Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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Appendix

Mesoappendix

Ileocecal junction

Mesoappendix divided

and appendiceal artery

ligated

FIGURE 38 –5

Purse-string suture

in cecum

Ligature tied and

appendix divided

at its base

Appendiceal stump invaginated

and purse-string suture tied

FIGURE 38 –6

CHAPTER 38 • Open Appendectomy 409

410 Section IV • T

HE ABDo MEN

STEP 4: POSTOPERATIVE CARE

◆ Dietary resumption may begin immediately in the case of acute appendicitis, but if free

purulence was found at operation, postoperative ileus mandates awaiting the return of

bowel function.

◆ Postoperative antibiotics are not necessary in acute appendicitis but should be continued in

the presence of intra-abdominal purulence.

STEP 5: PEARLS AND PITFALLS

◆ Placement of the skin incision slightly cephalad to the anticipated position of the appendix

in its anatomic position will allow easier manipulation of the cecum, once brought out of

the RLQ wound.

◆ Despite preoperative evaluation, a missed diagnosis (normal appendix at exploration) should

include a search for the underlying pathologic condition, including perforated duodenal

ulcer, pancreatitis, urinary tract infections or calculi, gynecologic pathologic ﬁ ndings, or

Meckel’s diverticulum.

SELECTED REFERENCES

1. Silen W, Cope Z: Cope’s Early Diagnosis of the Acute Abdomen, 21st ed. New York, Oxford University

Press, 2005, pp 67-83.

2. Lally KP, Cox CS Jr, Andrassy R: The appendix. In Townsend CM, Beauchamp RD, Evers BM, Mattox KL

(eds): Sabiston Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 1381-1399.

411

STEP 1: SURGICAL ANATOMY

◆ Intussusceptions in infants and toddlers occur as a result of invagination of proximal bowel

(intussusceptum) into the lumen of the distal bowel (intussuscipiens). It typically involves

the ileocolic region of the intestine with variable degree of colonic involvement. The leading

point of the intussusception is typically a Peyer’s patch in the terminal ileum. Occasionally,

Meckel’s diverticulum may be the leading point of the intussusception.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Sudden, intermittent, colicky, severe abdominal pain associated with calm, asymptomatic

periods in a toddler is characteristic. It is commonly associated with a history of preceding

upper respiratory tract infections. A jelly stool is another characteristic of this condition.

◆ Abdominal radiographs may demonstrate paucity of bowel gas in the right lower quadrant

along with soft tissue mass in the upper abdomen representing an intussusceptum.

◆ When the diagnosis is suspected, hydration status along with presence of acute abdomen

(peritonitis, perforation, or obstruction) should be assessed. Ultrasound examination can

identify the presence of an intussusception.

◆ Contrast (or air) enema study can conﬁ rm diagnosis and also potentially be therapeutic.

Hydrostatic or pneumatic reduction of intussusception is successful in approximately 60%

to 95% of cases. A history longer than 24 hours or radiologic evidence of bowel obstruction

signiﬁ cantly reduces the likelihood of successful reduction by enema.

◆ Contrast is instilled through a catheter from a reservoir 100 cm above the patient. Air is

delivered at 80 to 150 mm Hg. The criterion for successful reduction is reﬂ ux of contrast

or air into the terminal ileum.

◆ After a successful reduction, the child is observed overnight to ensure complete resolution

of symptoms and absence of recurrence.

CHAPTER

Intussusception

Dai H. Chung

412 Section IV • The Abdomen

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Operative reduction is necessary for failed enema reduction and/or multiple recurrent

intussusceptions.

◆ Preoperative prophylactic intravenous antibiotic should be administered 30 minutes before

skin incision.

◆ Patient is positioned supine and the right-sided transverse abdominal skin incision is made

slightly inferior to the umbilicus (Figure 39-1). Depending on the degree of intussuscep-

tion, the incision may be made at the level of or above the umbilicus.

2. DISSECTION

◆ Muscle-splitting technique is used to dissect through external, internal oblique, and trans-

versalis fascia.

Incision

J. Smith

FIGURE 39 –1

CHAPTER 39 • Intussusception 413

Invaginated ileum

within colon

M. Cooley

after J. Smith

Appendix

within colon

Milking ileum

out of the colon

FIGURE 39 –2

Reduced ileum

FIGURE 39 –3

◆ Bowel loops of intussusception are carefully delivered into the wound and reduction is

achieved by gently squeezing the bowel distal to the apex along with gentle pull of proximal

bowel to aid with the reduction (Figure 39-2). Traction or strong pulling of intussuscepted

bowel should be avoided, because this can easily result in further injury to the bowel.

◆ After reduction, general condition of the intussuscepted terminal ileum should be assessed

carefully (Figure 39-3). Occasionally, segmental bowel resection is necessary if reduction

cannot be achieved or necrotic bowel is identiﬁ ed after reduction. Commonly, reduced

terminal ileum appears dusky and thickened to palpation. Placement of a warm, moist

sponge for a few minutes can improve local tissue perfusion, thus, potentially avoiding

unnecessary surgical resection.

414 Section IV • The Abdomen

◆ Standard appendectomy should be performed if the adjacent cecal wall is normal

(Figure 39-4). In general, inversion appendectomy is not recommended.

