SGO - Bowel surgery Flashcards
Issues with enterotomy primary repair
- Size of the injury
- Type of injury
- thermal vs non-thermal
- Health of the small bowel or large bowel
- Location of injury/closure
- Trajectory of closure
- Proximity of closure to the vasculature
- should not impact vascular supply
- have ability to return later in the case
Primary repair of small bowel or large bowel injury
- sutures
- techniques
- Closure in two layers if possible
- 1st layer:
- Most commonly used suture = vicryl 2-0 or 3-0
- Almost always braided and multifilament
- Some vicryl can be monofilament
- Delay absorption of suture from hydrolysis and not
- Silk is natural and always braided and absoprtion is via phagocytosis –> inflammatory reaction/process
- Avoid for first layer
- Most commonly used suture = vicryl 2-0 or 3-0
- 2nd layer can be vicryl or silk
- For radiated bowel,
- Second layer can be PDS = monofilament and delayed absorption
- Needle-type: SH
How do you select stapler cartridges for bowel resection based on length?
GIA stapler
- Length of 55 mm
- Can use in SB if you know there’s not a lot of swelling and you won’t lose much luminal diameter
- used more with pediatric patients
- Can use in SB if you know there’s not a lot of swelling and you won’t lose much luminal diameter
- Length = 75 mm
- Usually the stapler of choice
- Lose 5 mm on each end by retraction and 1 cm on fibrosis
- Length of 90 mm
- Usually use for SB to LB connections
How do you select stapler cartridges based on staple size for resection?
2’s mm = vascular
3’s mm = SB
4’s mm = LB
What are considerations when choosing the appropriate stapler for bowel surgery?
What are the type of laparotomy staplers?
Describe the physics of the staples
- Anatomy of it
- what shape do staples form when fired?
Summary example of staple sizes
Remember these are subject to change based on manufacturer
Describe how GIA stapler works
Summary of GIA stapler length
Why would you use 3.8 mm / 75 mm GIA stapler for SB resection and STS anastomosis?
- Loss of length after tissue stretching
- Loss of length after use of TA stapler for side to side anastomosis completion
TA stapler
- Describe the physics of its use
- What staple size or length do you use?
EEA stapler
- Describe the physics
- What diameter of stapler will you choose?
- How much luminal diameter do you lose based following firing of the EEA stapler?
EEA stapler
- Describe the physics
- see figure
- What diameter of stapler will you choose?
- see figure
- How much luminal diameter do you lose based following firing of the EEA stapler?
- ~ 1 cm
What are the complication rates for bowel reanastomosis?
- How does this change with staplers vs hand-sewn?
What are anatomical concerns for reanastomosis sites for
- SB
- LB
What are the functions of the various parts of SB for absorbing nutrients?
- duodenum
- jejunum
- ileum
Blood supply to the small bowel?
Blood supply to ascending and transverse colon?
Blood supply to the descending colon?
Watershed area in the colon?
- If you affect middle colic of the transverse or the left colic artery…problematic
- Watershed area at the splenic flexure.
Venous drainage of colon
- Venous return of transverse colon –> directly to portal vein (low pressure system)
- Long pedicle of middle colic vein can cause a blood clot –> portal hypertension
When do you resect vs do a primary repair of bowel injury?
How do you do bowel resection and reanastomosis?
Video from SGO webinar (Dr. Al-Niaimi)
En bloc rectosigmoid resection also is also known as?
What are common key elements between en bloc vs isolated rectosigmoid resection?
- Radical oophorectomy
- Modified posterior exenteration
This is different than an isolated resection that would be done for rectal or sigmoid sigmoid resection. There are different approaches for rectosigmoid resection vs en bloc rectosigmoid resection.
What is a helpful trick when performing rectosigmoid resection in post-hysterectomy patient?
Placement of a sizer or probe in the vagina
- Helps to delineate anatomy
Limited proximal vaginectomy as part of resection helps give axis to the rectovaginal space since uterus is not there to be used as an anatomical landmark.
How do you enter the rectovaginal space for RSR?
- Video by Dr. Bristow
- Anterior colpotomy
- can use sponge stick, malleable, finger, etc.
- Circumscribe proximal vagina
- Using clamps, you can have sutures on hemostats that you can pull up on.
- Midline vs lateral approach to entering rectovaginal space
- Think of Jaz’s lateral approach in the paravagina/opening with clamp
- Rectal pillars are a continuation of uterosacral ligaments as they hug the rectum.
- Flash of yellow = fat in the RVS
- Use of colonic sizer in the rectum helps to delineate.
How do you prepare the rectosigmoid anastomosis?
- Video by Dr. Bristow
- Colonic sizers are useful to delineate where the proximal rectum is and mesorectum starts.
- Avoid devascularization of proximal rectum
- You can have <1.5-2 cm of rectum without associated mesorectum below your resection line and still be fine.
Tool of choice for resection of proximal rectum?
How do prepare for a tension free colorectal anastomosis?
First 2 are used more regularly then #3 then uncommonly #4 or #5
What is the “fan effect” when attempting to achieve a tension-free anastomosis for RSR?
It’s important to ensure blood supply from marginal artery
- You can do this via transilluminating marginal artery from left colic
What’s the Deloyers procedure?
One technique used to achieve left for tension free colorectal anastomosis
- Try to avoid leaving mesenteric window formation because could cause internal hernia
What’s a retroiliac transmesenter window technique for gaining mobility in colorectal anastomosis?
Rare technique used for achieving more length for colorectal anastomosis
What are the options for doing rectosigmoid reanastomosis?
- Circular end to end anastomosis (CEEA)
- Most common
- Needs dorsal lithotomy position
- Circular end to side anastomosis
- Enterotomy in corner of proximal colon and placement of anvil (such that it comes out on the anti-mesenteric side) and handpiece is the proximal rectum
- good technique if mesentery is too short to facilitate mobilization of the proximal colon into the pelvis
- Another way is doing EEA reverse
- Anvil is in proximal rectum and handpiece is the proximal colon
- Useful technique if not in dorsal lithotomy
- Enterotomy in corner of proximal colon and placement of anvil (such that it comes out on the anti-mesenteric side) and handpiece is the proximal rectum
- Alternate CEEA
- Creation of proximal colotomy and anvil is in the proximal rectum
- Bascially reverse CEEA
- Close the proximal colotomy with stapler or handsewn (always close perpendicular to the long axis of the bowel)
- Creation of proximal colotomy and anvil is in the proximal rectum
- Triangulation EEA
- Using 3 applications of the TA stapler.
- Cumbersome because with the next 2 applications of the TA stapler, the staple line has to be inverted
What do you do for securing the anvil in a rectosigmoid anastomosis?
Ensure eversion of lumen when securing and tying down purse string!
How do you confirm the integrity of the RS anastomosis?
Explain the use of ICG for bowel anastomosis integrity
What do you do with a positive air leak test?
- See figure
- Oversewing would be appropriate if it’s a small leak and optimal conditions: bowel is in good condition, good vasculature, no tension, no prior radiation, no poor nutritional status, etc
- silk 3-0 or vicryl 3-0
- If you big leak and bubbles, probably should take it down and redo it.
Criteria for bowel diverstion for rectosigmoid resection?
