Fig. 19.1
McBurney’s point can be found 2/3 of the distance from the umbilicus to the right anterior superior iliac spine
An appendix can be removed by an open procedure where a transverse Lanz incision is made over McBurneys point on the anterior abdominal wall or by a laparoscopic approach. Here we describe the laparoscopic approach:
Laparoscopic Appendicectomy
This involves a three-port technique – one for the camera and two for the instruments.
- 1.
The caecum is identified and the bowel is traced proximally to the ileum where the appendix can be found at the ileocaecal junction.
- 2.
The appendix mesentery and the appendicular artery are then divided using diathermy.
- 3.
The appendix is ligated at the base using at least one Endoloop (up to three loops may be used).
- 4.
The appendix is cut at the base and removed through a bag that is introduced via the camera port.
- 5.
The area is washed with fluid and any pus collections are suctioned out.
- 6.
The port sites are then sutured closed.
Complications
Intra-abdominal or pelvic collections
Wound infections
Surgeons’ Favourite Questions for Students
- 1.
Where is McBurneys point?
- 2.
What is the appendix?
- 3.
Where is the appendix found and in what positions can it lie?
- 4.
How can you differentiate the small from the large bowel?
- 5.
What layers do you cut through to reach the appendix in an open appendicectomy?
Abscess
An abscess is a pus filled cavity anywhere on or within the body.
Common abscesses include peri-anal abscess, pilonidal abscess, gluteal abscess, abscess in the axilla and abscess on the back.
Treatment
Incision and Drainage (I + D)
- 1.
A stab incision is made directly over the abscess and the pus filled cavity drained.
- 2.
The incision is then extended to a cruciate and the cavity debrided with a curette.
- 3.
The cavity is washed out thoroughly and then packed with ribbon gauze and a dressing placed over the top.
Follow-Up
The wound is packed and the dressing changed daily by a district nurse or the GP once discharged back into the community.
No formal outpatient hospital appointment is required.
Surgeons’ Favourite Questions for Students
- 1.
What is an abscess?
- 2.
Where would you commonly find an abscess?
- 3.
How is an I + D performed?
Upper Gastrointestinal (GI) Surgery
Upper GI surgery is subdivided into three subspecialties:
Oesophagogastric (OG).
Hepatopancreatobiliary (HPB).
Bariatric.
Investigations
Common investigations in upper GI surgery include:
Blood Tests
FBC (Full blood count).
U & E (Urea & electrolytes).
LFTs (liver function tests).
Amylase/ Lipase – this is important for excluding pancreatic disease. Amylase is frequently used, as it is the least expensive, however lipase is a superior test, being more specific for pancreatitis. Amylase is most commonly used in the UK, with lipase being more common worldwide, including in the USA and Australia.
CRP/ESR (inflammatory markers) – CRP increases acutely, whereas ESR suggests a more chronic inflammatory process.
Endoscopy
This enables direct visualisation of the upper GI tract.
Passage of instruments down the endoscope allows diagnostic and therapeutic procedures
Upper GI endoscopy enables the oesophagus, stomach and first two parts of the duodenum to be visualized.
Capsule endoscopy involves the patient swallowing a small capsule that is equipped with an imaging device. This then transmits images as it passes through the GI tract.
Double balloon endoscopy.
This involves the sequential inflation and deflation of balloons along the endoscope
Allows for visualisation of the entire length of the small bowel
Indications
Dyspepsia aged >55 years
Haematemesis
Iron-deficiency anaemia
Dysphagia
Investigation of malabsorption – a duodenal biopsy would be performed
Persistent vomiting
Therapeutic interventions
Treatment of varices – this may involve either banding or sclerotherapy
Palliation – stent insertion, laser therapy
Treatment of strictures – stent insertion, balloon dilation
Control of bleeding – diathermy, clipping, laser therapy
Complications
Cardiorespiratory arrest resulting from sedation.
Aspiration pneumonia.
Perforation.
Step-by-Step Summary: Endoscopy – Oesophagogastroduodenoscopy (OGD)
Patients are required to stop all anti-acid therapy for at least 2 weeks prior to having an endoscopy and should not eat or drink for 4 h prior to the procedure.
- 1.
The patient may be given a local anaesthetic throat spray for comfort or additional benzodiazepine sedation intravenously.
