Omentum - (omentum), EPIPLOON - a fold of the peritoneum that is attached to the stomach. The greater omentum is a fold of peritoneum that starts from the stomach. Having enveloped the stomach, both layers of the peritoneum in front and behind again converge at its greater curvature and descend down in front of the transverse colon and the loops of the small intestine. Having reached the level of the navel, and sometimes below, these two layers of peritoneum bend posteriorly and rise up behind the descending layers, as well as in front of the transverse colon and loops of the small intestine. The omentum hangs in front of the transverse colon and the loops of the small intestine in the form of an apron and is formed by four layers of peritoneum (ed.). The lesser omentum (lesser omentum) is two layers of peritoneum that connect the stomach with the hilum of the liver and the upper part duodenum. - Omental (omentat).;
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February 1, 2018 / Maksimov Alexey Vasilievich
Walls or groin area, including the umbilical, are dangerous due to infringement of the organ that is located in hernial sac (stuffing box, intestine, bladder, stomach, etc.) resulting in necrosis, gangrene, perforation, peritonitis and death. More details http://...
oncologist April 22, 2016 / Natalya / r.p. Vacha
Hello! In 2012, anterior hardware resection was performed directly. intestines signustomy mts rectum stuffing box. 9 courses of FOLFOX meth in the ovary, in 2013 - EM surgery with appendages, removal of the direct omentum, 12 courses of FOLFIR, meth. into the lungs. 2015 - operation VAT...
There are primary and secondary (metastatic) peritoneal tumors.
Primary benign and malignant tumors (endothelioma, psammoma) of the peritoneum and omentum are rare. Among benign tumors, fibroma, angioma, lymphangioma, neurofibroma and lipoma (usually omentum) are observed. Among malignant tumors, secondary metastatic tumors are relatively more common. Primary malignant tumor peritoneum (endothelioma, mesothelioma) is observed very rarely and is diagnosed only by biopsy or on a dissection table. Pseudomyxomas (accumulation of mucous masses in the thickness of the peritoneum) are also usually described in this group.
Primary peritoneal cancers differ from cancers of other organs primarily in that they spread diffusely over the surface of the peritoneum and do not grow into organs. The prognosis is usually poor if the tumor is not limited to one omentum. In the vast majority of cases, malignant tumors of the peritoneum are secondary as a result of germination from organs abdominal cavity.
Metastatic (from the ovary, stomach) cancers look like nodules scattered over a large surface (carcinomatosis). In this case, a clear, often bloody effusion is usually observed in the abdomen. Clinically, peritoneal carcinomatosis manifests itself as unpleasant painful sensations in a stomach. With fusions, NK phenomena can be observed. Large cluster fluid in the abdomen is externally manifested by an enlarged abdomen and dull pain. As a rule, the diagnosis is established only during laparotomy.
There is limited damage to the peritoneum (pseudomyxoma) - accumulation of mucous masses in the abdominal cavity, diffuse contamination of its pseudomyxoma growths (pseudomyxomatosis of the peritoneum) and pseudomyxoglobulosis (accumulation of mucus masses on the peritoneum).
Pseudomyxoma is of an implantation nature. It is formed from a primary source in the ovary or from 40. Mucus that reaches the surface of the peritoneum grows into connective tissue or is encapsulated, resulting in the formation of multiple cysts. Often the omentum is also affected by this process. The ruptured cysts continue to produce mucus, resulting in an increase in abdominal volume.
In most cases, the correct diagnosis is made only during surgery. When a malignant mucosal cyst ruptures, viable epithelial cells enter the peritoneum along with mucus, which are implanted into it and become a source of mucus formation. Pseudomyxomas clinical course are often malignant.
Other primary tumors in the peritoneum originate either from the mesentery, omentum, tissue at the root of the mesentery, or from the peritoneal layer itself. For cysts greater omentum characteristic: superficial location of the tumor, greater mobility, absence of dysfunction of any abdominal organ and the so-called “trembling symptom” [S.D. Ternovsky et al., 1959]. Correct diagnosis cannot be determined before surgery.
Among the cysts there are lymphangiomas, enterocystoma and much less often dermoid and teratoid cysts.
Primary adenocarcinomas of the peritoneum are malignant. Primary sarcomas in the peritoneum are less malignant.
Clinic and diagnostics. The disease may occur with symptoms chronic appendicitis or stomach tumors. Often the only sign is an enlarged abdomen. The diagnosis is made on the basis of the presence of dullness in the abdomen that does not shift with changes in body position, which suggests the mucous nature of the fluid. Laparoscopy and RI using pneumoperitoneum are widely used for diagnosis. But the final diagnosis is made only by a biopsy of the surgical material.
Treatment is surgical. Benign tumors are removed within healthy tissue. For peritoneal carcinomatosis surgical treatment impossible. In localized forms of mesothelioma, radical removal of the tumor cures the patient. For diffuse forms, surgical treatment is not indicated.
The prognosis for peritoneal carcinomatosis is unfavorable. If the disease is benign, you can expect recovery after surgery; if it is malignant, the operation does not prevent further accumulation of mucus.
Stuffing box I
Stuffing box
a wide and long fold of the splanchnic (visceral) peritoneum (See Peritoneum), between the layers of which there is loose connective tissue, rich in blood vessels and fatty deposits. Large S., consisting of 4 layers of peritoneum, starts from the greater curvature of the stomach, is fixed to the transverse colon and, covering the intestines in front, descends in the form of an apron ( rice.
). Performs a protective function in case of injuries and inflammatory diseases of the abdominal organs, for example, in case of Appendicitis. Lesser S. - doubled peritoneum stretched between the liver, the upper part of the duodenum and the lesser curvature of the stomach. Large S. is often used to cover sutures during operations on the stomach and intestines, as well as for tamponade of wounds of the liver and spleen. Acute inflammation large S. (epiploitis) can occur as a result of its infection, twisting or injury; accompanied by symptoms acute abdomen(See Acute abdomen). gland seal, seal used in machine connections to seal gaps between rotating and stationary parts; is carried out by cuffs, collars and other parts put on the shaft, or various packings (asbestos, asbestos wire, rubber fabric, etc.) placed in recesses or recesses (also usually called S.) of covers, housings, etc. parts. The term is falling out of use.
Great Soviet Encyclopedia. - M.: Soviet Encyclopedia. 1969-1978 .
Synonyms:See what “Oil seal” is in other dictionaries:
STUFFING BOX- (omentum, epiploon), large hollows of the peritoneum, going from one organ of the abdominal cavity to another and consisting of leaves of the peritoneum, large and small peritoneal sacs (Fig. 1). Usually C, i.e., the layers of the peritoneum, covers the vascular pedicle, ... ... Great Medical Encyclopedia
Fat fold in the peritoneum * * * (Source: “United Dictionary of Culinary Terms”) Omentum Omentum fat fold in the peritoneum. Dictionary of culinary terms. 2012… Culinary dictionary
In engineering, a seal is a sealed gap between a moving and a stationary part (for example, a piston rod and a cylinder). An oil seal with soft (asbestos, felt, rubber) and hard (e.g. metal) packings is used...
