Laparoscopic Splenectomy

Diana G. Weber Doctor , Aarti Mathur MD , in Surgical Pitfalls, 2009

Gastric Perforation (Gastrotomy)/Necrosis

• Consequence

Gastrotomy results in the spillage of gastric contents into the abdominal cavity, resulting in peritonitis. This can present immediately in the operating room from direct penetrating injury to the stomach during dissection, or it may present later with a delayed perforation from thermal injury or serosal tears during dissection. Use of a harmonic scalpel near the stomach can contribute to thermal or serosal injuries that may result in delayed perforation.

Grade 1/3/5 complication

• Repair

If recognized during the procedure, primary repair of a gastric perforation may exist attempted laparoscopically; withal, it is recommended to convert to laparotomy. 24 A delayed perforation requires laparotomy for repair.

• Prevention

It is not uncommon for the proximal greater bend of the stomach to straight abut the spleen. Therefore, advisable traction and clear visualization of tissues during partitioning of the short gastrics are essential. Care must also be taken to appreciate the structures that the heated portion of the dissector may bear upon. The ultrasonic dissector allows for less autopsy around the vessels shut to the stomach and spleen, reducing the incidence of gastric perforation.

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Peptic Ulcer and Other Conditions of the Stomach

L.R. SchererIII, in Pediatric Surgery (Seventh Edition), 2022

Treatment

Pyloric atresia tin can usually be recognized at the time of functioning; a fibrous string may join two blind ends (Fig. 79-3 ). Gastrotomy and distal passage of a catheter may exist required to notice bleary obstructions ( Fig. 79-4). Excision of a complete or fractional diaphragm with Heineke-Mikulicz or Finney pyloroplasty is the most straightforward corrective process. Haller and Cahill 106 warn against missing a pyloric spider web in association with a duodenal atresia. They recommend a broad gastrotomy and distal passage of a catheter after excision of the prepyloric diaphragm to place an associated duodenal diaphragm. In the presence of pyloric atresia with the atretic ends separated by a cordlike or discontinuous segment, gastroduodenostomy is necessary. Dessanti 107 and colleagues described an anatomic pyloric sphincter reconstruction procedure using the atretic cul-de-sac to perform an finish-to-end anastomosis. This procedure replaces the resection of the atretic segment and a side-to-side or end-to-oblique anastomosis because of the size disparity betwixt the stomach and duodenum. A temporary decompression gastrostomy and insertion of a transgastric feeding tube may be useful. Recent advances in endoscopy have stimulated development of alternate treatment strategies including airship dilatation, light amplification by stimulated emission of radiation spider web excision, and laser radial incisions of a type I membrane. The number of these cases is few, and long-term follow-up data are limited.

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EUS-Guided Drainage of Pancreatic Pseudocysts

Hans Seifert , Shyam Varadarajulu , in Endosonography (Second Edition), 2022

Surgical Cystogastrostomy

Open up surgical drainage entails the creation of a cystogastrostomy or cystenterostomy. This can also exist accomplished laparoscopically through an anterior transgastric approach, which requires an anterior gastrotomy for access and a cystogastrostomy creation through the posterior gastric wall, or a posterior arroyo through the lesser sac. 1 The procedure tin likewise be performed through a lesser sac approach, which is technically easier and is associated with less intraoperative bleeding. 2 Pancreatic pseudocysts that are not in close proximity to the tum crave the creation of a cystojejunostomy. 3 The cystojejunostomy is sometimes created through a Roux limb of jejunum. Although the technical and treatment success rates for surgery are loftier, the process is associated with a x% to 30% morbidity charge per unit and a i% to 5% mortality rate. four The technique is invasive, associated with prolonged hospital stay, and more than expensive than the alternatives 5 (Tabular array 22.1).

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Open Gastrostomy Feeding Tube Placement and Percutaneous Endoscopic Gastrostomy Tube Placement

Rebecca Evangelista Doc , Eleanor Faherty MD , in Surgical Pitfalls, 2009

Placement of the Gastrostomy Tube into the Stomach through the Anterior Abdominal Wall

Tube Harm/Inadequate Closure of Pursestring Sutures

• Issue

Firsthand or delayed failure of the balloon to retain inflation. Immediate or delayed leak from or around the tube. An early upshot 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 issue in extravasation of tube contents into the abdomen or along the abdominal wall tract leading to peritonitis or localized fasciitis, respectively.

