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Abe Fingerhut · Ari Leppäniemi

Raul Coimbra · Andrew B. Peitzman

Thomas M. Scalea · Eric J. Voiglio Editors

Emergency Surgery
Course (ESC®) Manual

The Official


Emergency Surgery Course (ESC®)
Abe Fingerhut • Ari Leppäniemi
Raul Coimbra • Andrew B. Peitzman
Thomas M. Scalea • Eric J. Voiglio

Emergency Surgery
Course (ESC®) Manual
The Official ESTES/AAST Guide
Abe Fingerhut, Doc hon c, FACS, Andrew B. Peitzman
FRCS(g), FRCS(Ed) Division of General Surgery
Department of Surgical Research University of Pittsburgh UPMC
Clinical Division for General Surgery Pittsburgh, PA
Medical University of Graz USA
Austria Thomas M. Scalea
R Adams Cowley Shock Trauma Center
Ari Leppäniemi University of Maryland Medical Center
Department of Abdominal Surgery Baltimore, MD
University of Helsinki Meilahti Hospital USA
Finland Eric J. Voiglio
Emergency Surgery Unit
Raul Coimbra University Hospitals of Lyon Centre
Department of Surgery Hospitalier Lyon-Sud
University of California San Diego Pierre-Bénite
Health Sciences France
San Diego, CA

ISBN 978-3-319-21337-8 ISBN 978-3-319-21338-5 (eBook)

DOI 10.1007/978-3-319-21338-5

Library of Congress Control Number: 2015960762

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2016
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Emergency surgery, or acute care surgery, has been part of every surgeon’s
daily work in facilities that receive acutely ill patients with non-trauma dis-
ease requiring quick decisions because of life- or organ-threatening disease.
However, it has been only within the last few decades that the “specialty” of
emergency surgery or acute-care surgery was created and formalized. The
need for specific training in this discipline was obvious, but in many coun-
tries, especially in Europe, training (both the knowledge and the surgical
competence) was incomplete or obscured by inclusion in general or gastro-
intestinal surgery programs.
Several years ago, it occurred to some members of the European Society
of Trauma and Emergency Surgery (ESTES) that there was a need to set up
and formalize Emergency Surgery Courses (ESC). The initial discussions
involved Abe Fingerhut and Selman Uranues from Graz, Austria, who imme-
diately materialized the first pilot course. Further discussions took place dur-
ing the ESTES Meeting in Antalya between Abe Fingerhut, the incoming
president at that time, Ari Leppänemi, Isidro Martínez Casas, and Dieter
Morales García, who then initiated discussions within the executive board of
Within a few months, a steering committee was set up under the leadership
of Abe Fingerhut, then president of ESTES, and included Ari Leppaniemi
(Helsinki, Finland), Korhan Taviloglu (Istanbul, Turkey), Fernando Turegano
(Madrid, Spain), Selman Uranues (Graz, Austria) and Eric Voiglio (Lyon,
France). Pilot courses were run in Graz, Istanbul, and Lyon, and the success
was immediate.
However, there was also a need for a manual, a didactic accompaniment to
guide the beginner and maintain a certain degree of standardization among
the more experienced – an up-to-date summary of how to make the right deci-
sions, decide the best timing for investigations and operative procedures,
which procedures to perform and obtain the best results for these emergency
As the idea spread, it became apparent that the need for such training and
the manual was universal, and after discussion with key members of the
American Association for the Surgery of Trauma (AAST) (Raul Coimbra,
Andy Peitzman and Tom Scalea), we decided to collaborate to finalize this
manual as a joint venture.
The final product is the fruit of many collaborators as authors, many of
whom are world known in the field (see list). The editorial work was the

vi Preface

product of the publication committee (Abe Fingerhut, Ari Leppäniemi, Eric

Voiglio, Raul Coimbra, Andy Peitzman and Tom Scalea) and ad hoc correc-
tions from Fernando Turegano and Korhan Taviloglu.
We trust that this guidebook will be of use for all surgeons who are called
upon to take care of the acutely ill, where urgent decisions and procedures are

Abe Fingerhut Graz, Austria and Athens, Greece

Ari Leppäniemi Helsinki, Finland
Raul Coimbra San Diego, CA, USA
Andrew B. Peitzman Pittsburgh, PA, USA
Thomas M. Scalea Baltimore, MD, USA
Eric J. Voiglio Lyon, France

This is to introduce you to the Emergency Surgery Course (ESC©), an educa-

tive initiative of the European Society of Trauma and Emergency Surgery
(ESTES) and the American Association for the Surgery of Trauma (AAST).
The goal of this course is to address the emergency and urgent surgical
settings that can arise in almost any emergency department throughout the
world. Based on the success of DSTC© in the trauma arena, the contents are
designed for all surgeons, ranging from trainees with budding experience to
accomplished (elective surgery) surgeons, visceral or orthopedic specialists,
who take call and may be confronted with emergency surgical situations that
they do not see every day. Moreover, training surgeons to meet emergency
and urgent surgical conditions is difficult, especially as we ride through the
beginning of the twenty-first century. The European Working restrictions
have limited the number of hours surgeons can remain in the hospital, reduc-
ing exposure to patients and the hospital duties such as call; cost-containment
of hospitals and spiraling technology have changed the face of treatment.
Ethical considerations are in the foreground, making it more difficult to guide
the toddling steps of novice surgeons on live patients, in the emergency set-
ting in the operation room. More than ever before, training must be accom-
plished outside the hospital setting, outside the emergency arena. Simulation
has taken giant steps in the training curriculum of young surgeons – training
surgeons to deal with urgent and emergency settings is no exception.
The distinction between emergency and urgent surgery are according to
the National Confidential Enquiry into Perioperative Deaths (NCEPOD)
1990 classification of degree of urgency of operation:

1. Emergency surgery entails immediate life-saving operation, usually within

one hour, simultaneous resuscitation.
2. Urgent means an operation as soon as possible after resuscitation, usually
within 24 h.

Of the scheduled operations, there are two types: (1) an early operation,
but not immediately life-saving is an operation usually within 3 weeks. (2)
An elective operation is one performed at a time to suit both patient and
We want this course to be a “must” for the surgeon on call, who, either
because of the ever evolving diagnostic modalities and management plat-
forms, or because of the relative rarity of the pathology or the remoteness

viii Introduction

of working conditions, requires acquisition or sharpening of specific

knowledge and skills to care for acute surgical problems in the best and
most appropriate way.
Knowledge of the most efficient diagnostic modalities, combined with
expedient pre-, intra- and postoperative decision making, topped by cutting
edge or time proven technical issues, constitute the core elements of the
Several modules will be available, the curriculum corresponding to the
duration of the course, ranging from 2 to 3 days. The course will be com-
posed of a mix of didactic lectures, interactive decision-making case scenar-
ios and hands-on (animal and/or cadaver) skill-acquisition sessions.

ESC Steering committee members

Abe Fingerhut, head
Ari Leppaniemi
Korhan Taviloglu
Fernando Turegano
Selman Uranues
Eric Voiglio

Joint publication committee

Abe Fingerhut (coordinator)
Ari Leppäniemi
Eric Voiglio

Andrew Peitzman
Raul Coimbra
Thomas Scalea

Campling EA, Devlin HB, Hoile RW, Lunn JN, eds. Report of the National Confidential
Enquiry into Perioperative Deaths 1990. National Confidential Enquiry into
Perioperative Deaths. London; 1992
Campling EA, Devlin HB, Hoile RW, Lunn JN, eds. Report of the National Confidential
Enquiry into Perioperative Deaths 199111992. National Confidential Enquiry into
Perioperative Deaths. London; 1993.
Campling EA, Devlin HB, Hoile RW, Lunn JN, eds. Report of the National Confidential
Enquiry into Perioperative Deaths 199211993. National Confidential Enquiry into
Perioperative Deaths. London; 1995.

Part I Generalities

1 Intraoperative Strategy: Open Surgical Approach. . . . . . . . . . 3

Brandon R. Bruns, Ari Leppäniemi,
and C. William Schwab
2 Leading Symptoms and Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Fernando Turégano-Fuentes
3 Management Options: Nonoperative Versus
Operative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Fernando Turégano-Fuentes and Andrés García Marín
4 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Ari Leppäniemi
5 Postoperative Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Ronald V. Maier and Abe Fingerhut
6 When to Operate After Failed Nonoperative
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Gregory A. Watson and Andrew B. Peitzman

Part II Techniques

7 Laparoscopy for Non-trauma Emergencies. . . . . . . . . . . . . . . . 55

Selman Uranues and Abe Fingerhut
8 Laparotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Eric J. Voiglio, Guillaume Passot,
and Jean-Louis Caillot
9 Lower Gastrointestinal Endoscopy . . . . . . . . . . . . . . . . . . . . . . 83
Halil Alis and Korhan Taviloglu
10 Percutaneous Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Isidro Martínez-Casas, Dieter Morales-García,
and Fernando Turégano-Fuentes
11 Upper Gastrointestinal Endoscopy . . . . . . . . . . . . . . . . . . . . . . 103
Hakan Yanar and Korhan Taviloglu

x Contents

Part III By Organ

12 Esophageal Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Demetrios Demetriades, Peep Talving,
and Lydia Lam
13 Stomach and Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Carlos Mesquita, Luís Reis,
Fernando Turégano-Fuentes, and Ronald V. Maier
14 Cholecystectomy for Complicated Biliary
Disease of the Gallbladder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Abe Fingerhut, Parul Shukla, Marek Soltès,
and Igor Khatkov
15 Choledocholithiasis [Common Bile
Duct (CBD) Stones] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
René Fahrner and Abe Fingerhut
16 Small Bowel Emergency Surgery . . . . . . . . . . . . . . . . . . . . . . . . 153
Fausto Catena, Carlo Vallicelli, Federico Coccolini,
Salomone Di Saverio, and Antonio D. Pinna
17 Colon and Rectum Emergency Surgery Techniques:
Exposure and Mobilization, Colectomies, Bypass,
and Colostomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Pantelis Vassiliu, Irene Pappa, and Spyridon Stergiopoulos
18 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Luca Ansaloni, Marco Lotti, Michele Pisano, and Elia Poiasina
19 Emergency Surgery for Hydatid Cysts of the Liver . . . . . . . . . 183
Chadli Dziri, Abe Fingerhut, and Igor Khatkov
20 Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Ari Leppäniemi
21 Diaphragmatic Problems for the Emergency Surgeon. . . . . . . 193
Peter J. Fagenholz, George Kasotakis,
and George C. Velmahos
22 Gynecologic Considerations for the Acute
Care Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
George C. Velmahos
23 Acute Proctology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Korhan Taviloglu
24 Necrotizing Soft Tissue Infections . . . . . . . . . . . . . . . . . . . . . . . 217
Eric J. Voiglio, Guillaume Passot,
and Jean-Louis Caillot
Contents xi

25 Surgical Emergencies Related to Abdominal

Wall Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Antonios Christos Sideris and George C. Velmahos
26 Thoracic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
François Pons and Federico Gonzalez
27 Vascular Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Luis Filipe Pinheiro
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Halil Alis Department of Surgery, Bakirkoy Teaching Hospital,

Istanbul, Turkey
Luca Ansaloni, MD, MBBS Director, General Surgery I,
Department of Emergency, Papa Giovanni XXIII Hospital, Bergamo, Italy
Brandon R. Bruns, MD Assistant Professor of Surgery,
University of Maryland Medical Center, Philadelphia,
Jean-Louis Caillot, MD, PhD Service de Chirurgie d’Urgence,
Centre Hospitalier, Lyon, France
Fausto Catena, MD General, Emergency and Transplant
Surgery Department, St Orsola-Malpighi University Hospital,
Bologna, Italy
Federico Coccolini, MD General and Emergency Surgery Department,
Papa Giovanni XXIII Hospital, Bergamo, Italy
Demetrios Demetriades, MD, PhD, FACS Professor of Surgery,
Department of Surgery, Keck School of Medicine, Director of the Division
of Acute Care Surgery, University of Southern California, Los Angeles
County + USC Medical Center, Los Angeles, CA, USA
Salomone Di Saverio, MD Emergency and Trauma Surgery Unit,
Maggiore Hospital Regional Trauma Center, Bologna, Italy
Chadli Dziri, MD, FACS Professor of General Surgery, Head Department
B-Charles Nicolle Hospital, University of Tunis, Tunis, Tunisia
Peter J. Fagenholz, MD Assistant Professor of Surgery, Harvard Medical
School, Division of Trauma, Emergency Surgery, and Critical Care,
Massachusetts General Hospital, Boston, MA, USA
René Fahrner, MD Service Surgery, Division of General, Visceral and
Vascular Surgery, University Hospital Jena, Jena, Germany
Abe Fingerhut, Doc hon c, FACS, FRCS(g), FRCS(Ed) Department of
Surgical Research, Clinical Division for General Surgery,
Medical University of Graz, Graz, Austria

xiv Contributors

Francisca García-Moreno, MD, PhD General Surgeon, University

Hospital Ramón y Cajal, Madrid, Spain
Federico Gonzalez, MD Department of General and Thoracic Surgery,
Percy Military Hospital, Clamart, France
Ulrich Güller, MD University of St Gall, St. Gallen, Switzerland
George Kasotakis, MD, MPH, FACS Assistant Professor of Surgery,
Division of Trauma, Boston University School of Medicine, Acute Care
Surgery and Surgical Critical Care, Boston, MA, USA
Igor Khatkov, MD Department of Surgical Oncology,
Moscow Clinical Scientific Center, Moscow, Russia
Lydia Lam, MD, FACS Assistant Professor of Surgery, Division of Acute
Care Surgery and Surgical Critical Care, Department of Surgery, Keck
School of Medicine, University of Southern California, Los Angeles
County + USC Medical Center, Los Angeles, CA, USA
Ari Leppäniemi, MD, PhD, DMCC Chief of Emergency Surgery,
Meilahti Hospital, University of Helsinki, Helsinki, Finland
Marco Lotti, MD General Surgery 1 Unit, Centre for Mini-invasive Surgery,
Ospedali Riuniti di Bergamo, Bergamo, Italy
Ronald V. Maier, MD, FACS Jane and Donald D. Trunkey Professor
and Vice Chair, Department of Surgery, University of Washington Surgeon-
in-Chief, Harborview Medical Center, Seattle, WA, USA
Andrés García Marín, MD Department of Surgery, University Hospital,
San Juan de Alicante, Alicante, Spain
Isidro Martínez-Casas, MD, PhD, FACS Serviciod e Cirugía General y
Digestiva, Complejo Hospitalario de Jaén, Jaén, Spain
Carlos Mesquita, MD Department of General Surgery, Coimbra Central
and University Hospitals, Coimbra, Portugal
Dieter Morales-García, MD, PhD Division of Surgery, Hospital de
Universitario Marqués de Valdecilla, Santander, Spain
Irene Pappa, BSc, MS GGZ Delfland, University of Athens, Rotterdam,
Guillaume Passot, MD, MSc Service de Chirurgie d’Urgence,
Centre Hospitalier, Lyon, France
Andrew B. Peitzman, MD Mark M. Ravitch Professor and Vice-Chair
Chief, Division of General Surgery, University of Pittsburgh, Pittsburgh,
Luis Filipe Pinheiro, MD Director of General Surgery 1, Hospital São
Teotónio, Viseu, Portugal
Contributors xv

Antonio D. Pinna, MD General, Emergency and Transplant Surgery

Department, St Orsola-Malpighi University Hospital, Bologna, Italy
Michele Pisano, MD General Surgery 1 Unit, Department of Emergency,
Centre for Mini-invasive Surgery, Ospedali Riuniti di Bergamo,
Bergamo, Italy
Elia Poiasina, MD 1st General Surgery Unit, Department of Emergency,
Papa Giovanni XXIII Hospital, Bergamo, Italy
François Pons, MD Department of General and Thoracic Surgery,
French Military Health service Academy. Ecole du Val de Grace,
Paris, France
Luís Reis, MD General Surgery Coimbra Central and University Hospitals,
General Surgery “C” Department, General Hospital, Coimbra, Portugal
C. William Schwab, MD Professor of Surgery, University of Pennsylvania
Perelman School of Medicine, Philadelphia, PA, USA
Parul Shukla, MD Cornell Medical School, New York, NY, USA
Antonios Christos Sideris, MD Division of Trauma, Emergency Surgery,
and Critical Care, Massachusetts General Hospital, Harvard Medical School,
Boston, MA, USA
Marek Soltès, MD I chirurgicka klinika, Kosice, Slovak Republic
Spyridon Stergiopoulos, MD, PhD Assistant Professor, University of
Athens, Athens, Greece
Peep Talving, MD, PhD, FACS Assistant Professor of Surgery, Division
of Acute Care Surgery and Surgical Critical Care, Department of Surgery,
Keck School of Medicine, University of Southern California, Los Angeles
County + USC Medical Center, Los Angeles, CA, USA
Korhan Taviloglu, MD Taviloglu Proctology Center - Abdi Ipekci Cad,
Nişantasi, Istanbul, Turkey
Fernando Turégano-Fuentes, MD, PhD, FACS Department of Surgery,
Hospital General Universitario Gregorio Marañón, Madrid Head of General
Surgery II and Emergency Surgery, University General Hospital Gregorio
Marañón, Madrid, Spain
Selman Uranues, MD, FACS Professor and Head, Section for Surgical
Research, Clinical Division for General Surgery, Medical University of
Graz, University of Graz, Graz, Austria
Carlo Vallicelli, MD General, Emergency and Transplant
Surgery Department, St Orsola-Malpighi University Hospital,
Bologna, Italy
Pantelis Vassiliu, MD, PhD, FACS Assistant Professor at the University of
Athens, “Attikon” University Hospital, Athens, Greece
xvi Contributors

George C. Velmahos, MD, PhD, MSEd Professor of Surgery, Harvard

Medical School Chief, Division of Trauma, Emergency Surgery, and
Critical Care, Massachusetts General Hospital, Boston, MA, USA
Eric J. Voiglio, MD, PhD, FACS, FRCS Service de Chirurgie d’Urgence,
Centre Hospitalier, Lyon, France
Gregory A. Watson, MD Department of Surgery, University of Pittsburgh
School of Medicine, Pittsburgh, PA, USA
Hakan Yanar Department of Surgery, Trauma and Emergency Service,
Istanbul Medical School, Istanbul University, Istanbul, Turkey
Part I
Intraoperative Strategy: Open
Surgical Approach 1
Brandon R. Bruns, Ari Leppäniemi,
and C. William Schwab

1.1 Introduction 3 Objectives
1.2 Postoperative Management 8 • Outline the key intraoperative decisions
in non-trauma emergency surgery.
• Identify factors that favor choosing a
definitive management strategy.
• Describe conditions that favor damage
control strategy.
• Briefly outline the main damage control
strategy components and techniques.
• Describe the management principles
following damage control laparotomy.

1.1 Introduction

• The vast majority of emergent surgery, despite

the urgent nature of the problems, deals with
patients that possess normal hemodynamic
B.R. Bruns, MD parameters and normal physiology:
Assistant Professor of Surgery, University of – These patients can be approached in a
Maryland Medical Center, Philadelphia, PA, USA methodical fashion employing a thorough
e-mail: physical examination, appropriate labora-
A. Leppäniemi, MD, PhD, DMCC tory studies, radiographic studies, and
Chief of Emergency Surgery, Meilahti Hospital, additional adjuncts to establish a specific
University of Helsinki, Helsinki, Finland
e-mail: diagnosis prior to the operative procedure.
– Once obtained, the diagnosis guides deci-
C.W. Schwab, MD (*)
Professor of Surgery, University of Pennsylvania sions in relation to need for resuscitation
Perelman School of Medicine, Philadelphia, PA, USA and antibiotics, patient positioning, laparo-
e-mail: scopic versus open surgical approach, type

© Springer International Publishing Switzerland 2016 3

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_1
4 B.R. Bruns et al.

of incision, need for assistance, and post- A surgical “time out” observed before the
operative care planning. beginning of the procedure to guarantee
– Most patients in this category require a that the correct patient is receiving the cor-
single operation for resolution of their rect operation on the correct area of the
pathologic state. body and to ensure that all equipment and
• Other patients may present with signs of an necessary blood products are available.
acute abdomen with diffuse peritonitis: Anesthesiology and surgical teams should
– These patients must be approached in a agree on timely prophylactic antibiotic
more expedited fashion. Resuscitation administration, the need for urinary cathe-
must commence immediately, and the ter, and nasogastric tube insertion before
history and physical examination is starting the procedure.
sometimes abbreviated. Diagnostic stud- In the severely ill patient, the following addi-
ies may be limited secondary to the tional precautions and procedures must be
patients underlying hemodynamic insta- considered:
bility, and the diagnosis may not be 1. Optimization of physiology: volume
secured in the preoperative phase of expansion, blood component therapy, anti-
patient management. biotics and vasoactive agents as needed,
• Lastly, in a very small subset of patients, and correction of hypoxemia, anemia, and
extreme alterations in physiology and hemo- cardiac failure.
dynamic parameters exist: 2. Mandatory placement of a urinary catheter
– This patient population presents shocked for close observation of urine output (goal:
and septic. Hypotension, acidosis, hypo- 0.5 ml/kg/h).
thermia, and coagulopathy necessitate a 3. Placement of a nasogastric tube
unique intraoperative approach. Normal preoperatively.
physiology cannot be fully restored pre- 4. Central venous lines, and arterial lines.
operatively or during the operation; 5. And, although debated, in some cases, a
therefore, abbreviated operations with pulmonary artery catheter can be helpful,
control of contamination, and occasion- especially in the elderly cardiac patient.
ally hemorrhage, are used to temporize 6. Early goal-directed therapy, including
and subsequently are followed by addi- early infusion of crystalloid and blood
tional operations – “damage control products (goal: central venous pressure
surgery.” of 8–12 mm Hg, mean arterial pressure
• Irrespective of patient condition, the following above 65 mm Hg, and mixed venous
precautions are common to most procedures oxygenation at least 70 %).
envisioned in this course: 7. Early initiation of broad-spectrum antibiot-
– Patient positioning and adjunctive ics at the onset of hypotension.
procedures: 8. In certain patients with abdominal com-
Critical aspect of any operation, the goal partment syndrome in the ICU, deemed
being to avoid interruptions to reposition, unsuitable for transportation to the operat-
re-prepare the patient with antiseptic, and ing room, a bedside laparotomy in an expe-
redrape the patient multiple times. ditious fashion to decompress the ACS.
Great care must be taken in securing the – Most intraperitoneal processes are easily
patient should extreme table tilt or rotation accessed with the patient in the supine
be needed, and in applying proper padding position on the operating room table.
to pressure points and areas where nerves – Need for access to the perineum (placement
run superficially. of transrectal stapling devices, access for
1 Intraoperative Strategy: Open Surgical Approach 5

endoscopic procedures, and the ability to In laparotomy depends on judicious use of

lavage the rectum and distal sigmoid colon) self-retaining or handheld devices, as
or to the thorax should be anticipated. needed.
– Patient positioning and draping should A few examples include the Balfour™-
allow for proper retraction, easy and quick type retractor, the Bookwalter™ retractor,
extensions of incisions and timely conver- or the Omni™ retractor.
sion from laparoscopy to laparotomy, and • Presence of additional operating room
performance of stoma and insertion of personnel:
drains, as needed. – The operating surgeon may desire the
assistance of a colleague or choose to oper-
• Incision: ate with another surgeon or surgical team.
– Both open and laparoscopic approaches Useful in long, difficult operations.
are possible in many, if not most stable • Staging:
patients. – The key intraoperative decision: can the
– Trocar positions and skin incision should patient tolerate definitive control and
take into account previous incisions and complete repair of the principal disease
operations, the possibility of full explora- process causing the emergency, be it hem-
tion of the peritoneal cavity, the need for orrhage, contamination, obstruction, or
adequate and proper retraction, as well as ischemia?
ample exposure adapted to the disease and If physiological stage of the patient is sta-
procedure to be accomplished. ble (not in hypovolemic or septic shock, no
In many cases, it is helpful to begin acidosis, hypothermia, or coagulopathy),
exposure in an area away from previous and the appropriate resources (personnel,
incisions in the hopes of avoiding trou- skills, equipment, time) are available,
blesome scar and underlying visceral removal of the underlying cause and defini-
adhesions. tive repair and restoration of function can
– The very obese patient poses a unique chal- be performed.
lenge secondary to excess subcutaneous Occasionally, the patient’s physiology
adiposity and intraperitoneal mesenteric fat. changes during the conduct of the opera-
Larger patients typically require larger tion, and the successful performance of an
incisions for adequate exposure of the operation is no longer feasible:
involved organ or organs. • The surgeon and anesthetist must per-
Laparoscopy, although often more difficult form an expedited search for the etiol-
and requiring conversion, is particularly ogy of the altered physiology and in the
well suited to the obese, providing that sur- instance that normal physiology can be
geon expertise is available. quickly restored; the operation can,
• Exposure: most likely, continue; and a definitive
– Proper positioning of operating room procedure can be performed.
lights, the need for a headlamp (best • If the patient remains unstable, the opera-
secured comfortably on the head prior to tive plan should be changed and a staged
beginning the operation), and ample and operation may become necessary:
adapted retraction are pivotal to safe and – The surgeon’s mindset must not be
adequate exposure. fixed; surgeon’s ego must be set aside:
– Retraction: Detect a change and react appropri-
In laparoscopy depends essentially on grav- ately is imperative for the safety of
ity, aided by table tilt and side rotation. the patient.
6 B.R. Bruns et al.

– Staged procedures are prudent – The acute abdomen (etiology unknown):

decisions in the case of gross con- Classically, patients with peritonitis are
tamination, visceral necrosis, and taken directly to the operating room after a
infection: short period of fluid resuscitation, antibiot-
The initial operation may serve to ics and analgesia for a full abdominal
control the source of infection and exploration in an attempt to localize the
evacuate whatever contaminated causative agent and manage the pathology:
products may be present. In this • Considerable debate exists as to whether
situation, return trips to the oper- these patients should undergo laparo-
ating room will allow the surgeon scopic exploration or laparotomy:
to ensure adequate contamination – With adequate expertise, many
control and do any additional patients can be treated through the
debridement, drainage of puru- laparoscopic approach.
lence, resection of nonviable – Otherwise, these patients are best
organs, or evacuation of infected evaluated utilizing a long midline
material. incision from the xiphoid to the sym-
Tissue beds are inspected for via- physis pubis through the linea alba.
bility and if found to be compro- • Upon entry into the peritoneal cavity,
mised may be debrided to healthy any blood, succus entericus, feculent
tissue. material, or purulence is evacuated from
In some instances, the initial operation may the cavity and sent for culture analysis:
leave some uncertainty as to the exact – A full and systematic exploration of
extent of the insult: all the abdominal viscera is essential
• For examples, when operating for mes- to avoid missing pathologies:
enteric ischemia, one strategy frequently Once the pathology is recognized
employed is the “second look” at and contamination controlled.
24–48 h after the initial operation to Inspection should be routine.
assess the viability of the bowel. Small bowel from the ligament of
• Besides mesenteric ischemia, the con- Treitz to the ileocecal valve:
cept of the “second look” can be applied • Taking care to examine the entire
to any questionable organ viability circumference and its mesentery
within the abdomen, skin and soft tis- Colon from the cecum to the peri-
sue, or chest. toneal reflection of the rectum:
Transfer to another facility may be appro- • If retroperitoneal colonic
priate should expert consultation or spe- abnormality is noted, the lat-
cific postoperative care be needed, but is eral peritoneal reflections can
not immediately available. be incised and the posterior
portion of the colon examined
• The Stable Emergency Surgery Patient with medial visceral rotation.
• The stable patient usually allows adequate Foregut from the diaphragmatic
workup and often the diagnosis is known or crura to the ligament of Treitz:
highly suspected. Planned trocar or skin • Stomach:
incision placement, adapted to patient body- – Anterior stomach perfora-
build, the disease and involved organ(s) are tions can be clearly seen
straightforward. Unforeseen adhesions and with simple inspection.
disease can usually be dealt with – However, to avoid
accordingly. missed gastric perfora-
1 Intraoperative Strategy: Open Surgical Approach 7

tions, the gastrocolic lig- • However, mobilization may

ament should be divided be required:
and the stomach reflected – Liver: the hepatic liga-
superiorly. ments can be incised.
– Superior retraction of the – Spleen: the lateral attach-
stomach allows visual- ments can be easily cut.
ization of the posterior – The Acute Abdomen and Septic Shock
gastric wall up to the Patients in septic shock complicated by
esophageal entry point acidosis, coagulopathy, and hypothermia
near the fundus. mandate a different resuscitative and oper-
Pancreas: ative approach from that of the typical
• Entry into the lesser sac also patient: abbreviated operations and trans-
allows inspection of the ante- port to an intensive care unit for restoration
rior portion of the pancreas. of normal physiology prior to definitive
Duodenum: operative repair or damage control surgery,
• Can be mobilized from its ret- applied as early as possible.
roperitoneal attachments by • Intraoperative evaluation:
performing a Kocher maneu- – Preoperative history, physical exami-
ver and inspecting the poste- nation, and diagnostic adjuncts may
rior surface be minimal.
Gallbladder: easily inspected in – Intraoperative decisions are guided
the liver bed by vigilant monitoring of the patient’s
Genitourinary system: physiologic status.
• Incise lateral attachments – Patient physiology guides the extent
of either the right or left colon of the operation:
to rotate the colon medially: Operating times should be
– Reveals Gerota’s fascia, minimized.
which can be incised, thus Abbreviated procedures performed.
facilitating an anterior view If physiology allows, definitive operation
of the kidney. can be performed:
– The ureter is easily identi- • However, this can be safely delayed to a
fied as it crosses the iliac second look laparotomy after physiol-
bifurcation into the internal ogy is restored. In the face of hemody-
and external branches. namic instability, a planned return to the
– Can be examined as neces- operating room in 24–48 h for definitive
sary by carefully incising operation and second look is the most
the retroperitoneal tissue prudent and safest for the patient:
overlying or adjacent to it: – Control of bleeding:
Great care should be taken Packing of raw, bleeding surfaces or
in the inflamed retroperito- solid organs.
neum to avoid injury to the Ligation of visible bleeding vessels
ureters. (unless end arteries).
Finally, the solid organs of the Balloon tamponade techniques for
abdomen: inaccessible bleeding sites.
• Most instances allow Flow in an occluded end artery can be
inspection of the organs in restored with a temporary vascular
their native beds. shunt.
8 B.R. Bruns et al.

– Hollow organ obstruction: uum devices that are available

Proximal diversion using tubes or either commercially or fash-
ostomies ioned in the operating room
– Control of infection: Additionally, skin and soft tissue infections
The source of contamination (infec- may require repeat trips to the operating
tion or necrosis) must be efficiency room for debridement and inspection of
removed, either with drainage, resec- areas of questionable viability.
tion, diversion, or closure of
• Holes can be stapled or sutured.
• In destructive injuries requiring 1.2 Postoperative Management
resection, the ends can simply be
tied off without attempting anas-
tomosis or diversion at the first • The stable patient can return to the ward if
operation. post-inventional surveillance is satisfactory.
• When resection is inappropriate • The unstable patient requires appropriate
(common bile duct, duodenum), postoperative monitoring in an intensive care
controlling contamination with unit setting:
diverting tubes inserted into the – Invasive hemodynamic monitoring
hollow organ and external drain- – Early detection of complications of care
age might be the only options – Restoration of normal physiology:
available. Restoration of body temperature (rewarm-
Copious irrigation of the abdo- ing with warmed intravenous fluids,
men with warmed crystalloid increased ambient temperature of the room
solution then helps remove par- and warming blanket)
ticulate matter and dilute bacteria Correction of coagulopathy (aside from
and debris. restoring body temperature back to
– Fashion a temporary abdominal normal): infusion of crystalloid, blood,
dressing: plasma, and cryoprecipitate as directed by
Temporary abdominal closure: laboratory parameters and signs of overt
• Slows excessive heat and fluid bleeding
loss and aids in the restoration Correction of acidosis: infusion of volume
of normal physiology and correction of body temperature
• Can be attained using dispos-
able plastic sheeting and vac-
1 Intraoperative Strategy: Open Surgical Approach 9

Hemodynamically Hemodynamically
Diagnosis Normal Unstable
Appendicitis Laparoscopic/open appendectomy Open appendectomy versus
drainage and antibiotics
Cholecystitis Laparoscopic/open cholecystectomy Cholecystostomy tube
versus antibiotics
Diverticular disease Resection, +/− ostomy or primary anastomosis +/− resection, drainage of phlegmon
Abdominal wall hernia Reduction and repair Reduction, +/− resection,
+/− second look
Ischemic bowel Resection and primary anastomosis Resection, +/− second look
Perforated viscus Repair, +/− resection Resection, +/− second look
Obstruction, adhesive Adhesiolysis Adhesiolysis,
+/− second look
Obstruction, hernia Reduction, +/− resection Reduction, +/− resection,
+/− second look
Obstruction, malignant Resection, +/− anastomosis, +/− ostomy +/− resection, fecal diversion,
+/− second look
Skin and soft tissue infection Drainage or debridement Drainage or debridement,
+/− second look
Leading Symptoms and Signs
Fernando Turégano-Fuentes

Contents 2.7 Leading Symptoms and Signs in the

Postoperative Abdomen 18
2.1 Generalities 11
2.8 Summary 19
2.2 Acute Generalized Abdominal Pain
with Tenderness 12 Selected Reading 20
2.2.1 Perforated Appendicitis 12
2.2.2 Colonic Perforation 12
2.2.3 Perforated Gastroduodenal Ulcer 12
2.3 Localized Abdominal Pain with • Categorize different abdominal clinical
Tenderness (Epigastric, Umbilical,
RUQ, LUQ, Hypogastric, RLQ, and conditions in relation to the characteris-
LLQ) 13 tics of the pain and the presence or
2.3.1 Periumbilical and Epigastric Pain 13 absence of tenderness
2.3.2 RUQ Pain 13 • Describe other symptoms and signs
2.3.3 LUQ Pain 14
2.3.4 Pain in the Hypogastrium 14 leading to acute surgical intervention
2.3.5 RLQ Pain 14 • Describe the specifics of clinical diag-
2.3.6 LLQ Pain 15 nosis in the postoperative abdomen
2.4 Acute Abdominal Pain Without
Tenderness 16
2.4.1 Acute Mesenteric Ischemia 16
2.4.2 Pain Radiating to the Back 16 2.1 Generalities
2.4.3 Other 17
2.5 Nonspecific Abdominal Pain (NSAP) 17 • Acute abdominal pain accounts for up to 50 %
2.6 Painful Abdominal Wall Swelling: of emergency surgery consultations.
Incarcerated and Strangulated Hernia • All abdominal crises present with one or more
and Other Conditions 17 of five main symptoms or signs:
– Pain (often alone and inaugural)
– Vomiting
– Abdominal distension
F. Turégano-Fuentes, MD, PhD, FACS – Muscular rigidity
Department of Surgery, Hospital General – Shock
Universitario Gregorio Marañón, Madrid Head of • The severity and the order of occurrence of the
General Surgery II and Emergency Surgery,
symptoms are important for diagnosis,
University General Hospital Gregorio Marañón,
Madrid, Spain together with the presence or absence of fever,
e-mail: diarrhea, constipation, and others.
© Springer International Publishing Switzerland 2016 11
A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_2
12 F. Turégano-Fuentes

• The presence of tenderness on palpation is a somatic, localized pain, with rapid generaliza-
hallmark of potential acute abdominal problem tion and diffuse tenderness
of surgical importance, and it generally implies – Sometimes inaugural
inflammation of the visceral peritoneum. – Otherwise after a slow but rapid, progression
– May be accompanied or not by muscular
rigidity (defense guarding or guarding).
– Several grades (maximum: boardlike rigid- 2.2.2 Colonic Perforation
ity typical of perforated ulcer).
– Usually implies inflammation of the pari- • The most common causes:
etal peritoneum. – Colonic malignancy
• Sometimes, it takes a great deal of clinical The tumor (usually rectosigmoid)
acuity and experience to differentiate – Distension upstream from malignant
between voluntary and involuntary guard- obstruction (usually cecum)
ing. In the past (pre-CT-scan era), errors • Often after several days of unrelieved com-
with this distinction have led to numerous plete obstruction in a patient with a compe-
unnecessary abdominal explorations. tent ileocecal valve. Presenting symptoms
• Clinical expertise should not be replaced by include tenderness of the abdomen on
easy availability of ultrasound (US) and CT the right side (sign of impending perfora-
scan; the latter is complementary and may tion) and history of previous abdominal
sometimes be lacking. distention associated with recent onset of
constipation and lack of flatus.
• Peritoneal irritation and tenderness are
2.2 Acute Generalized usually diffuse.
Abdominal Pain – Acute sigmoid diverticulitis. Peritonitis is
with Tenderness diffuse in large, non contained perforations,
with free intraperitoneal gas on abdominal
• Generalized peritonitis consists of: X-ray or CT.
– Diffuse severe abdominal pain
– Patient:
Who looks sick and toxic 2.2.3 Perforated Gastroduodenal
Typically lies motionless Ulcer
Has a tender abdomen with “peritoneal
signs” (rebound tenderness, defense guard- • Incidence has decreased drastically, with some
ing, or boardlike rigidity) exceptions in socioeconomically disadvan-
• The three most common causes of generalized taged populations worldwide.
peritonitis in adults are: – In the Western world, perforated duodenal
– Perforated appendicitis ulcers (DUs) are much more common than
– Colonic perforation perforated gastric ulcers (GUs), presenting
– Perforated duodenal ulcer at times without a previous history of pep-
• An occasional patient with acute pancreatitis tic ulcer disease.
may present with a clinical picture mimicking • Signs and symptoms vary according to the
diffuse peritonitis. time which has elapsed since perforation
– Classically:
Abdominal pain
• Intense.
2.2.1 Perforated Appendicitis • Of sudden onset.
• Located in upper abdomen.
• Typical history: midabdominal visceral dis- • Accompanied most often by signs of dif-
comfort, shifting to the RLQ and becoming a fuse peritoneal irritation and tenderness.
2 Leading Symptoms and Signs 13

• May mimic acute appendicitis if spill- derness, pointing more definitely to the
age of gastroduodenal contents along nature of the lesion) may then be found
the right gutter.
• May be associated with pain on the top
of the shoulder (Kehr’s sign). 2.3.1 Periumbilical and Epigastric
• The finding of “coffee ground” or fresh Pain
blood in the NG tube suggests the pos-
sibility of kissing ulcers – the anterior • Uncommon in the absence of incarcerated
perforated, the posterior bleeding. umbilical hernia and omphalitis
– Patients: • May be due to:
• Restless – Simple intestinal or biliary colic
• In great pain – Initial stage of small bowel obstruction
• Have boardlike abdomen – Acute pancreatitis
– Investigations: – Or even initial stages of acute cholecystitis
• Free gas under the diaphragm in about
two-thirds of perforated patients, best
seen on an upright chest X-ray 2.3.2 RUQ Pain
– Differential diagnosis
Acute pancreatitis • If the chest is clear (no right basal pneumonia):
• In the absence of free air, marginal • Calculous acute cholecystitis (AC)
elevation of amylase (perforated – The most common cause.
ulcer can cause hyperamylasemia). – RUQ pain and tenderness (Murphy’s
• Abdominal CT scan is excellent at sign) are accompanied by systemic evi-
picking up minute amounts of free dence of inflammation (fever, leukocyto-
intraperitoneal gas and free peri- sis) and usually by a mild or moderate
toneal fluid. elevation of bilirubin or liver enzymes,
Acute perforative appendicitis sometimes also mild elevation of the
Ruptured ectopic gestation serum amylase.
Acute intestinal obstruction – Diagnosis is usually confirmed with US.
– Diffuse peritonitis from other causes – Intramural gas, and gas within the gallblad-
(perforated gallbladder with bile peri- der lumen (acute emphysematous chole-
tonitis among other more rare causes) cystitis), typical of AC in diabetic patients
can also be seen on abdominal X-ray.
• Acute Cholangitis
2.3 Localized Abdominal Pain – Characterized by Charcot’s triad (RUQ
with Tenderness (Epigastric, pain, fever, and jaundice).
Umbilical, RUQ, LUQ, – Disproportionate pain may be due to coex-
Hypogastric, RLQ, and LLQ) isting AC.
– Can progress to include confusion and sep-
• Pain and tenderness are not always over the tic shock (Reynold’s pentad) in the elderly
site of disease. patient, or when medical intervention is
– Initial pain of appendicitis may be epigas- delayed.
tric or umbilical. – Typical biochemical panel shows mildly
– Obstructive pain arising from the trans- elevated transaminases, variably elevated
verse colon may be hypogastric. total bilirubin with a direct preponderance,
– Golden rule: examine the patient again and a disproportionately elevated alkaline
within 2 or 3 h. phosphatase and glutamyl transferase.
– In nearly every serious case, other symp- – Diagnosis usually confirmed by US, which,
toms (such as vomiting, fever, or local ten- besides gallstones in the gallbladder, usu-
14 F. Turégano-Fuentes

ally demonstrates mild intra- and extrahe- • Carcinoma or Stricture of the Splenic Flexure
patic ductal dilatation. – May rarely cause severe localized pain.
– If no gallstones are seen, malignant peri- – Constipation is common.
ampullary biliary obstruction must be • Left Perinephric Abscess
suspected. – Rare, pain may be lumbar
• Pyogenic liver abscess, amoebic liver abscess • Spontaneous splenic rupture of a normal
(in tropical climates), and hydatid disease spleen is very rare.
(endemic regions) may give rise to similar – Splenic infarcts, common in sickle-cell cri-
signs and symptoms. ses, may cause pain aggravated by breathing.
• Acute Acalculous Cholecystitis • Rupture of an Inflamed Jejunal Diverticulum
– Manifestation of the disturbed microcircu- – Rarer cause among others
lation in critically ill patients.
– Fever, jaundice, leukocytosis, and dis-
turbed liver function tests are commonly 2.3.4 Pain in the Hypogastrium
present but are entirely nonspecific.
– Pain may be minimal or difficult to discern • Associated with rigidity
because of patient status. – In a young or middle-aged man is usually
– Early diagnosis requires a high degree of due to appendicitis
suspicion in patient with otherwise unex- – In an older man acute diverticulitis or,
plained septic state or SIRS. infrequently, a rectosigmoid cancer with
localized perforation
– In a young woman, appendicitis or gyneco-
2.3.3 LUQ Pain logical condition
• Acute Urinary Bladder Retention
• Rare – Should always be considered in an elderly
• LUQ contains tail of the pancreas, fundus of patient with a history of advanced prosta-
the stomach, spleen and its blood vessels, tism, and a tumor-mass effect will be felt
splenic flexure of the colon, and upper pole of on palpation.
the left kidney, each of which may on occa- – In the pre-US and CT-scan era, this condi-
sion cause acute abdominal symptoms. tion has been known to lead to an occasional
• Acute Pancreatitis misdiagnosis and abdominal exploration.
– One of the most common causes of pain in
the LUQ.
– Vomiting and retching are frequent. 2.3.5 RLQ Pain
• Perforation (uncommon) of fundic gastric
ulcer localized by adhesions • Acute appendicitis (AA)
– Free air is rarely seen. – Is the most common cause
– Often discovered intraoperatively. – Initial pain is epigastric or periumbilical;
• Leakage or Rupture of an Aneurysm of the the localization in the RLQ usually takes
Splenic Artery (Uncommon) place some hours afterward.
– Tends to have a predilection for the preg- – Associated signs and symptoms:
nant patient Anorexia is very frequent.
– Pain – Diarrhea, especially in children, is occa-
Is usually isolate unless rupture with severe sionally misleading (can be caused by a
intraperitoneal hemorrhage occurs pelvic appendix irritating the rectum by
May be intense when the aneurysm rup- contiguity, or irritation by a pelvic abscess).
tures into the lesser peritoneal sac – Fever and leukocytosis may be mildly
May closely simulate pain of peptic ulcer above normal, almost never precede the
perforation or acute pancreatitis onset of pain.
2 Leading Symptoms and Signs 15

Moderate tachycardia is common. Crohn’s disease (inflamed iliac AA) (dis-

– Abdominal examination tinguished by the almost invariable history
Palpation: McBurney’s point of tenderness of previous attacks, together with bouts of
corresponds roughly to the position of the diarrhea)
base of the appendix, just below a line join- • Nevertheless, AA caused by Crohn’s
ing the anterior superior iliac spine and the disease may be the initial manifestation
umbilicus. of that chronic process.
Tenderness elicited by light percussion is a Yersinia ileitis should also come into
remarkably reliable indication of parietal consideration.
peritoneal irritation. Acute gastritis or gastroenteritis (where
No local muscular rigidity in a case of appen- pain and diarrhea somewhat dominates the
dicitis without any peritonitis is common. clinical picture).
Rigidity of the psoas should be tested for Acute salpingitis is one of the most diffi-
by extending the right thigh with the patient cult conditions to distinguish from AA.
on his or her left side. Salpingitic pain is frequently felt on both
Pressure over the LLQ will sometimes sides from the onset, and the presence
cause pain in the appendicular region of vaginal discharge should aid in the
(Rovsing’s sign). diagnosis.
Occasionally, palpation of a mass over the Twisted ovarian cyst or hydrosalpinx or
RLQ, together with a clinical picture con- ruptured follicular cyst (Mittelschmerz or
sistent with appendicitis of several-days pain at mid-cycle), ruptured corpus luteum
duration, should prompt the diagnosis of an cyst (pain with the menses), ruptured pyo-
appendiceal phlegmon. salpinx, and ruptured ovarian endometri-
– Anatomic variations oma can be misdiagnosed as AA on clinical
– When an appendix situated in the true pel- grounds; imaging is essential.
vis ruptures, the pain will more frequently Influenza, although backache, headache,
be felt in both RLQ and LLQ; there is usu- and pain in the eyeballs are more likely
ally no rigidity of the lower abdominal to be felt in influenza, and vomiting may
muscles, even when a pelvic abscess has precede the abdominal pain.
formed, and clinical diagnosis is fre- Acute porphyria, but pain does not usually
quently overlooked. Usually, a tender localize in the RLQ.
swelling can be felt on rectal exam. This An acute crisis of diabetic ketosis.
location, with the pelvic appendix lying Meckel’s diverticulitis is infrequent.
against the rectum, frequently causes diar- Cecal ulcers are rare.
rhea, leading to misdiagnosis of
Small bowel ileus can obscure the diagno- 2.3.6 LLQ Pain
sis of perforated iliac appendix lying
behind the end of the ileum. • Acute diverticulitis (AD) of the sigmoid colon
Ascending (retrocecal or paracecal) is the most frequent cause.
inflamed AA may mimic acute cholecysti- – Signs and symptoms:
tis, and a variety of acute right kidney or Sometimes rigidity of the overlying mus-
ureteric conditions (renal colic, pyelitis, cular abdominal wall.
acute hydronephrosis, pyonephrosis, or Fever is often moderate.
perinephric abscess) Increased C-reactive protein and leukocy-
– Differential diagnosis tosis with left shift.
– Acute cholecystitis, renal colic, pyelitis, Vomiting is rare.
acute hydronephrosis, pyonephrosis, or Previous attacks of diverticulitis are often
perinephric abscess (see above) reported but may occur many years apart.
16 F. Turégano-Fuentes

Colonic obstruction may occur (usually Nonocclusive Mesenteric

after repeated acute attacks of diverticulitis Ischemia
with development of extreme narrowing
and thickening of the inflamed sigmoid). • Due to a low-flow state, in the absence of doc-
• Inflammation around cancer of the sigmoid umented arterial thrombosis or embolus
colon: associated tenderness – Often due to a combination of low cardiac
output, reduced mesenteric flow, or mesen-
teric vasoconstriction, in the setting of a
2.4 Acute Abdominal Pain preexisting critical illness
Without Tenderness – May involve the entire small intestine and
colon, often in a patchy distribution
2.4.1 Acute Mesenteric Ischemia • Clinical picture may be indistinguishable
from that of organic occlusion of the mesen- Mesenteric Arterial Thrombosis teric vessels. Any patient who takes digitalis
or Embolism and diuretics and who complains of abdomi-
nal pain must be considered to have nonoc-
• Clinical examination is remarkably nonspe- clusive ischemia until proved otherwise.
cific (in early mesenteric ischemia). – Chronic renal insufficiency patients on
• Signs and symptoms: hemodialysis are prone to this condition.
– Severe abdominal pain, with very little
findings on physical examination. Mesenteric Venous Thrombosis
– Previous abdominal angina will be consis-
tent with arterial thrombosis (mild central • Much less common
cramping abdominal pain is frequent). – Occurs in patients with underlying hyper-
– Presence of an arrhythmia such as atrial coagulable state or sluggish portal flow due
fibrillation points to embolism. Any patient to hepatic cirrhosis.
with an arrhythmia such as auricular fibrilla- – Use of contraceptive pills has been impli-
tion who complains of severe abdominal pain cated as a pathogenetic factor.
of sudden onset should be highly suspected of – Has also been described after splenectomy.
having embolization to the superior mesen- • Clinical presentation is nonspecific: abdominal
teric artery (SMA) until proved otherwise. pain and varying gastrointestinal symptoms may
• Most patients present late after the onset of last a few days until eventually the intestines are
symptoms (once intestinal gangrene has set in). compromised, and peritoneal signs develop.
– Associated signs and symptoms:
Abdominal distension Differential Diagnosis
Generalized tenderness
– Signs of intestinal hypoperfusion (frequent • Acute diaphragmatic myocardial infarction
bowel movements are common and usually very often manifests as acute epigastric pain
contain either grossly or microscopically without tenderness.
detectable blood)
• Plain abdominal X-rays are obsolete.
– Used to be normal in the early course of the 2.4.2 Pain Radiating to the Back
– Later, used to show adynamic ileus, with vis- Dissecting Aneurysm
ible loops of small bowel and fluid levels of the Aorta
• Laboratory studies:
– Usually normal until the bowel loses via- • Pain is unbearable.
bility, when leukocytosis, hyperamylase- – On questioning, the pain is found to start in
mia, and lactic acidosis develop the thorax, radiating through the back, extend-
2 Leading Symptoms and Signs 17

ing down to the abdomen and, initially, with- – No immediate cause can be found during
out any tenderness or rigidity on palpation. the acute admission.
– Significant arterial hypertension of pro- – Specifically does not require surgical
longed duration is usually a forerunner, and intervention.
there will almost certainly be serious differ- • Presenting symptom of a large number of
ences between an upper- and a lower-limb minor and self-limiting conditions
pulse according to the position of the lesion. – Constitutes a diagnosis by exclusion.
– Clinical misdiagnosis with a renal colic has – Up to 10 % of patients with NSAP over the
not been uncommon in the pre-CT-scan age of 50 years have subsequently been found
era, with dire consequences for the patient. to have an intra-abdominal malignancy.
– Association between NSAP and irritable bowel Leakage or Rupture syndrome or celiac disease has been described.
of an Abdominal Aneurysm • Women account for about 75 % of admissions
with NSAP.
• Is by far the more common cause of abdomi- • Compared with active clinical observation,
nal pain radiating to the back early laparoscopy has not shown a clear ben-
– Any patient with a known aneurysm and efit in women with NSAP.
recent abdominal pain should be regarded
as being in imminent danger of rupture.
– When present, the pain prior to rupture is of
a throbbing (pulsatile) or aching nature, and 2.6 Painful Abdominal Wall
it is located in the epigastrium or the back. Swelling: Incarcerated
– Pain becomes steady when rupture has and Strangulated Hernia
occurred. and Other Conditions
– Collapse in a patient with a known aneu-
rysm almost always indicates rupture. • Incarcerated hernia
• Abdominal and flank examination usually – One of the commonest forms of intestinal
reveals a mass which may occupy almost any obstruction
part of the abdomen. • Strangulated hernia
– Usually represents the extravasated hema- – Symptoms: those of intestinal obstruction,
toma, and the left flank is the most com- with the addition of a painful, tender, and often
mon site. tense swelling in one of the hernia regions.
– In certain cases there may be little local
2.4.3 Other – When omentum alone is strangulated or if
a Richter’s hernia is present, there will be
• Biliary colic pain, constipation, nausea, and sometimes
– Pain as well as epigastric and RUQ symp- vomiting, but the obstruction of the gut is
toms are self-limited, disappearing within a never complete.
few hours. – Diagnosis is usually easy as the patient will
– No local tenderness. have usually been aware of the existence of
– No systemic evidence of inflammation. the hernia for some time.
– Torsion or inflammation of an undescended
inguinal testis will be ruled out by the
2.5 Nonspecific Abdominal Pain absence of the testicle from the scrotum on
(NSAP) the affected side.
Strangulated femoral hernia gives rise to
• Defined as: more mistakes in diagnosis than a strangu-
– Pain lasting a maximum of 7 days. lated inguinal hernia.
18 F. Turégano-Fuentes