OIL SEAL, oil seal, male 1. A section of the peritoneum rich in fat deposits from the stomach to the lower part of the abdominal cavity (anat.). 2. A type of food from this part of the animal’s body (kul.). 3. A lubricating device at the piston that prevents steam from escaping... ... Dictionary Ushakova
Seal, device, gap, gasket Dictionary of Russian synonyms. omentum noun, number of synonyms: 9 belly (29) ... Synonym dictionary
stuffing box- a, m. sale adj. outdated Loving greasy. Well, how can I go to the mazurka with him as an officer! It would be a key fob for a watch! Dad winced, barking: Oil seal. White beginning of the century. // Star. Arbat 40… Historical Dictionary of Gallicisms of the Russian Language
In anatomy, a wide and long fold of the visceral layer of the peritoneum in mammals and humans, part of the mesentery. The connective tissue of the omentum is rich in blood vessels and adipose tissue. Protective organ of the abdominal cavity... Big Encyclopedic Dictionary
SEALING, huh, husband. (specialist.). 1. Fat fold in the peritoneum. 2. A part that hermetically closes the gap between the moving and stationary parts of the machine. | adj. omental, oh, oh. Ozhegov's explanatory dictionary. S.I. Ozhegov, N.Yu. Shvedova. 1949 1992 … Ozhegov's Explanatory Dictionary
- (omentum), a wide and long fold of the visceral layer of the peritoneum of mammals, in which there is a loose connective tissue, tissue rich in blood vessels and fatty deposits. Large S. double fold of the dorsal mesentery of the stomach, consisting of 4 leaves, ... ... Biological encyclopedic Dictionary
- (Stuffing box, stuffing gland) a part for sealing the gaps between holes and parts moving in them in order to prevent the leakage of liquid or gas. Compaction is achieved through various packings. Samoilov K.I. Marine... ...Marine Dictionary
A sealing device for rods, rods and tubes where they pass through an opening in the wall (lid) separating two spaces with unequal pressure. C. a critical part that serves to prevent the passage (leakage) of steam, water... ... Technical railway dictionary
PROGRESS OF THE OPERATION. In cases of a malignant tumor of the stomach, it is recommended to remove the greater omentum due to the possible implantation of metastases into this structure. Removing the greater omentum is not difficult; it usually requires less technical effort than dividing the ligament of the stomach and colon adjacent to the greater curvature. Therefore, some prefer to use this operation constantly, regardless of the indication for almost complete gastrectomy. The transverse colon is removed from the wound, and the surgeon and assistants lift the omentum steeply upward and hold it (Fig. 1). Using Metzen-Baum scissors, excision begins on the right side adjacent to the posterior cord of the colon. In many cases, the peritoneal junction may be easier to divide with a scalpel than with scissors. A thin and relatively vascular peritoneal layer can be seen, which can be quickly cut (Fig. 1, 2 and 3). The greater omentum continues to be pulled upward, while using blunt separation with gauze, the colon is pushed down, freeing it from the omentum (Fig. 2) As this procedure progresses, several small blood vessels in the anterior cord of the colon may require division and ligation. As a result, a thin, avascular peritoneal layer above the colon will be visible. It is dissected, obtaining a direct entrance to the omental bursa (Fig. 4 and 5). In obese patients, as a preliminary step, it may be easier to separate the connections of the omentum to the lateral wall of the stomach under the spleen.
If the upper edge of the splenic flexure is clearly visible, then the ligament of the spleen and colon is divided and the omental bursa is entered from the left side, and not over the transverse colon, as shown in Fig. 6. The surgeon must be constantly careful not to injure the splenic capsule or middle vessels of the colon, since the mesentery of the transverse colon may be closely adjacent to the gastric-colic ligament, especially on the right side. As the division moves to the left, the omentum of the stomach and colon is divided, and the greater curvature of the stomach is separated from its blood supply to the desired level (Fig. 6). In some cases, it may be easier to ligate the splenic artery and vein along the superior surface of the pancreas and remove liver, especially if there is a malignant tumor in the area. It should be remembered that if the left gastric artery is ligated proximal to its bifurcation and the spleen is removed, the blood supply to the stomach becomes so compromised that the surgeon is forced to perform a complete gastrectomy.
In the presence of a malignant tumor, the greater omentum over the head of the pancreas is removed, as well as the subpyloric The lymph nodes(Fig.7). When approaching the duodenal wall, small curved clamps should be used, and the middle vessels of the colon, which may be adjacent to the stomach-colon ligament at this point, should be carefully inspected and circumvented before clamps are applied. If you are not careful, severe bleeding may occur and the blood supply to the colon will be at risk.
CHAPTER 23. STOMACH RESECTION, SUB-TOTAL - REMOVAL OF THE GREAT OPLUM
CHAPTER 24. STOMACH CUTTING, POLY METHOD
INDICATIONS. The Polya method, or a variation of it, is one of the safest and most widely used techniques used after extended gastric resections performed for ulcers or cancer.
PROGRESS OF THE OPERATION. The diagram (Fig. 1) shows the location of the internal organs after completion of this operation, which is essentially the attachment of the jejunum to the open end of the stomach. The jejunum can be anastomosed behind or in front of the colon. An anastomosis of the anterior colon is usually used. In a posterior anastomosis, the jejunal loop is passed through a fissure in the mesentery of the colon to the left of the middle vessels of the colon and near the ligament of Treitz (Fig. 2). When performing an anastomosis of the anterior colon, a longer loop must be used to pass in front of the colon, freed from the fatty omentum. If resection is made for an ulcer in order to control the acid factor, it is important that the jejunal loop be fairly short, since long loops are more prone to subsequent formation of a marginal ulcer. The jejunum is grasped with Babcock forceps and passed through an opening made in the mesentery of the colon, with the proximal portion adjacent to the lesser curvature of the stomach. (Fig. 2) Then the abdominal cavity is covered with warm, damp tampons. The jejunal loop is grasped with an enterostomy forceps and brought close to the posterior surface of the stomach adjacent to the non-pressure forceps using a series of interrupted 00 silk mattress sutures placed close together. (Fig. 3) This posterior row should include the greater and lesser curvature of the stomach. Otherwise, subsequent closing of the corners may not be reliable. The ends of the seams are cut off, with the exception of the seams on the large and lesser curvature, A and B, which are left for traction (Fig. 4) When the ends of the stomach are closed with staples, a non-pressure enterostomy clamp is applied a few centimeters from the line of staples. This provides support for the gastric wall during suturing and also controls bleeding and major contamination. The border of the stomach is cut off with scissors. A hole is made longitudinally in the jejunum, bringing it closer in size to the hole in the stomach. Use your fingers to press the jejunum downwards and make an incision close to the suture line (Fig. 5).
The mucous membranes of the stomach and jejunum are approximated with a continuous mucosal suture or a thin catgut or absorbable synthetic suture while the opposing surfaces are approximated using Allis forceps placed at each corner (Fig. 6). A continuous stitch is started with a straight or curved needle in the middle and continued to each corner as a running stitch or as a closing continuous stitch, as desired. The corners are turned out with a Connell seam, which is continued towards the front, and the final knot is tied on the inside of the midline (Fig. 7). Some prefer to approximate the mucosa with multiple interrupted sutures made on French needles with 0000 silk. The anterior layer is closed with knots on the inside using an interrupted Connell suture. The enterostomy clamps are removed to inspect the anastomosis for consistency. Additional stitches may be required. Then the anterior serosal layers are brought together using interrupted mattress sutures with 00 silk, made either with straight hat
needles, or small French needles. (Fig. 8). Finally, additional mattress sutures are placed at the upper and lower corners of the new stoma so that any tension applied to the stoma is applied to these additional serosal reinforcement sutures rather than to the anastomotic sutures (Figure 9). In a posterior colonic anastomosis, the new stoma is attached to the mesentery of the colon with interrupted mattress sutures, taking care to bypass the blood vessels in the mesentery of the colon. (Fig. 10).
If enough stomach remains, a Stamm gastrostomy is performed (Chapter 9). The stomach wall should extend without tension to the anterior wall of the peritoneum. To ensure the necessary mobility, especially of the small ventricle, mobilization of the fundus of the stomach and spleen may be indicated so that the stomach wall can be sutured to the peritoneum near the gastrostomy tube without unnecessary tension.
CLOSING. Closure is performed as usual without drainage.
POSTOPERATIVE CARE. When the patient is conscious, he is placed in a semi-sitting position. Any deficiencies resulting from measured blood loss during surgery should be corrected by whole blood transfusion. Antibiotics can be used as a prophylactic agent against peritoneal sepsis, especially in the presence of achlorhydria.
Daily fluid intake is maintained at a volume of approximately 2,000 ml by intravenous administration of lactated Ringer's solution. All the time that intravenous fluids are administered, the value of serous electrolytes is determined daily. The patient's weight is recorded daily. It is imperative to keep accurate records of inputs and outputs from all sources. Vitamins can be given parenterally.
