fig. 47–3), and there appeared to be intimate contact between the tumor and the femur over a significant portion of its circumference. Rather than plan an amputation, exploration to evaluate local resection showed the periosteum to
Figure 47–2 Computed tomography (CT) scan (left) and magnetic resonance imaging (MRI) (right) of a patient with low-grade liposarcoma of the thigh. Lesion is indistinct on CT, but precisely delineated by MRI.
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Figure 47–3 MRI of high-grade sarcoma of the thigh shows what appears to be intimate contact with the femur over a large portion of the femoral circumference. The signal of MRI may overestimate the extent of malignancy owing to edema or inflammation in compressed adjacent tissue. This patient had limb-sparing resection with a histologically negative periosteal margin.
be uninvolved, and a small periosteal stripping and local resection achieved a satisfactory margin, which was then followed by postoperative radiotherapy. Although she subsequently developed aggressive metastatic disease and expired, there was never any evidence of local recurrence. This patient would have been disserved by an amputation performed in anticipation of a positive margin based on the MRI and demonstrates the potential for MRI to overestimate tumor extent. In difficult cases, both CT and MRI may be needed to preoperatively assess and anticipate the need for resection of important structures. In rare cases in which bona fide bony involvement is the critical point, a nuclear medicine bone scan can also be quite revealing. In general, the burden of proof in this preoperative assessment and planning is on those who advocate resecting vital functional structures; that approach is usually reserved for high-grade or recurrent lesions in which imaging indicates substantial direct involvement of the structure by surrounding, unequivocally malignant tissue.
AVOIDING RECURRENCE AFTER DEFINITIVE SURGICAL RESECTION The major pitfall for the surgeon in the planning of the definitive resection of an STS is to underestimate the size of the lesion and the involved compartments. Local recurrence can be a significant problem, and therefore, adequate planning and execution are critical. The approach to surgical procedures for sarcoma has swung back and
forth over the last 50 years, and apparent contradictions have been generated that are not completely resolved. Prior to the work of Pack, Stout, and others, minimal excisional procedures were often utilized and typically failed to control local disease. Advocating more radical resections, sarcoma surgeons of the 1950s and 1960s pointed to improved local control and a consistent cure rate in uncontrolled trials as evidence of the efficacy of this approach. Then, the major success story from the 1970s was the addition of radiation to lesser, limb-sparing surgeries to achieve comparable local control and survival rates (again, with only one small randomized trial on the subject).6,7 Finally, randomized, prospective trials of limb-sparing surgery with and without adjuvant radiation therapy supported the concepts that many lesions could be treated with limb-sparing procedures without radiation and that salvage of patients with local recurrence was often possible without clearly impairing overall survival.8,9 At first glance, this seems to effect the complete undoing of 50 years of “progress” in the surgical management of sarcomas. Yet other factors, also evolving over this time interval, may offer a better interpretation. Earlier diagnosis and improved recognition of sarcomatous lesions with lower lethality have improved the overall prognosis of sarcomas as a group. Improvements in surgical imaging, planning, and technique have also allowed the more satisfactory extirpation of these tumors without violating tumors, encountering hemorrhage, or destroying function. In addition, when needed, radiation remains a proven adjunct to surgery to improve local control for difficult lesions, and improvements in technique have
47 MANAGEMENT OF SOFT TISSUE SARCOMA dramatically reduced the complications and morbidity of this modality.
AVOIDING THE PITFALL OF OVERAGGRESSIVE THERAPY AND POOR FUNCTIONAL OUTCOME In view of the developments previously discussed, current pitfalls in surgical management of sarcomas are as likely to be from overtreatment as from undertreatment or technical misadventure. The surgeon should have a clear grasp of the minimum of structures needed to retain a productive extremity. Although largely outmoded by new developments in prostheses, the original Tikoff-Lindberg procedure as a substitution for forequarter amputation was an early example of this concept. Neurovascular service to the hand and forearm still maintained a productive extremity even without shoulder joint integrity. Often, the argument is made that major resections of muscle groups will result in a poorly functioning limb with more protracted rehabilitation than even an amputation. Yet, it is often underappreciated that several major lower extremity muscle groups can be largely removed with only specific and minor deficits. Loss of the lower extremity biceps group has minimal impact in daily function and normal ambulation. Loss of the quadriceps group causes most difficulty in ascending and descending stairs, but if even a trace of knee extensor activity is preserved, this allows knee hyperextension that supports weight-bearing in normal ambulation with only a minor alteration in gait. Knee bracing can often compensate for even total loss of quadriceps function when walking on level ground. The concept that sarcomas do not have true capsules and that the “pseudocapsule” often surrounding them does not represent a safe excision plane, has been well established. This envelope encompassing the obvious sarcomatous mass does not represent a true fibrous capsule, but is rather compressed reactive normal tissue, frequently infiltrated by malignant cells. Therefore, a truly negativemargin surgical procedure remains outside of this transition zone. Conversely, surgeons often fail to realize that a true fibrous or fascial structure adjacent to a sarcomatous mass is often an adequate boundary if not invaded by malignant cells. Thus, the fascia of a major muscle group or the periosteal membrane, even when in direct apposition to the tumor, can represent an adequate margin if not directly invaded. In those cases, there is no arbitrary radial distance that defines the term wide (as in “wide local excision”). This is important because most large extremity sarcomas, high and low grade, will abut the fascia of a muscle compartment, and performing multiple compartment excisions or amputations is typically not necessary to procure a sufficient margin at that interface. The determination of actual bony invasion on preoperative studies can be problematic. Often, the limits of an STS are vague on CT scanning because tumor and normal soft tissue
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densities are similar. MRI can be more sensitive but will detect inflammation and edema as well as malignancy and not discriminate well between these entities. As mentioned, we often use both modalities to estimate likely surgical margins, realizing that the former can suffer from false negatives whereas the latter can have false positives. Without clear evidence of bony destruction, we will typically assume that the periosteal margin will be adequate and confirm this at surgery by frozen sections. When determining adequate margins intraoperatively, one must proceed with a clear contingency plan in mind in the event that bony involvement is encountered. This can be orthopedic and prosthetic backup or amputation, and the initial approach to the tumor must not compromise the backup plan. The initial incision should respect the layout for optimal closure of a possible amputation or allow a satisfactory approach to a segmental or total bone resection en bloc with the primary tumor mass. Often, one encounters the “minimal” positive margin, in which, for example, tumor closely approaches a major nerve or vessel over a very limited segment without frank involvement. If this is the only point of compromise for an otherwise satisfactory resection, a segmental resection of the neurovascular structure versus a potential compromise of the resection must be weighed. Segmental vascular resection results in a more consistently satisfactory functional outcome than that of nerve resection and grafting or repair. Ultimately, the preservation of a poorly functional limb is not a desired outcome, so careful marking of the point of compromise (as well as the wider limits of the entire surgical field) by surgical clips and the administration of postoperative adjuvant radiotherapy can be a realistic choice. A randomized study showed that local recurrences of low-grade tumors were reduced to very low frequency with adjuvant, postoperative external beam radiotherapy (Fig. 47–4A).8 In the case of low-grade tumors, one should select this option without much reservation if the alternative is significantly morbid. Randomized studies also indicate that even highgrade lesions can be well managed by this approach in many circumstances. The significant retrospective association in many studies between local recurrence and metastatic recurrence and death led many to conclude that improved survival would result if one achieved better local control. Yet, when this was subjected to randomized, prospective studies testing local control measures, this hypothesis was not substantiated. Two studies of postoperative radiotherapy for high-grade tumors after limb-sparing surgery (one by external beam and the other using brachytherapy) demonstrated significantly improved local control with radiation, but neither documented an improvement in overall survival8,9 (see Fig. 47–4B). In one study, the local recurrences without radiotherapy were either accompanied by prompt and aggressive metastatic relapse (in which local recurrence was not a major component of the clinical picture) or durably salvaged by reresection of the local recurrence, implying that the local relapse was not seeding new metastatic sites after failure
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Percent without local recurrence
100 90 80 70
No radiation
60 50 40 30 20
P2⫽.016
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2
4
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10
12
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80 70 60 50 40 30 20
80
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P2⫽.003
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Percent survival
Percent without local recurrence
Radiation 100 90
P2⫽.71
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4
6
8
10
12
Follow-up (years)
2
4
6
8
10
12
Follow-up (years)
Figure 47–4 A, Randomized trial of adjuvant postoperative external beam radiotherapy versus no radiotherapy after limb-sparing resection of low-grade extremity sarcomas. Radiation significantly reduced local recurrences in this malignancy. B, Randomized trial of adjuvant postoperative external beam radiotherapy versus no radiotherapy after limb-sparing resection of high-grade extremity sarcomas. Local recurrences were significantly reduced with radiotherapy (left), but this had no demonstrable effect on overall survival (right). (A and B, From Yang JC, Chang AE, Baker AR, et al. Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity. J Clin Oncol 1998;16:197–203.)
of the primary resection.8 Therefore, it is misguided to apply a radical approach to resection when there are other lesser options because of the concept that it is somehow more “curative.” The strong retrospective association between local recurrence and death10 is more plausibly due to the aggressive intrinsic biology of some tumors, and successfully reducing local recurrences does not affect their tendency for distant metastases. This finding should not be misconstrued as an excuse for poor or inadequate surgery or neglect of the primary. Local recurrences can severely affect quality of life, and the limited size of the studies cited cannot exclude all possibility of an impact of poorer local control on metastatic disease. Rather, these studies indicate that after optimal limb-sparing surgery by experienced sarcoma surgeons, the application of postoperative adjuvant radiotherapy can further reduce the already low incidence of local recurrence. Yet those patients who do not receive this adjuvant do not suffer a demonstrably reduced overall survival. Both findings (adjuvant
radiotherapy is locally effective, and local recurrences do not clearly degrade overall survival) support the alternative of relying on postoperative adjuvant radiotherapy in the case of “minimally compromised” surgical margins in which the surgical procedure necessary to rectify this compromise is morbid or defunctionalizing. A relatively dramatic example of this is illustrated in Figure 47–5 in which a patient with a very large low-grade sarcoma of the quadriceps was explored and transfascial infiltration into the lateral portion of the biceps compartment was found. Because hemipelvectomy was the only procedure that could achieve widely negative margins and because the lesion was of low grade, it was elected to resect the majority of the quadriceps compartment and all gross disease in the biceps compartment and apply postoperative radiation. Care was taken to preserve the posterior thigh skin in the event that hemipelvectomy was ultimately necessary. With 6 years of follow-up, this patient has a functional gait without prosthesis and is free of evident disease.
47 MANAGEMENT OF SOFT TISSUE SARCOMA
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EARLY DETECTION, DIAGNOSIS, AND TREATMENT OF RECURRENCES
Figure 47–5 A patient with very large low-grade liposarcoma of the quadriceps compartment with transfacial extension to the posterior compartment found at surgery. Rather than proceed to amputation, a local resection of all gross disease was performed followed by postoperative adjuvant radiotherapy. The patient has useful function of the extremity, requires no assistance with ambulation, and has shown no sign of recurrence for over 6 years. The low metastatic risk of low-grade lesions supports the safety of such a conservative surgical approach.
At this point, even if he suffers a local recurrence and requires an amputation, he will have benefited from the use of the functional limb for a substantial time and have a survival expectation not significantly affected by the attempt at lesser surgery. Although such an approach is not recommended for extensively infiltrating high-grade tumors, in this case, the main pitfalls in trying this strategy for a low-grade tumor are poor follow-up that does not detect the local recurrence until it is not amenable to amputation or not technically preserving the amputation as a salvage option during the first procedure. The merit of this approach seems evident when dealing with lowgrade lesions, and the two randomized trials cited earlier indicate that it can also be entertained safely for many high-grade tumors that are marginally resected. Gross high-grade residual disease is not likely to be controlled with this approach (and such patients were not included in the randomized studies), but adjuvant radiotherapy, careful follow-up, and a fall-back plan can be a safe option for avoiding amputation after a marginal resection for many of these tumors.
If a recurrence occurs despite the best efforts of the surgical team to properly plan and execute a definitive surgical resection, a salvage operation may be required. Adult STS recur either locally or systemically. Although retrospective studies indicate that local recurrences can be harbingers of poor outcome, as noted previously, that appears to be a reflection of underlying aggressive biology rather than a result of a cause and effect relationship. Therefore, when a local recurrence appears in the absence of disseminated disease, it should be treated vigorously, and there would be some expectation that some of these patients can yet be cured. If the patient has already been treated with limb-sparing surgery and adjuvant radiotherapy for a high-grade lesion, most surgeons will have to proceed to an amputation as their salvage procedure. If no adjuvant radiation therapy was given originally and the recurrence is small or localized, a second limb-sparing operation is possible in many patients. In almost all such cases, this second procedure should be accompanied by adjuvant radiotherapy because the primary has already demonstrated its propensity for local recurrence. For lowgrade tumors, the option of amputation is reserved for those patients with very large and infiltrating recurrent lesions that cannot be cleanly re-resected. Otherwise, adjuvant external beam radiotherapy is also a useful component of treatment after re-resection of these recurrences if not already used. The more difficult situation is when dissemination is systemic and hematogenous. Fortunately, there is a marked predilection for metastases to go exclusively to the lungs. Here, a common pitfall is to not pursue pulmonary metastasectomy adequately. In our experience, even the third metastatic recurrence from sarcoma can be exclusively pulmonary and still technically resectable.11 Because systemic therapies such as chemotherapy are, at best, of brief benefit to a small minority of patients, surgery is the mainstay of treatment for limited metastases confined to the lungs. Although the success of pulmonary metastasectomy is reduced with a higher number of lesions and a shorter disease-free interval, there can still be extended periods of tumor-free survival for some of these patients,12–14 and the real limitations are technical, related to pulmonary reserve and resectability.
SUMMARY OF POTENTIAL PITFALLS AND HOW TO AVOID THEM Most often, mistakes in the management of primary adult STS result from inadequate or inaccurate pathologic grading and selection of suboptimal function-destroying choices in surgery. Randomized studies have shown that intrinsic biologic determinants are probably driving prognosis more than are therapeutic options, implying that
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draconian therapeutic options are less likely to improve outcome than to impair quality of life. Yet, knowing when a lesser, conservative resection is appropriate and safe is still one of the most difficult clinical decisions. Isolated local recurrences after limited surgery are often amenable to curative surgical salvage procedures if one carefully allows for such an “exit strategy” during planning for the first procedure. Lastly, aggressive pulmonary metastasectomy represents the best and only route to cure or prolonged disease-free survival once metastatic disease occurs. The potential benefits of such a resection should be considered for each patient with metastatic disease and should be rejected only when the clinical course or technical considerations clearly predict rapid failure of this strategy.
REFERENCES 1. Helman LJ, Meltzer P. Mechanisms of sarcoma development. Nat Rev Cancer 2003;3:685–694. 2. Alvegard TA, Berg NO. Histopathology peer review of high-grade soft tissue sarcoma: the Scandinavian Sarcoma Group experience. J Clin Oncol 1989;7:1845–1851. 3. Wunder JS, Healey JH, Davis AM, Brennan MF. A comparison of staging systems for localized extremity soft tissue sarcoma. Cancer 2000;88:2721–2730. 4. Barth RJ Jr, Merino MJ, Solomon D, et al. A prospective study of the value of core needle biopsy and fine needle aspiration in the diagnosis of soft tissue masses. Surgery 1992;112:536–543.
5. Marcus SG, Merino MJ, Glatstein E, et al. Long-term outcome in 87 patients with low-grade soft-tissue sarcoma. Arch Surg 1993;128:1336–1343. 6. Rosenberg SA, Tepper J, Glatstein E, et al. The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with postoperative radiotherapy in the treatment of soft tissue sarcomas in adults. Am J Roentgenol 1975;123:123–129. 8. Yang JC, Chang AE, Baker AR, et al. Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity. J Clin Oncol 1998;16:197–203. 9. Pisters PW, Harrison LB, Leung DH, et al. Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol 1996; 14:859–868. 10. Pisters PW, Leung DH, Woodruff J, et al. Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities. J Clin Oncol 1996;14: 1679–1689. 11. Potter DA, Glenn J, Kinsella T, et al. Patterns of recurrence in patients with high-grade soft-tissue sarcomas. J Clin Oncol 1985;3:353–366. 12. Pogrebniak HW, Roth JA, Steinberg SM, et al. Reoperative pulmonary resection in patients with metastatic soft tissue sarcoma. Ann Thorac Surg 1991;52:197–203. 13. Rizzoni WE, Pass HI, Wesley MN, et al. Resection of recurrent pulmonary metastases in patients with soft-tissue sarcomas. Arch Surg 1986;121:1248–1252. 14. Weiser MR, Downey RJ, Leung DH, Brennan MF. Repeat resection of pulmonary metastases in patients with soft tissue sarcoma. J Am Coll Surg 2000;191:184–190.
48
Isolated Limb Perfusions and Extremity Amputations Joseph A. Blansfield, MD and James F. Pingpank, Jr., MD INTRODUCTION In-transit metastatic disease in melanoma is defined as recurrent melanoma within the intradermal or subcutaneous lymphatics that does not enter the nodal basins. In the current American Joint Committee on Cancer (AJCC) staging system, in-transit disease without metastatic lymph nodes is considered stage IIIb and carries with it a 5year survival of 30% to 50%.1 For recurrent melanoma confined to an extremity, simple excision can usually eradicate the disease. Simple excision is sufficient and a wide local excision is not necessary because it does not improve recurrence rates. For larger numbers of lesions, simple excision becomes technically prohibitive. For these patients, isolated limb perfusion (ILP) is the treatment of choice. ILP involves surgical isolation of an extremity’s circulation and placing that circulation into an extracorporeal circulation, which is separated from the systemic circulation. After creating the new circuit, the isolated limb is perfused with high doses of heated chemotherapy. ILP should be contemplated in patients with intradermal or subcutaneous in-transit melanoma metastases confined to an extremity when there is no evidence of systemic metastatic disease. ILP was first used to treat melanoma in the late 1950s by Creech and coworkers.2 His group introduced the practice of using an extracorporeal oxygenator to treat melanoma confined to an extremity. Stehlin and associates3 modified the technique 20 years later to include hyperthermia to enhance the cytotoxic effects of the chemotherapy. Hyperthermia can enhance the cytotoxicity of some chemotherapeutic agents and can cause selective killing of neoplastic cells.3 Hyperthermic ILP with melphalan leads to an objective response rate in 79% of patients, with a complete response in 54%.4 Patients with a complete response have the best prognosis. In patients with a complete response after perfusion, the 3-year survival is 60%, versus 35% in patients not obtaining a complete response.4 Unfortunately, despite the high objective response rates including a majority of
patients with complete remissions after ILP, there is a 22% to 100% recurrence rate.5 Patients can be eligible for repeat ILPs for recurrence. Melphalan is the chemotherapeutic agent of choice for ILP.6 Melphalan is an alkylating agent that is a derivative of phenylalanine. Phenylalanine is a precursor in melanin synthesis and is taken up preferentially by melanocytes, making it an optimal choice for the treatment of melanoma.7 Other agents, including cisplatin, interferon, and tumor necrosis factor–alpha (TNF-α), have been used in combination with or separately from melphalan, but response rates and durations of response are not significantly higher than with melphalan alone. The high tissue levels of chemotherapy obtained in the bypass circuit can lead to some tissue toxicity. Also, if the chemotherapy leaks into the systemic circulation, there can be some systemic toxicity. Regional side effects include skin, nerve, and muscle toxicity from the melphalan. Systemic side effects include nausea and vomiting as well as bone marrow suppression.
Isolated Limb Perfusion in Melanoma INDICATION ● Patients with in-transit metastatic melanoma confined
entirely to an extremity whose melanoma is not amenable to surgical excision
OPERATIVE STEPS Step 1 Step 2 Step 3 Step 4
Blood vessel dissection and collateral ligation Cannulation and attachment to pump oxygenator Tourniquet application Reestablishment of circulation with flush
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OPERATIVE PROCEDURE
Box 48–1 Wieberdink Grading System for Regional Tissue Toxicity after ILP11
Blood Vessel Dissection and Collateral Ligation
Grade I Grade II Grade III
The first step in ILP is to isolate inflow and outflow vessels to the perfused extremity. ILP of the lower extremity is most commonly performed through the external iliacs but can also be performed via the femoral or popliteal vessels. The location of vessel dissection depends on the distribution of the in-transit metastases as well as technical considerations. These technical points include the patient’s body habitus as well as history of previous lymph node dissections or previous surgeries in the area. ILP in the upper extremity is most commonly performed via the axillary vessels; however, brachial vessels can also be used, depending on the circumstances. In the lower extremity, a more proximal perfusion does not improve the rate of inguinal nodal recurrence. Thus, inguinal nodal recurrences are comparable for iliac and femoral vessels.8 The external iliac vessels are found via a retroperitoneal approach. This approach is made in the lower abdominal wall via a hockey-puck “transplant”–type incision. Both the artery and the vein are circumferentially dissected distally, and all collaterals arising proximally or at the inguinal ligament are ligated and divided.
Vascular Injuries as a Result of Dissection See Section X, Chapter 60, Infrainguinal Revascularization.
Cannulation and Attachment to the Pump Oxygenator The external iliac vessels are cannulated and connected to the inflow and outflow lines of an extracorporeal bypass circuit. The perfusion circuit contains a heat exchanger, an oxygenator, and a roller pump. The circuit is primed using 700 ml of balanced salt solution, 1 unit of packed red blood cells, and 1500 units of heparin. The typical hematocrit in the circuit is 25%. One unit of blood is used because regional toxicity cannot be further prevented by providing a higher hematocrit.9 Flow rates of 300 to 500 ml/min for the lower extremity and 150 to 300 ml/ min in the upper extremity are optimal for the perfusion. Flows are adjusted depending on line pressure and volume of the reservoir or because of systemic leak.10 The circuit is warmed using a heat exchanger, and the extremity is covered in external warming blankets to maintain tissue temperatures of 38.5°C to 40°C. Temperatures are monitored by thermistor probes placed in the lower extremity. Dosing for melphalan is based either on body weight or on actual limb volume. Older series used dosing regimens based on body weight and ranged from 0.8 to 2.0 mg/kg for the lower extremity and 0.45 to 0.75 mg/ kg for the upper extremity. Wieberdink and coworkers11 modified the dosing regimen so that it was based on measuring the actual volume of the limb. They then developed
No subjective or objective evidence of reaction Slight erythema and/or edema Considerable erythema and/or edema with some blistering; slight disturbed mobility permissible Grade IV Extensive epidermolysis and/or obvious damage to the deep tissues, causing definite functional disturbances; threatening or manifest compartmental syndromes Grade V Reaction that may necessitate amputation
a system to grade regional toxicity related to the perfusion11 (Box 48–1). The volume of the extremity is determined by the volume of water it disperses when submerged in a container of water, with an additional 10% added for the lower extremity to estimate the volume of the lateral thigh that is not submerged. Based on this regimen, an optimal dose of melphalan was found that resulted in reversible grade II or III toxicity in the majority of perfusions. In the lower extremity, this dose is 10 mg/L. The upper extremity can tolerate a slightly higher dose of 13 mg/L. These doses are currently used by most centers.
Toxicities of Melphalan Toxicities of melphalan are due to the direct effect of melphalan in the perfusion circuit or to melphalan that leaks into the systemic circulation. Regional side effects in the field of perfusion include effects on the skin, nerve, and muscle.12 In one group of 425 patients after ILP, 85% of patients had Wieberdink grade I or II toxicity, 15% had grade II/IV toxicity, and 0.5% (2 patients out of 425) had grade V toxicities.13 ● Consequence Virtually all patients undergoing ILP have some evidence of skin toxicity and dependent edema. Most of these reactions are transient, and most patients recover completely. Skin erythema typically starts 2 to 5 days after the perfusion and reaches its maximal intensity at about day 35. Over the subsequent 2 to 3 months, the erythema fades to a bronze. Skin reaction can be more severe including blistering or peeling of the skin, especially of the soles of the feet and the palms of the hands. Dependent edema can also occur and may be a result of the lymph node dissection that accompanies the vessel isolation. Peripheral neuropathy occurs in about half of the patients undergoing ILP. Shooting pains down the treated extremity typically occurs 2 to 3 weeks after a perfusion and can last up to 3 months.14 A subset of patients has longer-lasting neuropathy. Twenty percent of patients after axillary perfusion and 2% of patients after iliac perfusion have neuropathy that is considered long term (defined as lasting >3 mo).15
48 ISOLATED LIMB PERFUSIONS AND EXTREMITY AMPUTATIONS Muscle effects tend to be the most troublesome longterm effects after ILP.2,14 The clinical presentation of the muscle injury can be extremely variable. Patients may have little to no muscle effects with transient myalgias or may have direct myotoxicity that leads to chronic pain and atrophy. Grade 1/2/3/4 complication, but typically grade 1/2 complication ● Repair Skin effects including erythema, blistering, and edema can be managed by supportive care and applying silver sulfadiazine (Silvadene) to blisters once they have unroofed. Edema can be controlled with Jobst stockings and is typically self-resolving. Neuropathy is also self-resolving about 3 months after treatment but can be treated with gabapentin for pain relief. Myotoxicity occurs in a significant form in up to 10% of patients and is so far idiopathic. Fasciotomy does not improve the direct effects of melphalan on muscle and should be performed only with high compartmental pressures. Regional toxicities must be carefully documented in patients, especially myotoxic effects of the melphalan. Patients who are reperfused tend to have enhanced muscle toxicity with each subsequent perfusion.16 ● Prevention Unfortunately, these complications of perfusion cannot be prevented except by strictly compliance with dosing regimens, as outlined previously.
Tourniquet Application An Esmarch tourniquet is placed around the root of the extremity to occlude any superficial veins that may allow leakage of the chemotherapy into the systemic circulation. Meticulous surgical ligation of all collaterals and tourniquet application to control superficial vessels avoids perfusate flow into the systemic circulation and also prevents systemic blood from entering the perfusion circuit.
Systemic Leakage of Melphalan Melphalan leak into the systemic circulation can cause a variety of side effects including gastrointestinal upset and bone marrow suppression. Nausea and vomiting occurs within 24 hours of a perfusion if there is systemic absorption, and the bone marrow can be suppressed beginning about 7 to 10 days after the perfusion. Blood leakage into or out of the perfusion circuit must be monitored during the course of the perfusion. Reservoir volume is a key indicator for blood leakage into or out of the circuit. An increase in the amount of blood in the reservoir is indicative of a leak of blood into the perfusion circuit from either the arterial or the venous side. Increasing flow rates will increase the line pressure, which can overcome arterial flow into the circuit. By partially occluding the venous outflow and thus
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increasing the venous perfusion pressure, venous side leakage into the circuit will stop. A decrease in the amount of blood in the reservoir is indicative of a leak into the systemic circulation. Flow rates can be decreased and/or the tourniquet can be tightened to stop leakage into the circulation. Continuous intraoperative assessment of perfusate leakage into the systemic circulation is an important technique to discriminate small amounts of leakage. 131Iradiolabeled albumin or 99Tc-labeled red blood cells is allowed to circulate in the isolated circulation during the procedure. A gamma counter is placed precordially to provide continuous intraoperative monitoring of leak during a perfusion.17 This system can discriminate a leak of less than 1%.18 Systemic leak rates of less than 1% can be achieved in the vast majority of patients (90%) using the leak-monitoring systems.19 ● Consequence The nausea and vomiting associated with melphalan is self-limiting. Bone marrow suppression can lead to possible neutropenic fevers, thrombocytopenia and anemia, and infectious complications. With intraoperative continuous assessment of leak detection, and consequently low levels of systemic melphalan, most patients experience only transient nausea and vomiting for a day after surgery and low levels of bone marrow suppression approximately 7 to 10 days after treatment. Grade 1 complication ● Repair Nausea and vomiting can be treated supportively with antiemetics postoperatively. Bone marrow suppression should be treated with neupogen if neutropenia is present and with transfusions for anemia or thrombocytopenia.
Reestablishment of Circulation The perfusion circuit is disconnected after a 60-minute perfusion, and residual drug is washed out of the tissues with a 3-L flush of the extremity. This flushes any residual drug from the vascular system to further lessen systemic exposure to melphalan.
Extremity Amputations In the era of ILP and immunotherapy to treat melanoma, amputation is performed rarely to treat locoregionally intractable extremity melanoma. Kapma and colleagues20 presented a series of 451 patients who underwent 501 ILPs over a 23-year period with only 11 patients (2.4%) who needed to undergo an amputation for locoregionally intractable melanoma. Amputation for melanoma confers no increase in survival6,21 and should be performed only for palliation.
500
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REFERENCES 1. Balch CM, Buzaid AC, Soong SJ, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol 2001;19:3635– 3648. 2. Creech O, Krementz ET, Ryan RF, Winblad JN. Chemotherapy of cancer: regional perfusion utilizing an extracorporeal circuit. Ann Surg 1958;148:616–632. 3. Stehlin JS, Giovanella BC, de Ipolyi PD, et al. Results of hyperthermic perfusion for melanoma of the extremities. Surg Gynecol Obstet 1975;140:339–348. 4. Klaase JM, Kroon BB, van Geel AN, et al. Prognostic factors for tumor response and limb recurrence-free interval in patients with advanced melanoma of the limbs treated with regional isolated perfusion with melphalan. Surgery 1994;115:39–45. 5. Thompson JF, Hunt JA, Shannon KF, Kam PC. Frequency and duration of remission after isolated limb perfusion for melanoma. Arch Surg 1997;132:903–907. 6. Fraker DL. Hyperthermic regional perfusion for melanoma and sarcoma of the limbs. Curr Probl Surg 1999;36:841–907. 7. Luck JM. Action of p-dichloroethyl amino-L-phenylalanine on Harding-Passey mouse melanoma. Science 1956;123: 984–985. 8. Klaase JM, Kroon BB, van Geel AN, et al. The role of regional isolated perfusion in the eradication of melanoma micrometastases in the inguinal nodes: a comparison between an iliac and femoral perfusion procedure. Melanoma Res 1992;2:407–410. 9. Klaase JM, Kroon BB, van Slooten GW, et al. Comparison between the use of whole blood versus a diluted perfusate in regional isolated perfusion by continuous monitoring of transcutaneous oxygen study: a pilot study. J Invest Surg 1994;7:249–258. 10. Alexander HR, Fraker DL, Bartlett DL. Isolated limb perfusion for malignant melanoma. Semin Surg Oncol 1996;12:416–428. 11. Wieberdink J, Benckhuysen C, Braat RP, et al. Dosimetry in isolation perfusion of the limbs by assessment of
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
perfused tissue volume and grading of toxic tissue reactions. Eur J Cancer Clin Oncol 1982;18:905–910. Olieman AF, Koops HS, Geertzen JH, et al. Functional morbidity of hyperthermic isolated regional perfusion of the extremities. Ann Surg Oncol 1994;3:382–388. Klaase JM, Kroon BB, van Geel BN, et al. Patient and treatment related factors associated with acute regional toxicity after isolated perfusion for melanoma of the extremities. Am J Surg 1994;167:618–620. Bonifati DM, Ori C, Rossi CR, et al. Neuromuscular damage after hyperthermic isolated limb perfusion in patients with melanoma or sarcoma treated with chemotherapeutic agents. Cancer Chemother Pharmacol 2000; 46:517–522. Vrouenraets BC, Eggermont AM, Klaase JM, et al. Longterm neuropathy after regional isolated perfusion with melphalan for melanoma of the limbs. Eur J Surg Oncol 1994;20:681–685. Vrouentaets BC, Hart GA, Eggermont AM, et al. Relation between limb toxicity and treatment outcomes after isolated limb perfusion for recurrent melanoma. JAMA 1999;188:522–530. Barker WC, Andrich MP, Alexandre HR, et al. Continuous intraoperative external monitoring of perfusate leak using I-131 human serum albumin during isolated perfusion of the liver and limbs. Eur J Nucl Med 1995; 22:1242–1248. Hoekstra HJ, Naujocks T, Schraffordt-Koops H, et al. Continuous leaking monitoring during hyperthermic isolated regional perfusion of the lower limb: techniques and results. Reg Cancer Treat 1992;4:301–304. Klaase JM, Kroon BB, van Geel AN, et al. Systemic leakage during isolated limb perfusion for melanoma. Br J Surg 1993;80:1124–1126. Kapma MR, Vrouenraets BC, Nieweg OE, et al. Major amputation for intractable extremity melanoma after failure of isolated limb perfusion. Eur J Surg Oncol 2005;31:95–99. Lienard D, Eggermont AM, Kroon BB. Thirty-five years of isolated limb perfusion for melanoma: indications and results. Br J Surg 1996;83:1319–1328.
Section VIII
HERNIA Stephen R. T. Evans, MD and Leigh A. Neumayer, MD Every great mistake has a halfway moment, a split second when it can be recalled and perhaps remedied.—Pearl S. Buck
49
Open Inguinal Hernia Repair with Plug and Patch Technique Derrick D. Cox, MD and Parag Bhanot, MD INTRODUCTION Groin hernias, which can be further classified as inguinal and femoral hernias, are among the most common conditions for which patients undergo surgical intervention, with approximately 800,000 cases performed annually.1 The lifetime risk of having a groin hernia repair is estimated to be 14% for men and 2% for women.2 Elective surgical repair is usually advised because of concerns regarding incarceration and/or strangulation, particularly with femoral hernias. A number of clinical studies have proved elective surgical repair to be safe and effective with a very low morbidity rate. This is in contrast to emergency operations, which are associated with a substantial morbidity and mortality; especially when concomitant bowel resections are performed.3 A number of open repairs have been described and classified depending on the type of dissection (anterior, posterior) and the use of different mesh (Lichtenstein, plug and patch, Prolene hernia system). The type of repair performed is primarily based on the type of hernia as well as the surgeon’s expertise. This chapter is dedicated to the plug and patch technique; although much of the discussion also applies to groin hernia repairs in general.
INDICATIONS AND CONTRAINDICATIONS The most common indications for groin hernia repair are listed in Box 49–1. Repair of groin hernias in minimally symptomatic individuals is still an area of debate. A randomized clinical trial conducted by Fitzgibbons and associates4 of 720 men concluded that this cohort can be followed by delaying surgical intervention with minimal morbidity. Femoral hernias represent a different clinical entity with an increased incidence of complications and emergent operations.5 Although there are few contraindications to groin hernia repair, a number of considerations may delay repair (Box 49–2).
OPERATIVE STEPS Although there is some variance in the technical aspects of the plug and patch repair, the operation has welldefined steps. Step 1 Step 2
Patient preparation Skin incision
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Box 49–1 ● ● ● ●
Symptomatic hernias Prevention of progression of symptoms Prevention of complications (incarceration, strangulation) Treatment of complications (incarceration, strangulation)
Box 49–2 Repair ● ● ● ●
Indications for Groin Hernia Repair
Contraindications to Groin Hernia
Uncontrollable ascites Soft tissue infection Pregnancy Reversible causes of increased intra-abdominal pressure (benign prostates hyperplasia [BPH], acute respiratory issues)
Step 3 Step 4 Step 5 Step 6 Step 7 Step 8
Dissection of subcutaneous layer and Scarpa’s fascia Incision of external oblique fascia Mobilization of spermatic cord Identification and reduction of hernia (direct and/or indirect) Mesh fixation Anatomic closure of abdominal wall layers
OPERATIVE PROCEDURE Dissection of the Subcutaneous Layer and Scarpa’s Fascia Hemorrhage ● Consequence Significant postoperative bleeding would be very unusual from this dissection. However, ecchymosis or superficial hematoma may result from improper ligation of smaller venous branches. Grade 1 complication ● Repair Hematomas of significant size may need to be evacuated to prevent subsequent soft tissue infection. Otherwise, conservative measures may be employed. ● Prevention Preoperatively, patients should be instructed to avoid antiplatelet and other anticoagulation medications. A number of small veins encountered in the subcutaneous layer can simply be cauterized. One or two prominent superficial epigastric veins are also located in the incision near the pubic tubercle, and these must be sutureligated to prevent bleeding.
Incision of the External Oblique Fascia Ilioinguinal Nerve Injury The ilioinguinal nerve is solely a sensory nerve with a distribution of the upper and medial aspects of the thigh
and scrotum. It is located overlying the spermatic cord directly underneath the external oblique fascia and is at risk for transection at this stage. ● Consequence Inadvertent transaction of the ilioinguinal nerve will result in sensory deprivation in the associated dermatomes described. Inability to recognize that the nerve has been transected may also lead to a neuroma and chronic inguinal pain.
Grade 1/2 complication ● Prevention An understanding of the anatomy of the nerve is crucial to recognizing its usual course through the field of dissection. Care should be taken when incising the external oblique fascia to ensure that the nerve has been separated from its underside. This can be accomplished by first partially transecting the fascia in the direction of the superficial ring and then lifting up on the medial and lateral leaflets to further expose the inguinal canal (Fig. 49–1).
Mobilization of the Spermatic Cord Ischemic Orchitis/Testicular Injury ● Consequence Ischemic orchitis is the result of venous congestion within the testicle secondary to venous thrombosis within the spermatic cord. This process may lead to testicular atrophy. The reported incidence is less than 1%.6 Grade 3/4 complication ● Repair The management of orchitis includes observation and use of nonsteroidal anti-inflammatory medications for several weeks. A duplex ultrasound should be performed to assess perfusion of the testicle. Ischemia and/or infarction may warrant orchiectomy. ● Prevention This injury can be prevented by limiting dissection within the spermatic cord. This requires precise identification of the indirect hernia sac to safely mobilize it from the medial aspect of the cord (Fig. 49–2). In patients in whom the hernia sac is large and adherent, the distal portion of the sac can be left in situ with a high ligation proximally.
Hemorrhage ● Consequence Mobilization of the spermatic cord usually requires division of the cremasteric muscle fibers overlying the hernia sac. Improper recognition of bleeding from the transected muscle fibers may result in hematomas. Grade 1/2 complication
49 OPEN INGUINAL HERNIA REPAIR WITH PLUG
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A Figure 49–2 The Penrose drain encircles both the indirect hernia sac and the spermatic cord. The testicular vessels (tip of the hemostat) are directly adjacent to the hernia sac and can be easily injured.
istration.7 An increased risk is associated with incarcerated and femoral hernias. The sequela of an infection is dependent upon the source of infection, the degree of infection, and the type of mesh placed for the repair. Exposed mesh is considered to be contaminated and is included in the same algorithm. Grade 3/4/5 complication
B Figure 49–1 A, The external oblique fascia has been transected into medial and lateral leaflets. The ilioinguinal nerve is just visible overlying the spermatic cord (tip of the forceps). B, The ilioinguinal nerve has been carefully dissected along its course from the internal ring to the pubic tubercle without the use of cautery or excessive retraction.
● Repair Hematomas of significant size may need to be evacuated to prevent subsequent soft tissue infection. Otherwise, conservative measures may be employed. ● Prevention Division of the cremasteric muscle is necessary to fully mobilize the hernia sac from the spermatic cord. Cautery is usually sufficient to prevent bleeding from the muscle fibers, but it must be done before retraction occurs.
Mesh Fixation Mesh Infection and/or Exposure ● Consequence Mesh infection accounts for over 40% of all adverse events, as reported by the U.S. Food and Drug Admin-
● Repair The majority of plug and patch meshes are constructed from polypropylene. This type of mesh can resist bacterial colonization and has the ability to incorporate into native tissue. This accounts for a higher likelihood of being able to salvage the mesh with long-term antibiotic administration and/or drainage of any associated abscess. However, if the source of infection is an enteric fistula, mesh removal is required. In the presence of sepsis, aggressive measures are instituted with immediate operative exploration and systemic antibiotics. ● Prevention The most important preventive measure is to maintain strict sterile technique throughout the operation. The surgical team has to be vigilant in not compromising the surgical field or contaminating the mesh before its placement. Preoperatively, any remote sources of infection, such as pneumonia, urinary tract infection, or soft tissue infections, should be addressed before the operation. Although there has been some debate in the literature on the use of intravenous antibiotics for hernia cases, the authors believe that this is an important measure coinciding with the conclusions from several randomized studies.8–11 Lastly, despite the lack of level-one evidence, the authors believe that the use of adhesive surgical barriers that serve as physical barriers against bacterial migration between the skin and the mesh is important.
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Enterocutaneous Fistula ● Consequence The reported incidence of enterocutaneous fistulas is less than 1% in large series and is described as isolated case reports.12 Consequences include mesh infection, intra-abdominal abscess, sepsis, and mortality. Grade 3/4/5 complication ● Repair The management of intestinal fistulas should follow surgical principles in terms of patient resuscitation and sepsis control. Eventually, the treatment also needs to take into account the associated mesh infection. The operation will include exploratory laparotomy, excision of mesh, repair of fistula, and closure of the abdominal wall without mesh. ● Prevention Prolene mesh is known to be associated with significant adhesion formation that may lead to mesh erosion into the bowel and resultant fistula.13,14 The principal concept in prevention is to avoid direct opposition of the mesh with bowel. This is particularly relevant with the plug placement because a significant portion is placed into the preperitoneal space for direct hernias and adjacent to the hernia sac in indirect hernias. If the hernia sac has been opened, a secure high ligation must be performed.
Hernia Recurrence ● Consequence The lifetime recurrence rate is less than 5% in most large series.15,16 Multiple risk factors include morbid obesity, diabetes, connective tissue disorders, smoking, ascites, and previous hernia repair. Patients will present with symptoms similar to their initial complaints of the presence of a bulge, new onset of inguinal pain, and incarceration with possible strangulation. It is important to note that most failures are secondary to technical causes and can be prevented. The major complication of a recurrent hernia repair is the increased recurrence rate of approximately 20%.17 Hematomas, seromas, testicular atrophy, and chronic pain all have an increased incidence as well. Grade 3/4 complication ● Repair With symptomatic recurrences in surgical candidates, a repeat attempt at a hernia repair is warranted. Many large series, including the randomized clinical trial by Neumayer and associates,18 have demonstrated superior results with a laparoscopic approach to the repair of a recurrent hernia. This approach has the advantage of avoiding scar tissue and altered anatomy caused by the previous repair. However, depending on the surgeon’s expertise, an open approach may be used with placement of an additional plug and patch.
Figure 49–3 Although the onlay portion of the mesh has been secured to the edges of the inguinal canal, the repair is compromised secondary to improper reconstruction of the internal ring.
● Prevention There are several important technical considerations to ensure the lowest rate of failure. As previously listed, there are individual considerations of each patient that may warrant delaying the operation. The identification of all concomitant hernias (direct and indirect components) is critical. A recurrence through the internal ring can occur if the indirect hernia sac is not properly dissected and reduced prior to placement of the plug component or if the onlay mesh is excessively loose around the proximal spermatic cord (Fig. 49–3). A direct hernia recurs if the onlay portion does not adequately reinforce the inferomedial portion of the inguinal floor.
Vas Deferens Obstruction ● Consequence Vasal obstruction related to inguinal herniorrhaphy is an uncommon complication, but it is recognized as a cause of azoospermia in the male infertility patient with an incidence of 0.3%.19 The obstruction is due to a foreign body reaction to the mesh with resultant decreased vasal luminal diameter. Grade 2/3 complication ● Repair Vasogram is the “gold standard” to diagnose the injury. In addition to the presence of mesh, vasal obstruction can also result from direct iatrogenic injury caused by ligation or cauterization, vascular compromise, or extrinsic compression. Most of these injuries may be identified intraoperatively and a primary repair may be attempted, maintaining fertility. Microsurgical repair of an injury to the vas deferens has excellent outcomes with a patency rate of 65% at follow-up.20 Vasal obstruction secondary to a desmoplastic reaction to the mesh will ultimately require reexploration of the groin.