Grade ane/2 complication

• Repair

After passing the tube through the tract in the abdominal wall, test a balloon, if used, or affluent the tube with saline and look for a leak. A dilute solution of methylene blue can as well be used if harm to the tube is suspected just unclear with saline flush.

• Prevention

After the tract in the anterior intestinal 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 clench to avoid damage to the tube as it is being pulled through the layers of the intestinal wall.

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Laparoscopic Roux-en-Y Gastric Bypass

W. Lynn , Due south. Agrawal , in Metabolism and Pathophysiology of Bariatric Surgery, 2022

Fully Stapled Technique

The fully stapled technique has been popularized by Dillemans et al. [21] . The gastric pouch creation is performed as per the linear stapling technique. The gastro-jejunostomy is so formed as follows. A gastrotomy is made in the pouch in the same area equally per linear stapling and stretched. A handbag string suture is then placed around this gastrotomy and a circular stapler anvil is introduced into the belly and manipulated into the pouch. The purse string is then tied. Splitting of the greater omentum is then undertaken, if required. The required length of BP limb is measured out and brought toward the pouch in an antecolic fashion. Five centimeters (5  cm) before the desired site of anastomosis, an enterotomy is formed, and the circular stapling device introduced into the jejunum and the stapler connected to the anvil as per the circular stapling technique. The blind loop is resected to close the introduction site of the stapling device. Formation of the jejuno-jejunostomy begins by measurement of the Roux limb, and an enterotomy is formed at the desired point as well as in the BP limb. Two firings of a laparoscopic stapling device are then used to form the jejuno-jejunostomy. The enterotomy from the JJ is then lifted with three stay sutures and the defect stapled closed with a further firing of a laparoscopic stapling device. Excess blind BP limb is so resected and the mesenteric defects closed.

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Critical Intendance Neurology Part I

E.F.M. Wijdicks , in Handbook of Clinical Neurology, 2022

Management of the comatose patient

The run a risk of a favorable outcome in the care of astute brain injury leading to blackout can be easily diminished if full general principles of high-quality intensive care are not aggressively attended to. An immobile mechanically ventilated patient fed through a percutaneous gastrotomy (PEG) ( Fig. eight.three) requires vigilance, specialized nursing care, and stewardship. Every 24-hour interval, infections may present, skin may suspension down, and fluid shifts may crusade rapid imbalance of homeostasis. Drugs (peculiarly antibiotics) take potential short- and long-term adverse effects. Adequate management of eye, mouth, and skin at pinch sites requires frequent change of linens, patches, and protective pads. Splinting of extremities may be needed to avoid contractures. At that place are few hard information to support whatsoever of these interventions. The hard truth is that maintenance of a comatose patient is fraught with difficulties.

Fig. 8.3. Tracheostomy allowing speech for recovering patients.

Inability to close eyelids completely after trauma and, in particular, nocturnal lagophthalmos are risk factors for conjunctivitis and corneal erosion (Lavrijsen et al., 2005). Polyethylene moisture chambers are required to prevent early epithelial breakdown, just some patients may take to be treated with lateral tarsorrhaphy. Filamentary keratopathy is a common dry-eye syndrome in patients in prolonged coma. Prolonged eyelid contact with the cornea and reduced blinking impair lacrimal fluid turnover and may be contributing factors.

Tracheostomy reduces pulmonary complications and provides easier access for pulmonary toilet. Tracheostomy will reduce length of stay, but information technology should more often than not be postponed until approximately two weeks in patients who can potentially exist liberated from the ventilator if they show early signs of substantial neurologic improvement (Fig. 8.iv). Gradually, after the patient is weaned off the ventilator, the tracheostomy can be closed, including in patients with prolonged unconsciousness. Pulmonary care involves frequent culturing of sputum when secretions change in color and texture and immediate antibody coverage to care for pneumonia and sepsis. Pleural effusions are frequent as a manifestation of anasarca and big pleural collections may need to be tuckered. Gastrointestinal issues vary from gastroparesis to paralytic ileus, resulting in distension of the colon and increased risk of perforation. Daily bowel care may include motility agents.

Fig. 8.4. Percutaneous gastrostomy.

