Palliative upper GI bypass

Biliary bypass adds 2-5 months life
Surgical bypass procedure of choice cf stenting in patient fit for surgery with > 4month life expectancy, although failure rate still 25%

Obviously need GB filling on ERCP before cholecystojejunostomy

20% patients with pancreatic cancer will develop gastric outlet obstuction

Hydration important in jaundiced patients

Laparoscopic partial gastrectomy

GIST (b/w muscularis propria and muscularis mucosa, controversial to resect laparoscopically if over 5cm as higher malignancy rate, endoscopically have central punctate ulcer)
Carcinoid only if LN metastases unlikely

Position as for Nissen
Stand between legs
Nathanson
Divide gastrocolic omentum
Dissect down toward pylorus and divide right gastroepiploic
Divide lesser omentum and clip right gastric artery
25mm bumgun stapler with anvil in duodenum for Bilroth 1 (need pliable duodenum with stomach remnant that will come down without tension

12% leak rate in one series

Distal pancreatectomy

Oversewing pancreatic duct is associated with a lower pancreatic stump leakage rate

Laparoscopic Hellers myotomy

Beanbag
Stirrups
20-30 Reverse Trendelenburg
Compression stockings
Stand between legs
Nathanson
Divide gastrohepatic ligament
Separate right crus from diaphragm with blunt dissection
transect peritoneum and phreno-oesophageal membrane
Separate left crus by blunt dissection
Continue into posterior mediastinum to expose 6-7cm of oesophagus
Identify and preserve anterior and posterior vagal divisions
Divide short gastrics all the way to the angle of His
Hook diathermy myotomy to submucosal plane 2cm down onto stomach to 5cm past GE junction
Avoid diathermy if bleeding encountered as can cause delayed perforation
If perforation suspected, intstil saline and blow air down orogastric, if found repair with 3-0 PDS
Combine with fundoplication
Ba swallow only if perforation suspected
Avoid meat or bread for 2 weeks

PEG

Contraindictions
Acites: can leak and cause peritonitis
Inability to transilluminate (can cutdowm to fascia to facilitate or can use bedside US)

Several different techniques: push, pull or Seldinger

Proc
Give Abx
Thorough endoscopy
Insufflate until rugal folds disapear
Transilluminate skin and bounce finger
Infiltrate with LA, bigger skin incision than PEG to allow infection to drain
Introduce needle 45 deg cephalad
Pass wire and grasp with endosnare
Push or pull PEG
Visualise with endoscope, button should rotate freely to avoid gastric wall necrosis


Complications
15% total
10 infection rate if antibiotics used
Leak is usually caused by too much tension causing gastric necrosis
Confirm with fluoroscopy or CT
If confirmed, pull PEG and place NG
Pneumoperitoneum may persist for several weeks
Progressive enlargement of stoma is usually due to excess movement of PEG. Need to correct movement rather than placing bigger PEG
Gastrocolic fistula is rare. Be suspicious if patient develops perifeeding diarrhoea several weeks after placement
Fuoroscopy is diagnostic
Rx is removal of PEG

Gastrojejunostomy

Alternative to pyloroplasty in obstructing duodenal ulcer (more effective) and less morbid than antrectomy.

Need to add vagotomy to prevent marginal ulceration

Upper midline incision
Clear dependent portion of greater curvature of omentum
Divide gastroepiploic arcade
Retrocolic probably gives better functional result
Clear window in mesentery, usually to left of middle colics
Usual anatomosis
Once complete, pull anastomosis back through mesocolon, then tack stomach to transverse mesocolon to prevent slippage
If chronically distended stomach, consider tube gastrostomy to avoid long term NG