49 OPEN INGUINAL HERNIA REPAIR WITH PLUG
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● Prevention The use of mesh results in a desmoplastic reaction, and thus, it is important to avoid placement of the plug component in direct contact with the vas deferens. The spermatic cord should be handled carefully during dissection of the hernia sac to reduce the risk of exposing a bare vas deferens to the mesh. Also, the patch placed for reinforcement of the transversalis fascia should have a slit large enough to allow safe passage of the spermatic cord through the deep ring.
Nerve Entrapment/Chronic Inguinal Pain ● Consequence The literature is equivocal with regard to elective division of the ilioinguinal nerve to reduce the risk of an inadvertent injury and consequent chronic pain. A randomized, controlled trial by Picchio and coworkers21 concluded that the occurrence of postoperative pain is unaffected by elective division of the ilioinguinal nerve. Moreover, the purposeful transection of the ilioinguinal nerve was related to sensory disturbances in the corresponding dermatome. Grade 2/3 complication ● Repair Chronic pain secondary to nerve entrapment can be frustrating to manage. Outpatient management includes injection of local anesthetic combined with steroids in the location of the nerve and/or point of tenderness. If this is not effective, exploration of the groin is warranted. However, identification of the affected nerve may be difficult secondary to scar tissue. If the nerve can be located, it should be freed from the scar tissue with possible reimplantation. Neurectomy of either the ilioinguinal, the iliohypogastric, and/or the genitofemoral nerves may ameliorate the neuralgia.22 ● Prevention Meticulous attention must be paid to identifying all nerves and branches in the surgical field, especially the ilioinguinal nerve. When obtaining exposure and repairing the hernia, care should be taken not to damage the nerves by entrapment with staples, sutures, or prosthetic materials (Fig. 49–4). One should avoid excessive retraction on the nerve. Cautery should be kept away from the nerve to prevent electrical injury.
Femoral Vessel Injury ● Consequence Injury of the femoral vein as a result of unobserved constriction by suture placement can manifest with subsequent thromboembolic complications. Femoral artery injury may cause vascular compromise depending on the presence of collateral arterial flow. In addition, delayed complications include aneurysms and arteriovenous fistulas. Grade 3/4 complication
A
B Figure 49–4 A, The plug component has been properly secured at the level of the internal ring orifice. However, the ilioinguinal nerve is clearly in contact with the mesh, predisposing to nerve entrapment and chronic pain. B, The onlay component used to reinforce the transversalis fascia has entrapped the ilioinguinal nerve with one of the permanent sutures.
● Repair Management of the vascular injury depends on the severity of the complication and the vessel involved. Patients with acute venous injury presenting with deep venous thrombosis should be appropriately anticoagulated. If there is severe compromise of venous outflow from the lower extremity, an angiogram may be needed to determine the extent of the thrombosis and possible intervention. Reoperation may be needed to remove the offending suture(s). Intraoperative arterial injury can be repaired primarily with adequate exposure. Most suture needle injuries can be controlled with direct pressure without placement of additional sutures. Long-term sequela such as aneurysms and arteriovenous fistulas has to be evaluated with additional studies before repair is attempted.
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506
Cord
Ext. oblique
Poupart’s lig. Femoral v.
Cooper’s lig.
Ant. femoral fascia
Figure 49–5 The external iliac vessels become the femoral vessels as they transverse underneath the inguinal ligament. These vessels can be injured during dissection of the inguinal floor or during placement of sutures into the shelving edge of the ligament.
● Prevention The surgeon has to be aware of the anatomy of the underlying femoral vessels when placing sutures for fixation of the mesh (Fig. 49–5). This is important specifically during repair of femoral hernias in which the femoral vein is situated lateral to the hernia sac. Compression of the femoral vein is a well-reported complication of the McVay repair.23 For inguinal hernias, the lateral border of the mesh should be secured to the shelving edge of the inguinal ligament, which will avoid the anterior wall of the vein. Injury to the femoral artery can occur during reconstruction of the inguinal floor near the deep inguinal ring, at which point the artery is situated just posterior to the transversalis fascia. Lastly, any significant bleeding must be controlled with appropriate exposure and direct visualization.
Anatomic Closure of Incision Seroma ● Consequence A postoperative seroma will develop in 1.2% of patients.6 Most seromas are usually asymptomatic and resolve without any intervention (Fig. 49–6). Grade 1/2 complication ● Repair The management of a symptomatic or infected seroma follows a different algorithm. Seromas that are persistent can be aspirated if large and symptomatic. This must be done under sterile conditions, and the risk of contamination of the wound and underlying mesh has
Figure 49–6 Computed tomography (CT) scan obtained in the early postoperative period to evaluate for a recurrence demonstrates a moderate-size seroma in an asymptomatic patient. This seroma resolved after 2 months without any intervention.
to be considered. Infected seromas may be a sequela of a deeper infection. As with any abscess and soft tissue infection, the wound may have to be opened and explored formally to ensure a potential bowel injury does not exist. ● Prevention Careful dissection of the appropriate tissue planes will help to prevent seromas. Excessive subcutaneous tissue should be suture-ligated to control lympathics.
Other Complications Bowel Obstruction Small or large bowel obstruction may occur during reduction of the indirect hernia sac.24,25 If a high ligation is performed before placement of the plug component, it is important to assess whether there is bowel within the sac and to completely reduce it before ligation is completed to avoid trapping the bowel. Conservative measures may be employed, but there should be a low threshold for exploration. Grade 2/3 complication Mesh Migration The plug component may migrate from its desired location at the orifice of the internal ring and be found entirely in the preperitoneal space, intraperitoneal, or the scrotum (Fig. 49–7). Depending on the location of the migrated mesh and resulting sequela, it may have to be removed. This complication can be avoided by proper anchoring of the plug of the mesh to the inguinal floor. Grade 3/4 complication
49 OPEN INGUINAL HERNIA REPAIR WITH PLUG
Figure 49–7 Laparoscopic view of the intraperitoneal migration of the plug component. The external iliac vessels are adhered to the mesh, which precluded its safe removal. In addition, the potential for a bowel injury exists because the sigmoid colon is in close proximity.
Ileovaginal Fistula This complication has been cited as case reports in the literature after repair of a strangulated femoral hernia.26 Care should be taken to ensure adequate reduction of all herniated contents to avoid the risk of perforation secondary to suture placement. The presence of a fistula should raise the concern for infected mesh, and the algorithm previously described should be followed. Grade 3/4 complication Paravesical Abscess This rare complication has been reported in a case series of six patients by Imamoglu and colleagues.27 These individuals underwent operations for treatment of paravesical abscess related to previous inguinal hernia repairs. The injury was determined to be caused by sutures that had been placed into or adjacent to the urinary bladder. Fixation sutures for the mesh must be appropriately placed. Grade 3/4 complication
REFERENCES 1. Rutkow IM. Demographics and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am 2003;83:1045–1051. 2. Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the United States population. Am J Epidemiol 2007;167:1154–1161. 3. Nilsson H, Stylianidis G, Haapamaki M, et al. Mortality after groin hernia surgery. Ann Surg 2007;245:656–660. 4. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting versus repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006;295:285–292.
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5. Alimoglu O, Kaya B, Okan I, et al. Femoral hernia: a review of 83 cases. Hernia 2006;10:70–73. 6. Bittner R, Auerland S, Schmedt CG. Comparison of endoscopic techniques versus Shouldice and other open nonmesh techniques for inguinal hernia repair: a metaanalysis of randomized controlled trials. Surg Endosc 2005;19:605–615. 7. Robinson TN, Clarke JH, Schoen J, et al. Major meshrelated complications following hernia repair: events reported to the Food and Drug Administration. Surg Endosc 2005;19:1556–1560. 8. Rios A, Rodriguez JM, Munitiz V, et al. Antibiotic prophylaxis in incisional hernia repair using prosthesis. Hernia 2001;5:148–152. 9. Yerdel MA, Akin EB, Dolalan S, et al. Effect of singledose prophylactic ampicillin and sulbactam on wound infection after tension-free inguinal hernia repair with polypropylene mesh: the randomized, double-blind, prospective trial. Ann Surg 2001;233:26–33. 10. Aufenacker TJ, van Geldere D, van Mesdag T, et al. The role of antibiotic prophylaxis in prevention of wound infection after Lichenstein open mesh repair of primary inguinal hernia: a multicenter double-blind randomized controlled trial. Ann Surg 2004;240:955–960. 11. Perez AR, Roxas MF, Hilvano SS. A randomized, doubleblind, placebo-controlled trial to determine effectiveness of antibiotic prophylaxis for tension-free mesh herniorrhaphy. J Am Coll Surg 2005;200:393–397. 12. Losanoff JE, Rochman BW, Jones JW. Enterocutaneous fistula: a late consequence of polypropylene mesh abdominal wall repair: a case report and review of literature. Hernia 2002;6:144–147. 13. Harrell AG, Novitsky YW, Peindle RD, et al. Prospective evaluation of adhesion formation and shrinkage of intraabdominal prosthetics in a rabbit model. Am Surg 2006; 72:808–813. 14. Mahmouduslu HY, Erkek AB, Cakmak A, et al. Incisional hernia treatment with polypropylene graft: results of 10 years. Hernia 2006;10:380–384. 15. Bringman S, Ramel S, Heikknen TJ, et al. Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective randomized controlled trial. Ann Surg 2003;237:142–147. 16. Frey DM, Wildisen A, Hamel CT, et al. Randomized controlled trial of Lichtenstein’s operation versus meshplug for inguinal hernia repair. Br J Surg 2007;94:36–41. 17. Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichenstein repair. Surg Endosc 2007; 21:634–640. 18. Neumayer L, Giobbie-Hurder A, Jonasson G, et al. Open mesh versus laparoscopic repair of inguinal hernia. N Engl J Med 2004;350:1819–1827. 19. Shin D, Lipshultz LI, Golstein M, et al. Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia. Ann Surg 2005;241:553–558. 20. Sheynkin YR, Hendin BN, Schlegel PN, et al. Microsurgical repair of iatrogenic injury to the vas deferens. J Urol 1998;159:139–141. 21. Picchio M, Palimento D, Attanasio U, et al. Randomized controlled trial of preservation or elective division of
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ilioinguinal nerve on open inguinal hernia repair with polypropylene mesh. Arch Surg 2004;139:755–758. 22. Alfieri S, Rotondi F, DiGiorgio A, et al. Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicenter study of chronic pain. Ann Surg 2006;243:553–558. 23. Normington EY, Franklin DP, Brotman SI. Constriction of the femoral vein after McVay inguinal hernia repair. Surgery 1992;111:343–347. 24. Ferrone R, Scarone PC, Natalini G. Late complication of open inguinal hernia repair: small bowel obstruction
caused by intraperitoneal mesh migration. Hernia 2003;7:161–162. 25. Chuback JA, Singh RS, Sills C, et al. Small bowel obstruction resulting from mesh plug migration after open inguinal hernia repair. Surgery 2000;127:475–476. 26. Deshpande PV. Ileovaginal fistula: A complication following repair of a strangulated femoral hernia. Br J Clin Pract 1964;18:744–745. 27. Imamoglu M, Cay A, Sarihan H, et al. Paravesical abscess as an unusual late complication of inguinal hernia repair in children. J Urol 2004;171:1268–1270.
50
Prolene Hernia System— Hernia Repair Edward W. Nelson, MD INTRODUCTION The ideal method to accomplish the successful and durable repair of groin hernias remains a topic of ongoing debate; centuries after these defects were first described by early anatomists and more than 100 years after the first reported “surgical cures” by Marcy (1881), Bassini (1887), and Halsted (1889). Today, entire surgical texts and journals are devoted to the history, evolution, and ongoing progress in surgery for hernia repair.1,2 The most current literature describing the relative merits of the open versus the laparoscopic approach is a prime example of both the science and the emotion still generated by this common yet difficult problem.3 Ideally, repair of groin hernias should be safe, reliable, and easy to learn and, above all, have a low recurrence rate. Champions exist for a variety of currently popular repairs, but today, most surgeons performing open repairs have adopted the concept, first introduced by Usher and colleagues in 1960,4 of using mesh as part of the repair. Current literature comparing these various mesh repairs is limited by nonrandomization, short follow-up, and operative variability.5–7 Today, the Lichtenstein “tension-free” mesh repair, the plug and patch repair reported by Robbins and Rutkow, the preperitoneal Kugel repair, and the Prolene hernia system (PHS) are the most common anterior tension-free mesh repairs performed, all with excellent overall results and minimal recurrence rates when performed by experienced surgeons.8–12 Groin hernia repair using the PHS was first reported by Gilbert and associates in 1999,11 and numerous follow-up reports continue to document the ease of use and low recurrence rate of this system when compared with other methods.13–15 Unique to this system is the intent to have a mesh repair designed to cover the entire myopectineal orifice.16 With this intent, potential defects at the internal ring, inguinal floor, and femoral canal are covered with both onlay and underlay patches held together by a connector inserted into the hernia defect16 (Fig. 50–1). When the PHS repair is completed, the onlay patch covers the entire floor of the inguinal canal as in the Lichtenstein repair, the underlay patch covers and supports the preperi-
toneal space as in a Kugel or laparoscopic approach, and the connector “plugs” the defect without the risk of migration seen with the two-piece plug patch repair17 (Fig. 50–2). Using this repair in over 11,000 procedures, recurrence rates of 0.014% have been reported.13 A systematic series of steps have been well described in the correct use of the PHS to minimize the risk of pitfalls in its use in the repair of groin hernias.
INDICATIONS ● Inguinal hernia repair ● Direct hernia repair ● Indirect hernia repair
OPERATIVE STEPS Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
Exposure of inguinal floor Confirm type of hernia present Development of external pocket for onlay patch Prepare posterior space for underlay patch Deployment of underlay patch Secure onlay component
OPERATIVE PROCEDURE Exposure of the Inguinal Floor Like all open inguinal hernia repairs, the PHS repair requires a standard inguinal incision, opening in the subcutaneous fat, Scarpa’s fascia, and the external oblique fascia in the direction of its fibers to the external ring. Assuming a correctly placed incision, the complications that can occur during exposure of the inguinal floor and mobilization of the spermatic cord include excessive bleeding and hematoma formation in the subcutaneous space, incorrect placement of the external oblique fascial opening, and injury to the ilioinguinal nerve or spermatic cord.
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Figure 50–1 A stem connector inserted through the hernia defect holds together the onlay and the underlay mesh patches.
● Prevention Subcutaneous vessels, when encountered, require careful attention to hemostasis with either electrocautery or absorbable ties, if necessary. The external oblique fascial opening should be oriented on clear identification of the external ring. A carefully placed incision in the direction of the fascial fibers with clear identification of the nerve and cord prior to completion of the opening is mandatory. For the PHS repair, the ilioinguinal nerve need not be elevated off the cord, thereby minimizing traction and potential injury.
Confirm the Type of Hernia Present Once the cord is mobilized, the floor of the inguinal canal can be inspected for the presence of a direct hernia. If a direct hernia is found, the possibility of an indirect hernia must also be perused by opening the external spermatic fascia at the anterior medial aspect of the cord near the internal ring. If the preoperative examination suggested a femoral hernia, Cooper’s ligament must be exposed to allow inspection for a femoral defect.
(B) (A)
● Consequence Unless the cord is inspected for an indirect sac, the potential for recurrence at the internal ring will be greatly increased. ● Prevention Methodical and consistent inspection for both direct and indirect defects is mandatory in all hernia repairs.
Development of the External Pocket for the Onlay Patch Figure 50–2 The underlay patch (A) supports the preperitoneal space and is connected to the onlay patch (B) covering the floor of the inguinal canal.
● Consequence Excessive bleeding in the subcutaneous space can result in hematoma formation and increased risk of secondary infection. Making the opening in the external oblique fascia either too high or too low can compromise exposure of the cord, risk injury to the iliohypogastric nerve as it penetrates the abdominal musculature, and make closure of the fascia over the onlay patch more difficult. Careless technique in opening the external oblique fascia and mobilization of the cord can result in injury to the ilioinguinal nerve with resultant postoperative numbness in its area of sensation, or injury to the spermatic cord or its contents resulting in cord hematoma, vas deferens injury, or compromise of testicular circulation with secondary pain, swelling, and possible atrophy.
The space between the external oblique fascia and the internal oblique muscle must be opened to allow placement of the onlay patch. This dissection includes clearing the attachments from the shelving edge of the inguinal ligament and opening the space lateral to the internal ring to the upper third of the ligament (Fig. 50–3). ● Consequence Injury to the iliohypogastric nerve during the superior part of the dissection can occur, and several perforating vessels may also be disrupted. Most importantly, if the lateral and superior spaces are not opened completely enough, the onlay mesh will not lie flat in order to conform to the abdominal wall. Especially in thin patients, onlay mesh that is not flat may be palpable or cause discomfort. ● Prevention The space for the onlay mesh must be developed with attention to creating a space large enough to cover not only the floor of the inguinal canal but also the superior and lateral areas beyond the area normally covered by other open mesh repairs. When done under direct
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Figure 50–3 The fascial plane beneath the external oblique fascia is dissected to create a space for the onlay patch.
Figure 50–4 The preperitoneal space is dissected through the hernia orifice to allow space for the underlay patch.
vision and with adequate care, the space can be opened without nerve or vessel injury. If necessary, the onlay mesh can be trimmed slightly in smaller patients to appropriately cover the area needed.
neum will result in the underlay mesh laying directly on the abdominal viscera.
Prepare the Posterior Space for the Underlay Patch The preperitoneal space, between the abdominal wall and the preperitoneal fat, is developed to allow space for the underlay patch. For indirect inguinal hernias, this is done through the internal ring; for direct hernias, it is created through the posterior floor defect. At the internal ring, this requires taking down all fibers remaining between the cord and the hernia sac; for direct hernias, any remaining attenuated fibers of the inguinal floor must be opened to fully expose the direct sac. For both indirect and direct defects, the sac is not opened or ligated but rather inverted back into the abdominal cavity. In either case, the space is carefully created using finger dissection to sweep circumferentially to actualize the preperitoneal space (Fig. 50–4). A moist 4 × 4 gauze sponge can be used to facilitate this dissection and hold the space open. To be complete, the preperitoneal space should extend to Cooper’s ligament inferiorly and well back, beyond the defect in all other directions. ● Consequence Failure to completely actualize the preperitoneal space will not permit the underlay patch to flatten out against the underside of the abdominal wall to cover the entire myopectineal orifice. Opening or tearing the perito-
● Prevention The space for the underlay mesh must be carefully and completely developed. Although mesh trimming may be needed, it should be minimized. Any inadvertent holes in the peritoneum should be closed with running absorbable suture to prevent direct contact between the mesh and the abdominal viscera.
Deployment of the Underlay Patch The onlay patch is folded and grasped with a clamp or sponge forceps with the long axis parallel to the inguinal ligament. The entire underlay patch is inserted into the previously developed preperitoneal space, and with the onlay patch held above the defect, the underlay patch is spread out away from the connector using a finger or forceps (Fig. 50–5). Increased intra-abdominal pressure, when the patient later stands or strains, will enhance deployment by flattening the underlay mesh against the inside of the abdominal wall. If the defect is considerably larger than the connector, interrupted sutures should be placed to snug up the tissue around the connector. ● Consequence Failure to flatten the underlay mesh as much as possible will result in failure to adequately cover all areas where recurrent hernias may occur: the femoral canal, inguinal floor, and internal ring. Unless the underlay patch is
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Figure 50–5 The underlay patch is inserted and spread out in the preperitoneal space whereas the onlay patch is held above with the long axis parallel to the inguinal ligament.
deployed as completely as possible, the repair will be compromised and the risk of recurrence increased. If the defect is considerably larger than the connector, added risk of recurrence next to the connector or extrusion of the underlay mesh is possible. ● Prevention Correct deployment of the underlay patch begins with the careful creation of the preperitoneal space as described earlier in the section on “Development of the External Pocket for the Onlay Patch.” Once in place, the underlay mesh must be carefully and patiently spread out, to be as flat as possible. If the defect is much larger than the connector, the tissues around the connector should be approximated to ensure a snug fit.
Secure the Onlay Component Once the underlay patch is completely deployed, the onlay component is flattened and positioned in the previously created space between the external oblique fascia and the floor of the inguinal canal. The lateral flap is positioned first and the mesh trimmed to allow a flat fit, held in place with sutures at the pubic tubercle, transverse arc, and inguinal ligament. A slit is made to accommodate the cord and sutures placed between the mesh and the shelving edge of the inguinal ligament on either side of the cord. Fixation sutures should be placed at least ¼ inch from the edge of the mesh and the mesh fashioned to lie as flat as possible (Fig. 50–6).
Figure 50–6 The onlay patch should lie flat against the inguinal floor and under the external oblique fascia with anchoring sutures on either side of the cord and at the pubic tubercle.
● Consequence Failure to adequately open the pocket between the external oblique fascia and the abdominal wall as described earlier in the section on “Confirm the Type of Hernia Present,” can cause folding or wrinkling of the onlay mesh. Placing more sutures than needed will increase the risk of postoperative pain, especially when placed too deeply at the pubic tubercle. Sutures placed too tightly around the spermatic cord can result in compromise of cord circulation, with testicular swelling, pain, and atrophy. Sutures placed too close to the mesh edge can pull through. ● Prevention The PHS is a groin hernia repair requiring few sutures to secure the mesh, and the temptation to place more sutures than necessary must be resisted. A minimal number of stitches to attach the mesh to the tubercle, around the cord, and if needed, to the anterior abdominal wall should be used.
SUMMARY When appropriately applied, groin hernia repair using the PHS has a competitively low recurrence rate with minimal and largely preventable complications. To maximize the advantages of both an onlay and an underlay mesh system, special attention in creation of the space below the external oblique fascia and in the preperitoneum is required.
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REFERENCES 1. Condon RE, Nyhus LM. Hernia, 4th ed. Philadelphia: JB Lippincott, 1995. 2. Lichtenstein IL. Hernia Repair Without Disability, 2nd ed. St. Louis: Ishiyaku Euroamerica, 1987. 3. Neumayer L, Giobbie-Hurder A, Jonasson O, et al, and the Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh verses laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819–1827. 4. Usher FC, Cogan JE, Lowery TI. A new technique for the repair of inguinal and incisional hernias. Arch Surg 1960;81:847–854. 5. Nienhuijs SW, van Oort I, Keemers-Gels ME, et al. Randomized trial comparing the Prolene Hernia System, mesh plug repair and Lichtenstein method for open inguinal hernia repair. Br J Surg 2005;92:33–38. 6. Mayagoitia JC. Inguinal hernioplasty with the Prolene hernia system. Hernia 2004;8:64–66. 7. Huang CS, Huang CC, Lien HH. Prolene hernia system compared with mesh plug technique: a prospective study of short- to mid-term outcomes in primary groin hernia repair. Hernia 2005;9:167–171. 8. Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery. Including a new concept, introducing the tension-free repair. Int Surg 1986;71:1–7. 9. Robbins AW, Rutkow IM. The mesh-plug hernioplasty. Surg Clin North Am 1993;73:501–512.
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10. Kugel RD. The Kugel repair for inguinal hernias. In Bendavid R, Abrahamson J, Arregui ME, et al (eds): Abdominal Wall Hernias: Principles and Management. New York, Berlin: Springer-Verlag, 2001; pp 504–507. 11. Gilbert AI, Graham MF, Voigt WJ. A bilayer patch device for inguinal hernia repair. Hernia 1999;3:161–166. 12. Amid PK, Lichtenstein IL. Long-term result and current status of the Lichtenstein open tension-free hernioplasty. Hernia 1998;2:89–94. 13. Gilbert AI, Young J, Graham MF, et al. Combined anterior and posterior inguinal hernia repair: intermediate recurrence rates with three groups of surgeons. Hernia 2004;8:203–207. 14. Kingsnorth A, Wright D, Porter C, Robertson G. Prolene hernia system compared with Lichtenstein patch: a randomised double-blind study of short-term and medium-term outcomes in primary inguinal hernia repair. Hernia 2002;6:113–119. 15. Murphy JW. Use of the Prolene hernia system for inguinal hernia repair: retrospective, comparative time analysis versus other inguinal repair systems. Am Surg 2001;67: 919–923. 16. Fagan SP, Awad SS. Abdominal wall anatomy: the key to a successful inguinal hernia repair. Am J Surg 2004;188(6A suppl):3S–8S. 17. LeBlanc KA. Complications associated with the plug-andpatch method of inguinal herniorrhaphy. Hernia 2001;5: 135–138.
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Laparoscopic Inguinal Hernia Repair Benjamin Kim, MD and Quan-Yang Duh, MD INTRODUCTION Laparoscopic inguinal hernia repair has evolved to become a safe and effective alternative for inguinal herniorrhaphy. The first report of a laparoscopic approach was in 1990 by Ger and associates1 in which indirect inguinal hernias were repaired by a transabdominal laparoscopic staple closure of a patent processus vaginalis. Following this study, other reports were published including a transabdominal rolled mesh plug technique2 and an intraperitoneal onlay mesh technique.3 These methods were eventually abandoned owing to high recurrence rates. Over time, the laparoscopic approach built upon the idea of applying a prosthetic to the posterior wall of the groin developed by Nyhus, Stoppa, and Wantz.4 The hallmarks of this approach included complete dissection of the groin in the preperitoneal space, identification of all myopectineal orifices, and placement of mesh over the entire inguinal-femoral region (Fig. 51–1). This has now become the laparoscopic procedure of choice. Several reports have demonstrated the efficacy of the laparoscopic approach to inguinal hernia repairs. Liem and coworkers5 compared laparoscopic versus conventional anterior hernia repair and found that the laparoscopic group had faster postoperative recovery and a recurrence rate similar to that of the open group. A study by Andersson and colleagues6 found that laparoscopic totally extraperitoneal hernia repair resulted in less postoperative pain, shorter time to recovery, earlier return to work, and no difference in overall complications when compared with open tension-free repair. The results from the Veterans Administration (VA) Cooperative Study showed that, although laparoscopic repair of inguinal hernias resulted in less pain and earlier return to normal activity, recurrence was significantly more common after laparoscopic repair.7 However, this study also reported similar recurrence rates between laparoscopic and open inguinal hernia repairs when surgeons with a large volume of experience performed the laparoscopic procedures. This finding underscores the challenge in learning this approach and the need for technical mastery in order to achieve consistently satisfactory results.8
The laparoscopic approach to inguinal hernia repair can be divided into two types: the transabdominal preperitoneal approach (TAPP) and the totally extraperitoneal approach (TEP). Initially, most procedures were performed with the TAPP approach for exposure of the posterior floor of the groin because the groin anatomy was easier to delineate. However, the TEP approach avoids violation of the peritoneal cavity, potentially reducing some of the complications associated with the TAPP technique. Although understanding the inguinal anatomy from an extraperitoneal posterior view can be difficult, hernia surgeons have become more comfortable with this exposure and can achieve similarly low recurrence rates using this technique.4 By and large, the TEP approach can be applied to most clinical circumstances in which laparoscopic inguinal hernia repair is performed, and it is described here.
INDICATIONS ● ● ● ●
Recurrent inguinal hernias Bilateral inguinal hernias Patients who are able to tolerate general anesthesia Patients who are eager to return to normal activity earlier
RELATIVE CONTRAINDICATIONS ● Prior or planned extraperitoneal operations (e.g., radical
prostatectomy) ● Previous pelvic irradiation ● Extremes of age ● Contraindications to laparoscopy (e.g., severe chronic
obstructive pulmonary disease)
OPERATIVE STEPS Step 1 Step 2
Positioning and trocar insertion Dissection of preperitoneal space
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Inf
D I
F
Vas Sper
X x
Figure 51–2
x
Port placement.
Figure 51–1 Posterior view of potential right groin myopectineal defects. D, direct hernia defect; F, femoral hernia defect; I, indirect hernia defect; Inf, inferior epigastric vessels; Sper, spermatic vessels; Vas, vas deferens.
Step 3 Step Step Step Step
4 5 6 7
Exposure of pubic bone ligament Dissection of direct hernia Dissection of indirect hernia Placement of mesh Trocar removal
and
Cooper’s
OPERATIVE PROCEDURE Positioning The monitor is placed at the foot of the operating bed with the surgeon standing by the patient’s shoulder on the opposite side of the hernia. If bilateral inguinal hernias are present, the surgeon starts opposite the side of the larger, more symptomatic hernia. Both of the patient’s arms are tucked to the side, and the patient is placed in the Trendelenburg position once the dissecting ports are inserted. The patient needs to be paralyzed to allow for insufflation of the preperitoneal space.
Trocar Insertion Trocar insertion should be controlled and under direct vision to avoid serious complications. A standard threetrocar technique is used: a 10-mm port subumbilically, a
5-mm port in the right lower quadrant, and a 5-mm port in the left lower quadrant (Fig. 51–2). All ports are placed within the preperitoneal space. Complications of trocar insertion are discussed in Section I, Chapter 7, Laparoscopic Surgery. The first trocar placed is the 10-mm subumbilical port, using an open technique. This port is placed slightly off of the midline to stay in the space behind the rectus muscle and in front of the posterior rectus sheath. If it is placed in the midline, where the anterior and posterior rectus sheaths merge, it will enter the peritoneal cavity. Following this port placement, a 10-mm, 30° angled laparoscope is inserted and used to bluntly dissect the areolar tissue in the preperitoneal space, using a gentle sweeping motion. The preperitoneal space is cleared out laterally toward the anterior superior iliac spine to provide enough space for placement of the other ports. Alternatively, a balloon dissector can be used instead of manual dissection, although it is more expensive. The temptation here is to take down the areolar tissue and move toward the symphysis pubis rather than toward the anterior superior iliac spine. However, by making a conscious effort to move the dissection laterally, enough space can be created to place the other ports, after which the remaining areolar tissue can be dissected in a more precise fashion, using laparoscopic graspers.
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Right
Left
Coop Pubic Bladder
Dir
Figure 51–3 Midline view of preperitoneal space. Left, left Cooper’s ligament; Right, right Cooper’s ligament.
A
Exposure of the Pubic Bone and Cooper’s Ligament Coop
This step is done at the outset of the procedure in order to clearly define the midline. Cooper’s ligaments are found just lateral and slightly cephalad to the pubic bone (Fig. 51–3). Cooper’s ligament is where the mesh will be anchored medially. Small veins overlie the pubic bone, and they can be injured during exposure.
Injury during Exposure ● Consequence Bleeding can occur if these small veins are injured by excessive manipulation of the pubic bone, thereby obscuring the view of Cooper’s ligaments. Grade 1 complication ● Repair The bleeding will typically stop on its own. ● Prevention Identify the symphysis pubis and then, by gently probing, confirm the position of the pubic bone. There is no need for excessive rubbing.
Injury to the Bladder ● Consequence Injury to the bladder can occur during exposure of the pubic bone, given that this structure lies in close proximity to it and Cooper’s ligaments. Grade 2 complication ● Repair Bladder injuries can be repaired laparoscopically by suture closure. This is followed by suprapubic or Foley catheter drainage of the bladder. Urology consultation is often necessary. ● Prevention Emptying the bladder immediately preoperatively can reduce its size. Once the size of the bladder is reduced,
Dir
B Figure 51–4 A, Right direct hernia defect with contents reduced. Coop, Cooper’s ligament; Dir, direct hernia defect. B, Corresponding pictorial view.
avoid it and dissect the pubic bone under direct vision.
Dissection of Direct Hernia Identification of a Direct Hernia As Cooper’s ligament is exposed, a direct hernia, if present, will generally be reduced (Fig. 51–4). If it is not, gentle traction on the peritoneal attachments should provide enough force to reduce the sac. Occasionally, in chronic direct hernias, a “pseudosac” may be present. The pseudosac is a posterior invagination of the transversalis fascia and should be distinguished from the direct hernia sac, which is continuous with the peritoneum (Fig. 51–5). ● Consequence If not recognized, the pseudosac can be vigorously dissected, leading to confusion in identifying the groin anatomy and potential injury to the peritoneum or the iliac vein. The peritoneal tear can then result in entry
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Injury to the Inferior Epigastric Vessels
Coop Inf
● Consequence Bleeding from this injury can obscure the view of the groin anatomy. Unrecognized and untreated blood loss can potentially result in transfusions and lead to postoperative hematomas. Grade 2 complication ● Repair If the inferior epigastric artery or vein is injured, it is best controlled with endoclips.
Psd
● Prevention It is critical to identify the inferior epigastric vessels to prevent injury. It is a key landmark of the groin, and it separates the direct and indirect inguinal hernia defects. These vessels are identified behind the rectus muscles and are best left adhered to them during dissection of the preperitoneal space. Dissecting the inferior epigastric vessels off the rectus muscles will cause more bleeding during the procedure and makes placement of the mesh difficult.
A
Coop Inf
Dissection of Indirect Hernia Injury to the External Iliac Vessels
Psd
● Consequence Injury to the external iliac artery or vein causes severe bleeding and, potentially, a CO2 embolus. Grade 3/4 complication ● Repair Laparoscopic repair is very difficult, and open exploration and repair are usually required.
B Figure 51–5 A, Right-sided pseudosac is being dissected free from the direct hernia defect. Coop, Cooper’s ligament; Inf, inferior epigastric vessels; Psd, pseudosac. B, Corresponding pictorial view.
of air into the peritoneal space, obscuring the view of the anatomy. Grade 1 complication ● Repair Tears of the peritoneum can be repaired using an endoloop, clips, or suture. In general, peritoneal tears can be closed after the hernia is repaired. ● Prevention Recognizing the pseudosac can prevent confusion regarding the anatomy and avoid unnecessary dissection of this structure. The pseudosac needs to be dissected away from the true sac and left along the anterior abdominal wall, allowing the true sac and peritoneum to fall back toward the abdominal cavity. Gently pulling the peritoneum posteriorly while providing countertraction on the pseudosac anteriorly will peel the true hernia sac off.
● Prevention The external iliac vessels are located just below the area flanked medially by the vas deferens and laterally by the spermatic vessels. Dissecting within this area risks injury to the external iliac vessels. They can usually be identified by their pulsation and are best avoided by identifying the peritoneal edge of the hernia sac and gently pulling it away from the preperitoneal tissue under direct vision.
Identification of an Indirect Hernia The indirect hernia sac is found along the spermatic cord and just cephalad to it. Within the spermatic cord, the vas deferens and the spermatic vessels are located medial and lateral, respectively, merging through the internal ring. Together with the inferior epigastric vessels, the vas deferens and the spermatic vessels form the so-called Mercedes-Benz sign (Fig. 51–6). Cord lipomas, if identified, are usually found laterally along the spermatic vessels. Usually, the indirect hernia sac is reduced from the internal ring by gentle traction and dissection (Fig. 51–7). If the sac is too long or too large, it can be dissected
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Inf Inf
Coop
Ind
Vas
A Sper Inf
Coop
Figure 51–6 “Mercedes-Benz” sign. The inferior epigastric vessels (Inf), the vas deferens (Vas), and the spermatic vessels (Sper) represent the three spokes seen in the Mercedes-Benz symbol. Ind
at the internal ring and divided. The proximal part of the sac, which is continuous with the peritoneum, is dissected off of the cord structures and ligated with an endoloop. The distal end of the transected sac should be left open and not ligated. Ligating the distal sac will cause a hydrocele.
B
● Consequence During dissection of the cord structures, the indirect hernia sac can be torn, creating a pneumoperitoneum. Sometimes, the sac is intentionally transected, also creating a pneumoperitoneum. This can hinder the view of the anatomy in the preperitoneal space. Grade 1 complication
Figure 51–7 A, Left indirect hernia defect (Ind) with contents nearly completely reduced. Cooper’s ligament (Coop) has been exposed, and the inferior epigastric vessels (Inf) have been seen. B, Corresponding pictorial view.
● Repair Tears in the peritoneum are best repaired with endoloops. Clips or sutures can also be used for closure. If not repaired, loops of bowel can herniate through the defect, creating a “preperitoneal hernia.” Grade 3 complication
Avoiding Recurrence The mesh should be large enough to cover all potential hernia defects in the groin. It is also important to fix the mesh to minimize shrinkage and to prevent migration. Inappropriate mesh placement can lead to hernia recurrence because the mesh shrinks over time and can move within the preperitoneal space. The mesh also needs to lie flat against the anterior abdominal wall in order to prevent hernia recurrence around the edges of the mesh.
● Prevention Complete dissection of the indirect sac off of the spermatic cord is not necessary if the sac is long. The sac can be divided and the proximal end closed with an endoloop. Dividing the sac at the internal ring frequently helps in the dissection of the remaining spermatic cord structures.
Placement of Mesh
● Consequence Laparoscopic hernia repair should have similar or lower recurrence rates than those of open operation. Grade 3 complication
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Figure 51–9 Mesh placement in right indirect hernia repair. Figure 51–8 Mesh placement in right direct hernia repair.
● Repair If a hernia recurs, it can be re-repaired with either an open or a laparoscopic technique. ● Prevention Using a large piece of mesh and fixing the mesh decrease the chance of recurrence. Enough space should be dissected out laterally in order for the mesh to lie flat against the abdominal wall. The edge of dissected peritoneum should be beyond the edge of the mesh to prevent recurrence. When repairing direct hernias, preformed, contoured mesh (Bard, 3D Max Mesh, Davol Inc., Cranston, RI) can be used (Fig. 51–8). The contoured surface and stiffness of the mesh make it easy to manipulate, and it tends not to move much within the preperitoneal space. For an indirect hernia, however, we use a large (16 × 12 cm) piece of flat mesh that is slit medially, passing the lower tail around the spermatic cord structures (Fig. 51–9). The two tails are then overlapped and fixed to Cooper’s ligament medially. Slitting the mesh medially and placing the lower tail below the cord structures ensures complete coverage of the indirect inguinal hernia site without having to add additional points of fixation of the mesh.
Fixating the Mesh ● Consequence Unfixed mesh can move and compromise the repair. The mesh is usually fixed with an endotacker in two or three points. Inappropriate placement of the tacks, however, can cause painful neuralgias. Grade 2/3 complication
● Repair When a specific nerve is entrapped or injured, it can be diagnosed by pain in its distribution immediately after the operation. In such cases, the tacks should be removed. ● Prevention The mesh is fixated medially at Cooper’s ligament and laterally onto the anterior abdominal wall above the iliopubic tract (Fig. 51–10). Deep tacking into the pubic bone, instead of Cooper’s ligament, can cause chronic pain. There are several nerves at risk for injury by the tacks as well (Fig. 51–11). These nerves run at or below the iliopubic tract to innervate the upper thigh. When placing the tacks laterally onto the abdominal wall, the surgeon needs to be able to palpate the end of the tacking device with the opposite hand. If the tip is not palpable, the tacks can be placed below the iliopubic tract and cause nerve injury. The tacks are designed to simply hold the mesh in place. Do not use excessive force on the tacking device because the tacks can cause skin dimpling or even puncture the skin in very thin persons. After palpating the endotacker tip, gently push and simply allow the tack to hold the mesh in place against the anterior abdominal wall.
SUCCESSFUL LAPAROSCOPIC INGUINAL HERNIA REPAIR ● ● ● ● ●
Select appropriate patients Understand preperitoneal anatomy Use proven techniques Avoid common pitfalls Learn from experience
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Genital branch
Femoral branch
Lateral femoral cutaneous nerve
A Genital femoral nerve
Figure 51–11 Nerves at risk for injury during laparoscopic inguinal hernia repair.
REFERENCES
B
C Figure 51–10 A, Medial mesh fixation over a left-sided inguinal hernia defect. Two endotacks are placed in Cooper’s ligament. B, Lateral mesh fixation over a left-sided inguinal hernia defect, taking care to place the endotack above the iliopubic tract. The tip of the tacking device should be palpable with the opposite hand along the abdominal wall. C, Final orientation of the mesh covering all left-sided myopectineal orifices.
1. Ger R, Monroe K, Duvivier R, Mishrick A. Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac. Am J Surg 1990;159:370–373. 2. Schultz L, Cartuill J, Graber JN, Hickok DF. Transabdominal preperitoneal procedure. Semin Laparosc Surg 1994;1: 98–105. 3. Kingsley D, Vogt DM, Nelson MT, et al. Laparoscopic intraperitoneal onlay inguinal herniorrhaphy. Am J Surg 1998;176:548–553. 4. Conlon KC, Johnston SM. Surgical endoscopy for staging palliation of upper gastrointestinal malignancy. In Soper NJ, Swanstrom LL, Eubanks WS (eds). Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia: Lippincott Williams & Wilkins, 2005; p 50. 5. Liem MS, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336: 1541–1547. 6. Andersson B, Hallen M, Leveau P, et al. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: a prospective randomized controlled trial. Surgery 2003;133:464–472. 7. Neumayer L, Giobbie-Hurder A, Jonasson O, et al, and the Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819–1827. Epub 2004; April 25. 8. Grunwaldt L, Schwaitzberg SD, Rattner DW, Jones DB. Is laparoscopic inguinal hernia repair an operation of the past? J Am Coll Surg 2005;200:616–620.
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Umbilical and Epigastric Hernias Kamal M. F. Itani, MD INTRODUCTION
OPERATIVE PROCEDURE
About 10% of all primary hernias consist of umbilical and epigastric hernias.1 Umbilical hernias are classified into congenital, infantile, and adult types, based on their actual time of development in life. This section covers only the adult umbilical hernia, which in 90% of the cases, is an acquired hernia and represents an indirect herniation through the umbilical canal.2 Epigastric hernias are protrusions of the intra-abdominal contents through the linea alba between the umbilicus and the xyphoid. The origin and development of the epigastric hernia is still an enigma. Although originally considered a congenital defect,3 it is now assumed to be an acquired lesion.4 It is important to note that as many as 20% of these hernias are multiple, although it may not be apparent clinically that more than one hernia exists.5
Repair of umbilical and epigastric hernias can be performed through the open approach or laparoscopically. As with incisional hernias, smaller umbilical and epigastric hernias (3 cm) umbilical and epigastric hernias. Recurrence rate was nonexistent in two small series with less than 2 years follow-up.22,23 No relationship has been observed between obesity and recurrence.9
Seroma Seroma occurs in 2.9% of open umbilical hernia repairs and 3.5% of open epigastric hernia repairs.20 The incidence of seroma in the laparoscopic group is higher, at 10%.22 ● Consequence Seromas can be tender or uncomfortable to the patient. They can also become secondarily infected in both the open and the laparoscopic procedures, ultimately requiring removal of the mesh and recurrence of the ventral hernia. Treatment by aspiration or repeated aspiration of the seroma can be uncomfortable and annoying to the patient and has the risk of introducing bacteria. Grade 2 complication
52 UMBILICAL AND EPIGASTRIC HERNIAS ● Repair Most seromas will resolve with expectant therapy. Symptomatic seromas, large seromas, and persistent seromas can be aspirated; repeated aspirations might be required. A chronic seroma might need operative intervention using the open or laparoscopic approach with drainage of the fluid and removal of the pseudocapsule. ● Prevention Placement of subcutaneous drains has been advocated in the open repair that requires extensive dissection and development of flaps in order to prevent fluid accumulation and seroma. The use of a pressure dressing with a binder for 7 to 10 days after laparoscopic repair has also been advocated.24 Premature removal of a drain can result in fluid accumulation; however, this should be weighed against leaving a drain for a prolonged period of time with the potential for an infection to occur. It is believed that repeated aspiration of the fluid in a third of the patients is less morbid than placement of a drain in all patients undergoing the laparoscopic procedure. A small study suggested that cauterization of the hernia sac during the laparoscopic repair prevents seroma formation.25
Infection Despite the use of prophylactic antibiotics and advances in anesthesia techniques, infection rates of 3.3% with laparoscopic and 10% with open repair are still reported for umbilical and epigastric hernia repairs.22 Body habitus, diabetes, immunosuppression, and cigarette smoking are all risk factors for a surgical site infection in these patients. ● Consequence Postoperative cellulitis occurring around the incision is self-limited and usually resolves with oral or intravenous antibiotics. When unrecognized, it can progress to a deep surgical site infection. Grade 1/2 complication ● Repair In cases of cellulitis, antibiotic therapy is recommended until resolution of the redness and return of the temperature and white blood cell to normal. In cases of abscesses with no mesh placement, percutaneous or open drainage with local wound care and antibiotics should be performed. In the presence of a mesh, open drainage and removal of the mesh should be considered; in the cases of polypropylene mesh, consideration can be given to leaving the mesh in place and applying local wound care with wet to dry dressings and antibiotic therapy. All necrotic tissue should be débrided. ● Prevention Intravenous antibiotic prophylaxis within 60 minutes of incision time is recommended in patients at higher
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risk for infection undergoing mesh placement.26 Optimization of patient risk factors and adequate preparation of the surgical site should be observed.26 No relationship was found between wound infection and obesity.