The nearly common healthcare-related infections are pneumonia, urinary tract infections, or infections of indwelling venous catheters. Potentially difficult to eradicate microorganisms include Enterococcus faecalis or faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter cloacae. Clostridium difficile infections are also on the rise, particularly in patients with long hospital stays. The dilemma faced past treating physicians is that delayed initiation of antibiotics increases bloodshed, yet combination therapies to broaden the spectrum may lead to antibiotic resistance. Antibiotic therapy is complex and oft changing as a result of infectious disease consultation.

Fever in comatose patients is more often than not acquired by infections. Lingering infections have to be excluded earlier attributing fever to the encephalon injury. All the same, Paroxysmal sympathetic hyperactivity (PSH) syndrome is a usually seen in "unexplained" fever of comatose patients. PSH or dysautonomic storming all too ofttimes remains unrecognized and untreated. These spells are almost common in young patients with diffuse axonal traumatic brain injury, but tin occur with whatsoever major brain injury. Episodes of PSH tin can brainstorm during the acute phase, often in comatose patients, and keep into the rehabilitation stage. Patients go tachycardic, hypertensive (with widened pulse pressure), tachypneic, febrile, diaphoretic, and oftentimes develop markedly increased tone, which may event in dystonic posturing. Pupillary dilatation, piloerection, and peel flushing tin can as well be seen. The manifestations of PSH respond best to bolus doses of morphine sulfate (ii–eight   mg intravenously). This favorable response is not related to the analgesic effect of opiates, simply rather to modulation of central pathways that are responsible for the autonomic dysfunction. The response to morphine is rapid and quite reliable in aborting spells of PSH. Other effective medications for the treatment of PSH include noncardioselective beta-blockers (such every bit propranolol), clonidine, and dexmedetomidine (central alpha 2-receptor agonists), bromocriptine (a dopamine D2-receptor agonist), baclofen (a GABAB receptor agonist), benzodiazepines (GABAA receptor agonist), and gabapentin (which binds GABA receptors and voltage-gated calcium channels in the dorsal horn of the spinal cord). In our experience, beta-blockers and clonidine are useful in controlling the tachycardia and hypertension, but less then for the dystonia. Baclofen and benzodiazepines (especially diazepam) exercise cause muscle relaxation, only may not improve the other hypersympathetic features.

Continuous book replacement is needed for long-term care. The adequate intravascular condition is determined by satisfactory organ perfusion (urinary output, capillary refill, cold or warm extremities, claret lactate, and mixed venous oxygen saturation). Tissue edema may class over time, possibly as a event of overzealous fluid administration (east.1000., failure to suit intravenous fluid rate while advancing enteral nutrition, failure to concentrate medications). Volume depletion is less common in the longterm but may occur, peculiarly when extravascular compartment is expanded by sepsis. Hypotonic crystalloids, such every bit lactated Ringer's or half normal saline, should be avoided in traumatic brain injury. Albumin (v%) is a good volume expander, and may have a office in sepsis resuscitation, merely the safety in astute brain injury is unclear and may be deleterious in traumatic brain injury. In patients who take developed oliguria and a rise in BUN (BUN/creatinine ratio   >   20), aridity is very likely and should result in discontinuation of all diuretics and administration of normal saline.

Nutrition is somewhen provided through a PEG (Fig. 8.3), which is very safe. A report of 674 patients reported only two% of patient experienced reversible complications (Iizuka and Reding, 2005). Complications include wound infection, leakage, peritonitis, self-extubation or hemorrhage in the kickoff weeks of placement. The risk of gastrointestinal hemorrhage may be increased. Compared with nasogastric tubes, gastroesophageal reflux is lower in patients with a PEG.

A bowel care regimen should exist initiated. Bowel incontinence is often present, and the task is to proceed the peel clean and dry. Diarrhea may have many causes, but can be attributed to certain nutritional formulas and resolve with reducing fiber content. Antibiotics, as well as Escherichia coli or Clostridium difficile infections, are other possible causes of diarrhea. Failure to pass stool, or marble-like stools, should be treated with rectal enema or manual removal. Glycerol suppository can be helpful, but senna (ten   mL) and lactulose (twenty   mL) are common maintenance therapies. Comatose patients are at risk of adynamic ileus. Marked abdominal distension and auscultatory silence are early on signs. Metoclopramide (10   mg 4) or erythromycin (500   mg orally) can be very constructive to resolve the bowel distension.

