Dr Qamar Shahzad Joia General Surgeon

vs

There is no clear demarcation between jejunum and ileum, but

the small bowel does change gradually in character from proximal to distal.

The tends to have a and a wall, with more mucosal folds ( ),

the has a , more with more arcades.

The also contains of nodes (’s patches), which can occasionally become lead points in in childhood.

"Abdominal entry techniques"
𝗮)Hasson technique
𝗯)Veress needle technique
𝗰)Optical trocar
𝗱)“peek-port” technique
𝗥𝗲𝗳: Mastery of Endoscopic & Laparoscopic Surgery

𝗗𝗿𝘂𝗴 𝘁𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁 𝗼𝗳 𝗽𝗿𝘂𝗿𝗶𝘁𝘂𝘀 𝗶𝗻 𝗹𝗶𝘃𝗲𝗿 𝗱𝗶𝘀𝗲𝗮𝘀𝗲 (Differential diagnoses of cholestatic conditions & Current therapeutic recommendation for the management of pruritus in cholestatic liver diseases.
𝗥𝗲𝗳:https://www.rcpjournals.org/content/clinmedicine/15/4/351

"𝗛𝗮𝗻𝗴𝗶𝗻𝗴 𝘀𝗽𝗹𝗲𝗲𝗻 𝗧𝗲𝗰𝗵𝗻𝗶𝗾𝘂𝗲” during splenectomy (Effects of reverse Trendelenburg & 60° elevation):

•Proper patient positioning is a critical step. The patient is safely secured on a bean-bag with the left side up at a 60° angle in reverse Trendelenberg and the left arm positioned as for a left lateral thoracotomy (Fig. 12.1). This allows gravity to retract the abdominal organs and maximize the working space. This is the “hanging spleen” technique described by Delaitre and Gagner. The surgeon stands on the patient’s right side facing the left monitor, with the camera assistant on the same side sitting on a stool to his left to avoid a conflict with the elbows of the surgeon. The first assistant is on the opposite side, but the three members of the team all look at the left monitor to avoid mirror imaging and discoordination of the critical first assistant (Fig. 12.2).

•When the trocars are inserted, the patient is positioned in reverse Trendelenburg.Combined with a 60° tilt, this position has two important effects. First, gravity pulls the stomach and small bowel in a rostral direction out of the operative field. Second, the spleen is kept hanging from the diaphragm by its phrenic attachments, thus placing the gastrosplenic vessels under tension, simplifying dissection and division of the vessels later in the operation (Fig. 12.3). In the anterior approach, the hilar vessels are controlled first, and the phrenic attachments are divided at the end of the operation. In contrast, with a posterior approach, the lateral attachments are divided first, the spleen is mobilized laterally and the hilar vessels are controlled later, as done in open surgery (Fig. 12.4).
𝗥𝗲𝗳:Advanced Laparoscopic Surgery Techniques & Tips, 2nd Ed.

· Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know
· Ther Adv Gastrointest Endosc 2021, Vol. 14: 1–21
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8474323/pdf/10.1177_26317745211045769.pdf

𝗠𝗶𝘀𝘀𝗲𝗱 𝗶𝗻𝗷𝘂𝗿𝗶𝗲𝘀 Pay special attention to five locations where often miss a hole ln the gut:

•Missing a gastric perforation has the most immediate consequences. Since the stomach is the most vascular organ of the gut, missing a hole means you will be back in the OR within a couple of hours facing a stomach the size of a watermelon filled with blood and clots. Much like a bleeding gastric ulcer, the most problematic and easily missed gastric injuries are located high on the lesser curve or in the posterior wall near the cardia. Mobilize the greater curve of the stomach by dividing the gastrocolic omentum. Open the lesser sac widely and lift the greater curve up to have a good look at the entire posterior wall.

