228Surgical Procedures

LAPAROTOMY INCISIONS

•   The most common vertical incision used for an exploratory laparotomy in oncology is a vertical midline incision. A less commonly used vertical incision is the paramedian incision.

•   There are three common transverse skin incisions, with differences in fascial entry:

        Pfannenstiel: dissects fascia from rectus muscles

        Cherney: dissects the tendons of the rectus abdominis muscles from the pubic bone. A major complication with this incision is the development of osteomyelitis due to suturing of muscles back to bone.

        Maylard: muscle cutting. Involves ligating the inferior epigastrics prior to transection of the muscle bodies. This incision does not separate the transversalis fascia from the rectus muscles.

INCISION CLOSURE

•   Abdominal wall closure:

        Mass closure: made with one continuous length of suture material; includes all body wall layers, and incorporates the peritoneum, fascia, and muscles.

        Smead-Jones (far-near, near-far): a double loop, interrupted mattress suture technique that incorporates all the body layers in the outside suture (“far”) and fascia and peritoneum in the inner suture (“near”).

        Fascial incision strength after surgery: week 1: 10%, week 2: 25%, week 3: 30%, week 4: 40%, 6 months: 80%.

•   Subcutaneous tissue: if the wound is greater than 2 cm deep, subcutaneous suture or placement of a Jackson–Pratt (JP) drain is indicated.

•   Skin closure:

        Staples

        Subcuticular suture with Monocryl or Vicryl with or without a dermabond overlay

        Vertical mattress skin closure: useful in delayed primary closure of abdominal incisions and in perineal wound closure (place the knot lateral to the line of incision)

LYMPH NODE DISSECTION

•   The boundaries for the pelvic lymph node dissection (P-LND) are the following: superiorly the distal half of the common iliac vessels, laterally the anterior and medial aspect of the external and internal iliac vessels, the ureter or the superior vesical artery medially, the circumflex iliac vein inferiorly, and the obturator nerve posteriorly.

•   The boundaries for the para-aortic lymph node dissection (PA-LND) are the following: the fat pads over and lateral to the inferior vena cava and aorta, the inferior mesenteric artery (or up to renal vessels) superiorly, and the proximal half of the common iliac vessels inferiorly, and the ureters laterally (Figure 4.4).

•   For a high PA-LND, the LNs up to the renal vessels are removed medial to the ureters and anterior to the great vessels.

•   Sentinel LND: radiolabeled albumin with Technetium-99 is injected into the tumoral/peritumoral bed preprocedure (directly to the tumor for vulvar and cervical lesions; or into the cervix, the fundus via laparoscopic injection, or the corpus via hysteroscopic injection for uterine cancer). Lymphazurin blue or indocyanine green is then injected into the tumoral bed at initiation of surgical procedure and the first lymph node (LN) identified in the drainage basins from that tumor site is dissected and sent for frozen section. If negative, the procedure is considered complete. If positive, a complete lymphadenectomy is usually recommended. There may be more than one sentinel node and for midline structures/tumors, SLND should be evaluated bilaterally.

230BOWEL DIVERSION

•   When an ostomy is considered preoperatively, an ostomy consult should be obtained. The consult is for patient education in addition to identification of best placement; this includes evaluation of the patient’s waistline, common pant line, and any other individual body nuances.

•   A mucous fistula is the distal segment of bowel remaining at the time of end ostomy. It is brought through a separate ostomy site when an end ostomy is placed. The mucous fistula is performed when the remaining distal bowel is more than 10 cm from the anus. These mucous fistulas have minimal drainage. It is important to ensure that both ends are distant enough from each other so that cross fecal contamination and infection cannot occur.

•   Complications:

        Stricture: there is a 3% stricture rate for all ostomies. Dilation or surgical correction can be performed for strictures.

        Prolapse: the descending colon has the least risk of prolapse.

        Hernia

•   There are two common types of ostomy:

        An end ostomy is performed when a takedown is not planned. A mucous fistula needs to be constructed in most cases. The distal end of resected bowel needs management because it still produces mucus, gas, and sloughed cells, and could become dilated and perforate. Permanent colostomies prolapse in 1% to 3%. If the resection of the colon occurs at the rectosigmoid and 5 to 10 cm remain, this remaining rectum is then called a Hartmann’s pouch and functions as a mucous fistula with output through the anus.