Hematoma Hematomas are most commonly the result of trocar injury to abdominal wall vessels in the laparoscopic repair. In the open repair, hematomas are due to poor hemostasis at the time of dissection of the subcutaneous flaps. Hematomas in both procedures can also be the result of intraabdominal organ or mesenteric injury. ● Consequence Hematomas have been associated with pain at the surgical site, wound infections, intra-abdominal abscess formation, need for reexploration, and blood transfusion. Grade 1/2 complication ● Repair Most hematomas can be treated expectantly. Progression of a hematoma with a continuous drop in hematocrit will require reexploration of the surgical site, ligation of the bleeder, and proper hemostasis. Hematomas that are symptomatic or infected will need to be drained. A liquefied hematoma can be aspirated if symptomatic or persistent. ● Prevention Proper surgical technique and cauterization or ligation of all bleeders should be performed. Blunt dissection in the preperitoneal space can result in unrecognized bleeding. Inspection of all entered spaces for adequate hemostasis should be performed prior to final closure.
Bowel Injury, Intra-abdominal Abscess, Enterocutaneous Fistula Unrecognized serosal tear during laparoscopic dissection, placement of a polyester or polypropylene mesh within the peritoneal cavity, or migration of a plug into the peritoneal cavity can all result in bowel perforation, postoperative intraperitoneal abscess, and/or delayed enterocutaneous fistulas. ● Consequence When this complication occurs, removal of the mesh with recurrence of the hernia is inevitable. Resection of the involved bowel is necessary. Grade 3 complication ● Repair Percutaneous drainage of an intra-abdominal abscess, antibiotic therapy, and stabilization of the septic patient should be performed. Spontaneous closure of an enterocutaneous fistula secondary to bowel injury during the hernia repair or mesh erosion will not occur.
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In these cases, removal of the mesh and resection of the involved loop of bowel is the next step. The use of a bioprosthesis to bridge the fascial defect and prevent the recurrence of a hernia should be considered but is not proved to prevent hernia recurrence in the long term. ● Prevention The use of polypropylene and polyester meshes within the peritoneal cavity should be avoided and restricted to the preperitoneal space. In the laparoscopic repair, polytetrafluoroethylene should be used. Newer material such as allografts and combined material (Proceed) are under consideration. Inspection of the bowel for any sign of injury should be performed during laparoscopic cases and in open procedures in which the peritoneal cavity is entered.
Skin Necrosis Skin necrosis is rare and is the result of devascularization of the skin flaps at the time of dissection. ● Consequence Although small areas of skin necrosis can be self-limited, larger areas might get secondarily infected or result in skin dehiscence. Grade 1/2 complication ● Repair Areas of skin necrosis will usually require skin débridement and local care of the wound. In cases of infection, it should be treated as described previously. With mesh exposure, consideration should be given to flap advancement or skin grafting if the involved area is large and after proper granulation. ● Prevention Dissection of the skin and subcutaneous tissue flap should be carefully undertaken in order to avoid devascularization of the flaps and subsequent skin necrosis.
Umbilical Hernia Repair in Patients with End-Stage Liver Disease and Refractory Ascites Umbilical hernia is seen in up to 20% of patients with longstanding cirrhosis and ascites27 (Fig. 52–7). The strategy for treating umbilical hernia in patients with ascites has evolved considerably. Initial management consisted of nonoperative therapy secondary to fear of precipitating bleeding from esophageal varices. ● Consequence Occasionally, a patient will present with spontaneous rupture of an umbilical hernia and leaking ascites. Patients with ascites who present acutely with ruptured umbilical hernias have two distinct problems that need to be treated, namely, the ruptured umbilical hernia and the underlying ascites. Grade 3 complication
Figure 52–7 Patient with intractable ascites and protruding umbilical hernia at risk for rupture (Reproduced with permission from www.mef.hr/patologija/ch_3/c3_ascites_umb_hernia.jpg).
● Repair Prevention of infection and adequate fluid and electrolyte management in ruptured umbilical hernias in cirrhotic patients with ascites are crucial. Management of ascites with transjugular intrahepatic portosystemic shunting (TIPS) is currently favored, followed by repair of the umbilical hernia. ● Prevention Elective repair of an umbilical hernia in patients with ascites should be performed after proper optimization of the patient. Aggressive medical management of ascites with diuretics is advocated prior to elective hernia repair. In cases of refractory ascites, the treatment of choice becomes primary repair of the hernia with either concomitant or staged peritoneovenous shunting (PVS).27 Recently, transjugular intrahepatic portosystemic shunting (TIPS) has supplanted PVS as the treatment of choice in patients with intractable ascites prior to umbilical hernia repair.28
REFERENCES 1. Muschaweck U. Umbilical and epigastric hernia repair. Surg Clin North Am 2003;83:1207–1221. 2. Jackson OJ, Moglen LH. Umbilical hernia: a retrospective study. Calif Med 1970;113:8. 3. Larson GM, Vandertoll MD. Approaches to repair of ventral hernia and full thickness losses of the abdominal wall. Surg Clin North Am 1978;60:40–42. 4. Lang B, Lau H, Lee F. Epigastric hernia and its etiology. Hernia 2002;6:148–150. 5. Nyhus LM, Pollack R. Epigastric, umbilical, and ventral hernias. In Decker BC (ed): Current Surgical Therapy. St. Louis: Mosby, 1992; pp 536–539. 6. SSAT Patient Care Guidelines. Surgical repair of incisional hernias. J Gastrointest Surg 2004;8:369–370. 7. Evidence mounts for lap umbilical hernia repair. Two hernia giants report their findings. Gen Surg News
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8. 9.
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2002;29:14–15. Available at www.generalsurgerynews.com (accessed October 2002). Mayo WJ. An operation for the radical cure of umbilical hernia. Ann Surg 1901;34:276–278. Holm JA, Heisterkamp J, Veen HF, et al. Long term follow-up after umbilical hernia repair: are there risk factors for recurrence after simple and much repair? Hernia 2005;26:1–4. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population based analysis. Am Surg 2003;237:129–135. Bennett D. Incidence and management of primary abdominal wall hernias: umbilical epigastric and spigelian. In Fitzgibbons RJ Jr, Greenburg AG (eds): Nyhus and Condon’s Hernia, 5th ed. Philadelphia: JB Lippincott, 2002; pp 389–398. Celdran A, Bazire P, Garcia-Urena MA, et al. Hernioplasty: a tension free repair for umbilical hernia. Br J Surg 1995;82:371–372. Arroyo SA, Perez F, Serrano P, et al. Is prosthetic umbilical hernia repair bound to replace primary herniorrhaphy in the adult patient? Hernia 2002;6:175– 177. Arroyo A, Garcia P, Perez F, et al. Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults. Br J Surg 2001;88:1321–1323. Bauer JJ, Harris MT, Gorfine SR, et al. Rives-Stoppa procedure for repair of large incisional hernias. Experience with 57 patients. Hernia 2002;6:120–123. Petersen S, Henke G, Freitag M, et al. Experiences with reconstruction of large abdominal wall cicatricial hernias using Stoppa-Rives pre peritoneal meshplasty. Zentralbl Chir 2000;125:152–156.
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17. Kennedy GM, Matyas JA. Use of expanded polytetrofluoroethylene in the repair of the difficult hernia. Am J Surg 1994;168:304–306. 18. Leber GE, Garb J, Albert A, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998;133:378–382. 19. Cafer P, Dervisoglu A, Senyurek G, et al. Umbilical hernia repair with the Prolene hernia system. Am J Surg 2005; 190:61–64. 20. Muscharveck U. Umbilical and epigastric hernia repair. Surg Clin North Am 2003;83:1207–1221. 21. Perrakis E, Velimezis G, Vezakis A, et al. A new tensionfree technique for the repair of umbilical hernia, using the Prolene hernia system—early results from 48 cases. Hernia 2003;7:178–180. 22. Wright BE, Beckerman J, Cohen M, et al. Is laparoscopic umbilical hernia repair with mesh a reasonable alternative to conventional repair? Am J Surg 2002;184:505–508. 23. Lou H, Patil NG. Umbilical hernia in adults. Surg Endosc 2003;17:2016–2020. 24. Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic ventral hernia repair. J Laparoendosc Adv Surgl Tech 2000;10:79–84. 25. Tsimoyiannis EC, Siakas P, Glantzounis G, et al. Seroma in laparoscopic ventral hernioplasty. Surg Laparosc Endosc Percutan Tech 2001;11:317–321. 26. Barie PS, Eachempati SR. Surgical site infections. Surg Clin North Am 2005;85:1115–1135. 27. Belghetti J, Durand F. Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis 1997;17:219–226. 28. Fagan SP, Awad SS, Berger DH. Management of complicated umbilical hernias in patients with end stage liver disease and refractory ascites. Surgery 2004;135:679–682.
53
Open Primary and Mesh Repairs Mary Hawn, MD INTRODUCTION Incisional hernias complicate approximately 10% of all laparotomies. Repair of an incisional hernia is a challenging case and recurrence rates remain high. The first repair of an incisional hernia has the highest likelihood of success; therefore, considerable attention should be given to the surgical strategies that achieve optimal outcomes.1 The key factor associated with decreased likelihood of recurrence is the use of mesh for the repair.2 Long-term results of a randomized trial comparing suture with mesh repair demonstrated a 62% recurrence for suture repair and 32% for mesh repair.3 For small defects (40 cm2)—loss-ofdomain ventral hernia ● Epigastic (≤8–10 cm horizontal advancement requirement) ● Midabdominal (≤10–15 cm horizontal advancement requirement) ● Suprapubic (≤6–8 cm horizontal advancement requirement) Recurrence of hernia defect after prior primary closure attempt and contraindication for synthetic mesh Failed primary mesh hernia repair secondary to infection Bowel injury in setting of laparoscopic hernia repair Exposed mesh with unstable surrounding skin Presence of enterocutaneous fistula or ostomy in operative field Prior abdominal wall irradiation Systemically compromised patient ● Concurrent malignancy ● Systemic immunosuppression secondary to organ transplantation ● Active human immunodeficiency virus (HIV) infection ● Corticosteroid dependence ● Malnutrition ● Large body surface area burn
OPERATIVE STEPS Skin incision Enter peritoneal cavity with excision of splitthickness skin graft (STSG) 3 Develop adipocutaneous advancement flaps 4 Excise poorly incorporated mesh 5 Excise hernia sac 6 Lyse adhesions to an intraperitoneal level 4 cm lateral to fascial defect 7 Vertical incision of external oblique fascia 1 cm lateral to linea semilunaris 8 Muscle flap advancement and approximation 9 Adipocutaneous flap advancement and approximation 10 Assimilation of postoperative secrets for success
Step 1 Step 2 Step Step Step Step Step Step Step Step
OPERATIVE PROCEDURE Skin Incision Skin Necrosis and Dermal Dehiscence ● Consequence The surgical incision must be carefully planned to prevent unnecessary skin necrosis, skin flap dermal
dehiscence, and the need for prolonged dressing changes. Previous incisions should be used or extended when possible.9 Otherwise, the midline incision is recommended because it is the least damaging to neurovascular and functional structures.11 Grade 1/2/3 complication ● Repair Operative débridement of necrotic skin should be followed by the initiation of wet to dry dressing changes three times daily. The wound should be inspected routinely and repeat débridements completed at the bedside when indicated. If the wound appears well at 5 days, one may either return to the operating room for adipocutaneous flap readvancement and closure or initiate the placement of a wound V.A.C. (KCI, San Antonio, TX) negative-pressure dressing with changes every 3 days. Traditional dressing changes should continue if there is any question of ongoing infection. Specifically, V.A.C. therapy should not be used to control infected wounds. ● Prevention Careful attention should be addressed toward previous scars, surgical incisions, ostomy sites, and drain sites because these may have disrupted the blood supply from the intercostal arteries and may result in skin flap ischemia and necrosis. Midline incisions are most appropriate for thin patients. It is best to avoid transverse and subcostal incisions, which can interrupt the superficial epigastric arcades and the segmental vessels of the intercostal system.12 Morbidly obese patients with significant hernias may require a more sophisticated reconstructive plan. When massive hernias are repaired for these patients, the dependent pannus may be resected to promote wound healing. It is best to approach these patients with a limited midline skin incision that is excised in its entirety with an inferior adipocutaneous flap advancement and transverse closure. It is imperative not to place this final transverse incision at the juncture of the mons as in a traditional abdominoplasty because it is associated with a high risk of infection in obese patients. In addition, it limits revisional surgery in the context of wound dehiscence (Fig. 55–2). Extreme care must be extended to patients with prior ostomies. Skin bridges between midline incisions and the ostomy site are at high risk for ischemia. If the ostomy is to remain, one should consider a unilateral component separation procedure (Fig. 55–3). If intestinal reconstruction is a part of the operative intervention, one should consider complete excision of the ostomy site including the intervening skin bridge (Fig. 55–4). If not feasible, typically in the thin patient, we recommend primary closure of the ostomy site with expectant management. Wound dehiscence at the previous ostomy site can be treated with dressing changes and staged closure at 5 days or wound V.A.C. management.
55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
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Figure 55–2 Surgical incision placement in the morbidly obese patient with a plan for panniculectomy to reduce postoperative wound complications. A, Preoperative appearance of a 64-year-old man with a recurrent giant abdominal wall hernia with retained mesh, loss of domain and prior midline incision. B, Intraoperative wound closure with an inferior adipocutaneous flap advancement. The initial exploration was via a limited midline incision centered at the umbilicus. The access incision was completely excised with the advancement of an inferior adipocutaneous flap and a transverse closure remote from the mons and the native inferior skin fold to avoid potential wound infection.
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Figure 55–2, cont’d C, Postoperative appearance of skin flap closure at 4 months with no evidence of adipocutaneous skin flap necrosis or dermal dehiscence.
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Figure 55–3 Unilateral component separation for maintained ostomy in the operative field. A, Intraoperative appearance of a 43-yearold woman treated for ovarian cancer to include a total colectomy and end ileostomy complicated by multiple small bowel fistulas–to– composite mesh placed to treat a prior midline evisceration event.
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C Figure 55–3, cont’d B, No component separation is performed on the ipsilateral side of the end ileostomy in order to preserve ostomy function and to avoid possible parastomal hernia. C, Postoperative appearance at 6 months with no evidence of midline hernia and persistent good stoma function.
Enter Peritoneal Cavity with Excision of STSG Iatrogenic Enterotomy ● Consequence Reentry into the peritoneal cavity of patients with complex hernias with or without STSG can potentially result in iatrogenic enterotomies with contamination of the surgical field. Such a complication can be limited to wound cellulitis. In its most extreme form, the patient may develop an enterocutaneous or enteroenteric fistula heralded by possible intra-abdominal abscess and sepsis. Grade 1/2/3/4 complication
● Repair Simple oversewing of the enterotomy with running 30 polydioxanone (PDS) suture is appropriate for minor serosal injuries. More extensive devascularization injuries should be approached with possible bowel resection using accepted stapling techniques. ● Prevention Timing of exploration and STSG excision can be assessed on physical examination preoperatively. Typically, most patients are not ready for reoperation until the STSG can be lifted from the underlying bowel. Surgery should be delayed until this simple maneuver
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A3 B1 Figure 55–4 Adipocutanteous flap advancement and excision of prior colostomy site to promote wound healing. A, A 46-year-old woman with a history of rectal injury in the setting of open hysterectomy requiring diverting colostomy and open wound care, resulting in a midline hernia for repair. The patient has a prior Phanansteil incision concealed beneath her dependent pannus in addition to a right subcostal incision secondary to an open cholecystectomy.
55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
B2
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Figure 55–4, cont’d B, A midline incision was used for her exploration, given the patient’s prior right subcostal incision as a contraindication for an immediate transverse skin flap closure. Her transverse colostomy site was completely excised with medial advancement of her right-sided adipocutaneous flap to promote wound healing and improved abdominal wall contour.
injuries. Not all such injuries are preventable, particularly in patients with prior synthetic mesh placement. Judicious repair must be completed when injuries occur. We suggest aggressive staged irrigation of the abdomen and skin flaps during closure overtop of closed suction drains in the setting of iatrogenic bowel injuries.
Postoperative Ileus
Figure 55–5 Assessing time of elective hernia repair. Lifting the STSG from the underlying bowel should be a pain-free assessment in the clinic prior to elective hernia repair.
● Consequence A prolonged ileus is a common complication with a reported incidence of 27%.13 Uncomplicated ileus is the direct result of extensive enterolysis during the takedown of the hernia. It can be secondary to electrolyte abnormalities in patients having received a preoperative bowel preparation. Of more clinical concern, it can be an early sign of an intra-abdominal infectious process or intestinal anastomotic leak. Grade 1/2/3/4 complication
can be preformed in the clinic with minimal pain (Fig. 55–5). Patients without STSG should be delayed for a minimum of 6 months after they have achieved a closed wound. Meticulous sharp dissection during adhesiolysis using the surgical principles of traction and countertraction to develop dissection planes between loops of bowel and the abdominal fascia are necessary to prevent iatrogenic bowel
● Repair Potentially correctable sources for prolonged ileus should be examined to include serum electrolytes, leukocyte count, and urinary analysis. Fever, abdominal pain, leukocytosis, and abdominal distention associated with profound emesis should prompt consideration of abdominal computed tomography (CT) scanning to define possible intra-abdominal fluid collections and/ or abscess.
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● Prevention Patients are on nothing by mouth (NPO) with or without a nasogastric tube until they demonstrate evidence of bowel function. Ileus in an afebrile patient with a normal leukocyte count, normal serum electrolytes, and uncontaminated urine can be managed expectantly. Radiographic investigation should be concordant with the clinical setting.
Develop Adipocutaneous Advancement Flaps Ischemia and/or Venous Congestion ● Consequence Adipocutaneous flap ischemia and/or venous congestion can lead to partial or full-thickness necrosis and an open wound with its associated problems of caloric consumption, risk for infection and potential for fascial dehiscence/evisceration, and extended financial requirements of dressing supplies and continued surveillance. Grade 1/2/3 complication ● Repair Threatened adipocutaneous flaps require expectant management. Serial physical examinations with an experienced eye will facilitate the timing of surgical débridement. Initial steps to prevent progression of ischemia and venous congestion include bedside release of the skin closure sutures and edema control. Persistent tension on flap closure can result in progression of necrosis. Early release of tension is a preventive measure. Timely débridement and flap readvancement after the diuresis of third-space fluids may alleviate this problem. Incomplete wound closure can be addressed with dressing changes or wound V.A.C. placement. ● Prevention Adipocutaneous flaps should be elevated at the juncture of the anterior fascia, with minimal fat being left behind on the fascia. The technical focus is flap development using low-setting cautery and precise control of the perforators extending through the fascia. Distinct coagulation or clip and/or suture ligature of these perforators is necessary in order to prevent thermal injury down into the pedicle vessels supplying the underlying muscles or up into the adipocutaneous flap. Precise use of the cautery is imperative to prevent areas of fat necrosis within the flap. In addition, it is important to protect adipocutaneous flaps from traction, avulsion, and compression injury by surgical assistants. Some patients may require a significant fluid resuscitation secondary to a prolonged operative course in the setting of concomitant secondary procedures. Tissue edema may become problematic, particularly in patients with multiple prior skin incisions. Intraoperative use of colloid over crystalloid has been advantageous.14,15 Delaying the skin
flap closure or purposefully leaving marginal skin in place for 5 days is advised. Return to the operating room after a physiologic postoperative diuresis and skin flap margination is the sign of a thoughtful surgeon. All patients should be counseled preoperatively of this possible “staging” of their abdominal wall closure (Fig. 55–6).
Excise Poorly Incorporated, Previously Placed Mesh Infection and Recurrent Hernia ● Consequence Lack of mesh incorporation into surrounding tissues is consistent with a clinical diagnosis of chronic infection. Retained, poorly incorporated mesh may lead to persistent wound infection. Retained mesh with areas of suture line dehiscence from the fascia can lead to hernia recurrence and need for unplanned reoperation. Grade 2/3 complication ● Repair Retained infected mesh and missed suture line dehiscence from prior hernia repairs will necessitate redo exploration and secondary hernia repair. ● Prevention Intraoperative examination of previously placed mesh as a distinct step in the operative procedure is imperative. Aggressive débridement with care to preserve the vascular supply to the remaining abdominal wall is preferable over leaving chronically infected mesh or small suture-line hernias clinically not apparent preoperatively on physical examination.
Excise Hernia Sac Seroma and Possible Infection ● Consequence Retained hernia sac may lead to postoperative seroma. Devascularized retained hernia sac will result in wound infection and possible dehiscence and evisceration. Complete excision of the hernia sac will eliminate these complications and facilitate ease to a technically competent fascial closure. Grade 2/3 complication ● Repair Suprafascial seromas secondary to retained viable hernia sac can be treated expectantly with aggressive use of closed bulb suction drains that remain in situ until drain output is less than 30 ml/day per drain. Ultrasound-guided percutaneous drain placement is an acceptable approach to early postoperative seroma formation. Persistent drain output from a percutaneous drain or recurrence after 3 weeks is suggestive of the formation of a seroma capsule, which requires a surgical excision and reclosure.
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A3 Figure 55–6 Staging of adipocutaneous flap closure. A, A 64-year-old man with history of bladder extrophy presents with a recurrent hernia secondary to infected synthetic mesh in the setting of bilateral paramedian abdominal incisions and a right-sided sigmoidureterostomy. B, The patient was explored through a left paramedian incision with removal of a staged superior tissue expander. His fascial reconstruction was completed by the use of acelluar dermal matrix. Adipocutaneous flaps were allowed to marginate for 4 days prior to return to the operating room for ischemic flap excision and staged closure.
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Figure 55–6, cont’d C, The patient’s postoperative appearance at the time of Jackson-Pratt drain removal.
Infection secondary to retained nonviable hernia sac requires débridement and open management of the wound with a staged, secondary abdominal wall reconstruction. ● Prevention Precise excision of the hernia sac is the best prevention. Occasionally, we have used well-vascularized hernia sac
atop of synthetic mesh in the setting of threatened skin flaps (Fig. 55–7). If synthetic mesh or acellular dermis is used in combination with a component separation beneath thin adipocutaneous flaps with overlying hernia sac, one must use multiple closed suction drains, which receive aggressive stripping and perioperative surveillance. If the adipocutaneous flaps are lost, a portion of the hernia sac may protect the underlying mesh or
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AlloDerm against infection until an STSG can be applied in a staged fashion.
Complete Lysis of Adhesions to an Intraperitoneal Level 4 cm Lateral to the Fascial Defect Bowel Injury ● Consequence Small or large bowel adherent to the undersurface of the abdominal wall in near proximity to the hernia sac may inadvertently be injured or included in the suture used to reapproximate the fascia. Grade 3/4 complication ● Repair Unrecognized iatrogenic injury to or inclusion of the bowel within the fascial closure will require reoperation for an intra-abdominal catastrophe heralded by abdominal sepsis and possible dehiscence or evisceration. This too leads to open wound management followed by a staged, secondary reconstruction. C3 Figure 55–6, cont’d.
A1
● Prevention Surgeons of all ages and degrees of experience should maintain a level of attentiveness to prevent the inadvertent inclusion of a loop of bowel within the suture line of a fascial closure. Lysis of adhesions to a 4-cm margin will facilitate the ease of fascia reapproximation.
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Figure 55–7 Use of preserved, well-vascularized hernia sac beneath thin adipocutaneous flaps. A, A 64-year-old man presents for abdominal wall reconstruction for recurrent failed infected mesh. Comorbidities included obesity, diabetes mellitus, and congestive heart failure.
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B2 B3 Figure 55–7, cont’d B, Hernia sac was preserved for use overtop of an acellular dermal matrix repair, given the anticipated thin nature of his skin flaps.
55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
inadvertent transection of both the external and the internal oblique muscle layers has been reported in the literature with repair using onlay polypropylene mesh.16 AlloDerm should be considered in patients with a risk of infection. Intra-abdominal acellular dermal matrix or mesh placement can be completed using modified techniques of laparoscopic hernia repair, namely, transfascial lateral permanent suture placement and the use of efficient hernia tackers (Salute Fixation System, Davol, Inc., Cranston, RI) (Fig. 55–8).
Vertical Incision of External Oblique Fascia 1 cm Lateral to the Semilunaris Spigelian Hernia ● Consequence Dissection deep to the external oblique muscle can injure the internal oblique fascia or muscle, resulting in a defect similar to a spigelian hernia. This injury results in loss of fascial continuity and dynamic support with loss of intra-abdominal domain relative to the chronicity of a failure to diagnose or treat this unusual defect. Grade 3/4 complication
● Prevention Meticulous dissection and observation of proper anatomic landmarks are imperative. The linea semilunaris is noted by the insertion of the external oblique fascia at the lateral rectus abdominis border. The initial longitudinal incision should be placed 1 cm lateral to the linea semilunaris. Generally, the fascial planes are quite distinct and allow for easy dissection. The plane between the external and the internal oblique may be opened out to the posterior axillary line. However, the mobility of the innervated rectus abdominis–internal oblique– transversus abdominis muscle complex should routinely
● Repair If unintended injury to the underlying internal oblique fascia occurs, interrupted reinforcing stitches may be placed. Typically, the internal oblique fascia is friable and a braided Vicryl suture is best, although leaving one with a high risk of remote hernia formation. If the resulting defect or weakness is large, a piece of synthetic mesh may be placed to reinforce the area using an onlay technique, again noting a risk for hernia recurrence. Frank rupture of the transverse abdominal muscle after
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B
Figure 55–8 Intra-abdominal acellular dermal matrix placement for lateral fascial weakness secondary to internal oblique injury. A, A 54-year-old woman presented with a lateral abdominal wall hernia secondary to an avulsion injury in the setting of a motor vehicle accident. Her oblique muscles were avulsed from the right rectus abdominis muscle, and a delayed reconstruction included Vicryl mesh placement followed by AlloDerm, utilizing an open inlay technique. B, Percutaneous transfascial fixation sutures were used for lateral AlloDerm advancement in the manner they would be applied in the setting of a laparoscopic hernia repair. C, Salute laparoscopic hernia clips were then applied to reduce postoperative pain and surgical time.
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be evaluated to prevent excessive dissection laterally, therefore decreasing the chances for an accidental deep fascial injury. The typical component separation release separates the external oblique muscle and aponeurosis from its connection to the anterior rectus fascia from the costal margin to the iliac crest at a level just lateral to the linea semilunaris. The external oblique can then be separated off the internal oblique with blunt dissection, avoiding injury to the internal oblique fascia and allowing the muscles to slide relative to one other (Fig. 55–9).
● Prevention Finding the proper plane of dissection is crucial to avoid this potential complication. The surgical dissection plane is between the external and the internal obliques and is avascular. Excessive bleeding should prompt a higher level of attention to this potential complication. The intercostal nerves supplying the rectus abdominis run deep to the fascia of the internal oblique muscle lateral to the linea semilunaris.
Muscle Flap Advancement and Approximation
Denervation of Rectus Abdominis Muscle
Failure to Obtain Closure
● Consequence Dissection deep to the internal oblique muscle may cause denervation of the rectus abdominis muscle and resulting atrophy and “pseudohernia” or the appearance of an eventration. Nerve injury such as this theoretically can also result in neuromas and chronic pain syndromes. Grade 2/3/4 complication
● Consequence Not all hernias can be repaired by a component separation procedure. Fascial defects may be underestimated on physical examination by the operative surgeon. Flap advancements may fail to approach reported ranges. Lack of a concerted surgical plan can result in an acute failure to close the fascial defect. Skin flap closure over this type of a remaining fascial defect results in an immediate hernia and risk for skin flap necrosis and dehiscence and/or evisceration. Unstable or insufficient skin for closure results in a full-thickness open wound requiring staged reconstructive operative interventions. This last situation would likely result in a Vicryl mesh–based reconstruction in most centers (see Fig. 55–1). As is shown, expanded bilateral tensor fascia lata (TFL) flaps were designed as a backup plan
● Repair Intercostal nerve transection can be repaired with interrupted 9-0 nylon suture using microscopic magnification. Often, these injuries are of a traction/avulsion-type injury and respond poorly to repair. One should seek assistance from a consulting surgeon experienced in nerve repairs.
A1
A2
Figure 55–9 Component separation surgical procedure. A, A 23-year-old woman with ovarian cancer presented with midline incision hernia for autologous repair. Risk factors for hernia recurrence included body mass index (BMI) greater than 30, active malignancy, and dependent pannus.
55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
A3
B2
561
B1
C
Figure 55–9, cont’d B, The hernia sac has been completely excised, leaving a 6-cm midline fascial defect for repair. Methylene blue has been applied, outlining the linea semilunaris bilaterally. The umbilical stalk has been preserved with circumferential incision. C, The external oblique fascia is incised 1 cm lateral to the linea semilunaris (inked in blue) from the costal margin inferiorly to the iliac crest. The internal oblique is viewed dorsally within the component separation.
for reconstruction, should component separation have failed to provide a tension-free fascial closure. Grade 3/4 complication ● Repair Backup, or salvage, reconstructive options should be outlined preoperatively for the surgical team and for informed consent of the patient. Synthetic mesh hernia reconstruction can be used in combination with a component separation procedure. For patients at risk for or with active infection, we have used rotational
TFL flap reconstructions (Figs. 55–10 and 55–11). More recently, we have converted to AlloDerm cadaveric acellular regenerative tissue matrix, given its ease of acquisition and elimination of the donor site (Fig. 55–12). Long-term recurrent hernia rates utilizing acellular dermis are currently unavailable. Giant hernias repaired with acellular dermal matrices may display increased abdominal girth over time without a discrete hernia, necessitating excision of a midportion of the matrix to restore a functionally acceptable result. AlloDerm can have retained antibiotics, which may
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D1
D2
E
F1 Figure 55–9, cont’d D, The right-sided component separation is advanced to the midline and closed with running Prolene suture. The umbilicus is preserved at the midline. E, A superior-based adipocutaneous flap is advanced to the level of the mons for total excision of the dependent pannus to promote wound healing and function. This technique does require the creation of a full-thickness defect for umbilical reconstruction. Drains exit the lateral aspect of the incision to prevent additional drain site exit wounds. F, Postoperative appearance of right-sided component separation independent of synthetic mesh, with superior adipocutaneous flap advancement and closure resulting in a functional and esthetically pleasing result.
precipitate allergic reactions. We encourage careful review of the manufacturer’s product insert. Supplementary surgical techniques have been described to gain additional fascial advancement to the traditional component separation procedure. If there is inadequate coverage over the xiphoid and subxiphoid region with excessive tension on the closure, removal of the xiphoid process, excision of any neo-ossifications in the upper wound, or taking the external oblique fascia up on the costal margin 6 to 8 cm can provide some additional
mobility of the upper fascia.10 Release of the posterior rectus sheath 1.0 to 1.5 cm from the linea alba has been described in the literature in order to gain additional advancement of composite tissue flaps.1,17 This maneuver can result in injury to the neurovascular pedicle to the rectus abdominis muscle. Such a vascular injury could result in partial or total flap loss. Partial ischemia of the muscle flap can lead to atrophy, at best, presenting with pseudohernia or eventration. Total flap loss results in hernia recurrence requiring immediate revision. Failure to
55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
F2
563
F3
Figure 55–9, cont’d.
diagnose total muscle flap necrosis can lead to significant soft tissue infection and a more complex staged reconstruction. Given the risk of total flap loss in the hands of the inexperienced surgeon, we discourage this supplemental aspect of component separation procedures. Other “partition” methods are considered at high risk for such a complication and should be avoided (Fig. 55–13).6 ● Prevention Careful preoperative planning can prevent an unexpected failure of fascial closure. Abdominal CT scanning can define fascial boundaries in morbidly obese patients. Interdisciplinary teams including general and plastic surgeons dedicated to complex abdominal wall reconstruction can foster an environment to address the more difficult cases hallmarked by prior resistant soft tissue infections, radiation, profound loss of domain, and in particular, unstable skin.18 An additional approach to aid in obtaining closure, although invasive and requiring several weeks to perform, is the placement of inflatable tissue expanders between the external and the internal oblique muscles, parallel to the abdominal wall defect, to expand the lateral abdominal wall.7,8 Tissue expanders are inflated gradually, allowing for an expansion of the abdominal domain and possible closure of larger defects (see Fig. 55–1). The use of vacuum-assisted devices to help achieve early fascial closure is a promising new advance that may help facilitate closure of the fascia or aid in overall management of large abdominal wounds, although more experience is needed.19,20
Recurrent Hernia, Dehiscence, Evisceration ● Consequence The rate of recurrent incisional hernia after component separation closure of the abdominal wall defect varies between 0% and 32%, with most studies having recurrence rates in the range of 2% to 12%.1,3,16,21–23 Rates of acute dehiscence and/or evisceration have been reported as high as 43%.13 Grade 3/4 complication ● Repair Acute dehiscence/evisceration and recurrent hernia in the setting of prior component separation often require the addition of synthetic mesh, acellular dermis, or more complex rotational autologous flaps in the setting of a secondary reconstructive operation (see Figs. 55– 10 to 55–12). ● Prevention Dehiscence, evisceration, and hernia recurrence occurs more frequently in the morbidly obese population (mean body mass index [BMI] >30 kg/m2).16,24 Some consideration of weight loss prior to hernia surgery should be discussed with all overweight patients. Combined panniculectomy procedures may be beneficial to patients with more urgent surgical requirements (see Fig. 55–9). Prevention of excessive tension on the fascial closure by placement of either synthetic mesh or AlloDerm at the initial repair can reduce complication rates such as these. The difficulty lies in the common desire to avoid
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B1
A
B3
B2
B4
Figure 55–10 Rotational TFL flap for rectus abdominis resection and irradiation for sarcoma. A, A 26-year-old woman presents with a midline abdominal wound secondary to a sarcoma resection and postoperative irradiation. A portion of her right rectus abdominis muscle and overlying fascia was previously resected. B, A right TFL flap was used as an autologous method of reconstruction, given her history of irradiation and chronicity of her open wound.
55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
P1
P2
P3
P4
Figure 55–11 Abdominal wall reconstruction with TFL rotational flap in an infected field and history of failed synthetic mesh. A 56year-old man presents with infected Surgisis (COOK Biotech Inc., Indianapolis, IN) placed for an acute wound dehiscence in the setting of an intraperitoneal cadaveric renal transplant. An ipsilateral TFL flap is utilized for an immediate autologous reconstruction with complete removal of the infected synthetic mesh.
synthetic materials in many patients requiring component separation. This desire to avoid mesh materials and lengthy autologous flap reconstructions in these high-risk patients subjects them to tight wound closures that places them further at risk for dehiscence and recurrence. A subtotal autologous reconstruction including a component separation and acellular dermis with minimal tension fares better for an obese patient with significant loss of
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P5
domain over a component separation closed under undue tension. Some attention should be focused on the techniques of flap approximation. A recent meta-analysis looking at suture material and type of stitch for closure of abdominal hernias suggests that the use of a nonabsorbable suture in a running fashion may reduce the relative risk of incisional hernia by up to 32%.25
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Respiratory Insufficiency ● Consequence The loss-of-domain phenomenon can cause decreased total lung capacity, vital capacity, and functional residual capacity. This may be evidenced by difficulty with ventilation.3 Loss of domain causing respiratory insufficiency is likely the cause for an average stay of 2.7 days in a surgical intensive care unit.13 Grade 3/4/5 complication
Figure 55–12 Alternative method of reconstruction for failed component separation. AlloDerm acellular dermal regenerative tissue matrix is used for a recurrent hernia repair for a failed component separation. The need for a multiple-sheet “quilting” technique places the patient at risk for hernia recurrence.
● Repair If respiratory insufficiency or difficulty ventilating the patient is noted intraoperatively, the tension from the closure can be released by taking down the midline fascial repair and interposing synthetic mesh or AlloDerm. This will increase the intra-abdominal volume and should resolve any acute surgically induced respiratory insufficiency. ● Prevention Preoperative pulmonary function testing may be indicated to identify patients at risk for the respiratory
A External oblique fascia
Transverse abdominis fascia
RA EO IO TA
Partitioning method
B Figure 55–13 Additional component separation fascial partition method. A, Hernia defect and abdominal wall anatomy superior to the umbilicus after elevation of bilateral adipocutaneous flaps. B, Component separation with addition of partition method. See text for full description and technical warning.
55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL failure secondary to the loss-of-domain phenomenon.9 Patients should be screened for preexisting pulmonary insufficiency. Intraoperative observation of peak airway pressures should be routine throughout the surgical procedure. Aggressive pulmonary toilet postoperatively is mandatory in this population of patients to prevent perioperative pneumonia. Attention to alternative pain management protocols may be required for more complex hernia repairs to aid in early ambulation and pulmonary toilet.
Adipocutaneous Flap Advancement and Approximation Seroma, Hematoma ● Consequence Fluid collections in between the fascia and the overlying adipocutaneous flaps place patients at risk for superinfection, skin flap dehiscence, and prolonged wound healing problems. Grade 1/2/3 complication ● Repair Watchful waiting, needle aspiration, percutaneous drain placement, or reoperation are all options, depending on the clinical situation. ● Prevention Strategic closed suction wound drain placement intraoperatively in combination with meticulous adipocutaneous flap planning and development is the key to prevention of seroma formation. Drains must be cleared of occlusive exudates by “stripping” the drains every 4 hours for conventional component separation procedures and every 2 hours for those reconstructions including AlloDerm. The exudate from wounds containing AlloDerm are more viscous, the etiology of which is currently unknown. Drains are kept in place for up to 21 days for AlloDerm-independent reconstructions, with shorter durations for AlloDerm reconstructions in the range of 10 to 14 days. Drains are removed when outputs are less than 30 ml/day per drain. Prophylactic antibiotics for wound drains are controversial, but this is a common practice in our patients not requiring a preoperative bowel preparation. Subjectively, we have observed higher rates of Clostridium difficile colitis in patients who have received a bowel preparation and are maintained on postoperative prophylactic antibiotics. This association is currently under investigation at our institution. We look forward to the potential use of antibiotic-coated closed suction drains currently under development in order to alleviate the need for oral antibiotics (Bacterin International, Belgrade, MT). Closed suction drains do not prevent hematomas. Given the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in obese patients undergoing hernia repair,
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all patients are aggressively treated with subcutaneous heparin or enoxaparin.26,27 Care should be taken to alert the nursing staff not to inject anticoagulants into the abdominal adipocutaneous flaps to avoid a local effect predisposing a patient to a focal bleed. Acute resolution of drain output should alert one to the possibility of a compressive hematoma preventing fluid egress. Ultrasound can be a helpful diagnostic tool in the obese patient.
Wound Infection ● Consequence Superficial wound infections and focal incisional dehiscence can reflect poor surgical technique or lack of adherence to “best practices.” Grade 1/2 complication ● Repair Bedside débridement and local wound care typically result in the resolution of simple wound healing problems. ● Prevention Preoperative intravenous antibiotics are administered to all patients at least 30 minutes prior to incision. Maintaining standard principles of surgical sterility yields comparable infection rates according to the surgical contamination grade. Adipocutaneous flap development should reflect as limited a dissection as possible in an attempt to prevent ischemia and to promote a lower rate of wound infection. Smoking should be eliminated preoperatively, if at all possible.28 Interrupted dermal monofilament sutures (e.g., 3-0 Monocryl [Ethicon, Inc., Cornelia, GA]) followed by running subcuticular monofilament suture (e.g., 4-0 Monocryl) are used whenever possible. Deep sutures within the fat and surgical staples are avoided. We further reenforce our closures with DERMABOND (Ethicon, Inc., Cornelia, GA) as a barrier method to fight infection. Use of DERMABOND avoids the use of tape on delicate skin flaps, thereby avoiding tension bullae formation. In addition, it promotes early showering to keep skin bacterial counts low.
Assimilation of Postoperative Secrets to Success Skin Flap Bullae and Partial-Thickness Loss ● Consequence Use of abdominal binders and tape is discouraged owing to the potential for injury to skin flaps. Grade 1/2 complication ● Repair Shear and/or tension bullae and partial-thickness skin loss requires serial débridement and local dressing changes. It is important to provide a moist environ-
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ment to promote rapid healing should they occur. Antibiotic ointments covered by nonadherent dressings occasionally result in allergic reactions. Duoderm (ConvaTec, Ltd., Deeside, UK) semipermeable hydrocolloid dressing is an acceptable alternative. ● Prevention Once skin flap ischemia is no longer a concern, liposuction garments are preferred for abdominal wall compression owing to their inherent design to protect the skin (zippers, labels, and seams on the outside of the garment). Compressive liposuction garments may prevent seroma formation and should be encouraged for 3 to 6 months postoperatively. Liposuction garments can hold absorbent dressings in place without tape, should they be required. They are adequate in holding dressings over open wounds should extended would care be required. Many patients are more comfortable in some form of compression garment, therefore facilitating early ambulation.
DVT, PE ● Consequence Many hernia repair patients are at risk for perioperative venous thromboembolic complications. Risk factors include patient age, duration of general anesthetic, concomitant acute trauma or active malignancy, and elevated BMI.27 Grade 1/2/3/4 complication ● Repair Systemic anticoagulation with heparin or enoxaparin and potential for inferior vena cava filter placement according to accepted practice guidelines are recommended.27 ● Prevention Patients participate in an active postoperative ambulation protocol. Our patients walk in the hallway on the evening of surgery and seven times daily thereafter. They record their walking on a chart, which they subsequently use at home after discharge. Each walking chart is reviewed with the patient on their first postoperative visit to ensure continued ambulation and DVT/ PE prevention. Elastic compressive stockings, sequential compressive devices, and perioperative subcutaneous heparin or enoxaparin are aggressively applied.29 Consideration of home prophylaxis is important for patients with active malignancies, obesity, or conditions that predispose them to inactivity.29
CONCLUSIONS Component separation is a useful surgical technique to address the repair of complex abdominal wall hernias. Used alone or in combination with other ancillary techniques, it promotes maximal innervated musculofascial
coverage of the abdominal wall and improved function for the individual patient. Complications can be avoided by appropriate preoperative planning, familiarity of the essential abdominal wall anatomy, meticulous surgical technique, and attentive postoperative surveillance of the surgical wound.