•In addition to a very meticulous exploration routine, two safeguards help you to avoid missing a hidden injury to the Gl tract:
🅐︎ Reconstruct the trajectory of the wounding agent. This trajectory must be linear and make sense. Bullets and knife blades do not disappear into thin air only to reappear out of nowhere in another part of the abdomen. You must be able to connect the dots. When the trajectory of the wounding missile is unclear or does not make sense, you probably are missing an injury.

🅑︎ Be concerned when finding an odd number of holes in the gut.Tangential wounds certainly occur, and occasionally a missile perforates only one wall, but this is uncommon. Therefore, an odd number of holes should prompt you to re-evaluate the area in search of a missed perforation. The only exception is a single stab wound to the anterior gastric wall, which is relatively common.

•When examining the colon, it pays to be relentlessly paranoid. Because much of the colon is retroperitoneal or covered with omentum and pericolic fat, missing a small colonic perforation is easier than you think.
•Do not leave any subserosal hematoma on the colon, no matter how small and innocent-looking, without unroofing it by opening the overlying and peritoneum. Very often, this seemingly innocent superficial staining hides a perforation. If the wounding agent passed close to the right or left colon, mobilize it and look carefully at the posterior wall.

•The ureter, too, carries a high rate of missed injuries. Whenever a bullet trajectory passes anywhere near a ureter, mobilize the relevant side of the colon, identify the ureter, and trace it proximally and distally to ensure it is intact. Intravenous methylene blue dye helps identify a ureteral injury that is not immediately obvious.
𝗥𝗲𝗳:
•Hirshberg & Mattox, Top Knife, The Art & Craft Of Trauma surgery
•Advanced Trauma Operative Management

Cholecystectomy in the obese patient:

In the case of an obese patient, the surgeon should not struggle to try to retract the fat. Two tricks can be used:
𝗔-Placing the patient on steep reverse Trendelenburg
𝗕-Inserting an extra 5 mm trocar above and to the left of the umbilical trocar (Fig. 2.1).

This additional trocar can be very helpful. If used, it should be added at an early stage, permitting the insertion of an irrigation/suction device, which can be used as a retractor to push down the duodenum and the greater omentum. It will also serve for hydrodissection. This extra trocar should be used for all obese patients, & also when the duodenum is stuck to the G.B & the surgeon requires extra duodenal retraction.The insertion of the extra 5 mm trocar will not affect the surgical result or the cosmetic appearance but will dramatically increase the safety of the procedure & reduce operative time.
𝗥𝗲𝗳:Advanced Laparoscopic Surgery Techniques & Tips, 2nd Ed.

Ⓐ︎ Ideal port placement for laparoscopic cholecystectomy
Ⓑ︎ The American & French positions of laparoscopic cholecystectomy.
𝗥𝗲𝗳:Advanced Laparoscopic Surgery Techniques & Tips, 2nd Ed.

Laparoscopic Cholecystectomy is all about traction & counter traction:

•Once the fundus of the gallbladder is retracted & the liver is moved up, some adhesions on the inferior surface of the liver will occasionally prevent adequate liver retraction. Such adhesions should be removed first before even attempting dissection of the triangle of Calot, as at this point of the procedure, maximal superior retraction of the gallbladder is needed.

•Lateral retraction is the key to safe dissection of the triangle of Calot (Fig. 2.3a).This is performed with the left hand of the surgeon pulling laterally and inferiorly (towards the right Anterior Superior Iliac Spine) on Hartmann’s pouch while the first assistant retracts the fundus of the gallbladder towards the lateral right hemidiaphragm. This will open up the triangle of Calot and the risk of a common bile duct (CBD) injury will be minimized. Wrong retraction closing the angle between the cystic duct and the CBD is depicted in Fig. 2.3b. If the anterior peritoneum overlying the cystic duct and artery is scarred, it is very important to retract the cystic duct in a cephalad direction and incise the posterior peritoneum as closely as possible to the neck of the gallbladder. That will allow safe dissection of the cystic duct next to the neck of the gallbladder, and will create a window around the cystic duct.