- 2.
The endoscope is passed down the oesophagus – suction is used to prevent aspiration in to the lungs.
- 3.
Instruments can then be passed down the scope and interventional procedures performed.
Patients must be advised not to drive for 24 h following the procedure.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
This is an endoscopic technique involving cannulation of the main pancreatic duct and common bile duct to enable investigation and/or therapeutic intervention
Indications
Investigation of biliary disease – choledocholithiasis (stones in the CBD), biliary tumours, strictures and intrahepatic biliary disease
Investigation of pancreatic disease e.g. strictures
Therapeutic interventions
Removal of calculi in the CBD
Stenting – CBD stones, strictures and tumours
Sphincterotomy- where the sphincter of Oddi is cut to enable passage of stones
Complications
Perforation- of the oesophagus or duodenum
Bleeding – following therapeutic procedures e.g. sphincterotomy
Post-ERCP pancreatitis
Post-ERCP cholangitis
Respiratory depression and arrest – due to sedative over-medication
Imaging
Magnetic Resonance Cholangiopancreatography (MRCP)
A non-invasive imaging technique used to investigate the pancreatic ducts and intra- and extra-hepatic biliary ducts.
It avoids the morbidity associated with ERCP; however, it cannot be used to perform therapeutic interventions.
Ultrasound
Ultrasound is an important imaging modality when investigating both intra-abdominal and biliary disease. This technique enables detailed visualisation of abdominal and biliary structures whilst remaining a non-invasive and relatively cheap imaging technique. It can also be used to guide biopsies of specific lesions.
Indications
Gallstones and biliary tract obstruction – first line investigation
Abdominal masses and organomegaly
Ascites
Imaging of the small bowel
X-rays
Abdominal x-rays are commonly used to investigate:
Paralytic ileus
Intestinal obstruction
They may also detect:
Gallstones
Calcified lymph nodes
Renal stones
An erect chest x-ray may also be performed if perforation is suspected. This would be indicated by the presence of free air under the diaphragm.
Contrast studies.
These are x-rays that are performed after ingestion of contrast medium.
They may be used to investigate: anatomical abnormalities (e.g. perforation or fistula) or disorders of motility (e.g. achalasia).
Endoscopy and more detailed imaging techniques have largely superseded the need for these studies.
Computed Tomography (CT)
Abdominal CT scanning is used for the evaluation of acute abdominal pain with a major role in the evaluation of renal calculi, acute appendicitis and complex abdominal pathology.
Indications include:
Differentiation of causes of bowel obstruction ± signs of perforation
Evaluation of complications of hernias, pancreatitis, biliary obstruction, acute vascular compromise and abdominal aneurysm.
It is also used in planning of surgical treatment and in the diagnosis of postoperative complications. The patient must have adequate renal function and no known history of allergy before giving IV iodinated contrast. This contrast is nephrotoxic.
Magnetic Resonance Imaging (MRI)
MRI scanning is extremely useful for providing highly detailed images of soft tissues. It does not involve any radiation, and the contrast used, gadolinium, is less allergenic than the iodine-based contrast used in CT scanning. Unfortunately, MRI scanning of the abdomen is a lengthy procedure and patients are required to lie still for extended periods of time
MRI scanning is contraindicated in the presence of foreign bodies or metallic implants such as pacemakers, aneurysm clips, intra-ocular foreign objects and some cardiac stents
Common Procedures in Upper GI Surgery
Cholecystectomy
Indications
Symptomatic gallstones.
A cholecystectomy will not be performed with asymptomatic gallstones
Acute cholecystitis.
Gallbladder polyps and cancer (rare).
Presentation
Gallstones can be completely asymptomatic, or may present in a variety of ways from biliary colic to gallstone ileus.
Symptoms of biliary colic include:
Right upper quadrant pain.
Associated with radiation through to the back typically after the ingestion of fatty foods.
If the stone impacts in the gallbladder neck, acute cholecystitis can ensue which may cause right upper quadrant pain which is continuous and referred to the right shoulder due to the dermatomal distribution of pain.
Positive Murphy’s sign.
Pain on inspiration during palpation under the subcostal margin.
Pyrexia.
Suggests evidence of inflammation differentiating it from simple biliary colic.