POST OP
Maintain on PPI to prevent marginal ulceration

Total Gastrectomy

1.Prep and square drape, ensure NGT
2.Upper midline incision
3.Place a fixed retractor such as omnitract to aid in retraction of the liver. You may need to mobilise left lobe of liver by dividing the left triangular ligament
4.Conduct a laparotomy to confirm resectability.
Place a pack behind the spleen to bring it forward and help mobilise the spleen
5.Dissect the greater omentum off the transverse colon in order to include it with the specimen. At this point inspect the posterior surface of the stomach to ensure resectability.
6.Divide the gastro hepatic ligament to enter into the lesser sac of the abdomen and double ligate the right gastric artery sweeping nodes en bloc with the stomach.
7.Perform a truncal vagotomy (legacy). This is performed by incising the peritoneum over the abdominal oesophagus and identifying the crura. Insert your right finger aroung the back of the oesophagus to encircle it. There are often 1-2 anterior vagal (left) trunks. Divide and ligate these between artery forceps. The posterior vagal trunk is identified by encircling the oesophagus deeply across the front of the aorta to the deep surface of the right crus and then flexing the finger around. The posterior trunk should then be contained (i.e. it is often much posterior to the right surface of the oesophagus). It can also be found by inserting a finger above the left gastric artery and drawing it downwards, pulling the posterior vagus taut. A selective vagotomy (legacy) refers to a vagotomy just beyond and conserving the hepatic branch of the vagus. A highly selective vagotomy (legacy) refers to selective division of all the vagal branches to the stomach along with the branches of the left gastric artery, barring those to the distal antrum and pylorus. You need to identify the crow’s foot to determine the correct level. Pay attention to the criminal nerve of Grassi, which is a branch given off from the posterior vagus higher to the posterior cardia. Oversew the gastric lesser curve if performing a selective vagotomy only. Send a segment of the nerves for histological confirmation in order to confirm vagotomy. An endoscopic congo red test can also be performed by administering SC pentagastrin and 20 min later lavaging the stomach with 200ml congo red (vagally innervated parietal cells will turn black).
8.Divide the gastrosplenic ligament, the short gastric and left gastro-epiploic vessels.
9.Lift the stomach upwards to gain access to its posterior wall and divide the right gastro-epiploic vessels between it and the pancreas.
10.Divide the left gastric artery at its origin as well as its ascending branch to completely devascularize the stomach.
11.Divide the distal resection margin (duodenum) with a TA60 (3.5mm staples) linear stapler/scalpel division on the proximal side between an Allen clamp (this is aided by partially Kocherizing the duodenum that may also require mobilizing the hepatic flexure). Divide the proximal resection (having withdrawn the NGT) similarly between a TA60/right angled clamp with scalpel division on the proximal side of the stapler. You may re-inforce the duodenal stump closure with 3/0 PDS.
12.Place a pursestring at the distal oesophagus of 3/0 PDS and secure the anvil of a CEEA 28mm circular stapler
13.Create a roux limb by division of jejunum between a TA60/Allen clamp (dividing the bowel distal to the stapler and bring it up in an antecolic fashion.
14.Insert the circular stapler through the open cut end of the roux limb after placing a soft bowel clamp distally on the roux limb and fashion an end to side oesophago-jejunal anastomosis. Use a linear stapler to resect the redundant jejunum to complete the anastomosis. Oversew all staple lines with 4/0 PDS. A hand sewn end to end anastomosis can also be fashioned using interrupted 3/0 PDS. Place the posterior wall sutures first and parachute them down, then tie, completing the anterior layer subsequently. Be sure to pass a nasogastric tube down to the jejunum across the anastomosis.
15.Place soft bowel clamps at the site of intended jejuno-jejunal anastamosis (ensuring a 75cm roux limb). Create an end to side anastomosis using interrupted 4/0 PDS.
16.Haemostasis, drain the duodenal stump and oesophago-jejunal anastomosis.
17.Closure with 1/0 nylon and staples.

Complications
Early HIDA (Overall per-operative mortality 5-10% with an overall 50%5YS)
1.Haemorrhage
2.Intra-abdominal sepsis
3.Duodenal stump leak
4.Anastomotic leak

Late post-prandial sequelae SDHDB
1.Satiety
2.Dumping
3.Hypoglycaemic attacks
4.Diarrhoea VDOS due to vagotomy (mechanism unknown), as part of a dumping syndrome, bacterial overgrowth, steatorrhoea.
5.Bilious reflux.