𝗥𝗲𝗳:Advanced Laparoscopic Surgery Techniques & Tips, 2nd Ed.

𝗙𝗶𝗻𝗴𝗲𝗿𝗼𝘀𝗰𝗼𝗽𝗶𝗰 treatment of complicated appendicitis: (Less practised in Modern Era)

•This technique restores the surgeon’s tactile ability & allows gentle and safe blunt dissection of appendiceal masses under laparoscopic guidance. The technique is applied without enlarging the port incision & reduces the conversion rate to an open procedure.

•The finger-assisted laparoscopic appendectomy is a simple technique that restores tactile feeling & allows blunt & atraumatic dissection of an appen-diceal phlegmon. The technique restores the surgeon’s ability to distinguish between necrotic & healthy tissues & intuitively mimics the maneuvers used in the open technique. This is not possible with even the best atraumatic laparoscopic instruments. There is no learning curve, & the technique speeds the procedure. Conceptually, it is not different from other assisted techniques, such as laparoscopic assisted colectomy, in which the sigmoid colon is exteriorized & manipulated outside the abdomen. The only potential risk inherent in the technique is postoperative wound infection at the trocar site, but this is minimized by careful irrigation of the right trocar site at the end of the procedure with a diluted antiseptic solution. We did not encounter any trocar port abscess or seroma in this series

•The technique does have limitations and is difficult to perform on obese patients with a thick ab-dominal wall.

•In 𝗦𝘂𝗺𝗺𝗮𝗿𝘆, the finger-assisted technique de-scribed here has allowed a reduction of the conversion rate for complicated laparoscopic appendectomy in our series. It has the potential to improve outcomes, as demonstrated by a shorter hospital stay in this study. These results, however, are based on
retrospective data, and the limitations of these studies are well known. These preliminary results have encouraged us to proceed with a prospective randomized study that will allow us to establish whether the laparoscopic finger-assisted technique is as effec-tive or better than the open procedure for the treatment of perforated appendicitis.

𝗥𝗲𝗳:
https://pdfslide.us/documents/laparoscopic-finger-assisted-technique-fingeroscopy-for-treatment-of-complicated.html?page=3

𝗠𝗮𝗻𝗮𝗴𝗲𝗺𝗲𝗻𝘁 𝗼𝗳 𝗗𝗶𝗮𝗽𝗵𝗿𝗮𝗴𝗺𝗮𝘁𝗶𝗰 𝗶𝗻𝗷𝘂𝗿𝗶𝗲𝘀:

The treatment for an injured diaphragm is operative whether an injury is acute or chronic. Regardless of mechanism, acute injuries can usually be repaired
primarily. This is especially true for penetrating injuries, which are much smaller. Larger defects secondary to acute blunt mechanisms appear to be more 𝗰𝗼𝗺𝗺𝗼𝗻 on the 𝗹𝗲𝗳𝘁 and are generally amenable to primary suture reapproximation. Complex repairs including use of mesh are uncommonlyrequired in the acute setting. Rarely, a hemidiaphragm may avulse from the chest wall and may be reattached with nonabsorbable sutures.

𝗧𝗲𝗰𝗵𝗻𝗶𝗾𝘂𝗲𝘀:
•Repair may be achieved via laparoscopy/laparotomy or via thoracoscopy thoracotomy depending on a patient’s hemodynamic stability and associated injuries and a surgeon’s experience with minimally
invasive techniques. Laparoscopic techniques continue to gain traction for definitive exploration and repair, especially for penetrating acute
diaphragmatic lesions with fewer associated injuries. Conversion to laparotomy is frequently required when an acute blunt diaphragmatic
rupture is diagnosed laparoscopically given the high likelihood of significant additional injuries.

•Laparotomy remains the most common operative approach for repair of both blunt and penetrating diaphragmatic injuries. Indications for thoracoscopic exploration remain undefined because intra-abdominal organs can rarely be adequately assessed operatively without an additional incision.