• Sometimes only a small knuckle of gut – Abdominal pain, vomiting, constipation,

comprising a small portion of the circumfer- and local tenderness indicate the need for
ence of the bowel may be caught in the fem- operation.
oral canal (Richter’s hernia), and scarcely • Obturator Hernia
any projection may be felt in the thigh. – Uncommon.
• Some of these patients, usually elderly – Most frequently found in wasted, elderly
ladies, will be worked-up with a presumed women.
diagnosis of intestinal pseudoobstruction, – Symptoms of obstruction of unknown
and only a CT scan can provide an accurate cause predominate.
preoperative diagnosis. Inflamed and – The only local symptom may be some pain
enlarged inguinal glands produce a more radiating down the inner side of the thigh
diffuse and fixed swelling, and fever is not along the distribution of the obturator nerve.
uncommon. Usually vomiting is absent. – If the diagnosis is suspected on clinical
Ultrasound may be helpful but, ultimately, grounds, something very unusual, rotation of
only surgical intervention will differentiate the thigh (Romberg’s sign) will elicit pain.
between both conditions in some patients. – Rectal examination may reveal a tender,
• The swelling of a strangulated inguinal her- palpable mass in the region of the obturator
nia comes out of the abdomen medially to the canal.
pubic spine and above the inguinal ligament, • Of note, uncomplicated inguinal or incisional
while strangulated femoral hernia is below. hernia may be locally painful when the patient
• An inflamed appendix in a femoral hernia has peritonitis of any other origin.
sac (Littre’s hernia) cannot be distin- • Rectus Sheath Hematoma
guished definitely from a strangulated fem- – Usually manifests itself as a painful
oral hernia before operation. abdominal swelling of moderate size and
• Differentiation between incarceration and imprecise limits.
strangulation: – Can be confused with other acute abdomi-
– Often difficult to make certain whether a nal conditions of surgical importance.
hernia is merely incarcerated or whether it – Diagnosis is more straightforward if skin
is strangulated (with advanced ischemia or discoloration is already present, together
necrosis of its content), for pain and consti- with the typical history of bouts of coughing
pation are usually present in both cases. in a patient on anticoagulation medication.
– With simple incarceration of short dura-
tion, pain tends to be milder than with
strangulation. 2.7 Leading Symptoms and
• Umbilical or Paraumbilical Hernia Signs in the Postoperative
– More common in women and the obese Abdomen
– Usually contains omentum and sometimes
large and small bowel • Uncomplicated Postoperative Abdomen
– Can be overlooked if small and deeply – Pain
embedded in fat, but a local tenderness on Usually present no longer than first 12–24 h
pressure can always be felt – Gradually diminishes during the next sev-
– Often difficult to say before opening the eral days
sac whether one is dealing with simple – Ileus
incarceration or strangulation Frequent watery stools are not uncommon
– Particularly frequent in cirrhotic with ascites at the completion of a long ileus, but may
• Ventral or Incisional Hernia also mean antibiotic-induced colitis.
– Small bowel is more commonly found in Beware that the passage of stool and gas
the sac, as compared to umbilical hernias. (and also resumption of an oral diet) is not
2 Leading Symptoms and Signs 19

always a guarantee that all is well within • Any unexplained signs or symptoms (oli-
the peritoneal cavity. guria and tachycardia, in the absence of
In patients who are operated on for perito- fever, or tachypnea, in the absence of
nitis, a persistent abdominal distention is atelectasis or pneumonia) should raise
common, and so is severe heartburn result- the suspicion of anastomotic disruption.
ing from the increased intra-abdominal • Superimposition of the recent abdomi-
pressure which overcomes the resistance of nal incision, postoperative narcotics,
a normal lower esophageal sphincter. and the common use of epidural analge-
– Fever sia all add to the difficulty of assessing
Axillary temperature higher than 37 °C is the changes in symptoms and findings
common on the first postoperative night in the postoperative abdomen.
and gradually decreases thereafter. – Radiological signs are often indirect.
No work-up is indicated for fever in the Pleural effusion
first 2–3 days, in an otherwise uncompli- Ileus
cated postoperative course. • Early diagnosis and treatment are essential.
Persistence or increase in body temperature – The key to an early diagnosis of a serious
(taken at the same time each day) after the abdominal complication that warrants an
first 2–3 days often portends the presence of early reoperation is a frequent daily
an abscess in the wound or within the abdo- assessment.
men, if other common causes have been – And for certain authors, early laparoscopic
ruled out (postoperative atelectasis or pneu- exploration, even when the initial operation
monia, UTIs, or phlebitis). was via laparotomy.
Conversely, the absence of fever in a postop- – Management
erative abdominal complication is not unusual, – Interventional radiology (percutaneous
since fever can be masked by antibiotics. drainage)
• Complicated Postoperative Abdomen Endoscopy (stents, clips, sponges)
– Pain Exploratory laparotomy or laparoscopy
Is frequent, and any new pain should be
regarded with suspicion
– Ileus Pitfalls
Delayed or adynamic ileus is probably • Disregarding the value of a detailed his-
episodes of incomplete small bowel tory in the diagnosis of most conditions
obstruction. • Overusing or underusing modern imag-
If accompanied by fever, deep organ-space ing techniques in the emergency ward
surgical site infection should be ruled out. • Not taking into consideration the diverse
– Tenderness and rigidity anatomic positions of an inflamed
Usually present appendix
May be so mild as to be misleading • Not having a high index of suspicion in
May be masked by other symptoms intestinal ischemia
– Fever • Not taking into account the differences
May be heralded by a rigor pertaining to elderly patients
– May be the only sign of deep organ-space
surgical site infection (without pain or
– Peritonitis 2.8 Summary
Almost always caused by an anastomotic
disruption. Acute abdominal pain accounts for up to 50 % of
However, signs and symptoms can be subtle. emergency surgery consultations. The presence
20 F. Turégano-Fuentes

of tenderness on palpation is a hallmark of sons for delay in treatment – a prospective study. Ann
R Coll Surg Engl. 2007;89(1):47–50.
potential acute surgical abdominal problem(s).
Fouda E, El Nakeeb A, Magdy A, et al. Early detection of
Surgeons must maintain the ability to diagnose anastomotic leakage after elective low anterior resec-
acute abdominal conditions on clinical grounds tion. J Gastrointest Surg. 2011;15:137–44.
in the emergency ward. Modern abdominal imag- Fukuda N, Wada J, Niki M, Sugiyama Y, Mushiake
H. Factors predicting mortality in emergency abdomi-
ing has revolutionized emergency abdominal sur-
nal surgery in the elderly. World J Emerg Surg.
gery, especially when the diagnosis is not clearly 2012;7:12.
evident. Makela JT, Kiviniemi H, Laitinen S. Risk factors for anas-
tomotic leakage after left-sided colorectal resection
with rectal anastomosis. Dis Colon Rectum.
Morino M, Pellegrino L, Castagna E, et al. Acute nonspe-
Selected Reading cific abdominal pain. A randomized, controlled trial
comparing early laparoscopy versus clinical observa-
Akiyoshi T, Ueno M, Fukunaga Y, et al. Incidence of and tion. Ann Surg. 2006;244:881–8.
risk factors for anastomotic leakage after laparoscopic Nyhus LM, Vitello JM, Condon RE, editors. Abdominal
anterior resection with intracorporeal rectal transec- pain: a guide to rapid diagnosis. Norwalk, Conn.:
tion and double-stapling technique anastomosis for Appleton & Lange; 1995.
rectal cancer. Am J Surg. 2011;202:259–64. Schein M, Rogers PN, Assalia A, editors. Schein’s com-
Arezzo A, Verra M, Reddavid R, Cravero F, Bonino MA, mon sense emergency abdominal surgery. 3rd ed.
Morino M. Efficacy of the over-the-scope clip (OTSC) New York: Springer-Verlag Berlin Heidelberg (as
for treatment of colorectal postsurgical leaks and fis- stated in the book); 2010.
tula. Surg Endosc. 2012;26:3330–3. Truong S, Bohm G, Klinge U, Stumpf M, Schumpelick
Assar AN, Zarins CK. Ruptured abdominal aortic aneu- V. Results after endoscopic treatment of postoperative
rysm: a surgical emergency with many clinical presen- upper gastrointestinal fistulas and leaks using com-
tations. Postgrad Med J. 2009;85:268–73. bined Vicryl plug and fibrin glue. Surg Endosc.
Cope Z (Revised by W Silen). Early diagnosis of the acute 2004;18:1105–8.
abdomen. 22nd ed. Oxford University Press; New van Koperen PJ, van Berge Henegouwen MI, Rosman C,
York. 2010. et al. The Dutch multicenter experience of the endo-
Davies M, Davies C, Morris-Stiff G, Shute K. Emergency sponge treatment for anastomotic leakage after
presentation of abdominal hernias: outcome and rea- colorectal surgery. Surg Endosc. 2009;23:1379–83.
Management Options:
Nonoperative Versus Operative 3

Fernando Turégano-Fuentes
and Andrés García Marín

3.1 Acute Appendicitis 22 Objectives
3.2 Acute Cholecystitis 22 • To review the indications for nonopera-
3.3 Gastrointestinal Perforations 22
tive management of the more common
“surgical” emergencies.
3.4 Intestinal Obstruction 24
• To define the role of interventional radi-
3.4.1 Small Bowel Obstruction 24
3.4.2 Large Bowel Obstruction 25 ology and endoscopic techniques as
alternatives to surgical management.
3.5 Gastrointestinal Bleeding 25
• To describe some less frequently
3.6 Acute Diverticulitis 27 encountered conditions and the specifics
3.7 Severe Acute Pancreatitis 27 involved in their management.
3.8 Miscellaneous Conditions 27
3.9 Summary 29
Bibliography 29
The decision to operate or observe a patient is at
times one of the more challenging decisions the
acute care surgeon must make. To help us make
that decision in the best interest of our patient, we
have to consider our personal experience and
clinical judgment, the natural history of the
underlying disease, and its different clinical
presentations, patient comorbidity and his/her
F. Turégano-Fuentes, MD, PhD, FACS (*)
surgical risk, the availability of interventional
Department of Surgery,
Hospital General Universitario Gregorio Marañón, radiology or endoscopic procedures, and the
Madrid Head of General Surgery II and Emergency information provided by imaging.
Surgery, University General Hospital Gregorio In practice, comorbidities and a high-surgi-
Marañón, Madrid, Spain
cal/anesthetic risk are probably the most impor-
tant factor to consider in nonoperative
A. García Marín, MD
management (NOM) for a specific patient. The
Department of Surgery, University Hospital,
San Juan de Alicante, Alicante, Spain anesthetic risk should be evaluated in collabora-
e-mail: tion with the anesthetist involved, using the ASA

© Springer International Publishing Switzerland 2016 21

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_3
22 F. Turégano-Fuentes and A.G. Marín

classification system, the APACHE II (Acute Rationale: avoids the risk of right hemico-
Physiological and Chronic Health Evaluation II), lectomy for a benign condition.
or p-POSSUM, according to individual practice CT scan is indicated to:
and preferences. • Rule out an abscess within the phleg-
In this chapter, we will review the indications mon, in which case percutaneous drain-
for NOM of the more frequent “surgical” age is indicated
emergencies encountered in clinical practice, • Detect complicated AA surrounded by
acknowledging that some of the assertions and an inflammatory phlegmon (no clinical
recommendations contained are also mentioned mass palpated on the RLQ), for which
in other chapters of this manual. By NOM or surgery is indicated.
conservative approach, we refer to a nonsurgical • NOM is not indicated in the pregnant woman
therapy, even though some interventional radio- because of increased morbidity and fetal loss.
logic or endoscopic procedure might be used
at times.
3.2 Acute Cholecystitis

3.1 Acute Appendicitis • NOM can be considered in high-risk patients,

irrespective of the grade of the Tokyo
• Despite the fact that early appendectomy has Guidelines.
been advocated as the gold standard of ther- – Clinical improvement can be expected in
apy to avoid perforation, recent evidence has 87 % patients.
shown that acute appendicitis (AA) can be – Predictors of failure include age >70 years,
successfully treated nonoperatively. history of diabetes, and persistent leukocyto-
– Several studies, including five randomized sis >15,000/mm3 at 48 h. These patients or
trials, have suggested that antibiotic treat- those who fail to respond rapidly (within
ment should be the first line of treatment 48–72 h) to medical management should
for uncomplicated AA and at times can undergo percutaneous drainage or operation.
cure AA. • AC that develops during the first or third tri-
– The results from two meta-analyses mester of pregnancy is best treated
showed that NOM for uncomplicated or conservatively with antibiotics, with delayed
complicated AA was associated with cholecystectomy either during the second tri-
reduced risk of complications and had a mester or the postpartum period, respectively.
similar duration of hospital stay compared
with appendectomy.
• The duration of antibiotic treatment has not 3.3 Gastrointestinal Perforations
been consensual;
– The failure rate (reported to be between 10 • Gastroduodenal
and 38 %) can be reduced to 3 % with a – NOM in the healthy patient with an early
longer antibiotic regimen (specifically healed perforation and no signs of
9–14 days). peritonitis.
– The necessity of an interval appendectomy Should be successful in most cases.
after successful NOM is controversial but Contrast CT should document sealing of
is usually advocated for patients with an the perforation.
appendicolith or an abscess on initial CT – NOM in the extremely high-surgical risk
scan. patient presenting with peritoneal signs
• NOM should be the first-line treatment Treatment consists of NPO, NG tube, anti-
– When appendiceal phlegmon is suspected biotics, thromboembolic prophylaxis, and
(clinical diagnosis) acid-reducing medication.
3 Management Options: Nonoperative Versus Operative Management 23

Development of abscesses can be drained – Perforations following diagnostic colonos-

percutaneously. copy often result in sizable rents in the
Low threshold for surgical intervention if colonic wall and thus require prompt surgi-
clinical deterioration occurs, especially in cal treatment.
patients age 70 or greater. • Postoperative anastomotic leaks
• Leakage after percutaneous endoscopic gas- – NOM is possible and the most reasonable
trostomy (PEG) course of action in many anastomotic leaks,
– Diagnosis: contrast study through the provided that there are no signs of general-
PEG tube (to eliminate intraperitoneal ized peritonitis or sepsis.
spillage). Biliary leaks:
– Treatment: attach tube to gravity drainage, • Most are amenable to NOM, provided
antibiotics, and i.v. fluids. interventional radiology and endoscopic
• Post-ERCP perforations therapy are available.
– Occur in 0.5–1.2 % of procedures with • Of note, the presence of free bile in
mortality as high as 15 % the peritoneal cavity can occasionally
– NOM: be very poorly tolerated with rapid
Nasogastric tube. sepsis warranting rapid surgical
Broad-spectrum antibiotics. intervention.
Repeat ERCP with insertion of a stent is an • Cystic duct stump leaks and ducts of
option for expert endoscopists. Luschka leaks:
– Ideal conditions for NOM: – Most common postcholecystectomy
Absence of free leakage on contrast causes of bile leaks.
examination – Low-grade leaks (identified
Absence of systemic inflammation or clini- after opacification of intrahepatic
cal peritonitis radicals): sphincterotomy alone.
Absence of large or increasing pneumo- – High grade (detected before radical
peritoneum opacification): biliary stenting.
• Colonoscopy perforations – Refractory leaks may require
– Common causes: barotrauma from exces- surgery.
sive insufflation of air, excessive use of – Main bile duct injuries may also
cautery, or overzealous dilatation of sometimes be treated with stents,
strictures while others require hepatobiliary
– NOM expertise surgery.
Indicated for patients who have had previ- • Multiple studies have now documented
ous bowel preparation, are minimally a 90–100 % resolution rate for bile leaks
symptomatic, without fever or tachycardia, posthepatic resection treated with
and with a benign abdominal exam, typi- sphincterotomy and stenting.
cally after small perforations following Pancreatic leaks:
therapeutic colonoscopy (e.g., polypec- • Many pancreatic-enteric anastomoses,
tomy or biopsy) usually less ominous events than in the
Treatment: nothing by mouth and broad- past, will resolve with NOM and percu-
spectrum antibiotics. Patients who taneous techniques.
respond to conservative management • Reoperation may be required either due
typically have no or minimal pneumo- to inaccessibility of an infected fluid
peritoneum and no or minimal leak of collection to percutaneous drainage or
contrast on CT. Perforations that fol- due to clinical instability associated
low are usually small and more amenable with uncontrolled sepsis. As early reop-
to NOM. eration carries a significant risk of mor-
24 F. Turégano-Fuentes and A.G. Marín

tality, it should be avoided if reasonable portal venous gas, intussusception, torsion

nonoperative alternatives exist. of mesentery, mesenteric edema, free intra-
Anastomotic leaks after esophagectomy: peritoneal fluid).
• Of critical importance: differentiate – In the case of early postoperative SBO,
between leaks and conduit necrosis, longer periods of observation may be toler-
especially after colonic interposition, ated as the risk of strangulation is low
and endoscopic examination is the best (<1 %).
method for making this assessment. – The exception to this watchful waiting
• Clinically stable patients (controlled approach is postoperative obstruction fol-
leaks or contained anastomotic disrup- lowing laparoscopic surgery which war-
tions) may be treated nonoperatively: rants an early surgical approach more often
endoscopically placed removable expand- than not. It is quite frequent that bowel is
able stents are first-line treatment options incarcerated within a peritoneal defect
• Leaks are controlled in 70–100 % of caused by trocar placement.
patients. – Occasionally, a patient may develop SBO
• Stent migration may occur in 20–40 % early in the aftermath of an operation for
of cases. adhesive SBO; this is a case for prolonged
NOM until adhesions mature and the
obstruction resolves.
3.4 Intestinal Obstruction – Similarly, patients with multiple prior epi-
sodes of SBO and patients who have under-
3.4.1 Small Bowel Obstruction gone numerous abdominal operations
should be treated NOM if possible.
• The majority of patients with partial adhesive • Treatment: fluid replacement and hemody-
small bowel obstruction (SBO) will respond namic monitoring and large bore NG tube
to NOM, while the opposite is generally true (softening the tube by immersion for a couple
for a complete SBO. of minutes in very hot water, and spraying the
– If there is gas seen in the colon on plain nostril with a local anesthetic can make the
abdominal X-ray, partial SBO is likely insertion less unpleasant)
– How long to wait before resorting to sur- – Adjunctive treatments
gery remains debatable (the traditional Steroids in SBO from Crohn’s disease
48 h time point has been challenged by Gastrografin, a water-soluble hyperosmo-
some groups who advocate prolonging the lar contrast medium that promotes intesti-
waiting period to up to 5 days) nal movement, is being increasingly used
• Oral and i.v. contrast-enhanced CT scan can at by many for diagnostic-prognostic and
times be very helpful in helping decide on a potential therapeutic purposes.
NOM course or otherwise, when one suspects • Technique: Instill 100 cc via the NG
a early postoperative SBO, or paralytic ileus tube, clamp the tube, and wait 4–6 h
or other non-adhesive cause of SBO like before ordering a plain abdominal
Crohn’s disease, peritoneal carcinomatosis or X-ray.
radiation enteritis, all potentially amenable • Presence of contrast in the large bowel
to NOM. proves that the SBO is partial, and reso-
– The “transition point” on CT scan does not lution can be expected
rule out a successful NOM, provided that • SBO from peritoneal carcinomatosis in a
signs of intestinal compromise or of a fixed known cancer patient or from advanced
SBO are absent (pneumatosis intestinalis, radiation enteritis, present sometimes a
3 Management Options: Nonoperative Versus Operative Management 25

medical and ethical dilemma which should into upper, mid, and lower has been
be solved with the patient, if appropriate, suggested.
and certainly his/her family and the clinical • With this new classification, UGIB is defined
oncologist. as occurring above the ampulla of Vater, mid
GIB as occurring between the ampulla and the
terminal ileum, and LGIB as that occurring
3.4.2 Large Bowel Obstruction within the colon.
• Most patients with GIB can be successfully
• Advanced metastatic colorectal or pelvic managed initially nonoperatively, by means of
cancer diagnostic and therapeutic endoscopy and/or
– Self-expandable metallic stents have been interventional radiology. The specific methods
proven useful as palliation. of endoscopic hemostasis depend on local
– However, there is a risk of perforation and skills and facilities and are dealt elsewhere in
migration. this manual.
• Uncomplicated sigmoid volvulus: colono- • Decision-making is complex and requires an
scopic decompression is well established. understanding of the perceived risk of rebleed-
– The mucosa should be assessed for the ing, the underlying pathology, morbidity asso-
presence, location, and degree of ischemia, ciated with surgery, and the morbidity
and a long rectal tube may be placed proxi- associated with failure of wait and see. Success
mal to the point of obstruction and left in rates with this approach vary depending upon
place for 48–72 h. the etiology of the bleed and the modality cho-
• Acute colonic pseudo-obstruction (Ogilvie’s sen, but even if control of hemorrhage is
syndrome): achieved initially by nonsurgical means, oper-
– Intravenous administration of the acetyl- ation may still be necessary.
cholinesterase inhibitor neostigmine is an • Upper GI bleeding
effective treatment with initial response – Variceal causes:
rates of 60–90 %. Rarely require surgery.
– Colonoscopic decompression is successful Endoscopy is 90 % effective in control of
in approximately 80 % of patients, with hemorrhage from esophageal varices, but is
surgery largely limited to those in whom not as effective in bleeding from hyperten-
complications occur. sive gastropathy (much more rare cause of
– CT-guided transperitoneal percutaneous severe UGIB).
cecostomy has been reported in a few high- For the 10 % of patients who continue to
risk patients unresponsive to maximal bleed or rebleed, transjugular intrahepatic
pharmacological and endoscopic therapy, portosystemic shunting (TIPS) is 95%
with good results. effective in controlling bleeding.
Urgent surgical shunts are rarely required
but can be considered in those who have
3.5 Gastrointestinal Bleeding good hepatic reserve and are not transplant
• Gastrointestinal (GI) bleeding has histori- – Non-variceal causes:
cally been defined as “upper” (UGIB) or Peptic ulcer disease (the most common
“lower” (LGIB) relative to the ligament of cause).
Treitz. However, with advances in endo- • Most cases resolve spontaneously.
scopic therapies and the advent of capsule Close monitoring of vital signs, observa-
endoscopy, a reclassification of GI bleeding tion of the number and character of melena
26 F. Turégano-Fuentes and A.G. Marín

stools, and serial hematocrit measurements (50–80 %) are active pulsatile bleeding
should detect further hemorrhage. or a visible vessel.
If an NG tube is used, it should be fre- – Conversely, nonpulsatile bleeding or
quently flushed. an adherent clot is associated with a
When bleeding persists, endoscopic ther- low risk of rebleeding.
apy remains the mainstay. • Ulcers >2 cm, posterior duodenal ulcers,
• Has been shown to result in primary and gastric ulcers also have a high risk
hemostasis in the majority of cases (76– of rebleeding.
100 %, depending on the type of endo- Mallory-Weiss tears
scopic therapy used). • Self-limited 90 % of the time, but if
• Repeat endoscopy is effective in intervention is required, endoscopy is
75 % of patients without increased highly successful.
morbidity. Stress gastritis is uncommon in the era of
– Administration of high-dose proton acid-suppression therapy and typically is
pump inhibitors (PPIs) reduces the successfully managed medically.
incidence of rebleeding and the need Dieulafoy’s lesion is successfully treated
for surgery following endoscopic endoscopically in 80–100 % of cases.
hemostasis. Hemobilia or hemosuccus pancreaticus
Angiographic embolization (AE) is another (bleeding into the bile duct or pancreatic
option: duct) is generally managed with therapeu-
• Less effective (reported clinical success tic angiography with high success rates.
rates of 65 %) • Mid and Lower GI bleeding
• Can be very useful in bleeding duode- – Accounts for approximately one-fourth to
nal ulcers when surgical risk is one-third of all GI bleeding events and
prohibitive stops spontaneously in about 80 % of cases.
• Risk factors for failure: use of antico- – Diverticular disease is the most common
agulants or corticosteroids at the time of source of LGIB. Massive lower GIB of
admission, the use of vasopressors diverticular origin originates in the right
before primary AE, and the use of coils colon in two-thirds of cases.
as the only embolic agent – Colonoscopy is generally effective at stop-
If rebleeding occurs: ping the bleed acutely. If this fails or the
• Mild or moderate in intensity and patient rebleeds, angiography can be
stemming from a superficial lesion, considered.
NOM may be continued, unless the Therapeutic angiography can halt LGIB in
patient is elderly and transfusion 40–85 % of cases, but the rebleeding risk is
requirements have exceeded four units high, particularly if the small bowel or the
of blood. cecum is the source.
• About 10 % of patients with upper GI – In diverticular disease, the overall risk of
bleeding (UGIB) will require an opera- rebleeding at 1 year is 10 % but rises to
tion. Identification of these patients is 50 % at 10 years.
challenging and the timing of surgery is – If the diseased segment has been localized,
unclear, although outcomes are clearly colonic resection is recommended in an
improved if surgery is performed in a elective setting for all except those patients
non-emergent fashion. who present a prohibitive operative risk.
• The two characteristics at endoscopy – Angiodysplasia is another common cause
that predict a high rebleeding risk of LGIB and can be diagnosed and treated
3 Management Options: Nonoperative Versus Operative Management 27

successfully in most patients with colonos- • Endoscopic sphincterotomy is the only inva-
copy or angioembolization. sive procedure that should be considered early,
– Meckel’s diverticule bleeding requires in the course of severe biliary AP, especially if
surgery ascending cholangitis is present.
• NOM is indicated unless infected pancreatic
necrosis is diagnosed/suspected or other acute
3.6 Acute Diverticulitis indications (i.e., abdominal compartment syn-
drome, gangrenous cholecystitis) arise.
• Acute, mild phlegmonous diverticulitis, even – Determining the presence of infected pan-
if recurrent, can be managed with oral antibi- creatic necrosis can be challenging, since
otics (such as metronidazole and ciprofloxa- sterile and pancreatic necrosis are clini-
cin) on an outpatient basis. cally indistinguishable.
• For Hinchey 1 and 2 disease, initial NOM – It should be suspected with fever, leukocyto-
consists of: sis, clinical deterioration, or failure to
– Bowel rest and antibiotics alone, even in improve, typically in the second or third week
patients with small (<5 cm) abscesses after symptom onset. Contrast-enhanced CT
– Percutaneous drainage (CT guided) for scan may show gas bubbles within the
larger pericolic abscesses necrotic pancreas, and this should be consid-
– CT manifestations of a severe attack ered pathognomonic of infection. If not, fine-
(extraluminal gas, leakage of contrast, or needle aspiration should be pursued. The
abscess) in a patient who has failed to false-negative rate is around 10–12 %, so
resolve after a few days of antibiotics are even in the absence of documented infection
not necessarily an immediate indication for (so-called sterile necrosis), surgery may be
operation. Minor free intra-abdominal gas required if clinical suspicion remains high.
is also not an immediate indication for sur-
gery if the patient is stable.
• Acute diverticulitis rarely affects patients with 3.8 Miscellaneous Conditions
jejunal diverticulosis. The key to diagnosis
and subsequent NOM and treatment with anti- • Esophageal perforations
biotics (usually successful) is a CT scan. • NOM is feasible in patients with small, con-
tained perforations promptly recognized,
especially in the cervical esophagus, but also
3.7 Severe Acute Pancreatitis in some cases in the thoracic esophagus.
– Criteria for NOM include minimal or no
• Current recommendations are not to give anti- signs of systemic response, absence of
biotics for all patients with acute pancreatitis. tachycardia, fever or pain, no associated
Some do based on APACHE II score >8. Most distal obstruction, and a perforation that is
authors give antibiotics only for extrapancre- not in the abdominal cavity.
atic infection, such as cholangitis, catheter- – As concerns endoscopic complications, it
acquired infections, bacteremia, urinary tract is particularly important to know when not
infections, and pneumonia (strong recommen- to operate rather than when to operate.
dation, high quality of evidence). – Despite strict adherence to these criteria,
– Imipenem, a wide-spectrum agent that up to 20 % of patients managed nonopera-
achieves high levels within the pancreatic tively develop complications within 24 h
parenchyma, appears to be the drug of that require surgical intervention.
choice, although the use of prophylactic – Broad-spectrum antibiotic treatment
antibiotics does not alter overall mortality. should be associated with nasogastric
28 F. Turégano-Fuentes and A.G. Marín

decompression, percutaneous drainage of of the superior mesenteric artery (SMA). A

chest collections if present, and parenteral very early diagnosis, coupled with an
nutrition. absence of peritoneal signs, and the pres-
– Endoscopically placed covered stents have ence of normal abdominal plain radio-
been used with good results, both in malig- graphs, together with radiologists skilled in
nant and benign perforations. the procedure and a close SICU monitor-
• Esophago-gastric caustic injuries ing, are absolute prerequisites for this
– Endoscopic evaluation of the depth and approach.
spread of caustic necrosis is challenging, • Rectus sheath hematoma
and initial endoscopy may overestimate the – Conservative treatment is the mainstay of
severity of the lesions. Moreover, superfi- management in hemodynamically stable
cial necrosis may heal after conservative patients with non-expanding hematomas.
management and thus enable resection to – Coil embolization can be an alternative in
be avoided. high-risk patients refractory to conserva-
– Zargar’s endoscopic classification can help tive therapy.
decide on the most appropriate course of Very rarely a surgical approach may be
action: stage I (inflammation alone), stage needed in case of failure of the NOM or
IIa (superficial ulceration), stage IIb (deep the development of an abdominal com-
or circumferential ulceration), and stage III partment syndrome.
[limited (IIIa) or extended (IIIb) necrosis • Spontaneous retroperitoneal hematomas (SRH)
involving the entire esophagus, and/or the – Increasingly encountered in clinical prac-
stomach, massive hemorrhage with tice as a result of anticoagulation therapy,
hematemesis. their clinical presentation may show a wide
• Acute gastric volvulus range of symptoms from femoral neuropa-
– The abdomen may appear relatively inno- thy to abdominal pain or a catastrophic
cent, with little epigastric pain and no shock or even abdominal compartment
abdominal findings on examination. syndrome.
– At times, the ability to pass an NG tube – Surgery or radiologic intervention (TAE)
provides some temporary relief of epigas- should be performed if the patient does not
tric/substernal pain and can buy some time respond to supportive therapy.
for surgery, but NOM has very little, if any,
role in the management of this infrequently
encountered condition, and a sense of
urgency must prevail in the surgical Pitfalls
management. • An incomplete knowledge and under-
• Acute mesenteric ischemia standing of the natural history and dif-
– Although very limited, there is definitely a ferent clinical presentations of the more
role for endovascular management in the common “surgical” emergencies
very earliest stages of acute mesenteric • Not taking into account the comorbidi-
embolism when necrosis is not a significant ties of the patient and the estimation of
risk. This situation is very uncommon in his/her surgical risk
clinical practice, and a late presentation of • Failure to understand the value of CT
the patient and late diagnosis is the rule, scan in helping decide on the most
when surgical treatment is either unavoid- appropriate course of action in some
able or already futile. cases and the value of less invasive man-
– The evidence in favour of successful intra- agement alternatives provided by inter-
arterial fibrinolysis and avoidance of sur- ventional radiology and endoscopic
gery comes mostly from isolated case procedures
reports or small series of acute embolism
3 Management Options: Nonoperative Versus Operative Management 29

3.9 Summary Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio

M, Rantanen T, Tuominen R, Hurme S, Virtanen J,
Mecklin J-P, Sand J, Jartti A, Rinta-Kiikka I, Grönroos
The increasingly advanced age of the surgical JM. Antibiotic therapy vs appendectomy for treatment
population, with its correspondent comorbidities, of uncomplicated acute appendicitis: the APPAC ran-
a better understanding of the pathophysiology of domized clinical trial. JAMA. 2015;313(23):2340–8.
many conditions, the easy availability of CT scan
Schein M, Rogers PN, Assalia A, editors. Schein’s com-
for emergency imaging diagnosis, and the mon sense emergency abdominal surgery. 3rd ed.
increasing experience gained with interventional New York: Springer; 2010.
radiology and endoscopic procedures, coupled Similis C, Symeonides P, Shorthouse AJ, et al. A meta-
analysis comparing conservative treatment versus
with the recognition of the effective use of antibi-
acute appendectomy for complicated appendicitis
otics and other drugs as the main treatment strat- (abscess or phlegmon). Surgery. 2010;147:818–29.
egy in many conditions formerly considered as Simó G, Echenagusia A, Camuñez F, Turégano F, Cabrera
mainly or exclusively surgical, has prompted a A, Urbano J. Superior mesenteric arterial embolism:
local fibrinolytic treatment with urokinase. Radiology.
revolution in the management of many “surgical”
emergencies. Some patients are just too sick to Tenner S, Baillie J, DeWitt J, Swaroop Vege S. American
withstand an emergency surgical procedure, and College of Gastroenterology guideline: management of
the wise surgeon must at times refrain from his acute pancreatitis. Am J Gastroenterol. 2013.
doi:10.1038/ajg.2013.218. advance online publication,
natural impulse to the scalpel and exercise his
30 July.
clinical wisdom, with the help from the new Vogel SB, Rout WR, Marin TD, Abbitt PL. Esophageal
knowledge and the new technologies. perforations in adults: aggressive conservative treat-
ment lowers morbidity and mortality. Ann Surg.
Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavu-
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acute uncomplicated appendicitis: an open-label, non-
Abbas S, Bissett IP, Parry BR. Oral water-soluble contrast inferiority, randomised controlled trial. Lancet.
for the management of adhesive small bowel obstruc- 2011;377:1573–9.
tion. Cochrane Database Syst Rev. 2007;(1):CD004651. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma
Ansolini L, Catena F, Coccolini F, Ercolani G, Gazzotti F, DJ, Garden OJ, Buchler MW, Gomi H, Dervenis C,
Pasqualini E, Pinna AD. Surgery versus conservative Windsor JA, Kim SW, de Santibanes E, Padbury R,
antibiotic treatment in acute appendicitis: a systematic Chen XP, Chan ACW, Fan ST, Jagannath P, Mayumi T,
review and meta-analysis of randomized controlled Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe
trials. Dig Surg. 2011;28:210–21. A. TG13 surgical management of acute cholecystitis. J
Cameron JL, Cameron AM, editors. Current surgical ther- Hepatobiliary Pancreat Sci. 2013;20:89–96.
apy. 10th ed. Philadelphia: Elsevier Saunders; 2011. Zielinski MD, Eiken PW, Bannon MP, Heller SF, Lohse
De Giorgio R, Knowles CH. Acute colonic pseudo- CM, Huebner M, Sarr MG. Small bowel obstruction-
obstruction. Br J Surg. 2009;96:229–39. who needs an operation? A multivariate prediction
Kuppusamy MK, Hubka M, Felisky CD, et al. Evolving model. World J Surg. 2010;34(5):910–9.
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gery. JAMA. 2015;313(23):2327–8. doi:10.1001/
Ari Leppäniemi

4.1 Introduction 31
• Characterize the pathophysiological
4.2 Hemorrhage 32 processes in abdominal emergencies.
4.3 Contamination 32 • Categorize these processes into corre-
4.4 Obstruction 33 sponding groups.
• Outline the systemic and local conse-
4.5 Ischemia 34
quences of these processes.
4.6 Toxic Injury 34 • Link the consequences into the develop-
4.7 Abdominal Compartment Syndrome ment of symptoms and signs.
(ACS) 34 • Describe the primary aim of therapy in
4.8 Summary 35 different pathophysiological conditions.
Bibliography 35

4.1 Introduction

Acute disease processes in the abdomen, whatever

the cause, manifest in the vast majority of cases in a
limited number of ways. These manifestations can
be grouped according to the principal pathophysio-
logical process and used as a guiding principle
toward both diagnosis and therapy. Regardless of
the organ or organ system involved, the clinical pre-
sentation of a specific pathological process in the
abdomen is constant. Knowing the usual presenta-
tion of a disease, i.e., appendicitis, ruptured ectopic
pregnancy, pelvic inflammatory disease, etc., allows
early diagnosis, expeditious formulation of the prin-
A. Leppäniemi, MD, PhD, DMCC
cipal goal of treatment, as well as understanding the
Chief of Emergency Surgery, Meilahti Hospital,
University of Helsinki, Helsinki, Finland natural course of the process if not interrupted by
e-mail: intervention that in most cases is surgical.

© Springer International Publishing Switzerland 2016 31

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_4
32 A. Leppäniemi

4.2 Hemorrhage ting factors to maximize the chance of hemosta-

sis that in most cases requires mechanical
Acute extravasation of blood can: intervention to seal off the bleeding vessel.

• Occur freely into the abdominal cavity (e.g.,

ruptured ectopic pregnancy or liver adenoma) 4.3 Contamination
• Be contained and confined to the retroperito-
neal space (ruptured abdominal aortic aneu- The sources of bacterial contamination in the
rysm) or specific pathological cavity (bleeding abdominal cavity include:
pancreatic pseudocyst)
• Bleed into a hollow organ such as the gastro- • Perforation of a hollow organ containing nor-
intestinal (bleeding peptic ulcer), biliary, or mal bacteria flora, such as the gastrointestinal
urinary tract (renal tumor). tract (most common source of contamination)
• Bacterial translocation through gangrenous
Depending on the amount of blood extrava- intestine (gangrenous appendicitis, ischemic
sated and speed of extravasation, the symptoms or gangrenous loop of bowel) or other hollow
are dominated either by local irritation or com- organ wall (gangrenous cholecystitis)
pression caused by the blood and blood clot or by • Previously contained abscess perforating into
systemic manifestations of acute hypovolemia the free intraperitoneal space
that, if untreated, can result in exsanguination of
the patient. Whether caused by translocation or frank per-
If the bleeding stops spontaneously, the foration, the bacterial contamination will induce
extravasated blood or clot can cause delayed both a local and systemic inflammatory response.
problems in form of: Depending on the size and location of the per-
foration and the ability of the adjacent organs and
• Compression on adjacent organs the greater omentum to seal off the perforation,
• Obstruction of hollow organs (urinary bladder the condition can progress to:
• Infected hematoma and subsequent abscess • Generalized secondary peritonitis
formation • Walled-off inflammatory process followed
• Recurrent bleeding (at high risk if the underly- either by resolution or formation of a mature
ing pathological process is not treated) abscess

The main aim of treatment is to stop the bleed- Occasionally, the bacterial contamination is
ing, utilizing one or more of the following preceded by chemical contamination (e.g., perfo-
interventions: rated peptic ulcer) causing the initial reaction and
symptoms, and the effects of bacterial contami-
• Operation nation will manifest within the next few hours.
• Endoscopic procedure The aims of treatment
• Interventional radiology (angioembolization)
• Control the source of contamination
The urgency of treatment depends on the rate • Correct the disturbed homeostasis caused by
of bleeding. Hypovolemic shock is corrected the systemic inflammatory reaction
with intravenous volume expansion avoiding
complete normotension in uncontrolled hemor- Source control can be achieved by
rhage, thus reducing the rate of bleeding and
decreasing the risk of recurrent bleeding after • Removal of the inflamed organ before or after
spontaneous hemostasis. Extravasated blood is perforation (acute appendicitis, strangulated
replaced with blood transfusion including clot- bowel loop, acute cholecystitis)
4 Pathophysiology 33

• Surgical closure of the perforation (perforated that often requires some form of mechanical
peptic ulcer) (endoscopic) or pharmacological (neostigmine)
• Diversion of the intestinal contents with intervention to prevent overdilatation of the
entero- or colostomy, if complete source con- colon.
trol in the gastrointestinal tract cannot be reli-
ably achieved or it is not safe to perform Biliary tract
primary closure or anastomosis (e.g., the • Obstruction in the main hepatic or common
Hartmann’ procedure for perforated sigmoid bile duct (usually caused by stone or tumor)
diverticulitis) will result in obstructive jaundice.
• Drainage of the content outside the body with • If not relieved, a secondary liver injury will
aptly placed drains to create a “controlled fis- follow.
tula,” such as in delayed perforation of the • An obstructed cystic duct will cause dilatation
duodenum with no chance of reliable primary of the gallbladder with ensuing acute chole-
closure cystitis, perforation, or empyema.

Urinary tract
4.4 Obstruction • Stone
• Tumor (including prostatic hyperplasia)
A mechanical obstruction of a hollow organ • Blood clot
leads to a distinct clinical picture dominated by
colicky pain when the body tries to overcome the Urinary obstruction will cause proximal dila-
obstruction by enhanced peristaltic contractions. tation of the urinary tract, renal insufficiency (if
The cause of the obstruction can be intraluminal bilateral), and eventually loss of a kidney, espe-
or caused by external compression, volvulus, or cially if the obstruction is prolonged or associ-
kinking. The progression and complications ated with an infection.
caused by the obstruction depend on the organ Aims of treatment of hollow organ
system involved. obstruction:

Gastrointestinal tract • Relieve the obstruction by correcting or

• Obstruction caused by peritoneal adhesions or removing the cause.
bands • Assess the viability of the obstructed organs.
• Obstructed hernia • In urgent or complex situations, temporary
• Twists (volvulus) relief of the obstruction by proximal diversion
• Tumors (especially in the colon) followed later by definitive treatment.

The obstruction will cause proximal dilatation, Examples of proximal diversion:

ischemic necrosis, and eventual perforation, if the
obstruction is not relieved. The risk of perforation • Proximal colostomy in obstructive distal colon
increases with the diameter of the dilated bowel or rectal cancer
thus causing the cecum to be the most likely per- • Percutaneous transhepatic cholecystostomy or
foration site in distal colonic obstruction, espe- biliary drainage
cially if the ileocecal valve is competent. • Suprapubic cystostomy
Temporary relief can be achieved spontaneously
(vomiting, incompetent ileocecal valve) or inten- Internal drainage utilizing endoscopic place-
tionally (nasogastric tube), and sometimes the ment of stents can also be a definitive procedure,
obstruction may resolve spontaneously, such as in as in patients with advanced cancer or chronic
adhesive small bowel obstruction. pancreatitis. In most cases, however, surgical
Colonic pseudo-obstruction (Ogilvie’s syn- removal of the cause of obstruction is the defini-
drome) is a nonmechanical dilatation of the colon tive treatment with best long-term effect.
34 A. Leppäniemi

4.5 Ischemia mechanical closed loop obstruction of the

bowel caused by adhesions or incarcerated
A complete or partial occlusion of a visceral external hernia. If not corrected in time, the
artery leads to end-organ ischemia unless suffi- strangulated bowel loop will become necrotic
cient collateral circulation exists. An acute and perforates.
obstruction is usually caused by thrombosis or an
embolus, but occasionally an acute low flow state
without obvious localized vascular obstruction 4.6 Toxic Injury
can have the same effect.
Depending on the organ involved, the symp- Ingested drugs, toxins, alcohol, or corrosive
toms and localizing signs manifest in different agents cause a wide range of acute emergency
areas of the abdomen. Ischemic pain is usually surgical problems including:
abrupt, severe, and sometimes poorly localized in
the initial stage, and the localizing peritoneal irri- • Alcohol-induced acute pancreatitis
tation might not be yet present. • Toxic hepatitis
Vascular inflow occlusion of the solid abdomi- • Corrosive injury to the esophagus, stomach,
nal organs (liver, spleen, kidneys) will result in and less commonly, duodenum
ischemic necrosis if revascularization is delayed • Inflammation of a solid organ can lead to
for more than a few hours. necrosis (liver, pancreas) and subsequent
infection (infected peripancreatic necrosis) or
• Warm ischemia is tolerated poorly by the kid- decrease or loss of function (endo- and exo-
neys, whereas in the liver, either the hepatic crine pancreatic insufficiency)
artery or the portal vein (if one of them is • In hollow organs, full-thickness necrosis usu-
intact) usually provide sufficient oxygen to ally leads to perforation and generalized infec-
prevent cellular necrosis. tion (mediastinitis, peritonitis)
• Occlusion of a branch of the main artery can
lead to partial infarction of the end organ, such The primary aim of surgical treatment is to
as the spleen or kidney. manage the complications caused by the toxic
injuries (pancreatic necrosectomy, resection of
Gastrointestinal tract necrotic esophagus) and subsequent restoration
• Acute occlusion of the superior mesenteric of function that can include complex reconstruc-
artery leads to massive necrosis of most of the tive procedures or organ transplantation.
small bowel and the right hemicolon.
• Thrombosis is usually more proximal than an
embolus where the first jejunal branches might 4.7 Abdominal Compartment
ensure the viability of a part of the proximal Syndrome (ACS)
• Occlusion of the celiac axis or the inferior Increased intra-abdominal pressure (IAP) can be
mesenteric artery seldom has dramatic effects. the result of
• Decreased flow to the left hemicolon can lead
to ischemic colitis. • Space-occupying process in the abdomen (pri-
• Thrombosis of the superior mesenteric vein mary ACS)
leads to venous congestion and bowel edema • Extensive fluid resuscitation (sepsis, burns)
with less clearly demarcated areas than arte- leading to visceral edema (secondary ACS)
rial thrombosis. In most cases, it can be man-
aged nonoperatively (anticoagulation) since Abdominal compartment syndrome is defined
the risk of necrosis is low. as sustained intra-abdominal hypertension
• Bowel strangulation is a special form of isch- (>20 mmHg) combined with evidence of new
emia where vascular occlusion is preceded by end-organ dysfunction.
4 Pathophysiology 35

Increased IAP will cause dysfunction of most 4.8 Summary

organ systems within and outside the abdomen
(most commonly in the renal, gastrointestinal, Acute abdominal emergencies present in a few
and respiratory systems) and can, if untreated, distinct forms that have specific local and systemic
lead to multiple organ dysfunction syndrome and manifestations, but with consequences that have
death. many similarities regardless of the site or organ of
While clinical recognition can be difficult, the the lesion. Massive hemorrhage leads to hypovole-
IAP is easily measured through a urinary bladder mic shock and exsanguination if the bleeding is
catheter. not stopped. Bacterial contamination of the perito-
The main aim of treatment is to lower the IAP. neal cavity can lead to generalized peritonitis and
septic shock unless limited by the body or source
• Initially with conservative methods by control achieved by surgical means. Hollow organ
decreasing intra-abdominal contents (naso- obstruction leads to proximal dilatation that often
gastric and rectal tubes, percutaneous drain- requires temporary or definitive measures to pre-
age of ascites) and increasing abdominal wall vent permanent organ damage or perforation.
compliance (short-term muscle relaxants, Acute ischemia can cause irreversible damage to
optimization of hemodynamics, removing the organ involved unless revascularization can be
constrictive bandages). performed rapidly. Finally, the complications
• If intra-abdominal hypertension persists, caused by ingestion of toxic or corrosive agents
prompt surgical decompression is necessary, often require surgical intervention.
leaving the abdomen open.

The management of the ensuing open abdo- Bibliography

men aims for delayed fascial closure when the
principal cause of the ACS has been treated. If Bradley III EL. Management of severe acute pancreatitis.
A surgical Odyssey. Ann Surg. 2010;251:6–17.
fascial closure is not possible, a planned hernia
Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R,
approach (usually with split-thickness skin graft- Malbrain ML, de Keulenaer B, Duchesne J, Bjorck M,
ing) is instituted and followed by delayed abdom- Leppaniemi A, Ejike JC, Sugrue M, Cheatham M,
inal wall reconstruction procedure performed Ivatury R, Ball CG, Reintam Blaser A, Regli A,
Balogh ZJ, D’Amours S, Debergh S, Kaplan M,
6–12 months later. If the abdominal fascia cannot
Kimball E, Olvera C. Intra-abdominal hypertension
be closed, coverage with native tissue is always and the abdominal compartment syndrome: updated
preferred, i.e., skin only closure. consensus definitions and clinical practice guidelines
from the World Society of the Abdominal
Compartment Syndrome. Intensive Care Med.
Malbrain ML, Cheatham ML, Kirkpatrick A, et al. Results
from the International Conference of Experts on Intra-
Pitfalls abdominal Hypertension and Abdominal Compartment
Syndrome. I. Definitions. Intensive Care Med.
• Failure to recognize early systemic
signs of hemorrhage Marshall JC, Maier RV, Jimenez M, Dellinger P. Source
• Inability to achieve reliable source con- control in the management of severe sepsis and septic
trol of contamination shock: an evidence-based review. Crit Care Med.
• Incomplete or delayed relief of hollow
Pieracci FM, Barie PS. Management of severe sepsis of
organ obstruction abdominal origin. Scand J Surg. 2007;96:184–96.
• Delayed recognition and treatment of Simmen HP, Heinzelmann M, Largadier F. Peritonitis:
intestinal ischemia classification and causes. Dig Surg. 1996;13:381–3.
• Ignoring the possibility of abdominal
compartment syndrome
Postoperative Complications
Ronald V. Maier and Abe Fingerhut

5.1 Peritonitis/Abscess 37 Objectives
• Discuss common serious complications
5.2 Paralytic Ileus 39
of operations for complex disease.
5.3 Bleeding/Coagulopathy 39 • Understand underlying pathophysiology.
5.4 Abdominal Compartment Syndrome • Explore decision-making process in
(ACS) 40 approach to care.
5.5 Damage Control (Open and • Elucidate prevention and treatment
Laparoscopic) 41 options.
5.6 Reoperation: Timing 41 Note: see individual chapters for spe-
cific complications.
5.7 Wound Dehiscence/Management 42
5.8 Summary 43
Bibliography 43
5.1 Peritonitis/Abscess

• Both are manifestations of intra-abdominal

– Peritonitis: diffuse infection of the perito-
neal space
• Somewhat localized to one quadrant
• Or generalized to two or more quadrants
R.V. Maier, MD, FACS (*) with a significantly increased risk of
Jane and Donald D. Trunkey Professor and Vice mortality
Chair, Department of Surgery, University of – Abscess: localized infection in the abdomen
Washington Surgeon-in-Chief, Harborview Medical
Center, Seattle, WA 98104, USA Forms anywhere
e-mail: • Within the peritoneal space
A. Fingerhut, Doc hon c, FACS, FRCS(g), FRCS(Ed) • In the extraperitoneal space, primarily
Department of Surgical Research, Clinical Division the retroperitoneum
for General Surgery, Medical University of Graz, • Or within the organs themselves, pri-
Graz, Austria marily the liver and spleen

© Springer International Publishing Switzerland 2016 37

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_5
38 R.V. Maier and A. Fingerhut

• Both occur more often today, postoperatively, Diagnosis can be made on physical
due to the increasing severity of disease and examination leading to prompt surgical
complexity of procedures (including damage intervention.
control) performed currently and the associ- – Conversely, postoperative abscess or ter-
ated increased survival of the patient. tiary peritonitis can be significantly more
• Causes: difficult to diagnose.
– By far the most common cause is anasto- The clinical picture is less straightforward,
motic leakage. and additional studies are frequently neces-
Management depends on patient status. sary to make the diagnosis.
• Stable: nonoperative management is • Current multi-slice abdominal CT scans
possible. are the most useful.
• Unstable: surgery is indicated. • Treatment requires both source control and
– Laparotomy or for some appropriate antibiotics.
laparoscopy – Diffuse peritonitis (almost always indicat-
If early intervention, the anastomosis can ing an uncontrolled GI source of contami-
be redone, with or without protective nation) mandates operative exploration for
stoma, if not, and most often. source control.
The two extremities should be brought out – In contrast, intra-abdominal abscess
(double-barrel ileostomy or colostomy). may be sufficiently treated by drainage
Hartmann’s procedure. alone.
Complete peritoneal toilet. Drainage is the appropriate initial step in
Drainage. the stable patient or patient responsive to
– Other causes are rare. initial therapy.
Collections (abscess) in a stable patient can Frequently can be placed percutaneously
be drained percutaneously. using radiologic guidance including fluo-
• There are no good guidelines on prevention of roscopy, CT, ultrasound, or laparoscopy.
postoperative infections. • There are no randomized prospective
– The current assumption is that factors that trials comparing open drainage to per-
decrease SSI will also have a beneficial cutaneous drainage, but solid cohort
effect on the incidence of deep organ space studies suggest that the net success
infections, both peritonitis and abscesses. and mortality appear to be equal
– These factors include: between the approaches, but percuta-
Avoidance of unintended injury to the neous or laparoscopy avoid the poten-
bowel or other organs during any operative tial iatrogenic morbidity of open
procedure (critical) drainage.
Avoidance of hypoxia, hypothermia, and • Open drainage is usually reserved for
hyperglycemia the patient in whom percutaneous drain-
Appropriate antibiotic prophylaxis and age has failed or is not technically
treatment feasible.
Adequate delay in definitive completion of – Importantly, approximately one fourth of
the surgery or closure of the wounds cases will require an additional interven-
• Diagnosis: tion to resolve the infection.
– Primarily: pain and abdominal tenderness. Need for reintervention is indicated when
– Fever and elevated WBC are frequent but the patient fails to improve or worsens fol-
may be absent early in the disease process. lowing intervention or when infection
– Specific to diffuse peritonitis: recurs.
Diffuse physical findings of tenderness, Mandatory or scheduled relaparotomies
rebound, and guarding, such as following have not been shown to reduce the morbid-
intestinal leak. ity or mortality in these complex cases.
5 Postoperative Complications 39

5.2 Paralytic Ileus 5.3 Bleeding/Coagulopathy

• Common postoperative disorder: • Can occur after any invasive procedure with
– Occurring to some extent in most patients increasing risk paralleling the increase in
undergoing abdominal surgery complexity of the procedure.
– Most often transient, usually lasting • Diagnosis:
2–3 days, but may last for more than – Should be suspected in any postoperative
7–10 days patient whom develops tachycardia, pallor,
• Caused by neural, humoral, and metabolic volume-dependent hypotension, oliguria,
factors: restlessness/anxiety, and/or abdominal
– Direct intestinal exposure, manipulation, distention.
and desiccation An anxious, agitated postoperative patient
– Retroperitoneal bleeding should never be sedated without evaluation
– Severe infection, both intraperitoneal and for ongoing bleeding.
extraperitoneal, such as pneumonia – Note that the hematocrit fall may be
– Electrolyte imbalances, particularly delayed in the acute setting until intravas-
hypokalemia cular volume is restored.
– Drugs, primarily narcotics – Evidence of bleeding site should be sought
Morphine binds to μ-opioid receptors in with physical exam and evaluation of all
the CNS and colon causing nonpropulsive tubes and wounds/dressings, along with any
electrical activity. evidence of diffuse bleeding from puncture
• Of clinical importance, should increase sus- sites indicative of a coagulopathy.
picion and help identify preemptively the – Coagulation tests, including platelet count,
onset of intestinal ischemia or an intra- bleeding time, and PT and PTT along with
abdominal infectious process, such as a fibrinogen levels and thromboelastograph
localized abscess or diffuse peritonitis, while (TEG) or rotational thromboelastometry
still reversible (ROTEM) may differentiate primary ver-
• Treatment: sus secondary hemostasis failure.
– Watchful support is in most cases appropri- • Causes:
ate and safe: – Absence or loss of surgical hemostasis
NG suction and fluid resuscitation. – Technical error
Rapid correction of electrolyte imbalances, – Resolution of vasoconstriction
especially hypokalemia. – Coagulopathy
The use of thoracic epidurals enhances • Management:
return of bowel function. – Absence or loss of surgical hemostasis and/
– In contrast, the development of secondary or refractory hypotension, ACS, or ongoing
ileus after initial return of bowel function need for blood transfusion usually requires
mandates evaluation for mechanical returning to the OR and reoperation.
obstruction or intra-abdominal sepsis from A discreet bleeding point is frequently not
abscess or peritonitis: found.
Modern multi-slice CT scanners is excep- However, evacuation of the dead space and
tionally effective. blood, breaking the endogenous thrombo-
Laparotomy may be necessary to defini- lytic cycle, is frequently successful.
tively exclude these factors and to rule out – Hemostatic failure due to platelet or coagu-
intestinal ischemia or threatened viability lation cascade failure.
of the intestinal wall due to intense and/or – Correction of hypothermia, suppression of
prolonged distension. drug-inducing agents.
40 R.V. Maier and A. Fingerhut

– Search for acquired secondary coagulopa- In critically ill patients, ACS can be either
thy (consumption and/or dilution from tis- primary from a direct increase in the intra-
sue injury, volume resuscitation, sepsis, or abdominal volumes or secondary due to ill-
transfusion with product poor blood com- ness outside the abdominal cavity:
ponent therapy). • Primary ACS is seen following events
– Low fibrinogen level should be treated with such as rupture of an AAA, spontaneous
FFP. retroperitoneal bleed, pelvic bleeding,
– Early aggressive transfusion plus FFP or direct injury to intra-abdominal
and possibly platelets to achieve a near organs.
1:1 ratio of packed RBC to FFP is associ- • Secondary ACS occurs following isch-
ated with an improvement in overall sur- emia/reperfusion, burns, or infection,
vival following massive blood loss and where total body, including intra-
transfusion and reduction in overall vol- abdominal, edema occurs due to the
ume of blood products required (based on host inflammatory response or systemic
recent military observations after severe inflammatory response syndrome
trauma). (SIRS).
• The variable impact on perfusion can fur- – In addition, the recent past trend of
ther damage and cause progression in vigorously (and overly) resuscitating
injured or diseased tissue or compromise the patient with large volumes of
the already completed repairs, leading to crystalloid to reach an arbitrary goal,
anastomotic break down, wound dehis- such as supranormal oxygen delivery,
cence, or intra-abdominal hypertension added an iatrogenic component to the
(IAH) and progress to abdominal compart- edema, increased volume of tissues,
ment syndrome (ACS). and IAH.
• Recurrent ACS is the redevelopment of
ACS after treatment for primary or sec-
5.4 Abdominal Compartment ondary ACS.
Syndrome (ACS) – IAH can be easily measured using the fluid
column height above the pubis in a Foley
• Definition: end-organ dysfunction (new or catheter, after instilling 50 cc of sterile
ongoing) related to intra-abdominal hyperten- saline inserted into the bladder.
sion (IAH) During ACS, IAH is defined as a pressure
– Physiopathology: greater than 20 mmHg, but pressures can
The abdominal compartment is contained vary greatly between patients without signs
with layers of initially elastic but ultimately of ACS.
poorly compliant tissue layers. The primary effects of ACS are through
Similar to cardiac tamponade, pressures impairment of perfusion and oxygenation:
may increase slowly until compliance of • Increased IAH
tissues is exceeded, with rapid increases – Decreases perfusion of all intra-
occurring to small volume changes. abdominal organs and the abdominal
When the intra-abdominal volume/pressure wall compromising wound healing
exceeds these limits, there is a direct effect – Increases venous collapse and resis-
on numerous organ functions, including tance with impaired renal, hepatic,
cardiac, respiratory, renal, neurologic, and and bowel function
muscular systems. – Leads to IVC collapse responsible
If not recognized and treated, the end result for decreased cardiac preload
is worsening organ failure and potential – Through elevation of the diaphragm
death. compresses the heart similar to tam-
5 Postoperative Complications 41

ponade, with decreased cardiac out- • Laparoscopic identification of a poorly

put and further decreases in organ identified bile leak after an ERCP
perfusion • Abscess from unidentified perforated
The restriction of the thoracic cavity colonic processes
compresses the lungs, elevates venti- • Almost always require a less than optimal
latory pressures and causes loss of closure of the incisions and need for further
FRC, and decreases oxygenation operative intervention.
with additional organ insult from
worsening hypoxemia.
– Rapid decompression through open- 5.6 Reoperation: Timing
ing of the abdomen creating an “open
abdomen” is critical. • Damage control reoperations
– Necessary to:
Complete repair or resection
Perform anastomoses to restore intestinal
5.5 Damage Control (Open continuity
and Laparoscopic) Evaluate for occult or missed injuries
Rule out progression of ischemia
See also Chap. 1 (schwab, Leppaniemi) Remove temporary packing used to control
• Definition: operations (whether via laparot- Remove temporary vascular shunts fol-
omy or laparoscopy) that are limited, “incom- lowed by vascular repair
plete” procedures performed in patients where Manipulate or replace drains or drainage
persisting to complete the procedure would tubes
significantly increase the morbidity and mor- Attempt delayed primary closure of the
tality of the patient. abdominal cavity
• Principal indications: • Timing of reoperation
– Operations performed for control of hem- – Dictated by:
orrhage, contamination, or potential Disease and injuries present.
ischemia. Physiologic response of the patient to the
– Injury to major vascular structures or initial or previous procedure.
highly vascular solid organs from extensive Somewhat variable (based on the above
resections for malignancy, infection, or considerations): most reoperations occur
other diseases. between 12 and 72 h, preferring the soonest
Particularly true when significant blood possible.
loss and massive transfusion leads to the • Specific considerations for potential ongoing
“Bloody Triad” of hypothermia, acidosis, or progressive ischemia:
and coagulopathy, associated with an unac- – Whether from chronic or acute mesenteric
ceptably high mortality. ischemia or subsequent to repair of the
– Laparoscopic procedures can produce or mesenteric artery or ligation of the proxi-
identify potentially morbid or lethal events mal mesenteric or portal vein.
that are unsafe to definitely pursue due to – Planned reoperation to rule out ischemia is
patient disease or comorbidity. indicated.
Examples (can be best treated with place- Lack of improvement or progression of base
ment of drainage to control the source, deficit, lactate levels, or ongoing require-
while life-threatening comorbidites are ments for fluid resuscitation all indicate the
corrected): likelihood of ongoing ischemia.
42 R.V. Maier and A. Fingerhut