Nutritional problems
1. Malnutrition
2. Specific deficiencies – Fe/Vit C supplements for 12 months, B12, Calcium (Vit D malabsorption) in post-menopausal and over 70

Distal Gastrectomy

In general perform a laparoscopy first if cancer operation. No need if if clear indication for palliative resection ie bleeding etc.

Resection provides better relief for obstruction than bypass

Distal gastrectomy for benign disease (Bilroth I or II)
1.Supine position
2.Upper midline incision. (Consider rooftop if wide xiphisternal angle)
Thorough laparotomy
3.Incise the gastro-hepatic omentum and place a hand behind the antrum to lift it off the mesocolon and the middle colic artery. The plane is easier to find on the left
4.Begin to mobilize the antrum by dividing the branches of the right gastro-epiploic as close to the anterior surface of the pancreas as possible (so as to include the infrapyloric nodes) staying within the arcade for its preservation up to a point half way up the stomach. The left side of the omentum is separated from the spleen dividing the gastrosplenic ligament including the left gastro-epiploic vessels
5.Divide the left gastric artery about halfway along the lesser curve leaving a stump of the left gastric artery at least 1cm in length (a small accessory left hepatic artery may be ligated, but a larger one may need preserving to prevent hepatic necrosis. Lesser omentum is divided along the left side of the hepatoduodenal ligmaent.
6.At the proximal margin, divide the stomach using a GIA80 (4.8mm staples) stapler over the right half and between two Allen clamps over the left half, the length of which is the approximate diameter of the duodenum. Make sure you have withdrawn the NGT prior to division. Oversew the staple line or hand sew the whole thing if thickened.
7.Identify and ligate the right gastric artery from the anterior aspect where it originates from the proper hepatic artery. Reflect antrum rostral and to the left. Do not divide short gastrics along proximal greater curvature.
8.Apply traction on the specimen to display the posterior wall of the duodenum and dissect out 1.5cm to allow anastomosis. There are often some vessels coming up from the pancreas that will require ligation.
9.To perform a Bilroth I anastomosis, divide the duodenal resection margin between Allen clamps and fashion an end to end hand-sewn anastomosis using 3/0 PDS if there is at least 1.5cm of duodenum to suture to.
10.To perform a Bilroth II (Polya), use a TA60 (3.5mm staples) to divide the duodenal resection margin and perform a gastro-enterostomy using a retrocolic (may also be antecolic, but limb will need to be longer) loop no more than 15cm from the ligament of Trietz in two layers using 3/0 PDS in the standard manner. Advance the NGT down the afferent limb (one book says don't need to do this). Oversew the previous staple line and re-inforce the angle of sorrow.(this is the angle of the lesser curvature which is prone to ischaemia. Note Hofmeister variation (only anastomosing jejunum to greater curvature half of stomach of Bilroth II (Polya) picture above.
11.Oversew and drain the duodenal stump, lavage and close.


Subtotal or distal gastrectomy for malignancy (Bilroth II or Polya)
1.Conduct a laparotomy and confirm resectability.
2.Start with mobilizing the greater omentum off the transverse colon (the blood supply of the gastric remnant is to be from the short gastric arteries). Can either take the omentum or not: no difference has been shown in recurrence. The right gastro-epiploic artery is divided at its origin while sweeping all nodes towards the specimen. Similarly ligate the left gastroepiploic artery while mobilizing the left side of the greater omentum along the line of gastric transection.
3.Lift the stomach upwards and to the right to identify the left gastric artery and the adjacent coronary vein at the top end of the lesser curvature via the undersurface. Doubly ligate this with vicryl and divide. All nodal tissue is not only swept upwards towards the specimen, but if involved followed to the celiac nodes. Can then skeletonise the coeliac, splenic and common hepatic artery to perform D2 lymphadenectomy. This also involves dissecting the proximal lesser omentum to harvest the right cardia nodes.
4.Replace the stomach down and incise the lesser omentum down to the pylorus. Identify the ascending branch of the left gastric artery and ligate it at the cardia.
5.Extend the incision over the left gastric artery along the hepatic artery in the posterior wall of the lesser sac in order to identify the origin of the right gastric artery. Ligate and divide the right gastric artery.
6.Perform a Kocher maneuver and mobilize the duodenum off the pancreas for a distance of 5cm.
7.Use a TA60 stapler or scalpel between Allen clamps to divide across D1 and a GIA80 (4.8mm staples) to divide across stomach having withdrawn the NGT. Consider frozen section to ensure tumour margins clear. 5cm proximal margin for cancers. 5cm distal margin not always possible.
8.Reconstruct using a handsewn Bilroth II gastrojejunostomy with 3/0 PDS (or a stapled gestro-enterostomy using the GIA80 and oversew the staple line using 3/0 PDS) using an antecolic roux loop. May need to re-inforce the angle of sorrow.
9.Feed a nasogastric tube down the afferent limb of the gastroenterostomy prior to completing the anastomosis as far as possible to drain the duodenal stump. Lavage, drain and close.