If the stone obstructs the common bile duct patients will also present with jaundice, pale stools and dark urine.
Acute cholangitis occurs when an infection supersedes resulting in right upper quadrant pain, jaundice and pyrexia (Charcot’s triad).
Investigations
Blood Tests
FBC, LFTs, U&E
CRP
Amylase – to exclude pancreatitis
If the patient has presented with biliary colic the blood results will usually be within normal limits. If, however, the patient has acute cholecystitis there will be increased inflammatory markers, a raised bilirubin level and potentially peripheral leukocytosis evident on blood results. Obstruction of the CBD usually present with deranged LFTs – the gamma glutamyl transferase (GGT) and alkaline phosphatase (ALP) levels would be raised.
As well as the above blood tests, it is important to work out the location of the stone. If a stone is in the gallbladder or cystic duct, a laparoscopic cholecystectomy can be performed.
If the stone is in the common bile duct the patient may require an ERCP (endoscopic retrograde cholangiopancreatography) in the emergency phase or an OTC (on the table cholangiogram) with CBD exploration during the laparoscopic cholecystectomy.
To determine the location of the stone the following investigations may be performed:
USS Scan
This is the gold standard of investigations for gallstones
It may show thickening of the gall bladder in cholecystitis or dilation of the extra and intra-hepatic ducts if the CBD is obstructed.
MRCP
This is used for further investigation if tests indicate an obstructing gallstone in the common bile duct (CBD).
Clinical Anatomy
The gallbladder is divided into four parts: the fundus, body, neck and Hartmann’s pouch. Hartmann’s Pouch is an out-pouching at the junction of the neck of the gallbladder and the cystic duct where gallstones commonly get stuck. An overview of anatomy can be seen in Fig. 19.2.
Fig. 19.2
Relevant surgical anatomy for a cholecystectomy
The cystic artery supplies the gallbladder and most commonly originates from the right hepatic artery. A networking of branching vessels arises from the cystic artery and supplies part of the common bile duct and hepatic ducts. Venous drainage consists of multiple, small veins that empty into the portal circulation.
Calot’s triangle is bound by the cystic artery, cystic duct and common hepatic duct; it is an important anatomical landmark when performing a cholecystectomy. The hepatocystic triangle is also bound by the cystic duct and common hepatic duct but its upper margin differs; formed by the inferior border of the liver.
Lund’s node is a lymph node found in the triangle and can become enlarged in cholecystitis or cholangitis.
Bile leaves the gallbladder via the cystic duct, which joins the common hepatic duct to form the common bile duct distally. Bile passes through the biliary tree and empties into the 2nd part of the duodenum via the ampulla of Vater, which is surrounded by a ring of circular muscle called the sphincter of Oddi.
Laparoscopic Cholecystectomy
Step-by-Step Summary: Laparoscopic Cholecystectomy (aka ‘Lap Chole’)
- 1.
This is normally a four port technique: one for the camera, one for an instrument to retract the gallbladder and two for instruments to perform the procedure.
- 2.
The gall bladder is retracted up and over the liver to display Calot’s triangle/hepatocystic triangle.
- 3.
Careful dissection of the peritoneal fold and fascia surrounding and within the triangle is used to identify the cystic duct and cystic artery, which are clipped and then cut.
- 4.
The gallbladder is dissected off the liver bed using diathermy.
- 5.
Once the gallbladder has been freed a bag is placed in the abdominal cavity and the gallbladder is placed in it.
- 6.
Haemostasis is checked and the area may be washed with fluid, particularly if there has been some bile spillage.
- 7.
The gallbladder is removed from the abdomen in the bag and all port sites closed.
Note that there are also single port 3D laparoscopy technologies available on the market. The first 3D laparoscopic surgery was performed in London in 2013. These machines utilize the same polarized 3D technology used in 3D cinema, with the intention of reducing error and improving surgeon performance. These are becoming more commonplace in the USA and India, but are still unusual in the UK.
Complications
Bile spillage/gallstone spillage.
Injury to the common bile duct.
Retention of a stone within the common bile duct.
Injury to the bowel.
Development of these complications may necessitate conversion to an open procedure.
Surgeons’ Favourite Questions for Students
- 1.
Describe the anatomy of the gallbladder and biliary tree.