•Surgery is indicated for chronic diaphragmatic hernias. Thoracotomy
has a definite role in these patients since there is no concern for an associated intra-abdominal injury. In addition, reduction through the chest may be easier, as bowel adhered to lung can make for a tedious and difficult dissection trans-abdominally. A mesh repair is practically guaranteed for the treatment of a chronic hernia, where primary reapproximation of the diaphragm would likely involve tension and produce suboptimal results.

𝗥𝗲𝗳: •Mastery of surgery 7th ed.
•Trauma,9th ed, 2020, McGraw Hill.

The“working space”concept in laparoscopy:

•Laparoscopy is performed in a closed abdominal cavity where space is limited. Tilting the operating table so that gravity provides natural retraction by pulling the intraabdominal organs to the lower side can increase available space significantly. It should be possible to position the patient in Trendelenburg or reverse Trendelenburg with either the right side or left side up depending on the procedure, and it is therefore important to use an appropriate table to allow such maneuvers. Some old tables are obsolete and it is worthwhile investing in a modern electrical operative table if one is to
embrace advanced laparoscopic surgery.

•Laparoscopic surgery demands great concentration. It is therefore important for the operating room to be quiet when the surgeon is performing laparoscopic surgery, especially in advanced cases involving knot tying.

•The abdomen is a closed unit and the working space is a virtual one that has to be created and maintained (Fig. 1.6a–c). The working space can be increased by means of various maneuvers such as tilting the patient – head up or head down, right side up or left side down – where gravity is used to displace adjacent organs from the operating site.

•In upper abdominal operations the working space is created by positioning the patient head up to allow the stomach, the colon, and the omental fat to drop down. For hernia repair the patient is placed in a steep Trendelenburg position, so that the small bowel is similarly moved up to free the pelvic area. For colon surgery & appendectomies working space can be created in the same manner, with the addition of lateral tilting of the table to move the small bowel away from the operative site. The splenectomy technique also involves creation of working space, with the patient being positioned head up, left side up allowing the stomach and the colon to fall to the right side, giving access to the left hypochondrium.

•During a laparoscopic procedure for small bowel obstruction, the same effect can be achieved by tilting the patient to the side opposite the presumed site of the obstruction as indicated by the preoperative physical examination and abdominal plain films.

•The working space concept is especially important upon inserting the laparoscope. If the working space is severely limited, as, for example, with small bowel obstruction, it is easy to injure the bowel with placement of the first trocar. For this reason, flexibility in the choice of trocar insertion sites is recommended, following the simple principle of triangulation that governs all trocar insertions.

•If the maximum pressure of 15 mmHg is reached with a flow of less than 2 L of CO2 upon insertion of the first trocar, one should convert to an open procedure as this indicates that there will not be adequate working space due to the distended bowel.The working space concept also explains difficulties of working in a gasless environment where the shape of the abdomen, once retracted with a gasless device, is not round but more trapezoidal (Fig. 1.7). This does not provide adequate working space, and is one of the reasons for which gasless laparoscopy has been abandoned.

𝗥𝗲𝗳:Advanced Laparoscopic Surgery Techniques & Tips, 2nd Ed.

𝗢𝗻-𝘁𝗮𝗯𝗹𝗲 𝗰𝗼𝗹𝗼𝗻𝗶𝗰 𝗹𝗮𝘃𝗮𝗴𝗲:

•On-table colonic lavage has also been advocated as a means of permitting resection and re-establishment of intestinal continuity in a single stage. Irrigation can be accomplished through a cecostomy, appendicostomy, or the open bowel.
•A prospective, randomized trial comparing segmental resection with on-table lavage and primary anastomosis with total colectomy with ileorectal anastomosis found no difference in perioperative complications (i.e., leak rates, sepsis) or perioperative mortality between the groups, and showed significantly improved bowel function in the lavage group. In summary, a complete segmental resection of the tumor-bearing segment of colon with on-table lavage and primary anastomosis may be performed safely and is effective in the management of colonic obstruction from colon cancer.
𝗥𝗲𝗳:Colorectal Surgery