Post op care
NG out on first or second day
Evidence that oral (500-750mcg) B12 is sufficient
Need iron replacement
Adjuvant chemotherapy should be considered routinely
No advantage to frequent follow up to detect recurrence
CT when symptomatic
Gastroscopy for stump cancer in long term survivors

Principles
Inspect posterior surface of stomach before ligating an vessels to confirm resectability

Perforated Peptic ulcer

Perforated peptic ulcer
1.Position the patient supine.
2.Make an upper midline incision
3.Conduct a laparotomy to determine the cause for the patient’s illness by examining the colon, SB, GB.
4.Follow the lesser curve of the stomach to find the site of perforation. If no disease is found examine the posterior surface of stomach and lesser sac.
5.Once perforation identified and any gross contaminating fluid aspirated, place three plication sutures in the long axis of the duodenum and hold them with an artery forcep.
6.Isolate a viable segment of omentum and secure it to the defect using the previously placed sutures. (Graham patch 1937) Alternatively can use piece of falciform
7.Lavage and mass abdominal closure (don’t usually drain)

Options for a difficult duodenal stump
1.Nissen Cooper technique whereby the anterior and posterior walls of the duodenum are sutured to the distal lip of the ulcer. A further layer of sutures is placed in the pliable anterior wall of the duodenum, suturing it to the proximal lip of the ulcer in an inverting manner.
2.Catheter duodenostomy (14F whistle-tip or Foley catheter brought out through the defect in the stump) to protect the integrity of a difficult stump closure.
3.Closure with a TA60 (4.8mm staples) stapler generally requires at least 1.5cm of pliable duodenum, in which case you should be able to do a Bilroth I.

Options for a bleeding duodenal or pyloric ulcer
1.Make a longitudinal gastroduodenotomy directly over the pyloric ring and oversew the bleeding point as well as in four quadrants around this point.
2.Repair with either a Heinecke-Mikulicz pyloroplasty or a Finney pyloroplasty.

Giant ulcer
10Fr Foley retrograde into 2nd part duodenum with distal feeding jejunostomy

Laparoscopic repair
Stapler or suture repair

Laparoscpic Nissen fundoplication

Indications include oesophageal pH <4, recorded 5cm above a manometrically defined LOS, present for >4%/24hrs,
Complicated - oesophagitis/stricture/Barretts on endoscopy,
Uncomplicated - failure to respond to conservative measures, desire to discontinue lifelong medication.

1.Position the patient in low Lloyd -Davies, reverse Trendelenberg
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.If the greater omentum is obstructing the view it can be picked up in a suture and brought out through one of the left sided ports.
5.Commence by identifying and dissecting the left crus with the assistant retracting the fundus downwards, extending the incision to the left over the fundus of the stomach. At this point it is also convenient to divide the short gastric vessels to enable a mobile fundus if required.
6.Divide and open gastro-hepatic omentum. The hepatic vagal branch in the lesser omentum may have to be sacrificed; however a smaller window prevents the wrap from slipping caudally.
7.Dissect the right crus, while retracting the oesophagus.
8.There should now be an adequate posterior window created in the retro-oesophageal space. Bring a grasper through to the left of the oesophagus staying close to the posterior wall of the oesophagus.
9.Place a Penrose drain in the abdomen and bring it through around the oesophagus to be used as a retractor.
10.Complete the definition of the left crus.
11.Perform the crural repair with 1-3 sutures (3/0 prolene). A bougie (56 or 58F) in the oesophagus can be used as a guide but I don’t normally use this.
12.Bring the fundus around the back of the oesophagus and get the assistant to hold the fundus at the site of intended wrap.
13.Fix the right side of the wrap to the right crus with 1-2 sutures to prevent the wrap from falling back around.
14.Complete the wrap by suturing the right and left sides of the fundus across the front of the oesophagus with three sutures (posterior partial or 270 degree wrap also known as Toupet).