5.7 Wound Dehiscence/ – Similarly, any systemic sign of infection,

Management or any local changes involving erythema,
purulence, skin blistering, or darkening at
• Causes: the wound site, mandates close evaluation,
– Inadequate perfusion due to the increased and opening of the superficial wound if
tension required for closure of swollen and concern exists.
noncompliant tissues or hypovolemia and • Management:
hypoxia from any other cause (e.g., effect – In virtually all cases of wound dehiscence,
of smoking) unless physiologically prohibitive, the
– Infection causing direct breakdown of tis- patient should be explored in the operating
sues and impairment of healing room.
– Increased intra-abdominal pressure – The fascia should be taken down and
– Systemic effects of: carefully inspected for ischemia or
Diabetes, malignancy, steroid or other infection.
immunosuppressive therapy, and chronic All diseased fascia should be resected back
lung disease to healthy tissue.
• Prevention: – Careful inspection of the abdomen is
– Consideration of time since insult helps necessary to rule out anastomotic leaks,
determine whether a wound should be intra-abdominal abscess, or peritonitis
closed or reopened that requires additional intervention. In
6–8 h is quoted for trauma, but no rules cases where the fascia requires little or
have been established in nontrauma surgi- no debridement and tension on closure is
cal emergencies. acceptable, repeat fascial closure may be
• e.g., a contaminated ischemic lower possible. To not repeat what has failed,
limb may never be safe to close. additional techniques are required, most
Opening a wound and delayed primary clo- commonly the wide-based, interrupted
sure is a viable option when in doubt. “mass closure” encompassing both lay-
– Currently, there is no evidence that running ers of fascia and rectus muscle with or
versus interrupted initial fascia closure has without including the dermis and subcu-
an effect on the risk of dehiscence. taneous tissue in each bite. In cases
– When in doubt – delay closure or reopen. where closure leads to unacceptable ten-
• In the critically ill patient, do not neglect both sion, the abdomen should be left open.
underlying malnutrition and inadequate levels
of structural protein and cofactors for healing,
as well as the additional stresses of the dis-
eases involved.
• Diagnosis: Pitfalls: Lack of Recognition
– All wounds should be inspected if the • Lethal pathophysiology – “Bloody
patient displays any evidence of infection Triad”
or if skin changes or significant drainage • Ongoing progressive disease: bleeding,
occurs at the wound site. ischemia, no source control
– The classic salmon pink fluid drainage of • Presence of IAH/ACS: possible
peritoneal fluid from disrupted fascia man- recurrence
dates removal of any dermal closure and • Need for reoperation
both visual and manual inspection of the • Wound compromise
wound fascia.
5 Postoperative Complications 43

5.8 Summary Favretti F, Segato G, Ashton D, et al. Laparoscopic adjust-

able gastric banding in 1,791 consecutive obese
patients: 12-year results. Obes Surg. 2007;17(2):
Procedures should be limited to prevent a poten- 168–75.
tial lethal outcome, and use a staged response to Koperna T, Schulz F. Relaparotomy in peritonitis: progno-
optimize survival. Aggressive restoration of sis and treatment of patients with persisting intraab-
dominal infection. World J Surg. 2000;24:32–7.
physiology and minimization of comorbidity
Malbrain MLNG, Cheatham ML, Kirpatrick A, et al.
during constant monitoring is crucial. Make the Results from the international conference of experts
commitment to a serial/ongoing process of care on intra-abdominal hypertension and abdominal com-
and plan on returning to “fight another day.” partment syndrome. I. Definitions. Intensive Care
Med. 2006;32(11):1722–32.
In effectively dealing with complications, the
Maron DJ, Fry RD. New therapies in the treatment of
surgeon must know and recognize the risks of postoperative ileus after gastrointestinal surgery. Am J
complication, using a “worst case scenario” Ther. 2008;15(1):59–65.
mentality. Offner PJ, de Souza AL, Moore EE, et al. Avoidance of
abdominal compartment syndrome in damage-control
laparotomy after trauma. Arch Surg. 2001;136:676.
Ohmann C, Yang Q, Hau T, et al. Prognostic modeling in
Bibliography peritonitis. Peritonitis Study Group of the Surgical
Infection Society Europe. Eur J Surg. 1997;163:
Balogh Z, McKinley BA, Holcomb JB, et al. Both pri- 53–60.
mary and secondary abdominal compartment syn- Reikvam H, Steien E, Hauge B, et al. Thromboelastography.
drome can be predicted early and are harbingers of Transf Apheres Sci. 2009;40:119–23.
multiple organ failure. J Trauma. 2003;54(5):848–61. Shapiro MB, Jenkins DH, Schwab CW, et al. Damage
Barker DE, Kaufman HJ, Smith LA, et al. Vacuum-pack control: collective review. J Trauma. 2000;49:969.
technique of temporary abdominal closure: a 7-year Thodiyil PA, Yenumula P, Rogula T, et al. Selective non-
experience with 112 patients. J Trauma. 2000;48(2): operative management of leaks after gastric bypass:
201–6. lessons learned from 2675 consecutive patients. Ann
Bohm B, Milsom JW, Fazio VW. Postoperative intestinal Surg. 2008;248(5):782–92.
motility following conventional and laparoscopic Tieu BH, Holcomb JB, Schreiber MA. Coagulopathy: its
intestinal surgery. Arch Surg. 1995;130(4):415–9. pathophysiology and treatment in the injured patient.
Cheatham ML, Malbrain MLNG, Kirpatrick A, et al. World J Surg. 2007;31:1055–64.
Results from the international conference of experts Van Ruler O, Mahler CW, Boer KR, et al. Comparison of
on intra-abdominal hypertension and abdominal com- on-demand vs planned relaparotomy strategy in
partment syndrome. II. Recommendations. Intensive patients with severe peritonitis: a randomized trial.
Care Med. 2007;33(6):951–62. JAMA. 2007;298:865–72.
When to Operate After Failed
Nonoperative Management 6
Gregory A. Watson and Andrew B. Peitzman

Contents 6.1 Introduction

6.1 Introduction 45
Initial nonoperative management of patients with
6.2 Gastrointestinal Bleeding (GIB) 45
acute pathology is commonplace for several dis-
6.3 Intestinal Obstruction 47 orders. Inherent in this decision is the belief that
6.4 Acute Cholecystitis 48 surgery is best performed in a delayed fashion
6.5 Diverticulitis 49
(when conditions are more favorable, both for the
patient and the surgeon) or that surgery can be
6.6 Acute Pancreatitis 50 avoided altogether. However, despite our best
6.7 Clostridium Difficile Colitis 50 intentions, nonoperative management will fail in
Conclusions 51 a certain subset of patients initially believed to
benefit from such an approach. In this chapter, we
Bibliography 51
will discuss when to consider operative manage-
ment (and, consequently, how to recognize that
nonoperative management has failed) for several
common conditions seen by general and acute
care surgeons. Since these topics have already
been described elsewhere in the text, details
regarding epidemiology, diagnostic evaluation,
and specific operative approaches will only
briefly be discussed.

G.A. Watson, MD 6.2 Gastrointestinal

Department of Surgery, University of Pittsburgh Bleeding (GIB)
School of Medicine, Pittsburgh, PA, USA
• Not a viable option for patients who present
A.B. Peitzman, MD (*) with massive gastrointestinal bleeding (GIB)
Mark M. Ravitch Professor and Vice-Chair Chief,
Division of General Surgery, University of Pittsburgh,
and shock: operation resuscitation and
Pittsburgh, PA, USA localization/treatment occur simultaneously
e-mail: in the operating room:

© Springer International Publishing Switzerland 2016 45

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_6
46 G.A. Watson and A.B. Peitzman

– Intraoperative endoscopic evaluation. intervention and 75 % of patients fol-

– Segmental clamping of the bowel to facil- lowing repeat endoscopy.
itate identification of the bleeding • Angioembolization is less effective
segment. (65 % success rate).
– Bowel resection without localization of the • Rebleeding is associated with increased
source is not recommended as the rebleed- mortality and about 10 % of patients
ing rate is high (50 % for hemicolectomy will require operation.
when the source is not localized). – The Forrest classification is a well-
• Indications for surgery in GIB include: described risk assessment for rebleed-
– Failure of nonsurgical hemorrhage control ing based upon ulcer characteristics.
– Ongoing hemodynamic instability The presence of active arterial hem-
– Transfusion of >6 units of blood orrhage (Forrest Ia) or large, non-
– Difficulty cross-matching blood (due to bleeding visible vessel (Forrest IIa)
antibodies) is associated with a substantial
– Suspected or known malignancy (particu- rebleed risk.
larly with gastric ulcer) Ulcers >2 cm, posterior duodenal
– Pathology not correctable without surgery ulcers, and gastric ulcers also have a
(aortoenteric fistula) high risk of rebleeding.
• After successful resuscitation outside the • If a patient has stopped bleeding, has
operating room, the nonoperative approach numerous high-risk factors for
(diagnosis and potentially therapy) is by rebleeding, and is not a prohibitive
endoscopy or interventional radiology: operative risk, surgery is recom-
– Success rates vary depending upon the eti- mended in a controlled, planned set-
ology of the bleed and the modality chosen, ting to avoid the morbidity of emergent
but even if control of hemorrhage is surgery.
achieved initially by nonsurgical means, Other causes are less likely to require
operation may still be necessary. operation:
– Decision-making is complex and requires • Mallory-Weiss tears are self-limited 90 %
an understanding of the perceived risk of of the time, but if intervention is required,
rebleeding, the underlying pathology, the endoscopy is highly successful.
morbidity associated with surgery, and the • Stress gastritis is uncommon in the era of
morbidity/mortality associated with failure acid-suppression therapy and typically is
of observation. successfully managed medically.
– Well-documented risk factors associated • Esophagitis is generally managed med-
with poor outcomes include age >60 years, ically with a high rate of success and
presence of comorbid disease, shock on endoscopy is useful for refractory
presentation, onset during hospitalization, cases.
persistent or recurrent hemorrhage, and • Dieulafoy’s lesion is successfully
need for emergent surgery. treated endoscopically in 80–100 % of
• Overall, 80 % of acute GIB is from an upper cases.
gastrointestinal source and is best discussed in • Bleeding into the bile duct or pancreatic
terms of variceal and nonvariceal causes: duct (hemobilia or hemosuccus pancre-
– Nonvariceal upper GIB: aticus) is generally managed with angi-
Peptic ulcer disease is the most common ography and intervention with high
cause: success rates.
• Hemorrhage is controlled in 80 % of – Variceal-related upper GIB:
patients following initial endoscopic Rarely requires operation.
6 When to Operate After Failed Nonoperative Management 47

Endoscopy is 90 % effective for esopha- eliminated, subtotal colectomy is recom-

geal varices (although repeat may be mended although the mortality is high
required) but is not as effective for gastric (30 %) when performed emergently.
varices. Tumor:
For the 10 % of patients who continue • Usually surgery, ideally nonemergent, is
to bleed or rebleed, transjugular intrahe- required.
patic portosystemic shunting (TIPS) – All patients who undergo angioemboli-
is 95 % effective in controlling bleeding. zation should be followed closely for
Urgent surgical shunts are rarely required signs of mesenteric ischemia (particu-
but can be considered in patients who have larly patients with significant vascular
good hepatic reserve and are not transplant disease), but the overall risk appears to
candidates. be low.
– Lower GIB (LGIB): • Up to one-third of patients with LGIB actually
Colonoscopy is effective in identification have a small bowel source:
of the source in 95 % of cases and has a low – If the patient’s clinical status permits, a
(0.5 %) complication rate. thorough search for the source should
Diverticular disease is the most common be performed before operation is
source. considered.
• Massive lower GIB originates in the
right colon in two-thirds of cases.
• Therapeutic colonoscopy is generally 6.3 Intestinal Obstruction
effective at stopping the bleed acutely.
• If this fails or the patient rebleeds, • Common problem and a frequent source of
angioembolization can be considered admissions to surgical services.
(success rate: 40–85 % of cases, but the • Diverse array of causes described
rebleeding risk is high, particularly if elsewhere.
the small bowel or the cecum is the • Patients most likely to be managed success-
source). fully without operation include those:
• The overall risk of rebleeding at 1 year – With partial obstruction secondary to adhe-
is 10 % but rises to 50 % at 10 years. sions (resolution in as many as 90 % of
• If the diseased segment has been patients but recurrence may be as high as
localized, elective colonic resection 50 %).
is indicated for good surgical – Whose condition derives from an inflam-
candidates. matory disorder (diverticulitis, inflamma-
Angiodysplasia can be diagnosed and tory bowel disease).
treated successfully in most patients with – With early postoperative obstruction.
colonoscopy or angioembolization: – Operation in the setting of simple obstruc-
• Segmental colectomy should be per- tion is associated with mortality of <5 %
formed if the lesion has been localized but rises to 30 % in the setting of necrotic
but continues to bleed. bowel.
• Hemicolectomy without specific local- • Criteria for continued observation or
ization of the source should be avoided operation:
because of the high risk of failure to – 24–48 h should be the upper limit of non-
resect the pathology, with high inci- operative management as the risk of
dence of rebleed. complications rises dramatically and the
• However, if the source is felt to be the likelihood of successful observation
colon, or if all other causes have been diminishes.
48 G.A. Watson and A.B. Peitzman

– Patients who are going to respond to non- – Complete and closed-loop obstructions
operative therapy will generally improve – Presence of peritonitis, pneumatosis, or
within 8–12 h following nasogastric pneumoperitoneum
decompression and resuscitation. – Suspected or confirmed strangulation
Close monitoring, frequent reexamination, – Incarcerated hernia
and perhaps repeat imaging are – Gallstone ileus
warranted. – Nonsigmoid colonic volvulus
• Poor candidates for nonoperative manage- • Criteria that constitute failure of observation
ment include those: include progression to any of the conditions
– With a prior midline incision, colorectal listed above or failure to improve in a timely
operation, retroperitoneal procedure, or a fashion (usually 24–48 h).
history of carcinomatosis • Several scenarios warrant caution and defini-
– With vomiting on presentation and certain tive nonoperative management is ill-advised in:
CT scan findings (intraperitoneal free fluid, – Sigmoid volvulus that responds to initial
mesenteric edema) endoscopic decompression should be
– Worsening abdominal distention or tender- treated surgically to prevent recurrence.
ness, persistently high nasogastric output – Patients with recurrent adhesive bowel
or development of feculent drainage, and obstruction who do not present a prohibi-
decreasing intestinal gas distal to the point tive operative risk likely benefit from semi-
of obstruction on radiographs elective exploration and adhesiolysis.
• In the case of early postoperative small bowel – Patients with partial colonic obstruction,
obstruction, longer periods of observation most often due to cancer, diverticulitis, or
may be tolerated as the risk of strangulation is stricture.
low (<1 %), but nutritional support (total par- – Bowel obstruction in the absence of prior
enteral nutrition) is necessary: abdominal surgery or hernia if improve-
– Condition occurring in approximately ment is not noted with 24 h (likelihood of
10 % of patients who have had abdominal significant anatomic pathology is high. are
surgery and must be distinguished from less likely to improve without operation)
– Almost 90 % of patients will improve with-
out operation, and 70 % will do so within 6.4 Acute Cholecystitis
the first 7 days.
– Indications for reoperation in this setting • Decision to pursue initial medical manage-
include: ment or operate urgently is complex:
Failure to respond within 2 weeks – Depending on the severity of the disease,
Worsening clinical condition the duration of symptoms, and the overall
Progression of obstructive symptoms condition of the patient
• Patients with an inflammatory etiology for • The Tokyo Guidelines, published in 2007,
intestinal obstruction (diverticulitis, radiation represent a severity scoring system which can
enteritis, inflammatory bowel disease) typi- be used to guide clinical decision-making and
cally respond well to supportive therapy and describe three grades of acute cholecystitis:
treatment of the underlying condition, and – Mild (grade 1): acute cholecystitis without
surgery is rarely required. evidence of organ dysfunction
• Generally speaking, clear-cut indications for – Moderate (grade 2): acute cholecystitis
urgent surgical intervention (conditions which with marked local inflammation, mild sys-
are unlikely to improve without operation) temic effects, or prolonged duration
include: (>72 h) of symptoms
6 When to Operate After Failed Nonoperative Management 49

– Severe (grade 3) acute cholecystitis with • For patients with milder forms of disease
organ dysfunction (grades 1–2) who are considered a high
• Indications: operative risk, cholecystostomy may not be
– Early laparoscopic cholecystectomy is rec- required.
ommended for most cases of grade 1 and 2 • Predictors of failure for conservative treat-
disease. ment alone include age >70 years, history
Safe of diabetes, and persistent leukocytosis
Associated with (vs. delayed surgery): >15,000/mm3 at 48 h. Thus, in patients
• Similar conversion rates to open with these risk factors or who fail to
procedure respond rapidly (within 48–72 h) to medi-
• Similar morbidity cal management, percutaneous drainage or
• Shorter hospital stay operation is warranted.
• Less complications of recurrence or
nonresolution (17.5 % of patients)
Recommended for elderly patients (at par- 6.5 Diverticulitis
ticular risk for morbidity if surgery is not
performed during the initial • The Hinchey classification describes four
hospitalization) stages of disease severity which correlate with
– If a nonoperative approach is initially cho- increasing morbidity and mortality and are
sen for patients with grade 1 or 2 acute helpful when considering management
cholecystitis: options. Hinchey stage 1 has small, confined
Close monitoring to detect signs of wors- mesenteric or pericolic abscesses; stage 2 has
ening clinical status or disease progression, larger abscesses often confined to the pelvis;
both of which prompt urgent intervention. stage 3 is purulent peritonitis and implies rup-
Surgery should be performed in patients ture of an abscess; and stage 4 is free diver-
who initially respond to medical manage- ticular rupture with fecal peritonitis.
ment or in recurrence (unless a prohibitive • Initial nonoperative management is indicated
operative risk). for uncomplicated diverticulitis and mild
– For the less common case of grade 3 acute (Hinchey 1 and 2) cases of complicated
cholecystitis or in those patients with diverticulitis:
milder disease (grades 1 and 2) who pres- – Conservative treatment with bowel rest and
ent a prohibitive operative risk, cholecys- antibiotics, even in patients with small
tostomy (percutaneous or operative) is a (<4 cm) abscesses, is usually effective.
viable option: Antibiotics:
Clinical improvement is generally seen • Amoxicillin and clavulanic acid (1 g
within 72 h of drainage and complications and 125 mg) IV, 3 per diem.
are infrequent (10–20 %) although mortal- • If penicillin allergy, ciprofloxacin
ity following the procedure has been 200 mg/12 h + metronidazole 500 mg
reported to be high (5–40 %), likely related every 8 h.
to the severity of the underlying disease • Intravenous antibiotics and fluids are
process. continued for at least 36–48 h until oral
Selection of patients for cholecystostomy feeding is tolerated.
depends on good clinical judgment: • Outpatient oral amoxicillin and clavu-
• Few would argue that patients with lanic acid (875 and 125 mg every 8 h)
severe acute cholecystitis and end-organ for 10 days is also possible.
dysfunction (grade 3) would benefit – Larger (>4 cm) abscesses should be drained
from drainage. as this appears to speed recovery.
50 G.A. Watson and A.B. Peitzman

– Patients whose abscess cavity contains fec- • Indications for surgery (required in 10–20 %
ulent material are unlikely to respond to of patients)
drainage alone and early operative inter- – Infected pancreatic necrosis:
vention should be considered. High suspicion in patients with fever, leu-
– Elderly patients and those who are immu- kocytosis, clinical deterioration, or failure
nosuppressed or immunocompromised are to improve, typically in the second or third
more likely to present with perforation and week after symptom onset.
a lower operative threshold is warranted. Contrast-enhanced CT scan may show gas
• Fewer than 10 % of patients admitted with bubbles within the necrotic pancreas, con-
diverticulitis require operation during the firming the presence of infection.
same admission. Fine-needle aspiration is confirmatory.
• Clear-cut indications for emergent operative • False-negative rate is around 10–12 %,
treatment include generalized peritonitis, so even in the absence of documented
uncontrolled sepsis, the presence of a large, infection (so-called sterile necrosis),
undrainable abscess, uncontained visceral surgery may be required if clinical sus-
perforation, and failure of medical manage- picion remains high.
ment or lack of improvement within 3 days. – Abdominal compartment syndrome
These findings are most characteristic of – Gangrenous cholecystitis
Hinchey stage 3 and 4 disease: • Timing of surgery:
– The overall rate of recurrence is 10–30 % – Surgery during the initial course of the ill-
within a decade of the index presentation, ness (first 2 weeks) is associated with mor-
and most patients (roughly 87 %) who suf- tality rates up to 65 % and should generally
fer one recurrence will not suffer a second. be avoided in the absence of specific
– The presence of a diverticular abscess on indications.
admission (even if drained successfully) and – Delaying intervention at least 2 weeks is rec-
those with multiple comorbid conditions ommended to allow demarcation of necrotic
(including obesity) are significantly more tissue, which limits the extent of surgery and
likely to suffer a recurrence and to require an may reduce the risk of bleeding.
intervention, so a more aggressive approach Mortality rates appear to be substantially
(i.e., elective resection) may be justified. lower (around 25 %) with this approach.
– Patients with diverticular stricture or fistula – In Western countries, gallstones are associ-
may be stabilized initially and evaluated, ated with acute pancreatitis 40–60 % of the
but operation will ultimately be required. time. However, cholecystectomy should be
– Although age less than 50 years had been an delayed until there is significant resolution
indication for elective resection in the past, of the inflammatory response and clinical
more recent data do not support this approach. recovery.
Acute, uncomplicated diverticulitis, even if
recurrent, does not warrant surgery.
6.7 Clostridium Difficile Colitis

6.6 Acute Pancreatitis • Nonoperative management includes:

– Discontinuation of the offending antibiotic
• Most patients present with a mild form of dis- – Metronidazole and/or oral vancomycin
ease and are unlikely to require surgery. • In case of lack of improvement within
• Nonoperative management includes: 3–5 days: operative treatment is indicated:
– Intravenous fluids – Total abdominal colectomy with end
– Antibiotics (debated) ileostomy
6 When to Operate After Failed Nonoperative Management 51

Indications: Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG,
McDonald LC, Pepin J, Wilcox MH, Society for
• Perforation, toxic megacolon with
Healthcare Epidemiology of America, Infectious
impending perforation, severe sepsis or Diseases Society of America. Clinical practice guide-
septic shock, peritonitis, end-organ dys- lines for Clostridium difficile infection in adults: 2010
function, need for vasopressor support, update by the society for healthcare epidemiology of
America (SHEA) and the infectious diseases society
and failure of medical management
of America (IDSA). Infect Control Hosp Epidemiol.
– Or diverting loop ileostomy with antegrade 2010;31(5):431–55.
colonic lavage Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson
Indications: BR. Meta-analysis of randomized controlled trials on
the safety and effectiveness of early versus delayed
• Need for ICU admission, hypotension
laparoscopic cholecystectomy for acute cholecystitis.
requiring vasopressor support, neurologic Br J Surg. 2010;97:141–50.
changes, respiratory failure necessitating Hayanga AJ, Bass-Wilkins K, Bulkley GB. Current man-
mechanical ventilation, increasing WBC agement of small-bowel obstruction. Adv Surg.
count ≥20,000/mm3, lactate concentra-
Hirota M, Takada T, Kawarada Y, et al. Diagnostic criteria
tion ≥5 mmol/L, and other signs of end- and severity assessment of acute cholecystitis: Tokyo
organ dysfunction guidelines. J Hepatobiliary Pancreat Surg.
– Both procedures can be performed 2007;14:78–82.
Jacobs DO. Clinical practice. Diverticulitis. N Engl J
Med. 2007;357(20):2057–66.
Millward SF. ACR appropriateness criteria on treatment
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Olivas AD, Umanskiy K, Zuckerbraun B, Alverdy
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Strasberg SM. Clinical practice. Acute calculous chole-
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Lankisch PG, Carter R, Di Magno E, Banks PA,
Whitcomb DC, Dervenis C, Ulrich CD, Satake K,
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Part II
Laparoscopy for Non-trauma
Emergencies 7
Selman Uranues and Abe Fingerhut

7.1 Ergonomics 56
7.1.1 Patient Position and Preparation 56 • Know how to position and prepare the
7.1.2 Surgeon and Table Position 56 patient.
7.1.3 Monitor and Screen Position 56
7.1.4 Trocar Setup, Creation
• Know how to get open access to the
of Pneumoperitoneum, and peritoneal cavity/first trocar.
Instrumentation 57 • Know how to explore the abdominal
7.2 Exploration of the Abdominal Cavity 58 cavity.
• Know how to expose solid organs and
7.3 Indications 58
7.3.1 Acute Cholecystitis 58
hollow viscus.
7.3.2 Perforated Gastroduodenal Ulcer 59 • Know how to control bleeding and
7.3.3 Acute Appendicitis and Acute Pelvic contamination.
Problems in the Female 59 • Know the principles of laparoscopic
7.3.4 Complicated Diverticular Disease 60
7.3.5 Intestinal Obstruction 60
bowel resection and anastomosis.
7.3.6 Incarcerated/Strangulated Hernias 61 • Know the principles of laparoscopic
7.3.7 Mesenteric Ischemia 61 lavage and abdominal drainage.
7.3.8 Peritonitis 61
7.3.9 Iatrogenic Perforations 62
7.3.10 Immediate Laparoscopy for Postoperative
Complications After Initial Laparotomy/
Laparoscopy Operations 62 Since its initial description in 1985, laparoscopy
Selected Reading 62 has acquired an increasing place in the diagnostic
and therapeutic emergency setting and now has
well-defined indications in the armamentarium of
surgery for acute diseases. Laparoscopy is not
S. Uranues, MD, FACS (*) only a technical variant or an additional therapeu-
Professor and Head, Section for Surgical Research,
tic option; it has become a genuine component of
Clinical Division for General Surgery, Medical
University of Graz, University of Graz, Graz, Austria the array of surgical treatment.
A. Fingerhut, Doc hon c, FACS, FRCS(g), FRCS(Ed)
Department of Surgical Research, Clinical Division
for General Surgery, Medical University of Graz,
Graz, Austria

© Springer International Publishing Switzerland 2016 55

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_7
56 S. Uranues and A. Fingerhut

7.1 Ergonomics • Patient should be prepped and draped in order

to correctly deal with any unexpected findings
• Are important issues and directly affect and intraoperative accident or to convert with-
outcomes out delay.
• Entail patient position and preparation, the
surgeon and table position, the operating room
(OR) setup, the trocar setup, and the instru- 7.1.2 Surgeon and Table Position
ments and technology needed
• The patient, table, and monitor should be posi-
tioned so that full access can be obtained to all
7.1.1 Patient Position four quadrants of the abdomen as required
and Preparation (Fig. 7.1).
• The surgeon should be able to move to either
• The patient is positioned supine, legs spread side or between the legs as necessary or
apart allowing the (assisting) surgeon to preferred.
stand between the legs enabling access to any • The table should allow inclination or tilting as
point of the abdominal cavity including the necessary.
• Precautions must be taken so that the patient
does not slide when the table is inclined or 7.1.3 Monitor and Screen Position
• Pressure points should be protected. • Optimal ergonomics call for:
• Arms in adduction especially in emergencies – A flat screen placed at 15° below eye level
of the lower abdomen or pelvis. (or at the gaze-down level, i.e., at the level
• Routine bladder catheter inserted (not only of the surgeon’s elbows).
when lower abdominal procedures are indi- – The monitor placed so that the surgeon’s
cated but also because the duration of the pro- vision, hands, target, and screen are
cedure is often unknown). aligned.

Fig. 7.1 Setup of the

operating table and the
positioning of the patient
7 Laparoscopy for Non-trauma Emergencies 57

– Either several monitors or the video moni-

tors should be mobile and moved accord-
ing to the site of the pathology to maintain
the [ideal] alignment necessary for optimal
ergonomic conditions.

7.1.4 Trocar Setup, Creation

of Pneumoperitoneum,
and Instrumentation

• Trocar setup:
– Initial trocar layout depends on clinical
findings and diagnostic probabilities:
Triangulation is recommended to allow
resection and adequate suturing as
Lateralization of trocar insertion is recom-
mended in case of intestinal distension
(intestinal obstruction or ileus secondary to
peritonitis or abscess).
Avoid insertion through previous scars Fig. 7.2 Trocar positions for diagnostic laparoscopy
(incisions or drainage sites) for the first
trocar. Insufflation should be stopped immediately
Add additional trocars as needed. in case of any drop in blood pressure, unex-
– Should allow full and unrestricted explora- plained tachycardia, or rise in respiratory
tion of the entire abdominal cavity as pressure.
necessary If the patient stabilizes, laparoscopy can be
– First trocar insertion: resumed but with extreme caution (reduced
Routine open approach is strongly recom- abdominal pressure and close monitoring).
mended (without use of the Veress needle), • Instruments
especially when there is considerable intes- – 30° scopes are recommended:
tinal distension. The 10 mm scope offers better lighting and
The periumbilical approach is recom- view.
mended in case of diagnostic doubt, unless The 5 and 3 mm laparoscopes offer less
prior surgery indicates otherwise. trauma but reduced lighting and view.
– Further trocars can be inserted once • Essential instrumentation includes:
a preliminary survey of the entire – 3, 5, 10, and 12 mm ports
abdominal cavity has shown that there is – Atraumatic grasping forceps and clamps
no need to abort or to convert to a – Right-angle forceps
laparotomy. – Titanium and absorbable clips
Two trocars are placed on the right and left – At least two needle holders
and lateral to the rectus muscle sheath at – Energy-driven devices for hemostasis and
the level of the umbilicus (Fig. 7.2). cutting according to availability and sur-
• Pneumoperitoneum geon preference
– Should be established progressively, under – Scissors
close monitoring: – Adequate suction-irrigation device
58 S. Uranues and A. Fingerhut

– Suture material and endoloops 7.3.1 Acute Cholecystitis

– Umbilical or vascular tapes
– Rubber drains, tourniquets, clamps and • Acute cholecystitis requires cholecystectomy.
bulldog clamps, and bowel and vascular – Cholecystectomy for acute cholecystitis
clamps can be challenging because of:
– Plastic bags for the extraction of the opera- – Inflammation (difficult dissection) of the
tive specimen as required gallbladder
Increased bleeding
Fragility (perforation is possible)
7.2 Exploration Adhesion to adjacent organs
of the Abdominal Cavity Altered anatomy
• Timing of operation
• Hemostasis – Although still debated, most authors agree
– Active bleeding in unstable patients that early (within 7 days of onset of signs)
requires open surgery. cholecystectomy appears to be safe and
– Otherwise, in stable patients: shortens the total hospital stay. In fact, as
Small vessels can be closed with clips or long as the patient is in good general health
with 3/0 monofilament sutures or with and there is no major anesthesia problem,
modern coagulation devices (ultrasonic early cholecystectomy can be performed
devices or Ligasure™). within 48 h from onset.
Large wound surfaces and lacerations of – Delaying cholecystectomy results in sig-
solid organs can be sealed quickly and nificantly higher conversion rates, surgical
effectively with autologous fibrin adhesive postoperative complications reoperation
(Tisseal®, Baxter) and tamponed in rates, and significantly longer postopera-
combination with a fleece (Hemopatch®, tive hospital stay, without any advantages.
Baxter). • Of note, the main biliary ducts are at increased
More active bleeding can temporarily be risk in acute cholecystitis, and this warrants
stopped by applying pressure followed by particular attention.
FloSeal® for permanent hemostasis. – As the critical view of safety (Fig. 7.3) is
more difficult and the demarcation of
Rouvière’s sulcus is present in only 70 %
7.3 Indications of patients, anterograde dissection, intraop-
erative cholangiograms (Fig. 7.4), and/or
The wide range of disease that may be diagnosed the use of indocyanine green is strongly
and treated by emergency laparoscopy includes recommended to landmark and delineate
acute cholecystitis, perforated duodenal ulcer, the biliary tree. Indocyanine green cholan-
appendicitis and other causes of acute right lower giography has the advantage of delineation
quadrant pain including adnexal disease, compli- before any dissection takes place.
cated diverticular disease, intestinal obstruction • Ideal treatment is based on the acute cholecys-
including intussusception, incarcerated or stran- titis Tokyo consensus guidelines:
gulated inguinal or incisional hernia, peritonitis – Grade I (mild acute cholecystitis, with no
of all origins, iatrogenic perforations, suspicion organ dysfunction and limited disease
of mesenteric ischemia, as well as certain postop- – Grade II (moderate acute cholecystitis:
erative complications. extensive inflammation but no organ
If the diagnosis is not recognized beforehand, dysfunction)
the surgeon should note the area of maximal – Grade III (severe acute cholecystitis includ-
inflammation, concentration of pus, or blood, as ing gangrenous cholecystitis or empyema
in the case of ruptured ectopic pregnancy. with organ dysfunction).
7 Laparoscopy for Non-trauma Emergencies 59

7.3.2 Perforated Gastroduodenal


• Laparoscopic repair is feasible and should

result in less postoperative pain and surgical
site morbidity.
• The treatment of choice is simple closure of
the perforation (Fig. 7.5) and adequate medi-
cal treatment of Helicobacter pylori.
– Sutures, glue, and/or omentum, sometimes
– A hybrid procedure consists of drawing the
omentum through the perforation by means of
an endolumenal endoscope.
– Open repair might be better when:
Patients are hemodynamically unstable.
Patients are at risk for pneumoperitoneum.
Patients have already undergone previous upper
GI surgery needing extensive adhesiolysis.
More extensive time-consuming operations
Fig. 7.3 Intraoperative view during laparoscopic chole- are necessary.
cystectomy showing critical view of safety with cystic Patients are at high risk (two or more Boey
duct and artery at Calot’s triangle
risk factors).
Chronic ulcer with a diameter of more than
20 mm is present.

7.3.3 Acute Appendicitis and Acute

Pelvic Problems in the Female

• Laparoscopic appendectomy (vs. open):

– Can be advantageous in the obese and the
– Can be performed in the pregnant women,
but care is warranted to adjust trocar inser-
Fig. 7.4 Intraoperative cholangiogram showing the anat- tion to uterine height.
omy and (unexpected) common bile duct stones

• Both grades I and II (mild and moderate)

cholecystitis can ideally be treated by
laparoscopic cholecystectomy. In case of
intraoperative difficulties subtotal cholecys-
tectomy can be performed (although there are
no proven advantages).
• Both grades II and III (moderate and severe)
in high-risk patients can be treated by transhe- Fig. 7.5 Closure of a perforated acute post-pyloric peptic
patic drainage (cholecystostomy). ulcer with two stitches
60 S. Uranues and A. Fingerhut

– Stump closure is no longer a matter of 7.3.5 Intestinal Obstruction

debate: recent studies have reversed the
purported advantages of staplers used rou- • Laparoscopy can be indicated for obstruction
tinely, and these should be reserved for related to adhesions or bands.
patients when loop closure seems difficult • It is of prime important to avoid all abdominal
or inappropriate (stump necrosis) or there scars for the creation of pneumoperitoneum
is need for rapid closure. Higher costs for and/or initial trocar insertion.
the staplers, however, must be considered, • The first trocar insertion should be performed
and loop-closure is often chosen instead “open.” at a location at a distance from the
• Adnexal torsion and ruptured ectopic expected site of obstruction, if possible avoid-
pregnancy: ing any scars.
– Ideal settings for emergency laparoscopic • Intraoperatively, caution is warranted when
surgery. running the distended intestinal loops.
– Patient must be hemodynamically stable. – The fragile serosa renders grasping and
– Requires specific equipment (vacuum, spe- retraction dangerous. Tilting the table is of
cial suction probe) for tubal preservation. great help to move the distended and heavy
bowel loops. The bowel should only be
grasped at the mesenteric attachments
7.3.4 Complicated Diverticular (Fig. 7.6). It is recommendable first to find
Disease the collapsed loops and run them orally
(Fig. 7.7).
• Hinchey stages I and IIa can be treated medi- – Special atraumatic dissectors (Maryland)
cally, sometimes combined with percutaneous and retractors are a wise precaution.
drainage. – Angled scopes may be useful for optimal
• Patients with persistent septic signs after drain- viewing behind and lateral to adhesions,
age and in those with Hinchey IIb, Hinchey III especially when mobilization of bowel is
and IV require surgical treatment. difficult.
– Laparoscopic treatment has been shown to – Extreme caution is warranted in case of
be safe and as effective as open treatment vascular compromise and/or necrotic
for Hinchey IIb and III. bowel, as it is preferable to convert
– Source control consisting of resection of rather than to provoke a rupture with
the perforated colon segment, with or with-
out immediate anastomosis, is still the
standard treatment and can be performed
– However, some surgeons advocate simple
laparoscopic lavage, associated or not with
suture and/or drainage, the goal being to
avoid a major bowel resection and poten-
tially a stoma:
Quantity: four liters of saline followed by
drainage plus antibiotic therapy.
Decreases mortality and morbidity (partic-
ularly surgical site complications).
Suture or fibrin glue closure of the perfora-
tion (if obvious) can be attempted, some-
times reinforced with an omental patch. Fig. 7.6 Exploration of distended small bowel loops
Usually no further surgery is required. grasped at the mesenteric attachments
7 Laparoscopy for Non-trauma Emergencies 61

• Either TEP or TAPP can be performed. but

many surgeons would not recommend insert-
ing prosthetic material in case of incarcerated
hernia with intestinal necrosis or if resection is
• Laparoscopy has been used to repair compli-
cated and/or nonreducible retro-xiphoid,
Morgagni or diaphragmatic hernias, parae-
sophageal hernias, rare acute abdominal wall
hernias, such as supra-vesical and Spigelian,
or obturator hernias, internal hernias.

Fig. 7.7 Search for obstruction site by running the small 7.3.7 Mesenteric Ischemia
bowel loops orally
• As intestinal ischemia occurs most often in the
elderly, frequently with comorbidity, diagnos-
tic laparoscopy may be better tolerated (than
• Of note, however, creation of pneumoperito-
neum may have a potentially adverse effect on
mesenteric blood flow: low intra-abdominal
pressure is recommended.
• After bowel resection with primary anastomo-
sis trocars may be left in place to accomplish a
second-look procedure, if indicated.

7.3.8 Peritonitis
Fig. 7.8 Laparoscopic resection of a small bowel tumor
causing obstruction. A stapled anastomosis is created with
endostapler before resection • Performed more and more often in peritonitis
by skilled laparoscopic surgeons, laparoscopy
can be an excellent choice to perform source
inundation of the peritoneal cavity with control (perforation closure, resection), reduc-
septic contents. tion of bacterial contamination (lavage), and
If necessary, intestinal resection with anas- prevention of persistent or recurrent infection.
tomosis may be performed via laparoscopy, • Under low-pressure pneumoperitoneum not
but by using bulldog bowel clamps, spill- exceeding 12 mmHg, laparoscopic aspiration of
age of septic intestinal contents has to be gross purulent exudates, fecal debris, food parti-
avoided at all costs (Fig. 7.8). cles, and intraperitoneal lavage is possible.
Timing is important, as laparoscopy is best
adapted to recent onset and localized peritonitis.
7.3.6 Incarcerated/Strangulated • All lavage fluid should be completely aspi-
Hernias rated before the abdominal cavity is closed.
• The advantages of laparoscopic treatment of
• Only cohort and case series studies have been peritonitis include:
published on laparoscopic repair of incarcer- – Complete exploration of the abdominal
ated groin hernias. cavity with minimal parietal insult.
62 S. Uranues and A. Fingerhut

– Most causes of peritonitis (perforated duo- bariatric surgery, reiterative adhesions, anas-
denal ulcer, perforated appendicitis, perfo- tomotic leakage after colectomy, and gastrec-
ration in diverticular disease, postoperative tomy. Of importance is the timing (as early as
leakage after index laparoscopic opera- possible), the atraumatic handling of the gas-
tions) can, if done quickly after onset, be trointestinal tract, and surgeon’s level of expe-
treated adequately via laparoscopy. rience in advanced laparoscopy.
– Whenever needed, stoma may be fashioned
Selected Reading
7.3.9 Iatrogenic Perforations
Laparoscopic Treatment of the Acute
• Laparoscopy is an ideal method to treat iatro-
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Eric J. Voiglio, Guillaume Passot,
and Jean-Louis Caillot

Contents 8.5.3 Volvulus 74

8.5.4 Intussusception 75
8.1 Preparation of the Abdomen 66 8.5.5 Neoplasms 75
8.1.1 Shave Prep 66
8.1.2 Skin Disinfection 66 8.6 Bowel Ischemia 76
8.1.3 Draping 66 8.6.1 Localized Bowel Ischemia 76
8.6.2 Diffuse Bowel Ischemia 76
8.2 Abdominal Incisions 66
8.2.1 Midline Incisions 66 8.7 Peritoneal Toilet and Intra-abdominal
8.2.2 Oblique and Transverse Incisions 68 Drains 76
8.2.3 McBurney Incision 69 8.7.1 Toilet 76
8.7.2 Drains 76
8.3 Exposure of Solid Organs
and Hollow Viscus 70 8.8 Abdominal Closure 79
8.3.1 Gallbladder 70 8.8.1 After Incarcerated Hernia 79
8.3.2 Liver 70 8.8.2 Surgical Incision Closure 80
8.3.3 Abdominal Esophagus 70
8.3.4 Spleen 71 8.9 Special Situations 81
8.3.5 Right Colon 71 8.9.1 Decompressive Laparotomy 81
8.3.6 Pancreas 72 8.9.2 Open Abdomen Technique 81
8.3.7 Left Colon 72 8.9.3 Enterocutaneous Fistulas 81

8.4 Source Control 72 Selected Reading 82

8.4.1 Bleeding 72
8.4.2 Contamination 73
8.5 Bowel Obstruction 74
8.5.1 Adhesions 74
8.5.2 Incarcerated Hernia 74

E.J. Voiglio, MD, PhD, FACS, FRCS (*)

G. Passot, MD, MSc • J.-L. Caillot, MD, PhD
Service de Chirurgie d’Urgence, Centre Hospitalier,
Lyon 69495, France

© Springer International Publishing Switzerland 2016 65

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_8
66 E.J. Voiglio et al.

8.1.3 Draping
• Be able to perform a midline laparotomy • Apply sterile impervious drapes to expose the
• Be able to perform an oblique or trans- entire abdominal wall (from nipples to pubic
verse laparotomy symphysis and far behind in the flanks).
• Be able to perform a McBurney incision – Rationale: possibility of extended incision,
• Know how to get access to the perito- making another incision or insertion of
neal cavity drains and/or stoma formation
• Know how to expose solid organs and – Meticulously, being sure that the skin at
hollow viscus umbilicus is dry in order to prevent adhe-
• Know how to control bleeding and sive drape lift
• Know the main causes of mechanical
obstruction 8.2 Abdominal Incisions
• Know the principles of surgical man-
agement of bowel ischemia • Remember: the coagulation mode of the elec-
• Know the principles of peritoneal toi- tric bistoury is meant to coagulate and the cut-
lette and abdominal drainage ting mode to cut. Coagulation is a third-degree
• Know how to close the abdomen burn, and inappropriate use of coagulation
• Know how to manage special situations while opening the abdominal wall jeopardizes
as abdominal compartment syndrome or healing of the operative wound.
enterocutaneous fistulas

8.2.1 Midline Incisions

• Xipho-pubic midline incision: incision of

8.1 Preparation of the Abdomen choice for exploratory laparotomy
– Gives access to all quadrants of the abdomen.
8.1.1 Shave Prep – When the nature of the pathology is in
doubt (and laparoscopy not available or
• Still debated today. contraindicated), begin the incision a few
• Most surgeons prefer depilatory creams, but in centimeters above and below the umbili-
the emergency setting, preoperative hair cus, and, according to the findings, extend
removal still has its proponents (as close to upward or downward.
surgery as possible and not in the OR). – If kept strictly midline, the incision will not
encounter any named vessel or nerve, only
one layer of fascia is cut, reducing the risk of
8.1.2 Skin Disinfection hematoma, preventing the risk of paralytic
hernia, and minimizing the risk of infection.
• Abdominal wall is cleaned with topical anti- • In case of previous midline laparotomy, adhe-
septic solutions. sions with underlying omentum or viscera are
– From nipples to external genitalia. frequent.
– Far behind in the flanks on each side to the – It is advisable to enter the abdomen through
table. an inviolated area.
– Be aware of adverse reactions and – In case of previous xipho-pubic incision,
incompatibilities. prefer the upper part of the abdomen to
– Leave adequate time for the antiseptic to enter, as the liver and stomach are fre-
dry completely (DO NOT blot or wipe quently easier to divide from parietal peri-
off!). toneum than the colon or small bowel.
8 Laparotomy 67

Procedure (Fig. 8.1): 9. Make a small hole in the peritoneum.

1. Place a pad on each side of the planned • Keep edges of fascia lifted and enlarge
incision. the hole; one finger cephalad and caudad
2. Maintain equal traction on each side and use the to be sure there is no adhesion under the
scalpel to cut vertically, straight on the midline. incision.
3. Incise to the left of the umbilicus, then • Scalpel can be used to cut up to the peri-
straight up and down. toneum, but most of the surgeons prefer
4. Cut the subcutaneous tissue, and expose the to use cautery (if so, use the section and
subcutaneous fat with pads on each side. not the coagulation mode).
5. Apply traction on each side with hooked fin- 10. In case of peritonitis:
gers on the pads to open the fat on the mid- • Withdraw liquid for analysis.
line and expose the linea alba. • Protect the abdominal wall from con-
6. Use bipolar cautery or monopolar coagula- tamination by placing wet pads in the
tion on forceps to selectively secure bleeding peritoneal cavity on each side of the
points. incision while enlarging the peritoneal
7. Identify (crossing fibers) and cut the linea opening.
alba with the scalpel on the entire length of 11. Keeping the edges of fascia lifted, ligate and
the incision without opening the peritoneum divide the ligamentum teres and incise the
(this prevents contamination of the abdomi- falciform ligament with cautery.
nal wall in case of peritonitis). 12. Place a plastic wound drape and remove the
8. Lift both edges of fascia with one or two Kocher clamps.
Kocher clamps on each side. 13. Place self-retaining retractors.

Fig. 8.1 Steps of midline xipho-pubic incision

68 E.J. Voiglio et al.

8.2.2 Oblique and Transverse oblique incision by another, or even cutting

Incisions parallel to a previous transverse or oblique
incision, may lead to acute necrosis of the
• Nerves and arteries (consequences): abdominal wall between the incision lines
– The intercostal nerves (T5 to T12) run (Fig. 8.4).
medially and caudad within the abdominal – Even if this severe complication is avoided,
wall. Division may result in weakness of incisional hernia is most probable.
the involved part of the abdominal wall, • Transverse incision should be performed only
potentially leading to paralytic hernia when the intra-abdominal affection is known,
(Fig. 8.2). as extension of the incision is difficult if not
– Intercostal arteries together with superior impossible.
and inferior epigastric arteries provide the • As closure involves several muscular and fas-
vascularization of the abdominal wall. cial layers, oblique and transverse incisions
– Whenever performing an incision other are reputed to create less incisional hernia.
than midline, try to avoid nerves and arter-
ies, i.e., incisions should be oblique medi- Procedure
ally and caudad remain laterally to the 1. Place a pad on each side of the planed inci-
rectus abdominis. sion; this should be at least 4 cm below the
– Strictly transverse incisions are a good costal margin.
compromise, as only one or two nerves are 2. Maintain equal traction on each side and use
sacrificed (Fig. 8.3). the scalpel to cut vertically.
– Avoid incisions of the abdominal wall that 3. Cut the subcutaneous tissue, and expose the
interrupt nerves and/or vessels. subcutaneous fat with pads on each side.
• In a patient with a previous transverse or Proceed down to the fascia.
oblique incision:
– Use a midline or the same transverse or
oblique incision: crossing a transverse or

Fig. 8.2 Oblique incisions that interrupt nerves lead to Fig. 8.3 Strictly transverse incisions preserve abdominal
paralytic hernia wall nerves
8 Laparotomy 69

(b) Protect the abdominal wall from con-

tamination by placing wet pads on either
side of the incision while enlarging the
opening (fascia and peritoneum).
10. Place a wound plastic drape and remove the
Kocher clamps.
11. Place self-retaining retractors.

8.2.3 McBurney Incision

• This incision, used on the right side for appen-

dectomy and on the left side for the Bouilly-
Volkmann procedure, is, in fact, a short
oblique incision.
– If performed laterally to the rectus abdomi-
nis muscle, and after dividing the fascia of
the external oblique muscle, the fibers of
the internal oblique and transverse muscles
can be gently separated to give access to
the peritoneum.
Fig. 8.4 Two parallel transverse incisions lead to abdom-
inal wall inschemia between the incision lines • As no muscle is cut (as long as the incision
does not need to be extended), the risk of her-
nia is minimal.
4. Use bipolar cautery or monopolar coagula-
tion on forceps to selectively secure bleeding Procedure
points. 1. The classic McBurney incision is perpen-
5. Incise the fascia of the external oblique mus- dicular to a line drawn from the anterosupe-
cle and the anterior rectus sheath. If the inci- rior iliac spine to the umbilicus, crossing this
sion is short, the fibers of the rectus abdominis line at the junction of medial and lateral
can be retracted medially. If needed, cut the thirds. The Rocky-Davis incision is a hori-
fibers with the scalpel and selectively coagu- zontal variant, more cosmetic and easier to
late the smaller vessels and ligate the larger extend.
vessels. The fibers of the internal oblique 2. Incise the skin with the scalpel.
muscle can usually be separated, exposing 3. Cut subcutaneous fat, fascia superficialis,
the fascia of the transversalis muscle in conti- and deep fat layer with scissors.
nuity with the posterior rectus sheath. 4. Place Farabeuf-type (flat right-angled
6. Lift the transversalis muscle fascia with two blades) retractors and expose the fascia of
Kocher clamps. the external oblique muscle. Clean the fat
7. Create small hole in the fascia and closely with a pad.
attached parietal peritoneum. 5. Coagulate bleeding points as necessary.
8. Keeping the fascia edges lifted, enlarge the 6. Incise the fascia of the external oblique
hole, introduce a curved finger up and down muscle parallel to its fibers. Remain strictly
to ensure there is no adhesions under the lateral to the rectus abdominis and do not
incision. open its sheath. If underlying fascia is visi-
9. In case of peritonitis (a midline incision ble, do not incise it: retract outward to
would have been advisable), expose muscular fibers of the internal
(a) Withdraw sample for analysis. oblique muscle.
70 E.J. Voiglio et al.

7. Split the muscular fibers of internal oblique 8.3.2 Liver

muscle by blunt dissection with large scis-
sors. If underlying fascia is visible, do not • To get access to the liver, make a large right
incise it: retract outward to expose muscular transverse subcostal incision, extended to left
fibers of transversalis muscle. Split the mus- or midline. Proceed with ligamentum teres as
cular fibers by blunt dissection with large for gallbladder exposure leaving about 5 cm of
scissors. ligamentum teres attached to the liver allows
8. Gently place the retractors to maintain the for gentle traction if needed. Cut (with cau-
opening down to the peritoneum, clear fat tery) the falciform ligament above the liver as
with a gauze. far to the rear as it remains thin (when it wid-
9. Grasp the cleaned peritoneum with two ens, middle and left hepatic veins are just
curved clamps and pull it out through the behind). Place a fixed retractor. Cut the chole-
hole up to the skin. Be sure that no viscus has cystoduodenocolic ligament.
been included in the grasp, and make a small • Open the lesser omentum to get access to the
hole with scissors. bursa omentalis. Passing a finger behind the
10. By pulling on each clamp, enlarge the hole. hepatic pedicle through the foramen bursae
11. Pull the peritoneum up to the skin with omentalis is the first step of the Pringle
clamps to protect the muscular wall from maneuver.
infection. • To mobilize the left lobe, cut (cautery) the left
12. Leave the clamps attached to the peritoneal triangular ligament, gently pulling the left
edge and place retractors in the peritoneum. lobe downward and medially. To protect the
abdominal esophagus, place a wet pad behind
the left triangular ligament before division.
The triangular ligament widens as it continues
8.3 Exposure of Solid Organs to the right, becoming the coronary ligament.
and Hollow Viscus Cautiously continue the dissection to the right
with scissors.
8.3.1 Gallbladder • To mobilize the right lobe, lift and rotate the
right part of the liver medially, in order to
• When entering the peritoneal cavity through a stretch the right triangular and coronary liga-
midline incision, access to the gallbladder and ments and divide them (cautery) close to the
right hepatic lobe is blocked by the ligamen- liver cautiously as you progress to the left
tum teres and falciform ligament; these struc- (use then scissors) where the inferior vena
tures must be divided as above. cava, accessory, and right hepatic veins will
• When entering through a transverse (or appear.
oblique) incision, division of the ligamentum
teres is not mandatory.
• Apply gentle traction with a wet abdominal 8.3.3 Abdominal Esophagus
pad and flat blade retractor on
– The transverse colon and the duodenum • A nasogastric tube should be placed.
caudad • Through an upper midline incision, proceed as
– The stomach to the left explained before to mobilize the left hepatic
• Divide the cholecystoduodenocolic ligament lobe. Hold it to the right with a retractor.
whenever present to expose the subhepatic • The esophageal hiatus of the diaphragm and
space. the esophagocardial junction are exposed.
• A third flat blade retractor placed at the infe- • Incise the peritoneum on the anterior aspect of
rior aspect of the liver left to the gallbladder the esophagus, caution being exercised not to
may improve exposure. injure the anterior vagal nerve.
8 Laparotomy 71

• Proceed gently with blunt dissection of the 6. Dissect, ligate, and divide the left gastroepi-
abdominal esophagus. At the posterior aspect of ploic vessels.
the esophagus, the posterior vagal truck is pal- 7. Ligate and divide the splenocolic ligament.
pable, and blunt dissection should pass behind it. • Ligation and division of the splenic vein
• Encircle the esophagus with an abdominal before mobilization is an option.
(vascular) tape. 8. Mobilize the spleen passing your left hand
between the diaphragm and the spleen (easy
of no adhesions) and rotate the spleen
8.3.4 Spleen medially.
9. Incise the peritoneal reflexion in order to
• The spleen is attached expose the posterior aspect of the tail of
– To the stomach by the gastrosplenic ligament, pancreas.
which contains 2–10 short gastric arteries and 10. If not done previously, ligate the splenic vein.
veins in the upper part and left gastroepiploic
artery and veins in the lower part, the lower Mobilization of the Spleen First
part is continued by the gastrocolic ligament This procedure is preferred to remove a bleeding
right and the splenocolic ligament left. spleen or when repair of a damaged spleen is
– To the left colic flexure by the (short) sple- attempted.
nocolic ligament.
– To the tail of the pancreas by the pancreati- 1. Wrap the spleen with a pad and grasp it with
cosplenic ligament (contains splenic artery your left hand.
and vein). 2. Clamp the splenocolic ligament on the colic
– To the diaphragm and left kidney by an side and divide it.
avascular fascia named phrenicosplenic 3. Wrap the inferior pole of the spleen with the
and splenorenal ligaments. pad.
• To mobilize the spleen, there are two options: 4. Rotate the spleen medially.
– Ligation of the splenic artery before mobi- 5. Incise the peritoneal reflexion (or force the
lization of the spleen way with your fingers) to divide the avascular
– Mobilization of the spleen followed by splenophrenic ligament.
ligation of the splenic artery 6. Expose splenic artery and vein at the posterior
• Expose the operative field with a retractor aspect of the tail of pancreas and clamp.
under the left costal arch. 7. Mobilization of the spleen is terminated by
putting wet pads in the splenic fossa to lift the Ligation of the Splenic Artery spleen and dividing the gastrosplenic ligament
First (and ligated short vessels).
1. Divide the gastrocolic omentum between the
stomach and the gastroepiploic arcade near
the left colic flexure. 8.3.5 Right Colon
2. Proceed dividing the avascular part of the
gastrosplenic ligament right to the gastroepi- 1. Expose the operative field with a self-retaining
ploic vessels. The created window opens the retractor.
bursa omentalis in front of the pancreatic tail. 2. Grasp the cecum and retract it medially, dis-
3. Incise the parietal peritoneum at the upper playing the peritoneal reflexion.
border to expose the splenic artery. 3. Incise the peritoneal reflexion to open Toldt’s
4. Gently dissect and ligate the splenic artery. fascia caudad to the right colic flexure.
5. Dissect each of the short vessels in the upper Caution is exercised to stay close to the colon,
part of the gastrosplenic ligament, ligate, and in order to avoid the ureter below and the duo-
divide them. denum above.
72 E.J. Voiglio et al.

