OPERATION: ESOPHAGECTOMY

Operative Technique:

        Patient in supine position

        Place a small sandbag under the patient’s right side to elevate that side 30⁰, with right arm abducted and suspended from the "ether screen" cephalad to the surgical field

        Turn the patient's head to left in case the right cervical region has to be exposed for the upper anastomosis

       Prepare right neck, right hemithorax and abdomen

       Perform a midline upper ab­dominal incision to initially explore the liver and lower esophagus

       Make an incision along the course of 5^th intercostal space from sternum to posterior axillary line in men. In women, make skin incision in the inframammary fold

       Incise pectoral and anterior serratus muscles with electrocoagulator along the fourth interspace

       Incise intercostal muscles along upper border of 5^th rib

       Divide internal mammary artery near the sternal margin between ligatures

       Enter pleura of 4^th intercostal space, and divide cartilaginous portion of 4^th rib near its articulation with sternum

       Clamp neurovascular bundle, divide it, and ligate with 2‑0 silk

       Separate the ribs

       Incise mediastinal pleura to expose esophagus

       Identify, skeletonize, divide and doubly ligate azygous vein with 2‑0 silk

       Encircle esophagus with finger at a point away from tumor

       Divide several small arterial branches to the esophagus between ligatures

       Dissect and include adjacent mediastinal lymph nodes in the specimen

       Dissect esophagus from apex of chest to diaphragmatic hiatus

       Do proximal gastric vagotomy

       Ligate esophageal lumen proximal and distal to the tumor with narrow umbilical tapes

       Cover thoracic incision with sterile towel

       Mobilization of Stomach

       Elevate sternum and left lobe of liver in a cephalad direction

       Incise peritoneum overlying abdominal esophagus

       Mobilize lower esophagus as in per­forming a vagotomy and transect vagal trunks and surrounding phrenoesophageal ligaments

       Cephalad portion of gastrohepatic ligament is doubly clamped, divided, and ligated with 2‑0 silk

       Elevate gastrophrenic ligaments and transect

       Short gastric vessel identify, clamp, divide and ligate

       Left gastroepiploic artery identify, clamp, divide and ligate

       Divide greater omentum serially between clamps

       Identify origin of left gastric artery at celiac axis

       Divide coronary vein between 2‑0 silk ligatures

       Divide left gastric artery between 2‑0 silk ligatures

       Do an extensive Kocher maneuver

o                     Incise peritoneum lateral to proximal duodenum, continuing until 3^rd portion of duodenum

o                     Divide lateral duo­denal "ligament" behind descending duodenum

      Dissect head of the pancreas from renal capsule, vena cava and aorta

      Pull up pyloroduo­denal segment high in the abdomen, 10cm from esophageal hiatus, allowing gastric fundus to reach thoracic apex, or neck, without tension

      Pyloromyotomy

o                     Make a 2cm incision across anterior surface of pyloric sphincter muscle

o                     Separate bluntly the muscle fibers with a hemostat until mucosa bulges out

      Ancement of Stomach into Right Chest

o                     Divide right crux of diaphragm transversely using electrocautery and di­late esophageal hiatus manually

o                     Advance stomach into right hemithorax

o                     Suture wall of stomach to the margins of hiatus with interrupted 3‑0 silk

o                     Expose esopha­gogastric junction in the right chest

      Cear the areolar tissue and fat pad from the region of esophagocardiac junction

      Apply a TA‑55 stapler to the gastric side of this junction and fire staples

      Apply a clamp to the esophagus, which should be transected flush with TA‑55 stapler

      Place an umbilical tape over divided esophagus

      Esophagogastric Anastomosis

o                     Select a point on proximal esophagus 10cm above the tumor for anastomosis

o                     Before re­moving specimen, insert posterior layer of sutures to attach posterior esophagus to anterior seromuscular layer of stomach at a point 6cm from cephalad end of fundus, using interrupted 4‑0 silk Cushing sutures deep enough to catch submucosa

o                     Transect posterior wall of esophagus 0.5cm beyond first line of sutures

o                     Make a transverse incision in stomach and control the bleeding points

o                     Approximate posterior mucosal layer with interrupted 4-0 silk sutures, with the knots tied inside the lumen

o                     Pass NGT from proximal esophagus through the anastomosis into the stomach

o                     Detach specimen by dividing anterior wall of esophagus, leaving anterior wall of esophagus 1cm longer than the posterior

o                     Execute anterior mucosal layer by means of interrupted sutures of 4‑0 silk, with the knots tied inside the lumen, thus inverting the mucosa

o                     Accomplish 2^nd anterior layer by means of interrupted Cushing sutures of 4‑0 silk

o                     Tack fundus of stomach to prevertebral fascia and me­diastinal pleura at the apex of thorax with interrupted sutures of 3‑0 silk