Complications PPPPDBV
1.Paraoesophageal hiatus hernia upto 5% (routine hiatal repair dramatically reduces)
2.PE
3.Pneumothorax in up to 2%
4.Perforation up to 1%
5.Dysphagia in nearly all
6.Bilobed stomach by using to distal stomach for wrap
7.Vascular injury rare.

Open Gastrostomy (Stamm)

1.Short upper midline incision
2.Choose area of mid-stomach, closer to greater curve and place a pursestring suture of 2cm diameter using 3/0 PDS or prolene.
3.Grasp left side linea alba via incision using Morrisons forceps and make a stab wound through skin and middle third of rectus opposite pursestring in stomach wall.
4.Pass Fraser forceps from peritoneal side through stab wound and bring through a 18F Foley catheter.
5.Perform gastrotomy through previously placed pursestring and insert Foley into stomach, then tie the pursestring.
6.Place a second row of pursestring suture to invert first pursestring.
7.Inflate Foley balloon and draw up to anterior abdominal wall.
8.Place four sutures of prolene on four sides of Foley catheter between stomach and anterior abdominal wall.
9.Close abdomen in layers.
10.The gastrostomy can be used immediately.

Oesophagectomy (Ivor-Lewis)

1.Double lumen tube. Conduct a laparotomy and assess resectability. Determine adequacy of right gastric and right gastroepiploic vessels.
2.Mobilize the stomach by dissecting the omentum off the transverse colon as well as the gastrohepatic omentum. The left lobe of liver may also require mobilization by dividing the left triangular ligament.
3.Divide the left gastric from the undersurface; and then the left gastro-epiploeic and short gastric vessels (preserve the arcade of the lesser and greater curves of the stomach, i.e. the main trunks of the right gastric and right gastro-epiploic)
4.Sweep the nodes en bloc with the vessels.
5.Perform a Kocher manouvre to mobilise the duodenum, this will give mobility to the right gastric vessels. Occasionally, the right gastric will need to be sacrificed for greater mobility.
6.Divide the phreno-oesophageal ligament and mobilize the cardio-oesophageal junction. You may need to divide the right crus to ensure there is no constriction of the gastric tube. Loosely suture the tube to the distal resection margin so you can retrieve it later.
7.Perform a pyloromyotomy by making an incision longitudinally across the pylorus.
8.Fashion a jejunal feeding tube before closing the abdomen. Make a trephine in the abdominal wall at a suitable site, insert a Fraser forcep from inside out and bring the feeding in through the abdominal wall. Place a pursestring at a suitable site in the jejunum, making an enterotomy, inserting the jejunal feeding tube heading distally and then tying the pursestring. Place a further pursestring to invert the previous one and then tunnel the feeding tube within an invagination longitudinally sequentially heading proximally along the jejunum with interrupted Lembert sutures. Finally suture the jejunum with feeding tube in situ to the abdominal wall in the three quadrants superiorly opposite the jejunal invagination (i.e. on the proximal side). This tube is to remain in situ for 3/52.
9.Perform a mass closure of the abdominal wall and close skin.
10.Turn the patient over to the left lateral position for a right posterolateral thoracotomy in the 5th intercostal space. The space is usually just below the inferior angle of the scapula.
11.Divide through skin, subcutaneous tissue, latissimus. Reflect any fibres of serratus off the 6th rib without division.
12.By lifting up the scapula, you can count the ribs to confirm the right intercostal space (usually the 2nd rib is the highest palpable rib). Elevate the periosteum over the 6th rib with a periosteal elevator.
13.Divide the intercostals at the upper margin of the 6th rib and resect a 2-3cm fragment of rib posteriorly.
14.Insert a Finochietto retractor to separate the ribs and enter the pleural cavity asking the anaesthetist to now ventilate the opposite lung.
15.Retract the lung antero-superiorly with an Allison lung retractor and make an incision in the mediastinal pleura. Dissect and ligate the azygos vein to gain better access to the oesophagus. Mobilize the oesophagus up to 10 cm above the tumour. Secure the tumour by ligating the oesophagus above and below using umbilical tape.
16.Bring the mobilized stomach into the chest and fashion the neo-oesophageal tube using a GIA80 (green cartridge 4.8mm staples). Reinforce the staple line with a continuous Cushing suture.
17.Perform an end-to-side oesophago-gastric anastomosis using either a hand-sewn 4/0 PDS in two layers or a CEEA28 circular stapler via a gastrotomy. Oversew all staple lines.
18.Check for a chyle leak – administer cream via the feeding jejunostomy at the conclusion of the abdominal phase to aid identification of the thoracic duct, which is routinely ligated.
19.Place two intercostal catheters and close the thoracotomy with 1/0 ethibond (figure of 8 sutures) and vicryl to reconstitute the latissimus and subcutaneous tissue/ skin. An alternative is to bury the rib by suturing the intercostals above and below the thoracotomy