4. Divide the gastrocolic ligament below the vas- 5. After identification of inferior mesenteric
cular gastric arcade and get access to the bursa vein, detach the body and tail of the pancreas
omentalis at the level of the distal antrum. by blunt dissection.
5. If present, divide cholecystoduodenocolic 6. According to the planned procedure, splenic
ligament. artery and vein are lifted with the pancreas
6. Proceed from left to right to mobilize the right together with the spleen (see mobilization of
part of the transverse colon, ligating all epi- the spleen), or separated from the pancreas by
ploic vessels. cautious blunt dissection and ligature of pan-
7. Clamp the right parietocolic ligament and creatic branches and left with the spleen.
divide it. Exercise caution when tracing the
right colic flexure, not to tear the gastrocolic
vein at the anterior aspect of the pancreatic 8.3.7 Left Colon
head (hemostasis extremely difficult): gently
tie and divide it. 1. Lift the sigmoid colon medially and cephalad
8. Right colon is fully mobilized. and free the colon from adhesions with pari-
etal peritoneum and internal genital organs in
8.3.6 Pancreas 2. Incise the root of the sigmoid mesocolon on
the left aspect and identify the ureter where it Mobilization of the Duodenum crosses the bifurcation of iliac artery.
and Head of Pancreas (Kocher’s 3. Incise from caudad cephalad the peritoneal
Maneuver) reflexion and open Toldt’s fascia by blunt dis-
1. Expose the operative field with a self-retaining section, until mobilization of descending colon
retractor. becomes difficult and dangerous for the spleen.
2. Mobilize the right colic flexure caudad and 4. Create a window in the gastrocolic ligament
medially (see right colon): this will expose the below the gastric vascular arch, serially ligat-
duodenum and the head of the pancreas. ing the epiploic vessels from right to left until
3. Incise the peritoneum along the duodenum to you reach the splenocolic ligament.
open the Treitz fascia and lift the duodenum 5. Divide the splenocolic ligament progressing
and head of the pancreas by blunt dissection alternately from right to left and left to right
while rotating them medially in order to until left colic flexure is fully mobilized.
expose the inferior vena cava. Exposure of the Body and Tail 8.4 Source Control

of the Pancreas
1. Open the bursa omentalis by tying off and 8.4.1 Bleeding
dividing the epiploic vessels from the level of
distal antrum to gastrosplenic ligament. • As in trauma surgery, stopping any bleeding is
(Another option is to dissect greater omentum top priority.
from the transverse colon to gain access to the • What differentiates nontrauma emergency
bursa omentalis). surgery from trauma surgery is that the source
2. Divide the gastrosplenic ligament up to the of bleeding is often not evident once the abdo-
short vessels. men is open, and therefore preoperative inves-
3. Retract the stomach upward and divide the tigations as endoscopy or angio-CT scan are
avascular folds between posterior aspect of the very useful.
stomach and anterior aspect of the pancreas. • Surgery should be used as the last resource,
4. Incise the parietal peritoneum along the infe- once endoscopic procedures or angioemboli-
rior border of the pancreas. zation has failed.
8 Laparotomy 73

– According to the physiological status of the – Rewash the peritoneal cavity.

patient, a definitive procedure can be per- – Drain in selected cases.
formed, or the abdomen is left open, and
definitive procedure is performed during a Hollow Viscus Perforation
second operation. • Perforation of a hollow viscus can be dealt
with as in damage control by simple drainage Temporary Control of Bleeding associated or not with direct suture (or closure
• Can be obtained by by other means) of the perforation.
– Direct compression • The perforated portion is isolated by wet
– Finger clamping of vessels swabs and the peritoneal cavity is washed with
– Direct suture with X stitches warm saline irrigation.
– Clamping of vessels (in that order of prior- • The cleansed peritoneal cavity is isolated with
ity, to avoid blind damage/sutures/ligation wet swabs and the lesion is treated.
of vital structures)
• Never proceed with an organ resection if tem- Perforated Ulcer
porary hemostasis has not been obtained. • May be treated by direct suture, fibrin closure,
completed or not by fixing a (vascularized) Definitive Control of Bleeding omental patch with few stitches.
• Definitive control of the bleeding is generally • Gastric ulcer should be resected for histologic
obtained by a procedure that either removes analysis; the defect is sutured and patched
the bleeding organ or part of organ (resection with omentum.
of Meckel’s diverticulum, colectomy for bleed-
ing diverticulitis or tumor, etc.) or is meant to Perforated Sigmoiditis
prevent recurrence of bleeding (vagotomy or • In case of fecal peritonitis (Hinchey IV),
antrectomy for bleeding duodenal ulcer, etc.). Hartman’s procedure is indicated. Ruptured Abscess

8.4.2 Contamination • Ruptured intraperitoneal abscess can be
treated by:
• Possible origins of contamination of the peri- – Aspiration of the pus
toneal cavity are: – Cleansing the peritoneal cavity
– Perforation of a hollow viscus (perforated – Drainage of the infected site (see drains)
gastric or duodenal ulcer, sigmoiditis, • If the origin is appendicitis or sigmoiditis,
appendicitis, cholecystitis, etc.) the cause is treated by appendectomy or
– Rupture of an abdominal abscess (liver, sigmoidectomy.
appendicular, sigmoid diverticular abscess,
infected collection of pancreatic origin) Direct Contamination
– Direct contamination of peritoneal fluid by • Generalized peritonitis may occur by direct
an infected viscus (appendicular general- contamination from:
ized acute purulent peritonitis) – Appendicitis
• Surgical strategy when operating for – Infected Meckel’s diverticulum
peritonitis: – Sigmoid diverticulitis even without previ-
– Withdraw fluids for bacteriology. ous development of an abscess or overt
– Give IV antibiotics. perforation
– Control the source of contamination. • In these cases, just cleanse the peritoneal
– Wash the peritoneal cavity (see peritoneal cavity and treat the cause.
toilet). • Drainage is not indicated if the peritoneal
– Treat the cause. cavity is left perfectly clean.
74 E.J. Voiglio et al.

8.5 Bowel Obstruction Laparoscopy or CT-Directed

• Symptoms When a unique band is the cause of obstruction,
– Abdominal pain this can be divided laparoscopically or through a
– Vomiting minilaparotomy guided by laparoscopy or by
– Obstipation CT-scan findings.
– Abdominal distension
• Diagnosis
– CT is essential to determine the cause, the 8.5.2 Incarcerated Hernia
site (transition point, tumor, small bowel
feces sign, etc.), and the severity of the The ultimate risk of incarcerated hernia is seg-
obstruction (parietal ischemia, fluid, etc.). mental bowel ischemia, which requires resection
– CT moreover: and anastomosis. Incarcerated hernias are an
Can guide the choice between nonopera- absolute emergency.
tive and operative management
Can allow in some cases minimally inva- Umbilical, Groin, and Incisional
sive procedures (laparoscopy or CT- Hernias
directed incisions) See chapter on herniorrhaphies.
• Treatment
– Nonmechanical obstructions (postopera- Rare Hernias
tive ileus, peritonitis, bowel ischemia, • These include:
spinal injury, drugs, hypokalemia): surgical – Obturator
only if the cause or the consequence is – Ischiatic
peritonitis or ischemia (see specific – Lumbar
paragraphs). – Paraduodenal hernias
– Mechanical obstructions are in most cases • Most can be diagnosed by CT or at explorative
surgical (except in the case of peritoneal laparotomy.
carcinomatosis, where high-dose corti- • Treatment consists in reduction and obstruc-
coids may be useful). tion of the defect by suture or mesh, or in case
of right paraduodenal hernia, transpositioning
of the right colon to the left.
8.5.1 Adhesions Two Potential Approaches 8.5.3 Volvulus

Classic Approach • Intestinal segments involved:

1. Midline laparotomy – Sigmoid
2. Division of all adhesions divided (the entire – Cecum
length of the involved bowel) – Small bowel
3. Retrograde emptying of the small bowel – Stomach
4. Rearrangement of small bowel loops • The ultimate risks are:
5. Lavage of the peritoneal cavity – Ischemia
6. Complete exploration, mainly to be sure not to – Peritonitis, particularly severe in case of
miss another cause of bowel obstruction as a sigmoid perforation
small obstructive colon cancer associated with • Volvulus, when suspected, is an absolute life-
small bowel adhesions saving emergency.
8 Laparotomy 75 Volvulus of the Sigmoid Colon • Intussusception is:

• Sigmoid colon volvulus may be derotated by: – Most frequent in children less than 2 years
– Blind intussusception with a rectal tube of age
(not recommended) – Also observed in adults, and in this case, a
– Derotation by rigid sigmoidoscope that allows small bowel tumor is often present.
to partially appreciate absence of gangrene • The correct way to reduce intussusception is
– Complete derotation and deflation of the to “milk” the telescoped bowel segment in ret-
whole colon by coloscopy (best option) rograde manner.
• If these maneuvers fail, or if gangrene is pres- • If reduction is impossible or impacted bowel
ent at endoscopy, laparotomy is mandatory. is necrotic, resection and anastomosis of the
– When possible, the best option is the involved bowel segment is mandatory.
Bouilly-Volkmann procedure with:
• An elective left McBurney approach
• Exteriorization of the sigmoid 8.5.5 Neoplasms
• Sigmoidectomy
• Confection of a double-barrel colostomy • Available options depend on surgical/medical
– If gangrene is extended, Hartmann’s proce- expertise:
dure is the second option. – Proximal diversion by a stoma
– Resection with primary anastomosis, pro- Volvulus of the Cecum tected or not with diverting stoma or termi-
• If presence of gangrene or cecum is preperfo- nal stoma
rative, the unique option is an ileocecal resec- – Internal intestinal bypass in case of unre-
tion with primary ileocolic anastomosis. sectable neoplasm
• If the devolvulated and deflated cecum is – Radiologically or endoscopically placed stents,
healthy, different treatments may be discussed either permanent or a bridge to later surgery
(appendectomy, cecopexy, cecostomy, etc.).
Currently, ileocecal resection with primary Obstructive Right Colon
anastomosis is a safe option. Neoplasm
• Right hemicolectomy with primary ileocolic Volvulus of the Small Bowel anastomosis is indicated (ideally).
• Surgical derotation of small bowel volvulus is
an absolute emergency, to save as much bowel Obstructive Left Colon
as possible. Neoplasm
• The procedure depends on the location of Volvulus of the Stomach the obstruction and the degree of upstream
• Surgical derotation and deflation by a naso- distension:
gastric tube is an emergency. – Segmental colectomy and formal colec-
• If gangrene is present, atypical gastrectomy tomy are both acceptable.
can be performed. – Subtotal colectomy with primary ileocolic
• In other cases, a gastropexy is an option that anastomosis may be necessary because
should prevent recurrence. of upstream distension (for single-stage

8.5.4 Intussusception Obstructive Rectal Neoplasms

• A diverting loop sigmoidostomy alleviates the
• Intussusception is a form of intestinal obstruc- obstruction and allows to manage the case
tion in which one segment of the intestine electively, associating chemotherapy, radio-
telescopes into the next. therapy, and then surgical resection.
76 E.J. Voiglio et al.

8.6 Bowel Ischemia • One to 2 days later, a second look:

– Viable and nonviable intestinal
• Bowel ischemia may result from: segments are clearly differentiated.
– Arterial obstruction (caused by thrombosis – Resection of nonviable segments is
or embolism) performed and digestive continuity
– Venous obstruction (caused by thrombosis) may be restored.
• Both may be caused by external compression by
a band, a volvulus, or incarceration in a hernia.
• The result is gangrene and subsequent perfo- 8.7 Peritoneal Toilet and
ration with peritonitis. Intra-abdominal Drains
• In case of external compression, once the
cause alleviated, time must be left for revascu- 8.7.1 Toilet
larization of the involved gut segment before
deciding resection. • The peritoneal cavity is cleansed, methodi-
cally, with warm (37–39 °C) isotonic saline,
abundantly, until obtaining clear fluid, which
8.6.1 Localized Bowel Ischemia is then completely aspirated (Fig. 8.5).
1. Hepatodiaphragmatic space, right then left
• Treatment is simple resection and primary to falciform ligament
anastomosis (ileoileostomy and ileocolos- 2. Bursa omentalis if contaminated, through a
tomy for small bowel). window either in the lesser omentum, or in
• Resection and double-barrel stoma or the gastrocolic ligament
Hartman’s procedure (for the colon). 3. Morrison’s space
4. Right paracolic gutter
5. Splenic fossa
8.6.2 Diffuse Bowel Ischemia 6. Right mesenteric gutter
7. Left mesenteric gutter
• Typically occurs after thrombosis or embo- 8. Left paracolic gutter
lism of superior mesenteric artery. 9. Pelvic fossa and Douglas’ cul-de-sac
– If diagnosed and operated very early, • Swabs should not be used to clean the perito-
embolectomy/thrombectomy or vascular neum (may damage the mesothelial layer and
bypass may be attempted. cause adhesions).
– In most cases, the surgeon faces a patch- • Intraperitoneal antiseptics and/or antibiotics
work of necrotized gut segments, viable have not been proven to be effective
gut segments, and large parts of in-between (removal of blood and debris is much more
gut segments. effective).
The best option is a “damage control” pro- • Inclination of the table helps for the final
cedure with planned second look: exploration and recovery of liquids.
• Immediately • At completion, ensure that:
– Nonviable segments are resected – Exploration is complete
with staplers. – Adequate hemostasis has been obtained
– No anastomosis. – No pads have been left
– No stoma.
– The closed gut segments are left in
the peritoneal cavity. 8.7.2 Drains
– Abdomen is left open and drained
with a vacuum pack. Goal: clear bile, pancreatic secretions, gastric
• Next: resuscitation measures and gut juice, collections
8 Laparotomy 77

Fig. 8.5 Methodic cleansing of the peritoneal cavity

However: not always effective (can ultimately • Rubber has been widely used but causes peri-
plug or be walled off), and drains have their own toneal inflammation that leads to drain exclu-
morbidity (as a foreign body, they can produce sion. Modern drains made of polyvinyl or
infection and digestive fistulas) silicone induce less inflammation. Silicone
drains are softer, cause less pain, and are more Passive Drains popular.
• Based on capillarity, maintaining a communi-
cation between the peritoneal cavity and Mikulicz’s Drain
ambient air • A passive drain whose efficiency can be
– Should be avoided in low-pressure zones increased by a central suction tube resulting in
(diaphragmatic cupolas) because of risk of a hybrid system
infection by reversed current) • Procedure:
• Include – Cover cavity to be drained with the sack.
– Fabric meshes – Place the retrieval thread to facilitate
– Corrugated sheet drains removal at the end of treatment.
– Open tubes – Place a two-channel tube (irrigation and
– Multitubular sheets aspiration) in the middle of the sack and
– Tubes filled with mesh pack 3–5 numbered gauze tents.
78 E.J. Voiglio et al.

– Maintain moisture by irrigation with iso- need of a second look, or abdominal wall
tonic saline (mandatory to allow progres- infection/gangrene) or by necessity (abdomi-
sive and nontraumatic mobilization of the nal compartment syndrome, impossibility to
gauzes). close the abdominal wall).
– Mobilize first gauze, under analgesia, • Main advantage is effective drainage while
fourth to sixth POD. preserving the abdominal wall.
– The whole system should be removed com- • The operative technique includes [Brock, Am
pletely by the end of second week. Surg 1995]:
1. Placement of a fenestrated polyethylene Active Drains sheet between the abdominal viscera and
Active drains are negative pressure drains with or anterior parietal peritoneum
without air vent. 2. Placement of a moist, sterile laparotomy
towel over the polyethylene sheet
Open Drains 3. Placement of two closed suction drains
• These drains have an air vent and need aspira- over the towel
tion (–30 to –100 cmH2O). 4. Placement of an adhesive backed drape
• Negative pressure can be modulated and the over the entire wound, including a wide
air vent prevents drain obstruction by stagna- margin of surrounding skin
tion and coagulation of liquids or by impac- 5. Suction applied to the drains, creating a
tion of surrounding tissues in the drain holes. vacuum and rigid compression of the lay-
• Some variations are equipped with a bacterial ers of closure material
filter on the vent (Shirley’s drain) or a second • This creates a tight, external seal of the adhe-
irrigation channel (Vankemmel’s and Worth’s). sive backed drape and facilitates drainage of
• Open negative pressure drains may be wrapped the peritoneal cavity.
with a multitubular sheet to prevent obstruc- • When this device is used to drain peritonitis,
tion of the drain holes by surrounding viscera. adding pads or gauze tents too may be helpful.
• Negative pressure drains may be converted to • Commercial kits are available, provided with
passive drains by stopping the aspiration. an autonomous suction pump that allows con-
tinuous controlled suction during patient
Closed Drains transfer from OR to ICU.
• Have no vent and are connected to a vacuum
bottle. Principles of Peritoneal Cavity
• Water and air tightness should prevent second- Drainage
ary infection. Some areas may be drained electively; others
• Some drains (Redon) may cause traumatic must not be drained.
impaction of surrounding viscera and have
been replaced by grooved channel, flat, or Supramesocolic Space
round drains. • Easiest space to drain because only solid
• Close monitoring is mandatory to replace organs are present (spleen and liver) and there
recipients when full. is absence of intestinal loops
• Association of a closed drain with an opened • Five areas can be drained:
or a passive drain is illogical and must be 1. Hepatodiaphragmatic space
avoided as air inlet will instantly lead to an 2. Splenic fossa
inoperative drain system. 3. Hiatus region
4. Morrison’s space
Vacuum Pack 5. Bursa omentalis (either through hiatus,
• May be used when abdominal wall is left open either through a window in the gastrocolic
either deliberately (severity of the infection, ligament)
8 Laparotomy 79

• Because of the obliquity of the mesocolic • If several defects are present, it is best to resect
root, drains are best exteriorized through the fascia between them in order to deal with only
right flank. one large fascial defect.
• The peritoneum may be closed with a running
Inframesocolic Space suture, but some prefer not to suture the
• Three areas may be drained without major iat- peritoneum.
rogenic risk: – If closure may be performed without ten-
1. Right paracolic gutter (and right Toldt’s sion, suture the linea alba in two layers in a
fascia if right colon has been mobilized) vest-over-pants fashion.
2. Left paracolic gutter (and left Toldt’s fascia – If tension is present, prefer the
if left colon has been mobilized) component-separation technique (gain of
3. Douglas’ cul-de-sac length by vertical incision of the posterior
• Placement of drains between intestinal loops aspect of the rectus, abdominis fascia,
must be avoided. and/or incision of the aponeurosis of
• Drains should be exteriorized through the external oblique muscle laterally to rectus
shortest route possible. abdominis).
• Drains should not be exteriorized through the
incision. Umbilical Hernia Repair
• Drain orifices should be placed according to • Small umbilical hernia can be repaired hori-
existing or possible stomas. zontally using a pants-over-vest technique.
• Large umbilical hernias are repaired in the Indications of Drainage same manner as midline-incision hernias.
• Prophylactic drainage is rarely indicated.
• Drains can be placed: Inguinal and Femoral Hernia
– Surgically Repair
– Endoscopically • Suture repairs are preferred by most, but
– Via interventional radiology (guided by (absorbable) mesh repairs have their propo-
ultrasound or CT scan) nents. McVay, Bassini, and Shouldice
• Only objective bile or pancreatic leaks and repairs are efficient to repair both inguinal
nonresectable intra-abdominal infected sites (direct and indirect) and femoral hernias.
need efficient drainage. Open or laparoscopic techniques have been

8.8 Abdominal Closure Typically for Open Repair

1. Incise the skin 1 cm above inguinal ligament
8.8.1 After Incarcerated Hernia (line from anterosuperior iliac spine to pubic
• Emergency herniorrhaphy may be per- 2. Incise the external oblique aponeurosis.
formed after surgical reduction of incarcer- 3. Identify the external ring and cut the exter-
ated gut. nal oblique muscle aponeurosis from
• This is considered as a contaminated surgery, the ring cephalad and laterally, parallel to
and use of prosthesis is not advisable. fibers.
4. Identify the spermatic cord (or round ligament Midline Incisional Hernia Repair in female) and inguinal ligament.
• After incision of the skin, control of incarcer- 5. The incarcerated hernia is either:
ated sac contents, and resection of infarcted • Within the spermatic cord (indirect)
bowel as necessary, the sac is dissected laterally • Besides the cord (direct)
up to the fascia and under the edge of the defect. • Below the inguinal ligament (femoral)
80 E.J. Voiglio et al.

Indirect Hernia • Hemostasis of the operative field should be

1. Dissect the sac from cremasteric muscles on perfect.
one hand and deferens and spermatic vessels • Adequate drainage, if needed, should be
on other hand, and resect the cremasteric placed.
muscle. • Instrument and swab count should be correct.
2. Open the sac and control incarcerated bowel.
3. If necessary, resect infarcted bowel. Midline Incision
4. Ligate and amputate the sac. • Peritoneal closure:
5. Incise fascia transversalis to expose pectineal – Not necessary for some: there is no evi-
ligament. dence that closing the peritoneum reduces
Direct Hernia – Only possible if muscle relaxation is cor-
1. Open the sac and control incarcerated rect and there is no excessive intra-
bowel. abdominal pressure.
2. If necessary, resect infarcted bowel. – Many surgeons change gloves, instru-
3. Close the sac. ments, and clean draping once the perito-
4. Dissect cremasteric muscles from spermatic neal cavity is closed.
cord and check for associated indirect hernia • Tissues are rinsed with isotonic saline and
within spermatic cord. bleeding spots selectively coagulated.
5. Incise fascia transversalis to expose pectineal • A running monofilament slowly absorbable
ligament. (preferred) suture on the linea alba is usually
performed by most surgeons (interrupted
Femoral Hernia sutures may also be performed).
1. Incise fascia transversalis. – Bites should be thick enough to provide solid
2. Incise underlying peritoneum. repair but not too thick not to create tension,
3. Reduce the hernia and control incarcerated ischemia, and consecutive weakness.
bowel. – Bites have to be placed at sufficient inter-
4. If necessary, resect infracted bowel. val not to be ischemic, but not too wide,
5. Then reduce and resect the sac to expose pec- not to shorten the length of the incision
tineal ligament, and close the peritoneum. creating pain and excessive traction on the
McVay Repair • Some approximate the subcutaneous fat
1. Suture conjoined tendon to pectineal ligament (absorbable stitches), but this has never been
with interrupted sutures lateral to femoral shown to be of any real benefit.
vein. • Skin is closed with stitches, staples, or con-
2. Then suture conjoined tendon to inguinal liga- tinuous sutures (avoided in the case of mas-
ment laterally with interrupted sutures. sive contamination).
3. The last stitches calibrate the internal ring.
4. External oblique aponeurosis is sutured super- Oblique and Transverse
ficially to the spermatic cord calibrating the Incisions
external ring. • The first layer is constituted by the peritoneum
and the transverse muscle and aponeurosis.
• It is advisable to landmark the edges of inter-
8.8.2 Surgical Incision Closure nal oblique muscle and aponeurosis (external
oblique muscle and aponeurosis) by angle
• Before closing a surgical incision, abundant stitches.
lavage of the peritoneal cavity should be done • Each plane is repaired by a continuous, slowly
to remove debris. absorbable suture.
8 Laparotomy 81

• When the incision crosses the rectus abdomi- Isolated Skin Closure
nis, the posterior part of rectus abdominis • Only the skin is closed, resulting in an inci-
sheath is repaired in continuity with the trans- sional hernia that will be repaired several
verse plane and the anterior with external months later.
oblique plane. Fibers of the rectus abdominis • If the skin cannot be closed without excessive
should not be sutured (but adequate hemosta- tension, skin-relaxing incisions in the flanks
sis is necessary). can be performed.
• Subcutaneous tissue and skin may be closed
as above. Absorbable Mesh Closure
• An absorbable mesh is sutured (with absorb- Delayed Skin Closure able stitches) to the fascia.
• Delayed skin closure is indicated when the • Granulation appears in few days from under-
risk of subcutaneous infection (e.g., massive lying omentum or gut.
contamination in obese patients) is present. • A skin graft may be performed when granula-
• Fascia is closed but skin sutures are placed tion is sufficient.
and left untied in the dressing. • Definitive repair of the resulting hernia is
• The stitches are tied 48–72 h later. performed when the healing process is

8.9 Special Situations Component-Separation

8.9.1 Decompressive Laparotomy • This should not be performed in a context of
peritoneal infection because of the risk of
• Abdominal compartment syndrome (ACS) is abdominal wall gangrene.
defined as a sustained intra-abdominal pres- • In absence of infection, this technique can be
sure (IAP) >20 mmHg (with or without an used for primary closure of small defects after
abdominal perfusion pressure (APP) laparotomy, otherwise, for larger defects, a
<60 mmHg), associated with new organ dys- two-stage procedure (component separation in
function or failure. the second stage) may be advisable.
• ACS is confirmed by measure of IAP.
– Intra-abdominal pressure is best measured
via the urinary catheter with a transducer 8.9.3 Enterocutaneous Fistulas
after inflation of the bladder with 50 ml of
saline. • Occur often postoperatively or are consecu-
• ACS must be suspected in patients with a tive to an intestinal disease (e.g., Crohn’s
tense abdomen who become anuric, acidotic, disease)
or develop respiratory failure. • Diagnosis in clinic (presence of gastrointesti-
nal fluid on or near skin incision)
– Signs of local infection (inflammatory
8.9.2 Open Abdomen Technique skin) and general infection (hyperthermia)
are frequently associated.
• The vacuum pack (see drainage) in the poor – Biology confirms inflammation.
man’s or commercial variety has completely – Life-threatening signs of peritonitis or sep-
supplanted other techniques (Bogota bag or tic shock have to be sought.
nonabsorbable membranes). If present, urgent management is required.
• If primary closure of the laparotomy is – Imaging such as CT scan, entero-CT, or
not possible, a variety of possibilities are entero-MRI can confirm diagnosis, show
available. intraperitoneal fluid collections, localize
82 E.J. Voiglio et al.

the exact origin of the fistula, and demon-

strate downstream obstruction (findings are Pitfalls
important for surgical strategy). • A nonadhering adhesive drape is worse
• Management is adapted to clinical and bio- than no drape.
logical severity. • Do not use coagulation mode of the cau-
– Septic shock commands urgent operative tery to cut: this mode cuts poorly and
management to clean and drain the peri- the extended burn jeopardizes healing
toneal cavity and most frequently divert and favors infection.
the gut. • Too small and/or malpositioned incisions.
– Fluid resuscitation and antibiotic therapy • Not choosing a damage control proce-
have to be started early. dure in an exsanguinating or physiologi-
– In absence of peritonitis, surgical manage- cally compromised patient.
ment may be delayed. • Not identifying an incarcerated groin or
– Effective skin dressings are important to umbilical hernia preoperatively.
prevent cutaneous complications. • Drains have their own morbidity; they
– The output of the fistula is important to do not compensate poorly performed
consider. surgery.
Low output (<500 ml/24 h): medical treat- • Not recognizing an abdominal compart-
ment based on diet, antisecretory drugs, ment syndrome.
parenteral nutrition, and sometimes antibi-
otics may suffice.
High output (>500 ml/24 h): initial medical
treatment usually fails (but helps restore
Essential Points
nutritional status before surgery).
• When in doubt, use a large midline incision.
– Goals of surgery: treat the peritonitis or
• Do not proceed further if bleeding is not tem-
abscess and dry the fistula
porarily controlled.
In case of peritonitis, gut diversion is
• Incarcerated hernia is a common cause of
In absence of peritonitis, a simple resection
• Complete peritoneal toilet is essential.
of the fistulized gut and fistula track fol-
lowed by anastomosis is the best option.
• If resection is too difficult, internal
Selected Reading
bypass of the fistulized gut segment is
• In case of complex and multiple early emergency- general-surgery-commissioning-guide .
postoperative fistulae in a hostile abdo- Accessed 10 Aug 2014.
men, immediate upstream diversion is best Scott-Conner CAH, Dawson DL. Operative anatomy.
Wolters Kluver Health; London, 2013.
to reduce fluid losses and denutrition. Squires RA, Postier RG. Acute abdomen. In: Townsend Jr
• Once local conditions have improved, CM, Beauchamp RD, Evers BM, Mattox KL, editors.
and after complete work-up, a new Sabiston textbook of surgery. 19th ed. Philadelphia:
operation is scheduled. Saunders Elsevier; 2012. chap 47.
Lower Gastrointestinal Endoscopy
Halil Alis and Korhan Taviloglu

Contents 9.1 Introduction

9.1 Introduction 83
• Although emergency endoscopy has clearly
9.2 Lower Gastrointestinal Bleeding 84
proved to be effective for both diagnosis and
9.3 Other Diagnostic Modalities in LGIB 85 management of upper gastrointestinal tract
9.4 Several Types of Possible Therapeutic emergencies, there is still debate regarding its
Colonoscopic Interventions 86 use in patients with lower gastrointestinal tract
9.5 Acute Mechanical (Large Bowel) emergencies.
Obstruction 87 • Irrespective of whether “emergency” refers to
Bibliography 91 the first 24 h or the first 72 h, the two main
goals of emergency endoscopy are diagnosis
and management:
– Diagnosis
Essential to guide the management.
Endoscopy provides necessary information
for risk assessment.
• High-risk patients may be referred to
appropriate institutes.
• Low-risk patients may be discharged
– Management
Endoscopy can be used as a potential
therapeutic tool in selected cases.
Therapeutic procedures include injection
therapy, sclerotherapy, endoscopic clip
H. Alis application, argon beam cauterization,
Department of Surgery, Bakirkoy Teaching Hospital, golden probe application, detorsion, tube
Istanbul, Turkey
placement, percutaneous endoscopic gas-
trostomy, and transcolonic and transrectal
K. Taviloglu, MD (*)
abscess drainage.
Taviloglu Proctology Center - Abdi Ipekci Cad,
Nişantasi, Istanbul, Turkey • Indications
e-mail: – Hemorrhage

© Springer International Publishing Switzerland 2016 83

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_9
84 H. Alis and K. Taviloglu

– Large bowel obstruction situations, particularly if physical

– Foreign body extraction examination is thought to be crucial for
– Treatment of anastomotic failure follow-up of the patient.
• Contraindications – Staff and equipment.
– Absolute Staff trained in emergency endoscopy.
Suspicion of perforation Adequate equipment for excessive irrigation.
Noncompliant patient – Complications
Shock Higher incidence of complications in
Respiratory distress emergency endoscopy (0.9 %) when com-
Clear indication for exploratory laparot- pared to elective endoscopy (0.1–0.3 %)
omy: diffuse peritonitis Types
– Relative • Cardiopulmonary complications (respon-
Coagulopathy (if life-threatening entity in sible for 50 % of deaths)
which a diagnostic and/or therapeutic • Infection
endoscopy is considered to be critical) • Hemorrhage
Patients who have had a gastrointestinal • Perforation
tract surgery (low-pressure endoscopy after
the fifth to seventh postoperative day)
Pregnancy 9.2 Lower Gastrointestinal
• Patient preparation Bleeding
– Major limiting factor in emergency
colonoscopy: lack of mechanical bowel Definition, incidence, and population
preparation. i. Lower intestinal hemorrhage is defined as
– It is wise to avoid oral laxatives for bleeding in the bowel distal to the ligament of
mechanical bowel preparation in critically Treitz and usually manifests with maroon
ill patients and in patients who may not stools or bright red blood per rectum.
tolerate dehydration: enemas should be ii. Incidence (not exactly known) but assumed to
preferred over oral laxatives in these be 20–30/100,000 population.
patients. i. Twenty-five percent of all gastrointestinal
Of note, polyethylene glycol (Golytely) is bleedings.
a fast-acting (4 h) oral solution and is ii. Male predominance.
responsible for relatively mild fluid- iii. The rate of hospitalization also increases
electrolyte disturbance. >200-fold between the third and ninth
Particular to emergency colonoscopy. decade of life related to the increased inci-
• Likelihood of overlooking colonic dence of diverticulosis and malignancy.
lesions is considerably high, and it is iii. Rarely massive (defined as exsanguinating or
usually not possible to advance the hemodynamically significant bleeding that
colonoscope into the cecum; there- persists and requires at least four units of blood
fore, the endoscopist should focus on over a period of 24 h).
identifying the emergency pathology 1. Most episodes are self-limiting and not
instead of exploring the whole colon hemodynamically significant and never
and should then carry out an elective have the precise site and cause
colonoscopy to exclude additional established.
pathologies. 2. However, older population (>65-year-old
• Avoid administration of sedatives and patients) and the patients with comorbidi-
analgesics as much as possible. Short- ties warrant hospitalization because of
acting agents, such as propofol and fen- high morbidity and mortality rates
tanyl, should be preferred in exceptional (10–20 %).
9 Lower Gastrointestinal Endoscopy 85

3. Up to 80 % of patients will stop bleeding

spontaneously, and the recurrence rate
reaches as high as 25 %.
4. Identification of the bleeding source
remains a diagnostic challenge.
Approximately 10 % of all patients will
never have a source identified, and up to
40 % of patients with LGIB have more than
one potential bleeding source.
iv. Causes.
1. Diverticula of the sigmoid colon and angio-
dysplasia are the two most common causes
of major acute LGIB.
(a) Bleeding from diverticula occurs more
often in elderly patients, particularly in Fig. 9.1 Colonic bleeding in colonoscopy
those taking NSAIDs or anticoagulants.
(b) Bleeding from angiodysplasia can be
massive and recurrent. 2. Insertion of nasogastric tube
2. Ischemic colitis. (a) To rule out upper gastrointestinal bleed-
(a) Seen in the elderly ing and evacuate the gastric contents
(b) Rarely presents with massive bleeding (b) Upper gastrointestinal endoscopy
3. Rectal cancer. iv. Recommended to carry out colonoscopy
(a) Bleeds overtly. immediately in patients with third and fourth
(b) Often the patient may have a history of degree hypovolemia and within 12–24 h in
tenesmus and of episodic minor bleed- patients with first and second degree hypovo-
ing with the stools for some time. lemia (Fig. 9.1).
4. Inflammatory bowel disease. 1. Early colonoscopy is superior to delayed
(a) Almost never the first symptom of the colonoscopy in means of identifying the
disease lesion, reduction of rebleeding rate, reduc-
i. Often preceded by diarrhea tion of morbidity and mortality rates, and
(b) Rarely massive decreasing the necessity of blood transfu-
5. Proctitis and especially radiation proctitis sion and surgical intervention.
and internal hemorrhoids may bleed 2. Mechanical bowel preparation is usually
significantly. not necessary because of the purgative
effect of intraluminal blood.
Immediate management 3. Therapeutic interventions during colonos-
i. Initiate ABC rules as for all patients in the copy are required only in 20 % of patients
emergency setting. The goal is to determine with lower gastrointestinal bleeding.
hemodynamic stability.
ii. Appropriate laboratory values should be
ordered including a complete blood count, 9.3 Other Diagnostic Modalities
coagulation profiles, and blood gases. An ini- in LGIB
tial type and screen should be completed in
anticipation that blood transfusion may be Radionuclide scintigraphy
required. i. Involves either technetium-99m (Tc-99m) sul-
iii. Determine whether the source of bleeding is fur colloid or Tc-99m-labeled red blood cells
upper or lower gastrointestinal tract. to localize bleeding from a gastrointestinal
1. Digital rectal examination source.
86 H. Alis and K. Taviloglu

ii. Scintigraphy can identify bleeding as low ment of Treitz, leaving most of the small
as 0.1 ml/min and has been advocated as a bowel unexamined.
safe, noninvasive, and accurate method iii. Wireless technology have paved the way for
identifying all types of gastrointestinal capsule endoscopy, a pill-sized capsule that
bleeding. the patient swallows and travels the entire
iii. No need for bowel preparation and repeat length of the GI tract by peristalsis. It is non-
scans can be easily performed in cases of invasive and causes no patient discomfort.
recurrent bleeding although limited by the
half-life of the radiotracer used.
iv. Scintigraphy is now used at most institutions 9.4 Several Types of Possible
as a screening tool to determine the group of Therapeutic Colonoscopic
patients who would be optimal candidates for Interventions
interventional angiography.
v. Negative scans may also be useful for screen- Injection therapy:
ing as they are also associated with a low like- i. Different types of liquid material can be
lihood of requiring surgical intervention. injected around the bleeding lesion with an
endoscopic needle
Angiography 1. Arrest of bleeding depends on two
i. This method allows for accurate localization principles:
of the source of bleeding at rates as low as (a) Compression of bleeding vessels by
0.5 ml/min. mass effect
ii. Can be therapeutic by injecting vasopressin or by (b) Biochemical effects
performing embolizations of bleeding vessels. 2. The most common biochemicals used are:
(a) Epinephrine.
Multi-Detector Row Helical Computed i. The most preferred agent used
Tomography (MDCT) worldwide
i. Allows for identification of extravasation of ii. Injection of a 1:10,000 solution into
intraluminal contrast before it is diluted by four quadrants around the bleeding
intestinal contents. lesion
ii. This modality has been used increasingly in iii.Leads to vasoconstriction
the diagnosis of vascular diseases as it is capa- (b) Sclerosing agents, alcohol sclerosing
ble of more precise imaging and 3-D format- agents, and alcohol lead to endarteritis
ting of vascular structures. and subsequent occlusion of bleeding
iii. MDCT demonstrates acute lower GI bleeding vessels.
rates as low as 0.2 ml/min, lower than that for (c) Fibrin glue and fibrin glue-thrombin
angiography and comparable to radionuclide complex.
scanning. i. Highly effective and less harmful
iv. Overall rates of detection and localization ii. Costly
range around 30 % and is comparable to iii. Leads to thrombus formation in
angiography. bleeding vessels
v. MDCT may be a more reliable method of 3. Success rate of injection therapy is about
screening when compared to RBC scintigraphy. 90 %; however, rebleeding rate is
15–20 %.
Others (a) Size of vessel is important (see below)
i. Push enteroscopy and capsule endoscopy have
been investigated for the diagnosis of LGIB. Heat therapy:
ii. Push enteroscopy uses a longer, thinner endo- i. Principle: coagulation of bleeding vessels
scope to examine the small bowel but only within the lesion by applying heat energy
reaches approximately 160 cm past the liga- through direct contact
9 Lower Gastrointestinal Endoscopy 87

1. Heat energy transferred via probe pressed ii. The incidence of rebleeding is 15–20 % after
directly upon the lesion therapeutic endoscopy.
ii. Types: monopolar and bipolar coagulation 1. Ongoing controversy between surgeons
heat probe, laser coagulation, and coaptive and endoscopists about whether rebleed-
coagulation ing should be treated by surgical interven-
1. Bipolar coagulation and heat probe is effec- tion or by second therapeutic endoscopy,
tive in bleeding vessels up to 2.5 mm in most surgeons prefer surgery!
iii. Is as effective and safe as injection therapy in
non-variceal bleeding 9.5 Acute Mechanical
iv. Main disadvantage: not possible to control the (Large Bowel) Obstruction
depth of penetration of heat energy
Colorectal cancer.
Laser photocoagulation: (a) Responsible for presentation in 30 % of
i. Coagulates the bleeding vessels by transfer- patients with colorectal cancers
ring heat energy to the bleeding lesion i. Rectal cancers account for 85 % of cases
1. Generally, Nd:YAG laser is used. with acute mechanical obstruction of large
(a) With a 3–4 mm depth of penetrance, bowel that undergo surgical treatment.
Nd:YAG is the treatment of choice in (b) Plain X-rays and computed tomography of the
angiodysplasia, and the success rate is abdomen are the most common methods used
about 84 %. for diagnosis.
2. Although it has the advantage of avoidance (c) However, colonoscopy is extremely valuable
of direct contact between the cautery and for diagnosis and therapy in patients who do
the bleeding lesion, laser device is not por- not have clinical signs of peritonitis.
table and overall cost of the procedure is i. The likelihood of the identification of the
considerably higher. obstructing lesion by colonoscopy is
greater than 90 %.
Mechanical means: ii. May also serve as a therapeutic tool by the
i. Appliances include endoclips and endoscopic application of self-expendable (or expand-
band ligation. able) metal stents.
1. Work by mechanical closure of bleeding 1. Used to avoid emergency operation by
vessels decompressing the large bowel and,
(a) Treatment of choice in major thus, offers a chance for the patient to
bleedings. have an elective procedure and serves as
i. Suits bleeding vessels larger than a bridge with lower risk (Figs. 9.2
1 mm in size (usually refractory to and 9.3) and lowers the rate of stoma for
injection therapy) critically ill patients
(b) Endoscopic band ligation is generally 2. Best suited to locally aggressive or
preferred in variceal bleeding and in metastatic colorectal cancers, in
apparently visible bleeding (Forrest 1A, patients who are poor candidates for
1B, 2A lesions and Dieulofoy’s lesion). surgery, obstructive metastatic colorec-
tal tumors, and inoperable intra-
The procedures mentioned above can also be abdominal tumors leading to extrinsic
used in combination. compression
i. Combined injection therapy and thermal ther- 3. Advantages/disadvantages
apy and injection therapy and mechanical (a) Complications are possible.
tools has been demonstrated to be more effec- i. Mal-positioning
tive than single therapy. ii. Perforation
iii. Bleeding
88 H. Alis and K. Taviloglu

Fig. 9.4 Sigmoid volvulus

Fig. 9.2 Colonic stent in colonoscopy

(d) The rates of mortality, perforation,

the migration of the stent, bleeding,
and re-obstruction related to colo-
noscopic stenting were estimated to
be less than 1 %, 0–7 %, 3–22 %,
0–5 %, and 0–15 %, respectively.

Sigmoid volvulus.
(a) Defined as an axial twisting of a portion of an
organ around itself or a stalk of mesentery
tissue to cause luminal and vascular
(b) Most common site of colonic volvulus
Fig. 9.3 Colonic stent (43–71 %).
i. But can also be seen in the cecum, the
iv. Migration right colon, the transverse colon, and the
1. Less frequently seen with splenic flexure in decreasing frequency
uncovered stents when com- (Fig. 9.4)
pared with covered stents in (c) Endoscopic decompression should be the ini-
acute mechanical obstruc- tial step.
tion of large bowel i. Successful in 70–80 % of the cases with
2. May be asymptomatic or rigid endoscopy and >90 % with flexible
present with rectal bleeding sigmoidoscopy
and tenesmus 1. Advantages of flexible sigmoidoscope
(b) Tumors of the right flexure and right (vs. rigid)
colon are not suitable for colono- (a) Air insufflation mechanism facilitates
scopic stenting. the detorsion process.
(c) Main reasons of failure in colono- (b) Aspirative function for removing
scopic stenting are locally aggres- the colonic contents after detorsion.
sive tumors that are fixed to adjacent (c) Insertion of the rectal tube by plac-
organs and failure to pass the guide- ing a guidewire.
wire through the obstructive lesion. (d) Lower complication rate.
9 Lower Gastrointestinal Endoscopy 89

ii. Contraindication
1. Signs of peritonitis
2. After initial failure of endoscopic
3. Recurrent episodes of sigmoid volvulus

i. If the mucosa is macroscopically viable, a
rectal tube (40–60 cm in length) is inserted
through the lumen of the endoscope or beside
the endoscope and is advanced till it reaches
the torsion site.
1. Torsion site is gently cannulated without
any rough movements.
2. Rectal tube should be fixed to the perianal Fig. 9.5 Ischemic colitis
area with sutures and should be kept for
48 h.
(e) Anastomotic strictures or due to anti-
Colonic pseudo-obstruction. inflammatory drugs, ischemic colitis (Fig. 9.5),
(a) Refers to acute dilation of the colon in the and radiation enterocolitis (resection)
absence of any mechanical obstruction.
(b) Usually occurs in critically ill patients who Foreign bodies
have congestive heart failure, hypomagnese- (a) Usually enter the body via transoral or trans-
mia, hypercalcemia, and hypokalemia. anal route.
(c) Diagnosis is made by colonoscopy which i. In rare cases, the cause is the migration of
shows no obstructing lesion in the entire colon. transmural or therapeutic agents.
(d) The initial step is to identify and to correct the (b) Approximately 10–20 % of foreign bodies
underlying factor and to avoid medication necessitate endoscopic intervention, while
with anticholinergic and sedative agents. 1 % warrants surgery.
(e) Colonoscopic decompression and mainte- (c) Symptoms:
nance of colonic decompression with the i. Abdominal pain, nausea and vomiting,
insertion of a rectal tube is one of the specific fever, rectal bleeding, and melena. Foreign
treatments. bodies that reach the colon are usually
(f) Cecum should be reached during colonos- spontaneously excreted with feces.
copy in order to rule out any obstructing ii. Specific problems.
lesion. 1. Batteries are especially hazardous
(g) Increasing number of studies in the literature because they contain toxic material
suggest the use of percutaneous endoscopic such as caustic salts and alkalines;
cecostomy as an alternative. therefore, every effort should be made
to extract the batteries.
Other various pathologies cause acute mechan- 2. Sharp, long, or angled foreign bodies
ical obstruction of large bowel. cause intestinal perforation in
(a) Metastatic tumors (stent) 15–30 % of cases. The most common
(b) Extraintestinal pelvic tumors (stent) sites of perforation are angled sites of
(c) Diverticular disease (resection) the gastrointestinal tract such as the
(d) Inflammatory bowel disease (medical treat- ileocecal valve and the rectosigmoid
ment initially) junction.
90 H. Alis and K. Taviloglu

Fig. 9.6 Appearance of a cucumber in colonoscopy

Fig. 9.7 Appearance of a colonic fistula colonoscopy

3. Body-packers are prone to anaphylactic

shock in case of sudden inundation of 6. Fluroscopic guidance is recommended
drugs. during the entire procedure, either surgi-
iii. Radiological investigation is also useful in cal or endoscopic.
patients who have atypical sexual behav-
iors, loose anal sphincter, and possible Anastomotic breakdown or leakage
mucosal injury. (a) Defined as incomplete or complete disruption
1. Important to obtain plain or contrast- at the anastomotic line.
enhanced graphies after the procedure (b) Generally accepted that endoscopy can safely
in order to exclude any possible be carried out after the fifth postoperative day
complication in patients who are not suspected to have an
iv. Endoscopic extraction of foreign bodies anastomotic complication (no clear evidence).
greater than 6 cm in size is still controver- (c) Nowadays, colonoscopy is widely used for
sial (Fig. 9.6). both diagnostic and therapeutic means in such
1. Various equipment such as endoscopic patients (Fig. 9.7).
balloons, snares, alligator forceps, and (d) Different endoscopic procedures have been
baskets can be used during this proce- defined for the management of such patients:
dure according to the shape, the size,
and the property of the foreign body. The closure of fistula tract
2. Foreign bodies can be retrieved via 1. Endoscopic debridement:
transanal route by anoscopy. (a) First define the tract, the connections, the
3. Risk of perforation during extraction is orifices, and the length by cannulation and
directly correlated with the experience of radiological imaging studies
the attending surgeon. (b) Removal of necrotic tissues by pressure,
4. Foreign bodies inserted or extracted via irrigation with physiological saline, or
transanal route may cause serious inju- other agents of choice
ries in the anal sphincter complex or 2. Fibrin glue:
rectosigmoid that may necessitate a (a) 1–4 ml of fibrin glue per session.
major surgery. (b) Mean duration for complete healing is 33
(a) Fecal incontinence estimated at 10 % (4–365) days.
after forced transanal extraction (c) Success rate of 70–80 %.
5. Enterotomy becomes rarely necessary 3. Clipping:
for the extraction of foreign body dur- (a) Anastomotic defects up to 12 mm can be
ing surgical treatment. sealed by this procedure.
9 Lower Gastrointestinal Endoscopy 91

4. Stenting: Kobayashi LM, Corsattor R, Coimbra R. A comprehen-

sive review of upper GI bleeding: the role of modern
(a) Extractable silicon, covered self-expend-
imaging technology and advanced endoscopy. J Surg
able metal, and biodegradable stents can Radiol. 2011;2(1):24–41.
be used. Lee J, Costantini TW, Coimbra R. Acute lower GI
5. Endovac: (abbreviation for endoscopic vac- bleeding for the acute care surgeon: current diag-
nosis and management. Scand J Surg. 2009;98:
uum therapy)
(a) Useful for complicated rectal and esopha- Magdeburg R, Collet P, Post S, Kaehler G. Endoclipping
geal anastomoses. of iatrogenic colonic perforation to avoid surgery.
(b) Prior to the endoscopic procedure, patho- Surg Endosc. 2008;22:1500–4.
Rahbari NN, Weitz J, Hohenberger W, et al. Definition
logical anatomy of the anastomotic com-
and grading of anastomotic leakage following anterior
plication should be defined by radiological resection of the rectum: a proposal by the International
studies. Study Group of Rectal Cancer. Surgery. 2010;147:
(c) First step is to identify the disruption site 339–51.
Sneider EB, Maykel JA. Management of anastomotic leak
at the anastomosis.
after low anterior resection with transanal endoscopic
(d) Then, all connected pathological cavities microsurgical (TEM) debridement and repair. JSCR J
are debrided endoscopically. Surg Case Rep. 2012;9:1. http://jscr.
(e) Insertion of an overtube under endoscopic
Stack LB, Munter DW. Foreign bodies in the gastrointesti-
nal tract. Emerg Med Clin North Am. 1996;14(3):
(f) A piece of special foam (especially poly- 493–521.
urethane) prepared in an appropriate size Truong S, Bohm G, Klinge U, Stumpf M, Schumpelick
is introduced through the overtube and is V. Results after endoscopic treatment of postoperative
upper gastrointestinal fistulas and leaks using com-
applied to the cavity.
bined Vicryl plug and fibrin glue. Surg Endosc.
(g) Continuous negative pressure is applied 2004;18:1105–8.
via the foam to promote healing. van Koperen PJ, van Berge Henegouwen MI, Rosman C,
(h) The foam is changed every 2–3 days, and et al. The Dutch multicenter experience of the
endo-sponge treatment for anastomotic leakage
endoscopic debridement is repeated.
after colorectal surgery. Surg Endosc. 2009;23:
i. Recent studies reported the mean duration 1379–83.
of complete healing and the success rate for van Koperen PJ, van der Zaag ES, Omloo JM, et al. The
the procedure as 10–14 days and 96 %, persisting presacral sinus after anastomotic leakage
following anterior resection or restorative procto-
colectomy. Colorectal Dis. 2011;13:26–9. doi:10.111
Verlaan T, Bartels SA, van Berge Henegouwen MI, et al.
Bibliography Early, minimally invasive closure of anastomotic
leaks: a new concept. Colorectal Dis. 2011;13:
Arezzo A, Verra M, Reddavid R, Cravero F, Bonino MA, 18–22.
Morino M. Efficacy of the over-the-scope clip (OTSC) von Bernnstorff W, Glitsch A, Schreiber A, et al. ETVARD
for treatment of colorectal postsurgical leaks and (endoscopic transanal vacuum-assisted rectal drainage)
fistula. Surg Endosc. 2012;26:3330–3. leads to complete but delayed closure of extraperito-
Barkun A. Urgent endoscopy: what is the rush? Interview neal rectal anastomotic leakage cavities following
by Paul C. Adams. Can J Gastroenterol. 2009;23(7): neoadjuvant radiochemotherapy. Int J Colorectal Dis.
475–6. 2009;24:819–25.
Barkun A. Emergency endoscopy cover: cost and bene- Weidenhagen R, Gruetzner KU, Wiecken T, et al.
fits? Gut. 2010;59:1012–4. Endoscopic vacuum-assisted closure of anasto-
Fouda E, El Nakeeb A, Magdy A, et al. Early detection of motic leakage following anterior resection of the
anastomotic leakage after elective low anterior rectum: a new method. Surg Endosc. 2008;22:
resection. J Gastrointest Surg. 2011;15:137–44. 1818–25.
Percutaneous Interventions
Isidro Martínez-Casas, Dieter Morales-García,
and Fernando Turégano-Fuentes

10.1 Central Venous Catheters 93 Objectives
10.1.1 Subclavian Access 95
10.1.2 Internal Jugular (IJ) Access 96
• To know the indications and learn the
10.1.3 Femoral Vein Access 96 surface anatomical landmarks of the
most common emergency percutaneous
10.2 Percutaneous Tracheostomy (PT) 97
10.3 Suprapubic Catheter Insertion (SCI) 98 • To know the pitfalls and technical tricks
10.4 Peritoneal Tap (PT) 99 for each procedure
10.5 Percutaneous Chest Tap (CT) 100 • To learn how to deal with procedural
10.6 Summary 101

Bibliography 101

Acute care and emergency surgeons should be

familiar with a few simple percutaneous proce-
dures for their daily activity. Among them are
central venous catheters, percutaneous tracheos-
tomy, suprapubic catheterization, and peritoneal
and chest tap. In this chapter, we will discuss the
indications, techniques, pitfalls, and frequent
complications of these procedures.
I. Martínez-Casas, MD, PhD, FACS
Serviciod e Cirugía General y Digestiva, Complejo
Hospitalario de Jaén, Jaén, Spain
e-mail: 10.1 Central Venous Catheters
D. Morales-García, MD, PhD
Division of Surgery, Hospital de Universitario Can be inserted either peripherally or via a direct
Marqués de Valdecilla, Santander, Spain access
F. Turégano-Fuentes, MD, PhD, FACS (*) • Peripheral vein insertion
Department of Surgery, Hospital General Universitario – Requires the use of long catheters to gain
Gregorio Marañón, Madrid Head of General Surgery II access to the central venous system
and Emergency Surgery. University General Hospital
Gregorio Marañón, Madrid, Spain – May be difficult to perform in the emer-
e-mail: gency setting (venous collapse)
© Springer International Publishing Switzerland 2016 93
A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_10
94 I. Martínez-Casas et al.

