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Maintain traction on the stomach to help generate a sufficient length of esophagus (Fig discount 100 mg vermox free shipping antiviral medication for warts. Move the two retractors apart in a spreading movement discount 100mg vermox hiv infection rates graph, Generally only one of the retractors is needed for the remain- parallel to the long axis of the esophagus (Fig purchase 100 mg vermox with amex acute hiv infection neurological symptoms. Test the mobility of the fundus by passing it back and forth anterior to the esophagus (Fig. If at any time there has been concern about injury to the esophagus or stomach, have the anesthesiologist instill meth- ylene blue into the nasogastric tube and look for staining. Creating the Wrap Remove the esophageal retractors and allow the esophagus to return to its normal anatomic position. For most adults, sequentially pass dilators until a 56–60F dilator is in place (Fig. Bring additional fundus over from the left side to meet the portion that has been passed behind (Fig. Catch a bit of the esophagus with the first suture or two to anchor the wrap well above the stomach (Fig. A Hypaque swallow the first post- Closing the Hiatus operative day should demonstrate free passage of Hypaque without extravasation. This is particularly important if The hiatus must be closed to avoid herniation of the stomach there is any question of the integrity of the wrap or or small intestine. Leave a gap to avoid overtight- ening the hiatus, which may cause postoperative dysphagia. Complications Dividing the Short Gastric Vessels Esophageal perforation Herniation of viscera through the hiatal opening The short gastric vessels tether the fundus of the stomach to Slipped wrap the spleen (Fig. Symptomatic and functional outcome after laparoscopic reoperation for failed antireflux surgery. Five-year subjective and objective results of lapa- roscopic and conventional Nissen fundoplication: a randomized trial. Comparison of long-term outcome of laparoscopic and conventional Nissen fundo- plication: a prospective randomized study with an 11-year follow- up. Mechanisms of gastric and esophageal perforations during laparoscopic fundoplication. Total versus partial fundo- plication in the treatment of gastroesophageal reflux disease: a Fig. Successful execution of this operation requires that the The median arcuate ligament constitutes the anterior esophagus be long enough to suture the esophagogastric portion of the aortic hiatus, the aperture in the diaphragm junction to the level of the median arcuate ligament without through which the aorta passes. This band of fibrous tissue cov- ers about 3 cm of the aorta above the celiac axis and is in See Chap. It can be identified by exposing the celiac artery and pushing it posteriorly with the finger at the inferior rim of the median arcuate liga- Pitfalls and Danger Points ment. For Hill’s operation, the surgeon dissects the celiac artery and celiac ganglion away from the overlying median Hemorrhage from laceration of celiac or inferior phrenic arcuate ligament in the midline, avoiding the two inferior artery phrenic arteries that arise from the aorta just to the right Injury to spleen and just to the left of the midline. Nerve fibers from the Improper calibration of lumen of lower esophageal sphincter celiac ganglion must be cut to liberate the median arcuate Excessive narrowing of diaphragmatic hiatus ligament. Failure to identify the median arcuate ligament An alternative method for identifying the median arcuate Injury to left hepatic vein or vena cava when incising trian- ligament is to visualize the anterior surface of the aorta gular ligament to liberate left lobe of liver above the aortic hiatus. Then with the left index fingernail push- ing the anterior wall of the aorta posteriorly, pass the finger- tip in a caudal direction. The fingertip passes behind a strong layer of preaortic fascia and median arcuate liga- ment. At a point about 2–3 cm caudal to the upper margin of the preaortic fascia, blocking further passage of the finger- C. Carver arcuate ligament to the aorta at the origin of the celiac College of Medicine, University of Iowa, artery. Vansant and colleagues believed that the foregoing maneuver constitutes sufficient mobilization J. Chassin of the median arcuate ligament and that the ligament need not be dissected free from the celiac artery and ganglion to perform a posterior gastropexy. We believe that a surgeon who has not had considerable experience liberating the median arcuate ligament from the celiac artery may find Vansant’s modification to be safer than Hill’s approach. If one succeeds in catching a good bite of the preaortic fascia and median arcuate ligament by Vansant’s technique, the end result should be satisfactory. If the celiac artery or the aorta is lacerated during the course of the Hill operation, do not hesitate to divide the median arcu- ate ligament and preaortic fascia in the midline.