REFERENCES 1. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519–526. 2. Kolker AR, Brown DJ, Redstone JS, et al. Multilayer reconstruction of abdominal wall defects with acellular dermal allograft (AlloDerm) and component separation. Ann Plast Surg 2005;55:36–41. 3. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast Reconstr Surg 2000;105:731–738. 4. DiBello JN Jr, Moore JH Jr. Sliding myofascial flap of the rectus abdominus muscles for the closure of recurrent ventral hernias. Plast Reconstr Surg 1996;98:464– 469. 5. Ennis LS, Young JS, Gampper TJ, Drake DB. The “openbook” variation of component separation for repair of massive midline abdominal wall hernia. Am Surg 2003;69: 733–742. 6. Lindsey JT. Abdominal wall partitioning (the accordion effect) for reconstruction of major defects: a retrospective review of 10 patients. Plast Reconstr Surg 2003;112:477– 485. 7. Jacobsen WM, Petty PM, Bite U, Johnson CH. Massive abdominal-wall hernia reconstruction with expanded external/internal oblique and transversalis musculofascia. Plast Reconstr Surg 1997;100:326–335. 8. Hobar PC, Rohrich RJ, Byrd HS. Abdominal-wall reconstruction with expanded musculofascial tissue in posttraumatic defect. Plast Reconstr Surg 1994;94:379– 383. 9. Rohrich RJ, Lowe JB, Hackney FL, et al. An algorithm for abdominal wall reconstruction. Plast Reconstr Surg 2000;105:202–216. 10. Jernigan TW, Fabian TC, Croce MA, et al. Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg 2003;238:349–355. 11. Core GB, Grotting JC. Reoperative surgery of the abdominal wall. In Grotting J (ed). Aesthetic and Reconstructive Plastic Surgery. St. Louis: Quality Medical, 1995; pp 1327–1375. 12. Hurwitz DJ, Hollins RR. Reconstruction of the abdominal wall and groin. In Cohen M (ed): Mastery of Plastic and Reconstructive Surgery. Boston: Little, Brown, 1994; pp 1349–1359. 13. Lowe JB 3rd, Lowe JB, Baty JD, Garza JR. Risks associated with “components separation” for closure of complex abdominal wall defects. Plast Reconstr Surg 2003;111:1276–1283.
55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 14. Sigurdsson GH. Perioperative fluid management in microvascular surgery. J Reconstr Microsurg 1995;11:57– 65. 15. Joshi GP. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg 2005;101:601–605. 16. de Vries Reilingh TS, van Goor H, Rosman C, et al. “Components separation technique” for the repair of large abdominal wall hernias. J Am Coll Surg 2003;196: 32–37. 17. Losanoff JE, Richman BW, Jones JW. Endoscopically assisted “component separation” method for abdominal wall reconstruction. J Am Coll Surg 2002;194:388–390. 18. Mathes SJ, Steinwald PM, Foster RD, et al. Complex abdominal wall reconstruction: a comparison of flap and mesh closure. Ann Surg 2000;232:586–596. 19. Suliburk JW, Ware DN, Balogh Z, et al. Vacuum-assisted wound closure achieves early fascial closure of open abdomens after severe trauma. J Trauma 2003;55:1155– 1160; discussion 1160–1161. 20. Miller PR, Meredith JW, Johnson JC, Chang MC. Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially reduced. Ann Surg 2004;239:608–614. 21. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg 2002;109:2275–2280.
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22. van Geffen HJ, Simmermacher RK, van Vroonhoven TJ, van der Werken C. Surgical treatment of large contaminated abdominal wall defects. J Am Coll Surg 2005;201: 206–212. 23. Lowe JB, Garza JR, Bowman JL, et al. Endoscopically assisted “components separation” for closure of abdominal wall defects. Plast Reconstr Surg 2000;105:720–729. 24. Langer C, Schaper A, Liersch T, et al. Prognosis factors in incisional hernia surgery: 25 years of experience. Hernia 2005;9:16–21. 25. Hodgson NCF, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a metaanalysis. Ann Surg 2000;231:436–442. 26. Prystowsky JB, Morasch MD, Eskandari MK, et al. Prospective analysis of the incidence of deep venous thrombosis in bariatric surgery patients. Surgery 2005; 138:759–763. 27. Buller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 suppl):401S–428S. 28. Ewart CJ, Lankford AB, Gamboa MG. Successful closure of abdominal wall hernia using the components separation technique. Ann Plast Surg 2003;50:269–273. 29. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:338S–400S.
Section IX
HEMATOPOIETIC Stephen R. T. Evans, MD It is a mistake to suppose that men succeed through success; they much oftener succeed through failures. Precept, study, advice, and example could never have taught them so well as failure has done.—Samuel Smiles
56
Laparoscopic Splenectomy Diana M. Weber, MD and Aarti Mathur, MD INTRODUCTION The birth of the laparoscopic era has revolutionized the surgical approach to the abdomen. Since Delaitre’s performance of the first laparoscopic splenectomy (LS) in 1991, LS has come to replace open splenectomy (OS), and it is now the standard procedure for patients with hematologic disorders.1 LS is associated with a lower complication rate than that of OS, primarily owing to the greater visualization of anatomic structures and the less invasive nature of laparoscopy.2 However, because of the fragile parenchyma, rich blood supply, and intimate relation to intra-abdominal organs such as the stomach, colon, and pancreas, LS, even when performed by experienced surgeons, is not without complications.3–5 Multivariate analyses show that these parameters increase the risk of complications associated with LS: learning curve of the surgeon, patient age, degree of hematologic malignancy, and extent of splenomegaly defined as splenic weight greater than 1000 g or craniocaudal length greater than 20 cm.6–8 Splenomegaly may compromise the surgeon’s ability to manipulate the spleen, achieve hemostasis, and retrieve the specimen.9 Malignant spleens also tend to weigh more than benign spleens.10,11 Large splenic size of greater than 2 kg has been shown to have a complication rate of 63% versus 25% for a normal-sized spleen.11 Complications are also greater in elderly patients (53% vs. 13%).7,12 Because LS has a steep learning curve,
performance of more than 10 cases has been recommended to achieve competency.12–16
INDICATIONS 17 ● Red blood cell disorders: sphereocytosis, elliptocytosis,
autoimmune hemolytic anemia, thalassemias, sickle cell ● White blood cell disorders: lymphoma (staging), myelo-
fibrosis, chronic lymphocytic leukemia, chronic myelogenous leukemia, hairy cell leukemia ● Platelet disorders: idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, Evans’ syndrome ● Secondary hypersplenism: cirrhosis, cystic fibrosis ● Miscellaneous: splenic trauma, abscess, cyst, tumor, angiomatosis, splenic artery aneurysms, Gaucher’s disease, sarcoidosis
CONTRAINDICATIONS 18 ● Severe coagulopathy or thrombocytopenia (platelet
110 mg/dl) confirms the diagnosis. Often, this complication is self-limited and resolves with dietary modifications, but occasionally, reoperation with thoracic duct ligation is required. Patients with chylothorax are prone to infectious complications and may develop a postoperative empyema.28 Residual intrapleural chylous collections may be addressed with imageguided percutaneous drainage techniques. Grade 2/3/4 complication ● Repair Appreciation of excessive lymphatic leakage intraoperatively after lymph node dissection can be addressed with direct suture or clip ligation. This, however, is not the usual occurrence, and chylothorax is often diagnosed postoperatively with increased chest tube drainage. Patients should be started on a medium-chain triglyceride diet, and if this is not effective, complete cessation of oral intake should be considered. All attempts should be taken to minimize residual postoperative pleural spaces. These maneuvers are usually successful in ameliorating this complication. However, when drainage exceeds 1 L per day for 7 days, most surgeons advocate operative exploration with thoracic duct ligation.29 ● Prevention Knowledge of the anatomic course of the thoracic duct may assist the surgeon in avoiding this potential complication. However, this may not be preventable owing to the proximity of the duct to the trachea, its often variable location, and the frequent existence of large collateral channels among mediastinal lymph nodes. Intraoperative realization and ligation of significant lymphatic injury may prevent chylothoraces from occurring. Careful lymphatic ligation with electrocautery or ultrasonic shears should minimize postoperative lymphatic leaks.
Recurrent Laryngeal Nerve Injury ● Consequence Unilateral recurrent laryngeal nerve dysfunction is usually well tolerated by most patients, but life-
65 LOBAR RESECTIONS threatening consequences are possible because patients are prone to aspiration events. Many patients undergoing pulmonary resections have compromised lung function owing to longstanding cigarette use. With the diminished ability to clear pulmonary secretions associated with vocal cord dysfunction secondary to recurrent nerve injury, the potential for significant morbidity exists. The diagnosis is usually fairly easy to make by physical examination at the bedside and can be confirmed with fiberoscopy. Watanabe and colleagues30 described their experience with lymph node dissection for clinical stage I lung cancer and reported on the incidence of recurrent laryngeal nerve injury. In this review of 221 VATS resections and 190 open resections via thoracotomy, there were 5 (2.3%) and 3 (1.6%) recurrent nerve injuries, respectively, in the two surgical groups. No mention was made regarding the consequence of this complication in these patients, nor is this complication expounded further elsewhere in the literature. Grade 2/3 complication ● Repair Direct repair is not advised, but several techniques have been devised to minimize the morbidity associated with this complication in regards to both improving voice quality and eliminating aspiration. Early treatment includes involvement of speech pathologists who can instruct patients on maneuvers to minimize aspiration events. Temporary unilateral vocal cord dysfunction can be remedied by injection of material into the cord for augmentation purposes.31 Medialization thyroplasty remains a definitive, yet more invasive, approach toward managing this complication.32 ● Prevention It is important for the surgeon to have a full understanding of the anatomy of the recurrent laryngeal nerves to avoid this complication. During mediastinal lymph node dissections of levels 5 and 6, care must be taken to isolate and protect both the vagus and the phrenic nerves in this region.
REFERENCES 1. Jemal A, Tiwari RC, Murray T, et al. Cancer statistics, 2004. CA Cancer J Clin 2004;528–529. 2. Nesbitt JC, Putnam JB, Walsh GL, et al. Survival in earlystage lung cancer. Ann Thorac Surg 1995;60:466–472. 3. Ginsberg R, Rubernstein L. Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer. Ann Thorac Surg 1995;60:615–623. 4. Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. Wedge resection versus lobectomy for stage I (T1N0M0) nonsmall cell lung cancer. J Thorac Cardiovasc Surg 1997; 113:691–700. 5. Warren WH, Faber LP. Segmentectomy versus lobectomy in patients with stage I pulmonary carcinoma. J Thorac Cardiovasc Surg 1994;107:1087–1094.
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6. Jacobeus HC. Ueber die moglichkeit de zystoskopie bei untersuchung seroser hohlungen anzuwenden. Munchen Med Wochenschur 1910;57:2090–2092. 7. Kirby TJ, Rice TW. Thoracoscopic lobectomy. Ann Thorac Surg 1993;56:784–786. 8. Walker WS, Carnochan FM, Pugh GC. Thoracoscopic pulmonary lobectomy. Early operative experience and preliminary clinical results. J Thorac Cardiovasc Surg 1993;106:1111–1117. 9. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg 1999;68:194–200. 10. Nagahiro I, Andou A, Aoe M, et al. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362–365. 11. McKenna RJ, Houck W, Fuller CB, et al. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421–426. 12. Sagawa M, Sato M, Sakurada A, et al. A prospective trial of systematic nodal dissection for lung cancer by videoassisted thoracic surgery: can it be perfect? Ann Thorac Surg 2002;73:900–904. 13. Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285– 1289. 14. Swanson SJ, Batirel HF. Video-assisted thoracic surgery (VATS) resection for lung cancer. Surg Clin North Am 2002;82:541–559. 15. Lewis RJ, Caccavale RJ, Bocage JP, et al. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy: a more patient-friendly oncologic resection. Chest 1999;116:1119–1124. 16. Benedetti F, Amanzio M, Casadio C, et al. Postoperative pain and superficial abdominal reflexes after posterolateral thoracotomy. Ann Thorac Surg 1997;64:207–210. 17. Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1994;107:1079–1089. 18. Xu WD, Gu YD, Lu JB, et al. Pulmonary function after complete unilateral phrenic nerve transaction. J Neurosurg 2005;103:464–467. 19. Freeman RK, Wozniak TC, Fitzgerald EB. Functional and physiologic results of video-assisted thoracoscopic diaphragm placation in adult patients with unilateral diaphragm paralysis. Ann Thorac Surg 2006;81:1853– 1857. 20. Higgs SM, Hussain A, Jackson M, et al. Long-term results of diaphragmatic placation for unilateral diaphragm paralysis. Eur J Cardiothoacr Surg 2002;21:294–297. 21. DiMarco AF, Onders RP, Ignagni A, et al. Phrenic nerve pacing via intramuscular diaphragm electrodes in tetraplegic subjects. Chest 2005;127:671–678. 22. Massard G, Wihlm JM. Early complications: esophagopleural fistula. Chest Surg Clin North Am 1999;9:617– 631. 23. Garcia JP, Richards WG, Sugarbaker DJ. Surgical treatment of malignant mesothelioma. In Kaiser L, Kron I, Spray T (eds): Mastery of Cardiothoracic Surgery. Philadelphia: Lippincott-Raven, 1997; p 683.
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24. Asamura H, Suzuki K, Kondo H, et al. Mechanical vascular division in lung resection. Eur J Cardiothorac Surg 2002;21:879–882. 25. Mackinlay TA. VATS lobectomy: an international survey. Presented at the IVth International Symposium on Thoracoscopy and Video-Assisted Thoracic Surgery, May 1997, Sao Paulo, Brazil. 26. Allen MS, Darling GE, Pechet TT, et al. Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG Z0030 trial. Ann Thorac Surg 2006;81:1013–1020. 27. Cerfolio RJ, Allen MS, Deschamps C, et al. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996;112:1361– 1365. 28. Schimizu K, Yoshida J, Nishimura M, et al. Treatment strategy for chylothorax after pulmonary resection and
29.
30.
31.
32.
lymph node dissection for lung cancer. J Thorac Cardiovasc Surg 2002;124:499–502. Patterson GA, Todd TR, Delarue NC, et al. Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula. Ann Thorac Surg 1981;32:44–49. Watanabe A, Koyanagi T, Obama T, et al. Assessment of node dissection for clinical stage I primary lung cancer by VATS. Eur J Cardiothorac Surg 2005;27:745– 752. Hartl DM, Travagli JP, Leboulleux S, et al. Clinical review: concepts in the management of unilateral recurrent laryngeal nerve injury after thyroid surgery. J Clin Endocrinol Metab 2005;90:3084–3088. Bielamowicz S. Perspectives on medialization laryngoplasty. Otolaryngol Clin North Am 2004;31:139– 160.
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Bronchial and Vascular Sleeve Lobectomy M. Blair Marshall, MD and Fabio May da Silva, MD INTRODUCTION Bronchial and vascular sleeve resections have come to replace pneumonectomy in the management of central disease of the airway and pulmonary artery (PA). Sleeve resection is performed in approximately 5% of patients undergoing resection for lung cancer.1 Although this technique was initially reserved for patients with inadequate pulmonary reserve, it is now considered the optimal technique in all patients, regardless of pulmonary status. Bronchial sleeve resection was introduced by Price Thomas in 1947 at the Brompton Hospital in London. In this case, sleeve lobectomy was carried out for a carcinoid tumor located in the right main bronchus.2 Following this, bronchial sleeve resection became the standard procedure for benign lesions of the central airway. In lung cancer patients, much of the credit for popularizing bronchial sleeve resection as an alternative to pneumonectomy has to be given to Paulson and coworkers.3,4 Initial reports of postoperative morbidity and mortality prohibited routine use of sleeve resection in patients with adequate pulmonary reserve. However, the increased morbidity in patients undergoing sleeve resection reflected the decreased pulmonary reserve, which required a sleeve resection in these early reports of sleeve lobectomy.5 Sleeve resection may be appropriate with any lobectomy but is most frequently performed in a right upper lobectomy (Fig. 66–1). Combined bronchovascular sleeve resections are most common on the left owing to the position of the PA (Fig. 66–2). Again, the most commonly performed sleeve resection on the left is the upper lobe. Bronchial and bronchovascular sleeve resections are complex, technically demanding procedures. Operative mortality ranges from 0% to 6.2%,6,7 with postoperative morbidity ranging from 10% to 50%.8,9 Some data demonstrate that the perioperative risks of bronchial and bronchovascular sleeve resection are comparable with those of standard lobectomy.1,10–12 Although concerns have been raised over the adequacy of oncologic clearance with this technique, the literature demonstrates equivalent local recurrence and long-term survival in patients under-
going sleeve resection compared with those receiving pneumonectomy.13–15 The advantages of sleeve resection have been clearly demonstrated. As the preoperative management strategy of patients with advanced lung cancer has shifted over the past two decades, additional data demonstrate that bronchial and bronchovascular sleeve resection may be performed safely after neoadjuvant therapy.13 Factors affecting survival include the presence of nodal disease, the type of bronchoplastic procedure, impaired lung function, and the presence of cardiovascular risk.16,17 An additional important consideration is the postoperative quality of life in patients who undergo pneumonectomy compared with sleeve lobectomy. Pneumonectomy, “a disease,” is associated with long-term sequelae of pulmonary hypertension and respiratory failure. Also, one must not forget that patients may go on to develop a second primary tumor.
INDICATIONS ● Tumors with involvement of lobar bronchus preclud-
● ● ● ●
●
ing lobectomy, but not infiltrating so far as to require pneumonectomy (Fig. 66–3) Patients with compromised pulmonary reserve who cannot tolerate pneumonectomy N1 Nodal disease with involvement of lobar bronchus and/or PA Metastatic malignancies with lobar extension to main bronchus Major bronchial disruption as result of penetrating or blunt chest trauma requiring débridement and reapproximation Benign bronchial stricture related to trauma or inflammatory disease
OPERATIVE STEPS Step 1
Bronchoscopy to evaluate extent of disease within airway by operating surgeon (Fig. 66–4)
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Figure 66–1 Tumor involving the right upper lobe bronchus with lines of transection demonstrate an adequate resection margin on the proximal and distal bronchus with reanastomosis.
Figure 66–2 Bronchial and vascular sleeve lobectomy specimen demonstrates the proximity of the left upper lobe bronchus and left pulmonary artery.
Figure 66–4 Bronchoscopic image demonstrates a right upper lobe tumor extending into the right main stem orifice.
Figure 66–3 Computed tomography (CT) images of a left upper lobe tumor that would suggest a potential for sleeve lobectomy.
66 BRONCHIAL AND VASCULAR SLEEVE LOBECTOMY
Figure 66–5 Intraoperative photograph of the tumor in Figure 66–4 with the proximal right main stem divided and stay sutures on the proximal and distal airway.
Step 2
Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10
Step 11 Step 12 Step 13 Step 14 Step 15
Step 16 Step Step Step Step Step
17 18 19 20 21
General anesthesia with double-lumen tube placed in bronchus opposite planned side of resection Lateral decubitus position Thoracotomy (posterolateral and anterior approaches both adequate) Thoracic exploration (visual and manual) Assess resectability prior to irreversible maneuvers Mediastinal lymphadenectomy Obtain proximal and distal control of PA, ligate and divide vein to lobe being resected Venous control if unable to get distal control of PA Circumferential dissection of main stem and distal bronchus. Place umbilical tapes to facilitate division Complete fissures around disease when possible Stay sutures on proximal and distal airway to orient anastomosis Harvest pericardium for vascular repair when needed Notify anesthesiologist when preparing for resection and clamping PA Heparin 30 units/kg intravenously when planning on vascular sleeve resection prior to clamping main PA Divide proximal airway and artery once vessels have been controlled (stay sutures) (Fig. 66–5) Frozen section margins (Fig. 66–6) Bronchial anastomosis (Fig. 66–7) Vascular anastomosis or patch angioplasty Wrap bronchial anastomosis with viable flap Closure
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Figure 66–6 Intraoperative photograph of a right upper lobe sleeve resection with both the proximal and the distal airways divided. Forceps are holding the lobectomy specimen.
Figure 66–7 Bronchial anastomosis being performed with the interrupted suture technique.
Step 22 Fiberoptic bronchoscopy Step 23 Extubate patient in operating room
Bronchoscopy The foundation of bronchial evaluation is bronchoscopy. This defines the extent of pathology in the bronchus. Rigid or flexible bronchoscopes can be used, although we routinely use flexible bronchoscopy. It is important that the operating surgeons perform the examination. Pertinent findings indicating a probable sleeve resection include endobronchial tumor, submucosal vascularity, and thickening. Careful evaluation of bronchial motion is important to infer the state of tissues outside the bronchus. It may be difficult to determine a need for pulmonary arterial reconstruction preoperatively; however, one should always be prepared, especially with central tumors or N1 disease. If there is a question about the extent of
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disease, multiple biopsies may be performed at the time of bronchoscopy. Sleeve lobectomy can be planned, but the surgeon must also prepare the patient and family for the possibility that a pneumonectomy may be required because of technical issues or tumor extension Complications of bronchoscopy are discussed in Section XI, Chapter 64.
Double-Lumen Tube Placement Misplacement of the double-lumen tube can lead to hypoxia and hypoventilation. Preoperative bronchoscopy ensures appropriate positioning, although the tube can become dislodged during the procedure when manipulating the airway. The endobronchial tube should be placed in the bronchus opposite the side of resection.
Intraoperative Displacement (Fig. 66–8) ● Consequence Hypoxia and hypoventilation during single lung ventilation. Grade 1–5 complication ● Repair Bronchoscopy is used to check the position of the bronchial cuff and to ensure that the orifice of the bronchial or tracheal lumen is neither pressed against the bronchial or tracheal walls nor blocking the orifice to the left upper lobe. For right-side tubes, the position of the slit in the bronchial cuff with respect to the orifice to the right upper lobe must be rechecked, as well as the patency of the right middle and lower lobes. During the dissection or once the airway has been divided, the double-lumen tube can herniate out of its appropriate position and result in occlusion of the bron-
Figure 66–8 Double-lumen tube correctly positioned in the airway initially, followed by mechanism for hypoxia when the doublelumen tube moves proximally and the balloon herniates, preventing the nonoperative lung from being adequately ventilated.
chus to the ventilated lung. Usually, one may simply inflate the operative lung in order to ventilate while the problem is identified and resolved. If, however, the airway has already been divided, this may not be possible. Deflation of the bronchial balloon eliminates the occlusion and allows the patient to be ventilated while the problem is investigated. ● Prevention During the operation, one must be aware of the pulse oximetry in order to intervene early if there has been a change in the ability of the patient to be ventilated.
Exposure Complications associated with the various exposures are covered in Section XI, Chapter 64.
Dissection of the Hilum Vascular Injury ● Consequence Bleeding that occurs as a result of PA injury ranges from minimal, which is controlled and resolved with direct pressure, to excessive and life-threatening; the latter is rare. Grade 1–5 complication ● Repair If injury to the vessel occurs, the bleeding should be controlled initially by direct pressure with a folded gauze sponge, specifically guarding against any maneuver that might further tear the vessel. Adequate exposure is obtained and both proximal and, when possible, distal control of the artery is obtained. The artery may be clamped without heparinization for short periods. If distal control cannot be obtained, control of the pulmonary veins is helpful to minimize blood loss during repair of large injuries or later during arterioplasty if necessary. Primary repair is usually all that is necessary. Vascular clamps may be applied to the area of injury when feasible with subsequent direct repair, although one should be careful when using this technique. When a tear in the artery extends proximally, cardiopulmonary bypass may be required for repair. ● Prevention One must be cautious when working with central tumors. Excessive traction on the mass, especially with left upper lobe tumors or bulky N1 disease, can result in arterial disruption. It is important to routinely obtain proximal control of the main PA trunk as well as the pulmonary veins prior to proceeding with the central dissection or resection to avoid devastating consequences. Because the veins are located more anterior, they are not commonly involved when performing a sleeve resection.
66 BRONCHIAL AND VASCULAR SLEEVE LOBECTOMY
Bronchial Anastomosis Anastomotic Torsion or Kinking ● Consequence Failure to orient the bronchial anastomosis properly can result in kinking of the airway or torsion. This is usually identified during the postoperative bronchoscopy and can be directly repaired by taking down the anastomosis. Retained secretions and pneumonia are suggestive of this in the postoperative setting. Grade 3/4 complication ● Repair When mild, retained secretions can be managed with aggressive pulmonary toilet and repeat therapeutic bronchoscopy. Stenting of the anastomosis can be effective in the management of luminal compromise. For those refractory to conservative techniques, reoperation is necessary with either revision of the anastomosis or completion pneumonectomy. ● Prevention Placing stay sutures prior to division of the airway helps to maintain proper orientation to prevent torsion. Liberal use of fiberoptic bronchoscopy and minitracheostomy in the postoperative setting aids in pulmonary toilet.
Leak/Dehiscence/Bronchovascular Fistula Circumferential dissection of the bronchus is performed prior to division of the airway when performing the resection. In performing a lymphadenectomy, much of the blood supply to the bronchus is compromised. This places the anastomosis at risk for complications. ● Consequence Although small air leaks may heal spontaneously, one should never leave the operating room with a leak from the bronchial anastomosis. Persistent postoperative air leaks, new air leaks, postoperative fever, or an elevated white blood cell count should alert one to the possibility of an anastomotic complication. Flexible bronchoscopy should be done to assess the bronchial anastomosis. In this setting, the morbidity can range from minimal, with the development of fever and leukocytosis, to empyema or bronchovascular fistula. The latter is rarely salvageable. Grade 2–5 complication ● Repair One should have a very low threshold for fiberoptic bronchoscopy during the postoperative period. Most thoracic surgeons advocate the routine use of bronchoscopy prior to discharge.1,10 A small persistent leak may be managed conservatively if clinically indicated, with some authors reporting the success of fibrin glue in this setting.12 Dehiscence requires a more aggressive
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approach with reoperation and repair of the bronchus, if viable, or completion pneumonectomy. One should remain clinically suspicious and intervene early because infections from bronchial dehiscence are associated with complications ranging from empyema and bronchopleural fistula to bronchovascular fistula, usually a fatal event. Anastomotic strictures occur late and can usually be managed with bronchoscopic interventions including dilation and stenting. ● Prevention When mobilizing the airway, the operating surgeon must pay close attention to the dissection of the bronchus itself and the corresponding bronchial vessels. Excessive dissection or failure to maintain an adequate blood supply to the airway may result in poor healing with dehiscence or stricture formation.18,19 The bronchial anastomosis may be performed in an interrupted, continuous, or combined fashion with no particular technique demonstrating superiority. When there is a size discrepancy between the proximal and the distal bronchi, an interrupted technique may allow for better approximation. If the size discrepancy is excessive, telescoping of the distal bronchus into the proximal, as with a lung transplant anastomosis, can be performed (Fig. 66–9).20 Stay sutures placed during the time of dissection may be tied together to help alleviate tension on the anastomosis. Division of the inferior pulmonary ligament will relieve some tension, but if not completely successful, a pericardial release will allow for greater mobilization of the lower lobe. The anastomosis should be tested at the time of the initial operation, and any air leaks should be primarily repaired. A flap of well-vascularized tissue should be used to wrap the anastomosis21 and, in particular, to separate the bronchial anastomosis from the PA. Most commonly, intercostal muscle, pleura, or pericardial fat is used. For the intercostal muscle, one must be careful not to wrap the bronchus circumferentially because ossification of the muscle with bronchial stricture may result.22 At the completion of the operation, prior to extubation, fiberoptic bronchoscopy should be performed to ensure that there is no luminal compromise or torsion.
Atelectasis ● Consequence Persistent atelectasis is one of the most common morbidities reported after bronchoplasty. It may be due to the interruption of the ciliary epithelium and lymphatics or to anastomotic edema. Grade 2 complication ● Repair Aggressive pulmonary toilet during the postoperative period is usually effective. However, if it is due to anastomotic compromise related to technical issues, these should be addressed as previously discussed.
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Figure 66–9 The intussusception technique for the bronchial anastomosis when size discrepancy is an issue.
● Prevention Anastomotic edema will resolve on its own, although some authors advocate the use of perioperative steroids.13
Pedicled Flaps Devascularization of the Flap ● Consequence If the vascular supply is not protected, the flap will be nonviable and can contribute to postoperative anastomotic complications. Grade 2/3 complication ● Repair Poor blood supply to the flap can be identified in the operating room. If this occurs, another flap should be used as an alternative. ● Prevention If planning on an intercostal flap, it should be harvested prior to placing the retractor against the ribs, thus avoiding trauma to the flap. For pericardial flaps, the dissection is begun at the base of the pericardium and the chest wall. As the flap is mobilized cephalad, one must be constantly conscious of the vascular supply to the pedicle. As the pedicle thins out, it is possible to inadvertently divide the vascular pedicle.
PA Reconstruction PA Thrombosis ● Consequence When PA thrombosis occurs, the remaining lobe necroses. This results in infectious symptoms with fever and
Figure 66–10 Intraoperative photograph demonstrates a pericardial patch arterioplasty on the left main pulmonary artery.
an elevated white blood cell count. One must have a high index of suspicion in any patient with a fever or elevated white blood cell count following vascular tangential or sleeve resection. Oligemia may suggest this on the postoperative chest film. The diagnosis is usually made with a perfusion scan or pulmonary arteriogram. Grade 3/4 complication ● Repair If a compromise in the lumen of the artery is identified at the initial operation, the anastomosis may be revised by either converting a tangential resection with reconstruction to a circumferential resection with end-to-end
66 BRONCHIAL AND VASCULAR SLEEVE LOBECTOMY
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circumference is involved, a circumferential resection with an end-to-end anastomosis may be preferable (Fig. 66–11). Torsion or kinking can occur when the arterial anastomosis is performed before the bronchial anastomosis. One must pay careful attention to the course of the artery once the lobe is reexpanded to identify this before leaving the operating room.
Lymphadenectomy It is preferable to accomplish the lymphadenectomy prior to the bronchial sleeve procedure to avoid traction on or manipulation of the anastomosis.
A
POSTOPERATIVE COMPLICATIONS ASSOCIATED WITH PULMONARY SURGERY ● ● ● ● ● ● ● ● ●
Bleeding Pneumonia Atelectasis Atrial fibrillation Esophageal injury Chyle leak Phrenic nerve injury Recurrent nerve injury Post-thoracotomy pain syndrome
REFERENCES B Figure 66–11 Intraoperative photographs demonstrate the technique for an end-to-end pulmonary artery sleeve resection. A, Both the proximal and the distal pulmonary arteries are clamped. B, The completed anastomosis.
anastomosis or revision of the primary anastomosis. If a sleeve resection of the artery was performed without need for a bronchial sleeve, the distal artery may not be able to be directly reconstructed to the proximal artery. In this setting, a tube graft can be fashioned from pericardium.23 Some authors advocate a sleeve resection of the bronchus to shorten the main stem and allow for the arterial ends to come together.24 ● Prevention Pulmonary arterial thrombosis occurs as a result of technical failure. Either the repair is too narrow or the artery is under torsion or kinked. When performing a tangential resection, if the resection exceeds over 25% of the arterial circumference, a patch angioplasty should be performed (Fig. 66–10).25 When more of the arterial
1. Suen HC, Myers BF, Guthrie T, et al. Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies. Ann Thor Surg 1999;67:1557–1562. 2. Thomas CP. Conservative resection of the bronchial tree. J R Coll Surg Edinb 1955;1:169–186. 3. Paulson DL, Shaw RR. Preservation of lung tissue by means of bronchoplastic procedures. Am J Surg 1955;89: 347–355. 4. Paulson DL, Urschel HC, McNamara JJ, Shaw RR. Bronchoplastic procedures for bronchogenic carcinoma. J Thorac Cardiovasc Surg 1970;59:38–47. 5. Faber LP, Jensik RJ, Kittle CF. Results of sleeve lobectomy for bronchogenic carcinoma in 101 patients. Ann Thorac Surg 1984;37:279–285. 6. Okada M, Yamagishi H, Satake S, et al. Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. J Thorac Cardiovasc Surg 2000;119(4 pt 1):814–819. 7. Hollaus PH, Wilfing G, Wurnig PN, Pridun NS. Risk factors for the development of postoperative complications after bronchial sleeve resection for malignancy: a univariate and multivariate analysis. Ann Thorac Surg 2003;75:966– 972. 8. Mezzetti M, Panigalli T, Giuliani L, et al. Personal experience in lung cancer sleeve lobectomy and sleeve pneumonectomy. Ann Thorac Surg 2002;73:1736–1739.
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9. Icard P, Regnard JF, Guibert L, et al. Survival and prognostic factors in patients undergoing parenchymal saving bronchoplastic operation for primary lung cancer: a series of 110 consecutive cases. Eur J Cardiothorac Surg 1999;15:426–432. 10. Ludwig C, Stoelben E, Olschewski M, Hasse J. Comparison of morbidity, 30-day mortality, and long-term survival after pneumonectomy and sleeve lobectomy for non–small cell lung carcinoma. Ann Thorac Surg 2005;79:968–973. 11. Yoshino I, Yokoyama H, Yano T, et al. Comparison of surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer. J Surg Oncol 1997;64: 32–35. 12. Lausberg HF, Graeter TP, Tscholl D, et al. Bronchovascular versus bronchial sleeve resection for central lung tumors. Ann Thorac Surg 2005;79:1147–1152. 13. Redina E, Venuta F, Giacomo T, et al. Safety and efficacy of bronchovascular reconstruction after induction chemotherapy for lung cancer. J Thorac Cardiovasc Surg 1997; 114:830–837. 14. Tronc F, Grégoire J, Rouleau J, Deslauriers J. Long-term results of sleeve lobectomy for lung cancer. Eur J Cardiothorac Surg 2000;17:550–556. 15. Deslauriers J, Gregoire J, Jacques LF, et al. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites of recurrences. Ann Thorac Surg 2004;77:1152–1156. 16. Fadel E, Yildizeli B, Chapelier AR, et al. Sleeve lobectomy for bronchogenic cancers: factors affecting survival. Ann Thorac Surg 2002;74:851–858. 17. End A, Hollaus P, Pentsch A, et al. Bronchoplastic procedures in malignant and nonmalignant disease: multivariable analysis of 144 cases. J Thorac Cardiovasc Surg 2000;120:119–127.
18. Vildizeli B, Fadel E, Mussot S, et al. Morbidity, mortality and long-term survival after sleeve lobectomy for nonsmall cell lung cancer. Eur J Cardiothorac Surg 2007;31: 95–102. 19. Kutlu CA, Goldstraw P. Tracheobronchial sleeve resection with the use of a continuous anastomosis: results of one hundred consecutive cases. J Thorac Cardiovasc Surg 1999;117:1112–1117. 20. Teddler M, Anstadt MP, Teddler SD, Lowe JE. Current morbidity and mortality after bronchoplastic procedures for malignancy. Ann Thorac Surg 1992;54:387–391. 21. Hollaus PH, Janakiev D, Pridun NS. Telescope anastomosis in bronchial sleeve resections with high-caliber mismatch. Ann Thorac Surg 2001;72:357–361. 22. Turrentine MW, Kesler KA, Wright CD, et al. Effect of omental, intercostal, and internal mammary artery pedicle wraps on bronchial healing. Ann Thorac Surg 1990;49: 574–578. 23. Deeb ME, Sterman DH, Shrager JB, Kaiser LR. Bronchial anastomotic stricture caused by ossification of an intercostal muscle flap. Ann Thorac Surg 2001;71:1700– 1702. 24. Rendina EA, Venuta F, De Giacomo T, et al. Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer. Ann Thorac Surg 1999;68:995– 1001. 25. Dartevalle P. How I do it: sleeve lobectomy. General Thoracic Symposium at Annual Meeting, American Association for Thoracic Surgery. Accessible at www. conferencearchives.com/aats2006/index.html 26. Shrager JB, Lambright ES, McGrath CM, et al. Lobectomy with tangential pulmonary artery resection without regard to pulmonary function. Ann Thorac Surg 2000;70: 234–239.
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Pneumonectomy James E. Davies, MD and Mark S. Allen, MD
INTRODUCTION
INDICATIONS
The first successful pneumonectomy was performed by Rudolph Nissen in 1931 in Berlin, Germany. His patient was a 12-year-old girl with severe bronchiectasis of the entire left lung. This was a staged procedure with a cervical phrenic crush performed initially, followed by a left thoracotomy. The pneumonectomy was performed by placing a rubber tube ligature around the hilum of the left lung. The chest was packed, and 2 weeks later, the lung sloughed off. A small bronchial fistula developed but closed spontaneously 2 months later.1 On April 5, 1933, Everts Graham,2 Chair of Surgery at Washington School of Medicine, performed the first successful single-stage pneumonectomy. The patient was a 48-year-old gynecologist with a squamous cell carcinoma of the left lung that could be removed only with a pneumonectomy. Since these early reports, the number of pneumonectomies has steadily increased and mortality rates have improved. These improvements are probably secondary to a combination of better surgical approaches, patient selection, anesthesia, and postoperative care. Wilkins and coworkers3 showed a decrease in operative mortality, from 56% to 11%, over a period of 4 decades (1931–1970) at the Massachusetts General Hospital. Numerous reports since 1980 have shown mortality rates from 3% to 12%.3–6 Certain risk factors associated with higher mortality rates have been identified. Right-sided pneumonectomies have a higher morbidity and mortality than left-sided pneumonectomies. Reports by Nagasaki and associates4 and Wahi and colleagues5 confirmed significantly higher mortality rates with right- versus left-sided pneumonectomies. Wahi and colleagues reported in 19895 that right-sided pneumonectomy had a 12% mortality versus only 1% with left pneumonectomy. In 2001, Martin and coworkers,7 from Memorial Sloan-Kettering Cancer Center, reported a 24% mortality for right-sided pneumonectomy versus 2.4% for left-sided pneumonectomy. Other risk factors shown to be associated with higher mortality include age greater than 70 years, neoadjuvant therapy, completion pneumonectomy, and resection for inflammatory or infectious disease.8–14
● Carcinoma of lung (centrally located) ● Inflammatory/infectious lung disease with destroyed
lung ● Proximal
bronchial stricture/obstruction with destroyed lung ● Completion pneumonectomy ● Extrapleural pneumonectomy for malignant mesothelioma ● Trauma
OPERATIVE STEPS Step 1 Step Step Step Step Step Step Step Step
2 3 4 5 6 7 8 9
Anesthesia (double-lumen endotracheal tube and epidural catheter) Posterolateral thoracotomy Exploration of pleural cavity Mediastinal lymphadenectomy Mobilization of pulmonary hilum Ligation of pulmonary veins Ligation of pulmonary artery Transection of bronchus Closure
Mediastinal Lymphadenectomy Chylothorax Chylothorax is a rare complication after pneumonectomy. In 1993, Vallieres and associates15 published a review of the literature that showed a total of only 27 cases. Since that time, other series have shown an incidence of 0.37% to 0.5% of pneumonectomies.16,17 Cerfolio and colleagues17 reviewed the Mayo Clinic experience from 1987 to 1995 (315 patients) and found an incidence of 0.37%. ● Consequence Initially, chylothorax is difficult to diagnose in the pneumonectomy patient because normally all chest tubes are removed within 24 hours. This leads to a delay in the diagnosis and a potentially extended hospital stay. The diagnosis should be suspected when
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there is rapid accumulation of fluid within the pleural cavity. In the series by Sarsam and coworkers,16 nine patients had a rapid accumulation of fluid but only four were symptomatic. These symptoms are normally increased respiratory difficulty or compromise. Tension chylothorax requiring emergency drainage was described by Karwande and associates in 1986.18 Chylothorax can lead to serious metabolic defects secondary to the composition of chyle. The loss of protein, fat, and fat-soluble vitamins requires increased nutritional support, and the immunologic status of the patient can be affected by the loss of chyle. Grade 2/3 complication ● Repair The initial treatment for a chylothorax is conservative management with external drainage, nutritional support, and observation. The diagnosis is suggested by the presence of milky white drainage and confirmed by an elevated triglyceride level of the fluid (>110 mg/ dl). The patient should be placed on total parental nutrition or a medium-chain triglyceride diet, and the volume of the fluid should be observed and recorded accurately. If it is greater than 500 ml/day, it is less likely to resolve with conservative therapy and surgical intervention should be performed. The leak can be isolated by giving 100 to 200 ml of olive oil or cream to the patient by nasogastric tube 2 to 3 hours prior to the surgical exploration.19 This will increase the output of the milky fluid from the duct and make it easier to identify intraoperatively. The chest should be reopened on the side of the pneumonectomy and the thoracic duct ligated. This can be done by direct closure on the leak, mass ligation of the ductal tissue, or supradiaphragmatic ligation of the duct on the right side. Other techniques that have been described include pleuroperitoneal shunting with double-valve Denver peritoneal shunts and the use of fibrin glue.20,21 ● Prevention The best way to prevent an injury to the thoracic duct during a pneumonectomy or any thoracic procedure is through knowledge of the anatomy of the duct (Fig. 67–1). It originates from the cisterna chyli at the level of the second lumbar vertebrae and ascends through the aortic hiatus into the chest. The duct continues superiorly on the anterior surface of the vertebral column behind the esophagus and between the aorta and the azygos vein. At the level of T4 or T5, it crosses the midline behind the aorta into the left side of the chest. The duct continues superiorly adjacent to the esophagus and drains into the left subclavian–jugular junction.22
Recurrent Laryngeal Nerve Injuries Recurrent laryngeal nerve injuries are not common with pneumonectomy or any pulmonary resection. They can be intentional (sacrificing the nerve for a complete onco-
Left jugular vein
Superior vena cava
Thoracic duct Aorta
Azygos vein
Diaphragm
Cisterna chyli
Figure 67–1 Anatomy of the thoracic duct.
logic resection) or unintentional (secondary to traction or direct injury). Mediastinal lymphadenectomy can lead to more injuries, especially on the left. Bollen and colleagues23 reported that 3 out of 62 patients undergoing complete mediastinal lymphadenectomy suffered unintentional injury. Conversely, in the American College of Surgical Oncology Group’s (ACOSOG) study24 of lymphadenectomy versus lymph node sampling, no increase was observed in the incidence of recurrent nerve injuries with mediastinal lymph node dissection. ● Consequence Injury to recurrent laryngeal nerve leads to unilateral vocal cord paralysis. The degree of dysfunction is variable, but it may cause inadequate cough, inability to clear secretions, or aspiration in the postoperative setting. Patient age, recent weight loss, and overall
67 PNEUMONECTOMY 3p
3a Vagus nerve 6
5
Phrenic nerve
Figure 67–2 Anatomy of the left aortopulmonary window with levels V and VI lymph nodes.
pulmonary function prior to resection correlate with the patient’s ability to compensate postoperatively. Grade 3 complication ● Repair The treatment and timing for recurrent laryngeal nerve injuries depend on the status and condition of the patient. Definitive treatment is with medialization of the vocal cords, normally performed by an otolaryngologist. Three techniques described include vocal cord injection, neuromuscular transfer, and vocal cord implant.25 ● Prevention Injury to the recurrent laryngeal nerve is most common on the left during resection of stations 5 and 6 lymph nodes. Care must be taken during this portion of the procedure to avoid direct injury or excessive traction on the recurrent laryngeal nerve. If needed, sharp dissection rather than cautery should be used. A vessel loop can also be placed around the nerve for gentle traction. This decreases the crushing effect of picking up the nerve directly. Figure 67–2 shows the anatomy of the nerve in relation to levels V and VI lymph nodes.