Leave NGT in situ for 1/52 and perform a GG swallow prior to starting oral intake.

Complications: ACRGS
1.Anastomotic leak <5%, early – re-explore, late – conservative treatment unless gastric resection line
2.Chyle leak 2-3%, transhiatal upto 10% - Test the fluid for fat, decreased serum lymphocytes (CD4). Treat conservatively if after 1 week, early leaks and prolonged leaks require re-operation to ligate the thoracic duct. High amount of leaks lead to loss of lymphocytes, immunosuppression (pneumocystis) and nutritional deficiency.
3.RLN palsy in cervical anastomosis (rare in Ivor-Lewis).
4.Gastric outlet obstruction – prevented by routine use of a pyloroplasty. Reflux I also common. Dumping symptoms resolve after 12 months.
5.Stricture (benign) related to stapled (higher rate) or handsewn.
6.Other- operative mortality of 5-10% overall with overall 20% 5YS, significant respiratory complications in 25-50%.

Laparoscpic Oesophago-myotomy

1.Position the patient in lithotomy, reverse Trendelenberg.
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.You will also need extra room at the head end of the table for a UGI endoscopy setup.
5.Begin by mobilizing the oesophagus as for Lap Nissen, however attempt this with minimal posterior dissection. It will decrease the incidence of post-operative reflux.
6.Pass a grasper under the oesophagus across to the left of the oesophagus and bring a Penrose drain around to be used as a retractor, lengthening the segment of intra-abdominal oesophagus.
7.Find a convenient point in the middle of the thickened segment of oesophagus and divide with diathermy scissors.
8.Atraumatic graspers can then be used to pull down on the longitudinal muscle to reveal the underlying thickened circular muscle layer.
9.Similarly divide the circular layer and watch the layer spring apart. Atraumatic graspers are adjusted to hold the divided circular fibre layer.
10.The epithelial tube can be protected by pushing it down with a right angled grasper. Extend the myotomy proximally and distally (should extend 1cm on to the stomach) until the muscle appears to thin out.
11.Irrigate with saline and fill the LUQ. Insufflate the oesophagus with the endoscope and watch for any leaks.
12.Perform an anterior partial wrap (Dor) if there is a leak once repaired with interrupted 3/0 PDS or a partial posterior wrap as it is supposed to help keep the edges of the myotomy apart.
13.Close in layers.