• Central venous access (CVA) Table 10.1 Complication rates of central venous cathe-
terization approaches
– Advantages: greater longevity without
infection, line security, avoidance of phlebi- Internal
tis, larger and multiple lumens and route for jugular Subclavian Femoral
nutritional support, long-term use antibiot- Arterial puncture 6.3–9.4 3.1–4.9 9–15
Hematoma <0.1–2.2 1.2–2.1 3.8–4.4
ics, and central venous pressure monitoring.
Hemothorax N/A 0.4–0.6 N/A
– The most frequent emergency indications
Pneumothorax <0.1–0.2 1.5–3.1 N/A
for CVA:
Thrombosis† 7.6 1.9 21.5
Volume resuscitation, emergent venous
Infection* 0.87 1.8 6.9
access for IV treatment, and central venous
Data from McGee DC et al., †Merrer J et al. and *Lorente
pressure monitoring
L et al.
– Contraindications to CVA:
Distorted anatomy (e.g., vascular injuries,
prior surgery, or previous local radiotherapy),
Table 10.2 Recommendations to avoid complications of
infection at insertion site, or uncooperative central venous catheterization approaches
Complications Recommendation
Relative: excessive overweight or under-
Infectious Use maximal sterile barrier
weight, anticoagulation, or coagulopathy
(especially for the subclavian approach, Choose subclavian access when
where it is difficult to stop bleeding by possible
compression) Use antimicrobial impregnated
– Choice of site of catheter insertion depends on: catheters
Purpose and duration of use of the catheter Mechanical Recognize risk factors for difficult
Experience and known complications of catheterization
the technique Seek assistance from an
experienced clinician
• Experience and comfort level with the
Avoid femoral venous
procedure are the main determinants to catheterization
the success of line placement Use ultrasound guidance if
• Internal jugular vein catheters have been available
reported to be associated with higher
risk for infection than subclavian or
femoral veins, but the level of evidence – Table 10.1 shows rates of more frequent
is low. complications for CVA. Preventive actions
• Generally speaking, lower extremity are shown in Table 10.2.
sites seem to be associated with higher • Knowledge of surface landmarks are critical
risk for infection and femoral catheters for success and safety.
are associated with higher risk for deep – Improper insertion position and inadequate
venous thrombosis than internal jugular landmark identification have been shown
or subclavian sites. as common technical errors.
• The risks and benefits of choosing a – The use of ultrasound and fluoroscopic
site to reduce infectious complications guidance decrease the rate of immediate
must be weighed against ease of access complications.
and the risk of mechanical compli- Ultrasound can detect thrombosed veins
cations (e.g., pneumothorax, subcla- and allows safe puncture in patients with
vian artery puncture, subclavian vein coagulopathy, avoiding arterial punc-
laceration or stenosis, hemothorax, ture. However, its use in the subclavian
thrombosis, air embolism, or catheter access has had mixed results in clinical
misplacement). trials.
10 Percutaneous Interventions 95

A chest radiograph is mandatory after CVA If resistance is encountered, rotate the

placement to check the catheter position and guide wire gently.
to assess for pneumothorax or hemothorax in Unsuccessful passing indicates misplace-
case of jugular or subclavian access (per- ment and never use force to advance the
formed before switching to the contralateral wire.
site after failed insertion). – Withdraw the introducer needle; make a
• General principles small stab against the wire to enlarge skin
– Most insertions use the Seldinger or modi- entry site.
fied Seldinger technique – Maintaining constant control of the wire,
– Whenever possible, explain the procedure, thread the dilator over the wire with a firm
the benefits, and risks to the patient or rela- and gentle twisting motion.
tives to obtain informed consent. – Remove the dilator and thread the catheter
– Check the equipment prior to starting the until wire exits the distal lumen.
procedure. – Push the catheter to desired length while
Central venous catheter tray (line kit) con- holding the wire.
taining a 26 gauge needle for injecting – Hold the catheter in place and remove
anesthesia (may also serve as a finder nee- the wire.
dle), a 22 gauge needle to access the vein, – Aspirate blood and flush 2 cc heparinized
syringe, flexible guide wire with J-tip, dila- saline in every catheter lumen.
tor, n° 11 scalpel, and single or multilumen – Attach the catheter to skin with sutures;
catheter apply a clean dressing.
Antiseptic solution (2 % chlorhexidine in
alcohol) with skin swab
Sterile gloves, drapes, and gown 10.1.1 Subclavian Access
100 ml of saline with heparin
Lidocaine 1 % • Most common access because:
Gauze and dressing – Simple
– Do not to use the patient as a table. – Consistent landmarks
– Infiltration of local anesthesia (1 % lido- – Patient comfort
caine) should be enough, but sometimes – Low potential for infection
analgesia and sedation can be helpful • Patient positioned supine, monitored, and
(operator should be familiar with the most Trendelenburg position (to reduce the risk of
commonly used analgesics, sedatives, and air embolism)
reversal agents). • Landmarks: sternal notch, angle of the
– Put on mask, sterile gowns, and gloves, and clavicle
drape the patient in a sterile fashion. • Prepare the insertion site and the neck as well.
– Flush the catheter with heparinized saline • Infiltrate skin, subcutaneous tissue, and cla-
before insertion. vicular periostium with lidocaine 1 %.
– Insert the introducer needle while pulling • The insertion site is 1 cm below the junction
on syringe piston, slowly advancing until of the middle and medial third of the clavicle,
reaching the clavicle and then slide under- at the deltopectoral groove or one finger-
neath the inferior border of the bone. breadth lateral to the angle of the clavicle.
– When venous blood is aspirated copiously, • Direct the insertion needle toward the sternal
disconnect the syringe, occlude the lumen notch, parallel to chest wall (to reduce the pos-
of the needle with a finger, and insert the sibility of pneumothorax).
guide wire while observing the heart rhythm • Attention:
(retract it 4 cm if arrhythmias result from – If the vein is not reached, remove the intro-
the guide wire being deep within the heart). ducer needle, flush the clots, and try again.
96 I. Martínez-Casas et al.

– Never change the needle position while Reduces failure rate and misplacement,
inserted. especially in the obese (for the femoral
– Change insertion site after three unsuccess- route) or in hypotensive patients (absence of
ful attempts. palpable adjacent (femoral) artery).
– Red pulsatile blood indicates arterial But can increase the risk of pneumothorax
puncture. in inexperienced hands (for subclavian
– Aspiration of air bubbles indicates a access).
pneumothorax. Avoid excessive compression of the skin
which will collapse the vein and distort
surface landmarks.
10.1.2 Internal Jugular (IJ) Access – Improper insertion position and inadequate
landmark identification are common tech-
• Optimal patient position is Trendelenburg nical errors.
with head turned to the opposite side of • Insert needle at a 45° angle to the skin, point-
insertion. ing to the ipsilateral nipple (or sternal notch
• Internal jugular vein lies underneath the tri- with posterior approach)
angle formed by the clavicle and the clavicu- • The line should be tunneled. It is preferable to
lar and sternal heads of the sternocleidomastoid avoid IJ insertion in patients with previous
muscle (Fig. 10.1). neck surgery.
• IJ is best localized at the apex of this triangle • As above, beware of multiple attempts for the
but can be also easily accessed cranially medial increased risk of damaging adjacent structures
to the sternocleidomastoid muscle and external (trachea, esophagus, carotid artery).
to the carotid pulse (anterior approach) or lat-
eral to the muscle (posterior approach).
– Ultrasound guidance with a high-frequency, 10.1.3 Femoral Vein Access
high-resolution probe (7–15 MHZ) has
decreased the rate of immediate • Advantages
complications. – Easiest if CVA is needed for resuscitation
from shock,
– Can be performed quickly.
– The femoral artery is an immediate palpa-
ble landmark.
– No risk for hemothorax or pneumothorax.
– The site is directly compressible if bleed-
ing or arterial cannulation occur.
Point of – Nerve damage is unlikely.
insertion – Local anesthesia may be omitted in an
emergent situation.
• Disadvantages
– Risk of deep venous thrombosis is
Needle pointing to increased sixfold, unrelated to duration of
ipsilateral nipple catheterization.
– The perineum is always considered as
potentially contaminated.
• Formal contraindication: known or suspected
Mastoid • Patient position: supine with the hip in neutral
position and the foot in moderate lateral
Fig. 10.1 Internal jugular vein catheterization landmarks flexion.
10 Percutaneous Interventions 97

Fig. 10.2 Femoral A

triangle and femoral
vein anatomic relations C


• Vein lies in the femoral triangle formed by the • Has replaced conventional tracheostomy
inguinal ligament superiorly, the adductor because
longus muscle medially, and the sartorius – Rapid
muscle laterally (Fig. 10.2), medial to the – Simple
(pulsating) artery. – Can be performed at bedside
• Insert needle 1 cm below the inguinal liga- – Smaller skin incisions
ment, 0.5 cm medial to (pulsating) artery. – Cost-effective
– Enter the skin cephalad at a 45° angle with – Fewer intraoperative complications
the 22-gauge needle. False passage
• Most frequent complications: Less tissue trauma
– Arterial puncture Less intraoperative minor bleeding
– Hematoma Pneumothorax
– Thrombosis Tracheal ring fracture
– Femoral nerve injury Posterior wall injury
• Less frequent complications: – Lower incidence of wound infection
– Pseudoaneurysm formation – Lower mortality
– Bowel puncture (beware of patients with • But a higher incidence of decannulation and
inguinal hernias) obstruction
– Bladder puncture • All PT techniques show similar complication
– Psoas abscess rates (10 % perioperative, 7 % postoperative):
– Osteomyelitis from bony puncture, espe- direct injuries to the vocal cords or recurrent
cially in children laryngeal nerve or tracheal stenosis, the most
important long-term complication, are
10.2 Percutaneous • Most common indications:
Tracheostomy (PT) – Need for prolonged mechanical ventilation
(>7 days)
• One of the most frequently performed proce- – Airway obstruction
dures in critically ill patients. – Need for improved pulmonary toilet
98 I. Martínez-Casas et al.

• Absolute contraindications: dilate the soft tissues anterior to the tra-

– Children chea, closed and reinserted over a guide
– Emergency airway necessity wire.
– Coagulopathy Loss of resistance occurs when tracheal
– Cervical injury membrane is pierced.
– Distortion of neck anatomy due to tumors, Insertion of tracheostomy tube with obtu-
goiter, or high innominate artery rator through guide wire.
• Relative contraindications: – The Rapitrach and the Ciaglia Blue Rhino
– Obesity techniques are variations of the previous
– Need for high positive end-expiratory pres- with different dilator forceps. After the
sure (PEEP >20 cm of water) procedure, air entry to the lungs must be
– Evidence of infection in the surgical site checked, excess of blood and secretions
• Several techniques are available, all based on suctioned, everyday antiseptic wound care
the use of a needle guide wire to gain airway provided, and cuff pressure monitored.
access. However, each method requires spe-
cific equipment and has a different intraopera-
tive procedural sequence 10.3 Suprapubic Catheter
– Common steps for all procedures include Insertion (SCI)
intravenous sedation, 100 % oxygen,
hyperextension of neck, partial withdrawal • Common urological procedure
of the endotracheal tube (ET) under bron- • Indicated in the emergency setting when
choscopic direct vision (recommended to transurethral catheterization is contraindi-
place the balloon caudal to the vocal cords) cated or technically not possible for neuro-
but protection needed to avoid untoward pathic bladder and urethral injuries or bladder
movement, sterile skin preparation and outflow obstruction
draping, infiltration of the skin with 2 % • Contraindications
lidocaine – Absence of an easily palpable or ultra-
– The percutaneous dilational tracheostomy sound localized distended bladder
technique • Relative contraindications:
Starts with a 1.5–2 cm transverse skin inci- – Coagulopathy, prior lower abdominal or
sion on the level of the first and second tra- pelvic surgery, or radiation (risk of bowel
cheal rings adhesions)
Blunt dissection until reaching the • Procedure
trachea – Obtain informed consent as possible.
Insertion of a 22 gauge needle between first – Check for necessary equipment before
and second, or, preferably second and third starting the procedure.
tracheal rings Sterile gloves, drapes, and gauzes
When air is aspirated, introduction of guide Antiseptic solution
wire and dilators (sequentially inserted Local anesthesia
from small to large) 10 and 60 ml syringes
Insertion of tracheostomy tube 18 and 25 gauge needles
Removal of guide wire and dilator n° 11 scalpel blade
Inflation of tube cuff Percutaneous suprapubic catheter set (nee-
Connection of breathing circuit dle obturator, Malecot catheter, connecting
Removal of ET tube tube and one-way stopcock)
– The guide wire dilating forceps technique Sterile urometer or urine bag
Employs a modified forceps that is Skin tape or suture
advanced through the soft tissues of the – Prepare the insertion kit by inserting the
neck until resistance is felt, then opened to needle obturator into the Malecot catheter,
10 Percutaneous Interventions 99

twist and lock it into the port, and connect ics are recommended.
the 60 ml syringe. – Simple irrigation with saline should resolve
– Patient positioned supine. catheter obstruction.
– Provide adequate parenteral analgesia (and – If malposition or displacement is suspected,
sedation if necessary). cystography may help the diagnosis.
– Clean and shave infraumbilical abdominal
wall skin.
– Palpate distended bladder and mark the 10.4 Peritoneal Tap (PT)
insertion site at the midline and no more
than 3 cm above the pubic symphysis. • Indications
– Use the 10 ml syringe with the 25 gauge – Diagnostic (obtention of peritoneal fluid
needle and local anesthetic agent to infil- sample for evaluation of ascites [malig-
trate the insertion site. nant, infected, or chylous]) and culture
– Alternating injection and aspiration, advance – Therapeutic (peritoneal lavage, relieve
needle through the skin, subcutaneous tissue, abdominal hypertension)
linea alba, and retropubic space until urine • No absolute contraindications
enters the syringe. • Relative contraindications (most can be cor-
– Make a 4 mm longitudinal stab with the rected or circumvented if paracentesis is abso-
blade along needle. lutely necessary)
– Direct the tip of the obturator catheter into – Coagulopathy or thrombocytopenia,
the skin incision with a 70° angle from the abdominal adhesions, severe bowel disten-
patient’s legs. sion, or pregnancy
– Stabilize the tip of the catheter with the non- • Equipment includes dressing pack, sterile
dominant hand while the dominant hand gloves, cleaning solution (iodine or
advances while aspirating until urine enters chlorhexidine), lidocaine 1–2 %, 10 ml
the syringe, and advance 4 more centimeters. syringe and 21G and 25G needles, 60 ml
– Unscrew the obturator from the catheter syringe with 16G aspiration needle for diag-
and advance it 5 cm more. nostic tap, paracentesis catheter, and tubes
– Remove the obturator. for samples
– Connect the catheter with the tube and the • Procedure
stopcock to a urometer. – Explain the procedure to the patient and
– Tape or (better) stitch catheter to the skin. obtain informed consent if appropriate
– Observe patient in the emergency depart- – Position the patient supine with the trunk
ment for 3 h after SCI. elevated 45° and expose the abdomen
– After the procedure, do not change the cath- – Percuss to identify the ascites (ultrasound
eter for 1 month to allow the tract to be estab- guidance is rarely needed)
lished and refer the patient to a urologist. – Prepare and prep the proposed site under
– Never remove the catheter unless under the sterile conditions
direction of a urologist’s indication or if it Left lower quadrant preferred
can be exchanged immediately. Avoid suprapubic area and sites of old
• The complication rate of the procedure is scars or cellulitis
10–29 %; mortality is low (0.8 %). – Infiltrate local anesthetic into the skin and
– Intraoperative complications include subcutaneous always aspirating as the nee-
anesthetic-related, catheter malpositioning, dle is advanced
exit site bleeding, and bowel injury; gross For “diagnostic tap”
hematuria is typically transient. • Introduce needle through tissues; perito-
– Late complications include exit site infection, neal cavity is entered (felt when the nee-
abscess or cellulitis, and occluded device. dle “gives” and confirmed when fluid
– Routine intravenous prophylactic antibiot- freely enters the syringe)
100 I. Martínez-Casas et al.

• Withdraw 20 ml of fluid for culture and for line and blunt dissection, 10 ml syringe, 11
analysis (glucose, LDH, protein, amy- blade scalpel, 1 or 3/0 suture, and gauze.
lase levels, and cytology) – If kits are unavailable in an emergency sit-
• Remove aspiration needle uation, either a Foley catheter or nasogas-
• Apply sterile occlusive dressing tric tube can be used.
For “therapeutic drainage” – Cut urine bag or glove finger can also be
• Ensure needle is in place (ascites used to replace water-sealed or pleur-evac
aspiration). devices.
• Slide catheter over needle into perito- • Procedure
neal cavity. – Explain the procedure to the patient and
• Allow drainage up to 1,000 ml of fluid, obtain informed consent if appropriate.
as slowly as possible, over 2 h. – Patient in half-sitting position with ipsilat-
• Maximum drainage of 2 l/day is usually eral arm abducted, ensuring continual
advised. monitoring of pulse oximetry.
– If unable to withdraw fluid, consider – Most common insertion site is the fifth
loculation of ascites; try to position intercostal space along anterior axillary
the patient sitting and leaning line.
forward. In case of empyema or pleural effusion,
• Fresh blood or fecal staining indicates vessel both should be localized by percussion or
puncture or hollow viscus perforation. ultrasound, and the needle should be
• Incisional site bleeding or ascites leakage may inserted one to two fingerbreadths below
require sutures. the top of the effusion.
– Insert needle through skin for anesthetic
10.5 Percutaneous Chest Tap (CT) – Continue insertion until air bubbles or fluid
is obtained, and then infiltrate all wall lay-
• Indications ers while withdrawing the needle.
– Diagnostic (obtention of air signifies pneu- – In the “open approach”
mothorax or infection), fluid sample for Make a 2 cm transverse skin incision.
evaluation of pleuritis (malignant, infected, Dissect the intercostal space bluntly over
or chylous), and culture the lower rib through the pleura, spreading
– Therapeutic (relieve dyspnea or respiratory to widen the hole.
distress due to air or fluid accumulation in Insert chest tube superiorly in case of pneu-
the pleural space) mothorax and inferiorly for hemothorax or
– Most frequent indications: spontaneous effusion.
pneumothorax, persistent pleural effusion, Clamp the drain and secure it before con-
malignant pleural effusion, empyema, or necting it to the pleur-evac or other selected
complicated paraneumonic pleural device.
effusion. – In the “closed access”,
– Relative contraindications: severe coagu- Also effective and safe in uncomplicated
lopathy or agitated and uncooperative air or serous effusions
patient. Same landmarks as the open approach
• Equipment includes dressing pack, sterile Technique:
gloves, cleaning solution, lidocaine 1–2 %, a • A pigtail is inserted by the Seldinger
28G intercostal drain or a 14G pigtail Kit, technique.
underwater seal or pleur-evac device, clamps • Insert needle into pleural space.
10 Percutaneous Interventions 101

• Pass guide wire through needle without 10.6 Summary

any resistance and then remove
needle. Percutaneous procedures are part of emergency
• Make 2 mm skin incision to pass dilator surgeons’ daily activity. In this chapter, we
over guide wire. explain the indications, contraindications, the
• Pass 14G pigtail over guide wire. necessary equipment, insertion techniques, land-
• Remove dilator. marks and tricks, pitfalls, and frequent complica-
• Connect selected draining device. tions of some of these procedures. Most
• Suture the drain. procedures are based on the Seldinger technique.
– A chest X-ray is compulsory after both To avoid complications, it is mandatory to know
procedures. the anatomical landmarks, contraindications, and
– Possible complications pitfalls for each procedure.
Misplacement (most frequent): no drain-
age occurs, no oscillation of sealed water
column when tube is inserted between the Bibliography
parietal pleura and chest wall
• More common in the obese Adams GA, Bresnick SD, editors. On call procedures.
Philadelphia: Saunders Elsewier; 2006.
Injury to structures such as lungs, spleen,
Ahluwalia RS, Johal N, Kouriefs C, Kooiman G,
liver, or heart (more severe): no air or Montgomery BS, Plail RO. The surgical risk of
sudden unexpected fluid. Before the suprapubic catheter insertion and long-term sequelae.
removal of a chest tube, be sure that it is Ann R Coll Surg Engl. 2006;88:210–3.
Ahmed SJ, Metha A, Rimington P. Delayed bowel perfo-
indicated and be prepared to replace it
ration following suprapubic catheter insertion. BMC
immediately. Urol. 2004;4:16.
Amesur NB, Zajko AB. Central venous acces. eMedicine.
422189-overview. 23 May 2008.
Brietzke SE, Kong MS. Percutaneous tracheostomy.
overview. 10 Sept 2008.
• Breach of aseptic technique.
Centers for Disease Control and Prevention. Guidelines
• False passages are not uncommon. for the prevention of intravascular catheter-related
• Complications to nearby structures may infections. MMWR. 2002;51(No RR-10):1–32.
be life threatening. Denise G. Practical procedures. In: Berger DL, editor.
Oxford American hand book of surgery. New York:
Oxford University Press; 2009. p. 200–12.
Govindarajan KK, Bromley PN. Central venous access,
internal jugular vein, anterior approach, tunneled.
Essential Points
• Check the equipment before use. overview. 30 Apr 2010.
• Know the anatomy and landmarks. Joynt GM, Kew J, Gomersall CD, Leung VYF, Liu
EKH. Deep venous thrombosis caused by femoral
• Use aseptic technique.
venous catheters in critically ill adult patients. Chest.
• Each procedure has its proper complications. 2000;117:178–83.
• Consider contraindications and patient char- Kilbourne MJ, Bochicchio GV, Scalea T, Xiao Y. Avoiding
acteristics before starting the procedure. common technical errors in subclavian central venous
catheter placement. J Am Coll Surg. 2009;
• Be prepared for failure and keep in mind an
alternative approach for the procedure. Lorente L, Henry C, Martín MM, Jimenez A, Mora
• Have experienced help nearby. ML. Central venous catheter-related infection in a pro-
• Whenever possible, explain the procedure to spective and observational study of 2,595 catheters.
Crit Care. 2005;9(6):R631–5.
the patient and obtain informed consent.
102 I. Martínez-Casas et al.

McGee DC, Gould MK. Preventing complications of cen- Partin WR. Emergency procedures. In: Stone CK,
tral venous catheterization. N Eng J Med. 2003; Humphries RL, editors. Current diagnosis & treatment
348:1123–33. emergency medicine. 6th ed. New York: McGraw-
Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffi B, Hill; 2008.
et al. Complications of femoral and subclavian venous Roe EJ. Central venous access, subclavian vein, subcla-
catheterization in critically Ill patients a randomized vian approach. eMedicine.WebMed. www.emedicine.
controlled trial. JAMA. 2001;286:700–7. 80336-overview. 11 Nov 2009.
Pal N. Central venous access, femoral vein. eMedicine. Shlamovitz GZ. Suprapubic catheterization. www.emedi-
Webmed. 14 Jan
80279-overview. 29 Apr 2009. 2010.
Upper Gastrointestinal Endoscopy
Hakan Yanar and Korhan Taviloglu

Contents 11.1 Upper Gastrointestinal (GI)

11.1 Upper Gastrointestinal (GI) Bleeding
Bleeding 103
11.2 Foreign Body Removal 104
• Common and potentially life-threatening
11.3 Corrosive Injury of the Upper GI • Causes:
Tract: Esophageal Perforation
and Stenting 106 – Peptic ulcer: 30–60 %
– Gastroduodenal erosion: 8–12 %
11.4 Metallic Stents in Malignant Duodenal
Obstruction and Gastric Outlet
– Variceal bleeding: 6 %
Problems 107 – Other less frequent causes include
Mallory-Weiss tear
11.5 Endoscopic Retrograde
Cholangiopancreatography (ERCP) 107 Erosive duodenitis
Dieulafoy’s ulcer (and other vascular
11.6 Endoscopic Drainage of Pancreatic-
Fluid Collections (PFCs) and lesions)
Pseudocysts and Endoscopic Neoplasm
Transmural Necrosectomy 107 Aorto-enteric fistula
11.7 Fibrin Glue and Clips 107 Gastric antral vascular ectasia
Prolapse gastropathy
11.8 Percutaneous Endoscopic
Gastrostomy (PEG) 107 • Requires endoscopy for diagnosis, assess-
ment, and possibly to treat the underlying
Selected Reading 107
– Within the first 24 h of is considered stan-
dard of care.
– Patients with uncontrolled or recurrent
bleeding should undergo urgent endos-
H. Yanar (*) copy to control bleeding and reduce the
Department of Surgery, Trauma and Emergency
Service, Istanbul Medical School, Istanbul University, risk of death (in addition, one multi-
Istanbul, Turkey center randomized controlled trial has
e-mail: shown that endoscopy within 6 h of
K. Taviloglu, MD admission reduces the amount of
Taviloglu Proctology Center - Abdi Ipekci Cad, transfusions).
Nişantasi, Istanbul, Turkey

© Springer International Publishing Switzerland 2016 103

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_11
104 H. Yanar and K. Taviloglu

– Gastric lavage improves the view of the tial procedure is questionable (one
gastric fundus but has not been proven to meta-analysis revealed that routinely
improve the outcome. repeating endoscopy reduces the rate of
– Accuracy: 90–95 % for acute upper GI recurrent bleeding but not the need for
bleeding. surgery or the risk of death).
• About 25 % of endoscopic procedures per- – Clinical scoring systems based on endo-
formed for upper GI bleeding include some scopic findings along with clinical factors
type of treatment such as injections of epi- on admission can be useful (Table 11.1).
nephrine, normal saline, or sclerosants, ther- These scoring systems are valuable for pre-
mal cautery, argon plasma coagulation (APC), dicting the risk of death, longer hospital
electrocautery, or application of clips or stay, surgical intervention, and recurrent
bands: all equally effective, and combinations bleeding (Fig. 11.1).
of these therapies may be more effective than
when used individually.
– Endoscopic therapy 11.2 Foreign Body Removal
Is recommended for patients found to have
active bleeding or nonbleeding visible • Ingestion of foreign bodies may be accidental
blood vessels, as outcomes are better with or intentional.
endoscopic hemostatic treatment than with • Patients are generally distressed and cannot
drug therapy alone. swallow.
• A recent meta-analysis found dual ther- • Endoscopy should be performed urgently
apy to be superior to epinephrine mono- under the following circumstances.
therapy in preventing recurrent bleeding, 1. Patients who cannot swallow saliva
need for surgery, and death. 2. Impacted sharp objects
Stops the bleeding in more than 90 % of 3. Ingestion of button batteries (which can
patients, but bleeding recurs after endo- disintegrate and cause local damage)
scopic therapy in 10–25 %. • Removal of other foreign bodies is less
– Reversal of any severe coagulopathy with urgent.
transfusions of platelets or fresh frozen • Techniques:
plasma is essential for endoscopic – At or above the cricopharyngeus, for-
hemostasis. eign objects can be removed with rigid
However, coagulopathy at the time of ini- instruments.
tial bleeding and endoscopy does not – For small, slippery, pointed, or sharp objects
appear to be associated with higher rates of (pins, razor, etc.), flexible gastroscopy is
recurrent bleeding following endoscopic
therapy for nonvariceal upper GI bleeding.
Table 11.1 Forrest classification of the bleeding peptic
– Patients with refractory bleeding are candi-
ulcer activity
dates for angiography or surgery.
However, endoscopy is important before Rebleeding
Classification Lesion rate
angiography or surgery to pinpoint the site
Grade Ia Arterial spurting High
of bleeding and diagnose the cause, even hemorrhage
when endoscopic hemostasis fails. Grade Ib Oozing hemorrhage High
A second endoscopic procedure is gener- Grade IIa Visible vessel High
ally not recommended within 24 h after the Grade IIb Adherent clot Medium
initial procedure. Grade IIc Dark base (hematin Low
• However, it is appropriate in cases in covered lesion)
which clinical signs indicate recurrent Grade III Lesion without active Low
bleeding or if hemostasis during the ini- bleeding
11 Upper Gastrointestinal Endoscopy 105

Forrest 1a Forrest IIb

Forrest 1b

Forrest IIc

Forrest IIa Forrest III

Fig. 11.1 Endoscopic appearance of various lesions according to Forrest classification

preferred: use of an overtube is recom- – For gastric bezoars, large polypectomy snares
mended to avoid damage to the esophagus are used to fragment the bezoar into smaller
and pharynx (Fig. 11.2). pieces so that these can pass spontaneously.
– Packets containing illicit drugs (plastic – Small batteries warrant immediate removal
wrappings or tubes swallowed) can be because of the high risk of local and sys-
removed with snare, care being taken to temic toxicity, and the smooth surface can
avoid damaging the covers. be grasped with a basket.
106 H. Yanar and K. Taviloglu

Fig. 11.2 Gastric (battery) and esophageal (pill) foreign bodies

11.3 Corrosive Injury of the Upper – Many studies advocate avoiding endoscopy
GI Tract: Esophageal between 5 and 15 days after caustic
Perforation and Stenting ingestion.
Mucosal sloughing occurs 4–7 days after
• Ingestion of corrosive agents initiates a pro- the initial injury and collagen deposition
gressive injury of the upper gastrointestinal may not begin until the second week; the
tract, the extent of which depends on the tensile strength of the healing tissue is low
agent, its concentration, quantity, and physical during the first 3 weeks.
state, as well as the duration of exposure. – Endoscopy alone, however, cannot detect
• While plain films of the chest and the abdo- extraluminal injury, and computed tomog-
men can reveal possible perforations of the raphy should be the routine method
upper gastrointestinal tract, early endoscopy for assessing injury to the adjacent
remains the standard method of diagnosis and structures.
evaluation of the esophagus and the stomach. – Late formation of esophageal stricture after
– Endoscopy is safe, but it must be performed corrosive esophageal burn.
by an experienced endoscopist and avoid Recently degradable esophageal stents have
unnecessary movements and too much been recommended for the treatment of a
insufflation of air. corrosive esophageal stenosis.
– Complete examination of the upper gastro- Esophageal intralumenal stenting has been
intestinal tract is essential to evaluate the used to decrease the likelihood of stricture
extent of injury and to find out the degree formation in patients with corrosive esoph-
of injury in all areas involved. ageal burns for several decades.
• Management depends on the degree of injury, • Esophageal perforations can be treated with
which is only defined by the means of stents.
endoscopy. When diagnosed early, mortality is decreased
– Most studies recommend endoscopy <24 h greatly.
after ingestion. Temporary esophageal stenting poses little
However, underestimation of severity is threat to the patient and represents an alterna-
possible if performed too early. tive to surgery.
11 Upper Gastrointestinal Endoscopy 107

11.4 Metallic Stents in Malignant 11.6 Endoscopic Drainage

Duodenal Obstruction of Pancreatic-Fluid
and Gastric Outlet Problems Collections (PFCs)
and Pseudocysts
• Malignant duodenal or pyloric obstructions are and Endoscopic Transmural
most commonly caused by direct invasion from Necrosectomy
local tumors or lymphadenopathy compression.
• Palliative internal (metallic) stenting is an • Indications include pseudocysts developing
option. after acute pancreatitis or trauma associated
– For patients unfit for surgical drainage (e.g., with pain, infection, obstruction of the GI or
gastrojejunostomy), general anesthesia or in the biliary tract, leakage, or fistulization of the
case of ascites and peritoneal metastasis. collection.
• Is successful in the majority of patients (with
an acceptable complication rate).
11.5 Endoscopic Retrograde
(ERCP) 11.7 Fibrin Glue and Clips

• Main indication: obstructive biliary, pancre- • Esophageal and gastric anastomotic leaks
atic duct, or major-minor papilla disease – Acute or chronic
• Is widely used to replace surgical exploration • Avoids complex surgical revision and repair
of common bile duct and treat
– Impacted stone at the papilla or in common
bile duct causing acute biliary obstruction 11.8 Percutaneous Endoscopic
– Acute obstructive cholangitis (stones, Gastrostomy (PEG)
malignant tumors)
– Choledocholithiasis • Goal: intentional formation of gastrocutane-
– Postoperative biliary surgery complica- ous fistulae for the purpose of enteral feeding
tions (leakage from cystic duct stump, bile • Used in patients unable to take in food by
duct injuries) mouth for a prolonged period of time
– Acute biliary pancreatitis (selected patients – Either normal or nasogastric feeding is
such as predicted severe acute pancreatitis, impossible.
associated cholangitis – Patients with swallowing disorder.
– Pancreatic duct injury due to trauma or • Two major techniques
pancreatitis – Pull technique more commonly used than
• Carries some risks including; the push technique
– Pancreatitis (most common complication) • To decompress the stomach contents in a
– Retroduodenal perforation (reported in patient with a malignant bowel obstruction,
<1 % of endoscopic sphincterotomies) called “venting PEmG”
Can be treated conservatively in stable patients – Placed to avoid nausea and vomiting
– Bleeding (most often results from sphinc-
terotomy performed too quickly)
Usually stops spontaneously
If continues, injection of 1:10,000 epineph- Selected Reading
rine into bleeding sites
Albeldawi M, Qadeer MA, Vargo JJ. Managing acute
– Repeat or de novo cholangitis (in case of upper GI bleeding, preventing recurrences. Cleve Clin
retained stones) J Med. 2010;77:131–42.
108 H. Yanar and K. Taviloglu

Cotton P, Williams C. Practical gastrointestinal endos- niques, and outcomes. Gastrointest Endosc.
copy. In: Foreign bodies and gastrointestinal bleeding. 2006;63:635–43.
Great Britain: Blackwell Science; 1996. p. 91–103. Marmo R, Rotondano G, Bianco MA, Piscopo R, et al.
Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in Outcome of endoscopic treatment for peptic ulcer
gastrointestinal bleeding. Lancet. 1974;2:394–7. bleeding: is a second look necessary? A meta-analysis.
Hookey LC, Debroux S, Delhaye M, et al. Endoscopic Gastrointest Endosc. 2003;57:62–7.
drainage of pancreatic-fluid collections in 116 Soehendra N, et al. Pancreatic pseudocyst drainage. In:
patients: a comparison of etiologies, drainage tech- Therapeutic endoscopy. Thieme; 1998. p. 164–71.
Part III
By Organ
Esophageal Emergencies
Demetrios Demetriades, Peep Talving,
and Lydia Lam

12.1 Introduction 111
12.1.1 Anatomical Considerations 111 • To be familiar with anatomy and the
12.1.2 Esophageal Microflora and Appropriate microflora of the esophagus
Antimicrobials 112 • To assess and diagnose nontraumatic
12.2 Esophageal Perforation 112 esophageal emergencies
12.2.1 Assessment and Diagnosis 112 • To apply initial treatment in esophageal
12.2.2 Treatment 114 emergencies
12.3 Caustic Ingestion 116 • To be familiar with surgical approach to
12.3.1 Assessment and Diagnosis 117 the esophagus
12.3.2 Treatment 117
• To recognize prognostic determinants in
12.4 Esophageal Foreign Bodies 118 esophageal emergencies
12.4.1 Causes 118
12.4.2 Food Impaction 118
12.4.3 Indigestible Foreign Body Obstruction 119
12.5 Esophageal Bleeding 120
12.1 Introduction
Selected Reading 122
Esophageal emergencies are associated with life-
threatening complications when overlooked or
subjected to delayed management. Nontraumatic
D. Demetriades, MD, PhD, FACS (*) esophageal emergencies encountered by the
Professor of Surgery, Department of Surgery, acute care surgeon comprise mainly esophageal
Keck School of Medicine, Director of the Division of perforation, caustic ingestion, foreign body
Acute Care Surgery, University of Southern
obstruction, and esophageal hemorrhage.
California, Los Angeles County + USC Medical
Center, Los Angeles, CA, USA
P. Talving, MD, PhD, FACS • L. Lam, MD, FACS 12.1.1 Anatomical Considerations
Assistant Professor of Surgery,
Division of Acute Care Surgery and Surgical • The esophagus begins at the level of the sixth
Critical Care, Department of Surgery, Keck School
cervical vertebra/cricoid cartilage and extends
of Medicine, University of Southern California,
Los Angeles County + USC Medical Center, to the cardia of the stomach, measuring
Los Angeles, CA, USA 25–35 cm (40–50 cm from incisors) in length.

© Springer International Publishing Switzerland 2016 111

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_12
112 D. Demetriades et al.

– The cervical esophagus lies behind the tra- 12.2 Esophageal Perforation
chea, anterior to the cervical spine between
the common carotid arteries. • The most frequent cause of esophageal perfo-
– At the thoracic inlet, the esophagus is ration is instrumentation.
located behind the great vessels and tra- – Diagnostic flexible endoscopy carries a rela-
chea. It gradually assumes an almost left tively low overall perforation risk of 1:3000.
paravertebral location in the lower left Despite the low risk, it is a widely used diag-
chest. nostic modality resulting in a significant
– The abdominal esophagus passes through number of esophageal perforations.
the esophageal hiatus to join the cardia of – Diagnostic interventions such as Maloney
the stomach. bougienage, Savary pneumatic dilatation,
• Thyroid arteries, tracheobronchial arteries, through-the-endoscope hydrostatic balloon
branches of the descending aorta, left gastric dilators, Sengstaken-Blakemore tube deploy-
artery, and splenic artery provide the arterial ment, sclerotherapy, and banding in esopha-
supply. geal varices, and endotracheal intubation
• Two sphincter muscles, the UES (upper increase the risk of perforation, particularly
esophageal sphincter) and LES (lower esopha- in patients with esophageal pathology.
geal sphincter), prevent regurgitation. – Dilatation in achalasia and strictures carry
• The esophagus has three major levels of con- relatively higher perforation rates at 2–6 %
strictions; UES, aortic arch impression, and and 0.3 %, respectively.
LES (Fig. 12.1). – Esophageal perforation can occur also after
• The absence of a serosal layer in the esopha- surgical interventions such as fundoplica-
gus increases risk of perforation and, when tion, esophageal myotomy, vagotomy, lung
perforation occurs, adds greater likelihood of resection, thyroid surgery, tracheostomy,
bacterial contamination. chest tube placement, mediastinoscopy, or
spine surgery.
• Spontaneous rupture of the esophagus caused
12.1.2 Esophageal Microflora by voluminous vomiting or retching is named
and Appropriate after Dutch physician Hermann Boerhaave
Antimicrobials who described the condition in 1724.
– The classic presentation of spontaneous
• A mixed aerobic and anaerobic microflora perforation includes sudden retrosternal
inhabits the esophagus. Streptococci, pain radiating to the neck associated with
Staphylococci, Klebsiella pneumoniae, and tachycardia and tachypnea.
Escherichia coli predominate. The anaerobic – Hematemesis is rarely seen in spontaneous
species include Prevotella, Porphyromonas, perforation which helps distinguish it from
Bacteroides fragilis, Fusobacterium, and the Mallory-Weiss tear.
Peptostreptococcus, in addition to frequent – Spontaneous rupture has been observed
colonization with yeast found in obstructive following blunt chest trauma, severe
diseases. coughing, weightlifting, and childbirth.
• The optimal antimicrobial treatment in
esophageal perforation is broad-spectrum
antimicrobials such as cefoxitin sodium, 12.2.1 Assessment and Diagnosis
clindamycin phosphate, beta-lactamase-
resistant penicillins, and antifungal agents • The initial investigation includes history,
when appropriate. examination, and chest radiography.
12 Esophageal Emergencies 113

Fig. 12.1 Topography and constrictions of the Incisor teeth

esophagus (F. Netter. Atlas of Human Anatomy. 4th
Edition, Saunders Elsevier, 2006, Philadelphia, PA.
page 233)



Piriform fossa (recess)

Pharyngo- Thyroid cartilage

Cricoid cartilage

(muscle) part of
Average length in centimeters
Thoracic constrictor

23 Arch of aorta

Left main

(inferior Diaphragm
38 “sphincter”)

Abdominal part
40 of esophagus Fund

Cardiac part
of stomach

• Signs and symptoms – In addition, odynophagia, dysphagia,

– Severe pain is the keystone manifestation fever, subcutaneous emphysema, hemop-
of esophageal perforation. tysis, or blood in nasogastric tube may be
– Cervical or thoracic perforation is associ- present.
ated with sudden sharp pain in the neck or • Chest X-ray
substernal area, respectively, shortly after – Shows nonspecific findings such as medi-
the spontaneous perforation or esophageal astinal emphysema or pleural effusion in
instrumentation. majority of cases (90 %).
114 D. Demetriades et al.

• Multidetector computed tomography (MDCT)

and MDCT esophagography has shown a high
accuracy for esophageal perforations. Screening
chest MDCT may depict mediastinal air, air-
fluid collections communicating with esopha-
geal air, or an abscess adjacent to esophagus.
Directed MDCT esophagography may confirm
perforation demonstrating leakage of contrast
media into mediastinum or pleural space. In
patients with empyema, thoracentesis may
yield pus-containing food particles.
• In summary, a high index of suspicion must
be maintained in suspected esophageal
perforation because outcome depends entirely
on timely diagnosis and prompt management.

12.2.2 Treatment

• Therapeutic options in esophageal perforation

depend on the anatomical site of the perfora-
tion, underlying pathology, time to diagnosis,
signs of severe sepsis, and extent of the perfo-
ration and leak.
Fig. 12.2 Thoracic esophageal perforation noted on • Although surgery is the gold standard in the
esophagography (arrow)
management of esophageal perforation, not all
esophageal perforations require operative
– An unexplained pleural effusion on chest
radiography is suspicious for esophageal Nonoperative Management
perforation. (NOM)
– Commonly, the perforation is confirmed • Is feasible in patients suffering small, con-
with contrast esophagography (Fig. 12.2). tained perforations with no signs of sepsis,
The study is performed initially with water- especially in the cervical esophagus
soluble gastrografin because it is less • Criteria for NOM include intramural
harmful if it leaks into the mediastinum. perforation, contained perforation communi-
However, if aspirated into the tracheobron- cating with esophagus, non-stricture and
chial tree or leaks through a nonmalignant perforation associated with
tracheoesophageal fistula into the lungs, mild degree of sepsis.
gastrografin may cause severe pneumonitis. • Some recent evidence advocates nonoperative
– The optimal diagnostic accuracy is “aggressive conservatism” that includes anti-
obtained with thin barium esophagogra- biotic treatment, aggressive drainage of medi-
phy performed in decubitus position for astinal and chest collections, and sequential
slower-contrast transit time through imaging
the esophagus. Barium contrast has supe- • The principles of NOM include restriction of oral
rior radiologic density and delineates intake, broad-spectrum antibiotics, CT-guided
mucosa better. With negative good-quality drainage of any fluid collections in the neck or
barium study, the perforation is unlikely. the mediastinum, and parenteral nutrition.
12 Esophageal Emergencies 115

Fig. 12.3 Endoscopically

placed stent in the esophagus

• Endoscopically placed stents in selected • Two-layer repair should be used: a running

cases have been used with good success absorbable suture to the mucosa followed by
(Fig. 12.3). an interrupted suture line to the muscular
layer. Operative Management • It is crucial to extend the myotomy to assess
the entire mucosal length of the defect.
Surgery – The mucosal primary repair can be carried
• The cornerstone of therapy in uncontained out over a large bougie.
perforations and in all patients with severe • The sternocleidomastoid or omohyoid muscle
sepsis or septic shock. can be placed over the repair
• Options include drainage alone, primary repair, • There is no evidence that nasogastric tube fol-
diversion, or esophagectomy depending on the lowing cervical esophageal repair provides
site of perforation, pathology, severity of sep- diversion of saliva and may compromise the
sis, and the interval from perforation to diagno- tenuous repair and healing of the wound.
sis. While immediate diagnosis of perforation
without preexisting pathology allows primary Thoracic Esophagus
repair, in those patients with preexisting disease • Thoracic esophageal perforations are repaired
or delay in diagnosis, primary repair will likely through a right fourth to fifth or a left sixth to
fail with devastating septic complications. Even seventh intercostal posterolateral thoracotomy
after meticulous surgical repair, leak rates range (Fig. 12.4).
from 25 % to 50 % mandating placement of • Running absorbable suture line for mucosa
closed suction drains near the repair. and interrupted absorbable for muscular layer
is appropriate.
Surgical Approaches • In mid and lower esophageal repairs, a dia-
Cervical Esophagus phragmatic buttress flap can be utilized.
• The cervical esophagus is relatively easy to – For that purpose, rotation-flap con-
approach using the left unilateral sternoclei- structed from the posterior aspect of dia-
domastoid incision. phragm is sutured over the esophageal
116 D. Demetriades et al.

repair. The diaphragmatic defect is pri-

marily closed.
• In preexisting disease without significant con-
tamination, resection of a tumor, myotomy for
strictures, or antireflux procedure may be
• Esophagectomy with primary reconstruction.
– May be successful in minimal contami-
– In severe contamination and inflammation,
diversion is appropriate. Closure of the per-
foration with proximal and distal staple
line, resection of the diseased segment, and
a proximal esophagostomy is established
with wide drainage and gastrostomy tube
for feeding. Major esophageal reconstruc-
tion is required at later stage.
– Another option includes closure of the Fig. 12.4 Left posterolateral thoracotomy, suction tube
passed through an esophageal perforation
wound over a 24-French T-tube drainage
brought out to the chest wall and placement
of chest drainage (Fig. 12.5).
Abdominal Esophagus
• Abdominal esophagus is accessed via lapa-
rotomy or more often via a thoracoabdominal Esophageal
incision. perforation
– A self-retaining retractor system is of great
value for optimal exposure of the gastro-
esophageal junction.
• The defect with minor contamination is debrided
and repaired in two layers added by buttressing
with a stomach patch around the repair site.
More destructive injuries may require resection
of the affected segment, mobilization of the
stomach, and esophagogastrostomy in the chest.
• In benign conditions with extensive tissue loss,
resection of the esophagus and reconstruction
with colon interposition may be needed.

12.3 Caustic Ingestion Fig. 12.5 Illustration showing T-tube drainage of an

esophageal perforation not amenable for safe repair
• Most commonly encountered in children and
in young adults when ingestion is accidental – Hence, adults frequently sustain more severe
or intentional, respectively. injuries as the ingested volumes are larger.
• The degree of injury depends on the nature of • The most prominent sites of caustic lesions
the ingested substance, concentration, quantity, are the natural narrowings of the esophagus
and duration of the caustic agent exposure. including UES, aortic impression, and LES.
12 Esophageal Emergencies 117

• Alkaline agents cause liquefying necrosis contraindicated as it may cause perforation

resulting in deep burns, whereas acids cause or emesis and aspiration.
coagulative necrosis resulting in eschar that • First-degree injuries
limits deep tissue penetration. – Require at least 24 h observation prior to
diet advancement
• Second-degree injuries
12.3.1 Assessment and Diagnosis – More extensive second-degree injuries that
do not require surgery should be treated
• Signs and symptoms with antibiotics and gastric acid suppres-
– The typical patient presents with oral pain, sion and monitored closely.
extensive drooling, and dysphagia. – Deep second-degree caustic injuries
– Stridor and hoarseness are signs of impend- develop strictures in 70 % and should be
ing airway obstruction. monitored for a minimum of 48 h
– Retrosternal and abdominal pain are signs (Fig. 12.6).
of possible intrathoracic or intra-abdominal – Patients who will be able to swallow saliva
perforation. and show no signs of sepsis can advance
– Extensive supraglottic edema may require diet as tolerated. Repeat swallow studies
emergent tracheotomy. are planned 3 weeks, 3 months, and
• Investigations: 6 months after injury.
– Chest and abdominal radiography are – Steroids are of no benefit, do not reduce the
obtained to exclude extraluminal air. incidence or severity of late strictures in
– Multidetector CT is more sensitive for second-degree injuries, and may increase
mediastinal air indicating perforation. the risk of infectious complications.
• Indications • Third-degree injuries
– In established perforation, septic shock or – Develop strictures in up to 90 % and prog-
peritonitis mandates immediate operative ress to perforation in 25 % of cases.
intervention. – Signs of full-thickness caustic injury
– All patients with stridor, intentional inges- include peritonitis, depressed mental sta-
tion, and symptomatic children require tus, shock, severe acidosis, and free air on
endoscopy to evaluate extent of injury abdominal film.
within 24 h. – If surgery is indicated:
– Asymptomatic children and patients who The optimal approach to the esophagus is
require surgery precludes need for via the abdominal cavity as it allows evalu-
endoscopy. ation of the stomach, resection of adjacent
– Endoscopic evaluation classifies injuries injured organs, establishment of feeding
into first degree (edema, hyperemia), sec- jejunostomy, and esophagectomy through a
ond degree (ulceration), and third degree transhiatal approach.
(black discoloration indicating full- Cervical esophagectomy is performed
thickness injury). through the neck incision.
– Nutrition will be provided via gastrostomy/
12.3.2 Treatment • Unlike other inflammatory causes of the
foregut scarring, caustic scarring is aggres-
• Immediate goal of therapy is airway assess- sive and may progress beyond a year after
ment, fluid resuscitation, and careful injury.
monitoring. • Options for delayed reconstruction are colonic
– No oral neutralizing agents have shown to interposition or gastric pull-up if the stomach
improve outcomes, and nasogastic tube is sustained less significant insult.
118 D. Demetriades et al.

– Impaction occurs in areas of esophageal

narrowing; UES (15–17 cm from incisors),
the aortic impression (23 cm), the left
mainstem bronchus (27 cm), and the LES
(36–38 cm).
• Food bolus impaction
– A common esophageal emergency, espe-
cially in elderly people.

12.4.2 Food Impaction

• Meat bolus is the predominant offending agent

Fig. 12.6 Caustic injury
causing 80–90 % of food obstructions.
• More frequently noted in elderly and in the
12.4 Esophageal Foreign Bodies – Signs and symptoms
Food bolus impaction in the cervical esoph-
• Acute care surgeons frequently encounter agus may present with stridor, dysphagia,
patients with foreign body ingestion or food odynophagia, or shortness of breath. The
impaction. The vast majority of swallowed Heimlich maneuver is the treatment.
material will pass the gut uneventfully. More frequently, a complete obstruction
Nevertheless, 10–20 % will require nonopera- occurs in the distal esophagus and the
tive intervention, and 1 % or less will require patient presents with significant sialorrhea
surgery. Recent series have reported low mor- and regurgitation.
tality rates in these instances. However, over- History should include preexisting esopha-
all 1500 individuals die worldwide annually geal conditions such as previous dysphagia
due to ingested foreign bodies in the foregut. or dilatation, Nissen fundoplication, gastric
The history should focus on the type of for- bypass, or stent placement.
eign body and symptoms suggesting gut – Management
perforation. Medical therapy utilizing glucagon is the
initial modality. Glucagon relaxes the LES,
decreasing the resting LES pressures up to
12.4.1 Causes 60 %. The common initial dose is 0.5 mg
and can be increased to 2 mg intravenously.
• Foreign body Some reports describe using glucagon and
– Occurs predominantly in children with the diazepam simultaneously with high suc-
highest incidence from 6 months to cess rates.
3 years. Most patients with an impacted food
Battery ingestion with impaction in the particle require flexible endoscopy for
esophagus requires emergent intervention extraction or push of the particle distally to
(common in children) because of risk of the stomach. Early removal is recom-
direct alkaline injury to the esophagus. mended to avoid pressure-induced isch-
– In the adult population, there is a strong emia in the esophagus.
association with psychiatric diseases. Other • Extraction of the food bolus is attempted first,
risk factors for foreign body obstruction particularly if the bolus is large and contains
include dentures, bridge work, and preex- sharp particles such as bones or if a preexist-
isting esophageal pathology. ing stricture is present.
12 Esophageal Emergencies 119

• A Roth retrieval net can be used with the – Objects found in the pharynx or UES are
advantage of complete encompassment of the removed by direct or rigid laryngoscopy.
food bolus precluding aspiration. – Foreign bodies in the esophagus without
• Another option for extraction is a polypec- sharp edges such as coins, toothbrushes,
tomy snare. In this setting, the endoscope and batteries can be extracted with flexible
along with snared food bolus is extracted to endoscopy.
the level of UES and pulled against the endo- Batteries lodged in esophagus should in
scope while the patients’ neck is extended and general be removed. Many batteries con-
the endoscope is removed with food bolus. tain alkaline substances and can result in
• If extraction of the foreign body fails, push alkaline injury.
method is used. – Endoscopy
– Push method can be considered only when Use the largest scope suitable for the
the bolus is soft and contains no sharp objects patient with the biggest suction channel for
and no esophageal stricture is present. debris and saliva suction.
– In this technique, slight pressure can be Polypectomy snare, Roth retrieval net, or
applied to the right side of the food bolus as grasp forceps are utilized for extraction
the bolus passes from right to left more (Fig. 12.8). In difficult cases, a rigid scope
easily. may be more effective for the extraction.
• A combination of scope-pushing and intrave- After the object is snared or grasped, the
nous glucagon has been reported as a success- endoscope is extracted along with the object
ful intervention. to the level of cricopharyngeal muscle, and
• In all instances, preexisting esophageal dis- then the object is snugly brought against the
ease work-up is considered. scope and extracted together with the endo-
scope. Neck extension may help, and care
should be given not to lose the grasp as it
12.4.3 Indigestible Foreign Body may be aspirated into the airway.

• The variety of ingestible foreign bodies is

extensive in the literature including bones,
pills, dental hardware, toothpicks, safety pins,
glass, coins, and batteries (Fig. 12.7).
• Signs and symptoms
– A complete esophageal obstruction is rarely
encountered and saliva can be swallowed.
– Careful initial examination is mandatory to
exclude esophageal perforation and
impending sepsis.
• Diagnosis
– The chest radiography may demonstrate a
radiopaque foreign body.
– Abdominal X-ray may reveal passage or pre-
viously ingested foreign bodies or free air.
• Management
– Majority of ingested foreign bodies will
pass in the stool; however, those obstruct-
ing the esophagus are lodged commonly in Fig. 12.7 Illustration showing a toothbrush in the
the proximal esophagus. esophagus
120 D. Demetriades et al.

Sharp objects in the esophagus must be (GERD), Mallory-Weiss mucosal tear, or vari-
retrieved because the perforation risk is ceal bleeding
considerable at 15–35 %. The sharp objects – GERD
can be grasped with endoscopy forceps and Although the hemorrhage due to GERD
removed through an overtube or with rotat- esophagitis is fairly uncommon, the rela-
able removal basket. tively high overall incidence of GERD
makes this clinical entity quite frequent
(Fig. 12.9).
12.5 Esophageal Bleeding The diagnosis and the extent of the disease
are confirmed by endoscopy. Any bleeding
• Rare source in the stomach and duodenum
• The common etiology of esophageal hemor- should be excluded.
rhage includes gastroesophageal reflux disease

Fig. 12.8 Instruments for

foreign body removal include
rat-tooth forceps, polypectomy
snares, rotatable baskets, and
an overtube
12 Esophageal Emergencies 121

Management Aspirin or alcohol use is frequently noted

• Discontinue aspirin and NSAIDs and in the history (31–80 %).
treat with proton pump inhibitors intrave- The typical patient presents with hemateme-
nously, in conjunction with resuscitation. sis following retching or vomiting. In
• The definitive treatment in GERD is 5–10 % of cases, hemodynamic compro-
abolishing the acid reflux either by pro- mise and massive hematemesis are seen.
longed proton pump inhibitors or The diagnosis is confirmed by endoscopy
fundoplication. with the common finding a mucosal tear
– Mallory-Weiss tear within 2 cm from the gastroesophageal
More common in male patients. junction (Fig. 12.10).
Other preexisting esophageal lesions are
frequently observed at endoscopy.
About 90 % of patients with Mallory-Weiss
hemorrhage stop bleeding without
– Esophageal varices (Fig. 12.11)
Diagnosis is easy in the context of liver
Primary intervention includes airway pro-
tection, insertion of nasogastric tube,
establishment of reliable intravenous
access, transfusion of blood products,
reversal of coagulopathy, proton pump
inhibitor, and emergent endoscopy with
sclerorotherapy and/or variceal ligation
Fig. 12.9 Illustration showing reflux esophagitis (arrow) (Fig. 12.12).

Fig. 12.10 Endoscopic view of Mallory-Weiss lesions (arrow)

122 D. Demetriades et al.

Overall, 5–10 % of variceal bleeding is not

controlled with endoscopic treatment and
requires Sengstaken-Blakemore or Linton-
Nachlas tube for hemorrhage control while
considering interventional radiological
percutaneous transhepatic embolization or
transjugular intrahepatic portosystemic
shunting (TIPS) (Fig. 12.13).
Adjuvant medical therapy with nonselec-
tive beta-blockers, vasopressin analogues,
and octreotide may be considered.