Mobilization of the Pulmonary Hilum Esophagopleural Fistula Esophagopleural fistula (EPF) occurs in 0.5% to 0.65% of patients undergoing pneumonectomy.26–28 EPFs are more
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common of the right side, and the incidence is increased in patients undergoing pneumonectomy for inflammatory or infectious diseases. This is most likely secondary to the difficulty in the dissection of the pulmonary hilum in these patients. Massard and Wihlm29 divided EPFs into two groups: early and late (>3 mo). The etiology in the early group was direct operative trauma or devascularization/ necrosis versus recurrent cancer or chronic infectious/ inflammatory disorder in the late group. The diagnosis can be difficult to make in either group because EPFs tend to present in the same way as a bronchopleural fistula (BPF). Therefore, the work-up tends to be directed at ruling out a BPF with a flexible bronchoscopy. If this is negative, a water-soluble swallow study should be performed immediately to rule out an EPF. ● Consequence EPF presents with an associated empyema in both the early and the late groups. Early reports cited a mortality of 50% in these patients.28,30 More recent reports, including one from the Mayo Clinic by Deschamps and coworkers in 2001,31 showed a mortality of approximately 7.5% in patients with empyemas after pneumonectomy. The increased mortality depends on the etiology of the fistula; the late group has a higher incidence of recurrent malignancy. Grade 3 complication ● Repair The initial treatment of empyema with EPF is drainage of the empyema, appropriate antibiotics, and nutritional support with nasogastric tube or parenteral nutrition. Definitive treatment depends on the etiology of the fistula, but EPF is treated in the same way as a BPF, which is discussed in detail later in this section. ● Prevention If a difficult dissection of the mediastinum is suspected or found during the operation, a large bougie may be inserted to aid in identifying the esophagus. This may help avoid but will not prevent direct injury to the esophagus. If an injury is suspected, methylene blue or air may be injected into the nasogastric tube to help identify the injury. Once the injury is located, it can be closed in two layers of fine nonabsorbable suture and buttressed with a pleural flap or other viable tissue.30
Cardiac Herniation Cardiac herniation or torsion is a rare complication after pneumonectomy, but it is associated with a mortality rate of 40% to 50%.32,33 It is associated with opening the pericardial sac for intrapericardial pneumonectomy. On the left, herniation results in strangulation of the left ventricle with decreased filling and ejection. There is also decreased or no coronary blood flow, leading to myocardial ischemia. The right-sided herniation leads to a counterclockwise rotation of the heart and obstruction of the superior and inferior vena cava (Fig. 67–3). These normally present
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Figure 67–4 Intraoperative large pericardial defect after intrapericardial pneumonectomy.
Ligation of the Pulmonary Veins Peripheral Tumor Embolus
Figure 67–3 Chest radiograph of right-sided cardiac herniation.
within 24 hours but have been reported up to 72 hours postoperatively. ● Consequence The patient will develop abrupt hypotension, tachycardia, increased venous pressure, and progressive cardiovascular collapse. If the diagnosis and treatment are not instituted immediately, fatality will result.32,33 Grade 3/5 complication ● Repair After diagnosis, the patient should be placed immediately with the operative side up and taken back to the operating room. Upon reopening of the thoracotomy, the cardiac herniation should be reduced and the pericardium reconstructed, usually with a synthetic patch. ● Prevention Closure of all but very small pericardial defects should be performed intraoperatively. If the pericardium cannot be closed without causing cardiac restriction, a synthetic patch should be used. This does not fully eliminate postoperative herniation, as reported by Veronesi and associates in 2001.34 Also, the pleural cavity should not be placed or kept on excessive suction. Figure 67–4 shows a large pericardial defect after a left extrapleural pneumonectomy.
● Consequence Peripheral tumor embolus during a pneumonectomy is a rare but potentially lethal complication.35 It was first described by Taber36 and Senderoff and Kirschner37 in the early 1960s. Whyte and colleagues38 reported that the distribution of the emboli were most commonly major arterial sites: the aortic bifurcation and femoral arteries (50%), the carotid and cerebral arteries (32%), and the visceral arteries (18%). Grade 3/4 complication ● Repair If a tumor embolus is suspected in the perioperative period, an angiogram should be performed. Once the diagnosis is confirmed, removal by an embolectomy is done if the patient is clinically stable enough to return to the operating room. ● Prevention If a tumor is suspected pre- or intraoperatively within the pulmonary vein, a transesophageal echocardiogram is performed to assess intra-atrial involvement.35,39 At the time of surgery, the intrapericardial portion of the pulmonary hilum is explored and assessed for resectability. Another technique described by Taber36 is placement of a pursestring suture in the left atrium and transatrial digital palpation. If the tumor involves the left atrium or distal pulmonary vein, it may be removed with or without cardiopulmonary bypass.35,38,39 Figure 67–5 shows a management algorithm described by Whyte and colleagues in 1992.38
Ligation of the Pulmonary Artery Pulmonary Artery Embolism/Thrombosis In 1966, Chuang and coworkers40 reported that approximately 1% of all pneumonectomy patients had a pulmonary embolus originating from the pulmonary arterial
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697
Palpable tumor within pulmonary vein (consider intracardiac tumor)
Intraoperative transesophageal ECHO digital palpation through left atrial pursestring suture
Intracardiac tumor Yes
No
Wedge resection of left atrium using endo stapling device Resection of CPB Unresectable
Intrapericardial ligation of vein
Tumor within line of transection
Yes
Peripheral vascular exam
Neurological exam
Normal
Abnormal
No change from preop
Carotid duplex scan
Head CT Medical management
No
EKG
Visceral angiography for any abdominal symptoms
Acute ischemia
Embolectomy
Possible carotid embolectomy if tumor lodged in extracranial carotid artery
Embolus
Negative
No change
Acute ischemia
Embolectomy or abdominal exploration
Coronary angiography
Medical management of MI
Coronary revascularization
Figure 67–5 Peripheral tumor embolus algorithm. (From Whyte RI, Starkey TD, Orringer MB. Tumor emboli from lung neoplasms involving the pulmonary vein. J Thorac Cardiovasc Surg 1992;104:421–425.)
stump. It occurs more commonly on the right, possibly secondary to the longer arterial stump.41 ● Consequence Overall, pulmonary artery embolus is the fourth leading cause of death in pneumonectomy patients.42 Grade 1/3 complication
● Repair Initial treatment of pulmonary arterial thrombosis is the same as with any postoperative patient with a pulmonary embolus, including supportive care and anticoagulation. If the patient is hemodynamically unstable, either a pulmonary embolectomy or a catheter-based treatment may be an option.
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● Prevention The exact etiology of a pulmonary embolus originating from the pulmonary arterial stump is unknown, but it is believed that appropriate arterial closure with a nonabsorbable suture or stapler may decrease the incidence. Also, postoperatively, prevention should include early mobilization, sequential compression devices, and/or subcutaneous anticoagulation.
Closure of the Bronchus Empyema with or without BPF The incidence of empyema after pneumonectomy is between 2% and 16%.4,43 A BPF is commonly but not always associated with empyemas. In a series from the Mayo Clinic in 2001,31 53 (7.5%) of 713 pneumonectomy patients developed postoperative empyemas and 32 (4.5%) had associated BPF. Risk factors for developing BPF include right-sided pneumonectomy, completion pneumonectomy, preoperative radiation therapy, pneumonectomy for inflammatory or infectious disease, residual/recurrent tumor, and intraoperative technical factors. A BPF can develop early (1–7 days), secondary to technical factors, or up to years later from multiple different factors.44,45 ● Consequence Mortality in patients with an empyema and BPF has been reported to be between 16% and 72%.46 Significant morbidity associated with BPF includes increased hospital stay, long rehabilitation, and recurrent operative procedures. Grade 3/4 complication ● Repair The initial management of patients suspected of having empyema with or without BPF includes stabilization of the patient, accurate diagnosis, and definitive treatment, including adequate pleural drainage, parental
A Figure 67–6 Débridement of the bronchial stump.
antibiotics, nutritional support, removal of necrotic tissue, and obliteration of the residual pleural space.45 If the patient presents acutely ill with signs of respiratory distress, she or he should be placed in the lateral decubitus position with the operative side down to prevent contamination of the contralateral lung. Once the patient has been stabilized, definitive treatment options include thoracoplasty, open pleural drainage, anterior transpericardial closure of the fistula, obliteration of the empyema space with fluid or muscle, primary closure of the bronchial stump with vascularized tissue, or the use of a continuous irrigation system.47–52 At the Mayo Clinic, a combination of the original Clagett technique and the use of a well-vascularized extrathoracic muscle is used to cover the bronchial stump.53,54 After initial stabilization, which may include tube thoracostomy, the patient is returned to the operating room and the thoracotomy is reopened. The BPF is identified by filling the pleural cavity with fluid and observing for leakage of air bubbles. Once the BPF is identified, it is débrided and reclosed near the carina with interrupted nonabsorbable sutures to prevent a long stump (Fig. 67– 6). A well-vascularized muscle flap is then used to cover the bronchial stump (Fig. 67–7). Options for the muscle flap include serratus anterior, latissimus dorsi, pectoralis major, or rectus abdominis. If the empyema exists without a BPF, muscle flap is not required but may be used to protect underlying structures. The remainder of the pleural cavity is irrigated, débrided, and packed with wet dressings (Fig. 67–8). Irrigation and débridement are repeated every 48 hours in the operating room until the pleural cavity is clean with good granulation tissue. The cavity is then filled with débridement antibiotic solution (DABS) (0.5 g neomycin, 0.1 g polymyxin B sulfate, and 80 mg gentamicin per liter of saline) and closed (Fig. 67–9).45 ● Prevention The bronchial stump should be handled gently to avoid devascularization and should not be left excessively
B
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A
A
699
B
B
Figure 67–7 Serratus anterior muscle flap to cover a bronchopleural fistula (BPF).
Figure 67–8 Débridement and packing of the pleural cavity.
long. No single technique of closure of the bronchial stump has been shown to be superior. The series from the Mayo Clinic31 showed a decrease in BPF with stapled versus hand-sewn closure of the bronchus. al-Kattan and associates55 had a 1.3% BPF rate in 530 pneumonectomies using interrupted nonabsorbable monofilament 2-0 polypropylene sutures. Also, the prophylactic use of a vascularized muscle flap is not clear. Deschamps and coworkers31 showed an increased incidence of BPF with the use of bronchial stump reinforcement in 2001, but this was not a randomized trial and the patients that had prophylactic muscle flaps were believed to be at significantly higher risk. It is generally recommended that patients having a pneumonectomy for inflammatory of infectious disease or those who received neoadjuvant radiation therapy should have a muscle flap to cover the bronchial stump at the initial procedure.
Postoperative Complications Cardiac Arrhythmias Postoperative cardiac arrhythmias occur in 14% to 40% of pneumonectomy patients.56 The majority of these arrhythmias are atrial in origin, with atrial fibrillation being the
Figure 67–9 Filling of the pleural cavity with débridement antibiotic solution (DABS).
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most common. Predisposing factors include advanced age, coronary artery disease, and more extensive procedures (e.g., extrapleural pneumonectomy). The exact etiology is unclear, but it probably results from a combination of factors including hypoxia, vagal stimulation, electrolyte imbalances, abnormal blood pH, reduced pulmonary vascular reserve, local inflammation of the atria, distention of the atria, and general anesthesia.56 ● Consequence Cardiac arrhythmias are associated with an up to 40% increased perioperative mortality.56 They may also lead to an increased length of intensive care unit and overall hospital stay. Grade 1 complication ● Repair Patients should have continuous cardiac monitoring postoperatively to help identify these arrhythmias. Ritchie and colleagues57,58 showed that over half of these arrhythmias occurred in the first 24 hours after surgery. Once the diagnosis has been confirmed, the patient should be stabilized and treated appropriately. This may include β-blockers, calcium channel blockers, digoxin, or electrical/chemical cardioversion. ● Prevention Prophylactic treatment of arrhythmias in the postoperative setting has been examined in multiple studies. The early studies using digoxin showed benefit, but this was not confirmed in more recent studies.57–60 Borgeat and coworkers61 looked at the use of flecainide as a continuous infusion and found a decrease in the incidence of arrhythmias, but the regimen was complicated and intravenous flecainide is not available in the United States. Amiodarone has also been studied with conflicting results.62,63 Some believe that the pulmonary complications of amiodarone in the setting of a pneumonectomy outweigh the potential benefit. Van Miegham and associates64 and Amar and colleagues65 showed a decrease in postoperative arrhythmias with calcium channel blockers. No single study has been absolutely conclusive; therefore, the prophylactic use of any of these medications is not routine.
Postpneumonectomy Pulmonary Edema Postpneumonectomy pulmonary edema (PPE) is a condition that occurs in the early postoperative period (usually within 72 hours), in which patients develop rapidly progressive hypoxia and infiltration of the contralateral lung.66 The incidence is between 3% and 5% of pneumonectomy patients and the mortality approaches 80% to 100%.66,67 Risk factors include right pneumonectomy, duration of surgery, extent of surgery, perioperative fluid overload, and postoperative pleural drainage.66–69 Initially, patients present with dyspnea that rapidly progresses despite optimal treatment, and they require mechanical ventilation within 12 to 24 hours after the
Figure 67–10 Chest radiograph of a right-sided postpneumonectomy pulmonary embolism (PPE).
onset of symptoms. The chest radiograph will quickly develop picture consistent with acute respiratory distress syndrome (ARDS) (Fig. 67–10). ● Consequence Even with early diagnosis and aggressive treatment, the mortality approaches 80% to 100%.66,67 Grade 4/5 complication ● Repair Once the patient begins to develop dyspnea and hypoxia, the differential diagnosis should include cardiogenic pulmonary edema, aspiration pneumonitis, infectious pneumonitis, pneumonia, massive atelectasis, pulmonary embolus, sepsis, and PPE. Normally, the patient is transported to the intensive care unit and supported with mechanical ventilation, but there have been reports of treatment with continuous positive airway pressure (CPAP) masks.70 Bronchoscopy, pulmonary artery catheter monitoring, pan-cultures with the initiation of empirical broad-spectrum antibiotics, and computed tomography (CT) scans of the chest should be performed to rule out other causes of the hypoxia. Normally, the patients require elevated levels of inspired oxygen and higher airway pressures to maintain adequate oxygenation. Pressure control ventilation may aid in decreasing the volutrauma associated with the mechanical ventilation in these patients. Nutritional support should also be started as soon as possible. Other therapies that have been described but have not been shown to have consistent improvement include steroids, extracorporeal membrane oxygenation (ECMO), and inhaled nitrous oxide.66,71,72 ● Prevention The etiology of PPE is not fully understood; therefore, no definitive prevention is known. In the initial
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701
Figure 67–11 Preoperative computed tomography (CT) scan of the chest in right-sided postpneumonectomy syndrome (PPS).
postoperative period, fluid restriction with the use of diuretics has been generally accepted. Intravenous fluid rates are kept between 30 and 50 ml/hr.73 Otherwise, standard postoperative care of the thoracic patient should include adequate pain control, early mobilization, and pulmonary rehabilitation.
Postpneumonectomy Syndrome ● Consequence Postpneumonectomy syndrome (PPS) results from major airway compression secondary to progressive mediastinal shift toward the side of the pneumonectomy. This leads to stretching and/or compression of the trachea or main stem bronchus. PPS is more commonly associated with right-sided pneumonectomies, and PPS after a left pneumonectomy is usually associated with a right-sided aortic arch.74,75 Although Shamji and coworkers76 reported a series of patients with PPS after left pneumonectomy and normal aortic arch anatomy. The right-sided PPS is secondary to a counterclockwise rotation of the heart and great vessels, leading to stretching of the left main stem bronchus with compression between the aorta and the pulmonary artery (Fig. 67–11). Left PPS has a clockwise rotation of the heart and mediastinum with compression of the right main stem bronchus over the vertebral body. PPS may present early or several years later. Shepard and associates77 reported a case of right PPS 37 years after resection. Other risk factors associated with PPS are young age and female gender, likely secondary to increased elasticity of the mediastinum in these patients.74 Grade 3 complication ● Repair The presentation of PPS is usually one of a slow progressive increase in dyspnea associated with repeated
Figure 67–12 Bronchoscopic view of a patient after right pneumonectomy with a narrowed left lower lobe orifice.
episodes of respiratory infection, coughing, and stridor.74 Initially, a chest radiograph may suggest the diagnosis, but it is confirmed with bronchoscopy and CT scan. The bronchoscopy may reveal narrowing of the airway or tracheobronchial malacia (Fig. 67–12). Once the diagnosis has been confirmed, treatment consists of stabilization of the patient, dissection of the adhesions on the operative side, placement of a prosthetic device, and correction of the tracheobronchial malacia if present. Many different materials have been described for expansion of the pleural space, but the best results appear to be with an expandable saline prosthesis (Figs. 67–13 and 67–14).75,76,78–81 The tracheobronchial malacia has been treated with expandable metallic stents.82–84
Platypnea—Orthodeoxia Syndrome Platypnea is a very rare complication after pneumonectomy: only 39 cases had been reported in the literature as of 1998.85 The first report was in 1956 by Schnabel and colleagues.86 Clinically, the patient presents with dyspnea and hypoxia while sitting upright or standing. In the supine position, the dyspnea and hypoxia are either absent or significantly decreased. The etiology is increased rightto-left shunting at the atrial level secondary to a patent foramen ovale (PFO) or atrial septal defect (ASD), which may or may not have been present preoperatively.85 Possible causative factors include increased pulmonary vascular resistance, decreased right ventricular compliance, or rotation of the heart with distortion of flow from the
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Figure 67–13 Intraoperative photograph after placement of a saline implant in a patient with right-sided PPS. Figure 67–15 Intraoperative transesophageal echocardiogram of a patent foramen ovale (PFO).
REFERENCES
Figure 67–14 Postoperative CT scan of the chest in a patient with right-sided PPS.
inferior vena cava.85 This leads to right-to-left shunting associated with increased intrathoracic pressures during sitting or standing. ● Consequence Platypnea is usually insidious in presentation and may be quite complex to diagnose because most pneumonectomy patients have some degree of dyspnea. Therefore, the diagnosis may be delayed along with the patient’s recovery. Repair of the PFO/ASD corrects the problem and is associated with limited mortality. Grade 2/3 complication ● Repair The diagnosis can usually be made with transthoracic echocardiography (Fig. 67–15), but occasionally, a right heart catheterization is required to demonstrate the defect. The PFO is then repaired surgically or with a percutaneous closure device.85–88
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71. Mathisen DJ, Kuo EY, Hahn C, et al. Inhaled nitric oxide for adult respiratory distress syndrome after pulmonary resection. Ann Thorac Surg 1998;66:1984–1992. 72. Gattinoni L, Presenti A, Mascheroni D, et al. Lowfrequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA 1986;256:881–886. 73. Slinger PD. Perioperative fluid management for thoracic surgery: the puzzle of postpneumonectomy pulmonary edema. J Cardiothorac Vasc Anesth 1995;9:442–451. 74. Mehran RJ, Deslauriers J. Late complications: postpneumonectomy syndrome. Chest Surg Clin North Am 1999; 9:655–673. 75. Grillo HC, Shepard JA, Mathisen DJ, Kanarek DJ. Postpneumonectomy syndrome: diagnosis, management, and results. Ann Thorac Surg 1992;54:638–650. 76. Shamji FM, Deslauriers J, Daniel TM, et al. Postpneumonectomy syndrome with an ipsilateral aortic arch after left pneumonectomy. Ann Thorac Surg 1996;62:1627– 1631. 77. Shepard JA, Grillo HC, Mcloud TC, et al. Rightpneumonectomy syndrome: radiologic findings and CT correlation. Radiology 1986;161:661–664. 78. Adams HD, Junod F, Aberdeen E, Johnson J. Severe airway obstruction caused by mediastinal displacement after right pneumonectomy in a child. a case report. J Thorac Cardiovasc Surg 1972;63:534–539. 79. Powell RW, Luck SR, Raffensperger JG. Pneumonectomy in infants and children: the use of a prosthesis to prevent mediastinal shift and its complications. J Pediatr Surg 1979;14:231–237. 80. Wasserman K, Jamplis RW, Lash H, et al. Post-pneumonectomy syndrome. Surgical correction using Silastic implants. Chest 1979;75:78–81. 81. Audry G, Balquet P, Vazquez MP, et al. Expandable prosthesis in right postpneumonectomy syndrome in childhood and adolescence. Ann Thorac Surg 1993;56: 323–327. 82. Evans GH, Clark RJ. Management of life threatening adult postpneumonectomy syndrome. Anaethesia 1995; 50:148–150. 83. Shah R, Sabanathan S, Mearns AJ, Featherstone H. Selfexpanding tracheobronchial stents in the management of major airway problems. J Cardiovasc Surg 1995;36:343– 348. 84. Kelly RF, Hunter DW, Maddaus MA. Postpneumonectomy syndrome after left pneumonectomy. Anaethesia 2001;71:701–703. 85. Wihlm J-M, Massard G. Late complications: late respiratory failure. Chest Surg Clin North Am 1999;9:633– 654. 86. Schnabel TG Jr, Ratto O, Kirby CK, et al. Postural cyanosis and angina pectoris following pneumonectomy: relief by closure of an interatrial septal defect. J Thorac Surg 1956;32:246–250. 87. Rao PS, Sideris EB, Hausdorf G, et al. International experience with secundum atrial septal defect occlusion by the buttoned device. Am Heart J 1994;128:1022–1035. 88. Godart F, Porte HL, Rey C, et al. Postpneumonectomy interatrial right-to-left shunt: successful percutaneous treatment. Ann Thorac Surg 1997;64:834–836.
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Chest Wall Resections Jessica S. Donington, MD INTRODUCTION Indications for chest wall resections are listed below, malignancy is the most common indication today.1 Resections for malignancy are performed for primary chest wall malignancies, metastatic spread to the chest wall from distant sites, or direct extension from lung cancer or breast cancer. Chest wall resections must be discussed hand-inhand with reconstruction. The tenets of chest wall resection and reconstruction are (1) remove all malignant or devitalized tissue, (2) restore rigidity to large chest wall defects to prevent flail chest, and (3) provide healthy soft tissue coverage that will seal the pleural space, protect underlying organs, and prevent infection. Functional reconstruction can often be more difficult than the resection for these cases. These patients are best cared for by a team of physicians, including reconstructive and thoracic surgeons. Appropriate planning is required prior to the start of surgery to ensure that adequate margins are obtained while necessary muscles and soft tissues needed for reconstruction are preserved.
MAJOR INDICATIONS ● Malignancy ● Infection ● Radiation injury
LESS COMMON INDICATIONS ● Congenital abnormalities ● Trauma
PREOPERATIVE PREPARATION Planning and Consultation Poor Planning and Lack of Preoperative Consultation ● Consequence Poor planning and lack of preoperative consultation with a reconstructive surgeon can leave the thoracic
surgeon alone in the operating room with a defect larger than anticipated and inadequate tissue to restore chest wall rigidity and provide soft tissue coverage. Grade 1/2 complication ● Repair Intraoperative consultation is necessary to provide closure, but it may require extensive operating time and tissue manipulation if the patient is not appropriately prepared or positioned. It may necessitate a staged operation to complete reconstruction. ● Prevention Consult a reconstructive surgeon prior to any chest wall resection that may result in a wound larger than 4 cm with concern for soft tissue coverage.
HISTORY The first reported chest wall resection was by Aimar in 1778; the next reports are from Parham in 18982 and Lund in 1913.3 Airway control, positive-pressure ventilation, and closed chest drainage systems were introduced at the end of the 19th century. These technologies and the expanded use of antibiotics dramatically advanced the field of thoracic surgery. In the 1930s and 1940s, large series of chest wall resections were published by Hedblom,4 Harrington,5 and Zinniger.6 At that time, operative mortality was as high as 29%. In the 1940s, treatment of injuries from World War II brought significant advancements in the management of infected pleural spaces, ventilatory mechanics, and reconstructive techniques with soft tissue coverage. Fascia lata grafts for large bony defects and rib grafts for sternal reconstruction were described.7,8 One of the major advancements in chest wall reconstruction has been the use of musculocutaneous flaps. Latissimus dorsi flaps for the reconstruction of chest wall defects after radical mastectomy were first described by Tansini as far back as 1906.9 Campbell10 also described use of musculocutaneous flaps in the 1950s, but the frequent use of muscle flaps for chest wall reconstruction did not begin until 1977, when Jurkiewicz and associates11 at Emory University began using them regularly. Their techniques are widely used today, and rotational muscle flaps are the workhorses of chest wall reconstruction. All major tho-
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racic muscles, including the latissimus dorsi, pectoralis major and minor, serratus anterior, rectus abdominis, and external obliques, can be used in chest wall reconstruction. With use of these modern techniques, autologous soft tissue coverage is almost always possible, even for the most aggressive chest wall resections. This chapter specifically addresses chest wall resections for primary chest wall tumors and chest wall resections performed en bloc with lung resections for direct extension from a bronchogenic carcinoma, with special consideration to Pancoast’s tumors and sternal resections for infection.
Resection of Primary Chest Wall Tumors Chest wall tumors generally present as slowly growing asymptomatic masses. Fifty percent to 80% of primary chest wall tumors are malignant. The most common malignant tumors of the chest wall are malignant fibrous histocytomas (MFH), chondrosarcoma, and rhabdomyosarcomas. The most common benign tumors are chondromas, osteochondromas, and desmoid tumors.1,12 Evaluation of patients with chest wall tumors includes a history and physical examination and conventional x-rays compared with previous x-rays, if available, to document rate of growth. In general, magnetic resonance imaging (MRI) is the preferred method for imaging primary chest wall malignancies. MRI allows visualization of the tumor in multiple planes and is superior to computed tomography (CT) at distinguishing tumor from nerves and vasculature. CT also plays a vital role because it is superior to MRI for evaluation of the pulmonary parenchyma for metastatic involvement. Each resection is unique, but the basic steps of the operation are outlined here.
OPERATIVE STEPS Biopsy Determine necessary resection margin Consider consultation with reconstructive surgeon Step 4 Epidural catheter, double-lumen endotracheal tube, and positioning Step 5 Skin incision Step 6 Dissection to chest wall Step 7 Enter pleural space Step 8 Palpate tumor inside of chest Step 9 Divide intercostal muscles Step 10 Resect ribs Step 11 En-bloc resection of involved underlying structures Step 12 Chest tube insertion Step 1 Step 2 Step 3
Step 13 Mesh reconstruction of bony chest wall Step 14 Soft tissue coverage Step 15 Skin closure
Biopsy Primary chest wall tumors require tissue diagnosis prior to treatment. A well-performed biopsy is one of the keys to the successful management of these tumors. An incorrectly placed biopsy or inadequate tissue sampling can severely compromise treatment. To allow for proper technique and placement, it is best if the surgeon who will perform the definitive resection also performs the biopsy. The biopsy needs to allow for maximal tissue for pathologic evaluation; small incisional biopsies and needle biopsies obtain limited amounts of tissue and can lead to misdiagnosis of low-grade malignancies. At tertiary cancer centers, core needle biopsy for diagnosis has been advocated, but only with the support of a specialized cytopathologist.13 At most other institutions, excisional biopsies are preferred for tumors smaller than 4 cm. The best chance for cure of low-grade malignancies is wide resection; without an adequate amount of tissue for diagnosis, the opportunity for cure can be missed. For tumors larger than 4 cm, an incisional biopsy is usually necessary. The skin incision for the biopsy needs to be placed so that it can be completely removed at the time of definitive resection and does not compromise any of the soft tissue or vasculature necessary for reconstruction. Soft tissue dissection should be minimal; tissue flaps should not be raised. The capsule of the mass should be closed after the biopsy to reduce tumor spillage. Careful operative technique is essential. A wound infection can significantly delay chemotherapy, radiation therapy, or definitive surgery, and a hematoma can lead to significant soft tissue contamination, resulting in a larger definitive resection.
Incorrectly Performed Biopsy ● Consequence Incorrectly performed biopsies can result in inadequate tissue for diagnosis, contaminated tissue planes, and unnecessary sacrifice of skin and soft tissue. Grade 2/3 complication ● Repair Definitive diagnosis is imperative, and a repeat biopsy may be needed if only a small tissue sample was obtained at the initial biopsy attempt. Because complete resection with wide margins is essential for cure, an improperly performed biopsy can lead to a significantly larger resection in order to encompass all tissue violated by a biopsy or to postbiopsy hematoma or infection. ● Prevention The surgeon who performs the resection should ideally perform the biopsy. In masses smaller than 4 cm, exci-
68 CHEST WALL RESECTIONS sional biopsy should be undertaken with plans to return for wider definitive resection if a malignant diagnosis is obtained. Incisional biopsy is used for larger tumors. The biopsy should be made as directly over the mass as possible, taking into account that the entire biopsy site will need to be removed with the definitive resection. Care should be taken to avoid vascular pedicles to musculature, which may be needed for reconstruction. Careful surgical technique and homeostasis are essential to minimize postbiopsy hematoma or infection. If incisional biopsy is needed because of tumor size, it is important that skin flaps are not raised and that the deep plane of the tumor, especially the pleural surface, is not disturbed. This needs to be left intact to prevent dissemination of tumor cells.
Resection When a diagnosis has been made, definitive resection can be carried out. The surgical approach is dictated by the location, histology, and extent of overlying soft tissue involvement. Preoperative assessment by a reconstructive surgeon is essential for many of these resections. An epidural catheter is recommended for those resections that do not involve the spine. A double-lumen endotracheal tube should be used to selectively deflate the ipsilateral lung; this helps to avoid lung injury, facilitates wedge resections, and allows for manual palpation of the lung to rule out metastasis. Decubitus positioning is used for most thoracotomies, but it may need to be modified in these cases based on the location of the mass. If a muscle flap is needed for closure, it must be considered prior to positioning and draping the patient. Obtaining adequate resection margins is essential to minimize the risk of local recurrence. The extent of resection should not be limited by the size of the resulting defect. The appropriate margin of resection for primary chest wall tumors varies depending on the type of neoplasm. High-grade tumors, such as MFH and osteogenic sarcomas, have the potential to spread within the bone marrow and along the periosteal tissue planes. Therefore, the entire involved rib, the corresponding anterior costal margin for anterior tumors, and partial resection of the ribs above and below the neoplasm should be removed. Resection of the entire sternum and bilateral costal arches is indicated for malignant tumors of the sternum. Less aggressive primary chest wall malignancies should be resected with at least 4-cm margins. In a Mayo Clinic review14 of survival after resection of primary chest wall malignancies, 56% of patients with margins 4-cm or greater were cancer free at 5 years compared with only 29% of those patients with 2-cm margins. Any attached structures including lung, thymus, pericardium, or overlying chest wall musculature, should be resected en bloc with malignant chest wall tumors. If there is any involvement of the overlying skin, at least a 1-cm margin of normal skin is recommended.15
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Most low-grade lesions and benign tumors can be resected with 2- to 3-cm margins. The exceptions to this are desmoid tumors, which are classified as low-grade malignancies but are locally very aggressive and have a very high rate of local recurrence. These are, therefore, managed surgically like malignant chest wall lesions, and 4-cm resection margins are recommended.16 When the skin is involved, the incision is dictated by that involvement, and full-thickness resection of skin, muscle, and chest wall is undertaken in a “cookie cutter” fashion. If the mass does not involve the overlying skin and soft tissue, a standard thoracotomy-type incision can be made in the area over the mass and flaps can be carefully raised and used for closure. One normal musculofascial plane should be included in the resection, but uninvolved tissues can be spared.17 The pleural space should be entered one full rib space above or below the involved tumor. The mass should be palpated on the underside of the chest wall to determine margins of resection (4 cm from the mass for malignant tumors and 2–3 cm for benign) (Fig. 68–1). Any attached structures should be resected en bloc. The lung should be palpated to evaluate for pulmonary metastases. Once the margins have been determined, the bony resection is undertaken. Electrocautery or the periosteal elevator can be used to lift the intercostal musculature and neurovascular bundle from the ribs at the superior and inferior margins of resection. At the anterior and posterior margins, cautery is used to clear a 1- to 2-cm length at each rib (Fig. 68–2). The intercostal neurovascular bundle can be divided with cautery or between clips through that space. A guillotine or shear rib cutter is used to divide the ribs. A 1-cm segment of each rib should be removed at the resection margin and submitted for pathologic examination after decalcification (Fig. 68–3). Any questionable soft tissue margin should be submitted for frozen section evaluation. One cannot overemphasize the importance
Figure 68–1 The surgeon palpates the tumor inside of the chest to determine the margins of resection.
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Figure 68–2 The intercostal muscles and neurovascular bundles are cleared with electrocautery over a 2- to 3-cm length at each rib space.
Figure 68–3 The technique for the division or ribs with rib shear, sending 1-cm margin from each rib for evaluation after decalcification.
of a wide resection with clear margins at the primary resection.
Reconstruction The goals of reconstruction include restoring the structural stability of the thorax and providing soft tissue coverage. In general, defects smaller than 4 cm do not require reconstruction of the bony portion of the chest wall. Fullthickness defects of the chest wall greater than 4 cm require reconstruction. The exception is high posterior defects, because the overlying scapula provides support. Defects located near the tip of the scapula need to be reconstructed to prevent impingement of the scapula with arm movement, which can be painful. The choice of material for reconstruction remains controversial. Autologous tissues such as fascia lata and ribs have been used,7,8 but
Figure 68–4 Mesh replacement is fixed with large monofilament suture around the ribs at the upper and lower extent of resection and through drilled holes in the cut ribs. The mesh is best fixed to the underside of the chest wall, so it is not pushed away from the chest wall with each breath.
prosthetic meshes are used most commonly today. The prosthetic materials most frequently used are polypropylene mesh (Marlex; Bard, Cranston, RI) and polytetrafluoroethylene (PTFE/Gore-Tex; W.L. Gore and Associates, Newark, DE). The Marlex mesh has interstices that allow for ingrowth of fibrin. It can be used in two layers with methyl methacrylate as a sandwich for contoured reconstructions. Marlex is not watertight. Gore-Tex is watertight and required when the skeletal resection accompanies a pneumonectomy, so that the pneumonectomy space can fill with fluid. Otherwise, both work equally well and are used at the surgeon’s discretion. In situations in which infection is present or the viability of soft tissue coverage is questionable, the newly available acellular dermal matrixes (Derma Matrix; Musculoskeletal Transplant Foundation, Edison, NJ), derived from cadaver skin, can be used to provide structural support to the chest wall. The mesh or dermal matrix is sewn in place with heavy monofilament suture. It should be anchored around the ribs at the inferior and superior margins. To facilitate fixation of the anterior and posterior margins without compromise of neurovascular structures, drilled holes in the ribs are recommended. These should be placed at least 1 cm back from the resection margin (Fig. 68–4). A handheld pneumatic drill is preferred to towel clips and rib punches because it creates less crush injury to the bone (Fig. 68–5). If the chest wall musculature has been removed, direct skin closure over the prosthesis is not recommended. Muscle or other soft tissue coverage is necessary and can be provided via a pedicled rotational flap from the pectoralis major or minor, serratus, latissimus, or rectus muscles. If those muscles are inadequate or not available, an omentum or a muscular free flap is used. The majority of large defects do not result in impairment of respiratory mechanics when properly reconstructed. Large anterior defects are most likely to create any risk of respiratory
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A
B Figure 68–5 A young male with a recurrent desmoid tumor of the right lateral chest wall. A, The resulting chest wall defect after resection. B, Patch reconstruction of the bony chest wall with dermal matrix.
compromise, secondary to the resulting weak cough and retention of secretions. Aggressive postoperative pulmonary toilet and bronchoscopy may be necessary in these patients. There is no advantage to empirically prolonged postoperative intubation; it provides no increase in stability of the reconstruction. Every effort should be made to extubate these patients in the operating room.
Chest Wall Resections for Lung Cancer Lung cancer is the leading cause of cancer death worldwide, with greater than 1 million new cases each year. Five percent to 8% of patients with non–small cell lung cancer (NSCLC) have contiguous chest wall involvement.18 Historically, these tumors were considered unresectable until Coleman’s series in 1947.19 Five patients survived, and two had long-term cure after resection of a lung with
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en-bloc removal of the chest wall for lung cancer. These are currently recognized as T3 tumors. In the absence of lymph node metastasis, survival rates after complete resection are 45%.20 The most common presenting symptom is pain, which occurs in 37% to 75% of patients.19,21,22 Preoperative evaluation includes the standard evaluation for patients undergoing NSCLC operations. This includes staging and metastatic work-up with CT and positron-emission tomography (PET), cardiopulmonary evaluation, and determination of pulmonary reserve with pulmonary function tests. In general, mediastinoscopy is performed at the discretion of the surgeon; however, if there is any suspicion of mediastinal lymph node involvement on CT or PET scan at station 2R, 4R, 2L, 4L, or 7, mediastinoscopy is a necessity prior to resection. Patients who are found to have N2 disease should consider chemoradiotherapy as either induction or definitive therapy. Appropriate anticipation and preparation for chest wall resection is one of the keys to a successful operation. Signs of chest wall invasion on CT include evidence of rib destruction, obliteration of the extrapleural fat pad, an obtuse angle of interface between the tumor and the chest wall, extended length of the tumor-pleural interface, and the relation between the length of that interface and the size of the tumor.23,24 MRI can be useful, as in primary chest wall tumors; it is superior to CT at delineating soft tissue invasion (Fig. 68–6).
OPERATIVE PROCEDURE Once the preoperative staging work-up is complete, the patient can move to thoracotomy. Some surgeons advocate thoracoscopy to evaluate for chest wall invasion.25 This step is largely unnecessary unless the tumor is so large that there is concern about where to safely enter the chest cavity. Thoracoscopy is an inadequate tool to assess chest wall invasion or to resect these aggressive tumors. Standard thoracotomy can be performed with care taken to enter the chest away from the area of chest wall involvement. Once inside the pleural space, evaluation for chest wall invasion is the first step and vital to good outcome. If only flimsy, inflammatory-type adhesions are present, they can be gently taken down or removed by extrapleural dissection. If there is any concern of invasion into the chest wall, an en-bloc resection should be performed. Numerous studies have demonstrated that an extrapleural dissection in this situation is inadequate.26–28 Inappropriate evaluation at this point can be costly, because frozen section evaluation of the chest wall margin is not very useful. There is typically a large tissue plane, and significant sampling error can occur. Complete resection is one of the main determinants of long-term survival29; therefore, this initial assessment is extremely important and should be performed with great care.
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A
C
B
Figure 68–6 The computed tomography (CT) scan (A), positron-emission tomography (PET) scan (B), and magnetic resonance imaging (MRI) (C) from a 65-year-old man with a T3N0M0 bronchogenic carcinoma of the right upper lobe involving the posterior aspects of ribs 3, 4, and 5. The patient presented with right-sided back pain.
Determine Necessary Resection Margin Inaccurate Evaluation and Incomplete Resection ● Consequence Inaccurate evaluation of chest wall invasion can lead to an incomplete resection that is typically not detected until the final pathologic evaluation. Incomplete resection is one of the main determinants of poor survival. Grade 4 complication ● Repair If, while taking down filmy adhesions or performing extrapleural dissection, there is any significant resistance from the tissues, the dissection should be aborted and en-bloc chest wall and lung resection performed, including wide resection of the chest wall around the area of dissection. ● Prevention The surgeon should have a low threshold for removal of the chest wall en bloc with a closely adherent lung cancer because of the overwhelming importance of negative surgical margins for long-term survival.
Dissection to the Chest Wall Once the determination for the need of a chest wall resection is made, the procedure starts; this includes formal lobectomy with complete hilar and mediastinal dissection and chest wall resection. The extent and location of chest wall involvement dictate the order of the procedure. Often, the chest wall resection is done first and dropped into the chest to provide hilar exposure. If the tumor is very large and its bulk hinders exposure to the hilum, a stapler can be fired through the normal lung to wedge the mass out and provide exposure for the lobectomy. Most of these operations are best approached through a standard posterolateral thoracotomy to allow maximal exposure to the hilum of the lung for the lobectomy and mediastinal lymph node dissection. Exposure for the chest wall resection may require extension of that incision and division of both the latissimus and the serratus muscles. The rib spreader can provide exposure to the chest wall by placing one blade in the rib space and the other under the chest wall musculature. For upper lobe tumors, the inferior blade is placed in the rib space and the cephalad blade is placed under the tip of the scapula (Fig. 68–7).
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anterior Pancoast’s tumors, which often require two incisions.
Enter the Pleural Space
Figure 68–7 Rib spreader placed with the inferior blade in the rib space and the cephalad blade retracting the scapula upward to expose the chest wall for resection of an upper lobe tumor invading the chest wall.
As the retractor is opened, it lifts the scapula and chest wall musculature off the chest wall, similar to opening the hood of a car. For lower lobe tumors that involve the chest wall below the thoracotomy, the upper blade of the rib spreader is placed in the rib space and the more caudal blade is used to retract back the skin and the overlying chest wall muscles. Without the scapula there, perforating towel clips can be used to keep the rib spreader from slipping.
Inappropriate Placement of the Skin Incision and Thoracotomy ● Consequence Placing the skin incision and thoracotomy over the area of chest wall involvement may facilitate the rib resection, but it will make the lobectomy and mediastinal lymphadenectomy technically challenging. Grade 1/2 complication ● Repair If the entrance into the pleural space is too high or too low to allow for safe and complete hilar dissection for the lobectomy, a second thoracotomy can be made through the same skin incision at the fifth intercostal space to facilitate the lobectomy and mediastinal lymph node dissection. ● Prevention A better approach is to perform a generous, standard posterolateral thoracotomy, which provides the best exposure to the hilum for the lobectomy, and use the rib spreader with one blade in the rib space and the other under the chest wall musculature to provide exposure for the chest wall resection. The exception is
The chest wall is removed with at least a 2-cm margin. Margins do not need to be as wide as those for primary chest wall tumors. The resection of the bony chest wall proceeds as described in the previous section. The overlying chest wall musculature does not need to be resected unless it is directly involved with the tumor. The principles of reconstruction are also similar to those described in the previous section. Small bony defects and those under the protection of the scapula do not require reconstruction; others are reconstructed with a mesh or dermal matrix patch. Tumors near the spine require special attention. Tumors that invade the spine are T4 and require consultation with a spinal surgeon. For tumors that approach the spine but do not invade it, the rib can be disarticulated from its transverse process or the head of the rib can be resected en bloc with the transverse process using an osteotome. To perform either maneuver, the paraspinous muscles, costotransverse ligaments, and costovertebral ligaments are lifted off the exterior of the chest wall with cautery past the midline to expose the joints. Inside the chest, the parietal pleura is elevated off of the anterior spinal column and resected with the tumor. The joint is disarticulated or resected flush against the vertebral body, and the rib is pushed anterior into the chest. This will expose the nerve root, which is clipped and divided close to where it exits the canal. Inappropriate traction at this location or mismanagement of the nerve root can result in an iatrogenic subarachnoid pleural fistula. This can result in a large pleural effusion as a result of cerebrospinal fluid (CSF) leak, tension pneumocephalus, or meningitis.
Excessive Traction and Avulsion of the Dorsal Nerve Roots ● Consequence Excessive traction and avulsion of the dorsal nerve roots as they exit the spinal canal can result in a dural tear and a communication between the intracranial vault and the pleural space. This can result in a postoperative CSF leak, tension pneumocephalus, or meningitis. Grade 2/3 complication ● Repair Subarachnoid pleural fistulas that are not recognized in the operating room are usually discovered in the first postoperative week,30 when patients present with excessive chest tube output or neurologic symptoms. Conservative management involves antibiotics, bedrest with a flat head position, and placement of a chest tube to water seal.31 Suction on the chest tube should be avoided when possible to prevent CSF extravasation,
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but resolution of pneumothorax is an important part of treatment. Therefore, low suction may be necessary if the air leak is significant.30 These maneuvers usually result in an improvement in symptoms within 48 hours. Fistulas that persist for longer than 2 weeks require surgical intervention.31 Surgical strategies for repair include laminectomy with placement of an intradural or extradural patch32 or thoracoplasty with proximal nerve ligation.33 Others advocate the use of fibrin sealant.34 ● Prevention Care should be taken to avoid undo traction on the dorsal nerve roots. They should be carefully identified as the rib is separated from the spine and ligated between vascular clips. If a fistula is recognized in the operating room, the neural foramen can be packed with muscle and conservative management initiated postoperatively.
Bleeding from the Intercostal Artery Bleeding from the intercostal artery can be bothersome at this location, and care needs to be taken to properly identify and ligate or clip these vessels prior to transecting. Again, undo traction on the ribs can result in avulsion. Cautery in this area should be performed with bipolar or between pickups to avoid thermal injury. The routine use of radiation therapy either preoperatively or postoperatively in patients with chest wall involvement but without N2 disease remains controversial. Preoperative therapy has the potential benefit of downstaging tumors and making an unresectable tumor resectable, but the majority of tumors invading the chest wall are resectable at presentation. Preoperative chemoradiotherapy has been shown to be very useful in the management of Pancoast’s tumors,35 but this approach has not been investigated for other patients with chest wall involvement. To date, preoperative therapy in patients who have resectable tumors that invade the chest wall has no proven benefit. In the face of negative surgical margins, postoperative radiation therapy to the area of chest wall resection is not recommended.