- 2.
What is Calot’s triangle or the hepatocystic triangle?
- 3.
What are the basic steps to of a laparoscopic cholecystectomy?
- 4.
What is an ERCP and when it is indicated?
- 5.
Can you tell me any common anatomical variations of the cystic duct and cystic artery?
Oesophagectomy
Indications
Cancer of the oesophagus – adenocarcinoma or squamous cell carcinoma.
High-grade dysplasia in Barrett’s oesophagus.
Oesophageal strictures
Rupture of the oesophagus
Presentation
Dysphagia – usually progressive and often painless
Hoarseness of voice
Weight loss and loss of appetite
Retrosternal chest pain
Lymphadenopathy
Investigations
Blood Tests
FBC, LFTs, U + E.
Flexible Oesophagogastroduodenoscopy (OGD)
The gold standard investigation.
Enables biopsy and brushings to be taken.
CT Scan
Can detect metastatic disease and lymph node involvement, and determine the extent of oesophageal thickening.
Endoscopic Ultrasonography (EUS)
An important staging modality.
Used to assess the degree of invasion in to the oesophageal wall, to identify any enlargement or abnormality in the coeliac axis and to determine if there is mediastinal lymph node involvement.
Any suspicious nodes can be sampled by fine needle aspiration.
PET Scan
Performed to identify rapidly proliferating cells and as such can be used for diagnosis, staging and monitoring.
Laparoscopy
This is performed for examination of any peritoneal masses and allows for tissue biopsies.
Clinical Anatomy
The oesophagus is a muscular tube, approximately 25 cm in length, which extends from the inferior border of the cricoid cartilage to the cardia of the stomach. It can be divided into cervical, thoracic and abdominal parts. The oesophageal wall includes an outer adventitia, a layer of longitudinal muscle, an inner circular muscle layer and the mucosa consisting of predominantly stratified squamous epithelium.
There are four points where surrounding structures may cause narrowing or compression of the oesophagus:
- 1.
At the junction with the pharynx.
- 2.
Where the arch of aorta crosses it.
- 3.
Where it is crossed by the left main bronchus.
- 4.
As it passes through the diaphragm at the level of T10.
Step-by-Step Summary: Oesophagectomy
Oesophageal resection is restricted to disease confined to the oesophagus in patients fit enough for surgery. It involves resection of the primary tumour and lymphadenectomy. The method used to resect the tumour depends on its location and patient factors.
Chemotherapy and/or radiotherapy may be used as a neo-adjuvant or adjuvant.
Ivor Lewis Two-Phase Oesophagectomy
This is the method of choice for middle and lower third tumours.
It involves mobilisation of the stomach and lower oesophagus by laparotomy.
The oesophagus is then resected after a right thoracotomy.
Finally, the stomach is brought up into the thoracic cavity and anastomosed with the remainder of the upper oesophagus.
Left Thoracotomy
This is the preferred method for tumours at the oesophageal gastric junction.
It is used particularly if further gastric resection is required.
Transhiatal Oesophagectomy
This is used in elderly patients in order to avoid thoracotomy.
It is also suitable for patients with early stage tumours or high grade dysplasia.
It is a 2-surgeon technique; one surgeon approaches through the neck whilst the other approaches through the abdomen.
The upper oesophagus is mobilised and extended down in to the chest whilst the stomach and lower oesophagus are mobilised through the hiatus, up into the neck for anastomosis to the proximal oesophagus.
Reconstruction
The preferred route for reconstruction of the oesophagus is posterior mediastinal.
If the stomach cannot be used, segments of the small intestine or colon can be used for reconstruction.
Post-operatively
Patients will be managed initially in HDU/ITU.
A feeding jejunostomy, which is inserted during surgery, is used to provide nutrition.
Complications
Chest infections
Anastomotic leak
Conduit necrosis
Gastric outlet obstruction
Benign anastomotic stricture
Follow Up
Patients undergoing a oesophagectomy are followed up closely in clinic.
Unfortunately, the procedure is associated with a poor prognosis with only a 20 % survival rate after 5 years.
Surgeons’ Favourite Questions for Students
- 1.
What is the blood supply of the oesophagus?
- 2.
What are the indications for an oesophagectomy?
- 3.
What are the four narrowest points of the oesophagus?