        A loop ostomy should be performed when there are plans to take the ostomy down. The bowel is brought through the abdominal wall and opened on its antimesenteric side. Both sides of the opened bowel are sutured to the skin. A Hollister bridge or glass rod is placed under the bowel loop for temporary support until healing occurs. The proximal end functions as the colostomy and the distal opening functions as the mucous fistula. It is easier to take down because it is not mandatory to know which end is proximal and which is distal.

•   Ileostomy: indications include diversion when no distal bowel is available, when small bowel is too dilated to perform an anastomosis, for protection of a distal anastomosis when an anastomotic leak is likely, or in the presence of a bowel perforation with peritonitis. These are high-output ostomies, so as distal an ostomy as possible is preferred. A Turnbull loop is recommended.

•   Gastrostomy tube (G-tube): G-tubes are indicated for decompression of the stomach and intestine to avoid long-term use of a nasogastric tube. They are also used for intractable small bowel obstructions associated with carcinomatosis and fistulas. The body or antrum of the stomach is chosen. A size 18 to 20 Malecot or Foley catheter can be used. The greater curve of the stomach is incised with a scalpel 0.5 cm in length. Two pursestring sutures of 2-0 gauge silk are placed to secure the tube to the stomach. The gastrostomy site is brought to the peritoneal surface and secured with interrupted Vicryl sutures. The catheter is then exteriorized through a skin incision and secured to the skin with 2-0 gauge prolene sutures. The G-tube needs to be changed every 2 months.

231BOWEL RESECTION

•   Bowel anastomosis can be performed using either hand-sewn or stapled technique.

        Types:

             End to end: the bowel is aligned with cut ends together and hand sewn together using a two-layer technique (the inner layer using 3-0 gauge Vicryl and the outer imbricating layer using 3-0 gauge Vicryl or silk). Alternatively, using a stapler, the bowel ends are aligned on their antimesenteric borders. An enterotomy is made on the antimesenteric corner of the two bowel sections. One prong of the GIA stapler is then advanced through each enterotomy and fired. The TA stapler is then used to close the connected bowel segments to create a functional end-to-end anastomosis. The mesentery should be closed and silk stay sutures are placed along the antimesenteric borders to reduce tension.

             Side to side: 5-mm enterotomies are made with the Bovie on each segment of the resected bowel 5 to 10 cm back from the primary transection site. One prong of the GIA stapler is then advanced through each enterotomy and the stapler is then fired. The TA stapler is then applied to close the defect transversely or longitudinally, whichever narrows the lumen least.

             Low rectal anastomosis is often performed after a rectosigmoid resection. It is important to consider placing a diverting loop colostomy or loop ileostomy to protect the anastomosis and allow for healing. The anastomosis should preferably be performed out of the irradiated field. The largest staple cartridge available and accommodated by the patient should be used. If a very low anastomosis is performed, consider construction of a J pouch to increase reservoir capacity and to decrease tenesmus.

             If fistula is present, consider excision of fistulous tract, pelvic rest × 6 weeks, fistulogram after healing and before takedown of diverting ileostomy or secondary reanastomosis.

        Anastomotic leaks complicate bowel surgery in 0% to 30%. Rectal anastomosis has a higher complication rate of about 6%.

        Requirements for a good anastomosis include the following: an adequate lumen of at least 2 to 3 cm, the anastomosis be tension free, there be adequate vascular supply from the mesentery with evidence of bleeding (viability) of the cut edges, and the presence of peristalsis.

        Watershed areas of the bowel include the ileocecal junction/terminal ileum, the splenic flexure of colon (Griffith’s point), and the rectosigmoid flexure (Sudeck’s point).

•   Meckel’s diverticulum represents persistence of the vitelline yolk sac. It is present in 2% of people. It is twice as common in men as women. It is usually located within 2 feet of the ileocecal valve. It should be removed when found, due to the presence of ectopic gastric tissue in 2% of patients, that is, Zollinger–Ellison syndrome.

URINARY DIVERSION: STENTS, CONDUITS, AND BLADDER RECONSTRUCTIONS

•   Ureteral stents should be placed in most ureteral injury cases. They can be placed via retrograde cystoscopy, retrograde cystotomy, ureterotomy, or antegrade through a percutaneous nephrostomy. A 6 French double pigtail stent or a pediatric feeding tube can be placed. These should be changed every 3 to 6 months. They can often be removed 2 to 6 weeks after surgery via cystoscopy.

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