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If the mucosa is bulging generic vermox 100 mg amex hiv infection rate in rwanda, approximating radiologic techniques vermox 100mg low cost hiv infection first week symptoms, including water-soluble contrast and the serosa on either side by interrupted Lembert stitches in a 42 Concepts in Surgery of the Small Intestine and Appendix 389 transverse direction repairs the area purchase vermox 100 mg without a prescription hiv infection initial symptoms. Determining the viabil- product that has been subjected to a controlled, randomized ity of a segment of small bowel that has been freed can be study; this trial demonstrated a reduction in the incidence, difficult. Clues such as improved color and visible, palpable extent, and severity of postoperative adhesions (Becker et al. Several series demonstrate fea- this reduction in adhesion formation is followed long term sibility and surgeon acceptance; the reports also illustrate by a decreased incidence of small bowel obstruction. The clinical trial, 52 patients treated with standard laparotomy membrane is inert and permanent. This material must be were compared to 52 patients treated laparoscopically sutured in place, but most importantly, it must be removed (Cirocchi et al. In a second controlled clinical trial Several operative techniques have been used in an attempt published in 2007, laparoscopic enterolysis demonstrated to prevent recurrent obstruction. Two are mentioned in order lower morbidity, shortened postoperative hospitalization, to discourage their use. One strategy has been to fix the intes- and earlier return of bowel function (Khaikin et al. Several retrospective reports note the frequent this was done by stitch plication of the small bowel, accom- need for conversion from laparoscopy to open technique. This procedure ing laparotomy versus laparoscopy for the treatment of adhe- requires significantly long operating times and is associated sive bowel obstruction in adult patients. It has not been shown to prevent A vexing problem for the general surgeon is the patient recurrent obstruction. Because of failure of suture plication, who presents with recurrent bouts of obstruction secondary long intraluminal (Baker) tube stents were introduced. Recurrent obstructions occur in 10–15 % of tubes are placed through the nose or through a gastrotomy cases. A number of products have been developed with the and left in place for 2 weeks (Chap. Even though there object of inhibiting the formation of adhesions in the postop- are single-institution successful reports of these techniques, erative period. Hyaluronic acid, a constituent of peritoneal no prospective studies have been performed to demonstrate surfaces and fluid, has been used in several formulations. Hyaluronic acid solutions have proven efficacy in animal models for the prevention of adhesions. Cross-linking Crohn’s Disease carboxylate groups on the hyaluronic acid molecule increases viscosity and is employed in several commercial applica- Crohn’s disease is a common inflammatory bowel disease tions. In a recent meta-analysis, prevalence of adhesions, characterized by granulomatous inflammation, by potential judged by second-look laparoscopy, was reduced by use of involvement of any portion of the gastrointestinal tract, and hyaluronate solutions (Ahmad et al. More than half of all patients afflicted with sion barrier composed of sodium hyaluronate and carboxy- Crohn’s disease require surgical therapy. The material may be placed without undergo operation, reoperation is required in 70 % and mul- suturing and is absorbed from the peritoneal cavity by 7 days tiple procedures in 30 % (Duepree et al. Seprafilm is the only has been applied widely in gastrointestinal diseases with 390 D. Antibiotic therapy with nitroimidazole agents is more Laparoscopic approaches are feasible for patients with effective than placebo, but the ability of most patients to tol- Crohn’s disease, but most reports are retrospective in nature erate this therapy is limited due to neurological side effects. In a recent meta-analysis Mesalamine shows benefit for prevention of postoperative comparing open and laparoscopic approaches to treatment of recurrence. Importantly, there was no significant difference in inci- dence of recurrent disease necessitating reoperation (Stocchi et al. The rate of conversion from laparoscopic Small Intestinal Stricturoplasty approach to open operation is moderate, approximately 11 % (Tan and Tjandra 2007 ). Multiple intestinal strictures are common sequelae of chronic The technique of anastomosis appears to be important in inflammation in patients with Crohn’s disease.