Pulmonary complications can be expected and the patient is frequently repositioned. The patient is advised to cough, etc. If the patient's condition allows it, he may be allowed to get out of bed on the first day after surgery. During the day after surgery, you are allowed to drink water in small sips. During the entire operation and for several days after it, the stomach is constantly suctioned. Suctioning can be stopped if the tubes are closed for 12 hours or more and no symptoms of gastric distension occur. After removal of the nasal tube or closure of the gastrostomy tube for a day, the patient can be placed on a postgastrectomy diet, which gradually moves from light liquids to six small meals per day. Drinks containing caffeine, excess sugar or carbon should be avoided. The gastrostomy tube is removed after seven to ten days. The diet appropriate for the ulcer regimen should be gradually replaced by an ad libitum diet. Patients who are significantly below their ideal weight are advised to take extra fat daily. For a long time after surgery, the patient may not tolerate carbohydrates very well, especially in the morning. Smoking should be prohibited until the patient's weight returns to a satisfactory level. Frequent assessment of the patient's diet and weight changes is strongly recommended during the first year after surgery, and after the first year this can be done less frequently for at least five years.
CHAPTER 24. GASTRIC RESECTION, POLYA METHOD
PROGRESS OF THE OPERATION. The diagram shows the position of the internal organs after completion of the operation. Essentially, it consists of closing approximately half of the gastric outlet adjacent to the lesser curvature and aligning the jejunum with the end of the remaining stomach (Figure 1). This operation is appropriate when very high resections are indicated because it provides more reliable closure of the lesser curvature. It may also slow down the sudden distension of the stomach after eating. The jejunum can be brought either forward to the colon, or through an opening in the mesentery of the colon to the left of the middle vessels of the colon. (Chapter 24, Fig. 2)
There are many ways to close the gastric opening adjacent to the lesser curvature. Some surgeons use a stapler (Figure 2). This gives a protruding cuff of the stomach wall.
The line of staples adjacent to the greater curvature is grasped with Babcock forceps to create a stoma approximately two fingers' width. In the mucous membrane protruding beyond the clamp in the area of the lesser curvature, they begin to apply a continuous suture of catgut or dissolving synthetic material using a straight or curved needle, and lead it down to the greater curvature until the suture reaches the Babcock forceps, which define top end stoma. (Fig. 3) Some prefer to approximate the mucosa with interrupted 0000 silk sutures. The pressure clamp is then removed and an enterostomy clamp is applied to the gastric wall. A series of interrupted mattress sutures made of 00 silk are placed to evert not only the mucosal suture line, but also the stapled gastric wall (Fig. 4). It is necessary to ensure that at the very top of the lesser curvature there is good approximation of the serosal surface. The threads are not cut, they can be saved and later used to attach the jejunum to the anterior wall of the stomach along the closed end of the small ventricle.
The loop of jejunum adjacent to the ligament of Treitz is placed in front of or behind the colon, leading it through the mesentery of the colon to bring it closer to the remaining part of the stomach. The jejunal loop should be as short as possible, but when the anastomosis is completed, it should reach the anastomotic line without tension. An enterostomy clamp is placed on the part of the jejunum that will be used for anastomosis. Proximal part of the jejunum
the intestines are attached to the lesser curvature of the stomach. An enterostomy clamp is placed on the remnant of the stomach, unless the position of this remnant is too high to prevent this. Under such circumstances, it is necessary to perform an anastomosis without applying clamps to the stomach.
A posterior serosal row of interrupted 00 silk mattress sutures attaches the jejunum to the entire remaining end of the stomach. This is done to avoid unnecessary bending of the jejunum, this row relieves tension from the stoma site and strengthens the closed upper half of the stomach from the back. (Fig.5). The stapled gastric wall, still in the Babcock forceps, is then cut with scissors and any active bleeding points are ligated (Figure 6). The stomach contents are aspirated if it is not possible to apply an enterostomy clamp to the side of the stomach. The mucous membranes of the stomach and jejunum are brought together with a continuous suture of thin catgut using a straight atraumatic needle (Fig. 7). Some prefer interrupted sutures of 000 silk. To evert the corners and the anterior layer of the mucosa, use a Connell-type suture. (Fig. 8). A series of interrupted mattress sutures continue to run from the closed part to the edge of the greater curvature. Both corners on the lesser and greater curvature are reinforced with additional interrupted sutures. The long threads remaining from the closure of the upper part of the stomach are threaded back into the needle (Fig. 9). These sutures are used to attach the jejunum to the anterior wall of the stomach and to strengthen the anteriorly closed end of the stomach, as was previously done with the posterior surface. The stoma is tested for patency, as well as the degree of tension applied to the mesentery of the jejunum. The transverse colon is placed behind the jejunal loops entering and exiting the anastomosis. If an anastomosis of the posterior colon was performed, the edges of the mesentery of the colon are attached to the stomach near the anastomosis (Chapter 24, Fig. 10)
CLOSING. The wound is closed in the usual way. In malnourished or sick patients, relief sutures should be used.
POSTOPERATIVE CARE. Cm. Postoperative Care, Chapter 24.
CHAPTER 25. RESECTION OF THE STOMACH, CHAMPIONSHIP METHOD
CHAPTER 26. COMPLETE GASTROCUTING
INDICATIONS. Complete gastrectomy may be indicated in the treatment of extensive gastric malignancies. This radical operation is not performed in the presence of carcinoma with distant metastasis to the liver or in the presence of a pouch of Douglas or dissemination through the peritoneal cavity. It can be done in conjunction with complete removal of adjacent organs, such as the spleen, body and tail of the pancreas, part of the transverse colon, etc. This operation is also advisable for controlling intractable ulcerative diathesis associated with non-insuloma tumors of the pancreas.
PREOPERATIVE PREPARATION. Blood volume should be restored and antibiotics given if achlorhydria is present. If the large intestine is suspected of being affected, appropriate antibacterial agents should be prescribed. Must be available for transfusion 4-6 units of blood. The colon should be emptied. Pulmonary function tests may be ordered.
ANESTHESIA. General anesthesia with endotracheal intubation.
POSITION. The patient is placed on the table in a comfortable position lying on his back, with his legs slightly lower than his head.
OPERATIONAL PREPARATION. The area of the chest is shaved above the nipple and down to the symphysis. The skin on the chest, lower chest wall and entire abdomen is washed with an appropriate antiseptic solution. If necessary, preparation should extend sufficiently high and to left side chest for a mid-sternal or left thoracoabdominal incision.
CUT AND EXPOSURE. A limited incision is made in the midline (Fig. 1 A-A) between the xiphoid process and the umbilicus. The initial opening should only allow the stomach and liver to be examined and the hand to be inserted to general examination abdominal cavity. Because metastases are common, a longer incision extending up to the xiphoid process and down to the umbilicus, or extending to the left of the umbilicus, is not made until it is determined that there are no contraindications for complete or nearly complete gastrectomy. (Fig. 1) Additional exposure can be obtained by removing the xiphoid process. Active bleeding points at the xiphocostal angle are sutured with 00 silk sutures, and surgical wax is applied to the end of the sternum. Some prefer to divide the sternum at the midline and extend the incision to the left into the fourth intercostal space. Proper exposure is essential for a reliable anastomosis between the esophagus and jejunum.