Laparoscopic Splenectomy

Anatomical clues
No two spleens have same anatomy
Size of spleen does not determine number of arteries
Notches and tubercles correlates with greater number of entering arteries
Splenic artery tends to be more tortuous with age and may arise from aorta, SMA, middle colic, left gastric and others
Arteries outside spleen are divided into first second and third terminal divisions, most spleens have 2-3 terminal branches entering hilum. The arteries are true terminal arteries, meaning there is an avascular plane between them in the spleen
Veins are usually posterior to arteries
Search for accessory spleens should occur at the start of the operation, most are found at the hilum and distal pancreas
Tail of pancreas is within 1cm of spleen in 70% patients
Tail of pancreas is in contact with spleen in 30%

Two arterial patterns (see photos) distributed 70% (short splenic trunk with long branches) and bundled 30%

Normal spleen <11cm, moderate splenomegaly 11-20cm

Therefore: a notched spleen with a wide hilum will have a complicated vascular anatomy

Ligaments
Gastrosplenic contains short gastrics and gastroepiploics
Lienorenal ligament contains hilar vessels and tail of pancreas
Other ligaments are avascular except in portal hypertension

Indication
Usually ITP with moderately enlarged spleens

1.Right lateral position with the table broken and bean bag
2.Surgeon stands to the patient’s right with the Tower to the patients left.
3.Hassan cutdown in subcostal position at the anterior axillary line with 10mm camera, one 10mm for endoGIA and remaining 5mm ports (i.e. may need an additional port for retraction (working, Hasson, working, retractor from anterior to posterior as for left adrenal)
Open the 'splenic tent' by opening lesser sac to identify anatomy (between gastrosplenic and lienorenal ligaments)
4.Using a Lap Ligasure or harmonic scalpel mobilize the splenic flexure.
5.Dissect medially by dividing the gastro-splenic ligament and ligating the left gastroepiploic and short gastric vessels to visualize the hilum. Identify the splenic artery, vein and tail of pancreas. Some authors suggest ligating the artery first to minimize risk of bleeding and diminish its size.
6.Divide the lienorenal ligament but not all attachments as they help secure the spleen.
7.Use an EndoGIA Roticulator stapler with white cartridges over the vessels completely, avoiding the tail of pancreas. You may need 2-3 cartridges
8.Once the hilum is secured, divide any remaining attachments to the diaphragm.
9.Deliver the spleen into an EndoCatch apparatus (10 or 15mm but will require removal of port if 15mm used and blunt insertion). Try and deliver the spleen intact if for malignancy by enlarging the most posterior/retracting port or it can be morcellated if for ITP.
10.Lavage and close in layers.


Morcellation and extract in bag, avoid spillage to avoid splenic rests

HALS if spleen more than 20cm in length

Complications
Portal vein thrombosis: suspect where unexplained fever or ongoing abdominal symptoms
Accessory spleens
10% patients
Around splenic hilum, greater omentum, mesentery, pelvis
CT and Nuclear med scan to localise

Laparotomy for Upper GI bleeding

2 assistants
Head light
Do upper GI scope yourself first
Midline laparotomy
Omintract/Book Walter (if unstable don't bother, just open and compress bleeding site if known, if not cross clamp aorta to allow anaesthetist to catch up)
Gastrotomy
GIA stapler to make gastroduodenotomy: wide access
Pack above and below (swab into duodenum)
identify bleeder: if posterior wall duodenum/GDA, suture PDS in north, south, east and west position
If cancer: consider oversew if can't do proper cancer operation (controversial)
Varices: Sengstaken Blakemore and get out
Gastroenterostomy of concern re pyloric stenosis
If bleeding site unknown, sequential Teflon tape through small bowel and observe for bleeding segment

No shame in unscrubbing to call a senior colleague and get advice

Pyloroplasty

Heineke Mikulicz:
For up to 10cm long strictures
Open longitudinally, close transversely in 2 layers

Finney (S. Mackay: historical operation, never done before: do gastroenterostomy as alternative in most situations)
For longer strictures
Side-side
U shaped incision then anastomose
Reduced reoperation rate compared to Heineke Mikulicz

Jaboulay stricturoplasty=side to side enteroenterosotmy

Judd:
for stricture with fistula
Heineke Mikulicz with excision of fistula by carving a disc of SB around the fistula

Splenectomy

ANATOMY
Splenorenal(containing splenic vessels and tail of pancreas) and gastrosplenic (containing short gastrics above and left gastroepiploic below) ligaments. These form splenic pedicle.
Splenic artery from coeliac trunk (with left gastric and common hepatic) Artery usually in front of vein. Accessory spleen in 10-30%.