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This problem may occur on the sur- passer buy generic vermox from india hcv hiv co infection rates, which consists of a long hemostat holding the 2-0 silk face of the pancreas buy vermox 100mg line hiv infection during pregnancy, where attempts to grasp a retracted ves- sel with hemostats can be much more traumatic than a small figure-of-eight suture of atraumatic 4-0 silk order 100mg vermox amex zovirax antiviral. Chassin Hemostatic Clips a large grounding electrode placed on the patient’s thigh or back. Two types of current are supplied by most electrocau- Metallic hemostatic clips offer a secure, expedient method tery generators: cutting and coagulating. Cutting current is for obtaining hemostasis, provided the technique is properly continuous-wave, high-frequency, relatively low-voltage applied. It produces rapid tissue heating, which allows the ference of a vessel is visible, preferably before the vessel has blade of the cautery to cut through tissue like a scalpel. Coagulating current is pulsed- incomplete occlusion of the vessel and continued bleeding, waveform, low-frequency, high-voltage current that heats following which the presence of the metal clip obstructs any tissues slowly. The resulting protein coagulation seals small hemostat or suture ligature in the same area. The resulting coaptive coagula- tion, such as when performing a Kocher maneuver, the sub- tion seals the front and back wall of the collapsed vessel sequent surgical maneuvers often dislodge the clips and together. Small punctate bleeders may be secured by touch- lacerate the vessels, producing annoying hemorrhage. Hemostatic clips may similarly interfere with application of Bipolar cautery units generally have a forcepslike con- a stapling device. It is It is futile to apply multiple clips in the general area from less useful, however, for cutting. Again it must be emphasized that applying a clip is stasis, provided certain contraindications are observed. As with hemostatic clips, In the absence of these contraindications, hemostatic clips any tissue that will subsequently be subjected to blunt dissec- speed dissection and allow secure control of bleeding ves- tion or retraction may not be suitable for electrocautery, as the sels. An example is in the mediastinum during esophageal friction often wipes away the coagulum, causing bleeding to dissection or in the retroperitoneal area during colon resume. Similarly, when many subcutaneous bleeding points are subjected to electrocoagulation, the extensive tis- Staplers sue insult may contribute to wound infection. Laparoscopic surgeons are familiar with use of staplers, loaded with “vascular cartridges,” for control of vessels too Ultrasonic Shears large to securely clip or ligate. These staplers are gradually making their way into common use during open surgery as Ultrasonic shears were initially introduced for minimal well. These devices use ultrasound to They appear particularly useful for large diameter veins such heat and coagulate tissue in a coapted position. The tissue is as the adrenal vein during adrenalectomy or the splenic vein then cut with the device or with scissors. Physicochemical Methods Electrocautery Gauze Pack With electrocautery a locally high current density is passed Physical application of a large, moist gauze pad has been through the target tissues to achieve rapid tissue heating. It Monopolar cautery devices allow the surgeon to cut or cau- enhances the clotting mechanism because pressure slows terize with a bladelike tip. The return current path is through down the loss of blood, and the interstices of the gauze help 6 Control of Bleeding 47 form a framework for the deposition of fibrin. Unfortunately, Control of Hemorrhage after the gauze pack is removed, bleeding sometimes resumes. Packing has been lifesaving after major hepatic Temporary Control trauma or for persistent pelvic bleeding during abdomino- perineal resection, particularly when the patient has become During the course of operating, the equanimity of the surgeon is cold or developed a coagulopathy. Packs may be left in and jarred occasionally by a sudden hemorrhage caused by inadver- removed after 24 h when the patient is stable and all hemo- tent laceration of a large blood vessel. The sequence should go something like the following: A variety of topical hemostatic agents are available in pow- 1. They vary in chemical formula- controlling bleeding from an artery, is simple application tion, but most are collagen or cellulose derivatives and act as of a fingertip to the bleeding point. In the case of a large a matrix and stimulant for clot formation; thus, the patient vein, such as the axillary vein or vena cava, pinching the must be able to form clot for these agents to work. It is wise laceration between the thumb and index finger is some- to remember the old axiom that topical agents work best in a times effective. Ascertain that the patient is fully stop oozing but do not substitute for definitive hemostasis of resuscitated, that large-bore intravenous catheters are in individual bleeding vessels. References at the end give fur- place, and that blood and blood products are available.


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