Line alba (a) and generous incision (b) for laparotomy
Intra-abdominal Esophageal Exposure
The intra-abdominal esophagus can be difficult to expose, and the difficulty increases with patients who have a higher body mass index.
The surgeon will be afforded better exposure through the use of self-retaining retractor systems. Once the self-retaining retractor system is in place, ask for the patient to be placed into reverse Trendelenburg. This will allow the viscera to move caudal to allow for better exposure. If possible, have the anesthesia providers place an orogastric or nasogastric tube. This allows for palpation of the esophagus in relation to the aorta and/or spinal column.
Use of the non-dominant hand can retract the stomach inferio-laterally to the patient’s left. Gross visual inspection in this region in the setting of trauma can provide several clues, including bleeding, hematoma, and enteric contents to assist with the identification of an injury of the intra-abdominal esophagus. If this doesn’t identify suspicion for injury and surgical dissection is warranted, then we would proceed with sharply incising the pars flaccida and continuing cranially into the phreno-esophageal ligament. Once around the esophagus in this region a large silicone tube (e.g., Penrose) or an umbilical tape can be encircled around the intra-abdominal esophagus to serve as a retractor. It is not uncommon for the surgeon to need to divide the short gastric vessels high on the greater curve of the stomach to provide complete exposure. Meticulous hemostasis and careful traction is required here to lessen bleeding from the short gastric vessels and splenic injury. The short gastric vessels should be taken between ties and/or clips and divided sharply (Fig. 6.2).
If an esophageal injury is identified, the surgeon must consider the time from injury, degree of contamination, velocity of the missile if a penetrating mechanism, and the patient’s physiology. Standard principles of repair should focus on a two-layer reapproximation of healthy, well-perfused tissue, minimal-to-no tension on the repair, wide drainage, and distal feeding access.
Low-velocity penetrating injuries that are less than 50% of the circumference of the esophagus can be repaired primarily. Opening the muscularis to identify the full extent of the mucosal injury is paramount to any esophageal repair. Then the mucosal injury should be repaired with absorbable suture; either interrupted or running is appropriate. The outer muscularis can be closed in numerous ways, but we recommend a slowly absorbable monofilament suture such as polydioxanone in an interrupted fashion (Fig. 6.3).
To achieve a tension-free repair the surgeon may have to mobilize the intra-thoracic esophagus. This plane should be largely loose areolar tissue and often bloodless plane. Gentle finger dissection can often achieve this, but sponges applied to graspers or Kittners can also be utilized. Avoid cautery here to prevent inadvertent thermal injury to the esophagus. The surgeon must also be cautious not to violate the thoracic pleura and the aortic perforators to the esophagus. Excellent retraction is required in this region and an additional experienced surgeon can provide time-saving assistance. Once the repair is done the surgeon should consider placement of a nasogastric tube, intra-abdominal drains, and the need for distal feeding access if the repair were to fail (e.g., feeding jejunostomy).
Exposure of the Stomach
The stomach is readily exposed through a midline laparotomy. The stomach is rarely injured from a blunt mechanism and is most commonly injured in penetrating trauma. Typically, the stomach can be thoroughly evaluated in the supine position; some cases, however, may require reverse Trendelenburg to increase visualization. Irrespective of the method of injury, the stomach should be thoroughly evaluated. The anterior portions of the stomach are often readily evaluated with hand traction and gross visualization. Posterior stomach exposure is most readily accomplished by opening the lesser sac. This is most readily accomplished on the left lateral aspect of the greater curvature of the stomach between the stomach and colon. The gastrocolic omentum can be elevated between forceps or the surgeon’s hands to identify a very thin peritoneal window. This can be opened bluntly, sharply, or with energy. There should be minimal bleeding. If bleeding or large vessels are encountered it is likely that the transverse colon mesentery is being entered. The more lateral (to the patient’s left) that the surgeon begins this entry in the gastrocolic omentum, the easier it is. The planes fuse together as you move toward the midline and patient’s right.