PROGRESS OF THE OPERATION. Complete gastrectomy should be considered for a malignant tumor located high on the lesser curvature, if there are no metastases in the liver or dissemination into the abdominal cavity in general, and in particular into the pouch of Douglas. (Fig.2). Before proceeding with a complete gastrectomy, the surgeon must clearly see behind the stomach to determine whether the tumor has spread to adjacent structures - i.e. pancreas, mesentery of the colon or large vessels(Fig. 3). This can be determined by deflecting the greater omentum upward, pulling the transverse colon out of the abdominal cavity and examining the transverse mesentery of the colon to see if it is affected by malignant growth. Using palpation, the surgeon must determine whether the tumor has free mobility without affecting connections with the underlying pancreas or large vessels, especially in the area of the left gastric vessels (Fig. 4),
The entire transverse colon, including the hepatic and splenic flexures, should be freed from the greater omentum and retracted inferiorly. While the greater omentum is retracted upward and the transverse colon downward, the venous branch between the right vein of the stomach and greater omentum and the middle vein of the colon is inspected and ligated to avoid dangerous bleeding. The greater omentum in the region of the head of the pancreas and the hepatic flexure of the colon must be freed by sharp and blunt division so that it can be completely mobilized from the underlying head of the pancreas and duodenum. In very thin patients, the surgeon may prefer a Kocher maneuver with an incision into the peritoneum, lateral to the duodenum, so that later it can be checked whether a tension-free anastomosis between the duodenum and the esophagus can be performed. Sometimes this is possible in thin patients with high mobility of the internal abdominal organs.
Having examined the omental bursa, the surgeon continues to further mobilize the stomach. If the tumor appears to be localized, even though it is large and involves the tail of the pancreas, colon, and kidney, a very radical extirpation may be performed. Sometimes there is a need for resection of the left lobe of the liver.
To ensure complete removal of the tumor, it is necessary to excise at least 2.5 - 3 cm of the duodenum and the distal pyloric vein. (Fig.2). Since metastases often occur in the subpyloric lymph nodes, they also need to be removed. Double ligation of the right gastric vessels and greater omentum is performed as far as possible from the inner surface of the duodenum to ensure removal of the subpyloric lymph nodes and adjacent fat (Fig. 5).
CHAPTER 170. EXCISION OF ZENKER'S DIVERTICULUM
INDICATIONS. Indications for surgery for Zenker's diverticulum include partial obstruction, dysphagia, choking, pain when swallowing, or coughing associated with aspiration of fluid from the diverticulum. The diagnosis is confirmed with barium. The diverticulum appears suspended on a thin neck to the esophagus. A Zenker's diverticulum is a herniation of the mucosa resulting from weakness of an area located in the midline of the posterior wall of the esophagus, where the inferior pharyngeal constrictors connect to the annular pharyngeal muscle (Figure 1). The neck of the diverticulum forms immediately above the annular muscle of the pharynx, is located behind the esophagus and is generally projected to the left of the midline. Barium accumulates and remains in the hernial formation of the esophageal mucosa.
PREOPERATIVE PREPARATION. The patient should take purely liquid food for several days before surgery. He should rinse his mouth with an antiseptic solution. Treatment with antibiotics may be started.
ANESTHESIA. Endotracheal anesthesia is preferred, using an endotracheal tube with a cuff that is inflated to prevent aspiration of the diverticulum contents. If general anesthesia is contraindicated, then the operation can be performed with local infiltration anesthesia using a 1% procaine solution.
POSITION. The patient is placed in a supine position with a bolster under the shoulders. The head tilts back (Fig. 2). The chin can be turned to right side, if the surgeon so desires.
OPERATIONAL PREPARATION. The patient's hair is covered with tight-fitting gauze or a honeycomb cap to avoid contamination of the surgical field. The skin is prepared in the prescribed manner, and the incision line is marked along the anterior border of the sternocleidomastoid muscle, centered at the level of the thyroid cartilage (Fig. 2). Skin wipes can be eliminated by using a sterile, tight-fitting clear plastic cover. A large sterile drape with an oval opening completes the cover.
CUT AND EXPOSURE. The surgeon stands on the left side of the patient. He should be familiar with the anatomy of the neck in detail and know that the sensory branch of the cervical plexus, the cervical cutaneous nerve, crosses the incision 2 or 3 cm below the angle of the jaw (Fig. 3). The surgeon applies firm pressure to the sternocleidomastoid muscle using a gauze pad. The first assistant applies similar pressure on the opposite side. An incision is made through the skin and subcutaneous muscle of the neck along the anterior border of the sternocleidomastoid muscle. Bleeding in subcutaneous tissues stopped using hemostatic clamps and ligatures made of silk 0000.
PROGRESS OF THE OPERATION. When the surgeon works at the top of the wound, he must avoid cutting the cervical cutaneous nerve lying in the superficial integumentary fascia (Fig. 3). The sternocleidomastoid muscle is then pulled laterally and its attachment to the fascia along the anterior border is divided. The scapulohyoid muscle crosses the lower part of the incision and is divided between the clamps (Figure 4). Hemostasis is achieved using a 00 silk ligature. The inferior end of the omohyoid muscle is pulled posteriorly while the superior end is pulled medially (Figure 5). When the middle cervical fascia covering the scapulohyoid and splenius muscles is cut at the upper
part of the wound, the superior thyroid artery is exposed, it is crossed between the clamps and ligatures are applied (Fig. 4 and 5). The cervical visceral fascia, covering the thyroid gland, trachea and esophagus, includes the medial carotid sinus. The posterior surfaces of the pharynx and esophagus are exposed by blunt dissection. Now, a diverticulum is usually easy to recognize unless there is inflammation causing adhesion to surrounding structures (Figures 6 and 7). If it is difficult to recognize the contours of the diverticulum, the anesthesiologist can insert a rubber or plastic catheter into it. Air is blown into this catheter to distend the diverticulum. The lower end of the diverticulum is freed from surrounding structures by blunt and sharp way, identify its neck and localize the place of its connection with the esophagus (Fig. 6, 7 and 8). Particular attention is paid to removing the connective tissue surrounding the diverticulum at the site of its formation. This area must be cleared to such an extent that only hernia formation mucous membrane, resulting from a defect in the muscular wall between the inferior constrictor muscles of the pharynx and the annular muscle of the pharynx below. Care should be taken not to cross the two recurrent laryngeal nerves, which may be on either side of the neck of the diverticulum or in the tracheoesophageal groove, more anteriorly (Fig. 8). Two securing sutures are then placed above and below the neck of the diverticulum (Fig. 9). These sutures are tied and straight hemostats are secured to the ends of the sutures for retraction and orientation. The diverticulum is opened at this level (Fig. 10), care must be taken not to leave an excessive amount of mucosa and, on the other hand, not to remove too much mucosa to prevent narrowing of the lumen of the esophagus. At this time, the anesthesiologist inserts a nasogastric tube through the esophagus into the stomach. It can be seen inside the esophagus when the diverticulum is dissected (Fig. 10). The suturing of the diverticulum in two layers begins. A first row of interrupted 0000 silk sutures is placed in the longitudinal plane to turn the mucosa with the knot tied on the inside of the esophagus inside out, and gentle traction is applied to the diverticulum to increase exposure. The diverticulum is gradually excised as closure progresses (Fig. 11). Then, a second row of horizontal sutures is used to close the muscle defect between the inferior pharyngeal constrictors and the annular pharyngeal muscle below. These muscles are tightened using interrupted 0000 silk sutures.
CLOSING. After thorough irrigation, hemostasis is ensured. A small Peprose drain or a long narrow rubber drain may be used and the omohyoid muscle is reconnected using several interrupted sutures. Interrupted 0000 silk sutures are used separately to suture the subcutaneous muscle of the neck and the skin. Finally, the bandage is made with light sterile gauze, but it should not surround the neck.
POSTOPERATIVE CARE. The patient is left in a semi-sitting position and is not allowed to swallow anything. Drinking water and feeding are provided using a nasogastric tube with a circuit to maintain fluid and electrolyte balance during the first three days. The drainage tube is removed on the second day after surgery, unless this is contraindicated due to the presence of copious discharge containing serum and blood elements coming out through the tube or saliva secretion when draining the wound. The nasogastric tube is removed on the fourth postoperative day and the patient is placed on a liquid diet. He is given more food if he can tolerate it. The patient is allowed to get out of bed on the first day after surgery and can be treated as an outpatient with a nasogastric tube inserted, but without clamps. Antibiotics are optionally prescribed, depending on the degree of infection.