The splenic artery is the most unpredictable in the human body
PROCEDURE
Consider bowel prep for splenomegaly as there may be adhesions between spleen and colon
Upper midline or reverse Kocher
Access lesser sac through gastrocolic ligament. Ligate gastroepiploic artery and vein
Locate splenic artery at superior border of pancreas
Double ligate with distal ligatures
Divide short gastrics one at a time
Divide splenophrenic ligaments
Mobilise spleen
Be careful of tail of pancreas
Divide and ligate all branches of the splenic artery

Feeding jejunostomy

Purse string antimesenteric border, do not tie off
Enterotomy
Feed tube into jejunum and blow up balloon
second outer purse string in jejunum and peritoneum

Total gastrectomy

ANATOMY
5cm margin from palpable edge of tumour
6cm margin if penetrated serosa
Total gastrectomy if within 7cm of GE junction (8 cm for serosa +ve)
D2 gastrectomy includes perigastric nodes and nodes along the main arteries of the stomach

PROCEDURE
Book Walter
Upper midline
Divide gastrocolic omentum diathermy (the bloodless plane between omentum and bowel will be about 1 cm from colon.
Mobilise splenic flexure and divide all adhesions between omentum and spleen so that capsule is not torn during dissection
Divide short gastrics: 2-0 vicryl tie loaded on roberts. Right angles to dissect and clamp vessels esp in LUQ near spleen
Divide lesser omentum along line of reflection of the liver capsule.
Divide right gastric (often insubstantial)
GIA 55 linear cutter stapler to 1st part of duodenum. Invert with seromuscular interrupted sutures
Divide left gastric: suture ligate
Mobilise oesophagus
Mobilise Roux loop: linear cutter stapler: can take loop retro or antecolic.
(Andrew Lowe: functional side:side anastomosis by making jejunotomy 5cm from end and oesophagotomy. Jejunal limb lies posterior then longitudinal linear cutter to anastomose. Close with 3-0 maxon interrupted.
End-side enterenterostomy 45cm down jejunum
Feeding jejunostomy

Pseudocyst drainage

Traditional indication is pseudocyst >6cm present for more than 6 weeks
Spontaneous resolution of asymptomatic pseudocysts expected in 60%

True indications are
1.Symptomatic (pain, fullness, weight loss, nausea)
2.Enlarging (of any size, but this is controversial)
3.Infected (confirm by gram stain and culture)

Open drainage: procedure of choice if neoplasm suspected, infected, recurrent or failure of other means

1.Position the patient supine.
2.Upper midline incision (or rooftop).
3.Conduct a laparotomy. If the GB is still present, perform a cholecystectomy and cholangiogram.
4.Explore the lesser sac by incising the gastrohepatic omentum or through lesser curvature and examining the posterior surface of the stomach. If the psuedocyst (>5cm) is densely adherent then cystogastrostomy is the procedure of choice.


Transgastric cystgastrostomy: esp for the most common cyst which is body and tail lesions

Anterior incision in gastric wall (6-7cm) corresponding to cyst and parallel to blood supply
Grab margins of gastrotomy with Babcocks
Aspirate cyst
Incise through posterior gastric wall into cyst and excise an ellipse 3-6cm in length (send for frozen section)
Suture cyst through posterior gastric wall (ensure full thickness bites of cyst wall and stomach)
For a more inferiorly pointing cyst perform a roux-en-Y cystojejunostomy. Other options include cystoduodenostomy and distal pancreatectomy.
Lavage and close

?NGT through into cyst

Other methods
Percutaneous: If infected, place catheter. High rates of recurrence and failure
Endoscopic: Transmural or Transpapillary (if communicaiton with pancreatic duct) No ablility to biopsy so contraindicated if suspicious for neoplasm)