3. CLOSING

◆ Once reduction is achieved or resection performed (if required) and hemostasis is ensured,

abdominal fascia closure is performed in layers using 3-0 absorbable sutures in continuous

manner.

◆ The skin is reapproximated with a subcuticular stitch of 5-0 absorbable suture.

Appendix cut

anterior to purse string

and posterior to clamp

Appendectomy

complete

FIGURE 39 –4

CHAPTER 39 • Intussusception 415

STEP 4: POSTOPERATIVE CARE

◆ Nasogastric tube decompression is necessary if there were symptoms of bowel obstruction

preoperatively.

◆ The patient may be started on an oral clear liquid diet with return of bowel function and

gradually advanced to regular diet.

◆ Two postoperative doses of an intravenous antibiotic are administered.

STEP 5: PEARLS AND PITFALLS

◆ Recognition of acute abdomen is critical to prompt surgical management and to avoid un-

safe delays and risks to patients with attempts of enema reduction.

◆ Intussusception should be reduced by pushing the involved bowel retrogradely, with only

gentle pull if necessary.

SELECTED REFERENCES

1. DiFiore JW: Intussusception. Semin Pediatr Surg 1999;8:214-220.

2. Shehata S, El Kholi N, Sultan A, El Sahwi E: Hydrostatic reduction of intussusception: Barium, air or

saline. Pediatr Surg Int 2000;16:380-382.

416

STEP 1: SURGICAL ANATOMY

◆ In patients without malrotation, a broad mesentery and attachments at the cecum and

ascending and descending colon prevent volvulation of the small bowel around the superior

mesenteric vessels (Figure 40-1). Incomplete rotation of the intestine during fetal develop-

ment results in lack of these attachments, a very narrow mesentery, and peritoneal bands

(Ladd’s bands) that place the cecum close to the duodenum. This incomplete rotation may

cause obstruction in the second or third portions of the duodenum (Figure 40-2). The

absence of peritoneal attachments, in combination with a narrow mesentery and a relatively

ﬁ xed point to the duodenocecal area, creates the conditions in which the midgut can volvu-

late (in clockwise fashion) around the superior mesenteric vessels (Figure 40-3). Although

most patients present in the neonatal period or in the ﬁ rst year of life with bilious vomiting,

this condition may remain asymptomatic until adulthood.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ In children younger than 1 year of age, however, bilious vomiting must be considered due

to malrotation until proven otherwise. The diagnosis is conﬁ rmed by upper gastrointestinal

series, barium enema, or sonography. Once this condition is diagnosed, surgical correction

should always be treated as an emergency.

◆ In the presence of midgut volvulus, time is of the essence. Vigorous intravenous resuscita-

tion and broad-spectrum antibiotics are initiated. The stomach is decompressed with an

orogastric tube, and a urinary catheter is placed to measure urine output. The operation

should not be delayed in an attempt to correct metabolic imbalances, because this is usually

futile until the volvulus is managed.

◆ After thorough gastric suctioning, general endotracheal anesthesia is induced with the patient

supine. The abdomen is prepped with povidone-iodine (Betadine) solution.

CHAPTER

Correction of Malrotation

with Midgut Volvulus

Carlos A. Angel

CHAPTER 40 • Correction of Malrotation with Midgut Volvulus 417

Broad axis

inhibits volvulus

FIGURE 40 –1

Short axis with

potential for volvulus

FIGURE 40 –2

Volvulus

Duodenum

Ladd's

bands

FIGURE 40 –3

418 Section IV • The Abdomen

STEP 3: OPERATIVE STEPS

1. INCISION

◆ A right upper quadrant transverse laparotomy is performed, the muscles are divided in the

direction of the incision, and the umbilical vein in the free edge of the falciform ligament is

tied with 5-0 silk sutures and divided (Figure 40-4).

2. DISSECTION

◆ The entire bowel is delivered outside the incision to verify the presence or absence of a

midgut volvulus (see Figure 40-4). Because, in most cases, the volvulus has twisted clock-

wise, devolvulation should proceed counterclockwise (Figure 40-5). This maneuver usu-

ally produces signiﬁ cant improvement in the appearance of the intestine. Warm com-

presses can be applied to intestine of questionable viability and left alone for 10 minutes.

All intestines that are frankly gangrenous should be removed; intestines of questionable

viability should be left behind, and a second-look laparotomy planned in 24 to 36 hours

to allow for better demarcation of the segments to be resected. Often during this second-

look operation a primary end-to-end anastomosis can be performed. Ladd’s bands extend

from the cecum and ascending colon, attaching to the anterior surface of the duodenum

and across the duodenum to the posterior aspect of the right upper quadrant. These

bands are sharply divided (Figure 40-6). To relieve any obstruction, the surgeon must

free the duodenum from the Ladd’s bands on both its lateral and medial aspects. The du-

odenum is straightened by division of the ligament of Treitz. Takedown of Ladd’s bands

results in separation of the duodenum, cecum, and ascending colon and broadening of

the mesentery (Figure 40-7). A nasogastric tube is passed to make sure that there is no

further obstruction of the duodenal lumen. Because the cecum will ultimately lie in the

left upper quadrant, an appendectomy is performed (Figure 40-8). The intestines are re-

trieved into the abdominal cavity beginning with the duodenum, leaving the duodenum

and small bowel on the right side and the colon on the left side.

FIGURE 40 –4