CHAPTER 26. GASTRIC RESECTION, COMPLETE
CHAPTER 27. COMPLETE RESECTION OF THE STOMACH
PROGRESS OF THE OPERATION(continued) Right gastric vessels along top edge the first part of the duodenum is isolated by blunt division and double ligation is made at some distance from the wall of the duodenum (Fig. 6). The elongated gastrohepatic ligament is divided as close as possible to the liver up to its thickened part, which contains a branch of the inferior hepatic artery.
The duodenum is then divided using non-crushing straight forceps on the duodenal side and a pressure forceps, such as a Kocher forceps, on the gastric side (Fig. 7). The duodenum is divided using a scalpel. A sufficient amount of the posterior wall of the duodenum must be freed from the adjacent pancreas, especially from below, where several vessels may enter the wall of the duodenum. (Fig. 8). Even if it is quite mobile, the duodenal stump should not be anastomosed with the esophagus due to subsequent esophagitis from regurgitation of duodenal juices.
Then the area of the esophagus and fundus of the stomach is exposed and mobilized medially. First, the avascular suspensory ligament is divided
ku that supports left lobe liver. The surgeon grasps the left lobe with his right hand and determines the boundaries of the avascular subtensum ligament from below, pressing upward with his index finger (Fig. 9). This procedure is simplified if the ligament is divided with long curved scissors, held in the left hand. Sometimes a suture is required to control minor bleeding from the very apex of the mobilized left lobe of the liver. The left lobe should be carefully palpated for metastatic nodules located deep in the liver. The mobilized left lobe of the liver is folded upward and covered with a moist swab, on top of which a large S-shaped retractor is placed. At this point, the need to extend the incision upward or remove additional< грудины. Самую верхнюю часть желудочно-печеночной связки, ку входит ветвь нижнего диафрагмального сосуда, изолируют тупым раз^ лением. На утолщенные ткани как можно ближе к печени накладыва! два прямоугольных зажима. Ткани между зажимами разделяют, а соде жимое зажимов лигируют пронизывающими швами из шелка 00.(Рис.1(Разрез в брюшине поверх пищевода и между дном желудка и основан ем диафрагмы отмечен на Рис. 10.
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CHAPTER 28. COMPLETE RESECTION OF THE STOMACH
PROGRESS OF THE OPERATION.(Continued) The peritoneum above the esophagus is divided and all bleeding points are carefully ligated. When the peritoneum is divided between the fundus of the stomach and the base of the diaphragm, several small vessels may require ligation. The lower esophagus is released using a finger, similar to the vagotomy method (Chapters 15 and 16). The vagus nerves are divided to further mobilize the esophagus into the abdominal cavity. Using blunt and sharp division, the left gastric vessels are isolated from adjacent tissues. (Fig. 11) These vessels should be circled with the surgeon's index finger and carefully palpated for the presence of metastatic lymph nodes. A pair of clamps, such as half-length curved clamps, are placed as close to the origin of the left gastric artery as possible, and a third clamp is placed closer to the gastric wall. The contents of these clamps are first ligated and then threaded distally. The left gastric vessels at the lesser curvature should be ligated in a similar manner, which facilitates subsequent exposure of the esophagus-stomach junction. When the tumor is located near the greater curvature of the midstomach, it may be appropriate to remove the spleen and tail of the pancreas to allow en bloc dissection of the adjacent lymphatic drainage area. The location and size of the tumor, as well as the presence or absence of adhesions or tears in the capsule, determine the need to remove the spleen. If the spleen is to be retained, the gastrosplenic ligament is divided as described for splenic resection (Chapters 111 and 112). The blood vessels on the gastric side are ligated with 00 silk sutures extending to the gastric wall. The left vessel of the stomach and greater omentum is ligated twice. The greater curvature is released up to the esophagus. Usually there are several vessels entering the posterior wall of the fundus near the greater curvature.
The anesthetist should suction the stomach contents from time to time to prevent possible regurgitation from the stomach as it is pulled upward and to avoid contamination of the peritoneum during division of the esophagus.
The duodenum is closed in two layers (see Chapter 21). The duodenal walls are closed with a first layer of interrupted Connell-type sutures made of 0000 silk. These sutures are invaginated with a second layer of mattress sutures of 00 silk. Some prefer to close with staples.
Choose one of the many methods developed to restore gastrointestinal integrity.
The surgeon must take into account some anatomical features of the esophagus, which make working with it more difficult than with
the rest of the gastrointestinal tract. First, since the esophagus is not covered by the serosa, the layers of longitudinal and circular muscles may tear when sutured. Secondly, although the esophagus initially seems to be pulled well down into the abdominal cavity, when it is separated from the stomach, it is pulled into chest, and the surgeon has difficulty achieving the appropriate length. However, it should be mentioned that if exposure is insufficient, the surgeon should not hesitate to remove more of the xiphoid process or divide the sternum, extending the incision into the left fourth intercostal space. A common approach is to extend the superior portion of the incision through the cartilage into the appropriate intercostal space, creating a thoracoabdominal incision. Adequate and free exposure must be obtained to ensure a secure anastomosis.
The esophageal wall can be easily attached to the crus of the diaphragm on both sides, as well as anteriorly and posteriorly. (Fig. 12) to prevent the esophagus from twisting or being pulled upward. These sutures should not extend into the lumen of the esophagus. Two to three 00 silk sutures are placed behind the esophagus to approximate the crus of the diaphragm.
Many techniques have been developed to facilitate esophageal-jejunal anastomosis. Some prefer to leave the stomach attached as a retractor until the posterior layers are completed. It is possible to divide the posterior wall of the esophagus and close the posterior layers before removing the stomach by dividing the anterior wall of the esophagus. Another method is to apply a non-crushing Pace-Potts type vessel clamp to the esophagus. Because the esophageal wall is easily torn, it is recommended to stiffen the esophageal wall and prevent fraying of the muscular layer by fixing the mucosa to the muscular covering, the proximal point of separation. A series of circular mattress sutures made of 0000 silk can be inserted and surgically knotted (Fig. 13). These sutures span the entire thickness of the esophagus (Fig. 14). To prevent rotation of the esophagus when it is attached to the jejunum, fillet sutures A and B are used (Fig. 14).
The esophagus is then divided between this suture line and the stomach wall itself. (Fig. 15). Contamination should be prevented by suctioning with a Levine tube extended into the lower esophagus and placing a clamp through the esophagus on the gastric side. If there is a very high-lying tumor that reaches the junction of the esophagus with the stomach, it is necessary to remove several centimeters of the esophagus to remove the tumor. If 2.5 cm or more of the esophagus does not extend beyond the crus of the diaphragm, the inferior mediastinum must be exposed to ensure a secure, tension-free anastomosis.
"Chapter 28. GASTRIC RESECTION, COMPLETE (continued)
CHAPTER 29. COMPLETE RESECTION OF THE STOMACH
PROGRESS OF THE OPERATION(Continued) The next step is to mobilize a long loop of jejunum large enough to easily reach the open esophagus. The jejunal loop is brought out through the hole in the mesentery of the colon to the left of the middle vessels of the colon. It may be necessary to mobilize the area around the ligament of Treitz so that the jejunum reaches the diaphragm and easily approaches the esophagus. The surgeon must be sure that the mesentery is truly adequate so that all layers of the anastomosis can be completed.
To ensure that the patient’s nutrition after surgery is better and the number of symptoms after complete removal of the stomach is less, different methods. Typically a large loop of jejunum with enteroenterostomy is used. Regurgitant esophagitis can be reduced by Ro-ux-en-Y anastomosis. Interposition of jejunal segments between the esophagus and duodenum, including reverse short segments, showed satisfactory results.