      Cervical Esophagogastric Anastomosis

o                     In treating carcinoma of mid‑esophagus it is often necessary to resect entire thoracic esopha­gus, requiring an esophagogastric reconstruction in the neck

o                     With patient's head turned slightly to the left, make an oblique incision along anterior border of right sternocleidomastoid muscle, carrying the incision through platysma

o                     Identify and transect omohyoid muscle

o                     Retract sternocleidomastoid muscle and carotid sheath laterally and retract the prethyroid muscles medi­ally to expose thyroid gland

o                     Middle thyroid vein, when present, should be doubly ligated and divided

o                     Apply a TA‑55 stapler to the specimen side and transect the esophagus low in the neck flush with the stapler

o                     Remove specimen through thoracic incision

o                     Pass the fundus of stomach through the thoracic inlet into cervical region

o                     Anchor it to prevertebral fascia with several 3‑0 cotton sutures

o                     Insert posterior layer of sutures to attach posterior esophagus to anterior seromuscular layer of stomach at a point 6cm from cephalad end of fundus, using interrupted 4‑0 silk Cushing sutures deep enough to catch submucosa

o                     Make a transverse incision in stomach and control the bleeding points

o                     Approximate posterior mucosal layer with interrupted 4-0 silk sutures, with the knots tied inside the lumen

o                     Pass NGT from proximal esophagus through the anastomosis into the stomach

o                     Detach specimen by dividing anterior wall of esophagus, leaving anterior wall of esophagus 1cm longer than the posterior

o                     Execute anterior mucosal layer by means of interrupted sutures of 4‑0 silk, with the knots tied inside the lumen, thus inverting the mucosa

o                     Accomplish 2^nd anterior layer by means of interrupted Cushing sutures of 4‑0 silk

      Lavage operative site with saline sol­ution

      Place a Penrose drain out from prevertebral region through lower pole of incision

      Approximate anterior border of sternocleidomastoid to strap muscles by inserting a layer of interrupted 3‑0 Vicryl sutures

      Approximate the platysma using interrupted 3‑0 Vicryl sutures

      Close the skin with continuous 4‑0 Vicryl subcuticular suture

      Make a stab wound in the 7^th intercostal space at the anterior axillary line

      Insert a 36F chest tube through the stab wound and anchor it to the posterior pleura in the upper thorax with a 3-0 chromic catgut

      Thoroughly irrigate thoracic and ab­dominal cavities with a saline solution

      Ap­proximate the ribs with 4 interrupted pericostal sutures of PDS-1

      Approximate serratus and pectoral muscles in layers by means of continuous 2‑0 Vicryl 2-0

      Close the skin with interrupted 3‑0 silk

      Before closing the abdomen, insert a needle­ catheter feeding jejunostomy

      Hemostasis

      Layer by layer closure of the abdomen

o                     Peritoneum and fascia closed as single layer using  PG 0 continuous interlocking suture with interrupted silk 0 suture over the fascia every five continuous interlocking sutures

o                     Subcutaneous tissue approximated using chromic 3-0 inverted T sutures

o                     Ski9n closed by silk 3-0 interrupted sutures

      Betadine

      DSD

      Patient tolerated procedure well

OPERATION: FISTULA-IN-ANO

Operative Technique:

§        Patient lying supine in lithotomy position

§        Asepsis, antisepsis

§        Sterile drapes placed

§        External opening noted

§        Fistulous tract and internal opening identified by inserting a probe through the external opening and simultaneously palpating the anal canal

§        Cannulate internal opening from the outside

§        Intersphincteric Fistula -- Simple Low Fistula

§        Place a rectal speculum and insert anal circumference

§        Divide internal sphincter and over­lying anoderm up to the internal orifice of the fistula approximately at the dentate line

§        Transsphincteric Fistula -- Uncomplicated

§        Insert a probe through fistulous opening in the skin and along the track until it enters rectum at internal opening of fistula

§        Divide all the overlying tissue

§        Occasionally one of these fistulas crosses the external sphincter closer to the puborectalis muscle. In this case, if there is doubt that entire pubo­rectalis can be left intact, external sphincter may be divided in two stages. Divide distal half in first stage

§       Insert a seton through remaining fistula, around remaining muscle bundle, and leave it intact for 2 months before dividing remainder of sphincter

Ø        Examination of anal canal under anesthesia

Ø        Perform an internal sphincterotomy and place internal sphincterotomy directly over the site of abscess

Ø        Evacuate the pus

Ø        Explore the cavity

OPERATION: PYLOROPLASTY

Operative Technique

        Patient in supine position

        Asepsis/antisepsis done

        Sterile drapes placed

        Midline incision done from xiphoid down to about 5 cm below umbilicus

        Vagotomy done

        Pylorus identified with the pyloric vein as landmark

        Kocher maneuver done

HEINEKE-MIKULICZ

        Traction suture using silk 0 are placed at the superior and inferior margins of the pylorus