Fig. 12.11 Illustration of esophageal varices

Selected Reading
Biancari F, D’Andrea V, Paone R, et al. Current treatment
and outcomes of esophageal perforations in adults:
meta-analysis and meta-regression of 75 studies.
World J Surg. 2013;37:1051–9.
Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR,
Kucharczuk JC. Evolving options in the manage-
ment of esophageal perforation. Ann Thorac
Surg. 2004;77(4):1475–83. doi:10.1016/j.athoracsur.
Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG,
Baker RR. Selective nonoperative management of
contained intrathoracic esophageal disruptions. Ann
Thorac Surg. 1979;27(5):404–8.
Cattan P, Munoz-Bongrand N, Berney T, Halimi B, Sarfati
E, Celerier M. Extensive abdominal surgery after
caustic ingestion. Ann Surg. 2000;231(4):519–23.
de Jong AL, Macdonald R, Ein S, Forte V, Turner
A. Corrosive esophagitis in children: a 30-year review.
Fig. 12.12 Esophageal varices treated with banding Int J Pediatr Otorhinolaryngol. 2001;57(3):203–11.
Duncan M, Wong RK. Esophageal emergencies: things
that will wake you from a sound sleep. Gastroenterol
Clin North Am. 2003;32(4):1035–52.
Fulton JA, Hoffman RS. Steroids in second degree
caustic burns of the esophagus: a systematic pooled
analysis of fifty years of human data: 1956–2006.
Clin Toxicol (Phila). 2007;45(4):402–8. doi:10.1080/
Garcia-Pagan JC, Morillas R, Banares R, et al. Propranolol
plus placebo versus propranolol plus isosorbide-5-
mononitrate in the prevention of a first variceal bleed:
a double-blind RCT. Hepatology. 2003;37(6):1260–6.
Longstreth GF, Longstreth KJ, Yao JF. Esophageal food
impaction: epidemiology and therapy. A retrospective,
observational study. Gastrointest Endosc. 2001;53(2):
Muir AD, White J, McGuigan JA, McManus KG, Graham
AN. Treatment and outcomes of oesophageal perfora-
tion in a tertiary referral centre. Eur J Cardiothorac
Fig. 12.13 Portosystemic shunting with TIPS (arrow) Surg. 2003;23(5):799–804; discussion 804.
12 Esophageal Emergencies 123

Patch D, Sabin CA, Goulis J, et al. A randomized, van Heel NC, Haringsma J, Spaander MC, Bruno MJ,
controlled trial of medical therapy versus endoscopic Kuipers EJ. Short-term esophageal stenting in the man-
ligation for the prevention of variceal rebleeding in agement of benign perforations. Am J Gastroenterol.
patients with cirrhosis. Gastroenterology. 2002;123(4): 2010;105(7):1515–20. doi:10.1038/ajg.2010.104.
1013–9. Vicari JJ, Johanson JF, Frakes JT. Outcomes of acute
Suarez-Poveda T, Morales-Uribe CH, Sanabria A, Llano- esophageal food impaction: success of the push tech-
Sánchez A, Valencia-Delgado AM, Rivera-Velázquez nique. Gastrointest Endosc. 2001;53(2):178–81.
LF, Bedoya-Ospina JF. Diagnostic performance of Vogel SB, Rout WR, Martin TD, Abbitt PL. Esophageal
CT esophagography in patients with suspected esoph- perforation in adults: aggressive, conservative treat-
ageal rupture. Emerg Radiol. 2014;21(5):505–10. ment lowers morbidity and mortality. Ann Surg.
doi:10.1007/s10140-014-1222-4. Epub 2014. 2005;241(6):1016–21; discussion 1021–3.
Tanomkiat W, Galassi W. Barium sulfate as contrast Zwischenberger JB, Savage C, Bidani A. Surgical aspects
medium for evaluation of postoperative anastomotic of esophageal disease: perforation and caustic injury.
leaks. Acta Radiol. 2000;41(5):482–5. Am J Respir Crit Care Med. 2002;165(8):1037–40.
Stomach and Duodenum
Carlos Mesquita, Luís Reis, Fernando
Turégano-Fuentes, and Ronald V. Maier

Contents 13.10 Iatrogenic Injuries 135

13.10.1 Management 136
13.1 Stomach and Omentum 126
13.1.1 Disease 126 13.11 Aortoduodenal Fistula 136

13.2 Duodenum 126 13.12 Summary 136

13.3 Peptic Ulcer Perforation Bibliography 136

and Bleeding 126
13.3.1 Gastroduodenal (G-D) Perforation 126
13.3.2 G-D Bleeding 128
13.4 Surgical Techniques 128
13.4.1 Access and Exposure 128
13.5 Stomal Ulcer Bleeding 132 • Describe the most frequent emergency
13.6 Dieulafoy’s Lesion 132 surgery situations involving the stomach
13.7 Acute Hemorrhagic Gastritis 132
and duodenum (perforated and bleeding
gastroduodenal ulcer disease)
13.8 Bariatric Emergencies 133 • Describe the methods of surgical access
13.8.1 Bleeding 133
13.8.2 Leakage 133 and mobilization techniques of the differ-
13.8.3 Marginal Ulcer (MU) Perforation 134 ent parts of the stomach and duodenum
13.8.4 Obstruction 134 • Underline the techniques used to protect
13.9 Gastric and Omental Volvulus 135 a duodenal repair
13.9.1 Management 135
13.9.2 Omental Volvulus or Torsion 135

C. Mesquita, MD (*) F. Turégano-Fuentes, MD, PhD, FACS

Department of General Surgery, Department of Surgery, Hospital General Universitario
Coimbra Central and University Hospitals, Gregorio Marañón, Madrid Head of General Surgery II
Coimbra, Portugal and Emergency Surgery, University General Hospital
e-mail: Gregorio Marañón, Madrid, Spain
L. Reis, MD
General Surgery Coimbra Central R.V. Maier, MD, FACS
and University Hospitals, Jane and Donald D. Trunkey Professor and Vice Chair,
General Surgery “C” Department, Department of Surgery, University of Washington
General Hospital, Coimbra, Portugal Surgeon-in-Chief, Harborview Medical Center,
e-mail:, Seattle, WA 98104, USA e-mail:

© Springer International Publishing Switzerland 2016 125

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_13
126 C. Mesquita et al.

13.1 Stomach and Omentum 25–40 % of patients, a vascular critical area exists
at the level of D4, and consequently, anastomosis
Gastric resections, even total, even functional, should be avoided at this area.
like in bariatric surgery, are well-tolerated proce-
dures. The rich vascularization of the stomach, • Urgent or emergency surgical procedures
apart from being a potential source of problems, involving the duodenum are usually required
like in Dieulafoy’s disease or portal hypertension- for duodenal ulcer (DU) perforation, in upper
related varices, is also a window of opportunities, GI bleeding from DU or varices, duodenal fis-
considering, for example, the therapeutic possi- tulae, obstruction (extrinsic) or tumoral, and
bilities of angiography in bleeding ulcers. The iatrogenic injuries during surgical or endo-
greater omentum offers great possibilities of scopic procedures.
repair in defects of the stomach or other intra- • Complications related to the duodenal repair
abdominal structures. Adequately developed, a include suture line leaks, duodenal stenosis or
pedicle flap of omentum can reach the entire obstruction at the suture line, and bleeding.
anterior surface of the trunk, the head and neck,
and the proximal limbs.

13.3 Peptic Ulcer Perforation

13.1.1 Disease and Bleeding

13.3.1 Gastroduodenal (G-D)

• Peptic ulcer disease can be located in the pre- Perforation
pyloric or pyloric area, as well as in the duode-
nal bulb (D1), with perforation and hemorrhage Peptic ulcer perforation, gastric or duodenal,
as the most frequent emergencies. remains a serious problem, despite the major rev-
• Other purely gastric emergencies are, in gen- olution in medical management of peptic ulcer
eral, more difficult to deal with, including disease (development of anti-secretory drugs and
postoperative bleeding, leaks and obstruc- recognition of the role of Helicobacter pylori).
tions, variceal bleeding, gastric and omental Morbidity and mortality remain high (20 % to
volvulus, and malignant perforations, just to more than 60 % and less than 10 % to more than
name the most common. 30 %, respectively).
• Normal access to the stomach and the esopha-
gogastric junction can be through laparoscopy • About 50 % of perforated peptic ulcers are
or laparotomy (most often a midline incision). located in the first part of the duodenum, 35 %
in the pylorus, and 15 % in the stomach.
• Patients usually present with abdominal pain
and signs of peritoneal irritation.
13.2 Duodenum – However, physical examination findings
may be equivocal, and peritonitis may be
The duodenum is divided into four parts: the first minimal or absent, particularly in patients
or postpyloric (D1), second or descending (D2), with contained leaks.
third (D3), and the fourth or ascending (D4). The – Patients presenting in extremis with altered
arteries supplying the duodenum are the pyloric mental status can further complicate an
and superior duodeno-pancreatic branches of the accurate physical examination.
hepatic artery and the inferior duodeno-pancreatic • Laboratory studies tend to be nonspecific in
branch of the superior mesenteric artery. In the acute setting.
13 Stomach and Duodenum 127

– Leukocytosis, metabolic acidosis, and ele- – Formal gastric resection (usually an antrec-
vated serum amylase are often associated tomy) with reconstruction, with or without
with perforation. vagotomy, is considered by many as the
– Free air under the diaphragm found on an standard operation.
upright chest X-ray is indicative of hollow – However, gastric body partition (GBP) with
organ perforation. gastrojejunostomy, after simple closure of the
Patients without pneumoperitoneum on perforation to prevent leakage at the closure
chest X-ray should be evaluated with oral site, has also been confirmed as a safe and
contrast-enhanced CT scan. fairly easy to perform procedure (Fig. 13.1).
• For gastric ulcers
– While benign gastric ulcers can perforate, Management (Technical excision of the ulcer for pathologic exami-
Details Are Described Later) nation is primordial to rule out the possibil-
Surgical treatment is the gold standard for G-D ity of malignancy.
ulcer perforation. Since the discovery of Malignancy, although unusual, occurs in
Helicobacter pylori, suturing the ulcer to close elderly patients.
the perforation is all that is needed. However, – During the emergency operation, it is often
simple suture can be problematic in giant impossible to confirm the diagnosis, partic-
(>2.5 cm) and/or chronic ulcers. ularly when a frozen section is unavailable.
– A two-stage operation can be preferred in
• For ulcers <2.5 cm in diameter this setting, with the initial operation being
– In most cases (90 %), simple suture is usu- a damage control procedure directed to
ally sufficient. Several duodenal closure perforation and peritonitis.
procedures are possible (see later). After recovery and histological confir-
– Treatment by antibiotics to eradicate H. mation of malignancy, adequate staging
pylori and PPI is essential to complete the can be completed, and a radical onco-
management. logical operation, if appropriate, may be
– The laparoscopic approach can be used in planned.
low-risk patients. – Nonoperative management
– The delay to surgery is critical: mortality As many as 50 % of perforations will seal
increases proportionally as the interval without formal surgical intervention, and
before surgery increases. nonoperative management (NOM) can be
• For ulcers (>2.5 cm in size) an option in these patients if:

Simple closure Partition


Fig. 13.1 Gastric body partition, Duodenostomy

gastrojejunostomy, and simple
closure of the perforated peptic
ulcer. A lateral duodenostomy
may be added for bile drainage
128 C. Mesquita et al.

• Hemodynamically stable • Patients bleeding from ulcers of the posterior

• Onset of symptoms of less than 24 h wall of the duodenal bulb require surgical
• Minimal pain treatment when life-threatening hemorrhage
• Absence of systemic signs of sepsis cannot be controlled by endoscopic treatment
• Age under 70 (see upper GI endoscopy) or arterial
• Requires close observation and a low embolization.
threshold for surgical intervention if – Direct suture (Fig. 13.2)
clinical deterioration occurs Hemostasis is obtained via duodenotomy
However, all patients with severe comor- by underrunning the base of the DU (and
bidities, hemodynamic instability, onset of bleeding vessel) with deeply placed
symptoms longer that 24 h in duration, sutures.
peritonitis on physical examination, and Caution is warranted upon duodenotomy
systemic signs of sepsis and those who are closure to avoid narrowing of the lumen.
age 70 or greater should be considered for – Dubois’ operation (antroduodenectomy
early operative intervention. without ulcer excision and gastroduodenal
anastomosis) (Fig. 13.3a, b) is an
13.3.2 G-D Bleeding Risks
The most common causes of upper GI tract • Papilla is usually far away, further down.
bleeding are gastric and duodenal ulcers (55 %), • Common bile duct: an intraoperative cholan-
followed by acute gastric erosions (18 %), giogram should be performed in case of doubt.
Mallory-Weiss tears (10 %), esophageal varices – Closure: the duodenotomy should be
(6 %), and gastric carcinoma (6 %). Surgery for a closed without constricting the lumen (pre-
bleeding ulcer is infrequent today but still neces- fer sutures perpendicular to intestinal
sary in some settings that do not respond to non- lumen)
surgical alternatives. For example, when duodenotomy is
extended across the pylorus (Heineke-
Mikulicz pyloroplasty)
– In the rare cases of persistent bleeding
after sphincterotomy by ERCP, a longitu-
dinal duodenotomy in the second part
will allow access to the papilla of Vater.
After control by suture ligature, it is
advisable to convert the sphincterotomy
to sphincteroplasty.

13.4 Surgical Techniques

13.4.1 Access and Exposure Incisions
• Both the stomach and duodenum can be
reached easily via a midline laparotomy.
– An extended transverse incision offers ade-
Fig. 13.2 Duodenotomy and suturing quate duodenal exposure.
13 Stomach and Duodenum 129


Gastric stump

Gastric stump



Duodenum Duodenum

Fig. 13.3 (a) Antroduodenectomy, which respects the posterior ulcer without its dissection. (b) For the anastomosis,
the posterior side of the gastric stump is applied to the anterior side of the ulcer

• For laparoscopic access, the trocar setup is simi- the lateral border of D2 down to the right
lar to that for elective gastric (and hiatal) surgery, portion of the root of the transverse meso-
or for the duodenum, as for cholecystectomy. colon, until revealing the right genital vein,
inferior vena cava, and aorta (Fig. 13.4).
This allows visualization of D3. Intraoperative Landmarks 2. The Cattell and Braasch maneuver (right
• The pylorus is recognized by palpation in medial visceral rotation) (Fig. 13.5)
open surgery and by the pyloric vein of Mayo • The right and transverse colon and the root
in both open and laparoscopic surgery. of the small bowel are moved to the left.
• Small bowel is mobilized by sharply incis-
ing its retroperitoneal attachments from the Exposure right lower quadrant to the ligament of
In open surgery, the posterior wall of D1 can be Treitz.
explored from the lesser sac, by opening a win- • Incision of the ligament of Treitz allows
dow in the gastrohepatic ligament and the greater mobilization of the duodenojejunal junc-
omentum. The right index finger is placed to pal- ture and exposes D4.
pate the posterior wall. Duodenal Decompression
• Complete exposure and mobilization of the • Rationale: protect the primary duodenal repair
whole duodenum can be achieved either with the goal of decreasing the risk of duode-
through laparoscopy or laparotomy with two nal suture dehiscence.
maneuvers: • Techniques
1. Kocher’s maneuver (KM) – Duodenostomy tube
KM0 allows access to the supra-mesocolic The tube should exit the duodenum
duodenum. away from the suture line, preferably
• The retroperitoneum is opened lateral to from the duodenal stump closed
the duodenal loop (D2). around the tube, and the site should be
• The peritoneal incision continues through covered with the omentum. An exter-
an avascular plane, extending from the nal drainage should be placed next to
lower part of the foramen of Winslow along the suture line.
130 C. Mesquita et al.

Fig. 13.4 Kocher’s


Fig. 13.5 The Cattell and Liver

Braasch maneuver


Ureter Cecum

Different techniques of decompression gastric tube or gastrostomy, retrograde and

have been used (Fig. 13.6): antegrade tubes for duodenal decompression,
• Primary, where the tube is inserted into the and feeding jejunostomy, respectively).
duodenum and the exit site is covered with a Disadvantages include new perforations in
few stitches (Witzel technique) the gastrointestinal tract, lack of evidence as
• Antegrade, where the duodenum is proximally to the efficacy to decompress appropriately,
decompressed with a tube passed through a and the possibility of accidental tube
gastrotomy and across the pylorus extraction.
• Retrograde, where the tube is placed distally • The duodenostomy tube stays patent for a few
through the jejunum days and should not be removed until the tube
• Triple tube decompression was introduced in path has been blocked, usually after minimum
trauma surgery as a “triple ostomy” (naso- of 10–12 days (interval variable according to
13 Stomach and Duodenum 131

Fig. 13.6 Different techniques Malecol’s

of duodenal decompression


Omental flap

Large Intestine

the indication, the local and general conditions – Roux-en-Y duodenojejunostomy (preferred)
of the patient, bowel function recovery, and – Jejunal patch
nutritional status). • Special situation: hemorrhage from an aorto-
duodenal fistula.
– D3 is fixed retroperitoneally and in close Duodenal Resection proximity to the aorta and therefore is the
• Very uncommon. bowel segment most vulnerable to vascular
• Resection of D1 can theoretically be done in impingement.
cases of complicated duodenal ulcers. – Besides aortic reconstruction with patch
• Resection of D2 is not possible because of the graft, a duodenorraphy or segmental duo-
shared vascular supply with the pancreas. denal resection might be necessary (access
• Mobilization of the duodenum a few millime- via Cattell and Braasch maneuver).
ters from the pancreas is necessary to avoid
• Interrupted nonabsorbable 3/0–4/0 sutures are Pyloric Exclusion (Fig. 13.7)
preferable. • Devised in trauma setting as alternative to the
• A drain should always be left in place, and more extensive duodenal diverticulization
depending on circumstances, a tube duode- procedure (goals: shorten the operative time
nostomy might be considered. and make the procedure reversible)
• In atypical resections, mainly in D2 and D3, • Indicated after large posterior iatrogenic duo-
when duodenoduodenostomy is not possible, denal perforations during ERCP and/or stent
several alternatives exist: placement when the perforation (seen many
132 C. Mesquita et al.

Fig. 13.7 Pyloric exclusion

hours after the insult) is not amenable to pri- the anastomosis, and the bleeding ulcer should
mary closure (induration and inflammation of be underrun with a few deeply placed absorb-
the tissues) able sutures.
• Technique: • Complicated reconstructive gastric surgery
– After primary repair of the duodenal defect, should be avoided.
if possible.
– Gastrotomy along the greater curvature, in
the antrum. 13.6 Dieulafoy’s Lesion
– The pyloric ring is grasped and closed with
a running slowly absorbable suture via the • Infrequent
gastrotomy or closed by a linear stapler. • Is best managed by transgastric local excision
– A gastrojejunostomy is fashioned at the or underrunning
gastrotomy site.
– An alternative: Gastric body partition
(Fig. 13.1). 13.7 Acute Hemorrhagic Gastritis

• Surgery is indicated extremely rarely. Duodenal Diverticulization – Truncal vagotomy (TV) and drainage have
• Includes a distal Billroth II gastrectomy, clo- a high rate of rebleeding.
sure of the duodenal wound, placement of a – Total gastrectomy has a prohibitive mortal-
decompressive catheter in the duodenum, and ity rate.
drainage of the duodenal repair. Truncal – Gastric devascularization (ligating the two
vagotomy and biliary drainage can be added. gastroepiploic and left and right gastric
It is rarely performed today because of its arteries near the stomach wall) is a less
complexity. aggressive alternative.

Bleeding esophageal or gastric varices

13.5 Stomal Ulcer Bleeding • Initial management is medical and endoscopic

(see upper GI endoscopy).
• Usually self-limiting or amenable to endo- – Vasoactive drugs (e.g., vasopressin and
scopic treatment. somatostatin)
• Persisting or recurrent hemorrhage in the – Endoscopy (banding, sclerotherapy)
high-risk patient should be approached – If persistent bleeding: balloon tamponade
through a small gastrotomy, perpendicular to with a Sengstaken tube
13 Stomach and Duodenum 133

13.8 Bariatric Emergencies • Sites

– Bleeding may exit through drains, but no
• As bariatric operations are performed more bleeding through drains does not exclude
and more often, postoperative complications this complication.
are being seen increasingly. The most com- – Blood exteriorized per oral usually origi-
mon cause of death following bariatric sur- nates from the proximal pouch, while rec-
gery remains pulmonary embolism (PE). The tal bleeding comes from the distal stomach
most common postoperative surgical compli- or small bowel.
cations include anastomotic leaks with perito- – Bright red bleeding usually requires upper
nitis or abscess formation. endoscopy or exploratory surgery.
• Essentially, four types of postoperative com- – Melena is more likely to be managed with
plications occur in bariatric patients: bleeding, replacement therapy and discontinuation of
anastomotic leakage, marginal ulcer (MU) anticoagulants.
perforation or necrosis, and obstruction (the
latter includes specific obstructive mecha-
nisms such as internal hernia, acute gastric 13.8.2 Leakage
pouch or remnant dilatation, and, with gastric
band placement, food intolerance, reflux, and • Anastomotic and staple line leaks occur in
band slippage). 1–8 % of cases with up to a 20 % mortality
• Particular to bariatric surgical emergencies (second most common cause of death follow-
– Bariatric patients do not exhibit the signs ing obesity gastric surgery).
and symptoms that surgeons would nor- • Leaks occur most commonly at the gastrojeju-
mally expect. nostomy but can occur from any staple line,
– Bariatric patients do not have a normal including the gastric pouch, the gastric rem-
functional reserve when a complication nant, jejunojejunostomy, or the gastric staple
occurs. Last, it may be problematic to per- line in a sleeve gastrectomy.
form imaging procedures such as CT scan • Symptoms and signs
in obese patients if the adapted equipment – The classic signs and symptoms of intesti-
is not available. nal leakage are tachycardia, hypotension,
tachypnea, abdominal pain, chest pain,
and fever. Frequently, the first and only
13.8.1 Bleeding symptom of leakage can be unexplained
tachycardia. A heart rate of greater than
• Acute postoperative bleeding occurs in less 120 bpm should be alerting, even if the
than 3 % of patients after Roux-en-Y gastric patient otherwise feels good and appears
bypass (RYGBP), linear gastrectomy, and iso- well. In fact, some patients may demon-
lated or as a part of duodenal switch proce- strate no signs of leakage and be com-
dure and may be either intraperitoneal, with pletely asymptomatic.
early signs, or gastrointestinal (GI), with late – Leaks can occur immediately postoperatively,
signs. may present 1–2 weeks postoperatively and
• Mesenteric transection, gastric remnant staple can occur at any anastomosis or staple line, or
line, trocar site, or iatrogenic injury of the can be due to iatrogenic lesions of the esopha-
omentum or spleen are possible sites of intra- gus or any other part of the GI tract.
peritoneal bleeding, whereas gastric remnant – These leaks are potentially fatal and it is cru-
or gastric pouch staple lines, perigastric ves- cial to maintain a high index of suspicion.
sels, and gastrojejunal or jejunojejunal anasto- Diagnosis can be through an upper gastroin-
mosis may be the sites of intraluminal GI testinal tract water-soluble contrast radiog-
bleeding. raphy or an oral contrast medium-enhanced
134 C. Mesquita et al.

CT scan, but initial contrast studies may not mal contamination, definitive resectional
always demonstrate a leak (as it may require surgery may be an option.
some time for ischemic tissue to progress to
the point of disruption and gross leakage).
– As in other operations with anastomoses or 13.8.4 Obstruction
staple lines, drains are not 100 % foolproof.
Most drains are excluded within 24–48 h. • Closed loop bowel obstructions and internal
• Management hernias can occur in gastric bypass patients.
– Abscesses may be drained percutaneously. – Can be lethal if necrosis of the bowel
– If all other examinations are negative develops
(40 %) and the suspicion remains, re- • Initial evaluation should include a flat and
laparoscopy or laparotomy should be con- upright abdominal X-rays but often completed
sidered without delay. by abdominal and pelvic contrast-enhanced
– In very select stable patients, a contained CT, an upper GI and small bowel series.
leak can be managed nonoperatively with • Management
adequate IR, stent placement (see upper GI – Via exploratory laparoscopy or laparotomy.
endoscopy) or laparoscopic and/or percuta- – Adhesive or distal obstructions, unrelated
neous drainage, NPO, and antibiotics. to the bariatric procedure, must also be
Surgical treatment involves re-exploration, considered.
copious irrigation, leak control usually – The abdomen must be completely inspected.
with omental patching rather than direct The entire small bowel must be run from
reanastamosis or repair alone, and wide the duodenojejunal juncture to the cecum.
drainage, along with broad-spectrum anti- A full view of the colon and intraperitoneal
biotics +/− antifungal agents. rectum should complete exploration.
– When the surgeon does not know which
bariatric procedure was performed and/
13.8.3 Marginal Ulcer (MU) or the anatomy is confusing, particularly
Perforation in the face of internal hernias, it is best
to begin distally at the cecum and work
• The incidence of endoscopic-confirmed MU retrograde, inspecting and closing all
after RYGB reaches 16 %. mesenteric defects, and perform intraop-
• The most common presenting complaints are erative endoscopy to rule out a stoma
bleeding – occult or acute – pain, nausea, and stenosis.
vomiting. • Slipped bands
• The etiology of MU is multifactorial and may – Gastric prolapse or slippage of the band
be related to gastric acid, tobacco, nonsteroid distally with herniation of the stomach
anti-inflammatory drugs, Helicobacter pylori, cephalad and enlargement of the gastric
anastomotic tension or ischemia, foreign body pouch above the band is not uncommon.
(suture), and pouch size. Most of these risk – Immediate treatment includes emptying of
factors are preventable. the band contents.
• Perforated MU can occur without any anteced- – Other major complication include erosion
ent symptoms, and its clinical presentation is of the band into the stomach, which occurs
similar to that of any other perforated viscus. primarily due to the gastrogastric sutures,
• Management placed to hold the band in place, being too
– Is almost always surgical and involves tight and causing increased pressure on the
repair of the perforation with the aid of an inflexible band material.
omental patch and placement of drains. – These complications require reoperation,
– If the patient is stable with known chronic laparoscopic or open, repositioning or pos-
MU and the perforation is small with mini- sible replacement of the gastric band, or
13 Stomach and Duodenum 135

sometimes conversion to another opera- • In poor candidates to surgery, endoscopic

tion, either during the same operation but reduction may be attempted as a temporary
most often as a staged procedure. measure allowing medical optimization prior
to emergency or elective surgery but carries a
risk of perforation.
13.9 Gastric and Omental
13.9.2 Omental Volvulus or Torsion
• Gastric volvulus is an extremely rare clinical
entity that can be defined as an abnormal rota- Omental volvulus or torsion (greater omentum
tion of the stomach of more than 180°, result- twisted longitudinally with resultant vascular
ing in incarceration and strangulation of the compromise)
More frequent in children and uncommon • Five or six times more common in middle age
in adults before age 50, with males and male adults than in children, more often pri-
females equally affected. mary than secondary
Most often secondary to congenital dia- – Primary torsion is unipolar, with one end of
phragmatic defects, such as paraesopha- the omentum free.
geal hernias. – Secondary torsion is bipolar, with the end
Stomach rotation can be classified as organo- opposite to the vascular pedicle fixed to
axial, mesentericoaxial, or combined. adhesions or secondary to some other
– Signs and symptoms pathologic associated condition.
Gastric volvulus can manifest as an acute – Omental torsion leads to hemorrhagic
abdominal emergency or as chronic inter- infarction and fat necrosis, with character-
mittent problem. istic serosanguinous fluid extravasation.
• Acute gastric volvulus: sudden onset Right side of the omentum is most fre-
of severe epigastric, left quadrant, or quently involved.
intrathoracic, chest pain (radiating to A rare cause of acute abdomen, omental
the left side of the neck, shoulder, torsion is often confused with acute appen-
arms, and back, mimicking myocar- dicitis in these patients.
dial infarction), sometimes with Typically the diagnosis is only made at sur-
upper gastrointestinal bleeding due gery, and surgical excision of the involved
to mucosal ischemia and sloughing omentum is the treatment of choice.
• The “Borchardt triad,” consisting of
pain, retching, and inability to pass a
nasogastric tube, occurs in 73 % of 13.10 Iatrogenic Injuries
Iatrogenic injuries from endoscopic interven-
tional procedures are increasingly observed in
13.9.1 Management clinical practice.

• In essence, this is a typical emergency sur- • Perforation rates from ERCP range from 0.1
gery situation for which the goals are to 0.6 %.
decompression, reduction, and prevention • Three distinct types
of recurrence. – Guidewire-induced perforation
• Surgical repair may consist of diaphragmatic – Periampullary perforation during
hernia repair, gastropexy, or partial or even sphincterotomy
total gastrectomy, especially in cases compli- – Luminal perforation usually remote from
cated by necrosis. the papilla
136 C. Mesquita et al.

• Risk factors 13.12 Summary

– Concomitant sphincterotomy
– Previous surgery (Billroth II) The most common condition requiring access
– Difficult progress to the duodenum is perforated ulcer, ideally
– Biliary stricture dilation treated laparoscopically. With lesser frequency
– Malignancy today, emergency surgical access to the duode-
– Precut access num can be required for bleeding duodenal
• Diagnosis ulcers. Tube decompression is considered a
– Often diagnosed during the procedure safe adjunct in the closure of a difficult duode-
– Otherwise: retropneumoperitoneum is the nal stump. Iatrogenic injuries from endoscopic
hallmark interventional procedures are increasingly
observed in clinical practice, and pyloric exclu-
sion is an excellent indication in this setting.
13.10.1 Management The rare aortoduodenal fistula should be sus-
pected and dealt with in cases of torrential
• Nonoperative (86 % success rate) bleeding in patients with previous prosthetic
– Aggressive biliary and duodenal drainage repair of the abdominal aorta.
(nasobiliary and nasogastric tubes)
– Broad-spectrum antibiotics
• Pyloric exclusion is an excellent indication in
this setting (see above).
Agresta F, Ansaloni L, Baiocchi GL, Bergamini C,
Campanile FC, Carlucci M, Cocorullo G, Corradi A,
13.11 Aortoduodenal Fistula Franzato B, Lupo M, Mandala V, Mirabella A,
Pernazza G, Piccoli M, Staudacher C, Vettoretto N,
Zago M, Lettieri E, Levati A, Pietrini D, Scaglione, de
Masi S, de Placido G, Francucci M, Rasi M, Fingerhut
• Rare A, Uranues S, Garattini S. Laparoscopic approach to
• Should be suspected and dealt with in cases of acute abdomen from the Consensus Development
torrential bleeding in patients with previous Conference of the Societa’ Italiana di Chirurgia
Endoscopica e nuove tecnologie (SICE), Associazione
prosthetic repair of the abdominal aorta Chirurghi Ospedalieri Italiani (ACOI), Societa’
– Aortic reconstruction with non-prosthetic Italiana di Chirurgia (SIC), Societa’ Italiana di
patch Chirurgia d’Urgenza e del Trauma (SICUT), Societa’
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and the European Association for Endoscopic Surgery
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Behrman S. Management of complicated peptic ulcer dis-
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• Incomplete exposure and mobilization E, Oei HI, Smulders JF, Steyerberg EW, Lange
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• Failure to understand that a controlled Boey J, Choi SKY, Alagaratnam TT, Poon A. Risk stratifi-
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than an uncontrolled fistula dation of predictive factors. Ann Surg. 1987;205:
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Cholecystectomy for Complicated
Biliary Disease of the Gallbladder 14
Abe Fingerhut, Parul Shukla, Marek Soltès,
and Igor Khatkov

Contents Objectives
14.1 Safe Cholecystectomy 139 • Describe safe techniques of cholecys-
14.2 Special Settings 141
14.2.1 Acute cholecystitis 141 • When to start or convert to open
14.2.2 Acute Biliary Pancreatitis 142 cholecystectomy
14.2.3 Biliary Peritonitis 143 • How to treat unexpected intraoperative
14.2.4 Acalculous Cholecystitis 143 findings or incidents
14.2.5 Cirrhosis 143
14.2.6 Bilioenteric Fistula 143 • How to manage complicated gallblad-
14.2.7 Sclero-atrophic Gallbladder and Cancer 144 der disease
Bibliography 144

Complicated biliary disease of the gallbladder

A. Fingerhut, Doc hon c, FACS, FRCS(g), FRCS(Ed) (*) includes biliary stone-related complications
Department of Surgical Research, Clinical Division
(acute cholecystitis, empyema, gangrene, com-
for General Surgery, Medical University of Graz,
Graz, Austria mon choledocholithiasis with cholangitis or
biliary pancreatitis, bilioenteric fistula) as well
Surgical Department of Surgery Hippokration
Hospital, University of Athens, as complications without lithiasis such as acal-
Athens, Greece culous cholecystitis, or other settings (with or
e-mail: without lithiasis) such as atrophic or sclero-
P. Shukla, MD atrophic gallbladder, liver cirrhosis, and/or can-
Department of Surgery, Weill Cornell Medical College, cer. Therapeutic procedures for complicated
New York, NY, USA
gallbladder disease include cholecystectomy,
Cornell Medical School, New York, NY, USA biliary drainage, subtotal cholecystectomy,
removal of associated common bile duct stones,
M. Soltès, MD, PhD sphincterotomy, and treatment of biliary tract
1st Department of Surgery, Pavol Jozef Safarik
University, Kosice, Slovak Republic
I chirurgicka klinika, Kosice 04190, Slovak Republic
14.1 Safe Cholecystectomy
I. Khatkov, MD
Department of Surgical Oncology, Moscow Clinical
Scientific Center, Moscow, Russia Safe cholecystectomy means removal of the gall-
e-mail: bladder without injuring the common bile duct or
© Springer International Publishing Switzerland 2016 139
A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_14
140 A. Fingerhut et al.

liver, undue bleeding, bile or stone spillage, or and the hepatic pedicle): look for fistula and
bile leak. do not create iatrogenic perforation.
– Whether performed openly or through a lapa- • Several time-proven techniques of cystic duct
roscopic approach, many of the steps are the identification:
same. – Infundibular technique
– The principles of “safety” are the same for all Not recommended because can be difficult
cholecystectomies, whether for simple, or even hazardous in acute or chronic cho-
uncomplicated, or complicated disease. lecystitis when cystic duct is short, or with
• Exploration large stone in Hartmann’s pouch, or Mirizzi
– First step: evaluation syndrome
Determine: – Antegrade dissection
Degree of inflammation of the Can be difficult in acute cholecystitis, as
gallbladder. the acute inflammation increases bleeding
whether there is associated peritoni- and dissection takes place before ligation
tis by a complete, 360° exploration of cystic artery
of the abdomen. Increases risk of traction injuries to the
• Exposure and retraction common bile duct
– Take down adhesions between the gallblad- – Displaying lower confluence (cystic duct
der and omentum, Sometimes freeing a with the common hepatic duct)
pocket of pus or infected bile. Can be difficult (and dangerous) in acute
– Puncturing the gallbladder to empty some cholecystitis for same reasons
of the bile enables the surgeon to place a – Identification of Rouvière’s sulcus
toothed grasper on fundus to properly Cleft running to the right of the liver
retract the gallbladder fundus to the right, hilum, anterior to caudate process con-
especially useful when gallbladder wall is taining the right portal pedicle (visible in
thick or inflamed, or gallbladder is more than 75 % of patients), and accu-
distended. rately identifies the plane of the common
– Exposure can be enhanced by suspending bile duct. Dissection should always be
the liver (by placing a trancutaneous suture anterior to the sulcus.
through the falciform ligament so when – “Critical view of safety”
tied, the round ligament lifts the liver, best Consists of identification of two (and only
achieved when the suspension is to the left two) structures (cystic duct and artery)
of the midline, and the suture is as close as before any division, by initial dissection of
possible to the liver without undue tension the neck of the gallbladder, freeing the lat-
that might tear the liver). ter from the cystic plate (of the liver bed)
– Small intestine is retracted from field of (i.e., unfolding Calot’s triangle)
view. Safer to start dissection from behind (lat-
Push down and hold by abdominal pads eral), opening the peritoneum below the
or retractors (open surgery). cholecystocystic junction and then moving
Incline the table to a reverse to the anterior aspect of the triangle
Trendelenburg’s position with a left tilt Difficult with:
(laparoscopy). • Variant anatomy
– Initial traction should aim at exposure of • Inflammation
the Calot’s triangle. • When the cystic duct is:
• Caution (when freeing adhesions between the – Short
gallbladder and duodenum, small intestine, – Stumpy
14 Cholecystectomy for Complicated Biliary Disease of the Gallbladder 141

– Hidden or effaced by a large stone • Dissection of gallbladder from its bed

– Hidden because of difficulty in – Best by combined blunt and sharp dis-
retracting the gallbladder section, in a retrograde fashion. There
– Infrared indocyanine green fluorescence may be dense fibrotic or inflammatory
Requires specific equipment tissues between the liver parenchyma
Less irradiation than intraoperative and the gallbladder wall, making it
cholangiography difficult to find the correct plane of
Quicker to perform dissection.
Preventive measure that can be performed • Place the gallbladder in retrieval bag.
before dissection begins – To avoid any contamination of the
– Intraoperative cholangiography abdominal wall during extraction.
Used routinely, reduces rate/severity of – If many stones and large diameter,
biliary injury Open the bag from the outside, and
• Early recognition remove as many stones as necessary
• Prevents complete transection to reduce the volume and allow
• Increases rate of good initial repair extraction of the gallbladder, rather
Better view of ductal variations than enlarging the extraction site,
Will only succeed if the cholangiogram is always possible.
interpreted correctly Remove the gallbladder from within
• Complete upper bile duct fill essential, the bag, rather than pulling on the
increases incidence of detection of bili- bag which can tear.
ary tract injury
• Radiation 14.2 Special Settings
• Extra time
– Intraoperative ultrasound 14.2.1 Acute Cholecystitis
Operator dependent
• Of note, the only techniques of cystic duct • Can be classed in three groups according to
identification that can be performed before the 2007 Tokyo consensus guidelines
dissection begins include identification of – Grade I (mild acute cholecystitis): acute
Rouvière’s cleft, infrared indocyanine fluo- cholecystitis in a patient with no organ dys-
rescence, and Introperative ultrasound function and limited disease in the gall-
• Cystic artery and duct may now be divided bladder, making cholecystectomy a
safely (after correct identification of cystic low-risk procedure
structures, whatever the method). – Grade II (moderate acute cholecystitis): no
• Close the distal stump with either absorb- organ dysfunction but extensive disease in
able clip or ligation. the gallbladder, resulting in difficulty for
– Avoid metallic clips (because of electric safe cholecystectomy
dangers, possible migration, and stone Elevated white blood cell count
formation in the common hepatic duct). Palpable, tender mass in the right upper
– If the diameter of the cystic duct is abdominal quadrant
greater than the length of the autolock- Duration of more than 72 h
ing clip, it may be necessary to use an Imaging studies indicating significant
Endoloop or suture-ligate the duct – and inflammatory changes in the gallbladder
double check that you are not dealing – Grade III (severe acute cholecystitis): acute
with the main bile duct. cholecystitis with organ dysfunction
142 A. Fingerhut et al. Surgical Approach 14.2.2 Acute Biliary Pancreatitis

• Open surgery has its proponents.
• Laparoscopic cholecystectomy may be con- • Of the three recent guidelines published on
sidered an acceptable indication even in severe acute pancreatitis, one was solely dedicated to
acute cholecystitis (gangrenous cholecystitis recommendations for laparoscopic manage-
or empyema). ment of acute biliary pancreatitis (Consensus
– However, conversion is increased Development Conference of the Società
threefold. Italiana di Chirurgia Endoscopica e nuove
– Overall postoperative complication rate is tecnologie (SICE), Associazione Chirurghi
higher. Ospedalieri Italiani (ACOI), Società Italiana di
– Advisable to convert when you are no lon- Chirurgia (SIC), Società Italiana di Chirurgia
ger making progress in the operation or are d’Urgenza e del Trauma (SICUT), Società
uncertain of the anatomy (but not in case of Italiana di Chirurgia nell’Ospedalità Privata
suspected bile duct injury). (SICOP), and the European Association for
Endoscopic Surgery (EAES)).
– In gallstone pancreatitis, laparoscopic cho- Caution lecystectomy is indicated to prevent dis-
• Electric diffusion is increased and electrocau- ease recurrence.
tery less efficient in edema. In mild pancreatitis, as soon as the patient
• If a large stone is palpated in the neck of the has recovered and during the same hospital
gallbladder, the surgeon should not hesitate to admission.
open the gallbladder, remove the stone, and In severe pancreatitis, cholecystectomy is
then pursue dissection once the cystic orifice delayed until there is sufficient resolution
has been identified from within the open of the inflammatory response and clinical
gallbladder. recovery (LE2b).
– Timing for laparoscopic cholecystectomy
In mild gallstone-associated acute pancre- Alternatives atitis, laparoscopic cholecystectomy should
• Cholecystostomy or subtotal cholecystectomy be performed as soon as the patient has
– Although there is no hard evidence that recovered and during the same hospital
cholecystostomy or subtotal cholecystec- admission (GoR B).
tomy is better, both have proponents in In severe gallstone-associated acute pan-
case of difficult dissection. creatitis, laparoscopic cholecystectomy
– Useful (and safety measure) in case of dif- should be delayed until there is sufficient
ficulty in finding the correct plane of dis- resolution of the inflammatory response
section between gallbladder wall and bed. and clinical recovery (GoR B).
Ligate cystic duct from within the open – Apart from cases in which an emergency
gallbladder (if not already done) ERCP is indicated, common bile duct stone
Controversy exists as to whether to: clearance should be obtained by preoperative
• Coagulate mucosa in case of subtotal ERCP or by laparoscopic removal of bile duct
cholecystectomy (no evidence); stones during cholecystectomy (GoR A).
suture the gallbladder walls (not Two meta-analyses showed no differences
recommended) when preoperative ERCP was compared to
• Coagulation of gallbladder bed intraoperative removal of CBD stones
• Percutaneous drainage and secondary chole- (LE1b). The choice of treatment should be
cystectomy determined by local expertise, since lapa-
14 Cholecystectomy for Complicated Biliary Disease of the Gallbladder 143

roscopic CBD exploration requires a sig- 14.2.6 Bilioenteric Fistula

nificant surgical skill.
When pancreatic necrosis requires treat- • Rarely responsible for an emergency setting
ment (clinical signs of sepsis or multior- except when stone migration gives rise to gall-
gan failure that do not improve despite stone ileus (treated elsewhere in this manual)
optimal therapy), see pancreas chapter. and local (right upper quadrant) phlegmon
– The only indication for immediate surgery which has to be treated at the same time.
in acute pancreatitis is the presence of a • Fistula usually results from inflammation
compartment syndrome, which should be associated with acute cholecystitis and occurs
managed by surgical decompression (lapa- between the gallbladder and an adjacent hol-
rostomy or fasciotomy) (LE 4); laparoscopy low viscus.
is formally contraindicated in these cases. – A second mechanism is pressure necrosis
from a large stone within the gallbladder
14.2.3 Biliary Peritonitis • Communication
– The duodenum is the most commonly
• Due to perforation of the gallbladder: indica- involved portion of the intestinal tract,
tion for urgent cholecystectomy and drainage. accounting for approximately 75 % of
• Percutaneous cholecystostomy tube should be these communications.
considered for poor surgical candidates, with – The colon is involved in approximately
consideration of referral later for cholecystec- 15 % of cholecystoenteric fistulas.
tomy if clinical situation improves. • If ileus is the main symptom, it can be
treated by stone extraction after milking the
stone back from the point of obstruction.
14.2.4 Acalculous Cholecystitis Resection is rarely necessary in the emer-
gency setting.
• Occurs often in seriously ill patients with comor- • Caution: Do not tackle the right upper quad-
bidity where percutaneous cholecystostomy is an rant; i.e., do not take out the gallbladder, and
attractive alternative to major surgery do not attempt to take down the choleduode-
– Can be performed at the bedside under nal fistula if chronic and well established
local anesthetic and is suitable for patients (which it generally is).
in intensive care units and those with burns – Ileal or colonic resection is rarely needed.
– May be definitive treatment or used as a • Spontaneous closure of a cholecystoenteric
temporizing measure to drain infected bile fistula can occur, particularly when no distal
and delay the need for definitive treatment obstruction is present, stones are no longer
• Otherwise, whenever possible, cholecystectomy present in the gallbladder, and the acute
inflammation has resolved.
– The decision to perform cholecystectomy
14.2.5 Cirrhosis later is determined by patient status.
– Asymptomatic patients in whom no persis-
• No controlled studies, but case reports and tent cholecystoenteric fistula is demon-
series indicate that laparoscopic cholecystec- strated by contrast study do not usually
tomy is preferable in the cirrhotic patients require elective cholecystectomy.
– Less postoperative ascites (portacaval cuta- – Persistence of symptoms or demonstrated
neous anastomoses are preserved in laparo- failure of fistula closure suggests additional
scopic surgery) stones in the gallbladder and requires chole-
144 A. Fingerhut et al.

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d’Urgenza e del Trauma (SICUT), Società Italiana di
of the intestine (small or large intestines).
Chirurgia nell’Ospedalità Privata (SICOP) and the
European Association for Endoscopic Surgery (EAES).
Surg Endosc. 2012. doi:10.1007/s00464-012-2331-3.
14.2.7 Sclero-atrophic Gallbladder Buddingh KT, Nieuwenhuijs VB. The critical view of
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and Cancer complement each other as safety measures during cho-
lecystectomy. J Gastrointest Surg. 2011;15:1069–70.
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– Usually are intraoperative findings and Blaauw CB, van Dam GM, Ploeg RJ, Hofker HS,
Nieuwenhuijs VB. Documenting correct assessment
warrant appropriate treatment as indicated
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Chiappetta Porras LT, Nápoli ED, Canullán CM, Quesada Controversial Issues BM, Roff HE, Alvarez Rodríguez J, Oría
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Henneman D, da Costa DW, Vrouenraets BC, van
• Puncture the thick-walled, inflamed, distended Wagensveld BA, Lagarde SM. Laparoscopic partial
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Campanile FC, Carlucci M, Cocorullo G, Corradi A, Ibrahim IM, Wolodiger F, Saber AA, Dennery B.
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De Masi S, De Placido G, Francucci M, Rasi M, tectomy in the treatment of complicated cholecystitis.
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Choledocholithiasis [Common Bile
Duct (CBD) Stones] 15
René Fahrner and Abe Fingerhut

Contents 15.1 Introduction

15.1 Introduction 147
Choledocholithiasis is defined as the presence of
15.2 Diagnostic Pathways 147
15.2.1 Tools 147 gallstones in the common bile duct (CBD). An
15.2.2 Leading Symptoms 148 estimated 10–18 % of patients undergoing a lapa-
15.3 Interventions and Indications 148
roscopic cholecystectomy because of cholecysto-
lithiasis (stones in the gallbladder) also have
15.4 In Biliary Pancreatitis 149
choledocholithiasis. The underlying pathology of
15.5 Essential Points and Summary 149 choledocholithiasis is most frequently cholecysto-
Bibliography 150 lithiasis; however, residual stones as well as
denovo choledocholithiasis may also occur several
weeks to several years after cholecystectomy.
Emergency treatment is necessary when signs
Objectives and symptoms occur; choledocholithiasis is often
• Describe the common clinical manifes- clinically and biologically silent.
tations of common bile duct stones.
• Outline the management options of
CBD stones. 15.2 Diagnostic Pathways
• Explain the treatment strategies in dif-
ferent scenarios of CBD stones. 15.2.1 Tools

• Blood tests may show elevated alkaline phos-

phatase, gamma-glutamyl transferase, and
(direct) bilirubin.
R. Fahrner, MD (*)
Service Surgery, Division of General, Visceral • Abdominal ultrasonography (US) is inexpen-
and Vascular Surgery, University Hospital Jena, sive, without any side effects (e.g., radiation).
Jena, Germany Sensitivity in the detection of choledocholi-
e-mail: thiasis, although very operator dependent,
A. Fingerhut, Doc hon c, FACS, FRCS(g), FRCS(Ed) ranges between 38 and 82 %. US helps diag-
Department of Surgical Research, Clinical Division nose concomitant cholecystitis.
for General Surgery, Medical University of Graz,
Graz, Austria • Preoperative endoscopic retrograde chol-
e-mail: angiography (ERC) offers diagnostic and

© Springer International Publishing Switzerland 2016 147

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_15
148 R. Fahrner and A. Fingerhut

therapeutic options with high sensitivity – Bacteriemia: 13.3 %

and specificity; sometimes multiple proce- – Acute cholangitis: 4.1 %
dures are necessary. – Pancreatitis: 6.2 %
• Magnetic resonance cholangiography (MRC) is • If impossible, surgery (ideally laparo-
associated with sensitivity and specificity rang- scopic) is the best alternative.
ing between 93–100 % and 96–100 %. Although • In patients having undergone endoscopic
abdominal computed tomography is not the best removal of CBD stones, a laparoscopic
diagnostic tool for choledocholithiasis, it is cholecystectomy should be performed
often used to eliminate other disease. within 1 week after endoscopic treatment
to avoid recurrent biliary complications
and repeated hospital admissions.
15.2.2 Leading Symptoms 2. Surgery (removal of CBD stones).
• Can be performed laparoscopically or in
Patients with choledocholithiasis can present open surgery.
with signs of incomplete or complete obstruction • Laparoscopic choledochotomy requires
of the common bile duct or biliary pancreatitis. advanced laparoscopic skills but has good
clearance rates and has been recently
• Incomplete obstruction: acute crampy abdom- shown to be as effective as open surgery in
inal pain associated with vomiting and nausea. the emergency setting.
The abdomen is usually soft without general- • Both require general anesthesia.
ized or localized peritoneal signs and patients • Extraction of stones can be performed via
are afebrile. the cystic duct or choledochotomy.
• Complete obstruction: usually characterized – Decision whether to perform vertical or
by jaundice, fair stools, and dark urine, more horizontal choledochotomy depends on
rarely by itching. size of stone and CBD, inflammatory
– Cholangitis is characterized by the classi- status, and also surgeon preference.
cal triad of Charcot including right upper – Extraction can be done either with a bal-
quadrant pain, fever, and jaundice. loon dilatation (or Fogarty) catheter or,
Acute cholangitis occurs as a result of bac- better with a Dormia basket catheter,
terial infection superimposed on obstruc- inserted through the cystic or the choledo-
tion of the biliary tree. chotomy, and for the latter, with or with-
Severe cholangitis may be associated with out a small-diameter choledochoscope.
hepatic microabscesses that usually • Surgery may be hampered by aberrant
carry a poor prognosis. anatomy, proximal stones, strictures, and
• Biliary pancreatitis: usually presenting with large or numerous stones.
diffuse abdominal pain, elevation of pancre- • The open bile duct may be addressed with
atic enzymes, signs of inflammation and – in closure over a T-tube, an exteriorized tran-
severe cases – pancreatic necrosis and multi- scystic drain, or primary closure with or
organ failure (associated with high mortality). without endoluminal drainage (preferred).
• At the end of the procedure, a completion
cholangiography should confirm that the
15.3 Interventions common bile duct is free of stones.
and Indications • If complete removal of CBD stones is not
possible, alternatives include:
1. ERCP, usually performed with papillotomy. – Conversion to open surgery (if initial
• Requires experienced endoscopist, seda- laparoscopy)
tion, or general anesthesia. – Postoperative ERC
• Post-interventional complications include: 3. Laparoscopic cholecystectomy, the standard
– Mortality: 0.5 %, approach for the treatment of cholecystolithiasis
15 Choledocholithiasis [Common Bile Duct (CBD) Stones] 149

and cholecystitis, may be performed after or 2. One-stage surgery, laparoscopic, or open

before ERCP or as part of a one-stage laparo- (a) CBD exploration is at least as efficient
scopic procedure. as ERC, but less dangerous.
• Several publications have demonstrated 3. Laparoscopic cholecystectomy followed
the feasibility and safety of simultaneous by ERCP
laparoscopic cholecystectomy and tran- NOTE: Current data does not suggest clear
scystic bile duct exploration and/or cho- superiority of any one approach; decisions regard-
ledochotomy in elective surgery. The ing treatment are most appropriately made based
morbidity rate in these series was 7.5– on surgeon preference as well as the availability
12.6 % and included reoperations, biliary of equipment and skilled personnel.
leakage, bleeding, wound infections, pan-
creatitis, liver dysfunction, and pulmonary
embolism. Whether the same is true for 15.4 In Biliary Pancreatitis
emergency surgery remains to be shown.
4. In patients with prior gastric or intestinal Early endoscopic sphincterotomy is NOT indi-
operations, e.g., gastric bypass or gastric cated in benign acute biliary pancreatitis, except
resection with Roux-en-Y reconstruction, the in case of severe cholangitis associated with
passage to the main bile duct via stomach is severe acute biliary pancreatitis (see chapter on
closed and special therapeutic approaches are Pancreatitis)
• Laparoscopic-assisted ERC and papillot-
omy, relatively easy Pitfalls
– The endoscope is passed through a • Failure to distinguish between common
15 mm trocar inserted into the remnant bile duct obstruction by choledocholi-
stomach via an anterior gastrotomy, thiasis and pancreatic head or duodenal
made watertight by a pursestring, and malignancy.
advanced to the papilla vateri for papil- • Rarely parasites are responsible for
lotomy and stone removal. obstruction: treatment is not dissimilar.
5. Indications
In the absence of pancreatitis, three options
are possible:
1. ERCP, usually performed with papillotomy, 15.5 Essential Points
followed or not by cholecystectomy and Summary
(a) May be performed selectively before,
during, or after cholecystectomy In patients who present with jaundice and abdom-
i. With little discernable difference in inal pain, choledocholithiasis must be included in
morbidity and mortality and similar the differential diagnosis. Diagnostic tools
clearance rates when compared to include blood test (increased bilirubin, alkaline
laparoscopic common bile duct phosphatase, and gamma-glutamyl transferase)
exploration and an abdominal sonography. Treatment con-
(b) Performed routinely preoperative sists of the removal of the stones from the com-
ERCP will likely result in unnecessary mon bile duct and subsequent cholecystectomy.
procedures with higher mortality and Choosing between initial ERCP to remove the
morbidity rates common bile duct stones followed by laparo-
(c) Performed after laparoscopic cholecys- scopic cholecystectomy or laparoscopic one-
tectomy (with intraoperative cholangio- stage cholecystectomy and choledocholithotomy
grams) rather than before minimizes via laparoscopy, increasingly performed, depends
costs and morbidity on available surgical expertise, equipment, and
150 R. Fahrner and A. Fingerhut

staff. Timing of cholecystectomy should be Ke ZW, Zheng CZ, Li JH, Yin K, Hua JD. Prospective
evaluation of magnetic resonance cholangiography
within 1 week after ERCP to avoid biliary
in patients with suspected common bile duct stones
complications. before laparoscopic cholecystectomy. HBPD Int.
Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A.
Comparison of laparoscopic common bile duct explo-
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Small Bowel Emergency Surgery
Fausto Catena, Carlo Vallicelli,
Federico Coccolini, Salomone Di Saverio,
and Antonio D. Pinna

16.1 Acute Band or Adhesive Small Bowel
Obstruction 154 • To identify those patients with bowel
obstruction who require an urgent oper-
16.2 Crohn’s Disease 155
ation because of bowel strangulation
16.3 Small Bowel Neoplasms 155 • To recognize on a CT a mechanical small
16.4 Meckel’s Diverticulum and Acquired bowel obstruction and the location of
Jejunoileal Diverticulosis 156 obstruction and small bowel feces sign
16.4.1 Meckel’s Diverticulum 156
16.4.2 Acquired Jejunoileal
Diverticulosis (JID) 157
16.5 Acute Mesenteric Ischemia 157
The small bowel measures 6–7 m in length from
16.6 Miscellaneous Conditions 157
16.6.1 Gallstone Ileus 157
pylorus to ileocecal valve. The jejunum begins
16.6.2 Pneumatosis Intestinalis 158 at the ligament of Treitz. Jejunum and ileum are
16.6.3 Small Bowel Ulceration 158 suspended by a mobile mesentery covered by a
16.6.4 Accidental or Intentional Ingestion visceral peritoneal lining that extends onto the
of Foreign Bodies 158
external surface of the bowel to form the serosa.
Bibliography 158 Adhesions may limit the mobility of loops and
lead to obstruction or internal hernia. Jejunum
F. Catena, MD (*) • C. Vallicelli, MD • A.D. Pinna, MD and ileum receive their blood from the superior
General, Emergency and Transplant Surgery mesenteric artery (SMA). Although mesenteric
Department, St Orsola-Malpighi University Hospital, arcades form a rich collateral network, occlu-
Bologna, Italy
e-mail:; sion of a major branch of the SMA may result in; segmental intestinal infarction. Venous drain is via the superior mesenteric vein, which then
F. Coccolini, MD joins the splenic vein behind the neck of the
General and Emergency Surgery Department, pancreas to form the portal vein. Peyer’s patches
Papa Giovanni XXIII Hospital, Bergamo, Italy are lymphoid aggregates present on the antimes-
enteric border of distal ileum. Smaller follicles
S. Di Saverio, MD are present through all small bowel. Lymphatic
Emergency and Trauma Surgery Unit, Maggiore
Hospital Regional Trauma Center, Bologna, Italy drainage of intestine is abundant. Regional
e-mail: lymph nodes follow the vascular arcades and