- 4.
At what level does the oesophagus pass through the diaphragm?
Anti-reflux Surgery
Gastro oesophageal reflux disease (GORD) is caused by excessive reflux of gastric acid into the oesophagus, and large hiatus hernias.
Symptoms of GORD occur as a result of a weakness of the lower oesophageal sphincter (LOS). The aim of surgery is to reconstruct an anti-reflux valve at the gastro-oesophageal junction (GOJ).
Presentation
Epigastric pain.
Retrosternal pain (heartburn).
Odynophagia (pain on swallowing).
Dysphagia (difficulty swallowing).
Persistent vomiting – resulting in progressive weight loss.
Investigations
Upper GI endoscopy – this is done to assess the degree of oesophagitis and to investigate for hiatus hernia.
24-h ambulatory pH monitoring – this is to assess reflux.
Manometry – used to exclude primary oesophageal motility disorders.
Clinical Anatomy
The oesophagus is a muscular tube connecting the pharynx to the cardia of the stomach. It passes through the diaphragm into the abdomen at the level of T10. It has a lower oesophageal sphincter where it meets the stomach, which prevents acid and stomach contents refluxing into the oesophagus.
The oesophageal branches of the left gastric artery supply the lower third of the oesophagus. The vagus nerve, CN X, lies in close proximity to the oesophagus; the left vagus lies anteriorly and the right vagus lies posteriorly.
The stomach is divided into the fundus, cardia, body and pylorus. It has a lesser and greater curvature and connects to the duodenum at the pylorus. The lesser curvature of the stomach is supplied by the left gastric artery superiorly and the right gastric artery inferiorly. The greater curvature of the stomach is supplied by the left gastro-epiploic artery superiorly and the right gastro-epiploic artery inferiorly. The short gastric artery supplies the fundus of the stomach.
Laparoscopic Anti-reflux Surgery: Nissen’s Fundoplication
Step-by-Step Summary: Nissen’s Fundoplication
- 1.
The patient is positioned in the reverse Trendelenburg position.
- 2.
The surgeon is usually positioned between the legs, with assistants on the patient’s left and right sides.
- 3.
A five port technique is used – one for the camera, one for a fan retractor to retract the liver, two ports for the surgeon’s instruments to perform the procedure and one port for the assistant’s instruments to retract tissue to create views for the surgeon.
- 4.
The oesophagus and the gastric fundus are mobilised whilst preserving the vagus nerve.
- 5.
The fundus of the stomach is brought around the oesophagus from behind and sutured anteriorly to form a wrap around the lower part of the oesophagus. The short-gastric vessel may be divided to achieve full fundal mobilisation
- 6.
A bougie is introduced orally into the intra-abdominal oesophagus to calibrate the size of the wrap.
Complications
Postoperative dysphagia
Bloating
Hiatal stenosis/hiatus herniation
Vagus nerve injury
Perforation (oesophageal, gastric, duodenum, bowel)
Pneumothorax
Pneumomediastinum.
Pulmonary embolism
Bariatric Surgery
Indication
Surgery is considered in patients with a BMI >40 kg/m2 who will benefit from long-lasting weight loss and improvement in obesity-related co-morbidities such as Type 2 diabetes, hypertension, sleep apnoea, asthma, arthritic disease and depression.
Investigations
BMI
Obesity Surgery-Mortality Risk score (OS-MRS) is calculated.
Roux-en-Y Gastric Bypass Surgery
A small proximal pouch of the stomach is created and anastomosed to a limb of jejunum to bypass the stomach and duodenum, as shown in Fig. 19.3.
Fig. 19.3
A Roux en Y bypass, commonly used in bariatric surgery
Complications
Anastomotic leaks
Bleeding from the staple line
Closed-loop obstruction
Stricture at the pouch-enterostomy
DVT and PE
Gastric Sleeve
A gastric pouch/tube is created using a linear stapler along the greater curvature of the stomach starting close to the pylorus.
The lesser curvature pouch/tube is formed using a bougie, which is introduced orally.
One major complication is leakage along the staple line.
Gastric Banding
A band is placed around the gastro-oesophageal junction with an attached port to allow for inflations and deflation of the band.
Complications
Band slippage/erosion.
Infection of the gastric band port.