Pancoast’s Tumors The classic definition of a Pancoast tumor is that of a carcinoma involving the apex of the chest that causes pain down the medial aspect of the arm and Horner’s syndrome owing to involvement of the nerve roots in the lower part of the brachial plexus and the stellate ganglion.36 Biologically, Pancoast’s tumors are not different from other NSCLCs; they are unique owing to their location. They involve structures that are technically difficult to approach with surgery, and the extent of resection is limited by the risk for long-term disability. Therefore, wide local excision with negative margins can be challeng-
ing. Resection of a Pancoast tumor should include a lobectomy and removal of the affected chest wall. The importance of a complete resection with negative margins cannot be overemphasized. In up to one third of resections for Pancoast’s tumors, a complete resection is not achieved,37 and survival is no better than if surgery had not been performed.37–39 The use of neoadjuvant chemoradiation has significantly improved the rate of R0 resection for Pancoast’s tumors, as demonstrated in the North American Intergroup Trial 0160.35 In that trial, complete resection resulted in a 5-year survival rate of 53% and a local recurrence rate of only 12%.40 Induction chemoradiotherapy resulted in a pathologic complete response rate of 66%, a significant improvement over historic controls. No randomized, controlled trial has been done on tumors of the superior sulcus, and because of their rarity (110 mg/dl
● Consequence Chyle is rich in protein, fat, and white blood cells. Prolonged high-volume loss of chyle leads to nutritional failure and immunosuppression. Wound healing problems, anastomotic leakage, and infectious complications are all possible. Hospital stays are extended, pending resolution of this problem. Grade 2/3 complication ● Repair After diagnosis, enteral feedings are held to put the gastrointestinal tract at rest and reduce chyle flow through the thoracic duct. Intravenous feedings are initiated. Treatment plans are largely based on chyle drainage volume. Leaks less than 500 ml/day generally resolve with drainage. Leaks with greater than 1000 ml/ day invariably need operative intervention for resolution. If drainage is high, a time period should be set during which the leak should lessen quickly or operative intervention will proceed. Generally, this time period is 5 to 7 days. If daily drainage is 500 to 1000 ml/day, it is hard to predict the clinical course. Start with drainage and intravenous feedings, follow output, and wait for 5 to 7 days to see the trend. Operative repair involves low right thoracotomy or thoracoscopy with thoracic duct ligation just above the right hemidiaphragm (Fig. 70–8).10 Chylous leaks should promptly resolve with surgery. ● Prevention Understanding thoracic duct anatomy during surgery and prophylactically ligating the duct at surgery are the best and only methods of prevention.
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Lung (retracted)
Injured thoracic duct IVC
Aorta Esophagus (retracted) Diaphragm
Figure 70–8 Operative ligation of the thoracic duct is performed through the right chest. The thoracic duct is identified and ligated low in the chest, close to the diaphragm. A right thoracotomy is shown; however, the procedure could also be performed by thoracoscopy. (Adapted from Rodgers BM. The thoracic duct and the management of chylothorax. In Kaiser LR, Kron IL, Spray TL [eds]: Mastery of Cardiothoracic Surgery. Philadelphia, New York: Lippincott-Raven, 1998; pp 212–220.)
● Repair Progressive solid food dysphagia within 2 to 6 months of esophagectomy, especially when a patient’s swallowing was initially not restricted, is a sure sign of anastomotic narrowing. The diagnosis can be confirmed by contrast esophagogram, but this is not always needed. Flexible esophagoscopy will also make the diagnosis of anastomotic stricture. It is essential that early endoscopy be performed for later strictures to rule out recurrent tumor. Treatment is dilation. Our experience has been that these are “soft” strictures that dilate easily but have a tendency to recur unless they are dilated slowly, in stages.26 Generally, two to three dilations are needed to open the stricture in steps so that, once open, it will stay open. Recurrence is then uncommon. ● Prevention It may not be possible to prevent strictures. Careful preoperative patient selection and preparation, mobilization of the esophageal conduit without ischemia, and creation of a tension-free anastomosis will help to reduce the chance of stricture. Some data suggest that avoiding neck anastomosis will reduce the incidence of strictures. However, a cervical anastomosis prevents the risk associated with leakage—a much more serious problem. Some believe that a stapled anastomosis reduces stricture formation, whereas others have demonstrated good results with hand-sewn methods.
OTHER COMPLICATIONS Additional specific complications associated with a thoracoabdominal approach or Ivor Lewis approach to esophagectomy are predominantly associated with the thoracotomy incision.
Postdischarge Complications Anastomotic Stricture Anastomotic narrowing with healing may occur after surgery. Most anastomotic strictures occur between 2 and 6 months after surgery. Risk factors for stricture include location of anastomosis, conduit ischemia, early postoperative anastomotic leakage, preexisting low cardiac output, and anastomotic technique. Factors believed to be associated with a high risk of stricture include cervical anastomosis, leakage, low preoperative cardiac output, and hand-sewn anastomosis.30 Strictures may occur even without these risk factors. Late anastomotic strictures (>1 yr postoperative) must raise the suspicion of recurrent cancer. ● Consequence Significant anastomotic narrowing results in poor swallowing, reduced quality of life, reduced oral intake with potential for weight loss, and increased risk of “overflow” aspiration. Grade 1/2 complication
Diaphragmatic Hernia/Paraesophageal Hernia The esophageal hiatus is widened during esophagectomy to permit passage of the replacement esophageal conduit up into the chest. Postoperative herniation of abdominal structures through the hiatus, alongside the conduit, has been reported. This complication presents in two ways. The first is an acute presentation early in the postoperative course. The second is as a late finding on surveillance films.33 ● Consequence Early herniation is generally an acute event, with significant herniation of transverse colon and omentum into the right chest. It is associated with acute respiratory symptoms and requires operative repair. Late herniation usually involves a section of the transverse colon, is a radiographic finding, is asymptomatic, and does not require intervention. Grade 3 complication ● Repair Early herniation presents as an acute event with prominent respiratory symptoms. Early transabdominal exploration is indicated. The herniated contents are reduced and the hiatus narrowed. Abdominopexy of abdominal contents may sometimes be needed. Late herniation is invariably an asymptomatic radiographic finding and does not require intervention.
70 ESOPHAGEAL SURGERY ● Prevention At the initial surgery, open the hiatus only as much as needed for intrathoracic dissection and passage of the stomach conduit. If needed, narrow the hiatus anteriorly before closing the abdomen.
REFERENCES 1. Brock MV, Venbrux AC, Heitmiller RF. Percutaneous replacement jejunostomy after esophagectomy. J Gastrointest Surg 2004;4:407–411. 2. Matory YL, Burt M. Esophagogastrectomy: reoperation for complications. J Surg Oncol 1993;54:29–33. 3. Postlethwaite RW (ed). Surgery of the Esophagus, 2nd ed. Norwalk, CT: Appleton-Century-Crofts, 1986; p 410. 4. Baue AE, Geha AS, Hammond GL, et al. Surgical options for esophageal resection and reconstruction with stomach. In Orringer MB (ed): Glenn’s Thoracic and Cardiovascular Surgery, 6th ed. Stamford, CT: Appleton & Lange, 1996; pp 899–922. 5. Black E, Niamat J, et al. Unplanned splenectomy during oesophagectomy does not affect survival. Eur J Cardiothoracic Surg 2006;29:244–247. 6. Gockel I, Kneist W, Junginer T. Influence of splenectomy on perioperative morbidity and long-term survival after esophagectomy in patients with esophageal carcinoma. Dis Esophagus 2005;18:311–315. 7. Wormuth J, Heitmiller RF. Esophageal conduit necrosis. Thorac Surg Clin 2006;16:11–22. 8. Heitmiller RF, Heitmiller ES. Surgery for myasthenia gravis. In Franco KL, Putnam JB Jr (eds): Advanced Therapy in Thoracic Surgery, 2nd ed. Hamilton, London, Ontario: BC Decker, 2005; p 413. 9. Heitmiller RF. Impact of gastric tube diameter on upper mediastinal anatomy. Dis Esophagus 2000;13:288–292. 10. Rodgers BM. The thoracic duct and the management of chylothorax. In Kaiser LR, Kron IL, Spray TL (eds): Mastery of Cardiothoracic Surgery. Philadelphia, New York: Lippincott-Raven, 1998, pp 212–220. 11. Gillinov AM, Heitmiller RF. Strategies to reduce pulmonary complications after transhiatal esophagectomy. Dis Esophagus 1998;11:43–47. 12. Law S, Wong KH, Kwok KF, et al. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg 2004;240:791–800. 13. Arozullah AM, Conde MV, Lawrence VA. Preoperative evaluation for postoperative pulmonary complications. Med Clin North Am 2003;87:153–173. 14. Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology 2005;102: 838–854. 15. Kita T, Mammoto T, Kishi Y. Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma. J Clin Anesth 2002;14:252–256.
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16. Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagestomy: clinical experience and refinements. Ann Surg 1999;230:392–400. 17. Avendano CE, Flume PA, et al. Pulmonary complications after esophagectomy. Ann Thorac Surg 2002;73:922– 926. 18. Lin J, Iannettoni MD. Transhiatal esophagectomy. Surg Clin North Am 2005;85:593–610. 19. Gockel I, Kneist W, Keilmann A, Junginger T. Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma. Eur J Surg Oncol 2005;31:277–281. 20. Katariya K, Harvey JC, Pina E, et al. Complications of transhiatal esophagectomy. J Surg Oncol 1994;57:157– 163. 21. Gandhi SK, Naunheim KS. Complications of transhiatal esophagectomy. Chest Surg Clin North Am 1997;7:601– 610. 22. Heitmiller RF, Tseng E, Jones B. Prevalence of aspiration and laryngeal penetration in patients with unilateral vocal fold motion impairment. Dysphagia 2000;15:184–187. 23. Heitmiller RF, Jones B. Transient diminished airway protection after transhiatal esophagectomy. Am J Surg 1991;162:442–446. 24. Loran DB. Thoracic surgery in the elderly. J Am Coll Surg 2004;199:773–784. 25. Murthy SC. Atrial fibrillation after esophagectomy is a marker for postoperative morbidity and mortality. J Thorac Cardiovasc Surg 2003;126:1162–1167. 26. Heitmiller RF, Fischer A, Liddicoat JR. Cervical esophagogastric anastomosis: results following esophagectomy for carcinoma. Dis Esophagus 2000;12:264–270. 27. Atkins BZ, Shah AS, et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004;78:1170–1176. 28. Crestallano JA, Deschamps C, Cassivi SD, et al. Selective management of intrathoracic anastomotic leak after esophagectomy. J Thorac Cardiovasc Surg 2005;129:254– 260. 29. Michlet P, D’Journo XB, Roch A, et al. Perioperative risk factors for anastomotic leakage after esophagectomy: influence of thoracic epidural anesthesia. Chest 2005;128: 3461–3466. 30. Briel JW. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg 2004;198:536– 541. 31. Ercan S, Rice TW, Murthy SC, et al. Does esophagogastric anastomotic technique influence the outcome of patients with esophageal cancer? J Thorac Cardiovasc Surg 2005;129:623–631. 32. Rao DV, Chava SP, Sahni P, Chattopadhyay TK. Thoracic duct injury during esophagectomy: 20 years experience at a tertiary care center in a developing country. Dis Esophagus 2004;17:141–145. 33. Heitmiller RF, Gillinov AM, Jones B. Transhiatal herniation of colon after esophagectomy and gastric pull-up. Ann Thorac Surg 1997;63:554–556.
71
Cervical Tracheal Resection and Reconstruction Joseph B. Shrager, MD INTRODUCTION
INDICATION
A wide variety of conditions cause anatomic or functional narrowing of the trachea. The most efficient and effective treatment for most of these conditions is tracheal resection with subsequent end-to-end anastomosis (TR). Techniques have been standardized since the 1960s to allow these procedures to be performed with excellent results and low morbidity and mortality. Release techniques have been developed that frequently allow even long segments to be resected with the creation of a tension-free anastomosis that will usually heal without incident. However, even in the most experienced hands, TR can engender a variety of complications—some of which are emergent and life threatening. This chapter reviews the basic operative steps of TR and the complications that can be encountered as they relate to each step. The management of each complication is presented as well as technical details that can be followed in order to try to prevent the complication from occurring. I focus upon “simple cervical tracheal resection”—the excision of a segment of the upper trachea, not including the cricoid cartilage or higher, carried out through a curvilinear neck incision just above the jugular notch. More complex resections including the larynx or the distal trachea approaching the carina, though utilizing many of the same basic principles, require somewhat different and more advanced techniques that are beyond the scope of this chapter. Further, it has been established that as the anastomotic level ascends, a progressive increase in complication rate occurs: failure rates rise from 2.2% for trachea-trachea anastomosis to 6.0% for trachea-cricoid anastomosis to 8.1% for trachea–thyroid cartilage anatomosis.1 Two centers pioneered the techniques of TR that are now in standard use around the world: these are the groups formerly headed by Hermes Grillo at the Massachusetts General Hospital (MGH) and by Griffith Pearson at the Toronto General Hospital. Because I am more familiar with the methods and results of the MGH group, having trained with Grillo, I focus upon their techniques and their published results in reporting the incidences of the various complications.
● Tracheal stenosis in upper third of trachea caused by
prior tracheostomy or endotracheal intubation, inflammatory disorders, or tumors
OPERATIVE STEPS Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8
Rigid bronchoscopy with or without dilation Circumferential dissection of involved portion of trachea Tension-releasing maneuvers Airway division Cross-table or high-frequency jet ventilation (HFJV) Anastomosis “Chin stitch” Extubation
OPERATIVE PROCEDURE AND COMPLICATIONS Rigid Bronchoscopy with or without Dilation Rigid bronchoscopy is nearly always performed immediately prior to TR for a variety of reasons. First, the view of the mucosa with a Hopkins lens system passed via a rigid bronchoscope is superior to that obtained through a flexible bronchoscope, therefore, decisions regarding whether acute inflammation has resolved and whether or not there is any need to delay the procedure can be made most accurately. Second, measurements of the length of the stenosis, the distance from the distal end of the stenosis to the carina, and the distance from the proximal edge of the stenosis to the vocal cords can be made most accurately with a rigid scope. The most important reason for carrying out rigid bronchoscopy immediately preoperatively, however, is the frequent need for tracheal dilation immediately prior to the procedure. One would like to pass at least a size-5 and preferably a size-6 endotracheal tube (ETT) beyond the
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Figure 71–1 Bronchoscopic view of a postintubation tracheal stenosis just prior to dilation with the rigid bronchoscope through which the stenosis is seen. Dilation is performed to allow placement of an endotracheal tube (ETT) prior to resection. It is done by stretching the stenosis with serially larger rigid bronchoscopes.
stenosis prior to positioning and operation so that the airway is secure and the dissection can proceed without undue haste up to the point of initial airway division. In situations in which a size-6 tube cannot be passed because of the tight nature of the stenosis, progressive dilation with rigid scopes will generally allow passage of such a tube. The technique of dilation involves beginning with a scope with a diameter only slightly larger than the visible tracheal lumen (Fig. 71–1). This bronchoscope is passed through the stenosis and deeply into the airway, and it is held there for at least 1 minute as the stenosis is stretched, maintaining ventilation through the bronchoscope. A scope that is 0.5 to 1 mm larger is passed next, and the procedure is repeated until the lumen is sufficiently large to pass the ETT. For a critically tight stenosis, one can use Jackson dilators passed through the bronchoscope initially until the lumen is large enough to pass the tip of the scope itself.
Preoperative Loss of Airway ● Consequence If not rapidly salvaged, this complication can lead to death. Its occurrence requires the rapid and focused application of all of the knowledge and abilities of a team consisting of surgeon, anesthesiologist, and nurses. Often, tracheostomy is necessary, complicating
● Repair The onus is clearly upon the surgeon to reestablish an airway. If edema at the site of stenosis and prior dilation is the cause of the loss of airway, a single attempt to reintroduce a smaller rigid bronchoscope is the initial maneuver. One can then ventilate via this scope as a more detailed plan is formulated. If one is unable to pass the scope into the trachea because of an unusually large epiglottis or other supraglottic abnormalities, visualization of the cords with use of a Miller blade on the laryngoscope may be useful, followed by passage of the rigid bronchoscope through cords that have been directly visualized in this manner. If the patient is persistently desaturated to less than 75% and an airway cannot be reestablished from above, emergent tracheostomy is necessary. Typically a size-6 tracheostomy is selected. The opening in the trachea is made directly through the area of stenosis, if at all possible. This will preserve the length of remaining healthy trachea and will not increase the length of the ultimate tracheal resection that will be required. If, for some reason, an actual tracheostomy cannot be performed or if it cannot be performed expeditiously, and if HFJV is available, a needle may be passed into the airway through or below the stenosis and HFJV instituted. ● Prevention A surgical set sufficient to perform tracheostomy must always be fully opened before the performance of rigid bronchoscopy with dilation, and a variety of endotracheal and tracheostomy tubes must be immediately available should they be needed. Ideally, HFJV will also be available. The surgeon and anesthesiologist need to discuss in detail before the induction of anesthesia the anesthetic and bronchoscopy plan, the likelihood of an untoward event, and the plan in case of an untoward event. During dilation, one should hyperventilate and superoxygenate the patient through the scope each time a scope is passed beyond the stenosis. This will allow a greater period of time to pass the next larger scope before desaturation or hypercarbia ensues. One should never attempt to pass a flexible bronchoscope, which does not allow ventilation through a tight stenosis—particularly not outside of an operating room where rigid scopes, ETTs, and tracheostomies are available. This may precipitate airway occlusion without the ability to salvage the situation.
Circumferential Dissection of the Involved Portion of the Trachea After the curvilinear cervical skin incision has been made, subplatysmal flaps are mobilized down to the jugular
71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION
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Figure 71–2 Typically, one first dissects the trachea circumferentially only at the distal end of the diseased area. A Penrose or red rubber drain is then passed around the trachea in this location.
notch and up to the thyroid cartilage, and the anterior wall of the trachea is exposed by division of the thyroid isthmus. The critical portions of the operation are then begun. In many cases, the distal extent of the internal stenosis can be seen by thickening and scar tissue visible on the external surface noted during mobilization. When this line is unclear, a flexible bronchoscope can be introduced from above, and its light or visualization of a needle passed into the lumen from without can be used to demonstrate the distal extent to the operating surgeon. A fine suture is placed on the external tracheal surface at this level to indicate the extent of mobilization required and the ultimate point of distal division. The involved region of trachea is then mobilized first from its lateral, vascular attachments, then from the posterolaterally placed recurrent laryngeal nerves, and finally from the esophagus, which is closely apposed to the posterior, membranous tracheal wall. A Penrose or red rubber drain can then be placed around the trachea (Fig. 71–2). Almost all of the circumferential dissection is carried out sharply. In some cases, when there is little scarring or inflammation, circumferential dissection of virtually the entire involved segment can be done prior to airway division. In most situations, however, I mobilize only the most distal portion of the involved airway circumferentially, leaving the posterior dissection of the more proximal portion from the underlying esophagus for after the division of the airway distally. After this distal division has been carried out, the proximal segment to be resected can be progressively lifted up, facilitating its dissection away from the nerves and esophagus (Fig. 71–3). It is critical that circumferential dissection be taken only about 5 mm beyond what will become the margins of resection in order to maximally preserve blood supply to the anastomosis (see the section on “Anastomosis,” later).
Figure 71–3 After placing distal, midlateral stay sutures of 0-0 Vicryl and withdrawing the ETT, sharp division is carried out with a scalpel. From this point on, cross-table ventilation is carried out. Next, the proximal involved segment of trachea is dissected more proximally away from the esophagus and recurrent nerves until the proximal point of division is reached. (From Grillo HC. Surgery of the Trachea and Bronchi. United States, BC Decker, Inc; 2004.)
Recurrent Nerve Injury ● Consequence Injury to one recurrent laryngeal nerve will cause hoarseness, but it may also cause incomplete airway compromise and swallowing dysfunction that can lead to aspiration. A nerve is sometimes injured or stretched but not actually divided; in this case, its function may return over several weeks. In addition, the opposite vocal cord may adapt over time, coming across the midline to improve voice and prevent aspiration. However, function will not be restored in the case of complete division. If a nerve becomes paralyzed in a medial position, it may serve as an obstruction to airflow but aspiration is less likely. If it becomes paralyzed in a lateral position, it will not obstruct airflow, but voice will be weak and coughing difficult. Further, with a cord in the lateral position, aspiration is more likely. Injury to both recurrent laryngeal nerves usually creates an airway emergency, with the patient being unable to spontaneously ventilate adequately after extubation. This will require urgent placement of a tracheostomy if one has not been placed prophylactically after TR. It will also typically cause severe aspiration difficulties requiring the establishment of long-term enteral feeding. Out of a total of 521 TRs for postintubation stenosis reported by the MGH group since 1986, 25 patients (5%) had varying degrees of postoperative laryngeal dysfunc-
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tion.1–3 This included 62 patients who required complete resection of the anterior cricoid (higher than a “simple” TR). The laryngeal dysfunction was considered minor or temporary in 14, but 11 patients had more severe dysfunction. Of these, 7 required tracheostomy (3 permanent), 1 required a permanent T-tube, and 1 required a subglottic stent. Two patients required tube feedings for persistent aspiration. TRs for tumors of the upper trachea, as one might expect given the greater extent of lateral dissection often required to allow complete tumor excision, likely lead to a greater incidence of recurrent nerve injury and laryngeal dysfunction. The MGH group reported 26 cervical TRs for tumor in a series of 126 primary tracheal tumors reported in 1990.4 Among the 126, 11 (8.7%) suffered vocal cord paralysis. Six (4.7%) suffered aspiration. Because this number includes patients who underwent more extensive resections and even carinal resections, the incidences of these complications after simple cervical TR for tumor are difficult to glean, but I believe it is fair to say that resections for tumor have a higher rate of nerve injury than those for postintubation lesions. Grade 2–4 complication ● Repair Bilateral recurrent nerve injury requires emergent tracheostomy and will almost certainly require prolonged enteral feeding owing to chronic aspiration. Unilateral recurrent nerve injury, if it is not associated with significant aspiration and if the patient has an adequate airway, can generally be monitored for improvement over approximately 6 months. If, after that period of time, an acceptable voice has not returned owing to a persistently lateralized cord, that cord can be medial-
ized by a minor procedure performed by an experienced otorhinolaryngologist. If a unilateral recurrent nerve injury is associated in the early postoperative period with aspiration and/or difficulty generating a sufficiently strong cough owing to lack of cord apposition, medialization can be performed early. If aspiration persists, enteral feeds must be begun, but this is almost always a temporary necessity in unilateral nerve injury. ● Prevention Careful operative technique minimizes the risks of recurrent nerve injury. When circumferentially dissecting the trachea, one should not try to identify the recurrent nerves. Rather, one hopes not to see them whatsoever. The dissection is maintained directly on the wall of the tracheal cartilage at all times. If this rule is adhered to, only very rarely (e.g., in cases which a vigorous inflammatory process has destroyed that cartilage and/or drawn the nerve into a matted mass of inflammatory tissue) that a nerve will be injured. If the wall of the trachea is not clearly visualized, it is far better to cut into what will ultimately be the resected specimen while dissecting the trachea out than to try to stay outside of it and risk injuring the nerve(s). It must be understood by the tracheal surgeon that as one more closely approaches the larynx, the recurrent nerves (particularly on the right) are increasingly at risk because their position becomes progressively more medial and closer to the trachea until they finally disappear behind the posterior cricoid plate (Fig. 71–4). It is, therefore, at the upper end of the dissection and during true subglottic resections that one must be most careful to stay directly on the trachea.
Right vagus nerve Right subclavian artery
Left common carotid artery Left subclavian artery
Right recurrent laryngeal nerve Right and left brachiocephalic veins Brachiocephalic artery Superior vena cava
Right common carotid artery Left vagus nerve Aorta
Left recurrent laryngeal nerve Pulmonary trunk
Figure 71–4 Demonstration of how the recurrent nerves become closer to the trachea and, thus, are at greater risk of injury, as the dissection ascends cephalad toward the larynx. (From Grillo HC. Surgery of the Trachea and Bronchi. United States, BC Decker, Inc; 2004.)
71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION In addition, cautery should be used extremely judiciously as one approaches the posterior one half of the trachea. The best technique is simply not to use cautery whatsoever in this region because the punctuate bleeders that develop here almost always seal spontaneously. However, if cautery is necessary, only the exact point of bleeding should be cauterized, and the device should be set on an extremely low setting, preferably using the bipolar cautery. Because nerve injury does occasionally occur, these patients should always be begun initially on thickened liquids rather than clear liquids by mouth because thickened liquids are less easily aspirated. The initial feeding should be carefully monitored for signs of aspiration. Only after thickened liquids have been tolerated for about 2 days should clear liquids be attempted.
Esophageal Injury Esophageal injury is very rare and often recognized intraoperatively. It is most likely to occur either as one encircles the trachea prior to distal tracheal division or as one proceeds with cephalad dissection of the membranous wall of the trachea off of the underlying esophagus. ● Consequence If discovered and repaired immediately, as is usually the case, a small injury to the esophagus rarely leads to any postoperative problems. An undiscovered esophageal injury, or a repair that breaks down, may lead to wound infection and neck cellulitis or tracheoesophageal fistula. The latter results from development of a communication between the area of esophageal injury and the membranous wall portion of the tracheal anastomosis. Grade 1–4 complication ● Repair If discovered intraoperatively, the esophagus should be closed in two layers, and a strap muscle should be mobilized based upon its inferior vascular pedicle and interposed between the esophagus and the posterior portion of the tracheal anastomosis (Fig. 71–5). I prefer to tack the muscle circumferentially onto the area of injury prior to creating the tracheal anastomosis. An esophageal injury that is discovered late postoperatively is more problematic and involves complex management options beyond the constraints of this chapter. ● Prevention Esophageal injury, like recurrent nerve injury, can generally be prevented by staying directly on the wall of the trachea. This is somewhat more difficult on the membranous than the cartilaginous wall because the former is often less well defined. There have been cases of resection of benign tracheal stenoses during which I have left some of the posterior tracheal scar (remnant of the membranous wall) in place on the esophagus in order to avoid any possibility of creating an esophageal
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Esophagus
Figure 71–5 Technique of mobilizing strap muscle for placement between the esophagus and the trachea in the event of an esophageal injury. The larger and more superficial of the strap muscles, the sternohyoid, is divided at the upper end of the operative field and rotated into the space between the trachea and the esophagus. It is tacked circumferentially around the injury with interrupted horizontal mattress 00-00 Vicryl sutures taken into the esophageal muscularis only. This type of muscle flap can also be used to isolate the anastomosis from a tracheostomy tube on the rare occasion in which a small tracheostomy is left in place at the completion of the procedure. (From Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin North Am 2003;13:271–290.)
injury. The technique mentioned previously of initially mobilizing only the most distal portion of the involved trachea circumferentially, then dividing at this level before trying to dissect the trachea off of the esophagus more proximally (see Fig. 71–3), is generally successful at allowing safe dissection in this plane.
Tension-Releasing Maneuvers Maximal reduction of tension on the tracheal anastomosis is probably the most important single technical aspect of these operations. The basic tension-releasing maneuvers are preferably performed prior to airway division. In every patient, the avascular, pretracheal plane is dissected all the way down to the level of the carina to allow the distal trachea to slide easily upward into the neck. In resections of 4 cm or greater in length, a suprahyoid laryngeal release (SLR) will often be required to create a tension-free anastomosis; this can be performed at this point as well. Alternatively, one can save this last maneuver to be carried out after one has carried out the resection. At that point, one can test the anticipated tension on the anastomosis by bringing the cut edges together as the neck is flexed by the anesthesiologists. If this demonstrates that tension will
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Figure 71–7 With the traditional technique of distal intubation with an ETT, seen here, intermittent removal of the ETT from the distal airway is required to allow placement of the anastomotic sutures. Note the silk suture that emerges from the proximal segment. This has been sutured to the end of the withdrawn ETT to ensure that it can be relocated distally just prior to completing the anastomosis.
Figure 71–6 The longer, more caudal incision pictured here is the primary incision through which the tracheal resection with subsequent end-to-end anastomosis (TR) is carried out.The smaller, more cephalad incision is at the level of the hyoid bone for performance of suprahyoid laryngeal release. Through this incision, the muscles attached to superior margin of the middle two thirds of the hyoid are divided, and the bone itself is divided at either end of this mobilized portion. This allows the larynx to descend toward the trachea, providing significant tension relief for more extensive TRs. The image here is taken after the release has been performed. The forceps are spread to denote the distance that the hyoid has descended after the release.
be present, the SLR can be performed at that time (Fig. 71–6). It is highly unusual for release maneuvers other than dissection in the pretracheal plane or SLR to be required for a standard cervical tracheal resection. When a more extensive tracheal resection that requires median sternotomy is being performed, infrahilar pericardial releases are often added. In what also might be considered a tension-releasing maneuver, a 0-0 polyglactin suture is placed in most cases in a midlateral location on each side of the proximal and distal tracheal segments. These sutures ultimately take tension off of the anastomosis when they are tied to one another prior to tying the actual anastomotic sutures, which have a less deep and thus less strong bite of tissue (see the section on “Anastomosis,” later).
Anastomotic Dehiscence or Restenosis See discussion under “Anastomosis,” later. The two most important technical features in avoiding anastomotic complications are creation of a tension-free anastomosis with the release procedures described here and maintenance of the blood supply to the anastomosis by limiting circumferential dissection of the trachea to no more than 5 mm beyond the limits of resection. Grade 3–5 complication
Airway Division The most distal end of the segment to be resected is divided first, and cross-table ventilation is instituted through a second ETT (Fig. 71–7; see also Fig. 71–3) or HFJV passed through the original ETT into the distal trachea (Fig. 71–8). The entire tracheal segment to be resected is then dissected circumferentially as proximally as necessary. The proximal point of division is then created, and the resected segment is removed from the operative field.
Cross-table or HFJV Both cross-table and HFJV have their advocates. The former has the advantage of being readily available, but it requires frequent removal and replacement of the tube in order to allow placement of the posterior wall of sutures. This can lead to hypoxia or hypoventilation occasionally, but it should not be a problem if it is appropriately attended to. HFJV allows a better, continuous view of the operative field without frequent manipulations (see Fig. 71–8), but it may have a somewhat higher incidence of
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Figure 71–9 The classic Massachusetts General Hospital (MGH) anastomotic technique wherein all 00-00 polyglactin sutures are placed prior to being tied down, with the knots situated on the outside of the tracheal lumen. The sutures are placed approximately 4 mm apart and 4 mm deep into the cut tracheal margin. (From Grillo HC. Surgery of the Trachea and Bronchi. United States, BC Decker, Inc; 2004.) Figure 71–8 The high-frequency jet ventilator cannula seen here passing through the anastomosis from above allows placement of all sutures without serially withdrawing and reinserting a distally placed ETT.
hypoventilation and requires more careful monitoring by the anesthesiology team.
Anastomosis Many technical methods of anastomotic creation have been described. Historically, interrupted silk or polyester sutures were used, but this led to an unacceptably high rate of granulation formation.1 Since then, high rates of success have been reported with interrupted polyglactin, running monofilament absorbable or nonabsorbable sutures, and combinations of these. My preference is for the MGH technique of interrupted 00-00 polyglactin. The detailed MGH method involves placing all of the sutures circumferentially beginning posteriorly, prior to securing them down (Fig. 71–9). They are then tied from front (cartilaginous wall) to back (membranous wall) after having tied the midlateral 0-0 tensionreleasing sutures (Fig. 71–10) to one another. Before these sutures are tied, the inflatable bag that has kept the neck extended until this point in the case is now deflated, and the anesthesiologist flexes the neck and then maintains this moderately flexed position until the end of the operation when the “chin stitch” can be placed.
With the MGH anastomotic technique, all knots are placed on the outside of the lumen. However, in relatively straightforward situations in which the lumen is of normal caliber after resection of a short involved tracheal segment, some have found that it is more convenient and appears to be equally successful to place the posterior half of the anastomotic sutures first with the knots within the lumen. These can then be tied without the use of midlateral stay sutures after having tied down at least two of the most posterior cartilaginous wall sutures in order to take off the initial tension. The anterior wall sutures can then be placed and tied last (Fig. 71–11). The two sides of thyroid isthmus can be reapproximated to provide some soft tissue coverage to the anterior portion of the anastomosis.
Anastomotic Granulation Formation ● Consequence Prior to the change from silk or Tevdek to polyglactin suture at MGH in 1978, 23.6% of patients had this problem.2 It leads to partial or, in rare cases, complete airway obstruction at the level of the anastomosis. Grade 2–4 complication ● Repair Granulations can generally be managed by bronchoscopic removal either mechanically or with careful use of the laser. The offending suture(s) should also be removed. This may require repeated bronchoscopic
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Figure 71–10 Midlateral stay sutures of 0-0 Vicryl are placed as shown here for the distal segment, in both the distal and the proximal segments to be brought together. These are tied down to one another as the shoulder bag is deflated and the neck flexed, immediately before tying the actual anastomotic sutures. This serves to take tension off of the anastomotic sutures. (From Grillo HC. Surgery of the Trachea and Bronchi. United States, BC Decker, Inc; 2004.)
that is most proved to avoid the formation of granulation tissue.
Anastomotic Dehiscence/Restenosis
Figure 71–11 An alternative anastomotic technique that can be used in simpler cases, in which the posterior half of the anastomotic sutures have at this point been placed and tied with the knots within the lumen. The anterior half-sutures have been placed and are about to be tied down.
débridement. Local steroid injections may prevent reformation of granulations. Severe cases may require temporary or permanent T-tube placement or even tracheostomy when the granulations cannot be controlled. ● Prevention After 1978, when the suture material used at MGH was changed to polyglactin, only 1.6% of patients have had a problem with granulation tissue formed at the site of anastomosis.2 Use of absorbable monofilament or even nonabsorbable monofilament suture also appears to virtually eliminate this problem. However, because the MGH series are the largest and most definitive, I believe polyglactin to be the anastomotic suture
● Consequence The failure rate after anastomosis for all postintubation stenoses was 5.8% in the MGH series. However, for simple lesions requiring only trachea-to-trachea anastomosis, the failure rate was only 2.2%.2 A 2004 review of all 901 patients who had undergone tracheal resection in all locations and for all types of lesions found on multivariate analysis that reoperation (odds ratio [OR] 3.03), diabetes (OR 3.32), greater than 4 cm resection length (OR 2.01), laryngotracheal resection (OR 1.80), age younger than 17 (OR 2.26), and need for preoperative tracheostomy (OR 1.79) were significant predictors of anastomotic complications.5 Early, complete dehiscence may lead to airway obstruction and death and is an emergency that may require Ttube placement6 or tracheostomy. Incomplete dehiscence or partial separation may not be noted clinically early on but may lead to healing with a cicatrizing circumferential scar that leads to restenosis. Either complete or incomplete dehiscence may, in rare cases, result in tracheoinnominate fistula (TIF) or even tracheoesophageal fistula. Seven of 29 patients in the MGH series with complete dehiscence died of this complication. Two of the deaths were due to TIF. Grade 3–5 complication ● Repair If early dehiscence is suspected, the patient is taken urgently back to the operating room for rapid and careful bronchoscopic evaluation. If a correctable technical error (such as lack of a needed release procedure)
71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION is suspected, reanastomosis with a protective size-4 tracheostomy tube placed two rings below the anastomosis or reanastomosis over a T-tube is reasonable. Alternatives include T-tube placement6 alone or fullsized tracheostomy placement alone. Patients with TIF create among the most difficult surgical emergencies. The airway in this situation must be secured by endotracheal intubation with a cuffed tube and the patient taken emergently to the operating room. Via a median sternotomy, the innominate artery must be divided before exsanguination or drowning occurs, the involved segment is resected, and the remaining ends of the artery are covered with surrounding muscle. In patients without major preexisting cerebrovascular disease, this will not lead to stroke. However, if intraoperative electrocardiographic monitoring can be rapidly arranged, a vein graft can be used for reinstitution of flow if significant changes are identified with clamping. The anastomosis can then be managed as described in the preceding paragraph. Late anastomotic stenosis that occurs during healing of an ischemic or partially separated anastomosis will present with the typical symptoms of upper tracheal stenosis: dyspnea and stridor. The MGH group published a series of 75 reoperations for tracheal stenosis occurring after an initial failed attempt at resection.7 Complications occurred
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in 39% of patients, but 79% had an outcome considered to be “good,” and another 13.3% had an outcome considered to be “satisfactory.” The repair was unsuccessful in only 5.3% of patients, and 2.6% died perioperatively. Options other than reoperation again include T-tube6 or tracheostomy. ● Prevention There are two critical technical issues that must be attended to in order to prevent anastomotic failure: (1) minimizing devascularization of the tissue to be anastomosed and (2) creating a tension-free anastomosis. To minimize devascularization, it is critical to maintain the blood supply to the tracheal segments to be anastomosed by leaving their lateral tissue attachments intact (Fig. 71–12), because these contain the major blood supply. The airways to be anastomosed should be mobilized circumferentially for no more than 5 mm beyond the cut margin, and the cut margin should be handled as little as possible to avoid tissue injury. Because the anastomotic sutures are placed 3 to 4 mm deep, 5 mm of mobilization is sufficient. To create a tension-free anastomosis, the tensionreleasing maneuvers utilized in TRs include
Coronal section of tracheal wall... Anterior transverse intercartilaginous artery
Lumen Trachea
Lateral longitudinal anastomosis
Submucosal capillary plexus Transverse intercartilaginous artery
Primary tracheal artery Posterior transverse intercartilaginous artery
Pattern of microvasculature of mucosa
Tracheoesophageal artery Primary esophageal artery
Esophagus
Muscular posterior wall of trachea
Secondary tracheal twig to posterior wall
Figure 71–12 Demonstration of the lateral tissue pedicles that contain the main blood supply to the trachea and thus must be left intact beyond 5 mm from the cut margin of the tracheal resection. Because the anterior, pretracheal plane is avascular, it is bluntly dissected as far as possible into the mediastinum as part of the routine tension-relieving procedures. (From Salassa JR, Pearson BX, Payne WS. Gross and microscopical blood supply of the trachea. Ann Thorac Surg 1977;24,100–107.)
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1. Dissection of the pretracheal plane to the level of the carina (described previously). 2. Suprahyoid laryngeal release (described previously). 3. 2-0 Vicryl lateral “stay” sutures tied to one another prior to tying anastomotic sutures (described previously). 4. Taking down the inflatable bag beneath the shoulders and using neck flexion during the tying down of the anastomotic sutures (described previously). 5. The “chin stitch” (described later). Numbers 1, 3, 4, and 5 are used in essentially all TRs, while SLR is used only for longer resections or when tension is noted upon the initial attempt to bring the cut margins toward one another. It is critical that the cut ends of the airway come together easily and with no more than minimal tension. If they do not, the anastomosis will not heal soundly. A third important point in avoiding anastomotic complications is to be sure not to operate upon a trachea that is in the acute phase of inflammation. If, upon preoperative bronchoscopy, the airway remains edematous or erythematous, it is best to postpone surgery until this inflammation subsides, even if this requires temporary stenting with a T-tube6 or even tracheostomy. Finally, if a patient has been on chronic steroids, these should be weaned preoperatively to as low a dose as possible, preferably to the point of having been stopped completely for a month or longer. Although preoperative steroid use did not fall out as a significant predictor in the MGH multivariate analysis described previously,5 common sense and experience dictate that weaning steroids is prudent if feasible. It may also be useful to administer vitamin A perioperatively in patients who remain on steroids to mitigate the known effects of steroids upon healing. With regard specifically to TIF, one means of avoiding this is always keeping the dissection plane directly on the trachea when separating the innominate artery from the airway. This leaves some investing soft tissue around the innominate artery that will generally prevent subsequent erosion. In situations in which there is reason to think that this investing tissue is not present, a flap of strap muscle should be interposed between the innominate and the anastomosis.
Chin Stitch Once the anastomosis has been completed and the wound closed over a Jackson-Pratt drain, a size 2 suture of Tevdek or polypropylene is placed between the submental skin and the skin over the angle of Louis (Fig. 71–13). It is important to note that the neck is to be held in only modest flexion. The intention of the skin stitch is more to prevent the patient from suddenly hyperextending and
Figure 71–13 The “chin stitch” shown here is intended not to maximally flex the neck but only to hold it in no more than 45° of flexion and, more importantly, prevent sudden extension. Note that this patient, who had a subglottic resection, has also had a small tracheostomy placed below the anastomosis as a precaution.
thus stressing the anastomosis than it is to maintain dramatic flexion.
Paraplegia ● Consequence Several case reports8 have described disastrous spinal infarcts believed to have resulted from severe neck flexion after TR. I am aware of one other unreported case of this terrible complication. Grade 4/5 complication ● Repair If lower extremity weakness is noted, the chin stitch should be immediately cut and the patient allowed to return his or her neck to a neutral position. Elevation of blood pressure to increase spinal perfusion might be helpful. ● Prevention The neck should generally be flexed to more than 45°. In the rare situation in which more than 45° of flexion is required to create a tension-free anastomosis, careful monitoring of neurological function should be carried out and the previously described maneuvers carried out urgently if any deficits are noted.
71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION
Extubation Extubation is performed immediately after TR in the operating room, if at all possible. This is facilitated by avoidance of paralytic agents in the anesthetic. Occasionally, one is sufficiently worried about the anastomosis that one “protects” it by placing a small, size-5, uncuffed tracheostomy two rings below the anastomosis. Another alternative after difficult resections, high laryngotracheal resections, or resections in children in whom a small amount of edema can reduce the smaller lumen significantly is to maintain intubation for 2 to 3 days postoperatively as a rapidly tapering course of steroids is given to reduce edema.
Postoperative Airway Edema ● Consequence Most TR patients have some degree of airway edema postoperatively, either at the level of the vocal cords or at the anastomosis itself. However, this generally becomes a problem only in those patients with anastomoses in the subglottic region or in children with smaller airways. In these patients, stridor may develop 12 to 48 hours postoperatively that was not present immediately postoperatively. Grade 1–3 complication ● Repair Symptomatic airway edema can usually be managed with head elevation, racemic epinephrine nebulizers, diuretics, and a rapidly tapering 24-hour cycle of steroids, if this was not already instituted. Heliox is also a useful adjunct because its use reduces the resistance to flow in the airways.9 In rare cases, the patient must be taken back to the operating room for placement of a small tracheostomy below the anastomosis or for very careful reintubation from above with an uncuffed ETT. ● Prevention A rapidly tapering 24-hour cycle of steroids is appropriate for those with subglottic resections, children, and those in whom more than the usual amount of cord trauma was believed to have occurred during intubation or rigid bronchoscopy. All TR patients should have minimal fluid replacement postoperatively and be managed with the head of the bed elevated. For those considered to be at highest risk, a small tracheostomy
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placed at the time of surgery or a planned, 2- to 3-day postoperative period of intubation with an uncuffed ETT can be considered.
SUMMARY With careful attention to the details of surgery and postoperative management, cervical tracheal resection can be performed with anastomotic failure rates as low as 2.2% and all other complications together totaling less than 5%. The incidence of complications rises, however, as the proximal point of resection enters the larynx. This chapter has reviewed the management and prevention of all complications of tracheal resection that occur in substantial numbers.