Nosocomial urinary tract infections will probable occur in comatose patients with long-term indwelling catheters. Bacteriuria involves Escherichia coli and Pseudomonas aeruginosa in two-thirds of all cases, with less frequent pathogens, including Enterococcus spp., Acinetobacter spp., Klebsiella spp., and Proteus spp. Increased take chances for bacteriuria in patients admitted to ICU is conveyed past female gender (brusk urethra and flora contamination), length of ICU stay, antibiotic use, and duration of catheterization; thus, they are to some caste unavoidable. The types of drainage systems, aseptic handling, and other avoidance measures accept been successful in reducing infection rates. This includes preventing the catheter tubing from kinking, regular elimination of collection purse, maintaining drainage systems beneath level of bladder, appropriate meatal care, and use of silver-impregnated urinary catheters or vesical irrigation with neomycin and polymyxin. The long-term care of the comatose patient is summarized in Table eight.5.

Tabular array eight.5. Daily concerns in care of the comatose patient

Lungs Mechanical ventilation settings
Weaning option
Tracheostomy care
Breast X-ray for infiltrates
Heart Cardiac arrhythmias
Electrocardiogram changes (i.e., QT prolongation)
Inotropes/vasopressors/beta blockade
Gastrointestinal Oropharyngeal hygiene
Diet and choice of formula
Targets glucose/insulin drips
Bowel motion assistance
Bladder Indwelling catheter
Urine analysis
Pare Decubitus
Conjunctiva/centre care
Prophylaxis Unfractionated heparin
Surveillance ultrasound of venous arrangement
Gastrointestinal prophylaxis
Fever control
Admission Peripheral catheter
Peripherally inserted central catheter
Subclavian
Peripheral intravenous
Medication Medication reconciliation
Antibiotic stop dates
Drug–drug interaction
Sedation/analgesia needs

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Intramural and Transmural Endoscopy

Lyz Bezerra Silva , Ricardo Zorron , in Clinical Gastrointestinal Endoscopy (Third Edition), 2022

Technique of Transgastric Surgery

The patient is sedated with general anesthesia and placed in a Lloyd-Davies position. Pneumoperitoneum can exist achieved using a Veress needle, followed past insertion of an umbilical laparoscopic optic, which allows peritoneoscopy to evaluate the feasibility of the procedure, safe transluminal entrance of the endoscope to the abdominal crenel, and facilitates closure of the gastric wound after the process.

The access technique starts by perorally passing a flexible endoscope into the stomach. The gastric contents are aspirated before advancement into the peritoneal crenel, and lavage with dilute chlorhexidine can be performed. Use of an esophageal overtube can protect confronting esophageal trauma due to instrumentation. The site of the gastric puncture is selected by laparoscopic guidance, with two relatively avascular areas in the stomach considered adequate for the approach: the proximal body, midway between the lesser and greater curvatures of the stomach, and a similar site in the distal antrum. 4 The gastric fundal region is avoided considering of danger of damaging short gastric vessels and the spleen. A perforation of the wall is created by needle knife at the chosen site. The needle is withdrawn and an endoscopic balloon dilator is passed over the hole and positioned across the gastrotomy. The balloon is dilated completely and the endoscope is progressed into the peritoneal cavity.

Specimens tin exist extracted without special bags, and when the specimen bore exceeds the diameter of the esophagus, open conversion by umbilical admission and extraction is the solution.

An effect of the TG arroyo is reliable gastrotomy closure, as postoperative leaks for TG abdominal surgery cannot exist tolerated. Tissue apposition and clipping have been widely used since early on reports, but the endoscopic clipping devices were developed for control of gastrointestinal bleeding and are therefore unreliable for NOTES closure.

The utilise of endoscopic clips for closure was reported in well-nigh experimental studies and in the first casuistic of Rao and Reddy. 4 Differently from a gastric incision or an iatrogenic perforation, the gastrotomy created by the balloon dilation technique closes spontaneously later removal of the endoscope. Multiple clips tin be applied to approximate and close the wound, starting from the periphery and moving to the center. However, near clips estimate only mucosa, and this can be an event for further applications. Similar techniques have been used to shut the gastric defects following endoscopic mucosal and submucosal resections.