© Springer International Publishing Switzerland 2016 153

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_16
154 F. Catena et al.

then drain toward the cisterna chyli. Jejunal and Insert nasogastric tube in patients with
ileal walls consist of serosa, muscularis, submu- emesis.
cosa, and mucosa. – In patients with adhesive small intestine
obstruction, water-soluble contrast medium
(Gastrografin) with a follow-through study
16.1 Acute Band or Adhesive is not only a diagnostic tool but can also be
Small Bowel Obstruction therapeutic
– Surgical intervention is mandatory for
• Common surgical emergency and major cause patients with complete small bowel
of admission to emergency surgery departments obstruction with signs or symptoms
• Early diagnosis is essential to management indicative of strangulation or those
– Principle symptoms are abdominal pain, patients with obstruction that has not
absence of flatus or stool, nausea or vomit- resolved within 24–48 h of nonoperative
ing, dehydration, and abdominal distension treatment
if the obstruction is not in proximal Laparotomy or laparoscopy can be used
jejunum. • Laparoscopy is best adapted to small
Proximal obstruction tends to present with bowel obstruction by bands, post
more frequent cramps, whereas distal appendectomy.
obstructions cause less severe cramps with • The open technique for first trocar inser-
longer duration between episodes. tion is mandatory.
– Laboratory tests: • Exposure may be difficult in case of
Elevated hematocrit because of intravascu- massive bowel dilatation, multiple band
lar volume loss. adhesions, and sometimes posterior
Significant leukocytosis is suggestive of band adhesions, more difficult to treat
strangulation. laparoscopically.
– Plain X-rays of the abdomen (not used in • Ischemia and/or necrotic bowel may
most places) reveals dilatation of the small require conversion.
bowel and air-fluid levels. • Predictive factors for successful laparo-
– CT scan, with IV contrast, shows the dila- scopic adhesiolysis include:
tation of proximal bowel and the collapse – Less than three previous laparotomies
of distal bowel. – A non-median previous laparotomy
Bowel wall thickening, mesenteric edema, (e.g., McBurney)
asymmetrical enhancement with contrast, – Unique band adhesion
pneumatosis, and portal venous gas are – Early laparoscopic management
suggestive of strangulation. (possibly within 24 h)
The zone between the presence and absence – No signs of peritonitis
of small bowel feces may also help identify – Surgeon experience
the site of obstruction. • Relative contraindication:
– Ultrasound may also be useful. – Three or more previous
• The key to management of small bowel laparotomies
obstruction is early identification of intestinal – Multiple adherences
strangulation, because mortality increases • Absolute contraindications
from two- to tenfold in such cases – Massive dilatation (more than 4 cm)
• Therapy – Signs of peritonitis
– Preoperatively – Severe cardiovascular or respiratory
Correction of depletion of intravascular comorbidities
fluids and electrolyte abnormalities. – Hemostatic disorders
Nothing by mouth. – Hemodynamic instability
16 Small Bowel Emergency Surgery 155

Goals of surgery • Alternative: resection with intestinal

• Adhesiolysis diversion is necessary.
• Determination of bowel viability: two – Usually laparotomy is necessary but lapa-
alternatives roscopy has its adepts.
– Resection of non-viable intestine • Abdominal (intraperitoneal, intermesenteric)
Extension of intestinal resection abscess
depends on demarcation between – Interventional radiology is first line.
purple or black discoloration of isch- – Surgical drainage.
emic or necrotic bowel from viable
intestine, recognized also by mesen-
teric arterial pulsations and normal 16.3 Small Bowel Neoplasms
– Observation of limited ischemia after • Very rare (1 % of all gastrointestinal neo-
adhesiolysis for 10–15 min, applying plasms and 0.3 % of all tumors).
warm saline, looking for possible • Most common modes of presentation: intestinal
improvement in the gross appearance obstruction by the tumor itself or by intussus-
of the involved segment ception and occult gastrointestinal hemorrhage;
• Obstruction by inflammatory bowel (see perforation and gross bleeding are rare.
Crohn’s disease) • Usually located in the proximal small bowel,
– Secondary to inflammation, abscess, fistula with the exception of adenocarcinoma in the
– Requires resection or strictureplasty contest of ileal Crohn’s disease and NETs.
• Tumors can be benign (usually asymptomatic
or pauci-symptomatic), malignant (often
16.2 Crohn’s Disease symptomatic), or intermediary, and these are
represented essentially by gastrointestinal
• Acute surgical emergencies are infrequent but stromal tumors (GIST).
may be life threatening – Benign small intestinal tumors include
• Bleeding adenomas (jejunal or ileal) (either tubular
– Often localized adenomas with low malignant potential or
– Caused by erosion of a blood vessel within villous adenomas with high malignant
multiple deep ulcerations potential), leiomyoma, hamartoma or des-
– Indications for surgery: moid tumors, and lipoma, more frequent in
Severe hemorrhage, rare the ileum.
Recurrent bleeding or persisting after 4–6 – Malignant neoplasms are dominated by
units of blood adenocarcinoma (50 % of all small bowel
– Preoperative localization of bleeding is malignancies), followed by lymphoma
difficult: (10–20 %), and also leiomyosarcoma, and
Gastroscopy, angiography, and the use carcinoids or metastatic neoplasms.
of a nuclear medicine labeled red cell Treatment: resection and immediate anas-
scans tomosis whenever possible, sinon
– Resection and primary anastomosis is the diversion
gold standard surgical treatment. • Adjuvant therapy is recommended for
• Perforation patients with positive margins.
– Incidence 1–3 % – Gastrointestinal stromal tumors (GISTs)
– Often sealed Symptoms: bleeding occurs in almost 50 %
– Treatment: of GISTs.
Jejunal and ileal perforations: resection • Approximately 35 % of patients present
and primary anastomosis if possible. with abdominal mass causing or not
156 F. Catena et al.

symptoms, and 20 % of patients have cer, ovarian cancer, gastric cancer, and
abdominal pain. primitive peritoneal neoplasms.
– Main symptoms: chronic bleeding and The diagnosis of peritoneal secondary
mild obstructive symptoms tumors as the cause of small bowel obstruc-
• Usually do not metastasize beyond the tion is often difficult.
gastrointestinal tract and the liver. • Obstruction typically never resolves
• Prognosis varies and depends on the completely and definitely by conserva-
site of GIST origin, mitotic index, and tive treatment, and surgical intervention
size. is almost always indicated: extensive
• When GIST presents as an emergency, cytoreductive surgery (CRS) and hyper-
surgery is the mainstay and the goal is to thermic intraperitoneal chemotherapy
completely resect the primary tumor, (HIPEC).
surrounding normal tissue, and all
involved adjacent organs.
• Because of their fragility, surgeon must 16.4 Meckel’s Diverticulum
handle GIST with great care to avoid and Acquired Jejunoileal
tumor rupture. Diverticulosis
• GISTs are resistant to chemotherapy
and radiotherapy. 16.4.1 Meckel’s Diverticulum
– Gastroenteropancreatic neuroendocrine
tumors (GEP-NET) are a heterogeneous • The most common congenital malformation
group of uncommon malignancies occur- of the gastrointestinal tract (2–4 % of the total
ring in the gastrointestinal system. population)
Incidence: 2–3 per 100,000 people per – Is localized on antimesenteric border of the
year. distal ileum, usually 30–40 cm from the
Symptoms depend on the tumor cells of ileocecal valve.
origin and the effects of secreted – A true diverticulum.
substances. Lined mainly by the typical ileal mucosa.
• Small bowel NETs are the most com- • However, in 20 % of cases, ectopic gas-
mon and occur more frequently in ileum tric mucosa may be found: increasing
than in jejunum. the risk of complications two- to
• About 10 % of patients with metastatic threefold.
ileal NETs have classic carcinoid – Globally the incidence of complica-
syndrome. tions ranges from 4 % to 16 %,
• Occasionally, ileal NET presents with a three to four times more frequent in
massive gastrointestinal bleeding, sec- males.
ondary to sclerosis of vasa recta, due to Is the most common cause of bleeding in
hypersecretion of serotonin. the pediatric age group.
• Sclerosis of arterial vessels may also The risk of complications decreases with
provoke a bowel ischemia. increasing age.
• Otherwise, endoluminal growth of the • In adults: most frequent complications
cancer and mesenteric fibrosis are are obstruction (intussusception or
responsible for intestinal obstruction. adhesive band), ulceration, diverticuli-
– Intestinal involvement of metastatic cancer tis, and perforation.
is common, mostly in the form of perito- • Technetium 99-m scan is the most com-
neal carcinomatosis. mon and accurate noninvasive investi-
All abdominal tumors can lead to peritoneal gation (when the diverticulum contains
carcinomatosis, particularly colorectal can- ectopic gastric mucosa).
16 Small Bowel Emergency Surgery 157

• In the presence of symptoms, the treat- 16.5 Acute Mesenteric Ischemia

ment of choice is the surgical resection:
diverticulectomy or, better, by the seg- • Uncommon (less than 1 case in every 1000
mental bowel resection and anastomo- hospital admissions)
sis, especially when there is palpable – Three times more frequent in females
ectopic tissue, intestinal ischemia, or – Usually between the age of 60 and 70
perforation. – Main cause: arterial embolism (40–50 % of
cases), most often originating from the
16.4.2 Acquired Jejunoileal Location
Diverticulosis (JID) • Proximal superior mesenteric artery
(SMA), just beyond the first jejunal
• Is a rare entity often asymptomatic and treated branches (35 %)
conservatively. • At the origin of the SMA (15 %)
• Incidence increases with age, with the peak • Distal to the middle colic artery (50 %)
occurring in the sixth and seventh decades of – Sparing proximal intestine and
life. ascending colon
• Are pseudodiverticula (herniation of mucosa – Presenting signs and symptoms
and submucosa through the muscularis on the Acute symptoms usually occur in patients
mesenteric border where paired vasa recta with a long history of chronic mesenteric
penetrate the bowel wall. ischemia.
• About 55–80 % of diverticula occur in the • Pain and shock are the most common;
jejunum, 15–38 % in the ileum, and 5–7 % in diarrhea and red blood per anum are
both. frequent.
• Two-third of patients have multiple diverticula Diagnosis
and therefore a major risk of developing • High-quality computed tomography angi-
complications. ography has supplanted angiography.
• Ten percent to 19 % of patients present with • Diagnostic laparoscopy is not widely
acute and emergent complications, and accepted because it may miss areas of
most complications require acute surgical nonviable bowel.
care. After initial resuscitation and stabilization
– Diverticulitis occurs in 2–6 % of patients of the patient
and can progress to gangrene with full- • Revascularization may be tempted.
thickness necrosis and perforation asso- • Resection as necessary (frank necrosis or
ciated with a mortality rate as high as perforation or peritoneal soilage).
40 %. – Usually without reanastomosis
Perforation presents either with localized or
generalized peritonitis, and the mainstay of
treatment includes resection of the affected 16.6 Miscellaneous Conditions
segment and primary anastomosis.
– Obstruction occurs in 2–4 % of patients, 16.6.1 Gallstone Ileus
due to adhesions, intussusceptions, volvu-
lus, extrinsic compression from a fluid- • Develops with the passage of gallbladder
filled diverticulum, or enteroliths. stones through a fistula to the duodenum.
– Bleeding complications occur in 3–8 % of • Obstruction in a narrow section of the distal
patients. small bowel which is generally terminal ileum.
Surgical resection of the affected bowel • Aerobilia may be visualized on plain abdomi-
and anastomosis is mandatory. nal X-ray or CT.
158 F. Catena et al.

16.6.2 Pneumatosis Intestinalis Bibliography

• Defined as the presence of gas within the Berg DF, Bahadursingh AM, Kaminski DL, et al. Acute
surgical emergencies in inflammatory bowel disease.
abdominal wall of the bowel Am J Surg. 2002;184(1):45–51.
– Sometimes incidental finding without any Catena F, Pasqualini E, Campione O. Gastrointestinal
underlying pathology stromal tumors: experience o fan emergency surgery
Is seen in patients with COPD, asthma, or department. Dig Surg. 2000;17(5):503–7.
Catena F, Gazzotti F, Ansaloni L, et al. Emergency sur-
pulmonary cystic fibrosis gery for recurrent intraabdominal cancer. Word J Surg
– Elsewhere the result of primary intestinal Oncol. 2004;2:23.
pathology requiring urgent surgery Catena F, Ansaloni L, Gazzotti F, et al. Small bowel
Results from necrosis caused by ischemia, tumors in emergency surgery: specificity of clinical
presentation. ANZ J Surg. 2005;75(11):997–9.
infarction, neutropenic colitis, volvulus, Di Saverio S, Catena F, Ansaloni L, et al. Water-soluble
and necrotizing enterocolitis obstruction or contrast medium (gastrografin) value in adhesive
ischemia and usually require urgent small intestine obstruction (ASIO): a prospective,
surgery. randomized, controlled clinical trial. Word J Surg.
Only the ischemic bowel segment must be Di Saverio S, Tugnoli G, Catena F. A tenacious complete
resected. small bowel obstruction. Gut. 2009;58(6):812.
Dindo D, Schafer M, Muller MK, et al. Laparoscopy for
small bowel obstruction: the reason for conversion
matters. Surg Endosc. 2010;24:792-7.
16.6.3 Small Bowel Ulceration Farinella E, Cirocchi R, La Mura F, et al. Feasibility of
laparoscopy for small bowel obstruction. Word J
• Usually the result of ingested medications Emerg Surg. 2009;4:3.
like enteric-coated potassium chloride, Grande C, Haller DG. Gastrointestinal stromal tumors
and neuroendocrine tumors. Semin Oncol Nurs.
nonsteroidal anti-inflammatory drugs, and 2009;25(1):48–60.
– Clinical presentation: intermittent small HealthProfessional. Consulted Dec 2013.
bowel obstruction.
intestine/Patient/. Consulted Dec 2013.
– Preoperative localization is difficult (requires Jobanputra S, Weiss EG. Strictureplasty. Clin Colon Rect
palpation of the small bowel at laparotomy Surg. 2007;20(4):294–302.
or an intraoperative endoscopy). Levard H, Boudet MJ, Msika S, Molkhou JM, Hay JM,
– Treatment is surgical resection rather than Laborde Y, Gillet M, Fingerhut A. Laparoscopic treat-
ment of acute small bowel obstruction: a multicentre
suture repair because of a high rate of retrospective study. ANZ J Surg. 2001;71:641–6.
suture breakdown. Rosenthal RJ, Bashankaev B, Wexner SD. Laparoscopic
management of inflammatory bowel disease. Dig Dis.
Sagar J, Kumar V, Shah DK. Meckel’s diverticulum: a
16.6.4 Accidental or Intentional systematic review. J R Soc Med. 2006;99:501–5.
Ingestion of Foreign Bodies Vallicelli C, Coccolini F, Catena F, Ansaloni L, Montori
G, Di Saverio S, Pinna AD. Small bowel emergency
• Not rare surgery: literature’s review. World J Emerg Surg.
2011;6:1. doi:10.1186/1749-7922-6-1.
• Symptoms: Woods K, Williams E, Melvin W, et al. Acquired jejuno-
– Intestinal perforation is rare. ileal diverticulosis and its complications: a review of
– Resection is preferred over antibiotic treat- literature. Am Surg. 2008;74(9):849–54.
ment (associated with chronic infection or Wyers MC. Diagnostic mesenteric ischemia: diagnostic
approach and surgical treatment. Semin Vasc Surg.
stricture formation). 2010;23:9–20.
Colon and Rectum Emergency
Surgery Techniques: Exposure 17
and Mobilization, Colectomies,
Bypass, and Colostomies

Pantelis Vassiliu, Irene Pappa,

and Spyridon Stergiopoulos

17.1 Generalities 159 Objectives
17.2 Access 160
• Rapid access and operative ease
• Exposure and small bowel positioning
17.3 Mobilization 160
17.3.1 Right Colon 160 • Mobilization modules: ascending, trans-
17.3.2 Transverse Colon 161 verse, descending, sigmoid, rectum
17.3.3 Left Descending Colon 161 • Resection modules: right, left, sigmoid
17.3.4 Sigmoid 161 colon, rectum
17.3.5 Rectum 161
• Anastomoses: alternatives, pros and
17.4 Vessel Ligation 162
cons, surgical technique
17.4.1 Right Hemicolectomy 163
17.4.2 Left Hemicolectomy 163 • Stomas: surgical technique, alternatives
17.4.3 Sigmoidectomy 163 • Internal bypasses: indications, technique
17.4.4 Low Anterior Rectal Resection 163 • Drains: indication, functional position-
17.5 Anastomoses 163 ing, optimal timing of removal
17.6 Bypasses 167
17.7 Stoma 167
17.7.1 Diverting Stomas 167
17.7.2 Decompressive Stomas 168 17.1 Generalities
17.7.3 Advice 170
17.8 Drains 170 • Colonic contents: in emergency surgery of the
17.9 Particularities of Colectomy Related to colon, there is no time for colonic preparation.
Disease 170
– If simple spillage occurs intraoperatively,
17.10 Summary 172 fecal contents must be swiped out and the
Bibliography 172 abdominal cavity washed with warm saline
at the end of the operation.
P. Vassiliu, MD, PhD, FACS (*) – To drain and give antibiotics for 24 h is
Assistant Professor at the University of Athens, optional.
“Attikon” University Hospital,
Athens, Greece
S. Stergiopoulos, MD, PhD I. Pappa, BSc, MS
Assistant Professor, University of Athens, GGZ Delfland, University of Athens,
Athens, Greece Rotterdam, The Netherlands
e-mail: e-mail:

© Springer International Publishing Switzerland 2016 159

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_17
160 P. Vassiliu et al.

17.2 Access • Whether performed through a classical laparot-

omy or through laparoscopy, the steps and pre-
• Laparotomy cautions are similar, but the order may differ.
– Abdominal midline incision is most com- – Two approaches are possible: the classical
monly used; it should be long enough to lateral to medial, which can be used both in
enable visualization and mobilization of all open and laparoscopic surgery; and the
parts of the colon. medial to lateral, usually performed in
– If stoma formation is the only goal of an laparoscopy.
acute operation, a minimal skin incision on
top of the mobilized bowel loop intended to
be brought out is sufficient. The incision 17.3.1 Right Colon
used for access is then used to fix the bowel
to the skin. • Make an incision from the mesenteric surface of
• Laparoscopy terminal ileum, along the avascular line where the
– Several configurations are possible: the parietal peritoneum fuses with the mesentery.
principle of triangulation, the scope, and all • Continue around the cecum to the line of Toldt.
instruments directed toward the target must – Facilitate your effort by retracting the
be respected to optimize the ergonomics. ascending colon (grasper or with nondomi-
nant hand) against the parietal peritoneum.
• Dissection continues around the hepatic flexure,
17.3 Mobilization with caution taken to identify the duodenum.
• Division of the gastrocolic ligament
• Dissection is based on natural avascular planes – Danger: the gastrocolic trunk of Henle
(between the Toldt and Gerota fascias). (a short vein arising from the right gastro-
• Any anatomic deviation sometimes caused by epiploic, anterosuperior pacreatodudode-
disease must be pursued with caution to iden- nal, and right superior colic veins, draining
tify and avoid damage to neighboring struc- into the superior mesenteric vein (SMV))
tures (essentially ureter). (Fig. 17.1), is vulnerable to undue or

16 14 4 3


Fig. 17.1 A lethal danger spot in right colon dissection: superior mesenteric artery; SMV, superior mesenteric
Henle’s gastrocolic trunk (Ignjatovic et al. 2004; Lange vein; SV, splenic vein. (b) Variations of Henle’s gastro-
et al. 2000). (a) Demonstration of the gastrocolic trunk of colic trunk: the anatomy of venous tributaries of the supe-
Henle (GTH) with the corrosion cast method. ASPDV, rior mesenteric vein at the inferior border of the pancreas.
anterior superior pancreaticoduodenal vein; GTH, gastro- Numbers indicate numbers of subjects A, Superior mesen-
colic trunk of Henle; JV, jejunal vein (prima); MCV, mid- teric vein; B, right gastroepiploic vein; C, anterior supe-
dle colic vein; RGEV, right gastroepiploic vein; SMA, rior pancreaticoduodenal vein; D, right superior colic vein
17 Colon and Rectum Emergency Surgery Techniques 161

untoward tension to the root of transverse traction are similar to those followed in descending
mesentery and the root of greater omentum colonic mobilization; the sigmoid is mobilized by
on the right, and source of often cata- continuing the cautery incision on Toldt’s line at
strophic, difficult to control bleeding the outer aspect of the sigmoid. Alveolar tissue is
The only reasonable suggestion is to be exposed and can be pushed with a wet sponge
gentle and avoid this injury. down to the root of the sigmoid mesentery, care
• Hemostatic clamps and stitches complete dis- being taken to avoid injury to the left spermatic
section at this end of the gastrocolic ligament. vessels, and visualizing the left ureter. The ureter
lies on the posterior abdominal wall, crossing ante-
riorly the bifurcation of the internal and external
17.3.2 Transverse Colon iliac vessels. The ureter contracts with a gentle
touch of an atraumatic instrument; no need to mark
• Omental resection is optional. or tape it, just identify it to make sure to avoid it.
• Particular attention should be paid not to tear
the splenic capsule when dissecting near the
splenic flexure and/or while ligating the left 17.3.5 Rectum
end of the gastrocolic ligament and/or spleno-
colic attachments. As the sigmoid is pulled out of the abdomen, the
– Mobilization (without resection) of the peritoneal surface at the medial aspect of the
spleen may facilitate this dissection, as mesosigmoid root is incised, from the aortic bifur-
well as a surgical swab placed gently above cation caudally along the medial aspect of the right
spleen and below diaphragm. iliac vessels, and the incision is continued between
• A distended megacolon, or an inflammatory, the rectum and pelvic brim, rectum and bladder or
diseased colon, is vulnerable to tears and/or uterus, as the assistant applies opposite traction to
perforation at or near the splenic flexure. these organs. Parallel and superficial to the aortic
bifurcation lie the hypogastric nerves (sexual func-
tion) (Fig. 17.2). Once identified, avoid traction on
the nerves during the next step. Following the
17.3.3 Left Descending Colon alveolar plane below the aortic bifurcation bluntly
down to the pelvic cavity, the rectum/mesorectum
The nondominant hand elevates the colon, can be dissected free from the presacral space,
extracting it out of the abdomen and to the down to Waldayer’s fascia (Fig. 17.3). If cancer is
patient’s right, while the assistant retracts the not the problem, mobilization is accomplished
abdominal wall to the left. In this manner, the within seconds by gentle insertion of the dominant
white (Toldt) line comes into view under tension hand. Neither cautery nor ligation is needed. Avoid
between the parietal and descending colon peri- pressing against mesorectum with the tip of
toneums. Cutting with cautery precisely on this fingers, because this may perforate a fragile rec-
line exposes the underlying alveolar tissue. tum, leading to troublesome bleeding and a source
Gentle traction and cautery free the descending of potential contamination; use the palm of the
colon, which now is attached only by its hand. To complete rectal mobilization circumfer-
mesentery. entially, using (long shaft) cautery bursts dissect
all connective tissues laterally from both sides
freeing the lateral mesorectum from the pelvic fas-
17.3.4 Sigmoid cia. Usually, no vessel is encountered: no need for
ligation, as simple cautery forceps suffice. Finally
The sigmoid root has a length of 5–10 cm; the sig- the anterior rectal plane is incised and freed from
moid mesentery unfolds like a fan to 25–60 cm. its attachments to the uterus/vagina in women or
The surgeon’s and assistant’s positions as well as bladder/seminal vesicles/prostate in men. Putting
162 P. Vassiliu et al.

Fig. 17.2 The hypogastric plexus. IHP

Dissecting in the correct pelvic plane
(see Fig. 17.3) preserves nerve and
sexual function. IHP inferior
hypogastric nerve plexus, NE nervi
erigentes, HN hypogastric nerve,
SHP superior hypogastric nerve NE




Denonvilier’s fascia


venous Basivertebral Coccyx
veins Levator ani m.
system Presacral
Presacral fascia
fascia Waldeyer’s

Fig. 17.3 Lateral pelvis view. The correct plane to start on nerve damage, injury to adjacent organs. Waldayer’s and
mesorectum (left image, blue arrow) and continue the dis- Denonvilier’s fascias. False plane of pelvic dissection
section (right image, blue arrows); avoids hemorrhage, (Red arrow)

tension to rectum by posterior traction and contra- increased by temporarily stitching the dome of the
tension by pulling (e.g., with a St. Marks-type uterus to the pubic skin, elevating it out of the
retractor), the anterior tissues (vagina, bladder, operating field.
etc.) against the pubic bone, the correct plane is
found (Fig. 17.3); it is essential to remain in the
specific plane (Denonvillier’s fascia) until reach- 17.4 Vessel Ligation
ing the deepest part of dissection, avoiding dam-
age on nervi erigentes and its branches, responsible Vessel ligation differs according to the disease
for sexual function (Fig. 17.2). In women, vision and what segment (right and left colectomy,
can sometimes be improved and working space sigmoidectomy, low anterior resection, or seg-
17 Colon and Rectum Emergency Surgery Techniques 163

mental resection) is performed. The regional 17.4.4 Low Anterior Rectal Resection
lymph nodes reside along the feeding vessels
and can be removed as needed. In a non-onco- In low anterior rectal resection (defined as
logic emergency, just the diseased part of the resection of the proximal two thirds of the rec-
colon along with a sphenoid part of its mesen- tum, leaving the sphincter mechanism intact,
tery is all that has to be excised. The appex of and anastomosis below peritoneal reflection)
this sphenoid part goes down to the mesenteric superior, middle, and inferior rectal arteries are
root, so there are fewer vessels to ligate, saving ligated depending on the depth of resection of
time. Energy-driven devices (which seal and the rectum. Middle and inferior arteries are
cut vessels) are effective especially in areas rarely visualized and safely sealed with cautery,
with diminished working space (i.e., pelvis) or energy-driven devices. Retaining the rectal
and save time. ampulla or an ileorectal anastomosis (for total
colectomy) are important for quality of life.

17.4.1 Right Hemicolectomy

17.5 Anastomoses
Right hemicolectomy: Having mobilized the
right colon the vessels to ligate include the ileo- Prerequisites include:
colic, right colic, and right branch of middle
colic (retain main stem and the left branch) 1. Good blood supply to the bowel margins: this
arteries. can be evaluated by the color of the divided
bowel wall (in comparison with the adjacent
distal colon), ample bleeding at the cut edge
17.4.2 Left Hemicolectomy (or an nearby epiploic appendix), and also by
Doppler and/or indocyanine green.
Ligation of the inferior mesenteric at its origin 2. Avoid tension: a rule of thumb is that the two
(extended left hemicolectomy) means that ade- extremities must overlap each other for at least
quate vascular supply relies on the marginal 2 cm, without traction in an end to end anasto-
artery (from the transverse colon) above, and mosis. If not, further mobilization and/or mes-
requires excision of the sigmoid and extraperito- enteric incisions are mandatory, even if it
neal rectum with the specimen. means occasionally sacrificing a major vessel.
In a low rectal anastomosis where the rectum
cannot be mobilized, further length should
17.4.3 Sigmoidectomy come from the descending colon (splenic flex-
ure mobilization) with ligation and division of
Sigmoid trunk ligation at the root usually suf- the inferior mesenteric vein under the pancreas
fices. The taenia coli disappear at the rectosig- along the ligament of Treitz, and the inferior
moid juncture, forming a complete outer mesenteric artery at its root, leaving intact the
muscular layer in the upper rectum, which in bypassing branches of the marginal artery of
addition is the narrowest part of the colonic Drummond and the arc of Riolan supplying
lumen. This anatomic characteristic has been blood from the superior mesenteric artery
incriminated as responsible for diverticular dis- (Fig. 17.4). Always be cautious when there has
ease, and is the rationale for mandatory resection been previous operations (that have potentially
of this portion in diverticular disease. Ligation of occluded the arterial arcades), radiation ther-
the superior rectal artery (continuation of the apy, atherosclerosis and diabetes, or even radi-
inferior mesenteric artery) is not mandatory, and cal nephrectomy. Check colonic viability
some advise its preservation. before ligating the main vessels by temporary
vessel occlusion with a bulldog.
164 P. Vassiliu et al.

Fig. 17.4 Anastomotic arterial arc of Riolan, and marginal artery or Drummond, are the feeding arteries of a long
descending colon graft formed after division of inferior mesenteric artery (red line) and vein (blue line) (right image)

3. Once completed, the anastomosis should be • We describe herein, two of the most frequent
visually and palpably evaluated for tension. It applications:
should lie gently on the surroundings.
4. If a tension-less anastomosis is not possible, Right hemicolectomy:
create a stoma or, if an anastomosis is already
created, add a prophylactic ileostomy. Drains • Position the ileum and transverse colon side
or delaying the patient’s oral feeding will not by side (Fig. 17.5) at the location where you
heal an unsafe anastomosis. intent to anastomose (antimesenteric border
on ileum, taenia coli on transverse) in isoperi-
Technical issues regarding anastomoses: staltic position.
• Insert two stay sutures to hold them together.
• Hand sewn: Hand sewn or stapled anastomoses • Insert the two staple legs into two holes cre-
can be performed according to personal prefer- ated in each limb.
ences: there is no significant differences in • Make sure that
leakage rates; however, the immediate risks of – The lumens are parallel
bleeding (should decrease with new multi (>2) – The stapler locks ideally at the antimesen-
staple lines) and the long-term risk of stricture teric edge, as in this location it creates
are higher with the staples. Speed of construc- minimal disturbance to the blood supply
tion depends on the operator, more than on the (Fig. 17.6)
method. One layer, ideally extramucosal, is – No other tissues are trapped in the staple line and
enough. Interrupted or continuous is also a mat- Wait 20 s before you fire (to allow adequate
ter of surgeons’s preference and provide equally tissue creep)
satisfactory results when well done. Wait another 15/20 s before opening the jaws
• Staples are more expensive and can be associ- (hemostasis)
ated with mishaps (misfirings, incomplete staple • Inspect the staple line for bleeding and achieve
lines). Be aware of these and do not waste them. adequate hemostasis as necessary.
17 Colon and Rectum Emergency Surgery Techniques 165

Fig. 17.5 Stapled ileotransverse anastomosis

• Occlude the remaining opening with three • Most techniques involve a linear stapled
Allis clamps, and complete the anastomosis closure of the distal rectal stump and an end-
either hand-sewn or with a linear stapler. to-end circular stapled colo(ileo)-rectal anasto-
• Additional reinforcement is usually not mosis (circular stapler inserted via the anus:
necessary. attention do not force the sphincter; dilate gen-
tly and progressively before inserting stapling
Low anterior resection: gun or inject xylocaine in the sphicter
• Stapled anastomosis is the most widely prac- – Vertical linear stapling or use of special lin-
ticed technique today although some prefer ear staplers with angled arms (Roticulator®)
the “parachuting down” technique, which or curved edge (Contour®) linear staples
becomes more demanding as the anastomosis fascilitate a very low rectal stump closure
is performed deeper in pelvis. deep in pelvis.
166 P. Vassiliu et al.

Fig. 17.6 Blood supply to the Peritoneum Longitudinal m.

antimesenteric border Circular m.
Taenia Taenia libera
omentalis Submucosa

Lumen Mucosa

Taenia mesocolica Vasa

Vasa recta brevia recta longa

Vasa recta

Marginal artery

– Ideally, one firing, perpendicular to the the lumen proximal and distal from the pro-
intestinal lumen, is best (the leakage rate posed anastomosis. The bowel is divided
increases proportional to the number of fir- under suction 5 cm from the bowel clamp, and
ings) to close the rectal stump. the clamps are released only after anastomosis
– Some prefer a side to end anastomosis, is complete.
especially in case of diameter discrep-
ancy (another possibility is to cut a fish Advice:
mouth to enlarge the smaller lumen).
– No consensus as to the ideal diameter but • No proven need to close mesenteric defects.
best to use largest diameter compatible • Always test the anastomosis for air-tightness
with lumen. (anastomosis under saline), do not use dye
• In the emergency setting, the bowel may not (e.g., methylene blue) but air.
be clean. Although still debated, few surgeons – Occlude the proximal lumen, pour saline in
perform on-table lavage of the rectum. In the the pelvis to cover the staple line.
era of ERP (Enhanced Recovery Protocols) – Inject, through the anus, with a large
the elective bowel operations are performed syringe attached to a Foley catheter, with
without the use of pre-op laxative colon prepa- the balloon blocked at the anus, at least
ration. Despite that bowel is operated in full 150 cc of air in the anorectal lumen,
fecal content the infectious complication rate inspecting the fluid in the pelvic cavity.
has not raise. – If bubbles (leak) arise, oversew and retest,
– An alternative is to aspirate the air with a 16G or redo the anastomosis, and if all is not
needle perforating at a taenia coli, but not perfect, entertain a stoma.
attempting to evacuate the fecal contents • No need to drain (except conditions dealt with
(Fig. 17.7). A curved bowel clamp occludes later).
17 Colon and Rectum Emergency Surgery Techniques 167

Fig. 17.7 Initial decompression Intracatheter Purse

of the colon is achieved by needle 14 gauge needle string
and sheath
aspiration of air from the anterior Taenia coli
aspect of the distended colon


17.6 Bypasses The main characteristics of a protective stoma

Occasionally, the obstruction is unresectable and
a bypass is needed. • Preserved blood supply to distal anastomosis
(a sigmoidostomy may compromise blood
• When it is not possible to mobilize the two supply to the more distal anastomosis)
extremities, entertain a diverting stoma. • Complete diversion of the fecal stream
• Side-to-side anastomosis is performed as in • Easily reversible
right hemicolectomy (see above). • Avoid irritation of peristomal skin
Ileostomy responds more adequately to these
– Should be performed 15 cm from ileocecal
17.7 Stoma valve (to allow for a drop of the intralumi-
nal pressures developed close to the ileoce-
Stomas are created to divert the fecal stream in a cal valve, which after stoma reversal may
high-risk anastomosis, when the anal sphincter is compromise ileo-ileal anastomosis).
destroyed or functionally impaired, or to decom- – The “Brooke” nipple technique (Fig. 17.8)
press an obstructed colon. Allows bowel contents to drop into the
stoma bag before it touches the skin
Accomplishes complete diversion of
17.7.1 Diverting Stomas fecal stream
Prevents passage of contents to distal
High risk anastomoses include: lumen through the difference in
height between proximal and distal
• Those when undue tension, ischemia, or flat openings (Fig. 17.8)
inflammation are present and there is risk to Is easily reversed even under local
compromise first intention healing. anesthesia
• Infraperitoneal anastomoses.
• Patients with preoperative radiation (chemo) Permanent stomas are also completely divert-
therapy (especially within 6 months prior to ing. They are created when the distal part of the
operation). bowel is irreversibly impaired. They should be
168 P. Vassiliu et al.

a b

c d

Fig. 17.8 Loop (left) and terminal (right) ileostomy: both make certain which side is proximal. (C) Eversion. (D)
constructed with the Brooke technique, which protects Maturation. Illustration. Right: Maturation of ileostomy
from parastomal irritation. Left: Loop ileostomy. (A) stoma. (A) Three sutures are placed, incorporating the
Exteriorization. (B) The distal limb is incised from mes- seromuscular layer to facilitate eversion. (B) The sutures
entery to mesentery at skin level. Care must be taken to are secured, everting the bowel

created as distal as possible, to take advantage of Cecostomy (Fig. 17.10)

colon’s water absorption capacity. This stoma is
formed with an anastomosis of the proximal • Make a small incision above the distended
bowel loop to the abdominal wall and a skin cecum
opening. The distal bowel loop is either nonexist- • Grasp and hold the cecum to the abdominal
ing, or stapled and left within the abdominal wall
cavity. • Incise lumen along a taenia coli
• Either pass a decompressing tube or anasto-
mose the edges to the skin
17.7.2 Decompressive Stomas
Transverse colostomy (Fig. 17.11).
Stomas to decompress an intestinal portion prox-
imal to an obstruction (e.g., in a patient too sick • Can be accomplished with a small incision on
to tolerate formal surgery) the midline, lower third of the distance
between umbilicus and xiphoid
• The most frequent in the emergency setting • The omentum should be incised below trans-
• Not vital to differentiate between proximal verse colon to allow exteriorization of the
and distal stoma ends, because the fecal con- colon.
tent is not intended to be completely diverted • The steps hereafter are as in the cecostomy.
(Fig. 17.9)
• Can be performed in any mobile part of the Sigmoidostomy
colon (transverse, or sigmoid), or even to the Could serve as decompressive or diverting (or
fixed cecum, which is close to the skin permanent) stoma
17 Colon and Rectum Emergency Surgery Techniques 169

a b P


Fig. 17.9 Decompressing stoma is not indented to divert completely the fecal steam (P proximal lumen, D distal
lumen): (a) decompressing stoma, (b) diverting stoma


Fig. 17.10 Cecostomy. 10: (a) formal cecostomy. (B) Opening of the cecum. (C) Primary maturation to the
Technique of cecostomy. (A) Obliteration of the peri- skin. (b) Tube Cecostomy.
toneal opening by suture of the bowl wall to the fascia.
170 P. Vassiliu et al.

bowel loop (usually colon which is less mobile

than teminal ileum) on the skin.
The standard size of the skin and abdominal
wall opening to develop a stoma is two-finger
aperture (Fig. 17.13).

17.8 Drains

• Currently, there is strong evidence against

routine drainage in elective colorectal surgery,
but extrapolation of these data to emergency
surgery is controversial.
– Their value to detect postoperative bleed-
ing is questionable.
– Drainage will not protect against the conse-
quences of a high-risk or compromised
anastomosis; create a protective ileostomy
• Ascites, regardless of the volume drained, is
not an indication to leave a drain.
• If used, drains should be placed below the site
of operation (gravity will guide fluids to the
drain in a patient lying in bed).
Fig. 17.11 Transverse colostomy
• Silicon tubes provoke the least inflammation
and foreign body reaction; closed suction drains
are associated with less infective complications.
• Incise through the rectus abdominis Drains are “cracked” (pulled out five centime-
• Grasp the mobile sigmoid and bring it to the ters) after passing flatus, and removed com-
skin edge pletely a day after, since no abnormal drain (p.e.
• Open the lumen at a taenia coli faecal content) occurs.
• Stitch to the skin

17.9 Particularities of Colectomy

Related to Disease
17.7.3 Advice
(a) Inflammatory bowel disease or complicated
With the exemption of the cecum, which is fixed diverticular disease
to the retroperitoneum, the rest of the locations • Resection of all diseased portions
(terminal ileum, transverse, sigmoid) can all be – In diverticular disease you resect the
formed in either a decompressive or a diverting disease (fistula, stenosis, abscess)
fashion if the appropriate surgical steps are AND the “heart” of the problem the
followed. sigmoid (the part of the colon with the
In case that the technique of loop stoma is not narrowest lumen and the strongest
mastered, a rod under the exstomosed bowel loop musculature -as the taenia coli join in
will create the diversion effect. (Fig. 17.12). The sigmoid wall to a complete external
rod technique is originally suggested to secure a longitudinal muscle). Diverticula prox-
17 Colon and Rectum Emergency Surgery Techniques 171

a b c

d e f

Fig. 17.12 The rod technique. Alteration for securing the loop of colon. (a) Rolled gauze. (b) Glass rod. (c) Glass rod
with rubber loop. (d) Glass rod with rubber sleeves. (e) Rubber tubing (f) Folded tubing or drain

Fig. 17.13 The standard aperture on the abdominal wall before creation of a stoma
172 P. Vassiliu et al.

imal of sigmoid if present do not create

problems as the afore mentioned fac- • Injury to hypogastric plexus and nervi
tors are not present. erigentes
• Mesenteric dissection may be close to colon • Deviate from avascular planes in pelvic
but marginal and rectal (superior rectal dissection
artery) vascularization must be preserved. • Anastomosis proximal to ileocecal
(b) Cancer valve or to irradiated bowel
• Respect oncological principles: no-touch • Anastomosis under tension, and subop-
technique, primary high vascular ligation timal blood supply
(debate still exists as to high or low liga- • In hand-sewn anastomosis stitch-
tion of inferior mesenteric artery), and occlude the lumen when stitching the
adequate lymphadenectomy. upper part of the bowel wall
(c) Ischemic colon (vascular origin, volvulus, • Failure to identify proximal and distal
strangulation) end in a protective ileostomy
• Revascularization may be attempted only
if ischemia is recent.
• Resection of all compromised colon
– Preservation may be a possibility if
detorsion of volvulus or reversal of 17.10 Summary
incarcerated/strangulated bowel is
accompanied by satisfactory recolor- Emergency colonic surgery requires individual-
ization and vascular patency. ization on the basis of hemodynamic status,
• Volvulus and hernia require prevention of acidosis, and septic symptoms. The operative
recurrence by appropriate cure of cause. strategy ranges from damage control principles
(d) In case of associated upstream dilation what- in a patient in extremis, to the elective princi-
ever the cause ples in a patient in stable condition.
• Dilated bowel means potential vascular
compromise: resect as proximal as neces-
sary to obtain well-vascularized tissues.
(e) In all emergency surgery for colorectal
disease Baxter NN. Emergency management of diverticulitis.
• Upstream protective stoma will not pre- Clin Colon Rectal Surg. 2004;17:177–82.
vent fistula but will decrease the morbid- Brand MI, Dujovny N. Preoperative considerations and
ity associated with eventual leak. creation of normal ostomies. Clin Colon Rectal Surg.
Cataldo PA. Technique tips for the difficult stoma. Clin
Colon Rectal Surg. 2002;15:183–90.
Pitfalls Ciga MA, Oteiza F, Fernandez L, de Miguel M, Ortiz H.
Comparative study of one-stage colectomy of the
• Longer incision than required
descending colon in emergency and elective surgery
• Eviscerate small bowel if not needed without mechanical preparation. Dis Colon Rectum.
• Tear of gastrocolic vessels or Henle’s trunk 2010;53:1524–9.
• Splenic flexure perforation or tear to Corman ML. Colon & rectal surgery. 5th ed. Philadelphia:
Lippincott Williams & Wilkins; LWW, Philadelpia
splenic capsule
• Failure to identify (left) ureter Ignjatovic D, Stimec B, Finjord T, Bergamaschi R. Venous
• Destruction of vasculature (Drummond, anatomy of the right colon: three-dimensional topo-
Riolan) graphic mapping of the gastrocolic trunk of
Henle. Tech Coloproctol. 2004;8:19–21; discussion
• Leaving sigmoid unresected in
diverticulitis Kam MH, Tang CL, Chan E, Lim JF, Eu KW. Systematic
review of intraoperative colonic irrigation vs. manual
17 Colon and Rectum Emergency Surgery Techniques 173

decompression in obstructed left-sided colorectal Moore HG, Guillem JG. Total mesorectal excision in rec-
emergencies. Int J Colorectal Dis. 2009;24:1031–7. tal cancer resection. Clin Colon Rectal Surg. 2002;15:
Lange JF, Koppert S, van Eyck CH, Kazemier G, 27–34.
Kleinrensink GJ, Godschalk M. The gastrocolic Nelson RL, Glenny AM, Song F. Antimicrobial prophy-
trunk of Henle in pancreatic surgery: an anatomo- laxis for colorectal surgery. Cochrane Database Syst
clinical study. J Hepatobiliary Pancreat Surg. Rev 2009;(1):CD001181.
2000;7:401–3. Ruo L, Pfitzenmaier J, Guillem JG. Autonomic nerve
Lopez DE, Brown CV. Diverticulitis: the most common preservation during pelvic dissection for rectal cancer.
colon emergency for the acute care surgeon. Scand Clin Colon Rectal Surg. 2002;15:35–41.
J Surg. 2010;99:86–9.
Luca Ansaloni, Marco Lotti, Michele Pisano,
and Elia Poiasina

Contents 18.1 Appendectomy

18.1 Appendectomy 175
18.2 Open Appendectomy 175 Objectives: To Describe
18.2.1 Positioning and Personnel 175 • The most common technique
18.2.2 Exploration 176 • Technique for ectopic (retrocecal)
18.2.3 Mesoappendix Division and
Appendectomy 176 appendicitis
18.2.4 Search for Meckel’s Diverticulum 177 • Management of pelvic abscesses and
18.2.5 Drainage 177 peritonitis
18.2.6 Abdominal Closure 177 • Indications for conversion
18.2.7 Variations 177
• Open questions: treatment of the appen-
18.3 Summary of Open Appendectomy 178 dicular stump, drainage, optimal port sites,
18.4 Laparoscopic Appendectomy 178 treatment of associated Meckel’s divertic-
18.4.1 Equipment and Instruments 178 ulum, resection of a normal appendix
18.4.2 Positioning, Personnel, and Port Sites 178
18.4.3 Port Site Placement 178
18.4.4 Exploration 179
18.4.5 Mesoappendix Exposure and Division 179
18.4.6 Appendectomy 180
18.2 Open Appendectomy
18.4.7 Drainage (As Above) 180
18.4.8 Retrocecal Appendicitis 180 18.2.1 Positioning and Personnel
18.4.9 Pelvic Abscess 181
18.4.10 Retrograde Appendectomy 181
• The patient is placed supine and right arm
18.4.11 Normal Appendix 181
18.4.12 Conversion 182 tucked to the patient’s side.
18.4.13 Search for Meckel’s Diverticulum – Urinary catheter insertion is optional (may
(Via Laparoscopy and Laparotomy) 182 be omitted if the patient has voided imme-
Selected Reading 182 diately before anesthesia).

L. Ansaloni, MD, MBBS (*) M. Pisano, MD

Director, General Surgery I, Department of Emergency, General Surgery 1 Unit, Department of Emergency,
Papa Giovanni XXIII Hospital, Bergamo, Italy Centre for Mini-invasive Surgery, Ospedali Riuniti di
Bergamo, Bergamo, Italy
M. Lotti, MD
General Surgery 1 Unit, Centre for Mini-invasive E. Poiasina, MD
Surgery, Ospedali Riuniti di Bergamo, Bergamo, Italy 1st General Surgery Unit, Department of Emergency,
e-mail: Papa Giovanni XXIII Hospital, Bergamo, Italy

© Springer International Publishing Switzerland 2016 175

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_18
176 L. Ansaloni et al.

Fig. 18.1 Skin incision at the McBurney point

• The surgeon stands to the right of the patient, the Fig. 18.2 Blunt separation of the muscle fibers
assistant on the left, and if available scrub nurse
(second assistant) on right, close to the legs. organs); a small incision is performed with scis-
sors and then enlarged with finger guidance.
Draping: – Retractors (handheld or autostatic) are placed.
• Should allow extension of the incision (right
iliac fossa or midline) as well as insertion of
drain (laterally) 18.2.2 Exploration
Skin protection.
Adhesive skin protector is ideal but not mandatory. • Withdrawal of free fluid for bacterial
Antibiotic prophylaxis. identification.
• As per local protocol • The wound is protected with moist gauze.
Access to the abdominal cavity • The appendix is located, following the taenia
• 2–5 cm skin incision over McBurney’s point, coli toward the cecal base.
perpendicular to the line between the right • Adhesions can usually be freed with blunt
anterior superior iliac spine and the umbilicus dissection.
(junction one-third lateral, two-third from the • The cecum and the appendix are then exteriorized.
umbilicus (Fig. 18.1))
• Some authors prefer a shorter incision, parallel
to Langer’s lines, located two fingerbreadths 18.2.3 Mesoappendix Division
medial to the anterosuperior iliac spine. and Appendectomy
– Muscle splitting
The external oblique fascia is sharply • Division of the mesoappendix near the base of
incised lateral to the rectus sheath accord- the appendix, either between clamps and liga-
ing to the direction of its fibers. tion, or directly ligated with 2-0 absorbable
The internal oblique and the transversus suture
abdominis muscles are bluntly separated, • Placement of two wide jaw clamps parallel to
according to the direction of their fibers each other at the appendicular base
(Fig. 18.2). • Removal of the clamp close to the cecum
• Opening the peritoneum • Double ligation of the base of the appendix
– The peritoneum is grasped with forceps (cau- with 0 absorbable suture (Fig. 18.3)
tion being exercised not to pinch internal • Division of the appendix with scalpel
18 Appendix 177

Fig. 18.3 Ligation of the appendix base

• Treatment of the stump

– Several possibilities:
Some electrocoagulate the mucosa.
Others consider that this is dangerous and
prefer to strip it with a scalpel or use bipo- Fig. 18.4 Retrograde appendectomy
lar cautery.
Still others prefer to invert the stump using • In case of abscess or peritonitis, the utility of
a 3-0 absorbable purse string suture (but drainage is controversial type; open or closed
there is no evidence to show that this pre- may be used.
vents secondary blowout)
– Any pus or blood collection is aspirated.
18.2.6 Abdominal Closure
– Irrigate only when needed, to reduce the
risk of abdominal abscess.
• The peritoneum is grasped with four clamps
– Aspiration of fluid in the pelvis is advisable
and closed with 2-0 absorbable running suture.
to avoid early postoperative development
• The transverse and the internal oblique mus-
of fluid collections/abscesses.
cles are approximated with two 2-0 absorb-
able stitches (figure of eight stitches should be
avoided to limit muscle ischemia).
18.2.4 Search for Meckel’s • The external oblique fascia is grasped with
Diverticulum four clamps and then closed with 0 absorbable
running suture.
• Resection of an uninflamed Meckel’s diver-
• The skin is closed with interrupted sutures.
ticulum should be avoided in case of appendi-
– The incision may be left open in case of
citis complicated with peritoneal abscess or
frank contamination.
peritonitis (see chapter on small intestinal
pathology for more details).
• The decision for resection of an incidental 18.2.7 Variations
Meckel’s diverticulum should be discussed
with the patient before the operation and Appendicitis in Ectopic Appendix
informed consent obtained. • In case of appendicitis in a long retrocecal
appendix or in case of a difficult exterioriza-
tion of the appendix, retrograde appendec-
18.2.5 Drainage tomy should be preferred (steps 7 and 6 are
reversed; mobilization of the appendix is bet-
• Drainage is unnecessary in case of limited ter done close to the appendicular wall
phlegmonous or gangrenous appendicitis. (Fig. 18.4)).
178 L. Ansaloni et al.

• If needed, McBurney’s incision can be scissors, 10-mm curved dissecting forceps,

enlarged. 10-mm laparoscopic palpator, and 5-mm suc-
– However, especially in case of diffuse tion irrigator cannula
peritonitis, pelvic disease, or unusual • For ligation and retrieval: two absorbable
position of the cecum, some prefer to con- Endoloops, extraction bag, and 10-mm extrac-
tinue with a midline incision, while others tion tube
convert to laparoscopy (“reversed • Optional: one more 5-mm trocar, one 5-mm
conversion”). alligator grasper, 5-mm needle holder, laparo-
– The McBurney’s incision can be closed or scopic 45-mm flexible endocutter with
used for drainage. reloads, 10-mm clip applier, and 10-mm suc-
tion irrigator cannula Acute Perforated Appendicitis
• The inflamed appendix can usually be peeled
off from adjacent adhering organs, but care 18.4.2 Positioning, Personnel,
must be taken not to disrupt the serosa. and Port Sites
• In case of localized abscess, the cavity must
be washed abundantly and drained. • The patient is placed supine, secured by straps
• Careful inspection of the abdominal cavity is to prevent slippage during table position
required to search for and remove all contami- changes.
nated material and/or fecalith. – Left arm is tucked along the patient’s side.
– Urinary catheter insertion is optional (may
be omitted if the patient has voided imme-
18.3 Summary of Open diately before anesthesia).
Appendectomy • The surgeon stands on the patient’s left; the
assistant stands initially on the patient’s right
Open appendectomy is performed via McBurney’s and then moves to the left of the surgeon once
incision; the anterograde procedure is preferred all the trocars are in place.
(ligation of the mesoappendix, then division of the • The nurse is on the patient’s left, toward the
appendix at its base), except in long retrocecal feet.
appendicitis or fixed appendix where a retrograde • The monitor is on the patient’s right, facing
approach may be preferred. No guidelines exist on the surgeon.
the treatment of the appendix stump, drainage or
skin closure when contamination is likely. In case
of difficulty at any step, the McBurney’s incision 18.4.3 Port Site Placement
can be enlarged or access to the peritoneal cavity
through a midline incision is also an option. • For access: several setups are possible.
Triangulation with the manipulation angle
focused in the right lower quadrant is ideal.
18.4 Laparoscopic • The open technique or visual-assisted tech-
Appendectomy nique for the first trocar should be preferred,
especially in complicated appendicitis, where
18.4.1 Equipment and Instruments there is always some degree of ileus.
– The first port is usually supraumbilical.
• A 10-mm Hasson trocar (or Veress needle and – Alternatively, a Veress needle is placed
one 11-mm bladeless optical tip trocar), one supraumbilical in Palmer’s point.
10-mm trocar, and one 5-mm trocar – Or an 11-mm optical tip bladeless trocar is
• For dissection: 30-degree angled laparoscope, placed on the left side of the umbilicus.
two 5-mm graspers, 5-mm hook electrocautery, • 12 mmHg pneumoperitoneum is established;
bipolar coagulating forceps, 5-mm curved then, the abdominal cavity is explored.
18 Appendix 179

Fig. 18.5 Position of the personel and port sites position Fig. 18.6 Coagulation and division of the mesoappendix
by bipolar forcep and scissors

• A second 10-mm trocar is placed under vision,

two fingerbreadths medial to the left anterosu- • The appendix should be pursued only after
perior iliac spine, avoiding the epigastric ves- clear identification of the cecum and the ter-
sels; a 5-mm trocar is placed in the suprapubic minal ileus, completely freeing them from
midline (Fig. 18.5). adhesions with adjacent viscera.
• The gas tube is placed in the 10-mm trocar, • During adhesiolysis, periappendicular abscesses
coming straight from the column; the light and are eventually opened and evacuated with the
camera cables are fixed by Velcro straps on the suction irrigator cannula.
left side of the operating field, to prevent
• The laparoscope is placed in the 10-mm trocar 18.4.5 Mesoappendix Exposure
between the two manipulation trocars and and Division
held by the assistant.
• The patient is positioned in Trendelenburg
with table tilt to the left (right side up).
18.4.4 Exploration • The appendix is grasped with 5-mm grasper
introduced through the periumbilical trocar and
• In the presence of peritonitis, complete pulled upward to expose the mesoappendix.
removal of pus before attempting isolation – The mesoappendix is then electrocoagu-
of the appendix should help avoid further lated with the bipolar forceps, introduced
contamination during patient’s position in the suprapubic trocar (Fig. 18.6), and
changes. then divided with scissors, proceeding
• The abdominal cavity should be irrigated from the free edge of the mesoappendix
abundantly with saline and aspirated only if toward the base of the appendix. Accurate
peritonitis is generalized; otherwise, local bipolar electrocoagulation is sufficient
aspiration is usually sufficient (all fluids for control of the appendicular artery:
should be evacuated by suction). caution should be paid not to injure the
• Inflammatory adhesions between the bowel cecum or the terminal ileus during
and the peritoneal surface are best divided coagulation.
with the aid of the 10-mm palpator, also – Alternatively, some surgeons prefer elec-
used to access intermesenteric spaces trocoagulation and dividing the mesoap-
between the bowel loops, avoiding injury of pendix close to the appendicular wall,
the bowel. where only small vessels are encountered.
180 L. Ansaloni et al.

tion should be paid, however, to avoid heat

transmission to the stump sutures and the

Any collection of fluid or blood is then aspi-

rated, and the base of the mesoappendix is checked
for adequate hemostasis. Irrigation with saline is
performed only when gross contamination is evi-
dent, quickly followed by aspiration to avoid fluid
spreading to the abdominal cavity, due to gravity.