        A 2-3 cm longitudinal incision made on each side of the pyloric ring through all layers

        Gently pulled the two traction suture at opposite side to separate the incision and make it a diamond shaped

        Bleeders are controlled

        A seromuscular interrupted or Lembert sutures of silk 4-0 placed midline

        Continue closure from one corner to midpoint then the other corner to midpoint

FINNEY U-SHAPED PYLOROPLASTY

        Traction suture using silk 0 are placed at the superior margins of the midpylorus

        Second suture joins a point approximately 5 cm proximal to the pyloric ring on the greater curvature of stomach to a point 5 cm distal to the pyloric ring on the duodenal wall

        Suture together the gastric and duodenal wall

        Interrupted 4-0 Lembert suture use to approximate the greater curvature and duodenum. Sutures placed close the greater curvature and close to the junction of the duodenum and pancreas

        A U-shaped incision, 5-6 cm, is made into the stomach just above the traction suture, around the pylorus down to the duodenum stopped just above the traction suture

        Mucosal suture begin at the inferior surface of the divided pyloric spincter

        Use a 3-0 atraumatic PG through full thickness of the stomach and duodenum at pyloric sphincter then tie it

        Continue suture in a caudal direction with continuous interlocking suture

        Pass needle from inside out on the stomach

        Anterior mucosal layer approximated by Connell suture

        Second layer of interrupted Lembert 4-0 silk suture done

        Check for the patency of the lumen

        Hemostasis

        Layer by layer closure of the abdomen

     o         Peritoneum and fascia closed as single layer using  PG 0 continuous interlocking suture with interrupted silk 0 suture over the fascia every five continuous interlocking sutures

     o         Subcutaneous tissue approximated using chromic 3-0 inverted T sutures

     o         Ski9n closed by silk 3-0 interrupted sutures

        Betadine

        DSD

        Patient tolerated procedure well

OPERATION: GASTRECTOMY--SUBTOTAL

Operative Techniques:

§        Patient lying supine IN supine position

§        Asepsis, antisepsis

§        Sterile drapes placed

§        High midline incision done

§        Intraoperative findings noted

§        Penrose drain inserted as the right hand passed through an avascular portion of the gastrohepatic ligament above the pylorus through the avascular space along the greater curvature—use as traction

§        Stomach retracted upward

§        Left hand inserted behind the stomach

§        Spreading the fingers along the gastrocolic ligament to identify individual vessels

§        Epiploic vessels clamp, cut and ligated

§        Left gastroepiploic artery and short gastric arteries identified clamp, cut and ligated

§        At mid point between the esophagogastric junction and the pylorus insert a large hemostat

§        Left gastric vessels idenfied clamp, cut and doubly ligated

§        Two allen clamps applied for a distance of 3-4 cm at an angle of 90⁰ to the greater curvature (the amount of stomach in the allen’s clamp must approximate the size of anastomosis)

§        Another two Allen’s clamp applied at a cephalad angle to close the remaining stomach

§        Close by layer

     §          First, use 3-0 PG with straight intestinal needle, pass the needle back and forth from the lesser curvature  to the base of the Allen’s creating a basting suture

     §          Trim excess gastric tissue then remove the Allen’s clamp

     §          Return same suture to its origin as a continuous interlocking suture

     §          Invert mucosa using silk 4-0 lembert sutures

DUODENAL DISSECTION

§        Right gastric artery identify, clamp, cut and ligated

§        Apply anterior traction to exposed the posterior portion of the duodenum and the anterior surface of the pancreas

§        Small vessels identify, clamp, cut and ligated

§        1.5 cm of the posterior duodenum freed from the pancreas

§        Apply an Allen clamp immediately distal to the pylorus

§        Cut the duodenum distal to the clamp

§        Check the distal end of the specimen to make sure no antral mucosa left behind

§        Insert a finger into the duodenal stump and palpate for the ampulla of Vater

BILLROTH I (Gastroduodenal Anastomosis)

§        Insert corner suture to the stomach and duodenum by Cushing technique

§        Complete the remainder of the posterior layer with interrupted 4-0 silk seromuscular Lembert sutures

§        Remove the Allen clamp

§        Approximate the mucosa using 4-0 PG double arm start from midpoint of the posterior layer where the knot is tied

§        Take small bites doing continuous interlocking sutures

§        Approximate the anterior layer with continuous Connell suture, ending at midpoint

§        Seromuscular layer of interrupted 4-0 silk Lembert suture done

§        Do a seromuscular crown stitch over the “angle of Sorrow”

§        Loosely suture omentum over the anastomosisi