𝗗𝘂𝗼𝗱𝗲𝗻𝗼𝗱𝘂𝗼𝗱𝗲𝗻𝗼𝘀𝘁𝗼𝗺𝘆
For Duodenal atresia & stenosis
(Kimura procedure)
𝗢𝗽𝗲𝗻 𝗔𝗽𝗽𝗿𝗼𝗮𝗰𝗵:

•Historically, three distinct anatomic repairs have been described in the literature, chronologically, the duodenojejunostomy (1916), the gastrojejunostomy (1924), & the duodenoduodenostomy (1943). The gastrojejunostomy was ultimately abandoned secondary to the complications associated with chronic reflux of bilious and pancreatic secretions. By the middle of the 20th century, the duodenojejunostomy, typically performed in a retrocolic, side-to-side fashion, became the standard of care. More recently, duodenoduodenostomy, & its modification the “diamond duodenoduodenostomy” as described by Kimura in 1977, has been used to bypass congenital duodenal obstruction in an effort to hasten the return of intestinal function after surgery and to promote duodenal emptying. As expertise in advanced laparoscopy grows & innovations in technology afford greater versatility, minimal access techniques for treating congenital duodenal obstruction have been demonstrated as safe & feasible.
𝗥𝗲𝗳: Operative Pediatric Surgery, 88th ed, 2021

-𝗣𝗼𝘀𝘀𝗶𝗯𝗹𝗲 𝗰𝗼𝗺𝗽𝗹𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀 𝗼𝗳 𝗹𝗼𝘀𝘁 𝘀𝘁𝗼𝗻𝗲𝘀 𝗶𝗻 𝗮𝗯𝗱𝗼𝗺𝗲𝗻 𝗮𝗳𝘁𝗲𝗿 𝗹𝗮𝗽𝗮𝗿𝗼𝘀𝗰𝗼𝗽𝗶𝗰 𝗰𝗵𝗼𝗹𝗲𝗰𝘆𝘀𝘁𝗲𝗰𝘁𝗼𝗺𝘆:

•Despite the rare nature of gallbladder perforation and resulting scattering of bile stones into the abdominal cavity, they may still cause diagnostic challenges and substantial morbidity in both early and late postoperative periods. Complications due to peritoneal gallstones after LC are infrequent with a rate of 1.7 complications per 1000 cases. The reported incidence of gallbladder perforation is 10–40%, that of gallstone spillage is 7.3% and that of unretrieved peritoneal gallstones is 2.4%. In a report on 10 174 patients, stones spilled in 581 patients (5.7%) and were retrieved in only 34 patients. In the remaining 547 patients, only 8 patients (0.08%) developed complications.

𝗥𝗶𝘀𝗸 𝗳𝗮𝗰𝘁𝗼𝗿𝘀:
Stone spillage from gallbladder occurs during gall bladder extraction, by tearing with grasping forceps or during dissection of the gallbladder from the liver bed. Predisposing factors for gallbladder perforation and stone spillage include acute cholecystitis, pericholecystic adhesions, obesity and male s*x. The problem of stone spillage is aggravated by spread of calculi because of peritoneal irrigation and pneumoperitoneum.

𝗖𝗼𝗺𝗽𝗹𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀:
The reported complications due to gallstone spillage include peritoneal–cutaneous sinus tracts, intra-abdominal abscess, liver abscess, subhepatic inflammatory mass, persistent discharging trocar sites, micro abscesses, retroperitoneal abscess, granuloma, cholelithoptysis, small bowel obstruction, small bowel fistula, colonic fistula, bowel perforation and ileus as a result of sticking of small intestine inserts into the abscess wall. Bile stones may remain silent in the abdominal cavity for a long time until a septicemic focus causes calculus to become infected and produce abscesses.