The Roux-en-Y procedure can be used after dividing the jejunum approximately 30 cm away from the ligament of Treitz. By keeping the jejunum outside the abdominal cavity, the arch can be identified more clearly blood vessels using illumination with a portable lamp. (Fig. 16) Two or more arches of blood vessels are separated and a short segment of circulatory intestine is excised. (Fig. 17). A sleeve of the distal segment of the jejunum is passed through an opening made in the mesentery of the colon to the left of the middle vessels of the colon. An additional collar is divided if the end segment
The jejunum does not easily reach the crus of the diaphragm behind the esophagus and is not parallel to it. Once the required length is achieved, it is necessary to decide whether it is safer and easier to do an end-to-end anastomosis or an end-to-side anastomosis to the esophagus. If an end-to-side anastomosis is chosen, the end of the jejunum is closed with two rows of 0000 silk (Figs. 18 and 19). The end of the jejunum is then pulled through a hole made in the breastbone of the colon to the left of the middle vessels of the colon. (Fig. 20). It is necessary to avoid bending or twisting the mesentery of the jejunum when it is pulled into the hole. The jejunal wall is attached near the edges of the opening in the mesentery of the colon. All openings in the mesentery should be closed to prevent internal hernia. The hole created under the free edge of the mesentery and the posterior walls must be sealed with interrupted sutures applied superficially, without injuring the blood vessels.
The length of the jejunum should be checked again to ensure that the mesenteric border can be easily brought 5-6 cm or more to the base of the diaphragm behind the esophagus (Figure 21). It is possible to provide additional mobilization of a segment of the jejunum over a distance 4- 5 cm if releasing incisions are made in the posterior parietal peritoneum near the base of the mesentery. Additional distance can be gained by very carefully incising the peritoneum superior and inferior to the choroidal arch along with several short incisions towards the border of the mesentery. The figure shows that the closed end of the jejunum is directed to the right, although it is most often directed to the left.
CHAPTER 29. COMPLETE GASTRIC RESECTION (continued)
CHAPTER 30. COMPLETE RESECTION OF THE STOMACH
PROGRESS OF THE OPERATION.(Continued) A series of interrupted 00 silk sutures are placed to approximate the jejunum to the diaphragm on both sides of the esophagus and also just behind it (Fig. 22) It must be emphasized that the jejunal sleeve is attached to the diaphragm to relieve tension on the subsequent esophageal anastomosis . Once these anchoring sutures are tied, corner sutures are placed on both sides of the esophagus and jejunum. (Fig. 23, C,D) The wall of the esophagus must be attached to the upper side of the jejunum. Care should be taken to keep the interrupted sutures close to the mesenteric side of the jejunum, as there is a tendency to use the entire available jejunal surface in subsequent layers of closure. To complete the closure between corner sutures C and D (Fig. 24), three or four additional interrupted mattress sutures of 00 silk are required, grasping the esophageal wall from the serosal meninges. A small hole is then made in the adjacent intestinal wall, pulling back the small intestine so that during this procedure there is no excess mucosa from cutting too large. Exists
tendency to make too large an opening in the jejunum with prolapse and unevenness of the mucous membrane, making it quite difficult to perform an accurate anastomosis with the mucous membrane of the esophagus. To close the mucosal layer, a series of interrupted 00 silk sutures are required, starting with corner sutures at both ends of the jejunal incision (Fig. 25 E, F). The posterior layer of the mucosa is closed with a series of interrupted 0000 silk sutures. (Fig. 26) The Lewin tube can be directed down into the jejunum (Fig. 27) The presence of the tube in the lumen of the intestine facilitates the placement of interrupted Connell sutures that close the anterior layer of the mucosa (Fig. 27). You can get a wider lumen if you use an Ewald tube, which has a much larger diameter, instead of a Lewin tube. When the anastomosis is completed, this tube is replaced with a Levine tube. Another layer will be added to the back. Thus, when the jejunum is attached to the diaphragm, the esophageal wall, and the esophageal mucosa, a three-layer closure is achieved (Figure 28).
CHAPTER 30. COMPLETE GASTRIC RESECTION (continued)
CHAPTER 31. COMPLETE RESECTION OF THE STOMACH
PROGRESS OF THE OPERATION(Continued) A second row of interrupted 00 silk stitches is made in front (Fig. 29). The peritoneum, which was first incised to divide the vagus nerve and mobilize the esophagus, is then lowered down to cover the anastomosis and attached to the jejunum with interrupted 00 silk sutures (Figure 30). This provides a third row of support that goes anteriorly around the entire esophageal anastomosis and relieves any tension on the delicate line of the anastomosis (Fig. 31). The catheter can be pulled far down into the jejunum through an opening in the mesentery of the colon to prevent kinking of the bowel. A series of superficial thin sutures are placed to secure the edge of the mesentery to the posterior walls to prevent kinking and disruption of the blood supply (Fig. 31). These seams should not include
pancreatic tissue or vessels in the edge of the mesentery of the jejunum. The color of the jejunal sleeve should be checked from time to time to ensure proper blood supply. The open end of the proximal jejunum (Fig. 32, Y) is then anastomosed at a suitable point in the jejunum (Fig. 32, X) with two layers of 00 silk, and the opening to the mesentery under the anastomosis is closed with interrupted sutures to avoid any possibility of subsequent hernia formation. Figure 32A is a diagram of a complete Roux-en-Y anastomosis. Some people prefer to use a stapler to create an anastomosis of the esophagus and jejunum. Regardless of the technique used, attention should be paid to strengthening the corners with interrupted sutures, as well as anastomosing the jejunum with the adjacent diaphragm.
CHAPTER 31. COMPLETE GASTRIC RESECTION (continued)
CHAPTER 32. COMPLETE RESECTION OF THE STOMACH
PROGRESS OF THE OPERATION(Continued) In Fig. 33 and 3ZA shows anastomosis of a long loop of jejunum. This loop is first attached to the diaphragm behind the esophagus and a three-layer anterior and posterior closure is performed, shown in Fig. 28 Chapter 30. To relieve tension from the suture line and avoid sharp bending of the loop, two or three interrupted sutures may be required to “round” the fit to the diaphragm. The hole in the mesentery of the colon is closed near the jejunum with interrupted sutures to prevent rotation of the loops and to prevent the possible formation of a hernia through the hole (Fig. 34). An enteroentrostomy is made at the base of the loop. This requires a stoma two to three fingers wide. Some prefer a very long enteroenterostomy, which may include more of the loop, in order to obtain a pocket with greater absorptive capacity.
Some attempts to improve postoperative nutrition and to achieve a reduction in gastrointestinal symptoms are reflected in operations where segments of the jejunum are inserted between the esophagus and duodenum. A 12-15 cm long segment of jejunum can be used as a bridge across this gap (Fig. 35A). The blood supply to this isolated loop of AA" can be improved if the large arcades are not divided, but the jejunum proximal and distal to the selected segment is excised at the mesenteric border (Fig. 35). The intestine on both sides of the remaining segment AA" is excised to a point below the opening of the mesentery of the colon , leaving a wide mesentery for supply for a short distance (Fig. 36) A two-layer end-to-end anastomosis is made into the esophagus and duodenum. The jejunum should be attached to the diaphragm behind the esophagus and to the peritoneal flexure anteriorly as a third support layer. It is necessary to constantly monitor the color of the intestine and the presence of active arterial pulsations in the mesentery.
Regardless of the type of pocket constructed, it is necessary to restore the integrity of the jejunum. In preparation for anastomosis, the loops of the jejunum below the mesentery of the colon are freed from blood supply for a short distance (Fig. 37). A two-layer end-to-end anastomosis is performed (Fig. 38). All holes remaining below the anastomosis are closed with interrupted sutures made of thin silk. A final check should be made to ensure that there is no tension at the anastomotic sites and that the color of the mobilized segments clearly indicates that the blood supply is good. Using two jejunal sleeves to insert between the esophagus and duodenum may result in improved nutrition with few symptoms. (Fig. 39). One segment, 25 cm long, YY\, is anastomosed to the esophagus, while the other segment, XX\, is turned in the opposite direction and one end is anastomosed to the duodenum. A large enteroenterostomy is made between these two loops. Approximately 5 cm of this reversed
well, the segment extends beyond the enteroenterostomy and anastomosis with the jejunum (Fig. 39.
CLOSING. The wound is closed as usual. In obese or very debilitated patients, the use of unloading sutures may be appropriate. There is no need for drainage.