REFERENCES 1. Grillo HC, Zannini P, Michelassi F. Complications of tracheal reconstruction: incidence, treatment and prevention. J Thorac Cardiovasc Surg 1986;91:322–328. 2. Grillo HC, Donahue DM, Mathisen DJ, et al. Post intubation tracheal stenosis; treatment and results. J Thorac Cardiovasc Surg 1995;109:486–493. 3. Lanuti M, Mathisen DJ. Management of complications of tracheal surgery. Chest Surg Clin North Am 2003;13:385– 397. 4. Grillo HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac Surg 1990;49:69–77. 5. Wright CD, Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004;128: 731–739. 6. Gaissert H, Grillo HC, Mathisen DJ, Wain JC. Temporary and permanent restoration of airway continuity with the tracheal T-tube. J Thorac Cardiovasc Surg 1994;107:600– 606. 7. Donahue DM, Grillo HC, Wain JC, et al. Reoperative tracheal resection and reconstruction for unsuccessful repair of postintubation stenosis. J Thorac Cardiovasc Surg 1997;114:934–938. 8. Silver JR. Paraplegia as a result of tracheal resection in a 17-year-old male. Spinal Cord 2007;45:576–578. 9. Ho AM, Dion PW, Karmakar MK, et al. Use of heliox in critical upper airway obstruction: physical and physiologic considerations in choosing the optimal helium:oxygen mix. Resuscitation 2002;52:297–300.
Section XII
TRAUMA SURGERY Edward E. Cornwell III, MD The only real mistake is the one from which we learn nothing.—John Powell
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Evaluating Trauma Literature David C. Chang, MD INTRODUCTION In some surgical specialties, new procedures and guidelines are frequently developed and adopted based on uncontrolled case series, despite the fact that selection bias often appears in these series (to select the “best” possible surgical candidate patients to demonstrate the feasibility of the new procedure). This bias makes the results difficult to generalize to the “average patient.” In contrast, conclusions based on carefully analyzed evidence in the literature have played an ever-increasing role in the development of clinical guidelines in trauma care. The most prominent early example of evidence-based guidelines in trauma grew out of important work performed by the Brain Trauma Foundation, in collaboration with the American Association of Neurologic Surgeons.1 Guidelines were developed around 13 specific clinical issues in patients with severe traumatic brain injuries. In highlighting the importance of evidence-based surgical practice in trauma, this chapter emphasizes specific pitfalls to be avoided in evaluating the trauma literature. The example of the evolution of management of traumatic colon injuries are utilized to illustrate the pitfalls.
PITFALL 1: GENERATING A CLASS I RECOMMENDATION BASED ON CLASS III DATA In 1943, the Surgeon General of the United States issued guidelines that all colon injuries sustained by soldiers in
the North African theater during World War II be managed by colostomy either at or proximal to the site of injury, rather than by primary repair or resection and anastomosis.2 Retrospective analysis of this recommendation included the observations that colon injuries during the Civil War carried an associated 90% mortality, whereas those experienced during World Wars I and II carried a 60% and a 30% mortality, respectively. The reduced mortality of injuries experienced during World War II was attributed to the policy of mandatory colostomies, ignoring the contribution of advances in fluid resuscitation, plasma preservation, blood-banking techniques, the availability of antimicrobial agents, and superior military triage and evacuation. ● Consequence For the two decades after World War II, the military mandate led to the assumption in civilian practice that colostomy should be the standard of care for traumatic colon injuries. This led to thousands of patients receiving colostomies and the need for subsequent operations with their associated morbidity. Tradition and intuition would play a large role in the choice of management until Stone and Fabian published a report in 19793 comparing the outcomes of colostomies versus primary repair in patients with less severe injuries. ● Repair/Prevention The prevention of future misassumption is hopefully feasible with the development of the principles of evidence-based medicine. These principles dictate that
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class II (prospective nonrandomized) and class III (retrospective) data should generate questions rather than answers. Once the feasibility and estimated complication rates of two possible treatment arms (colostomy/ diversion versus primary repairs/anastomosis) are established, the development of clinical guidelines should ideally be derived from well-designed prospective, randomized trials. In retrospect, attributing the decreased mortality from colon injuries in World War II to the policy of mandatory colostomy was probably unfairly indicting primary repair and unduly promoting colostomies.
PITFALL 2: INAPPROPRIATE COMPARISON OF COMPLICATION RATES BETWEEN RETROSPECTIVE AND PROSPECTIVE SERIES When a clinical researcher and a study nurse formally define complications (such as intra-abdominal abscess after colon repairs) and prospectively compile them, the magnitude of the complication rates will almost always be higher than the complication rates generated by chart reviews and retrospective recall. An example of a remarkably low complication rate generated by retrospective methodology is seen in a 1984 study of traumatic colon injuries at an urban trauma center.4 In this series of 56 patients over a 6-year period, none developed an intraabdominal abscess. These incredible results raise the question as to whether more severely injured patients who developed complications somehow eluded the investigators’ chart reviews. Subsequent retrospective series published over the ensuing decade would echo a near 0% septic complication rate among patients undergoing primary repair of penetrating colon injuries.5,6 Interestingly, these excellent outcomes are unattainable when the same patients are evaluated prospectively.7,8 ● Consequence Patients, malpractice attorneys, hospitals, and performance-improvement committees may well develop the unreasonable expectation that the management of traumatic colon injuries carries a 0% septic complication rate.
PITFALL 3: GENERATING A CLASS I RECOMMENDATION FROM CLASS II DATA When surgeons began to appreciate the difference between high-velocity military injuries and low-velocity injuries seen in the civilian setting, the wartime practice of routine colostomy would gradually come under challenge. A report in 1951 identified a 9% mortality rate when primary repair of selected colon injuries was used.9 American surgeons trained from the 1950s through the 1980s developed the ability to identify patients who have extremely severe injuries and pronounced physiologic derangement. These sicker patients with predictably higher complication rates have generally been managed with colostomies. Not surprisingly, virtually every retrospective or prospective, nonrandomized study analyzing intraabdominal septic complications found that patients who received primary repair had complication rates equal to or less than those who received colostomy. This culminated in a paper in 1997 entitled, “Primary repair of 58 consecutive penetrating injuries of the colon: should colostomy be abandoned?”10 ● Consequence Surgeons initially credited colostomy and impugned primary repair in the 1950s based primarily on class III data (i.e., retrospective review of data) from World Wars I and II. Subsequently, surgeons impugned colostomy in the 1980s based on primarily class II data (prospective but nonrandomized trials), ignoring the trend that colostomy was becoming reserved for a progressively severely injured subset of patients. ● Repair/Prevention Clearly septic complications can be predicted to occur in patients with penetrating colon injuries. The question remained whether colostomy decreases that risk, which can only be answered by prospective, randomized analyses in which patients are equally likely to receive one treatment mode or the other, without regard to the severity of their injuries. There are four such trials in the literature.11–14 In all four trials, primary repair patients had outcomes that were as good as those of colostomy patients.
FUTURE DIRECTIONS ● Repair/Prevention Unlike other fields of medicine, the development of many surgical treatment modalities remains unregulated; therefore, each new advance in treatment requires some form of self-regulation. Only by insisting upon proper interpretation of clinical data and the avoidance of unsupported conclusions can we guard against the unrealistic expectation described previously.
A question arises of whether there are enough severely injured patients in the prospective randomized trials who require resection and anastomosis under physiologically compromised situations to routinely recommend primary repair in every circumstance. There has been a total of only 37 patients described in the prospective, randomized studies discussed earlier who underwent resection and anastomosis; and in three of those four trials, the severity
72 EVALUATING TRAUMA LITERATURE of injuries were represented by the groups’ average Penetrating Abdominal Trauma Index (PATI). Therefore, it was unclear how many of the 37 patients were at actual high risk for septic complications. Although none of the 37 patients had identified suture line disruption, there appears to be an inadequate number of patients with destructive colon injuries and other major risk factors to recommend that colostomies to be abandoned altogether. Guidelines developed by the Eastern Association for the Surgery of Trauma (EAST) reflect these concerns, reserving colostomy as a level II recommendation for patients with destructive colon injuries that require resection in a setting of shock, underlying disease, or severe associated injury.15
REFERENCES 1. Brain Trauma Foundation. The integration of brainspecific treatment to the initial resuscitation of the severe head injury patient. J Neurotrauma 1996;13:653–659. 2. Circular Letter No. 178. Washington, DC: Office of the Surgeon General of the United States. October 23, 1943. 3. Stone HH, Fabian TC. Management of perforating colon trauma: randomization between primary closure and exteriorization. Ann Surg 1979;190:430–435. 4. Adkins RB Jr, Zirkle PK, Waterhouse G. Penetrating colon trauma. J Trauma 1984;24:491–499. 5. Nallathambi MN, Ivatury RR, Shah PM, et al. Aggressive definitive management of penetrating colon injuries: 136 cases with 3.7 per cent mortality. J Trauma 1984;24:500– 505.
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6. Levison MA, Thomas DD, Wiencek RG, Wilson RF. Management of the injured colon: evolving practice at an urban trauma center. J Trauma 1990;30:247–251; discussion 251–253. 7. George SM Jr, Fabian TC, Voeller GR, et al. Primary repair of colon wounds. A prospective trial in nonselected patients. Ann Surg 1989;209:728–733; discussion 733– 734. 8. Demetriades D, Charalambides D, Pantanowitz D. Gunshot wounds of the colon: role of primary repair. Ann R Coll Surg Engl 1992;74:381–384. 9. Woodhall JP, Ochsner A. The management of perforating injuries of the colon and rectum in civilian practice. Surgery 1951;29:305–320. 10. Jacobson LE, Gomez GA, Broadie TA. Primary repair of 58 consecutive penetrating injuries of the colon: should colostomy be abandoned? Am Surg 1997;63:170– 177. 11. Chappuis CW, Frey DJ, Dietzen CD, et al. Management of penetrating colon injuries: a prospective randomized trial. Ann Surg 1991;213:492–498. 12. Falcone RE, Wanamaker SR, Santanello SA, Carey LC. Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs ostomy. Dis Colon Rectum 1992; 35:957–963. 13. Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: a prospective randomized study. J Trauma 1995;39:895–901. 14. Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injuries: is it necessary? J Trauma 1996; 41:271–275. 15. Eastern Association for the Surgery of Trauma. Trauma practice guidelines. 1998. Accessed at www.east.org
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Evaluation and Acute Resuscitation of the Trauma Patient Elliott R. Haut, MD INTRODUCTION Although not all trauma patients need surgical intervention, they do require immediate evaluation and resuscitation. Therefore, trauma continues to be a surgical disease. Early intervention in critically injured patients can significantly influence mortality, morbidity, and disability after major trauma. Patients have improved outcomes when treated at these specialized centers1–3 and when additional resources and commitment are dedicated to trauma care.4–6 The Advanced Trauma Life Support (ATLS) course sponsored by the American College of Surgeons Committee on Trauma is the “gold standard” for teaching trauma management and heavily emphasizes the importance of the initial trauma resuscitation.7 This chapter utilizes the ATLS framework to highlight the essentials and potential pitfalls in the evaluation and resuscitation of the injured patient.
PRIMARY SURVEY Upon arrival at the trauma center, rapid primary survey should include evaluation of the Airway (with cervical spine protection considered), Breathing and ventilation, Circulation with hemorrhage control, Disability (neurologic status) and Exposure/Environmental control. These ABCDEs are the basic initial management emphasized by ATLS. Major pitfalls at this point can rapidly cause death. It is ideal to strictly adhere to systematic performance of the primary survey and focus on the ABCDEs to ensure that the most life-threatening injuries are dealt with first. Do not be distracted by major external injuries. Although these obvious injuries are often quite impressive and gruesome, they are not immediately life threatening. If a major finding is identified on the primary survey, it should be treated immediately before moving on to the next step.
Airway Airway management is always the first step in trauma evaluation. When in doubt, the safest route is often to intubate the patient and completely control the airway.
Loss of Airway ● Consequence Loss of airway during trauma resuscitation can rapidly lead to respiratory and then cardiopulmonary arrest and death. Grade 5 complication ● Repair If an airway problem is found, it needs to be definitively remedied before moving on to breathing and circulation. If at any time during the evaluation the need for airway control is recognized, start back at airway evaluation and reconsider performing standard endotracheal intubation. ● Prevention All potential alternatives must be anticipated. Do not assume that the first attempt at endotracheal intubation will be immediately successful. If endotracheal intubation cannot be done expeditiously, advanced airway manipulation (e.g., fiberoptic intubation, laryngeal mask airway) may be the next attempted maneuver. The ultimate backup is surgical airway by cricothyrotomy, which should be in the armamentarium of every surgeon treating trauma patients (Fig. 73–1). Occasional providers still attempt to achieve emergency surgical airway by means of a tracheostomy. This dangerous practice ignores the anatomic fact that the cricothyroid membrane is the most superficial access point to the airway and the trachea immediately dives deep into the mediastinum.
Allowing an Episode of Hypoxia ● Consequence Even short periods of hypoxia are known to worsen outcomes after traumatic brain injury (TBI). Grade 4/5 complication
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Hyoid bone
Thyrohyoid m.
Sternohyoid m.
Omohyoid m.
Anterior jugular v.
Thyroid cartilage
Cricoid cartilage
Cricothyroid membrane Sternocleidomastoid muscle
Thyroid gland isthmus
Trachea
MC
A
Skin incision over cricothyroid membrane
B Figure 73–1 Cricothyrotomy. A, The cricothyroid membrane is located between the thyroid cartilage above and the cricoid ring below. B, The operator’s nondominant hand holds the thyroid cartilage while the other hand performs the procedure. A vertical skin incision avoids the anterior jugular veins to minimize bleeding.
73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
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Cricothyroid membrane
C
Cricothyroid membrane
D
Cricoid cartilage
Thyroid gland
Figure 73–1, cont’d C, The cricothyroid membrane is incised transversely. D, The opening is widened with a small hemostat.
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Tracheostomy tube
Tracheostomy tube
E
Figure 73–1, cont’d E, The tracheostomy tube is placed into the airway and the cuff is inflated.
● Repair If hypoxia is noted, urgent attention should be paid to airway management. High-flow oxygen should be given. If endotracheal intubation is not successful, surgical airway (cricothyrotomy) should be rapidly performed. ● Prevention Delays in obtaining a definitive airway can lead to hypoxia, which has significant negative impact on outcomes in head-injured patients. This is yet another reason why airway management is the first critical step in trauma evaluation.
Conversion of a Metastable Airway to an Unstable Airway ● Consequence Conversion of a metastable airway to an unstable airway can rapidly change a difficult situation into an impossible one. Death from airway loss is never a pretty sight. Grade 5 complication ● Repair Often, this error leads to emergent cricothyrotomy instead of a smoother, controlled airway management scheme.
73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
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● Prevention Before dosing a patient with paralytics for rapidsequence intubation, consider the potential consequences in a patient with a metastable airway. Paralytics may convert a patient who is protecting her or his own airway and able to oxygenate and ventilate to a patient who is no longer breathing and is unable to be intubated. Consider letting the patient sit up to help clear blood and secretions, rather than making her or him lay flat and possibly inducing aspiration.
● Prevention Decreased breath sounds on one side should lead to an immediate chest tube before radiographic evaluation in patients with significant respiratory distress or shock. In this case, treatment of a tension pneumothorax can be life saving. Tension pneumothorax should be a clinical diagnosis made by physical examination, not radiographically. Tracheal deviation (away from the tension pneumothorax) helps confirm the diagnosis in patients with decreased breath sounds and hypotension.
Causing Worse Neurologic Injury with Spine Manipulation
Placing an Unnecessary Chest Tube
● Consequence Exacerbating neurologic deficits by not immobilizing the cervical spine can have long-lasting devastating consequences. Patients with spinal column injuries may have no neurologic deficit or only an incomplete spinal cord injury. It is incredibly tragic when patients such as this have worsening of their injury from inappropriate cervical spine immobilization. Grade 4/5 complication ● Prevention Cervical spine stabilization is emphasized during airway management by ensuring that the head stays in neutral position. Hyperextending the neck in a patient with an unstable cercival spine injury may change a patient’s functional outcome significantly by exacerbating neurologic injury. A patient may be rendered permanently quadriplegic with even small manipulations of the neck.
Breathing The next step of evaluation during the trauma resuscitation is breathing and ventilation. Often, it is quite difficult to differentiate a breathing problem from an airway issue. In this situation, if the airway is controlled and the problem continues, there is most likely a lung or breathing problem. Physical examination is the key first maneuver to making the appropriate diagnosis.
● Consequence Tube thoracostomy is not a benign procedure. It is associated with injury to structures within the chest and abdomen and has the potential to cause infection. Appropriate tube thoracostomy placement can be necessary; however, if a patient does not need a chest tube, we should not place one. Grade 2 complication ● Prevention In the hemodynamically stable patient who is physiologically normal from a respiratory standpoint (e.g., no hypoxia, shortness of breath, use of accessory muscles), consider getting an early chest x-ray to clearly define whether a hemo- and/or pneumothorax is present before intervention. Providers must always be cognizant of the benefit of listening very closely with an unbiased stethoscope. Often, when there is a wound over one hemithorax, we expect (and subsequently believe we find) decreased breath sounds when there may be no anatomic pathology. An early chest x-ray can save the patient a potentially unnecessary chest tube placed for “unequal breath sounds” in the physiologically normal trauma patient. However, this recommendation should not be taken as a suggestion to wait for a chest x-ray in an unstable patient with signs of respiratory distress or tension pneumothorax.
Conversion of Simple Pneumothorax to Tension Pneumothorax with Positive-Pressure Ventilation
● Consequence Missing tension pneumothorax on physical examination or waiting for a confirmatory chest x-ray can lead to an unnecessary prolonged period of hypotension, shock, hypoperfusion, anoxic brain injury, and/or death. Grade 5 complication
● Consequence Trauma patients may have a small pneumothorax, which may be too small to see on chest x-ray or computed tomography (CT) scan. These may be of no consequence and heal on their own without intervention. However, if there is a hole in the visceral pleura over the lung, this simple pneumothorax can be converted to a tension pneumothorax with positivepressure ventilation. Grade 5 complication
● Repair Immediate chest decompression (by needle) followed by tube thoracostomy.
● Repair Immediate chest decompression (by needle) followed by tube thoracostomy.
Missed Tension Pneumothorax on Physical Examination
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● Prevention Ventilation may rapidly deteriorate with endotracheal intubation and positive-pressure ventilation owing to a worsening pneumothorax. In patients with known pneumothorax, consider placing a chest tube as soon as the patient is intubated, rather than waiting until a confirmatory chest x-ray is performed.
Main Stem Intubation Leading to Unnecessary Chest Tube ● Consequence Straightforward successful intubation is the expected outcome after plans for controlling the airway. Main stem intubation is a common minor complication of endotracheal intubation. In and of itself, it does not cause major problems. However, if unrecognized, it may lead the team to perform further procedures (e.g., tube thoracostomy for presumed hemo- or pneumothorax owing to decreased or absent breath sounds) before the simple diagnosis is made. Grade 2 complication ● Repair Pull the endotracheal tube back to the appropriate position and reconfirm by chest x-ray or fiberoptic bronchoscopy. ● Prevention Main stem intubation (more commonly into the right main stem bronchus) can give the appearance of chest pathology owing to absent or decreased breath sounds. Always consider this possibility rather than assuming another lung pathology (such as hemo- or pneumothorax). Confirming endotracheal tube placement by early chest x-ray or pulling the endotracheal tube back may avoid an unnecessary tube thoracostomy.
Air Embolism ● Consequence Intubation and positive-pressure ventilation may cause air embolism. Hypovolemic patients whose penetrating injuries produce direct communications between the small airways and the pulmonary venous tributaries are at particularly high risk. When positive pressure is applied to the bronchial tree, air may go through these abnormal connections and eventually enter the left side of the heart. Air can then flow to the brain causing stroke or the coronary arteries causing myocardial infarction. Grade 4/5 complication ● Repair Initial treatment includes increasing the fraction of inspired oxygen (FIO ). Hyperbaric oxygen therapy may have a role, but there are no large studies to prove its benefit. 2
● Prevention Air embolism is difficult to prevent. Key maneuvers include minimizing the time of positive-pressure ventilation before attempting surgical control of a penetrating lung injury. Prompt hydration and fluid resuscitation will also help ensure a full venous system, which may help prevent air embolism as well.
Circulation Uncontrolled External Hemorrhage ● Consequence Ongoing external hemorrhage can rapidly lead to shock, exsanguination, and death. Grade 5 complication ● Repair Control of external hemorrhage during the early phase (circulation) of resuscitation is imperative. ● Prevention External bleeding is best controlled by direct digital pressure. Frequently, a patient with a small head laceration presents to the trauma center with a large, loosely wrapped, bulky gauze dressing saturated with blood. When the trauma team removes this dressing and sees a 2-cm laceration, digital pressure from one finger can completely stop this external hemorrhage and save multiple units of blood transfusions for this patient.
Exacerbating a Vascular Injury by Blind Clamping ● Consequence Blindly placing a clamp into a bleeding wound has considerable potential to enlarge a small arterial or venous injury. This may change the necessary surgical procedure significantly. What may have taken one or two simple sutures may now require a complex vascular repair. Grade 3/4 complication ● Repair Surgical repair of major vascular injury as indicated will be the only way to correct this injury. These more complex injuries may require an interposition vein or prosthetic conduit placement to restore flow to the injured extremity. ● Prevention In the extremities, external bleeding is often best controlled with digital pressure directly on the bleeding wound. Blind clamping should be avoided to prevent further major vascular injury. Imprecise clamp placement can convert a small partial-thickness arterial injury to a complete transaction requiring a larger, more complex arterial reconstruction. Although there is con-
73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT troversy about their use, tourniquets may be considered if direct pressure does not stop the ongoing hemorrhage.8 A blood pressure cuff placed directly over the wound and inflated to above the arterial blood pressure should temporize the situation and control external hemorrhage while the rest of the ABCDEs are addressed. The primary and secondary surveys can be finished expeditiously while a definitive plan (surgical exploration) for hemorrhage control is undertaken.
Assuming that a Normal Heart Rate or Blood Pressure Ensures that a Patient Is Not in Shock ● Consequence Making a false assumption such as this will ultimately delay the diagnosis of shock. This may allow a patient enough time to continue to exsanguinate. Hemorrhage is a major cause of death after trauma. In a recent review of 2594 deaths at a large regional trauma center, delayed intervention for hemorrhage accounted for the largest percentage of preventable death.9 Grade 5 complication ● Repair As soon as the diagnosis of shock is made, work-up directed at the differential diagnosis of bleeding sites is imperative. Ongoing active fluid resuscitation should be performed simultaneously during this evaluation. ● Prevention Early consideration of control of internal hemorrhage is important, although this often falls into the secondary survey in hemodynamically stable patients. Pitfalls during this portion of resuscitation can occur in specific patient populations. Young, well-trained athletes and patients who are well β-blocked will continue with a normal heart rate (or bradycardia), even after significant blood loss has occurred. Patients in class II hemorrhagic shock (blood loss of 15%–30% of blood volume or 750–1500 ml) will compensate with tachycardia and vasoconstriction but may still have “normal” vital signs. The only physical examination finding may be a narrow pulse pressure. Take the example of a patient whose baseline blood pressure is 120/80 mm Hg and heart rate is 60. His or her vital signs after trauma (blood pressure 110/90 mm Hg and pulse 90) may be in the overall “normal” range but represent a 50% decrease in pulse pressure and a 50% increase in heart rate. Elderly patients also may not exhibit typical signs and symptoms of hemorrhage and shock (e.g., tachycardia, hypotension) after major trauma. These patients may not have the physiologic reserve that their younger counterparts do. Extra vigilance must be used in elderly trauma patients to ensure timely diagnosis and treatment because elderly patient may not be able to recover if the therapy is delayed. Trauma team activation and early intensive monitoring may improve outcomes in trauma patients older than 70 years.10,11
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Assuming Hemodynamic “Stability” Excludes Significant Hemorrhage after Penetrating Abdominal Trauma ● Consequence Delay in laparotomy once the diagnosis of peritonitis is made can allow a longer period of bleeding and abdominal contamination. This may lead to the need for more extensive surgery, higher rates of abdominal sepsis, and death. Grade 3–5 complication ● Repair Early laparotomy should be undertaken as soon as signs of bleeding (i.e., dropping hemoglobin or hematocrit, hypotension) or peritonitis occur. ● Prevention In the modern era of selective management of penetrating abdominal trauma, not all patients with stab or gunshot wounds require mandatory laparotomy, as was the practice pattern for many years. Patients with a completely benign abdominal examination and normal vital signs may be safely treated expectantly, but the trauma team should be ready and willing to operate immediately at the first sign of clinical deterioration. Even patients who are stable at initial presentation may have significant injury. A recent review of 139 hemodynamically stable patients with penetrating abdominal trauma in whom peritonitis was the sole indication for laparotomy highlighted this point. In this large series from a busy trauma center in Los Angeles, major vascular injury (11%), intraoperative hypotension (25%), and blood transfusion (39%) were common. Nearly half of the patients required intensive care, 25% had at least one complication and 3 died (including 2 from exsanguination).12 Peritonitis should triage patients for emergent operation regardless of vital signs.
Disability Not Intubating a Patient with a Glasgow Coma Scale Score of 8 or Lower ● Consequence Failure to intubate a patient with a Glascow Coma Score (GCS) of 8 or lower may lead to hypoxia and cause secondary brain injury and worsen functional outcomes after TBI.13 Grade 4 complication Delay in intubation can also lead to aspiration in the patient who is unable to control her or his airway. Grade 3 complication ● Repair Intubate as soon as possible when a GCS of 8 or lower is noted.
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Table 73–1 Glasgow Coma Scale Score Motor
Verbal
Eye Opening
6 Obeys commands
5 Oriented
4 Spontaneous
5 Localizes pain
4 Confused
3 To voice
4 Withdraws to pain
3 Inappropriate words
2 To pain
3 Flexion to pain (decorticate posturing)
2 Incomprehensible sounds
1 None
2 Extension to pain (decerebrate posturing)
1 None
1 None
● Prevention It is often difficult to determine which patients have a TBI and which patients are confused or agitated for different reasons. The signs and symptoms of acute mental status change have a long list of differential diagnoses. Patients can have altered mental status owing to intoxication with alcohol and/or other drugs. Other causes such as hypoglycemia, hypoxia, hypercarbia, and hypotension resulting in shock must be considered and not missed or attributed to head injury, drugs, or alcohol. In the belligerent, aggressive patient, the entire list must be considered and each item should be ruled out before assuming that intoxication is the only significant cause of behavioral problems.
Missing a Subtle Spinal Cord Injury ● Prevention Use the GCS, which is the standard tool and a quick reliable score, to determine eventual outcome after a head injury (Table 73–1). All trauma patients should have the GCS completed even if there is no obvious/ overt head injury. If the GCS is 8 or lower, the patient should be immediately intubated owing to the risk of not being able to control or protect his or her own airway.
Hypotension ● Consequence Even a single episode of hypotension can worsen a patient’s functional status after TBI.13 Grade 4 complication ● Repair Aggressively treat hypotension in the setting of TBI. Aggressive fluid resuscitation, blood transfusion, and vasopressors are often part of the treatment algorithm. ● Prevention Patients with TBI have already suffered their primary insult. The most important thing we can do for them is to prevent secondary brain injury. Hypotension is a well-described cause of secondary brain injury and should be avoided.13
Attributing Mental Status Change to Drug Intoxication ● Consequence Delay in diagnosis of TBI can have dire consequences ranging from permanent neurologic disability to death. Grade 4/5 complication ● Repair Immediate appropriate work-up to rule out anatomic or physiologic brain injury is indicated.
● Consequence Early diagnosis of spinal cord injury with neurologic deficit may give the patient the best possible outcome by preserving any remaining neurologic function and potentially reversing the cause and allowing improvement. Grade 4 complication ● Repair As soon as the spinal cord syndrome is identified, appropriate neurosurgical consultation and intervention have the best chance to improve outcome. ● Prevention The disability evaluation must include a gross motor examination of both the upper and the lower extremities to avoid missing a clinically significant spinal cord injury. The motor component of the GCS is scored, paying ca reful attention to the ability to follow commands. A patient with a spinal cord injury and complete extremity paralysis may still potentially have a GCS of 15. As long as the patient can follow any motor command, for example, with her or his eyes, she or he can still have a normal GCS. Never perform the motor examination of the lower extremities only and assume that if the lower extremities are intact, the patient has no chance of having a spinal cord injury. This premise is incorrect. Patients with cervical spine stenosis may have a central cord syndrome and have physical findings only in the upper extremities with normal lower extremities. Frequent, neurologic reevaluation is critical to ensure early identification of any decrement in function.
Exposure/Environmental Hypothermia ● Consequence Hypothermia can lead to many downstream effects such as confusion, mental status changes, electrolyte abnormalities, cardiac arrhythmias, and death. Grade 4/5 complication
73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT ● Repair Immediate active warming of the patient should begin when the diagnosis of hypothermia is made. ● Prevention The exact steps in exposure and environmental evaluation depend on the patient’s specific situation. In the hospital setting (e.g., in the trauma bay), the patient should be fully disrobed and all wounds should be evaluated along with the rest of the patient’s physical examination. However, every effort must be made to avoid hypothermia, which has deleterious effects on most organ systems. Warming blankets, heat lamps, and warm intravenous (IV) fluids are utilized as soon as practically possible. Patients can get severely hypothermic in a room that is “not that cold.” Even on a warm, sunny, 80° day, a trauma patient may lose the ability to autoregulate temperature and can become severely hypothermic.
EARLY INTERVENTIONS Venous Access Placement of Insufficient IV Access ● Consequence Using the wrong size of IV catheter for fluid resuscitation can lead to significant underresuscitation of the severely injured trauma patient. This can lead to ongoing shock, multiple organ failure, and death if not rapidly remedied. Grade 4/5 complication ● Repair Place at least two appropriate large-bore IV lines. A short, large-bore catheter is the preferred line of choice. ● Prevention One of the most important early adjuncts to the primary resuscitation is adequate venous access for fluid resuscitation and medication administration. Optimal venous access is often obtained in the prehospital setting with a peripheral IV in the forearm or antecubital fossa. For patients in whom peripheral IV access cannot be obtained, the next step is placement of a central venous line via the Seldinger technique. A short, large-bore catheter will have optimal flow rates and is best to enable rapid fluid administration. Placement of a longer, narrow-gauge (e.g., triple-lumen) catheter in this situation would be inappropriate because the smaller diameter and longer length significantly impede flow. Emergent central venous access placement can be performed in the internal jugular, subclavian, or femoral vein. The anatomic location of choice will depend on the patient’s injury pattern. Trauma patients often have a cervical collar blocking access to the jugular vein and ruling
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out this site. The femoral position gives the easiest access when multiple other procedures are being performed simultaneously on the patient’s airway and chest. However, femoral access has significant drawbacks. Femoral cannulation is more difficult to place based on anatomic landmarks alone, has a higher rate of deep vein thrombosis, and is relatively contraindicated in patients with pelvic and/or extremity injuries. The subclavian vein probably has the most constant anatomic position, making it ideally suited for placement by anatomic landmarks. However, it does pose the risk of hemo- and pneumothorax.
Central Venous Access Complications These are discussed in Section I, Chapter 7, Laparoscopic Surgery.
Inability to Obtain Venous Access ● Consequence Inability to obtain venous access can cause significant morbidity and mortality. Life-saving fluids, blood, and medications are necessary to further an ongoing resuscitation. Grade 4/5 complication ● Repair Consider intraosseous needle placement (even in adults) as an alternative for fluid, blood, and drug administration. Use the endotracheal or intramuscular (IM) routes as appropriate. ● Prevention Other potential sources of venous access exist for difficult cases. Intraosseous needle placement (e.g, proximal tibia) has been a standard alternative IV access in children under 6 years of age. More recently, the intraosseous route has been found to be acceptable in older children and adults as well.14 Venous cutdown is still an option, but it has been replaced by the more commonly performed percutaneous route. Some medications can be given down the endotracheal tube (if the patient is intubated). These medications can be remembered by the simple mnemonic NAVEL (naloxone, atropine, vasopressin, epinephrine, lidocaine). Use the IM route for medications needed to enable intubation of a combative trauma patient in whom IV access is not obtainable. Ketamine and succinylcholine can be given intramuscularly for sedation and paralysis to allow intubation.
Resuscitation through a Femoral Venous Cannula in Cases of Major Abdominal Venous Injury ● Consequence If fluids, blood, or blood products are given through a femoral venous central line but bleed out into the abdominal cavity from a major venous injury (e.g., vena cava, iliac, hepatic), the patient will not get any
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benefit of the attempted resuscitation. This will lead to ongoing shock, hemorrhage, and death. Grade 5 complication ● Repair Venous access should be obtained in the antecubital fossa or a central vein above the diaphragm (internal jugular or subclavian). ● Prevention In certain situations, venous access above the diaphragm is more important than venous access below the diaphragm. The pitfall of placing the line in the femoral position begins with assuming that resuscitative fluids (or blood) given through a femoral vein reach the heart and central circulation. This assumption may be incorrect in the case of iliac vein, inferior vena cava, or hepatic vein injuries. Large amounts of blood and fluid resuscitation given through the groin may not stay intravascular, but rather end up pouring out of the venous hole and not helping the patient’s hemodynamics as expected.
Gastric and Urinary Decompression Adjuncts such as gastric and urinary decompression can be performed simultaneously with the rest of the evaluation and play an important role in the early resuscitation. ATLS suggests that these should be adjuncts to the primary survey,7 although in many instances, these commonly wait until after the secondary survey is performed.
Placing a Nasogastric Tube outside Its Normal Anatomic Pathway ● Consequence Gastric catheters can be necessary for gastric decompression, but they have associated risks. The most devastating complication is seen when the nasal route is chosen in a patient with a basilar skull or cribriform plate fracture. The nasogastric tube easily passes through the nares and directly into the brain. Grade 4/5 complication ● Prevention In patients with known (or suspected) skull base fractures, the nasal route is contraindicated for both gastric decompression and endotracheal intubation. In intubated patients, the orogastric route is preferred.
Exacerbation of a Minor Urethral Tear into a Complete Transaction ● Consequence Foley catheter insertion is important to measure urine output (as a marker of adequate resuscitation) and look for blood (gross and microscopic) in the urine. However, there is a risk of urethral injury when the
catheter is placed. In patients with incomplete urethral injuries, blind placement is contraindicated. This blind attempt at placement may convert a small, partial urethral tear into a complete transaction. Grade 2/3 complication ● Repair Urologic consultation will most likely be helpful in these situations. Repair will often necessitate suprapubic tube placement, cystoscopy for Foley catheter placement, and possibly, direct surgical repair of the torn urethra. ● Prevention There is a potential hazard in placing these urinary catheters, especially in patients with complex pelvic fractures and urethral injury. These injuries occur in men with some regularity. They are rare in women; however, the notion that they never occur is incorrect.15 Thorough physical examination should be performed to rule out the urethral injury before placement of a Foley catheter. Identification of blood at the penile meatus (or introitus), perineal ecchymosis, scrotal hematoma, a high-riding or nonpalpable prostate, gross hematuria, or complex pelvic fracture should serve notice of potential urethral injury. In this case, a retrograde urethrogram is warranted to rule out urethral injury before placement of a Foley catheter blindly. Skipping this crucial step can convert a minor urethral tear into a complete transaction.
Assessment of the Need for Transfer Delaying Transfer ● Consequence Delayed recognition of the patient who needs to be transferred potentially influences eventual morbidity and mortality. Grade 1–5 complication ● Repair Arrange for transfer (if appropriate) as soon as possible after immediate stabilization of the patient. ● Prevention Transfers of trauma patients are common when an additional higher level of care is necessary. Early consideration of the need to transfer should be entertained, but it should not delay resuscitative measures. Often, basic measures and procedures (e.g., intubation, tube thoracostomy, venous access) must be performed just to stabilize the patient enough for a safe transfer. A small, nontrauma hospital may not have the resources (e.g., operating room, radiology, intensive care unit, blood bank) to handle a patient, even though an individual trauma surgeon working there may be comfortable doing so.
73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
SECONDARY SURVEY Missed Injury ● Consequence Grade 1–5 complication ● Repair Treatment for any injury should be performed (or planned for) as soon as the injury is identified. ● Prevention The secondary survey immediately follows the primary survey and associated adjuncts to resuscitation. This secondary survey consists of a thorough, systematic, head-to-toe physical examination. This examination should be done in the same order on every patient, reducing the potential pitfall of missing any injury, however small it may be. Abnormal physical examination findings may direct one toward further evaluation and work-up. Certain physical findings are hallmarks of traumatic injuries and, when recognized, prompt further diagnostic evaluation. “Seat belt signs” are severely bruised areas where a shoulder belt or lap belt crosses the body. When found over the neck, blunt cerebrovascular injury (BCVI) and cervical spine injury should be considered. A seat belt sign over the torso prompts concern of sternal fracture, hollow viscus injury, and lumbar spine fracture (Chance fracture). The handlebar of a bicycle can cause a classic circular injury pattern that should prompt consideration of hollow viscus and solid organ injury.
Incorrect Assessment of Patients with Gunshot Wounds ● Consequence Incorrect assessment of patients with gunshot wounds can lead to missed injuries and delays in diagnosis. Some complications may be insignificant, but others may have major implications. Delayed diagnoses may lengthen hospital stay and lead to worse clinical outcomes, organ failure, amputation, and death, depending on the injuries. Inappropriate judgment may also lead to unnecessary operations and/or procedures, which could be avoided by correct assessment. Grade 1–5 complication ● Repair The situation can be remedied by careful reevaluation and assessment (making sure the number of holes plus the number of bullets is an even number). As soon as a potential injury is identified, appropriate work-up and evaluation should be performed. ● Prevention In patients with gunshot wounds, it is imperative to count the number of gunshot wounds and identify all
767
bullets retained in the patient’s body. When added together, this number must be even. Every bullet either makes an entrance and an exit wound or leaves a retained bullet. If the initial count is an odd number, the trauma surgeon may have made a mistake and must correct it immediately. Inadequate physical examination may miss holes within the hairlines, axilla, soft tissue folds, mouth, rectum, or vagina. Retained bullets are commonly missed on x-rays when the area between the chest and the pelvis films is not adequately interrogated radiographically or the soft tissues are not included on a chest x-ray of an obese patient. CT scan can be beneficial, even if only the scout film is used to look for retained bullets. You may count up to an odd number erroneously if an old bullet (from a prior gunshot wound) is counted. Ask patients if they have been shot before; specifically question where they have retained bullets and subtract these from the count.
TREATMENT OF SPECIFIC INJURIES Pelvic Injury Although suggested by ATLS, not every trauma patient needs a plain pelvic x-ray.7 The pelvic x-ray has limited sensitivity (68% in adults and 54% in children) for detecting pelvic fractures compared with CT scanning. Patients who are hemodynamically stable and are going to get an abdominopelvic CT scan during their immediate resuscitation do not need a plain pelvic x-ray. Early pelvic x-ray may be helpful in hemodynamically unstable patients, those with significant physical findings, and those who will not undergo immediate abdominopelvic CT scanning because of other clinical priorities.16
Ongoing Pelvic Hemorrhage ● Consequence Ongoing bleeding within the pelvis can have the same complications of bleeding as in all other patients (exsanguination, death). However, more commonly, it will lead to unnecessary blood transfusions, ongoing shock with hypotension and hypoperfusion, and further searches for possible bleeding sites. Grade 2–5 complication ● Repair Placement of a pelvic binder or external fixator to close down pelvic volume should be done as soon as an unstable pelvis at high bleeding risk is found. ● Prevention Clinical assessment of the pelvis early in resuscitation is important because pelvic hemorrhage is a common cause for shock after blunt trauma.17 The pelvis is first examined by lateral compression, looking for an unstable pelvic fracture. If the pelvis can be compressed, the examination should stop. Although this may seem like
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an ideal teaching case for every resident and student to examine the grossly unstable pelvis, this should not be done; only one person should examine the unstable pelvis. Every manipulation causes more arterial and venous bleeding from the pelvic fractures, only worsening the situation. A pelvic binder should be placed to close down the pelvic volume to control hemorrhage. External binding for pelvic stabilization is accomplished by using either a tightly wrapped bed sheet or a commercially available device (e.g., PelvicBinder) (Fig. 73–2).
Getting a Pelvic CT Scan without IV Contrast ● Consequence A pelvic CT scan without IV contrast cannot fully evaluate for contrast blush in the pelvis. This can lead to missing pelvic bleeding as a source of ongoing hemorrhage that may lead to shock, necessitate more blood transfusion, and possibly, lead to death. Grade 2–5 complication
A
● Repair Always order a CT scan of the pelvis with IV contrast administration. The same contrast bolus can be used to evaluate the rest of the torso (chest and abdomen) to screen for blunt aortic and/or solid organ injury, which is commonly associated with complex pelvic fractures. ● Prevention Abdominopelvic CT scan with IV contrast is critical to define the pelvic fracture and to evaluate for pelvic hematoma and arterial contrast blush (extravasation).18,19 The finding of arterial extravasation warrants immediate arteriography with therapeutic angioembolization. Angiographic embolization has rapidly become the standard of care for hemorrhage control after pelvic injury because operative attempts to control such bleeding are often unsuccessful. Pelvic vessel embolization has been shown to be safe and effective to control hemorrhage.20 Its application should be applied liberally. Older age (>60 yr) is associated with a higher risk of bleeding requiring intervention.21 Some trauma surgeons have suggested that certain specific anatomic injuries are associated with higher rates of bleeding.22,23 However, others have shown that the fracture pattern may not reliably predict which patients will benefit from intervention.24 Repeat angiography is warranted in cases of ongoing hemorrhage and shock, even after initially normal angiography.25
Blunt Cerebrovascular Injury (BCVI) Delayed Diagnosis of BCVI in a Neurologically Normal Patient ● Consequence BCVI is a rare but devastating injury seen in trauma patients. BCVI is most often associated with a highspeed deceleration mechanism or a direct blow to the
B
C Figure 73–2 A, Pelvic x-ray of a patient with a complex pelvic fracture and pubic symphysis diastasis. B, Pelvic x-ray of the same patient after placement of the PelvicBinder. C, A patient with the PelvicBinder in place. (A–C, Courtesy of and reproduced with permission of PelvicBinder, Inc., Dallas, TX.)
cervical area. The first sign or symptom of BCVI can be a massive stroke, after which clinical outcome is often poor. Grade 4/5 complication ● Prevention Aggressive screening practices are suggested to prevent this dreaded complication.26–28 Patients with significant
73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
Box 73–1 Proposed Criteria for Screening for Blunt Cerebral Vascular Injury (BCVI) ●
●
●
History ● Injury mechanism consistent with severe neck hyperextension, rotation, or hyperflexion ● Hanging ● Amaurosis fugax Physical Examination ● Arterial hemorrhage from the head or face from the mouth, nose, ears, or wounds ● Massive epistaxis ● Expanding cervical hematoma ● Bruit in the neck of a young patient (15). J Am Coll Surg 2006;202: 212–215; quiz A45. 3. Demetriades D, Martin M, Salim A, et al. The effect of trauma center designation and trauma volume on outcome in specific severe injuries. Ann Surg 2005;242:512–517; discussion 517–519. 4. Demetriades D, Berne TV, Belzberg H, et al. The impact of a dedicated trauma program on outcome in severely injured patients. Arch Surg 1995;130:216–220. 5. Cornwell EE 3rd, Chang DC, Phillips J, Campbell KA. Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care. Arch Surg 2003;138:838–843. 6. Scarborough K, Slone DS, Uribe P, et al. Reduced mortality at a community hospital trauma center: the impact of changing trauma level designation from II to I. Arch Surg 2008;143:22–27; discussion 27–28. 7. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 7th ed. Chicago: American College of Surgeons, 2004, p 73. 8. Welling DR, Burris DG, Hutton JE, et al. A balanced approach to tourniquet use: lessons learned and relearned. J Am Coll Surg 2006;203:106–115. 9. Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg 2006;244:371–380. 10. Demetriades D, Karaiskakis M, Velmahos G, et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg 2002;89:1319–1322. 11. Demetriades D, Sava J, Alo K, et al. Old age as a criterion for trauma team activation. J Trauma 2001;51:754–756; discussion 756–757. 12. Brown CV, Velmahos GC, Neville AL, et al. Hemodynamically “stable” patients with peritonitis after penetrating abdominal trauma: identifying those who are bleeding. Arch Surg 2005;140:767–772. 13. Brain Trauma Foundation and American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. Management and Prognosis of Severe Traumatic Brain Injury. Available at http://www2. braintrauma.org/guidelines/ (accessed June 16, 2006).