In the laparoscopic closure, another 3-mm trocar tin be inserted to help in gastrotomy closure, using single-mitt suture, by inserting a needle-holder through this trocar and a laparoscope through the umbilical trocar. This closure is too monitored by the endoscope, which is withdrawn and kept in the gastric lumen while the bytes are taken. ane

There are now several novel full-thickness closure devices, such equally T-Tag tissue anchors (Olympus Corporation of the Americas, Center Valley, PA), the flexible linear stapling device (Power Medical Interventions, Langhorne, PA), the Thou-Prox (USGI, San Clemente, CA), the Eagle Claw (Olympus), the OverStitch (Apollo Endosurgery, Austin, TX), and the OTSC (Over The Telescopic Clip, Germany). Studies are under way to evaluate the efficacy of these new methods. Apollo Overstitch is currently the most reliable method of closing gastric defects, and there are growing applications in endoscopic sleeve gastroplasty for primary endoscopic therapy for obesity 10 (Fig. 45.2).

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Congenital Anomalies and Surgical Disorders of the Breadbasket

Louisa W. Chiu , Oliver Southward. Soldes , in Pediatric Gastrointestinal and Liver Affliction (Fourth Edition), 2022

Treatment

As in hypertrophic pyloric stenosis, correction of dehydration and electrolyte disturbances must be addressed get-go. Immediate NG decompression may be necessary in cases of consummate obstruction. Webs may be treated by surgical excision via an incision over and across the web with transverse closure to widen the lumen (Heineke-Mikulicz type pyloroplasty) or by endoscopic incision or dilation. Gastrotomy with dilation without pyloroplasty has also been described. 43 Incidentally found or mildly symptomatic antral webs may be treated solely with modest, thickened feeds and antispasmodics. 44

For atresias, a short segment may exist bypassed with a Finney or Heineke-Mikulicz pyloroplasty. For longer atresias or a segmental gap, a gastroduodenostomy is preferable to a gastrojejunostomy. A catheter must be passed distally to eliminate the possibility of any other atresias. Prokinetics may exist useful for postoperative delayed gastric emptying. The overall mortality of pyloric atresia is greater than 50%, with the primary crusade of death related to associated anomalies or septicemia. 45 In the by, the clan of pyloric atresia with epidermolysis bullosa translated to sure mortality, but this is no longer true. Hayashi et al. accept reported long-term survival with aggressive treatment. 46

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Laparoscopic Gastric Bypass

Bruce Schirmer MD , in Surgical Pitfalls, 2009

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 pocketknife 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 forbid leakage. If there is hemorrhage, information technology must also be sutured to arrest information technology. Whatever defects in either the gastric pouch or the distal tummy staple lines must be repaired, reinforced, and tested (proximal is possible, distal is not). Distal gastrostomy may too be needed if there is concern nigh the staple line.

• Prevention

As mentioned previously for the jejunojejunostomy, most stapler misfires involve operator mistake. 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. Considering staple misfires do occur, there is no absolute mode to prevent this complication.

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Enteral Access Procedures

Benjamin Herdrich , Jon B. Morris , in Gowned and Gloved Surgery: Introduction to Common Procedures, 2009

Open Tube Gastrostomy

I.

Incision: Open up G-tube placement is performed through an upper midline incision, 6 to 8 cm in length. Alternatively, a left paramedian incision tin can be used.

II.

Insertion of the Gastrostomy Tube

A.

The stomach is identified and grasped with an instrument.

B.

The site for the gastrostomy tube is called, typically in the midportion of the breadbasket, closer to the greater curvature. Two concentric handbag-cord sutures are placed at the proposed site.

C.

A gastrotomy (an opening in the stomach) is made at the center of the purse-string sutures, and the tube is inserted into the tummy ( Fig. 10-iv).

D.

The inner and outer pocketbook-string sutures are tied down, invaginating the stomach wall around the gastrostomy tube.

III.

Securing the Stomach to the Inductive Intestinal Wall

A.

The distal terminate of the tube is brought out through a stab incision in the anterior abdominal wall left of the midline.

B.

The stomach surrounding the tube is sutured to the anterior abdominal wall around the go out site (Fig. 10-v).

Four.

Closure of the Wound

A.

The fascia and the skin are closed.

B.

The gastrostomy tube is secured to the intestinal wall with either a cocky-retaining bar or sutures.

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