POSTOPERATIVE CARE. Maintain constant suction through the nasogastric tube passed through the anastomosis and beyond. During this period, nutrition is provided by intravenous fluids and additional vitamins. The patient gets out of bed on the first day after surgery and is advised to gradually increase activity. In order to restore intestinal motility as early as possible, 30 ml of mineral oil is administered through a jejunal tube at regular intervals in the first few days after surgery. When intestinal motility is established, suction can be stopped. To avoid diarrhea, feed slowly with low content fats and carbohydrates. Typically, the patient tolerates only water well, after which 30-60 ml of skim milk is given. Oral feeding can be prescribed when there is complete confidence that a fistula has not formed at the anastomotic sites. Of course, these patients will require frequent small feedings and ensuring adequate caloric intake will not be easy. The patient's family will need to be discussed regarding diet. This will require the cooperation of a surgeon and a nutritionist. In addition, an additional vitamin B-12 will need to be prescribed every month. You can prescribe iron and vitamins orally for your entire life.
It is recommended that patients be readmitted to the hospital every 6 to 12 months to check caloric intake. Suture line stenosis may require dilatation. It may be necessary to restore blood volume and various nutritional adjustments.
When complete resection stomach was done in order to monitor the hormonal effects of pancreatic insulinoma, the levels of serosal gastrins were determined to assess the presence and development of residual tumor or metastasis. It is also recommended to measure calcium levels in the blood to determine the status of the parathyroid glands. The possibility of familial polyendocrine adenomatosis should be investigated in all members of the patient's family. Follow-up testing should include serial serum gastrin, calcium, parathyroid hormone, prolactin, cortisol, and catecholamine levels. Recurrent hyperparathyroidism often occurs. In the presence of residual gastrin-producing tumor, fasting levels of normal serosal gastrins may increase. The presence of one endocrine tumor is an indication for searching for others during subsequent examinations.
CHAPTER 33. ESOPHAGOCARDIOMYOTOMY
INDICATIONS. Swallowing disorders associated with enlargement of the esophagus due to cardiospasm (achalasia) can be corrected by extended extra-mucosal myotomy of the junction of the esophagus and stomach. First, a trial dilatation with hydrostatic dilators can be performed, provided that the patient does not have a distended sigmoid esophagus. The diagnosis of ahadasia must be confirmed by radiographic examination, as well as esophagoscopy. Radiography is used in distinguishing achalasia from organic damage due to achalasia. Associated benign and malignant pathological lesions of the esophagus should be identified by appropriate investigations, including manometric studies and pH tests.
It is necessary to take an x-ray of everything gastrointestinal tract, paying special attention to data indicating increased gastric secretion and deformation of the duodenum due to ulcers. In the presence of esophagitis, tests of nocturnal gastric secretion are indicated to collect data for possible control of increased secretion using vagotomy in combination with pyloroplasty.
PREOPERATIVE PREPARATION. Although some patients are in relatively good nutritional status, others require a period of high-protein, high-calorie, low-fibre nutrition or intravenous nutritional supplementation before surgery. In addition to inadequate oral intake, nasogastric tube feeding may be used. Blood volume is restored by administering whole blood and additionally giving liquid vitamins, including ascorbic acid.
The day before surgery, a large diameter rubber tube is inserted into the lower esophagus to help flush the esophagus. After thorough rinsing, this tube is replaced with a plastic nasogastric tube of smaller diameter, placed above the narrowing. Several ounces of a nonabsorbable antibiotic solution are administered every four to six hours. The night before surgery, a suction is placed on the tube to completely empty the dilated esophagus, and it is left in place for the duration of the operation.
Because these patients often experience recurrent aspiration in supine position, before surgery, it is necessary to completely check the condition of the lungs. Sputum culture and general antibiotics may be necessary.
ANESTHESIA. General endotracheal anesthesia is preferred.
POSITION. The patient is placed flat on the table, with the legs slightly lower than the head.
OPERATIONAL PREPARATION. Preoperative gastrointestinal tests should include esophagoscopy, overnight gastric test, and gastroduodenal barium test. If esophagitis is suspected based on barium swallow or esophagoscopy, if preoperative gastric secretions show high acidity and volume, or if there is incidental peptic ulcer disease, the patient and surgeon
must be prepared for vagotomy, pyloroplasty and gastrostomy. Co;
prepared from the nipples to the area well below the navel. Sticky plastic coverings may be used.
CUT AND EXPOSURE. An incision may be used different type depending on the patient's body structure. If a midline 1 incision is used, the xiphoid process can be excised to improve exposure. Good exposure is provided by a long left paramedian incision, dissecting the left sternocostal region and the extending lower umbilicus to the left of it. (Fig. 1)
Extramucosal myotomy of the esophagogastric junction using an abdominal approach allows for abdominal extirpation of associated pathological lesions and facilitates drainage procedures such as pyloroplasty or gastroenterostomy with or without vagotomy (Chapter 15).
PROGRESS OF THE OPERATION. After a general abdominal examination special attention to the area of the duodenal wall t subject of ulcerative deformation or scars, expose the lower end of the esophagus by mobilizing the left lobe of the liver. The triangular ligament going to the left lobe is divided, the left lobe is pulled upward and held medially with gauze pads, on which I place a large S-shaped retractor (Fig. 2). All small ligaments between the stomach and the free edge of the spleen must be separated, otherwise the splenic capsule will rupture and the spleen will need to be removed. You can put a small tampon on top of the spleen to pull it down, or you can leave the tampon off. If the exposure seems insufficient, you can excise the xiphoid process and divide the lower end of the sternum. The peritoneum over the esophagus is divided while the upper end of the stomach is pulled downwards using Babcock forceps (Figure 2). The avascular gastrohepatic ligament is divided, and the thick superior part of the gastrohepatic ligament, containing the branches of the inferior phrenic artery, is clamped (Fig. 3). This increases the mobilization of the junction of the esophagus and stomach and improves exposure especially in the front. The esophagus can be further mobilized by dividing the peritoneum and connections along the upper fundus of the stomach (Figure 4). There are vessels in this area that may require ligation. The surgeon then passes the index finger around the esophagus and further releases the lower end of the esophagus from adjacent structures (Figure 5). Usually a tightened area of the esophagus becomes visible. At first it may seem that the lower end of the esophagus will not be sufficiently mobilized and therefore further division with a finger upward around the lower part of the dilated esophagus may be required.
If there is evidence of esophagitis or increased gastric secretion, and especially if there is a history of duodenal ulcer or scars on the duodenal wall, then both vagus nerves should be divided. Division of both vagus nerves greatly increases the mobility of the lower end of the esophagus and forces the surgeon to resort to gastric drainage surgery such as pyloroplasty (Figure 5).
CHAPTER 33. ESOPHACOCARDIOMYOTOMY
CHAPTER 34. ESOPHAGOCARDIOMYOTOMY
PROGRESS OF THE OPERATION(Continued) After dividing the vagus nerves and bringing additional length of the esophagus into the abdominal cavity, the tissue near the anterior surface of the esophagus-stomach junction is cleared before making an incision through the muscle layers as part of the operation (Fig. b). To clear the area of all blood vessels and fatty tissue, rectangular forceps can be used and the contents ligated with 00 silk. During this procedure, the anesthetist repeatedly suctions the gastric tube that remains in place to minimize contamination if dilated. a hole will appear in the esophagus.
A variety of techniques are recommended to separate the muscle layers of the esophagus. It is advisable to cut the muscle well above the point of visible contraction and extend the cut far down through the stomach wall. To do this, you need to separate the muscles by at least 8 cm.