𝗠𝗲𝗱𝗶𝗰𝗼-𝗹𝗲𝗴𝗮𝗹 𝗮𝘀𝗽𝗲𝗰𝘁:
•Although early complications often occur in the form of peritonitis or abscesses, late complications usually occur as a result of migration of the stones. The organism tries to throw the stone out of it by accepting it as a foreign body. Generally, complications require surgical intervention. Such patients should be well informed after surgery, and stone spillage should be well documented in order to avoid medico-legal issues and diagnostic dilemmas in the future. Complications due to gallstone spillage may take months or years to present. Ultrasound, CT or magnetic resonance imaging can be used to detect a spilled stone in suspected cases presenting late after cholecystectomy.

𝗜𝗻𝘁𝗲𝗿𝘃𝗲𝗻𝘁𝗶𝗼𝗻𝘀:
Radiological interventions, laparoscopic methods and open surgery are available to remove such stones from the abdominal cavity and drain any abscess if present. Abscess puncture and aspiration without stone removal should be avoided because these often result in recurrence. An observational study involving 82 surgeons revealed that conversion to an open procedure was performed only in 3% of patients in whom gall stones were spilled during LC. Although removal of spilled gallstones is not recommended for all patients, an attempt at removal should be performed whenever possible.

𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻:
During LC, it is common to encounter gallbladder perforation ending up with spillage and loss of some gallstones. It is important to attempt to retrieve spilled gallstones. Though uncommon, these stones may lead to early or late complications, which can be a diagnostic challenge and cause significant morbidity to the patient.

𝗥𝗲𝗳:
•"Acute abdomen due to spilled gallstones: a diagnostic dilemma 10 years after laparoscopic cholecystectomy | Journal of Surgical Case Reports | Oxford Academic" https://academic.oup.com/jscr/article/2020/8/rjaa275/5896199

• Case Studies of Postoperative Complications after Digestive Surgery,2017.

•"Missed gallstones in the abdominal wall: complication of a laparoscopic cholecystectomy" https://www.panafrican-med-journal.com/content/article/37/381/full/

Open surgical management of helminth-associated intestinal obstruction:

•The principles of surgical management have been described mostly in case series and case reports as opposed to rigorous trials. If surgery is required, preservation of bowel length is recommended. Open techniques are also preferred to laparoscopic in order to prevent contamination of the peritoneal cavity with either eggs or adult worms. In the instance of obstruction, in an appropriately prepared supine patient, the bowel can be accessed via a small midline laparotomy incision. The affected small bowel can be delivered outside of the wound for inspection, protecting the wound edges with a sterile towel. When the affected segment is identified, it is sometimes possible to massage the bolus onward toward the caecum. This relies upon healthy small bowel and a more distally effected segment. In cases where this is not possible, or if the bowel appears friable and inflamed, non-crushing bowel clamps can be applied distally. Attempt to knead the bolus more proximally away from the diseased segment. A longitudinal enterotomy as in Fig. 6.5 can be made overlying the bolus to gently extract the content. Once the contaminants are removed, close the bowel in one or two layers transversely. If the bowel appears compromised or its viability is threatened, a limited small bowel resection can be performed. An end-to-end hand-sewn anastomosis and stapled anastomosis are acceptable options.

•When intestinal trematodiasis is associated with strictures secondary to microabscesses and fibrosis, treatment is similar to that seen in Crohn’s disease. If the strictured segment appears grossly inflamed over a short area of involvement, primary resection is preferred. Otherwise, stricturoplasty may be appropriate. The tightness of the stricture can be evaluated via a small enterotomy as described above. Balloon catheter dilatation is appropriate in strictures with a diameter greater than 20 mm. Strictures tighter than this, less than 20 mm, require a longitudinal full-thickness incision to be carried over the entire effected segment. This incision should be continued for approximately 1 cm beyond into normal tissue. The bowel is then closed transversely in one or two layers. In longer strictured segments, primary resection and anastomosis are preferred.

𝗥𝗲𝗳:The Surgical Management
of Parasitic Diseases© Springer Nature Switzerland AG 2020