73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT 14. Davidoff J, Fowler R, Gordon D, et al. Clinical evaluation of a novel intraosseous device for adults: prospective, 250patient, multi-center trial. JEMS 2005;30(10 suppl):20– 23. 15. Black PC, Miller EA, Porter JR, Wessells H. Urethral and bladder neck injury associated with pelvic fracture in 25 female patients. J Urol 2006;175:2140–2144; discussion 2144. 16. Guillamondegui OD, Pryor JP, Gracias VH, et al. Pelvic radiography in blunt trauma resuscitation: a diminishing role. J Trauma 2002;53:1043–1047. 17. DiGiacomo JC, Bonadies JA, Cole FJ, et al. Practice Management Guidelines for Hemorrhage in Pelvic Fracture. The Eastern Association for the Surgery of Trauma. Available at http://www.east.org/tpg 18. Pereira SJ, O’Brien DP, Luchette FA, et al. Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture. Surgery 2000;128:678–685. 19. Ryan MF, Hamilton PA, Chu P, Hanaghan J. Active extravasation of arterial contrast agent on post-traumatic abdominal computed tomography. Can Assoc Radiol J 2004;55:160–169. 20. Velmahos GC, Toutouzas KG, Vassiliu P, et al. A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 2002;53:303–308; discussion 308. 21. Kimbrell BJ, Velmahos GC, Chan LS, Demetriades D. Angiographic embolization for pelvic fractures in older patients. Arch Surg 2004;139:728–732. 22. Hamill J, Holden A, Paice R, Civil I. Pelvic fracture pattern predicts pelvic arterial haemorrhage. Aust N Z J Surg 2000;70:338–343. 23. Eastridge BJ, Starr A, Minei JP, et al. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002;53:446–450; discussion 450– 451. 24. Sarin EL, Moore JB, Moore EE, et al. Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma 2005;58:973–977. 25. Shapiro M, McDonald AA, Knight D, et al. The role of repeat angiography in the management of pelvic fractures. J Trauma 2005;58:227–231. 26. Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg 1999;178:517–522. 27. Cothren CC, Moore EE, Ray CE Jr, et al. Screening for blunt cerebrovascular injuries is cost-effective. Am J Surg 2005;190:845–849.
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28. Kerwin AJ, Bynoe RP, Murray J, et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 2001;51:308–314. 29. Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 2002;236: 386–393. 30. Mutze S, Rademacher G, Matthes G, et al. Blunt cerebrovascular injury in patients with blunt multiple trauma: diagnostic accuracy of duplex Doppler US and early CT angiography. Radiology 2005;237:884–892. 31. Bub LD, Hollingworth W, Jarvik JG, Hallam DK. Screening for blunt cerebrovascular injury: evaluating the accuracy of multidetector computed tomographic angiography. J Trauma 2005;59:691–697. 32. Biffl WL, Egglin T, Benedetto B, et al. Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries. J Trauma 2006;60:745–751; discussion 751–752. 33. Berne JD, Norwood SH, McAuley CE, Villareal DH. Helical computed tomographic angiography: an excellent screening test for blunt cerebrovascular injury. J Trauma 2004;57:11–17; discussion 17–19. 34. Eastman AL, Chason DP, Perez CL, et al. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma 2006;60:925–959. 35. Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeonperformed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg 1998;228:557–567. 36. Holmes JF, Harris D, Battistella FD. Performance of abdominal ultrasonography in blunt trauma patients with out-of-hospital or emergency department hypotension. Ann Emerg Med 2004;43:354–361. 37. Farahmand N, Sirlin CB, Brown MA, et al. Hypotensive patients with blunt abdominal trauma: performance of screening US. Radiology 2005;235:436–443. Epub 2005; March 29. 38. McMonagle MP. Images in clinical medicine. The importance of early cervical-spine radiography. N Engl J Med 2006;354(4):e4. 39. Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004;20:57–70. 40. Elie MC. Blunt cardiac injury. Mt Sinai J Med 2006;73: 542–552. 41. Haut ER. Blunt cardiac injury. In Cameron JL (ed): Current Surgical Therapy, 9th ed. Philadelphia: Elsevier, 2008; pp 1063–1066.
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Management of Thoracic Trauma David T. Efron, MD and Edward E. Cornwell III, MD INTRODUCTION As with all traumatic injury, the management of thoracic trauma is centered on both the rapid diagnosis and the correction of the insult. Particular to injuries to the chest is the possible simultaneous disruption of two of the three life-sustaining physiologic processes (namely, breathing and circulation). Therefore, life-saving treatment and diagnosis often must occur in congruity. Many of the pitfalls that present themselves in the management of thoracic trauma are mistakes of omission and carry the risk of extreme morbidity and mortality. Many of the physiologic principles apply in the management of both blunt and penetrating injuries. As such, specific injuries are addressed in this chapter rather than mechanism. The steps followed in the care of the traumatically injured patient are well described and outlined by the Advanced Trauma Life Support training put forth by the Committee on Trauma of the American College of Surgeons.1 Ensuring an airway and confirming effective breathing and circulation are prime goals and permit appropriate diagnosis and guide treatment options.
INDICATIONS ● Hypotension ● Chest wall defects (open or closed) ● Injury mechanism
MANAGEMENT OF THORACIC TRAUMA STEPS Step Step Step Step Step
1 2 3 4 5
Airway Breathing Circulation Disability Exposure
On arrival at the trauma bay, once an airway is deemed secure, the lung fields are auscultated with a stethoscope. Absence of breath sounds suggests loss of pulmonary
aeration and is likely due to collapse of the pulmonary parenchyma and replacement with air, blood, or abdominal contents owing to diaphragmatic rupture (very rare on the right). Adjunctive physical examination findings may aid in the cause of pulmonary collapse such as tracheal shift from midline, hyperresonance (pneumothorax), or dullness (hemothorax) to percussion. However, in a busy, loud trauma room, these are rarely discernible. Victims of penetrating trauma will have wounds that will aid in identification of potential injury and that must be sealed as a source of pleural air. Accompanying hypotension may suggest tension physiology, which requires immediate decompression either by placement of a large-bore intravenous catheter into the pleural space (via the second intercostal space in the midclavicular line) or by immediate chest tube placement if it is readily available. Chest radiograph as an adjunct to the primary survey is often helpful in identifying hemo- or pneumothorax in the hemodynamically stable patient.
Incomplete Pleural Decompression of a Pneumothorax ● Consequence Because victims of thoracic trauma are at risk of multiple injuries contributing to the overall picture, accurate diagnosis and treatment are vital. An inadequately performed decompression of a tension pneumothorax not only continues the circulatory embarrassment of the patient but also confuses the picture and may delay vital diagnostic and therapeutic decision making. The thoracic cavity may be entered in the initial attempt at tube placement, thereby relieving the immediate tension pneumothorax. However, if the tube is subsequently left in the subcutaneous space, the tension may reaccumulate owing to ongoing leak from the pulmonary parenchyma. Grade 4/5 complication ● Repair Replacement of the intravenous catheter. Replacement of a subcutaneous chest tube.
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● Prevention Intravenous decompression: The apex of the thoracic cavity at the level of the second rib slopes posteriorly, though the chest wall in most patients remains parallel to the floor in the supine patient. To properly position this catheter, it is angled in a caudal direction and passed over the third rib. Chest tubes: This is often identified at postprocedure chest x-ray. Making the skin directly over the sixth rib at the point at which the tube is intended to enter the thoracic cavity and not trying to tunnel the chest tube helps avoid subcutaneous placement and ensure correct positioning. Obese patients are particularly at risk.
Incomplete Decompression of a Hemothorax ● Consequence Persistent hypotension after appropriate treatment of tension pneumothorax suggests an alternative ongoing source of shock. Massive hemothorax with ongoing bleeding is a well-recognized indication for operative intervention. Unrecognized persistent hemothorax at minimum hinders respiratory status, but more worrisome is the failure to recognize the source of ongoing hemorrhage and basing decision making on incomplete or faulty data (i.e., unnecessary laparotomy or delayed thoracotomy). This may be due to ongoing thoracic bleeding or improper positioning or kinking of the chest tube. Grade 3/4 complication
Figure 74–1 This patient suffered multiple rib fractures on the left after a motor vehicle collision. Initial chest tube placed for a pneumothorax was kinked at the most distal hole. Persistent pneumothorax is evident at the left apex on the chest x-ray.
● Repair A postinsertion chest radiograph confirms positioning of the chest tube. Recognition of a kinked chest tube on x-ray leads the surgeon to reposition it appropriately (Fig. 74–1). Clotted chest tubes can occur; however, this scenario is often associated with massive hemothorax and ongoing blood loss (Fig. 74–2). ● Prevention Insertion of a large-bore chest tube (36, 38, or 40 Fr) allows for maximal drainage of blood in patients with hemothorax. By twirling the chest tube around its longitudinal axis while inserting it through the chest wall, one ensures that it is not kinked. This maneuver should be performed whether the tube is inserted for hemothorax or pneumothorax.
Unrecognized Aortic Tear In the absence of hemothorax, the approach to the management in this scenario depends upon whether the mechanism of injury is blunt or penetrating. Patients suffering blunt injury of significant force are at elevated risk for aortic tear, most frequently seen just distal to the left subclavian orifice. Frequently, chest x-ray evidence suggests signs of great vessel injury including widened mediastinum, loss of the aortic knob, and pleural capping.2 Other signs that indicate heightened energy
Figure 74–2 This patient suffered a gunshot wound to the right chest and presented with a hemopneumothorax. The persistent massive hemothorax can be seen despite the excellent position of two chest tubes.
transfer include high rib fractures and sternal or scapular fractures. ● Consequence The ultimate consequences of unrecognized aortic injury include rupture and death. In addition, if the rupture remains contained, subsequent thoracic aortic aneurysm may develop. Grade 4/5 complication
74 MANAGEMENT OF THORACIC TRAUMA ● Repair Acute thoracic aortic disruption requires repair, most frequently with short segment graft interposition. Despite some case reports, there is not consistent enough experience to recommend an attempt at endovascular repair outside major study centers.3,4 ● Prevention Aggressive work-up and recognition of these injuries are mandatory. The “gold standard” has traditionally been conventional aortography. However, thoracic computed tomography (CT) scan has been shown to be reliable. Transesophageal echocardiography, when available, is another potential alternative.
Unrecognized Abdominal Injury ● Complication Hypotension in the setting of blunt aortic injury must be ascribed to another source of shock. Noncontained aortic tears result in rapid demise from exsanguinating hemorrhage. The blood found in the periaortic tissue from a contained tear in and of itself is usually not enough to cause global shock. Patients suffering sufficient blunt injury to incur aortic tear are also at risk for multiple injuries including fractures and abdominal injuries such as liver and splenic fractures. These injuries are much more likely to be exsanguinating, especially in the time it takes to work up and treat the aortic tear. Missed abdominal injury in this setting is potentially lethal. Grade 4/5 complication
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warranted. The prime goals are to (1) release a tamponade by opening the pericardium, (2) potentially control the hemorrhagic source by direct pressure, and (3) ensure adequate blood flow to the brain and coronary vessels by applying an aortic cross-clamp. This is achieved via a left anterolateral thoracotomy in the fifth intercostal space. When access to the thoracic cavity is gained, the pericardium is opened.7,8
Delayed Transport to the Operating Room to Allow Intubation ● Consequence In the setting of penetrating injury to the pulmonary parenchyma, the relatively low-pressure pulmonary vasculature is directly exposed to the aerated regions owing to the disruption of the architecture of each. In the nonintubated patient, the bronchial tree is also a low pressure system. When the patient is intubated, positive-pressure ventilation often causes the bronchial tree to become the higher-pressure system, especially in the setting of deep hemorrhagic shock. This raises the risk of air embolus. Grade 4/5 complication ● Prevention Rapid transport to and intubation in the operating room minimize the exposure time of the injured pulmonary vessels to the potentially high positive-pressure ventilation transmitted across injured airways. This also minimizes the time to definitive surgical therapy.
Phrenic Nerve Injury
● Repair Rapid exploratory laparotomy is the only solution if the injury is recognized late.
● Consequence Left hemidiaphragm paralysis. Grade 2/3 complication
● Prevention Aggressive screening is vital. In the hemodynamically stable patient, CT scanning of the chest and abdomen is integral to accurate injury diagnosis. Patients who are hemodynamically unstable may undergo focused abdominal ultrasound for trauma (FAST) or diagnostic peritoneal lavage (DPL).5,6 The finding of intraabdominal fluid in this setting necessitates immediate laparotomy prior to the definitive work-up for aortic tear (which is undertaken immediately after the abdominal injuries are stabilized).
● Prevention As the phrenic nerve courses longitudinally along the anterior aspect of the pericardium in the left hemithorax, the nerve is identified and the opening in the pericardium is made in a longitudinal manner parallel to the course of the nerve.
Hypotension in the Setting of Penetrating Thoracic Injury Hypotension in the setting of penetrating thoracic injury is due to bleeding, tension physiology, or cardiac tamponade. Ongoing bleeding often requires immediate operative repair. Tamponade often results in patient arrest en route to or immediately after arrival at the trauma bay. When this occurs, emergency department thoracotomy is
Unrecognized Right Thoracic Injury at Left Thoracotomy ● Consequence Missed thoracic injury in the right hemithorax significantly delays appropriate management and may lead to a lethal delay. Grade 4/5 complication ● Prevention For penetrating injuries to the chest, especially in the case of multiple injuries and suspected transmediastinal trajectory, simultaneous right chest tube placement at the time of left thoracotomy is advisable.
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Figure 74–4 Laparoscopic view of a diaphragmatic injury in a patient suffering an isolated stab wound to the left lower chest posteriorly. The Kelly clamp has been passed through the external defect and defines the track of the injury.
It should be noted that up to 20% of diaphragmatic injuries are present in the setting of a normal chest radiograph.10
Inadequate Analgesia for Rib Fractures Figure 74–3 Barium enema study of a patient with herniation of his colon through the left diaphragm. The defect is a result of a stab wound to the left lower chest several years prior.
Other Issues Unrecognized Diaphragm Injury ● Consequence Forty percent of penetrating thoracoabdominal wounds demonstrate associated diaphragm injury.9 Over time, left hemidiaphragm lacerations are at risk for developing into diaphragmatic hernias (Fig. 74–3). The right side is well protected by adhesion to the dome of the liver. Grade 2/3 complication ● Repair Subsequent operative takedown of a transdiaphragm hernia and repair are required. ● Prevention We favor an aggressive approach to penetrating injuries to this region. Any patient suffering a penetrating injury to the left thoracoabdominal region (from the sternum at or below the level of the nipple around to the scapular tip posteriorly and inferiorly to the costal margins) is taken for exploratory laparoscopy to inspect the diaphragm (Fig. 74–4). Injuries may be repaired in an open manner or laparoscopically if the surgeon is confident that other intraperitoneal injury can be excluded.
● Consequence The force sustained during blunt injury required to cause multiple rib fractures is often transmitted to the underlying pulmonary parenchyma and results in pulmonary contusion. This combination of pathology can lead to severe respiratory embarrassment. The area of contusion behaves as an intrapulmonary shunt demonstrating perfusion without aeration. Early on postinjury, this physiology worsens as the contusion matures. In addition, the patient will ineffectively breathe to utilize the remaining pulmonary tissue because of the pain associated with rib fractures. Analgesia is vital to successful pulmonary toilet and maintenance of pulmonary function. Inadequate analgesia can result in respiratory failure with subsequent mechanical ventilation and potential development of pneumonia. Grade 2/3 complication ● Prevention Accurate recognition of the extent of the injury is key. Patients may require intravenous patient-controlled analgesia with narcotics combined with oral nonsteroidal anti-inflammatory agents. The Eastern Association for the Surgery of Trauma guidelines recommend that epidural anesthesia is the preferred method of pain control for rib fractures from blunt injury (level 1 recommendation), that all patients over 65 with four or more rib fractures should undergo placement of a thoracic epidural for pain control, and consideration of thoracic epidural anesthesia should be given to
74 MANAGEMENT OF THORACIC TRAUMA any patient with four or more rib fractures (level 2 recommendations).11
Retained Hemothorax ● Consequence Entrapped lung from fibrin peal formation and empyema. Grade 2/3 complication ● Repair Open thoracotomy for excision of fibrin peal and release of entrapped lung. This is often a difficult procedure, given the inflammation, and is frequently accompanied by moderate blood loss.12 ● Prevention Plain chest radiographic imaging has a poor sensitivity in predicting the absence or presence of a significant volume of retained pleural blood. The pulmonary parenchyma is often contused, and this can suggest fluid where there is none or mask a significant volume of retained blood. A CT scan of the thorax enables quantification of retained fluid.13 If done within the first 4 days postinjury (prior to the formation of the fibrin peal), a video-assisted thoracoscopic drainage of the retained blood is usually successful and avoids the need for thoracotomy and empyemectomy.14
REFERENCES 1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 7th ed. Chicago: American College of Surgeons, 2004. 2. Nagy K, Fabian T, Rodman G, et al. Guidelines for the diagnosis and management of blunt aortic injury. Eastern Association for the Surgery of Trauma: Trauma Practice Guidelines, 2001. Available at http://www.east.org/tpg/ chap8.pdf
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3. Tehrani HY, Peterson BG, Katariya K, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006;82: 873–877. 4. Hoornweg LL, Dinkelman MK, Goslings JC, et al. Endovascular management of traumatic ruptures of the thoracic aorta: a retrospective multicenter analysis of 28 cases in The Netherlands. J Vasc Surg 2006;43:1096– 1102. 5. Ma OJ, Gaddis G, Steele MT, et al. Prospective analysis of the effect of physician experience with the FAST examination in reducing the use of CT scans. Emerg Med Australas 2005;17:24–30. 6. Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med 2003;21:476– 478. 7. Branney SW, Moore EE, Feldhaus KM, Wolfe RE. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma 1998;45:87–94. 8. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma—a review. Injury 2006;37:1–19. 9. Murray JA, Demetriades D, Asensio JA, et al. Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg 1998;187:626–630. 10. Murray JA, Demetriades D, Cornwell EE 3rd, et al. Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries. J Trauma 1997;43:624–626. 11. Pain management in blunt thoracic trauma (btt)—an evidence-based outcome evaluation. Eastern Association for the Surgery of Trauma: Trauma Practice Guidelines 2004. Available at http://www.east.org/tpg/painchest.pdf 12. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg 2004;78:282–285. 13. Velmahos GC, Demetriades D. Early thoracoscopy for the evacuation of undrained haemothorax. Eur J Surg 1999; 165:924–929. 14. Ahmed N, Jones D. Video-assisted thoracic surgery: state of the art in trauma care. Injury 2004;35:479–489.
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Management of Pancreatic and Duodenal Injuries David T. Efron, MD and Edward E. Cornwell III, MD
INTRODUCTION The management of pancreatic and duodenal injuries is often difficult, primarily owing to the unforgiving nature of injured tissues in these organs. Damage to these structures is often associated with a high mortality, especially with a penetrating mechanism, because of simultaneous injury to major vascular and other intra-abdominal structures.1–5 Appropriate management requires accurate diagnosis of the injuries, a clear understanding of gastrointestinal physiology (with a plan for restoring disrupted continuity), and acute attention to the ongoing status and stability of the patient.
MANAGEMENT OF PANCREATIC AND DUODENAL INJURIES STEPS Step 1 Step 2
Step 3 Step 4
Stabilization and diagnosis Complete exposure of duodenum and pancreas (Kocher’s maneuver, exploration of lesser sac, mobilization of spleen and pancreatic tail) Determination of resection, repair, drainage Repair (dependent upon injuries present)
OPERATIVE PROCEDURE Stabilization and Diagnosis Patients presenting with penetrating injuries that result in pancreatic or duodenal injuries almost uniformly demonstrate signs requiring immediate laparotomy. Hypotension and abdominal distention indicative of excessive blood loss are suggestive of major associated vascular injury. This is the setting in which most patients are explored for and
the pancreatic and duodenal injuries must be suspected and ruled out. To accomplish this, the entire trajectory of the penetrating object must be assessed. Central retroperitoneal hematomas must be explored. In the hemodynamically stable patient, peritonitis is often identified on presentation and also warrants immediate exploration. Victims of blunt abdominal trauma are often hemodynamically stable, allowing for more substantial work-up and diagnosis of injuries. Many patients present with multiple injuries, the result of high-energy transfer, such as motor vehicle collisions, pedestrians struck, or falls from height. Other blunt mechanisms include focused-point blows to the epigastrium with transmitted force directly over the duodenum and pancreas (such as falling onto a bicycle handle).6 Admission and serial serum amylase measurements can be useful to guide a more focused investigation of pancreatic injury. However, serum amylase at presentation is a poor predictor of pancreatic injury requiring operative repair.7,8 Computed tomography scanning is useful because it provides the most anatomic information with regards to these injuries and can easily diagnose duodenal wall hematomas, pancreatic fracture, peripancreatic edema or hematoma, free extravasation of contrast from duodenal disruption as well as associated trauma such as splenic or hepatic fractures.4,5,9,10 However, isolated pancreatic injury may not be evident at the time of initial scanning when inflammation may still be minimal. Focused abdominal sonography for trauma (the FAST scan) clearly demonstrates free intra-abdominal fluid but cannot delineate a specific source and is not useful for the diagnosis of retroperitoneal injuries. In the stable patient without peritonitis, more specific diagnostic modalities are useful to assess for suspected pancreatic and duodenal injuries. An upper gastrointestinal contrast study with Gastrografin can identify both luminal narrowing (the result of a duodenal mural hematoma) and contrast extravasation.9 Esophagogastro-
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duodenoscopy (EGD) with endoscopic retrograde cholangiopancreatography (ERCP) allows nonoperative assessment of the integrity of both the main pancreatic and the common bile ducts.11,12
Inappropriate Radiographic Work-up Delaying Operative Intervention ● Consequence Delayed operative intervention for a patient with major intra-abdominal hemorrhage is potentially life threatening and can have highly morbid sequelae owing to the need for resuscitation, excessive blood transfusion, and risk of coagulopathy. Grade 4/5 complication ● Prevention Adherence to the principles of trauma management with recognition of the hard indications for abdominal exploration facilitates rapid transport to the operating room. Pancreatic and duodenal injuries in and of themselves are rarely a cause of hemodynamic instability. When present, this is the result of other injuries, which must be immediately addressed.
Complete Exposure of the Duodenum and Pancreas (Kocher’s Maneuver, Exploration of the Lesser Sac, Mobilization of the Spleen and the Pancreatic Tail) The entire trajectory of the penetrating object must be assessed, and central retroperitoneal hematomas must be explored. Complete mobilization of the duodenum and the head of the pancreas allows inspection and palpation of the posterior aspect of these organs and the potential injuries that may have resulted from a through-andthrough trajectory to this region. When the track of the bullet traverses to the right of the superior mesenteric artery and vein, complete mobilization of the second portion of the duodenum and the head of the pancreas is accomplished via an extensive Kocher maneuver. By retracting the hepatic flexure of the colon inferomedially, the avascular connective tissue along the left lateral and posterior borders of the duodenum is easily divided (Fig. 75–1). Often, the right colon must be mobilized from the retroperitoneum along the line of Toldt to allow access to this region. Care must be taken to remain close to the duodenum and posterior pancreatic head because the inferior vena cava, right renal veins, and Gerota’s fascia are just deep to this dissection. The mobilization is taken to the lateral (right) edge of the superior mesenteric artery and vein. The anterior surface of the body and tail of the pancreas is explored through the lesser sac. Access to the lesser sac is best achieved through the gastrocolic ligament, initially via the relatively avascular area to the left of the midline toward the splenic flexure. This provides a clear view of the anterior surface of the pancreas (Fig. 75–2). A hematoma overlying the pancreas is explored (Fig. 75–3).
Figure 75–1 Division of the connective tissue along the lateral edge of the duodenum as the beginning of the Kocher maneuver.
Figure 75–2 Exploration of the lesser sac demonstrates the length of the anterior surface of the pancreas. A central hematoma is shown.
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Figure 75–3 Hematoma overlying the pancreas is explored. The inferior border of the gland is safely mobilized so that the posterior aspect of the gland may be explored for injury.
The posterior aspect of the body and tail of the pancreas is visualized either by dissection along the relatively avascular plane at the lower border of the pancreas (see Fig. 75–3) or by the complete mobilization of the spleen and pancreas medially out of the retroperitoneum (Fig. 75–4). This aspect of medial visceral rotation is accomplished by freeing the retroperitoneal attachments of the spleen from along the diaphragm and Gerota’s fascia and subsequently elevating the pancreas from the retroperitoneum with the splenic artery and veins intact. This allows inspection of the posterior border of the pancreas for through-andthrough injury. The pancreas can be mobilized to the level of the superior mesenteric vessels. The Kocher maneuver allows inspection of the entire C-loop of the duodenum. The first, third, and fourth portions are more easily directly inspected. If an anterior injury is noted as a result of penetrating injury, a posterior exit should be sought.
Missed Pancreatic or Duodenal Injury ● Consequence Failure to identify pancreatic injury may result in pancreatic leak, peripancreatic abscess, pancreatic fistula, pancreatitis, pseudoaneurysm formation, sepsis, and pseudocyst formation.2–5,13 Similarly, failure to identify duodenal perforation can result in local abscess, duodenocutaneous fistula, and severe sepsis.13–15 Each carries elevated morbidity and mortality. Grade 4/5 complication
Figure 75–4 Medial rotation of the spleen and pancreas from the left retroperitoneum also allows access to the posterior aspect of the gland and is the principal maneuver in completing a distal pancreatectomy and splenectomy.
● Repair Control of leakage and wide drainage are the governing principles to treatment of missed injuries. In all but a very few stable patients, this includes reexploration for appropriate treatment. Isolated pancreatic duct injuries identified endoscopically may be treated with placement of a pancreatic duct stent (Fig. 75–5). ● Prevention Complete mobilization of the duodenum and the head of the pancreas allows inspection and palpation of the posterior aspect of these organs and the potential injuries that may have resulted from a through-and-through penetrating trajectory to this region. Complete mobilization of both the duodenum and the pancreas at the time of laparotomy is also important in blunt trauma in which there is suspicion of pancreatic or retroperitoneal duodenal injury.
Injury to a Replaced Right Hepatic Artery during Kocherization ● Consequence In 10% to 15% of patients, a replaced right hepatic artery is identified at the superior edge of the dissection.16 The difficulty of this dissection is at times
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Figure 75–5 Endoscopically placed pancreatic duct stent for successful isolation of traumatic pancreatic duct disruption.
increased by tissue hematoma from bleeding vessel branches. If this is injured in the dissection, significant hepatic ischemia may ensue, especially if there is concomitant injury to the portal vein. Grade 2/3 complication
The decision to proceed with a complex gastrointestinal reconstruction in this acute setting will invariably lead to exacerbation of the lethal triad of hypothermia, coagulopathy, and acidosis with subsequent patient demise.18
pancreatic duct is not easily identified in a normal gland, this is not always easily accomplished by inspection alone. Intraoperative fluoroscopic pancreatography (either endoscopic or transduodenal) aids in identifying duct disruption for the hemodynamically stable patient. Because neither the pancreatic duct nor the pancreatic parenchyma are well managed with primary repair, pancreatic duct disruption often necessitates pancreatic resection. Injury to the duct at the neck, body, and tail of the pancreas is well treated with a distal pancreatectomy. In patients with a normal gland prior to injury, up to an 80% distal pancreatectomy may be well tolerated without subsequent endocrine or exocrine insufficiency.19 This may be performed either with or without splenic preservation. If splenic preservation is opted for, careful dissection is necessary to ligate the numerous splenic arterial and venous branches found along the superior border of the pancreas (Fig. 75–6). Injury to the pancreatic parenchyma in the absence of main duct injury is best treated with wide drainage with closed suction drains placed at the time of exploration. These serve well to control the pancreatic fistulas reported in as many as 15% of cases.2–5
Hemodynamic Instability, Acidosis, Hypothermia, Coagulopathy
Failure to Identify the Pancreatic Duct
● Repair If the right lobe of the liver demonstrates critical vascular compromise owing to interrupted flow, arterial bypass emergent may be necessary.17 ● Prevention Careful palpation of a pulse in this vessel (if present) defines the superior limit of the Kocherization and avoids injury to this vessel.
Determination of Drainage, Repair, or Resection
● Consequence Death. Grade 4/5 complication ● Prevention Control of hemorrhage and intestinal spillage and temporary abdominal closure with transport to the intensive care unit for correction of the previously described physiologic perturbations are the only life-sustaining options. Interval return to the operating room to reestablish gastrointestinal continuity is undertaken when the patient is more stable.1,2
Pancreas Complete exposure of the injury to the pancreas allows assessment for main pancreatic duct injury. The integrity of this duct guides operative decision making. Because the
● Consequence High-output pancreatic fistula, metabolic acidosis, exocrine insufficiency. Grade 2/3 complication ● Repair Although consistent data are lacking for the definitive treatment of pancreatic fistulas, a number of options exist for control of the fistula. Strict nothing-by-mouth status with total parenteral nutrition decreases the stimulus of pancreatic exocrine function. The addition of subcutaneous octreotide (100 mcg three times per day) may also help, although prospective, randomized, controlled studies of octreotide use in elective pancreatic surgery provide conflicting evidence.20–24 ERCP may be useful in identifying a proximal pancreatic duct stricture the stenting of which may improve appropriate enteric
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may also be necessary to achieve hemorrhage control. As previously noted, in hemodynamically unstable patients, reconstruction of gastrointestinal continuity can be delayed until the patient is adequately resuscitated.
Failure to Identify the Course of the Common Bile Duct in the Head of the Pancreas or the Ampulla at the Duodeum ● Consequence Suture ligation of the common bile duct with complete biliary obstruction. Grade 3/4 complication
Figure 75–6 Careful dissection and ligation of the multiple vascular branches along the superior edge of the pancreas allow the option of splenic preservation in the course of distal pancreatectomy for significant injury to the distal body and tail of the gland.
flow of pancreatic juice. Occasionally, persistent fistula necessitates distal pancreatectomy (or revision distal pancreatectomy), or roux-en-Y pancreatoenterostomy (to the leaking distal pancreas) to control. Exocrine insufficiency is well treated with oral pancrelipase supplementation, whereas bicarbonate replacement for severe cases may also be provided via the oral route. ● Prevention Identification of the pancreatic duct and directed ligation at the time of distal pancreatectomy reduce the incidence of major leak.
Duodenum The management of penetrating injury to the duodenum is governed by the percentage of bowel wall involvement. Disruption of greater than 50% of the duodenal circumference precludes primary repair. Alternatively, these injuries can be repaired with direct patching via a jejunoduodenostomy (either a loop or a roux). If the patient is hemodynamically unstable, simple control of soilage is achieved as part of a damage control procedure, and definitive reconstruction is delayed. Extensive tissue destruction or complete disruption of the distal common bile duct resulting from combined pancreaticoduodenal trauma may require resection of the second portion of the duodenum and pancreatic head via a pancreaticoduodenectomy. This
● Repair Endoscopic transampullary imaging with endoscopic stent placement is possible for incomplete transection and incomplete ligation of the common bile duct. This may not be optimal in a patient with a fresh duodenal repair and suture line. A percutaneous transhepatic biliary drain can often be threaded across such a biliary structure. However, in the case of suture ligation, this is technically quite difficult. This may result in complete external drainage of biliary flow. In such cases, delayed choledochoenterostomy or hepaticoenterostomy is undertaken several months after recovery from the acute injury. ● Prevention At the time of initial exploration, the ampulla may be identified through the duodenal injury and a probe or dilator passed into the bile duct to guide the placement of repair sutures to avoid iatrogenic injury. If the ampulla cannot be identified in this manner, a cholecystectomy may be performed with passage of a catheter distally into the duodenum to identify both the common bile duct and the ampulla itself, again facilitating repair.
Repair (Dependent upon Injuries Present) The principles in the management of complex combined pancreatic and duodenal injuries include maintenance of enteric, pancreatic, and biliary flow; abundant drainage of all injuries; and repairs and isolation of injured and repaired tissue by diversion of the enteric stream. In addition to repair of the duodenal injury (either primary or patched) and drainage of the pancreatic parenchymal injury, the pylorus is surgically closed (pyloric exclusion), either by suture or by staples applied across the muscle, with additional creation of a gastrojejunostomy. Remarkably, the pylorus is often patent at 4 to 6 weeks regardless of the method of closure. At the time of repair, a feeding jejunostomy is fashioned to assist in postoperative enteral feeding should a pancreatic or proximal duodenal leak form precluding oral-enteral alimentation. Some surgeons add a retrograde intraluminal drainage tube to assist in enteric decompression.2,14,15
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Inadequate Pyloric Exclusion ● Consequence Inadequate isolation of injured duodenal segment. If sutures are placed in a prepyloric location, isolated distal gastric antrum is excluded from exposure to acid-losing feedback inhibition. This results in hypersecretion of gastrin, subsequent hyperacidity and potential for gastritis, and marginal ulceration at the gastrojejunostomy.25 Grade 2/3 complication ● Repair In the short-term, proton pump inhibitors may aid this. Sutures may potentially be cut endoscopically, but stapled exclusion is not amenable to this. Surgical revision is reserved for intractable cases.
11.
12.
13.
14.
15.
● Prevention Appropriate identification of the pylorus ensures correct placement of the exclusion. Internal digital palpation of the pylorus via a gastrostomy greatly facilitates correct identification.
16.
REFERENCES
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1. Rickard MJ, Brohi K, Bautz PC. Pancreatic and duodenal injuries: keep it simple. Aust N Z J Surg 2005;75:581– 586. 2. Lopez PP, Benjamin R, Cockburn M, et al. Recent trends in the management of combined pancreatoduodenal injuries. Am Surg 2005;71:847–852. 3. Vasquez JC, Coimbra R, Hoyt DB, Fortlage D. Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury 2001;32: 753–759. 4. Patton JH, Fabian TC. Complex pancreatic injuries. Surg Clin North Am 1996;76:783–795. 5. Patton JH Jr, Lyden SP, Croce MA, et al. Pancreatic trauma: a simplified management guideline. J Trauma 1997;43:234–239. 6. Jacombs AS, Wines M, Holland AJ, et al. Pancreatic trauma in children. J Pediatr Surg 2004;39:96–99. 7. Shilyansky J, Sena LM, Kreller M, et al. Nonoperative management of pancreatic injuries in children. J Pediatr Surg 1998;33:343–349. 8. Jobst MA, Canty TG, Lynch FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg 1999;34:818–824. 9. Degiannis E, Boffard K. Duodenal injuries. Br J Surg 2000;87:1473–1479. 10. Cornwell EE, Campbell K. Operative management of pancreatic trauma. In Baker RJ, Fischer JF (eds): Mastery
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of Surgery, 4th ed. Baltimore: Lippincott Williams & Wilkins, 2001; pp 1319–1325. Varadarajulu S, Noone TC, Tutuian R, et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005;61:568–575. Wolf A, Bernhardt J, Patrzyk M, Heidecke CD. The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma. Surg Endosc 2005;19:665–669. Tyburski JG, Dente CJ, Wilson RF, et al. Infectious complications following duodenal and/or pancreatic trauma. Am Surg 2001;67:227–230. Timaran CH, Martinez O, Ospina JA. Prognostic factors and management of civilian penetrating duodenal trauma. J Trauma 1999;47:330–335. Tsuei BJ, Schwartz RW. Management of the difficult duodenum. Curr Surg 2004;61:166–171. Covey AM, Brody LA, Maluccio MA, et al. Variant hepatic arterial anatomy revisited: digital subtraction angiography performed in 600 patients. Radiology 2002; 224:542–547. Samek P, Bober J, Vrzgula A, Mach P. Traumatic hemobilia caused by false aneurysm of replaced right hepatic artery: case report and review. J Trauma 2001;51: 153–158. Loveland JA, Boffard KD. Damage control in the abdomen and beyond. Br J Surg 2004;91:1095–1101. Slezak LA, Andersen DK. Pancreatic resection: effects on glucose metabolism. World J Surg 2001;25:452– 460. Hesse UJ, De Decker C, Houtmeyers P, et al. Prospectively randomized trial using perioperative low dose octreotide to prevent organ related and general complications following pancreatic surgery and pancreaticojejunostomy. Acta Chir Belg 2005;105:383–387. Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg 2000;232:419–429. Lowy AM, Lee JE, Pisters PW, et al. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg 1997;226:632–641. Montorsi M, Zago M, Mosca F, et al. Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery 1995;117:26–31. Buchler M, Friess H, Klempa I, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–130. Fang JF, Chen RJ, Lin BC. Controlled reopen suture technique for pyloric exclusion. J Trauma 1998;45:593– 596.
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Traumatic Brain Injury Adil H. Haider, MD and Edward E. Cornwell III, MD INTRODUCTION Traumatic brain injury (TBI) is one of the most significant trauma diseases of our time, with an estimated annual incidence of 1.4 million cases per year in the United States. These injuries result in upward of 50,000 deaths and 80,000 to 90,000 patients with lifelong or long-term disabilities each year.1,2 It is estimated that 5.4 million Americans are disabled owing to TBI, and the direct and indirect costs associated with this problem exceeded $50 billion dollars annually by 1995.3 Little can be done to reverse the initial traumatic insult and the resultant primary brain injury. However, secondary brain injury caused by decreased perfusion of the brain tissue can be prevented and is, therefore, the most important aspect in TBI management. Secondary injury is commonly a consequence of hypotension, hypoxia, or both. In a study of the Trauma Coma Databank,4 mortality rose from 25% to 75% if patients were subjected to both of these factors (Table 76–1). Guidelines for management of TBI have been developed by the Brain Trauma Foundation (BTF) and the American Association for Neurological Surgery (AANS), using the best available evidence.5 These guidelines use the following terminology: “standards” for level 1 recommendations, “guidelines” for level 2, and “options” for level 3. The guidelines have three standards that recommend against the use of certain previously practiced therapeutics including (1) hyperventilation, (2) use of steroids after head injury, and (3) prophylactic use of antiseizure medications to prevent late seizures. This chapter presents common TBI scenarios with management recommendations based on BTF/AANS guidelines.
SCENARIO 1 A 27-year-old man, nonhelmeted rider of a motorcycle is brought to the emergency department after colliding with a stationery vehicle. The paramedics report that the patient initially complained of something “wrong with my head” and now is verbalizing words that do not make any sense. On primary survey, his airway is clear, he has bilateral breath sounds, and his blood pressure is 101/61. Upon
painful stimuli, he opens his eyes and withdraws his extremities, making incomprehensible sounds. The paramedics suspect head injury, so the patient is immediately transported to the computed tomography (CT) scanner. The trauma team is concerned about intracranial hemorrhage, “he may need to be rushed to the OR (operating room),” comments the trauma team leader. Upon arrival at the CT scanner, the patient has agonal breathing— requiring emergent intubation—and suffers several minutes of desaturation.
Did not Intubate a Patient with a Glasgow Coma Score of 8 or Less ● Consequence Emergent airway establishment leading to hypoxemia and further brain injury. Grade 3/4 complication ● Prevention In the ABCDs of resuscitation, D is for disability, or quick neurologic examination with ascertainment of the Glasgow Coma Score (GCS) (Table 76–2). This patient has a GCS of 8 (eye opening [E] 2, verbal [V] 2, motor [M] 4). The two culprits most responsible for secondary brain injury leading to death and disability in TBI patients are hypoxia and hypotension. A patient with GCS of 8 or less must be intubated to protect the airway and prevent hypoxia. If endotracheal intubation proves to be difficult and is not achievable quickly, a cricothyroidotomy should be performed, and there should be no hesitation in establishing a surgical airway in trauma patients. In this scenario, the trauma team had the correct sense of urgency for obtaining the CT scan because the faster the scan the faster the patient can be triaged to the operating room for an operable lesion. Once the airway is secured and the primary survey is completed, a patient with a GCS of 8 should receive a CT scan of the brain as soon as possible to determine the extent of brain injury. In these cases, valuable time should not be wasted performing the secondary survey or doing routine procedures such as placing a Foley catheter (Fig. 76–1).
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SECTION XII: TRAUMA SURGERY
Table 76–1 Outcomes after Secondary Brain Insult among Patients with Traumatic Brain Injury Secondary Insult (N)
TBI with GCS 3-8
None to Moderate Disability (%)
Death (%)
Total patients (699)
43
37
Hypoxia (78)
45
33
Hypotension (113)
26
60
Neither (456)
51
27
6
75
Hypotension and hypoxia (52)
Adapted from Trauma Coma Databank: Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216–222.
Table 76–2 Glasgow Coma Score Score
Secure airway (Intubation vs cricothyroidotomy)
Complete primary survey (Secure IV access, ensure HD stable)
HD stable: Proceed to CT scan Bypass secondary survey
HD unstable: Continue ATLS protocol
Figure 76–1 Initial management of the traumatic brain injury (TBI) patient. HD, hemodynamically.
Criterion
Eye Opening 4
Spontaneous
3
To verbal command
2
To pain
1
None
Motor 6
Obeys commands
5
Localizes pain
4
Withdraws to pain
3
Abnormal flexion to pain (decorticate)
2
Abnormal extension to pain (decerebrate)
1
None
Verbal 5
Oriented and converses
4
Confused conversation
3
Inappropriate words
2
Incomprehensible sounds
1
None
Figure 76–2 Computed tomography (CT) scan shows frontal contusions without a midline shift.
Glascow Coma Score (GCS) = Eye opening + motor + verbal.
SCENARIO 2 A 52-year-old woman, restrained driver of a motor vehicle is brought to the emergency department after a head-on collision with another vehicle. Her heart rate is 65, blood pressure is 97/54, and she has a peripheral oxygen saturation of 97%. She is noted to make incomprehensible sounds, has an abnormal flexion of the limbs upon stimuli, and opens her eyes only after being stimulated. She is appropriately intubated to “protect the airway.” Initial CT
scan of the head reveals frontal contusions without midline shift (Fig. 76–2). No other injuries are noted. Her blood work is also within normal limits except for a mild base deficit on the arterial blood gas. The patient is slated to be transferred to the intensive care unit (ICU) and is to get a repeat CT scan in 8 hours. After a delay owing to bed availability, the patient arrives at the trauma ICU 3 hours later. The admitting nurse notes that the patient has fixed and dilated pupils and now has a heart rate of 54 and blood pressure of 194/107.
76 TRAUMATIC BRAIN INJURY
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Box 76–1 Risk of Intracranial Pressure Elevation and Progression to Coma according to GCS
Box 76–2 Calculation of Cerebral Perfusion Pressure, (CPP)
Mild TBI (GCS 13–15) < 3%
Cerebral perfusion pressure (CPP) = Mean arterial pressure (MAP) − Intracranial pressure (ICP)
Moderate TBI (GCS 9–12) = 10%–20% Routine ICP monitoring in these patients not indicated.
Severe Head Injury (GCS £ 8) and *Abnormal CT Scan = 50%–60% Place ICP monitor.
Severe Head Injury (GCS £ 8) and Normal CT = 13% In a patient with a normal CT, if any two of the following three factors are present: age >40 years; systolic blood pressure