An elastic balloon has proven to be very useful in helping to cut the muscle while simultaneously ensuring complete separation of all fibers and creating an appropriate lumen. (Fig. 7) A small incision is made on the anterior wall of the stomach between two Babcock forceps and a small, unfilled Foley catheter is passed up the esophagus. It is then filled with 5 or 10 ml of sterile saline, depending on the size of the esophagus and the degree of its contraction (Fig. 8). At the junction of the esophagus with the stomach, an incision is made through the muscles in the front in the midline (Fig. 8). Small curved forceps are used to create a cleavage plane between the underlying gastric mucosa and the upper muscle layers. All contractile fibers are separated with great care, being careful not to make an incision only through the mucosa (Fig. 9). As the incision passes through the point of visible contraction and up through the dilated part of the lower esophagus, the contents of the balloon can be released slightly. When the esophagus is moderately distended with the balloon, all contraction points can be identified by gentle palpation of the thinned remaining mucosa using the index finger. (Fig. 10) The incision is extended further upward above the contraction point (Fig. 11).
The surgeon must ensure that the incision extends 1 cm down through the anterior wall of the stomach and well up into the dilated wall of the stomach.
gullet above the point of contraction. After this, the balloon is inflated with saline solution until it stretches the mucous membrane to a diameter significantly larger than normal (Fig. 12). As the balloon is carefully pulled into the stomach, its fullness is reduced and this procedure is repeated several times. It may be necessary to separate additional contractile fibers higher up the wall of the esophagus, and also lower towards the stomach.
After satisfactory stretching and separation of the muscle layers, they carefully look for small cracks or holes in the mucous membrane and close them with thin silk sutures. When vagotomy is performed, pyloroplasty or posterior gastroenterostomy is performed in the area of the cavity. Some people choose to have pyloroplasty done regardless of whether a vagotomy is done.
Now, a hole in the anterior wall of the stomach through which a Foley catheter was inserted is used as a temporary gastrostomy. The Foley catheter is then directed down to the cavity area, several sutures are made through the stomach wall on either side of the catheter, and the stomach wall is everted near the catheter. The catheter is then withdrawn through the puncture wound to the left of the incision, and the stomach wall is secured to the walls of the cavity to seal the area, as described for gastrostomy (Chapter 9).
CLOSING. The wound is usually closed with interrupted sutures.
POSTOPERATIVE CARE. The end of the nasogastric tube can be left in place above the surgical site to allow decompression of the dilated esophagus within 48 to 72 hours. This may or may not be necessary, especially when a gastrostomy has been performed. Maintain fluid and electrolyte balance and give antibiotics if there is evidence of major contamination.
After two to three days, the patient begins to take clear liquids and then gradually switches to soft diet. Later postoperative barium studies of the esophagus may not show improvement consistent with the patient being free of dysphagia. Subsequent hydrostatic dilations may sometimes be indicated.
CHAPTER 34. ESOPHACOCARDIOMYOTOMY (continued)
CHAPTER 35. GASTROJUINOSTOMY ROUX-EN-Y
INDICATIONS. In some patients with persistent and severe symptomatic biliary gastritis Diversion of bile from a gastric outlet altered by pyloroplasty or some type of gastrectomy may be indicated.
PREOPERATIVE PREPARATION. It is necessary to establish a clear diagnosis of postoperative reflux gastritis. Endoscopic studies should confirm at the macro and micro levels severe gastritis of greater intensity than usually observed due to regurgitation of the contents of the duodenum through an altered gastric outlet. The stomach is examined for evidence of a previous complete vagotomy. Barium tests are usually done to determine serum gastrins. In addition to a clear clinical diagnosis of postoperative reflux biliary gastritis, there must be evidence of persistent symptoms despite prolonged intensive medical therapy. The operation is designed to completely divert the contents of the duodenum from the outlet of the stomach. If the acidity is not controlled by complete vagotomy in combination with an anthrectomy, an ulcer will form.
Constant gastric suction is established using a Levine tube. Systemic antibiotics can be given. Blood volume should be restored, especially in patients with prolonged complaints and significant weight loss.
ANESTHESIA. General anesthesia combined with endotracheal intubation is sufficient.
POSITION. The patient is placed supine with the legs 12 inches below the head.
OPERATIONAL PREPARATION. The skin of the lower chest and abdomen is prepared as usual.
CUT AND EXPOSURE. An incision is made through an old scar from a previous gastric surgery. The incision should extend superiorly beyond the xiphoid process, since examination of the junction of the esophagus and stomach may be necessary to determine the adequacy of the previous vagotomy. Care must be taken not to accidentally cut the intestinal loops. which may be adjacent to the peritoneum.
Even if a vagotomy has been previously performed, it is recommended to look for undetected fibers vagus nerves, especially the posterior vagus nerves, unless the strong fusion between the lower surface of the left lobe of the liver and the upper part of the stomach makes such a search too dangerous.
The site of the previous anastomosis is cleared so that it can be carefully inspected and palpated for ulceration and stenosis or evidence of previous nonphysiologic surgery such as a long loop, bend, or partial jejunostomy obstruction. A wide gastroduodenostomy can be detected (Fig. 1).
The extent of the previous resection must be determined to ensure that the cavity has been removed. Complete vagotomy, as well as anthretomy, is a prerequisite as a preventive measure against recurrent ulcer formation.
PROGRESS OF THE OPERATION. When modifying the Billroth I procedure, it is very important to carefully isolate the anastomosis anteriorly and posteriorly before applying straight Kocher forceps to both sides of the anastomosis (Fig. 2). Because of the previous Kocher mobilization and medial rotation of the duodenum to ensure that there is no tension on the suture line, it is important to sacrifice as little of the duodenum as possible (Figure 2). If further mobilization of the first part of the duodenum is performed, unexpected injury to the accessory pancreatic duct or common duct may occur.
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The main threat from oncological pathologies of the female genital organs is that each malignant tumor has the ability to spread its cells throughout the woman’s body, forming foci of secondary growth - metastases. Previously, it was believed that metastases form only in the late stages of tumor growth. But today, most doctors are inclined to believe that the risk of their occurrence exists from the very moment the tumor appears. Therefore, in the treatment of cancer, much attention is paid not only to the elimination of the tumor node, but also to the prevention of relapse of the disease, namely, the fight against metastases.
How are they formed?
Secondary tumor foci are formed from individual cells of the neoplasm, which split off from it and spread to neighboring, and even distant, organs through the blood and lymphatic fluid. These cells penetrate into the lymph first, so the lymph nodes located close to the affected organ pose the greatest threat in terms of relapse of the disease.
While the primary tumor is actively growing, the metastases are in a dormant state, because all the body’s forces are spent on feeding the “main” tumor. But when this neoplasm stops in its growth, having reached the last stage of development, or when it is removed from the patient’s body through medical intervention, metastases begin to develop. Then secondary foci form, that is, the disease begins to progress or recur.
How to deal with them?
The main way to prevent metastasis of malignant neoplasms is a thorough inspection of nearby organs and tissues and their removal. Thus, in case of oncological pathologies of the uterus and ovaries, not only regional lymph nodes are removed, but also the tissue of the greater omentum - its resection is performed.
Resection of the greater omentum
Resection of the greater omentum is a surgical procedure during which a fragment of the splanchnic peritoneum is excised, between the folds of which there are blood and lymphatic vessels, as well as adipose tissue. The abundance of vessels in the space of the greater omentum creates a high probability of its “contamination” with tumor metastases. Timely removal of potentially affected tissue significantly increases the effectiveness of treatment and the survival rate of patients.
In addition to surgical intervention, antitumor drugs are taken to prevent tumor metastasis and radiation therapy. These measures make it possible to eliminate cells that nevertheless managed to penetrate the body tissues and were not removed during the operation. In this regard, resection of the greater omentum also improves effectiveness. therapeutic measures, since after its removal the process becomes easier further treatment radioactive drugs.
Another advantage that this manipulation provides is a slower accumulation of ascitic fluid in the abdominal cavity, which often occurs after gynecological oncological operations.
How is the omentum resected?
Some doctors are inclined to believe that resection of the greater omentum should be done only during abdominal operations, since laparoscopic interventions do not make it possible to perform a thorough revision of it. But with good equipment and high professionalism of the surgeon, it is quite possible to perform resection by laparoscopy. The specific method of surgical intervention is determined individually, taking into account the characteristics of the course of the disease, the patient’s body and the capabilities of the medical institution.