Once in the lesser sac, the surgeon can identify the posterior wall of the stomach and the body and tail of the pancreas. Penetrating trauma from missiles (gunshot wounds) will often have two apertures a viscus or a tangential injury. If an aperture is identified, the surgeon must explore the entire stomach for a second aperture.
Injuries to the stomach that are less than 50% of the stomach can often be repaired primarily. Standard surgical principles apply, including: debridement of devitalized tissues and tension free repairs. Holes in the stomach can be repaired primarily in one or two layers with permanent or absorbable suture. These injuries can also be wedge-resected with intestinal stapling devices. Tangential injuries can be repair in a similar fashion.
Once the repair is completed, attention should be given to a nasogastric tube for gastric decompression and, depending on the severity of the injury, consideration for durable feeding access through a naso-enteral feeding tube or a feeding jejunostomy. Finally, placement of drains can be considered.
If the antrum of the stomach is destroyed or not amenable to standard repair techniques, then antrectomy should be considered. The stomach should be divided distal to the pylorus and several centimeters proximal to the injury with stapling devices. The surgeon can then choose reconstruction based on mobility of the stomach to provide a tension-free Billroth I reconstruction versus a Billroth II reconstruction. If a Billroth II reconstruction is chosen, we recommend a posterior gastrojejunostomy in a two-layer handsewn fashion. Outer layers with interrupted 3-0 silk sutures and the inner layer with a running, slowly absorbable monofilament suture with conversion to Connell. Stapling devices can be utilized with great success; however, the surgeon must take in to account the discrepant bowel thicknesses and staple heights as well as predictable anastomotic edema postoperatively.
Pyloric exclusion can be considered for rare and destructive injuries of the duodenum and pancreas [3–6]. The goal behind pyloric exclusion is to prevent enzymatic activation on pancreatic enzyme by inhibiting gastric enzymes from entering the duodenum, as well as decreasing the overall volume of enteric contents entering the duodenum from the stomach, which can be over 1500 ml/day. Pyloric exclusion is a highly morbid procedure that exposes the patient to many potential complications.
The stomach is opened on the greater curvature of the stomach in a longitudinal fashion. The pylorus is manually palpated and grasped with Allis clamps and delivered through the gastrotomy. The pylorus is closed with a running absorbable, monofilament suture (e.g., polydioxanone) with a large needle in a running forward-to-backward fashion, and tied.
Transverse anastomosis (TA) stapling devices can be used but are discouraged. There are reports of stapling devices being inadvertently applied to the duodenum instead of the pylorus, which is profoundly problematic for the patient because the duodenum will not recanalize after being stapled closed. The natural history of a pyloric exclusion is that the pylorus muscle pulls the suture or stapling apart and therefore becomes patent again. The muscle can be of varying thickness, which can make application of the stapler and staple height selection difficult and create a high risk for failure. There are patients in whom the pylorus may not reopen and can require endoscopic cutting of the suture to allow restoration of the pyloric conduit.
The secondary components to the pyloric exclusion can vary and often depend on the patient’s injury, disease burden, and surgeon experience. It is important to point out that gastrojejunostomy can be ulcerogenic, and that the majority of the duodenal injuries can be repaired primarily if other injuries are not prohibitive of the repair.
I will place a gastrostomy tube lateral and superior to the closed gastrotomy, a distal feeding jejunostomy, and a retrograde duodenostomy tube placed through a proximal enterotomy from the feeding jejunostomy. I will use a pediatric nasogastric tube as my retrograde duodenostomy tube to allow better draining of the duodenum. However, all types of tubes have been utilized successfully (red rubber catheters, etc.) so the choices are largely based on the surgeon’s preference and experience. Wide drainage of the repaired duodenum is recommended. Lastly, one can consider a t-tube placed in the common bile duct with concomitant cholecystectomy to increase biliary diversion. This is often not necessary, however, and further increases patient morbidity.