Liver Resections
Indications
Metastatic tumours – most commonly colorectal in origin.
Primary hepatic malignancy e.g. hepatocellular carcinoma.
Biliary malignancy e.g. cholangiocarcinoma.
Presentation
Liver malignancy may present with:
Non-specific constitutional symptoms, in particular weight loss.
Symptoms/signs of liver dysfunction.
Deranged liver function tests
Jaundice
Right upper quadrant pain.
Metastatic tumours are often asymptomatic and detected during staging investigations for malignancy in other tissues. In this case, symptoms of the primary tumour may also dominate the clinical picture.
Tumours impinging on the biliary tree may also present with obstructive jaundice.
Investigations
Blood Tests
Liver function tests – likely to be abnormal in patients with malignancy in the liver.
α-fetoprotein – a raised level suggests a primary hepatocellular carcinoma.
Carcinoembryonic antigen (CEA) – if raised, this supports the likelihood of a colorectal primary malignancy with metastatic spread to the liver.
Imaging
Abdominal ultrasound scan – useful to determine the number and size of any hepatic lesions.
Contrast-enhanced CT scan – to determine the number and size of hepatic lesions, as well as for the detection of any extra-hepatic metastases.
Clinical Anatomy
Anatomically, the liver is divided into the larger right lobe and smaller left lobe. This division is demarcated by the ligamentum teres – the embryological remnant of the umbilical vein. Within the larger right lobe, a further two anatomical lobes arise, the caudate and quadrate lobes.
The liver has a dual blood supply:
The common hepatic artery arises from the coeliac trunk, and becomes the hepatic artery proper after the cystic artery is given off. This divides into left and right hepatic arteries to supply the left and right lobes respectively.
The portal vein, draining blood from the gastrointestinal tract, is the source of 80 % of the hepatic blood supply.
The liver is drained by left, middle and right hepatic veins into the inferior vena cava.
An important anatomical division, with respect to liver resection, is the functional division of the liver. This also divides the liver into two lobes, the left and the right, in a sagittal plane. This plane is known as Cantlie’s line. Cantlie’s line extends posteriorly from the inferior vena cava to the middle of the gallbladder fossa anteriorly.
The liver is further divided into eight segments (I to VIII) based on the distribution of the portal triad structures (hepatic artery, portal vein and bile duct). The functional right lobe consists of segments V, VI, VII and VIII, while segments II, III and IV make up the left lobe. Segment I corresponds to the caudate lobe, which is functionally distinct from the rest of the liver.
Types of Liver Resection
- 1.
Segmentectomy – this involves the removal of a single liver segment.
- 2.
Right hepatectomy – this is the resection of segments V-VIII.
- 3.
Left hepatectomy – this is the resection of segments II-IV.
- 4.
Right lobectomy/extended right hepatectomy – this involves the resection of all segments lateral to the umbilical fissure i.e.: IV-VIII ± I.
- 5.
Left lobectomy – this is the resection of segments medial to the umbilical fissure i.e.: II and III.
- 6.
Extended left hepatectomy – this involves the resection of segments II-IV, plus part of the right liver (segments V and VIII).
Step-by-Step Summary: Liver Resection
- 1.
The abdominal cavity is opened using a bilateral subcostal incision.
- 2.
A laparotomy is performed in patients with malignancy to exclude spread to other regions of the peritoneum and regional lymph nodes.
- 3.
The position of the tumour is confirmed by palpation and using intraoperative ultrasound scanning.
- 4.
The arterial supply and venous drainage system of the section of liver being removed must be identified and controlled using diathermy for the smaller vessels or ligation/clips for the larger vessels.
- 5.
The appropriate portion of the liver is separated and removed.
- 6.
The surface of the remaining liver is examined and any bleeding controlled.
- 7.
A large tube drain is placed and the wound closed.
Complications
Death
Post-operative liver failure
Wound infection
Bleeding
Pneumonia
Intra-abdominal abscess
Bile leaks
Pancreaticoduodenectomy (Whipple’s Procedure)
Definition
Classical – removal of the head of the pancreas, the distal stomach and associated omentum, the duodenum and upper jejunum, the gallbladder and the distal biliary tree.
Pylorus-preserving – leaves the stomach and pyloric antrum intact (see Fig. 19.4)