Fig. 18.7 Ligation of the appendix base 18.4.7 Drainage (As Above) Wound Closure

• The base of the appendix is squeezed gently • Trocars are removed under vision and pneu-
with an atraumatic grasper to ensure easy liga- moperitoneum is released.
tion of the stump. • Hemostasis on the port sites can be ensured by
bipolar coagulation.
• Some surgeons advise to close only those port
18.4.6 Appendectomy sites greater than 5 mm, and others do not
close any.
• Simple or double ligation is performed at the
base of the appendix using absorbable
Endoloops (Fig. 18.7). 18.4.8 Retrocecal Appendicitis
– Endoloops are introduced in the perium-
bilical trocar, while the appendix is held • Failure to identify the appendix should sug-
with a grasper introduced through the gest a retrocecal position of the appendix.
suprapubic trocar. Conversion is not always necessary (to the
• Ligation should be performed close to the contrary, the parietal insult is minimized by
cecum: leaving a long stump is a risk factor for continuing via laparoscopy).
developing stump appendicitis (as in open). • Adequate cecal mobilization is mandatory to
• After ligation, the appendix is grasped close to ensure correct identification of the appendix
the point of division (using a grasper intro- and treatment of a retrocecal abscess.
duced in the suprapubic trocar), divided with – The parietal peritoneum is divided with
scissors, and then placed in an extraction bag sharp dissection in preference to hook
retrieved from the periumbilical trocar or electrocautery, while the cecum is pulled
extracted through one of the 10–12-mm tro- toward the midline.
cars (without the need of an extraction bag). – Occasionally, mobilization of the terminal
– Some surgeons favor closing the distal ileum is necessary to expose a retroperito-
stump with a stapler (dilated, fragile appen- neal appendix: caution should be exercised
dix, inflammatory involvement of the not to injury the right ureter.
base). Sutures should be used with caution, • An inflamed retroperitoneal appendix, adher-
especially in case of local inflammation. ent to the cecum and ascending colon, is better
– Others prefer to electrocoagulate the isolated via blunt dissection, with the aid of
mucosa of the proximal stump with bipolar the suction irrigation cannula and a 10-mm
forceps (avoid monopolar) with the intent palpator: in this case, another 5-mm trocar,
to prevent mucocele and the development inserted in the epigastrium, and a 5-mm atrau-
of a postoperative pericecal abscess: cau- matic grasper inserted by the assistant to help
18 Appendix 181

Fig. 18.8 Optional 4th port site

Fig. 18.9 Alternative port sites position

hold the cecum toward the midline may be
necessary. Alternatively, a 5-mm trocar is
inserted at the point of McBurney and used by 18.4.10 Retrograde Appendectomy
the surgeon: in this case, the assistant uses the
suprapubic port site to hold the cecum or the • In case of a long retrocecal appendix adhering to
terminal ileum (Fig. 18.8). the posterior wall of the ascending colon, where
the apex of the appendix can reach the liver and
is difficult to identify, the retrograde technique is
18.4.9 Pelvic Abscess safer. Again, it is not usually necessary to con-
vert, and the identification and management of
• In this case, a change of trocar placement may retrocecal appendicitis is perfectly adapted to
be necessary: one supraumbilical 11-mm blade- laparoscopy with adequate expertise.
less trocar (for first access), one 10-mm trocar – The base of the appendix is dissected first
placed where the transverse umbilical line and then divided either with sutures as
crosses the right midclavicular line, and one above, or a linear stapler.
10-mm trocar placed where the intra-iliac line – Dissection then proceeds close to the appen-
crosses the left midclavicular line (Fig. 18.9) dicular wall, where only small vessels are
• Pelvic abscesses are usually covered by the sig- encountered, using bipolar coagulation in
moid colon and small bowel adhering to the pari- preference to hook electrocautery.
etal peritoneum. Access is gained to the abscess
via gentle blunt dissection with the 10-mm pal-
pator to detach the sigmoid colon and the bowel 18.4.11 Normal Appendix
loops without injuring the intestinal wall.
• Complete aspiration of pus and abscess is bet- • Finding an apparently normal appendix should
ter achieved with the aid of a 10-mm suction prompt the surgeon to carefully inspect the
irrigation cannula used in combination with abdominal cavity for other causes of disease:
the 10-mm palpator. clearly one of the advantages of laparoscopy.
• The appendix often is found to adhere to the – Salpingitis, ruptured ovarian follicle, endo-
bowel or the pelvic peritoneum, and its metriosis, Meckel’s diverticulitis, diverticulitis
removal follows the same steps as above. of the sigmoid colon, Crohn’s disease, omen-
• Before ending the operation, the surgeon must tal infarction, cholecystitis, and perforated
inspect the small bowel, to ensure that it is free gastroduodenal ulcer are the most frequent
of adhesions, not twisted, and that the serosa causes of pain mimicking acute appendicitis:
is not torn. accurate diagnosis is possible, and in most
182 L. Ansaloni et al.

cases, adequate treatment can be performed Selected Reading

through laparoscopy.
• The decision to remove a normal appendix should Allemann P, Probst H, Demartines N, Schäfer M.
Prevention of infectious complications after laparo-
be discussed with the patient before operation. scopic appendectomy for complicated acute appendi-
– When the cause of the acute abdomen is citis—the role of routine abdominal drainage.
clear, removal of a normal appendix is Langenbecks Arch Surg. 2011;396(1):63–8.
questionable. When accurate laparoscopic Beldi G, Vorburger SA, Bruegger LE, Kocher T, Inderbitzin
D, Candinas D. Analysis of stapling versus endoloops
exploration of the abdominal cavity reveals in appendiceal stump closure. Br J Surg. 2006;
no cause for acute pain, removal of a nor- 93:1390–3.
mal appearing appendix could be consid- Chu T, Chandhoke RA, Smith PC, Schwaitzberg SD. The
ered, especially in subjects with recurrent impact of surgeon choice on the cost of performing
laparoscopic appendectomy. Surg Endosc.
episodes of pain in the right iliac fossa. 2011;25(4):1187–91.
Fingerhut A. Conversion from open to laparoscopic treat-
ment of peritonitis: “Reversed Conversion” revisited.
18.4.12 Conversion Surg Innov. 2011;18:5–7.
Guidelines for laparoscopic appendectomy. Practice/
clinical guidelines published on 04/2009 by the
• Most frequently needed when a chronically Society of American Gastrointestinal and Endoscopic
inflamed appendix is tenaciously adherent to Surgeons (SAGES).
the cecum or is embedded in a retroperitoneal tion/id/05/.
Hussain A, Mahmood H, Singhal T, Balakrishnan S,
abscess and the surgeon lacks the necessary El-Hasani S. What is positive appendicitis? A new
experience to accomplish the operation answer to an old question. Clinical, macroscopical and
laparoscopically. microscopical findings in 200 consecutive appendec-
• Some surgeons prefer to convert to a large tomies. Singap Med J. 2009;50:1145–9.
Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko
McBurney, or if needed, pararectal incision or CY, Esposito TJ. Comparison of outcomes after lapa-
median laparotomy. roscopic versus open appendectomy for acute appen-
dicitis at 222 ACS NSQIP hospitals. Surgery.
2010;148:625–35; discussion 635–7.
Khanna S, Khurana S, Vij S. No clip, no ligature laparo-
18.4.13 Search for Meckel’s scopic appendectomy. Surg Laparosc Endosc Percutan
Diverticulum (Via Tech. 2004;14:201–3.
Laparoscopy Sahm M, Kube R, Schmidt S, Ritter C, Pross M, Lippert
and Laparotomy) H. Current analysis of endoloops in appendiceal stump
closure. Surg Endosc. 2011;25(1):124–9.
Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic
Resection of an uninflamed Meckel’s diverticu- versus open surgery for suspected appendicitis.
lum does not seem to be associated with increased Cochrane Database Syst Rev. 2010;10:CD001546.
perioperative morbidity, but there is no evidence Schein M. Acute appendicitis. In: Schein, Rogers, editors.
Scheins’s common sense emergency abdominal sur-
of any benefit in routine removal. Resection of an gery. 2nd ed. Berlin: Springer; 2005. p. 245–54.
uninflamed Meckel’s diverticulum should be Shapiro R, Eldar S, Sadot E, Venturero M, Papa MZ,
avoided in case of appendicitis complicated with Zippel DB. The significance of occult carcinoids in the
peritoneal abscess or peritonitis. The decision to era of laparoscopic appendectomies. Surg Endosc.
resect an incidental Meckel’s diverticulum should Skandalakis JE, Skandalakis PN, Scandalakis LJ.
be discussed with the patient before the operation Appendix. Surgical anatomy and technique, A pocket
and informed consent obtained. manual. New York: Springer; 1995. p. 389–99.
Whether via laparoscopy or laparotomy, it is Smink DS, Soybel DI. Acute appendicitis. In: Cameron JL,
editor. Current surgical therapy. 8th ed. Pennsylvania:
important to resect the base of the diverticulum as Lippincott Williams & Wilkins; 2004. p. 241–4.
ectopic gastric or pancreatic tissue may be har-
bored there: simple diverticulectomy by mass
ligation should be avoided.
Emergency Surgery for Hydatid
Cysts of the Liver 19
Chadli Dziri, Abe Fingerhut, and Igor Khatkov

Contents 19.1 General Notions

19.1 General Notions 183
• Hydatid disease remains frequent in many
19.2 Goal of Management 183
regions in the world such as Mediterranean
19.3 Medical Treatment 184 countries, Asia, and Central America.
19.4 Surgical Management 184 • Increasing travel has led to increased inci-
19.4.1 Surgical Approaches 184 dence in non-endemic areas.
19.4.2 Common Surgical Techniques 184
• Emergency surgery is reserved for compli-
19.5 Complications and Danger Points 184 cated hydatid cysts of the liver, representing
19.6 Specific Procedures According to one out of five patients.
Complications 184 • Rupture into the biliary tract with a large
Bibliography 185 (>5 mm) bilio-cystic fistula (21–37 %), tho-
racic involvement (~2 %), rupture into the
peritoneum (<2 %), vessels, and other organs
(~1 %) represent the main complications. All
these complications can be life threatening
and call for immediate management.
C. Dziri, MD, FACS (*)
Professor of General Surgery, Head Department Chapter aims to provide the appropriate man-
B-Charles Nicolle Hospital, University of Tunis,
Tunis, Tunisia agement for each complication of liver hydatid
e-mail: cysts based on evidence-based surgery (level of
A. Fingerhut, Doc hon c, FACS, FRCS(g), FRCS(Ed) evidence and grade of recommendation indicated
Department of Surgical Research, Clinical Division whenever appropriate).
for General Surgery, Medical University of Graz,
Graz, Austria
19.2 Goal of Management
I. Khatkov, MD
Department of Surgical Oncology, Moscow Clinical
Scientific Center, Moscow, Russia To control the infection process, evacuate the
e-mail: contents of the cyst, and prevent recurrence

© Springer International Publishing Switzerland 2016 183

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_19
184 C. Dziri et al.

19.3 Medical Treatment – Blood or bile collections, potential sources

of deep suppuration, and persisting bile leaks
• Appropriate antibiotics are mandatory to stop – Prevention:
progression of infection. Drainage
• Adapted resuscitative measures. Closure of the edges (capsulorrhaphy) of
• Control of metabolic disorders (e.g. diabetes the residual cavity without drainage
mellitus). Capitonnage
• Postoperative antihelminthic drug treatment is Furrowing the margins of the cavity by
mandatory for most authors: albendazole “introflexion”
(10 mg per kg and per day) for 3 months, and Omentoplasty on the residual cavity (1 RCT,
especially after treatment of large biliocystic 1 meta-analysis) (level II evidence, grade A
fistula (level IV; grade C). recommendation)

19.4 Surgical Management 19.6 Specific Procedures

According to Complications
19.4.1 Surgical Approaches
Hydatid cyst ruptured into biliary tract
• Laparotomy is the standard approach: right sub-
costal incision prolonged if necessary to the left. Methods
• Laparoscopy may be considered in selected i. Common bile duct clearance via choledo-
cases. chotomy + intraoperative cholangiography
and choledoscopy.
1. After evacuation of all daughter vesi-
19.4.2 Common Surgical Techniques cles, insertion of T-tube is recommended
(level of evidence III, grade of recom-
• Removal of the cyst is usually described as mendation A).
“pericystectomy.” ii. Complete removal of cystic and pericystic
– “Closed total pericystectomy” removes the tissue with simultaneous treatment of the
cyst without opening it. fistulous tract is not easy to perform in the
– “Open total pericystectomy” sterilizes the context of emergency with acute cholangi-
contents with antiscolicidal agents, evacu- tis and is reserved for cysts that are located
ates the contents of the cyst, then removes peripherally.
the pericystic tissue. iii. Management of large (≥5 mm) biliocystic
• Partial cystectomy, called also unroofing, fistula.
involves sterilization of cyst contents, which 1. Suture
are removed after opening. (a) With absorbable material
• The unroofing procedure is preferable for (b) Indicated when edges of the fis-
endemic areas where the operations are per- tula are soft
formed by general surgeons. (c) Contraindicated when edges are
fibrotic or calcified
2. Controlled fistula
19.5 Complications and Danger (a) External: insertion of a tube into the
Points fistula through the liver parenchyma
(according to Praderi and Perdromo)
• Postoperative deep abdominal complication (b) Internal: remnant cavity/through
(DAC) (prevalence 12–26 %) fistula left opened/common bile
– Reasons: presence of a residual cavity or duct and Oddi’s sphincter associated
biliocystic fistula after unroofing closure of the remnant cavity edges
19 Emergency Surgery for Hydatid Cysts of the Liver 185

(capsulorrhaphy) by absorbable Indications

sutures • Depending on US or CT scan findings
– Thoracotomy is indicated when an
Indications intrathoracic collection is present,
i. Common bile duct exploration (with intra- adhesiolysis and treatment of the
operative cholangiography and choledo- pleural lesions, pulmonary lesions
choscopy) is always possible. (lobectomies, wedge resections, or
ii. Choice in management of large biliocystic decortications), are necessary and is
fistula: suture, controlled external or inter- sufficient when the biliary tract is dis-
nal fistulization depends on site (controlled ease free or already secured.
internal fistulization best for posterosupe- – The abdominal approach is mandatory
rior segments II, VII, and VIII), size of the when common bile duct drainage is
cyst (omentoplasty should be added to the required or to treat a rupture into bron-
other procedures except for controlled chi (level of evidence IV; grade C)
internal fistulization), proximity of vessels
(do not remove the pericyst close to ves- Hydatid cysts ruptured into peritoneal cavity
sels), involvement of upper biliary conflu-
ence (controlled internal fistulization best), Methods:
and pericystic fistula wall (soft: suture; i. Laparotomy to aspirate the intraperitoneal
fibrotic: suture; calcified: resection) (level liquid, to perform peritoneal cleansing
IV; grade C) with hyper saline solution, and to treat the
1. Postoperatively: endoscopic retrograde cysts: pericystectomy or partial pericystec-
cholangiopancreatography (ERCP) tomy (level IV; grade B)
(a) Combined with preoperative endo- ii. Medical treatment should be associated;
scopic sphincterotomy (ES) may albendazole is often preferred with 10–15 mg/
decrease the incidence of the develop- kg/day during 3 months (level IV; grade B).
ment of postoperative external fistula Indications
from 11.1 to 7.6 % (level IV; grade C) i. Ruptured hydatid cyst into the peritoneal
(b) Combined with postoperative ES cavity is an indication for immediate lapa-
may be indicated to manage postop- rotomy (level IV; grade B).
erative external biliary fistulae ii. Abbreviated treatment is indicated when
(level IV; grade C). patient health status is very poor.

Hydatid cyst involving the thorax

Methods Bibliography
i. Thoracic approach
Atli M, Kama NA, Yuksek YN, Doganay M, Gozalan U,
• A posterolateral right thoracotomy in the
Kologlu M, Daglar G. Intrabiliary rupture of a hepatic
bed of the fifth rib provides good access hydatid cyst: associated clinical factors and proper
to the cyst through the diaphragm, when management. Arch Surg. 2001a;136:1249–55.
the surgeon is sure that the common bile Atli M, Kama NA, Yuksek YN, Doganay M, Gozalan U,
Kologlu M, Daglar G. Intrabiliary rupture of a hepatic
duct is free from daughter vesicles pre-
hydatid cyst. Associated clinical factors and proper
operatively by US or CT scan. management. Arch Surg. 2001b;136:1249–55.
ii. Abdominal approach Dziri C, Paquet JC, Hay JM, Fingerhut A, Msika S,
• A right subcostal or bisubcostal approach Zeitoun G, Sastre B, Khalfallah T. Omentoplasty in
the prevention of deep abdominal complications after
offers adequate access to the liver, bili-
surgery for hydatid disease of the liver: a multicenter,
ary tract, and common bile duct, and via prospective, randomized trial. French Associations
the diaphragm, access to the communi- for Surgical Research. J Am Coll Surg. 1999;188:
cation with the thorax with safety. 281–9.
186 C. Dziri et al.

Dziri C, Haouet K, Fingerhut A. Treatment of hydatid El Malki HO, El Mejdoubi Y, Souadka A, Mohsine R,
cyst of the liver: where is the evidence? World J Surg. Ifrine L, Abouqal R, Belkouchi A. Predictive model of
2004;28:731–6. biliocystic communication in liver hydatid cysts using
Dziri C, Haouet K, Fingerhut A, Zaouche A. Management classification and regression tree analysis. BMC Surg.
of cystic echinococcosis complications and 2010;10:16.
dissemination: where is the evidence? World J Surg. Zaouche A, Haouet K, Jouini M, El Hachaichi A,
2009;33:1266–73. Dziri C. Management of liver hydatid cysts with a
El Malki HO, El Mejdoubi Y, Mohsine R, Ifrine L, large biliocystic fistula: multicenter retrospective
Belkouchi A. Intraperitoneal perforation of hepatic study. Tunisian Surgical Association. World J Surg.
hydatid cyst. Gastroenterol Clin Biol. 2006;30:1214–6. 2001;25:28–39.
Ari Leppäniemi

Contents For information about the diagnosis and treat-

20.1 Access and Exposure of the Pancreas 187 ment modalities see:
20.1.1 Maneuver 1: Anterior and Distal 188 Leading symptoms for pancreatitis
20.1.2 Maneuver 2: Inferior and Posterior 188 Common bile duct for biliary pancreatitis
20.1.3 Maneuver 3: Pancreatic Head 188
20.2 Pancreatic Necrosectomy 188
20.3 Splenic Artery Pseudoaneurysm 191
20.4 Summary 191 • Describe the main methods of surgical
Bibliography 191 access to pancreas
• Outline the mobilization techniques of
the different parts of the pancreas
• Describe the current terminology and
definitions associated with necrotizing
• Describe standard open pancreatic
• Describe surgical management of bleed-
ing splenic artery pseudoaneurysm

20.1 Access and Exposure

of the Pancreas

All surgical emergencies of the pancreas require

proper exposure, because limited exposure can
lead to underestimation of the severity and
A. Leppäniemi, MD, PhD, DMCC extent of the disease process and inadequate
Chief of Emergency Surgery,
Meilahti Hospital, University of Helsinki,
surgical treatment. Due to its retroperitoneal
Helsinki, Finland location, access to pancreas requires a series
e-mail: of specific and well-defined steps. Complete

© Springer International Publishing Switzerland 2016 187

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_20
188 A. Leppäniemi

a b

Fig. 20.1 Mobilization of the distal pancreas and spleen

exposure and mobilization of the different parts • With completion of this maneuver, the distal
of the pancreas can be achieved essentially with pancreas and the spleen are fully mobilized
three maneuvers. and can be rotated medially to inspect the pos-
terior surface of the distal pancreas (Fig. 20.1).

20.1.1 Maneuver 1: Anterior

and Distal 20.1.3 Maneuver 3: Pancreatic Head

• Divide the gastrocolic ligament widely to • Divide the lateral peritoneal attachment of the
expose the anterior surface of the body of the second part of the duodenum and mobilize the
pancreas. entire loop of the duodenum together with the
• Divide loose attachments to the posterior wall head of the pancreas (Kocher’s maneuver)
of the stomach. (Fig. 20.2). Mobilization should be wide, to the
• For additional exposure, extend dissection aorta in the retroperitoneum. Remember the
leftwards to completely mobilize the lower most lateral structure in the porta hepatis is the
pole of the spleen away from the colon and common bile duct, which must be identified
drop the splenic flexure of the colon away. and protected with a wide Kocher maneuver.
• Exposure can be considerably improved by
freeing the hepatic flexure of the colon and
20.1.2 Maneuver 2: Inferior extending the dissection to the loose avascular
and Posterior plane between the transverse colon and the
proximal part of the transverse duodenum.
• Mobilize the spleen laterally and superiorly
and extend the dissection in the avascular
plane posterior to the pancreas and anterior to 20.2 Pancreatic Necrosectomy
the left kidney toward the midline including
the splenic artery and vein. During the first 2 weeks into the disease process,
• Beware of the inferior mesenteric vein flowing extrapancreatic infections (bacteremia, pneumo-
into the splenic vein when dissecting the infe- nia) are more common, whereas infected pancre-
rior margin of the pancreas free from the atic necrosis peaks at 3–4 weeks. Fine-needle
retroperitoneum. aspiration is no longer used for diagnosis of
20 Pancreas 189

Fig. 20.2 Kocher’s


infected necrosis and has been replaced with • Clinically suspected or documented infected
signs of clinical deterioration, increase in necrosis with clinical deterioration or ongoing
C-reactive protein (CRP) level, worsening organ organ failure for several weeks
failure, and CT findings (gas bubbles). CT find- • Ongoing gastric outlet, intestinal, or biliary
ings of peripancreatic collections associated with obstruction due to mass effect of WON
necrotizing pancreatitis include acute necrotic • Failure to thrive or progress: patient not get-
collection (ANC) and walled-off necrosis ting better with WON but without infection
(WON). ANC is seen during the first 4 weeks, (after 8 weeks)
and it contains variable amount of fluid and • Disconnected duct syndrome (full transection
necrotic tissue within or around the pancreas. of the pancreatic duct) with persisting symp-
WON is a mature encapsulated collection of pan- tomatic collection with necrosis without signs
creatic or peripancreatic necrosis with a well- of infection (>8 weeks)
defined enhancing inflammatory wall requiring
usually more than 4 weeks to form. Technique for open pancreatic necrosectomy:
The indications for (surgical, radiological, or
endoscopic) intervention in necrotizing pancre- • Bilateral subcostal incision gives the easiest
atitis include: route to open pancreatic necrosectomy
190 A. Leppäniemi

• For additional exposure

– On the left, mobilize the left hemicolon and
create a plane between the descending
colon anteriorly, and the left kidney and
Gerota’s fascia posteriorly to connect to the
lesser sac.
– On the right, mobilize the right hemicolon
and limited Kocher’s maneuver (beware
not to injure the duodenum!).
• Necrosectomy should be as complete as pos-
sible without removing healthy pancreas.
• Irrigate the lesser sac.
• Secure hemostasis by temporary tamponade
Fig. 20.3 Necrotic distal pancreas removed during
necrosectomy with laparotomy pads followed by individual
ligation or electrocoagulation of the bleeders.
• Insert multiple, large bore closed suction sili-
(technique described below), but other alterna- con drains to the necrosectomy areas.
tives including the retroperitoneal approach and • Close the abdomen in layers unless there is a
minimally invasive techniques can also be used. risk of abdominal compartment syndrome.
• Divide the gastrocolic ligament avoiding
injury to the posterior wall of the stomach and Authors’ comments: Recent guidelines mention
the transverse colon, often adherent to the recommendations for laparoscopic management
pancreas (or necrotic tissues) (maneuver 1). of acute biliary pancreatitis.
• Suck out the liquid secretions and pus in the
lesser sac (bacterial specimens). • When pancreatic necrosis requires treatment
• Extend the window to the patient’s left as (clinical signs of sepsis or multiorgan fail-
much as needed to see the hilum of the spleen. ure that do not improve despite optimal
• Scoop out the loose peripancreatic necrosis by therapy):
blunt finger dissection exposing the transverse – Laparoscopic debridement can be done by
tentlike structure of the body and tail of the infracolic or retroperitoneal approach
pancreas (which usually are viable and need while transgastric endoscopic pancreatic
not to be removed). necrosectomy has also been reported.
• Occasionally, when faced with frank extended – Two recent prospective studies (one single
necrosis of the gland, removal of necrotic arm and one randomized suggest that the
parts of the pancreas can result in near-to-total presence of a well-demarcated necrosis
distal pancreatectomy. can be treated using a step-up approach
– Blunt dissection is usually sufficient without whenever possible (LE 1b).
mobilizing or removing the spleen (Fig. 20.3). The first step should be percutaneous
• If possible and identifiable, ligate the major drainage, followed, if necessary, by mini-
pancreatic duct at the stump selectively mal invasive retroperitoneal debridement.
(beware not to ligate the intrapancreatic part Open surgery should be the last step, to be
of the common bile duct in very proximal performed in cases where more conserva-
resections!). tive treatment has failed. This strategy has
• Use a recent CT scan as a map to identify been associated with a significantly lower
other areas of peripancreatic necrosis (usually morbidity (diabetes, incisional hernias)
on the right side behind the head of the pan- and lower new-onset multiple organ fail-
creas and right hemicolon and on the left side ure when compared to open surgery as the
behind the left hemicolon). first step.
20 Pancreas 191

20.3 Splenic Artery – Active bleeding: Identify the splenic artery

Pseudoaneurysm feeding the bleeding pseudoaneurysm and
apply pressure proximally before ligation.
In patients with chronic pancreatitis and pancre- – Blood clot in place proceeds as follows:
atic pseudocysts, expanding pseudocysts can • Select the resection line proximal to the lesion and
cause bleeding from major arteries around the remove the distal pancreas and the spleen together
pseudocyst, most commonly originating either with the remnant walls of the pseudocyst.
from the splenic artery or the gastroduodenal • Ligate the splenic artery and vein proximal to
artery. The longer the pseudocyst is present and the resection line.
with larger size of the pseudocyst, the higher the • Ligate the main pancreatic duct selectively
incidence of such complications. Unless the (figure of eight suture).
patient is in severe hemorrhagic shock, the best • Insert drain.
treatment is early angioembolization, especially • Close the incision as above.
in pseudoaneurysms of the head of the pancreas,
often from branches of the pancreaticoduodenal
arteries. If angioembolization is not available or Pitfalls
fails to stop major bleeding from a splenic • Incomplete exposure and mobilization
artery pseudoaneurysm, surgical intervention is of the pancreas
indicated. • Iatrogenic lesions while mobilizing the
• Bilateral subcostal incision gives the best • Performing pancreatic necrosectomy
exposure to the pancreas. too early or too late
– Can be extended more to the left in patients • Incomplete or too aggressive necrosectomy
with splenic artery pseudoaneurysm • Failure to identify the splenic artery
• Mobilize the entire distal pancreas together lesion feeding the pseudoaneurysm
with the spleen by performing maneuvers 1
and 2 completely.
• As soon as pseudocyst cavity (no proper cap-
sule) is entered (Fig. 20.4), either the lesion is 20.4 Summary
still bleeding or is temporarily stopped by a
blood clot. The key to successful surgical management of
acute pancreatic emergencies is adequate exposure
of the entire gland that can be achieved with three
basic maneuvers. The best time for pancreatic
necrosectomy is after 4 weeks from the onset of the
disease when the necrosis is clearly demarcated
and amorphic, easily removable by blunt dissec-
tion. Surgical management of a splenic artery pseu-
doaneurysm requires complete mobilization of the
distal pancreas and spleen, distal pancreatectomy
with splenectomy and adequate external drainage.

Agresta F, Ansaloni L, Baiocchi L, Bergamini C,
Campanile FC, Carlucci M, Cocorullo G, Corradi A,
Fig. 20.4 Splenic artery pseudoaneurysm Franzato B, Lupo M, Mandala V, Mirabella A, Pernazza
192 A. Leppäniemi

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(SICUT), Società Italiana di Chirurgia nell’Ospedalità Udd M, Leppäniemi A, Bidel S, et al. Treatment of bleed-
Privata (SICOP) and the European Association for ing pseudoaneurysms in patients with chronic pancre-
Endoscopic Surgery (EAES). Surg Endosc. 2012. atitis. World J Surg. 2007;31:504–10.
doi:10.1007/s00464-012-2331-3. Werner J, Hartwig W, Hackert T, Buchler MW. Surgery in
Banks PA, Bollen TL, Dervenis C, et al. Classification of the treatment of acute pancreatitis – open pancreatic
acute pancreatitis-2012: revision of the Atlanta classi- necrosectomy. Scand J Surg. 2005;94:130–4.
fication and definition by international consensus. Gut. Working Group IAP/APA Acute Pancreatitis Guidelines.
2013;62:102–11. IAP/APA evidence-based guidelines for the manage-
Bradley E, III. Management of infected pancreatic necro- ment of acute pancreatitis. Pancreatology. 2013;13:
sis by open drainage. Ann Surg. 1987;206:542–8. e1–15.
Diaphragmatic Problems
for the Emergency Surgeon 21
Peter J. Fagenholz, George Kasotakis,
and George C. Velmahos

21.1 Anatomy 193 • Understand basic diaphragmatic anatomy
21.2 Hiatal Hernia 194 • Understand when to operate urgently for
21.2.1 Classification 194 paraesophageal hernia
21.2.2 Symptoms and Diagnosis 194
21.2.3 The Decision to Operate and Surgical
• Know the four fundamental steps of
Technique 196 paraesophageal hernia repair
21.2.4 Postoperative Care and Complications 197
21.3 Late Presentation of Traumatic
Diaphragmatic Hernia 197
21.3.1 Mechanism of Injury 197
21.1 Anatomy
21.3.2 Diagnosis 198
21.3.3 Surgical Technique 198 • The diaphragm is a thin, sheet-like muscle
21.4 Summary 200 which divides the thorax superiorly from the
abdomen inferiorly.
Selected Reading 200 • The muscle fibers originate on the chest wall
and insert into the central tendon.
• Diaphragmatic excursion during respiration is
P.J. Fagenholz, MD
Assistant Professor of Surgery, Harvard Medical
School, Division of Trauma, Emergency Surgery, – Anteriorly can rise as high as the fourth
and Critical Care, Massachusetts General Hospital, intercostal space
Boston, MA, USA – Posteriorly extends as low as the L3 verte-
bral body
G. Kasotakis, MD, MPH, FACS • The phrenic nerves, which originate from the third
Assistant Professor of Surgery, Division of Trauma,
to fifth cervical nerve roots, supply motor innerva-
Boston University School of Medicine,
Acute Care Surgery and Surgical Critical Care, tion to the diaphragm, and the anatomy of their
Boston, MA, USA major branches must be appreciated to avoid
e-mail:; injury.
G.C. Velmahos, MD, PhD, MSEd (*) • The esophageal hiatus is an elliptical opening,
Professor of Surgery, Harvard Medical School Chief, just to the left of midline at the level of the
Division of Trauma, Emergency Surgery, and
T10 vertebral body.
Critical Care, Massachusetts General Hospital,
Boston, MA, USA • The anterior and lateral borders are formed by
e-mail: GVELMAHOS@PARTNERS.ORG the muscular arms of the diaphragmatic crura.

© Springer International Publishing Switzerland 2016 193

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_21
194 P.J. Fagenholz et al.

a b

Fig. 21.1 Key anatomy of the diaphragm. (a) Diaphragm Lippincott Williams and Wilkins; 2007). (b) Single-
viewed from the abdomen. Heavy dotted lines show the headed arrows show superior and inferior extent of the
paths of phrenic nerves. Dark lines show potential inci- diaphragm. Two-headed arrow delineated the zone of dia-
sions which can be made without damaging the phrenic phragmatic traverse (Fotosearch. http://www.fotosearch.
nerves (Thal ER, Friese RS. Traumatic rupture of the dia- com/LIF135/ga141002/)
phragm. In: Fisher JE, editor. Mastery of surgery. 5th ed.

• The median arcuate ligament contributes to – Paraesophageal hernias are uncommon and
the posterior border (Fig. 21.1). include a peritoneal layer forming a true
hernia sac.
– Contributing factors include age and gender
21.2 Hiatal Hernia (more common in women) and obesity.
– The EGJ and cardia remain in the abdo-
21.2.1 Classification men, while the fundus and greater curva-
ture protrude into the mediastinum.
Hiatal hernia occurs when the esophagogastric junc- • Type III or mixed hiatal hernia
tion (EGJ) migrates intrathoracically through the – Has components of both types I and II in
esophageal hiatus. There are four general types of that the EGJ is in the chest (as in sliding
hiatal hernia (Fig. 21.2a). Type I seldom requires hernias), and the fundus and greater curve
emergency management (bleeding), while types II to are also herniated.
IV carry the potential for incarceration and strangula- • Type IV hernias are defined by the presence
tion requiring emergency surgical management. of organs other than the stomach in the chest,
which herniate through the esophageal
• Type 1 or sliding hernia hiatus
• Most common type – Most commonly colon, omentum, or spleen.
– The EGJ moves upward into the posterior – Herniation occurs anterior to the esophagus.
– It is associated with gastroesophageal
reflux disease. 21.2.2 Symptoms and Diagnosis
– Longitudinal axis of stomach is aligned
with esophagus. The most feared complications of paraesopha-
• Type II or paraesophageal hernia geal hernia are incarceration and strangulation.
21 Diaphragmatic Problems for the Emergency Surgeon 195

Fig. 21.2 Hiatal hernias and the mechanics of strangula- M. Paraesophageal hiatal hernia. In: Shields T, Locicero
tion. (a) Type I sliding hiatal hernia. Type II paraesopha- JI, Reed C, Feins RH, editors. General thoracic surgery.
geal hiatal hernia. (b) Mechanics of paraesophageal 7th ed. Lippincott Williams and Wilkins; 2009)
hernia strangulation (Naunheim KS, Edwards

Twisting of the stomach within the hernia sac • Symptoms

can result in closed-loop physiology (Fig. 21.2b) – Slow progression of symptoms is usual.
which ultimately leads to necrosis, perforation, Dysphagia, nausea, vomiting, early satiety,
and death if untreated. regurgitation, and postprandial chest pain
196 P.J. Fagenholz et al.

are signs of an intrathoracic herniated 21.2.3 The Decision to Operate

stomach. and Surgical Technique
Anemia can result from chronic ulceration
of the gastric mucosa, though hematemesis • While watchful waiting is acceptable for
and melena are rare. asymptomatic or minimally symptomatic
Large hernias may cause pulmonary patients, especially older patients with signifi-
symptoms such as postprandial breath- cant comorbidities, the emergency surgeon
lessness through compression of the should intervene promptly and effectively if
lung. complications occur
It is important for the emergency surgeon • Several approaches are possible, open trans-
to recognize whether a significant change abdominal or thoracic, laparoscopic, or
in clinical symptoms or systemic signs of thoracoscopic.
sepsis have occurred mandating emergency • While most general surgeons will be more
intervention. comfortable with a transabdominal approach,
– Patients with incarceration usually present only very experienced laparoscopic surgeons
in extreme distress. should undertake laparoscopic repair of an
Chief complaint of chest or epigastric incarcerated and possibly strangulated parae-
pain. sophageal hernia
Nausea with retching and an inability to • Operative details
vomit are typical.
Often a long history of chronic hernia The basic steps are the same for all approaches:
symptoms can be elicited. (1) reduction of hernia contents, (2) mobilization
Borchardt’s triad of substernal chest pain, and resection of the hernia sac, (3) crural closure,
retching with inability to vomit, and inabil- and (4) eventually intra-abdominal fixation ±
ity to pass a nasogastric tube is the classic antireflux procedure.
clinical presentation.
If strangulation and necrosis of the 1. Reduction of the hernia sac’s contents
intrathoracic stomach has already pro- • Exposure of the hiatus is aided by dividing
gressed, patients will present with sys- the left triangular ligament and mobilizing
temic signs of sepsis and eventually segments 2 and 3 of the liver to the right.
septic shock. • While usually straightforward in the elec-
• Diagnosis tive situation, hernia reduction can be dif-
– Chest radiography should be the initial ficult in patients with incarceration causing
screening imaging modality and frequently gastric distension and edema.
shows a retrocardiac air bubble • Excessive force should be avoided as par-
– A barium swallow is diagnostic and an tial- or full-thickness tears in the already
usual part of the elective evaluation of sus- compromised stomach can lead to postop-
pected paraesophageal hernia. erative leak.
– Esophagogastroduodenoscopy and 24-h • Attempts should be made to guide a
pH monitoring are other components of nasogastric tube into the dilated stomach
elective evaluation that are avoided under to achieve decompression and ease
emergency circumstances. reduction.
– In the emergency setting, computed tomog- – Some authors advocate advancing a soft
raphy (CT) is often more readily available, rubber catheter around the viscera into
may confirm the diagnosis, and is useful in the hernia sac and insufflating air to
the evaluation other potential causes of relieve the vacuum that may be gener-
chest pain. ated when reduction is attempted.
21 Diaphragmatic Problems for the Emergency Surgeon 197

• If after these maneuvers the contents of the 4. Intra-abdominal fixation of the stomach
hernia cannot be easily reduced, a small The options include (1) fundoplication, (2)
anterior incision can be made in the hiatus tube gastrostomy, (3) simple gastropexy, or
to allow reduction. (4) no fixation.
2. Mobilization and resection of the hernia sac • In emergency patients who are stable, most
• Has never been proven to be necessary but surgeons prefer a (Nissen) fundoplication
is recommended by most experts because: performed around a 56 Fr bougie.
1. Removes the large potential space in the – Advantage: prevents gastroesophageal
mediastinum reflux, often a result of EGJ mobilization
2. Improves visualization of the GE junction, • In unstable patients, or frail elderly patients,
3. May improve crural closure healing by tube gastrostomy should be preferred.
removing the interposed peritoneal layer
• Care should be taken to avoid:
– Stripping the endoabdominal or endo- 21.2.4 Postoperative Care
thoracic fascia (this will leave bare mus- and Complications
cle fibers which may not hold sutures
well during crural closure) • A nasogastric tube is left in place (low wall
– Injury to the vagus nerves suction).
Must be repeatedly identified • Most authors perform a gastrograffin study through
3. Closure of the hiatal defect the tube of D1, completed by a thin barium swal-
• Usually performed after adequate mobiliza- low if leak and normal gastric emptying.
tion of esophagus, ideally 8–10 cm above the • Diet can be advanced from liquids to soft sol-
cardia, to allow the esophagogastric junction ids to regular over several weeks.
to reside easily in the abdomen without ten- • If gastric infarction, perforation, and subse-
sion and allow posterior crural repair quent mediastinitis or empyema occur, the
• Best to use three to six large, interrupted, mortality rate approaches 50 %. If interven-
number 0 nonabsorbable sutures on the tion precedes this, the mortality is <3 %.
crura posterior to the esophagus • Esophageal leak occurs in 1–3 % of cases.
– Many surgeons use pledgets to reinforce • While radiographic hernia recurrence is not
these sutures. uncommon if routine contrast studies are
• Use of synthetic or biological mesh to rein- performed, recurrence requiring reoperation is
force crural closure is controversial. relatively rare (2–3 %).
– Some retrospective studies have sug-
gested reduced recurrence rates with
synthetic mesh. 21.3 Late Presentation
– Polypropylene mesh has been associ- of Traumatic Diaphragmatic
ated with dysphagia as well as esopha- Hernia
geal erosion and stricture.
– Use of a biological prosthesis made of 21.3.1 Mechanism of Injury
porcine intestinal submucosa resulted in
decreased radiographically demonstrated Diaphragmatic trauma may result from blunt or
hernia recurrence in short-term follow- penetrating injury. Left-sided injury is more com-
up, but the durability and clinical signifi- mon, likely because it lacks the buffering provided
cance of this result are still unknown. to the right hemidiaphragm by the liver. Visceral
– Configurations for mesh or biological herniation may not occur immediately or may be
prosthesis application are shown in subtle, so the index of suspicion must be high to
Fig. 21.3. make the diagnosis during the acute phase.
198 P.J. Fagenholz et al.

Fig. 21.3 Crural closure. (a) Primary closure, (b) J. Paraesophageal herniation. In: Fisher JE, editor.
Keyhole patch, (c) Posterior crural patch, (d) Lateral Mastery of surgery. 5th ed. Lippincott Williams and
relaxing incision covered with patch (Critchlow Wilkins; 2007)

21.3.2 Diagnosis • Because long-standing herniation may result in

adhesions from the hernia contents to the tho-
rax, a transthoracic approach may offer an eas-
• While most posttraumatic diaphragmatic her- ier means of repair for long-standing hernias.
nias are discovered in the acute setting, some
patients present, sometimes many years later,
with complications. 21.3.3 Surgical Technique
• Missed injuries tend to enlarge with time, as
the diaphragm muscle fibers retract and nega- • Approaches: abdominal (open or laparo-
tive intrathoracic pressure pulls abdominal scopic) thoracic (open or thoracoscopic),
viscera into the defect. depending on the experience of the surgeon
• Gastrointestinal incarceration and strangula- and local resources
tion can occur and carry a high morbidity and • Reduction of the hernia contents
mortality. – Extreme caution is warranted
• Principles of repair are the same as for acute Not to aggravate pending rupture
injuries, though these defects are usually too To avoid spillage of hollow viscus contents
large to be closed primarily and typically into abdominal or thoracic cavity during
require patch closure. this maneuver
21 Diaphragmatic Problems for the Emergency Surgeon 199

Fig. 21.4 Repair of

traumatic diaphragmatic
injury. (a) Running or
interrupted and single- or
two-layer repairs can be
effective. (b) If primary repair
cannot be accomplished, a
prosthetic patch is necessary
(Davis JW, Eghbalieh
B. Injury to the diaphragm.
In: Feliciano D, Mattox K,
Moore E, editors. Trauma. 6th
ed. McGraw Hill; 2008)

– The diaphragmatic injury should be closed may be a safer alternative in the emergency
primarily if it can be accomplished without setting with septic potential
tension, attention paid to the location of the – If any enteric spillage has occurred, the
phrenic nerves (Fig. 21.1). hemithorax or abdomen should be irrigated
A variety of sutures (absorbable or nonab- and drained.
sorbable) and techniques (running or inter-
rupted, simple or horizontal mattress, single
layer or two layer) are acceptable (Fig. 21.4a). Pitfalls
Synthetic mesh repair is often necessary • Mistaking chronic paraesophageal her-
because of the magnitude of the defect nia symptoms for an emergency.
(Fig. 21.4b), but biological mesh repair
200 P.J. Fagenholz et al.

Davis Jr SS. Current controversy in paraesophageal hernia

• Inadequate mediastinal dissection dur- repair. Surg Clin N Am. 2008;88:959–78.
Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt
ing paraesophageal hernia repair – sac M, Sheppard B, Jobe B, Polissar N, Mitsumori L,
not resected, esophagus not mobilized. Nelson J, Swanstrom L. Biologic prosthesis reduces
• Short esophagus not addressed during recurrence after laparoscopic paraesophageal hernia
paraesophageal hernia repair – if ade- repair: a multicenter, prospective, randomized trial.
Ann Surg. 2006;244(4):481–90.
quately dissected and EG junction still on Pierre AF, Luketich JD, Fernando HC, Christie NA,
tension, perform lengthening procedure. Buenaventura PO, Litle VR, Schauer PR. Results of
• Vagal nerve injury during paraesopha- laparoscopic repair of giant paraesophageal hernias:
geal hernia repair. 200 consecutive patients. Ann Thorac Surg.
2002;74(6):1909–15; discussion 1915–6.
Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal
hernias: operation or observation? Ann Surg.
2002;236(4):492–500; discussion 500–1.
Essential Points
• Four-step repair for hiatal hernia: (1) reduce
hernia, (2) resect sac, (3) close crura, (4) intra- Diaphragm Injury
abdominal fixation.
• Cannot rule out diaphragmatic injury radio- Chen JC, Wilson SE. Diaphragmatic injuries: recognition
logically – perform laparoscopy or thoracos- and management in sixty-two patients. Am Surg.
copy in patients at risk in the acute setting.
Chughtai T, Ali S, Sharkey P, Lins M, Rizoli S. Update on
managing diaphragmatic rupture in blunt trauma: a
review of 208 consecutive cases. Can J Surg.
21.4 Summary 2009;52(3):177–81.
Friese RS, Coln CE, Gentilello LM. Laparoscopy is suf-
ficient to exclude occult diaphragm injury after pene-
The emergency surgeon will occasionally need trating abdominal trauma. J Trauma. 2005;58(4):
to evaluate and treat patients with diaphragmatic 789–92.
pathology. The skills required are well within Granal M, Popowich R, Shapiro M, West M. Posttraumatic
hernias: historical overview and review of the litera-
the grasp of the general surgeon. Paraesophageal
ture. Am Surg. 2007;73:845–50.
hernia can be easily diagnosed with routine Hanna WC, Ferri LE. Acute traumatic diaphragmatic
radiologic tests. If the patient’s symptoms and injury. Thorac Surg Clin. 2009;19(4):485–9.
physiology suggest strangulation, there should Kaw LL, Potenza BM, Coimbra R, Hoyt DB. Traumatic
diaphragmatic hernia. J Am Coll Surg. 2004;198:
be no delay in emergency operation, carried out
according to the principles described above: Larici AR, Gotway MB, Litt HI, Reddy GP, Webb WR,
complete reduction of the hernia with resection Gotway CA, Dawn SK, Marder SR, Storto ML. Helical
of the sac, secure crural closure, and intra- CT with sagittal and coronal reconstructions: accuracy
for detection of diaphragmatic injury. AJR Am J
abdominal fixation of the esophagogastric junc-
Roentgenol. 2002;179(2):451–7.
tion. Complicated diaphragmatic injuries are Leppaniemi A, Haapiainen R. Occult diaphragmatic inju-
usually challenging to diagnose and to repair: ries caused by stab wounds. J Trauma. 2003;55:
acute diagnosis and repair are easier. 646–50.
Murray JA, Demetriades D, Cornwell EE, Asensio JA,
Velmahos G, Belzberg H, Berne TV. Penetrating left
thoracoabdominal trauma: the incidence and clinical
Selected Reading presentation of diaphragm injuries. J Trauma. 1997;
Murray JA, Demetriades D, Asensio JA, Cornwell EE,
Paraesophageal Hernia
Velmahos GC, Belzberg H, Berne TV. Occult injuries
to the diaphragm: prospective evaluation of laparos-
Bawahab M, Mitchell P, Church N, Debru E. Management
copy in penetrating injuries to the left lower chest.
of acute paraesophageal hernia. Surg Endosc.
2009;23(2):255–9. Epub 2008 Oct 15. J Am Coll Surg. 1998;187(6):626–30.
Gynecologic Considerations
for the Acute Care Surgeon 22
George C. Velmahos

22.1 Ectopic Pregnancy 201
• Familiarize with the clinical presentation
22.2 Ovarian Torsion 203 of gynecologic emergencies that might
22.3 Infections Requiring Surgical require general surgical intervention.
Intervention 203 • Identify the indications for surgical
22.3.1 Pelvic Inflammatory Disease (PID) 203
intervention in commonly encountered
22.3.2 Bartholin’s Abscess 205
gynecologic infections.
22.4 Emergency General Surgical • Familiarize with the pregnancy-induced
Procedures in the Obstetric Patient 205
22.4.1 Appendicitis in Pregnancy 205 physiologic changes and how these
22.4.2 Pregnancy and Biliary Disease 208 affect management of the female pre-
22.5 Summary 208
senting a general surgical emergency.

Bibliography 209

22.1 Ectopic Pregnancy

• Definition: implantation of a viable embryo in

a location other than within the uterine
• May present as a surgical emergency if the
implantation site ruptures and hemorrhagic
shock ensues and source of significant mor-
G.C. Velmahos, MD, PhD, MSEd bidity in females of reproductive age.
Professor of Surgery, Harvard Medical School Chief, • Over 95 % of ectopic pregnancies occur in the
Division of Trauma, Emergency Surgery, and Critical
fallopian tubes, less frequently in the cervix,
Care, Massachusetts General Hospital,
Boston, MA, USA ovaries, omentum, pelvis, or elsewhere in the
e-mail: GVELMAHOS@PARTNERS.ORG lower abdomen.

© Springer International Publishing Switzerland 2016 201

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_22
202 G.C. Velmahos

Fig. 22.1 Common sites of ectopic pregnancy Fig. 22.2 Salpingotomy with retrieval of ectopic pregnancy

• Incidence: approximately 19 per 10,000 • In a normal pregnancy, these levels typically

pregnancies double every 48 h, as opposed to ectopic preg-
– More common in women with history of nancies, where the rise is typically subtler.
ectopic pregnancy or pelvic inflammatory – If not, an absolute hCG level may not dif-
disease (PID). ferentiate between a uterine versus an ecto-
– Other risk factors include history of tubal pic pregnancy. Rather, a trend should be
surgery, smoking, presence of an intrauter- followed over time.
ine device, and pregnancy arising from
assisted reproductive techniques (Fig. 22.1). Management
• The gold standard is exploration, with most
Symptoms and Signs experienced surgeons favoring the laparoscopic
• The triad of amenorrhea, vaginal bleeding, approach, unless the patient is in extremis.
and lower abdominal pain in sexually active – If the patient is in shock or if the abdomen
women should raise the suspicion for an ecto- is distended with blood, emergent laparot-
pic pregnancy. omy is preferred.
• Clinical exam should include a bimanual – The goal of exploration is to remove the
pelvic examination that may reveal unilat- ectopic gestation while preserving repro-
eral lower pelvic tenderness and an adnexal ductive function.
mass (depending on how advanced the If the fallopian tube appears mildly
pregnancy is). affected, salpingotomy (Fig. 22.2) – in
• Initial screening should include a rapid urine which the gestational sac is removed
pregnancy test, but a quantitative serum through an incision in its anti-ligamental
human chorionic gonadotropin (hCG) is aspect – might be possible
needed for confirmation. If the tube is more extensively damaged, com-
• Pelvic or transvaginal ultrasound is typically plete salpingectomy may be necessary.
warranted and may reveal a gestational sac • Carefully selected hemodynamically stable
within the uterus or in the adnexa (occasion- and reliable patients with pregnancies <3 cm,
ally even an embryo). absence of embryonic cardiac activity, and
• If an intra- or extrauterine pregnancy is not serum hCG levels of <10,000 mIU/ml may
seen with a highly suspicious clinical pre- also be considered for medical management.
sentation and an hCG level of 1500 mIU/ml – Several regimens based on the cytotoxicity
or less, the hCG should be repeated in of methotrexate on the developing embryo
24–48 h. have been proposed.
22 Gynecologic Considerations for the Acute Care Surgeon 203

– Consultation with an obstetrician gynecol- – Ultrasonography

ogist for follow-up is advisable. Typically demonstrates a mass in the
• Expectant management of a documented ecto- affected region
pic pregnancy may also be an option in physi- • However, arterial flow may or may not
ologically stable patients with minimal pain be noted even in the presence of torsion.
and with hCG levels <1000 mIU/ml and – CT: mass in the affected quadrant with
declining. benign characteristics, with the uterus typi-
– Patients must be counseled regarding the risks cally deviating towards the affected adnexa.
of rupture and hemorrhage, and emergency
management must be readily available. Management
– Serial serum hCG levels should be trended • Emergency surgical intervention is warranted
for appropriate decreases postoperatively or in all females with confirmed or suspected
with medical management or observation. ovarian torsion.
– Should at any point the pregnant female – Unless infarction has led to disseminated
deteriorate clinically or become hemody- peritonitis and hemodynamic instability, this
namically unstable, a trip to the operating can be undertaken safely with laparoscopy.
room is warranted. • Principles of management:
– Untwist the torsed adnexum
– Assess viability
22.2 Ovarian Torsion If viability is satisfactory, some advocate
securing the ovary onto the psoas (to mini-
• Definition: torsion of the fallopian tube and mize recurrence).
ovary around the infundibulopelvic ligament If there is no evidence of reperfusion or if
compromising vascular supply to the torsed infarction has occurred, oophorectomy.
organ represents a surgical emergency that, if Similarly, a gangrenous adnexum must be
left untreated, may lead to ovarian infarction completely removed.
and diffuse peritonitis with significant – Ideally, removal of the cause of the torsion
morbidity. (cyst resection – if present) should be done
• Causes: abnormal enlargement of the adnexa at the time of the initial procedure.
by neoplasms or more frequently by cysts. – However, cystectomy or partial oophorec-
• More commonly encountered in females in tomy may be very challenging in an
their early reproductive years but may also inflamed and fragile ovary.
occur after menopause. In such cases, it may be best to reevaluate
the patient in 6–8 weeks, and if the ovarian
Symptoms and Signs mass is persistent, schedule elective laparo-
• Usual presentation: scopic cystectomy.
– Typically, severe unilateral lower quadrant
pain of acute onset, frequently associated
with nausea and vomiting
Initially 22.3 Infections Requiring Surgical
After episodes of milder localized pain, Intervention
corresponding to partial twisting and spon-
taneous detorsion 22.3.1 Pelvic Inflammatory
– Clinical exam: unilateral lower quadrant Disease (PID)
tenderness and rigidity (may be mistaken
for acute appendicitis when it involves the • Defined as any infectious process of the upper
right adnexa) female genital tract caused by upward migra-
– Laboratory markers tion of pathogenic microorganisms, most com-
Elevated CRP monly Neisseria gonorrhea and Chlamydia
204 G.C. Velmahos

trachomatis or less commonly Mycoplasma, Management

Ureaplasma, or anaerobes from the lower uro- • Medical: the Centers for Disease Control and
genital tract. Prevention recommend one of the following
• Is not a single disease entity, but rather repre- regimens:
sents a spectrum of infectious processes – Outpatient treatment options
involving the uterus, fallopian tubes, and ova- Ceftriaxone plus doxycycline (in the
ries, resulting in endometritis, salpingitis, and absence of pregnancy) with or without
oophoritis; it may also involve adjacent pelvic metronidazole, usually for 14 days
organs resulting in peritonitis, tubo-ovarian Cefoxitin with probenecid plus doxycy-
abscesses (TOA), and less frequently perihep- cline with or without metronidazole, usu-
atitis (Fitz-Hugh-Curtis syndrome). ally for 14 days
– Prompt diagnosis and treatment is of para- Newer-generation fluoroquinolone with or
mount importance in order to preserve fer- without metronidazole for 14 days
tility and avoid complications associated – Inpatient treatment options
with PID, such as infertility, ectopic preg- Cefotetan every 12 h or cefoxitin every 6 h,
nancy, and chronic pelvic pain. plus doxycycline every 12 h or clindamycin
– Patients are usually young, have a long every 8 h plus gentamicin every 8 h or ampi-
sexual history typically with multiple sex cillin/sulbactam every 6 h plus doxycycline
partners, and lack of use of barrier every 12 h.
contraceptives. • After at least 24 h of intravenous antibi-
• Approximately 780,000 new cases of PID are otics, oral antibiotics (doxycycline or
diagnosed annually in the United States, but clindamycin) continued at home after
more likely many go unrecognized and untreated. discharge from the hospital. Total treat-
ment with medicine usually lasts for
Symptoms and Signs 14 days.
• Diagnosis can be challenging due to a wide • Surgery
range of presentations. – May be required for TOA (30 % of all
• Common symptoms include fever, nausea and patients hospitalized for PID)
vomiting, lower abdominal pain, and purulent Suspected in the presence of lateralized
vaginal discharge. lower abdominal pain that may mimic
• Differential diagnosis includes appendicitis, acute appendicitis and is typically identi-
inflammatory bowel disease, urinary tract infec- fied in women with recurrent episodes of
tions, ectopic pregnancy, and ovarian torsion. inadequately treated PID and chronically
• Presence of cervical motion tenderness and persistent symptomatology.
uterine or adnexal tenderness should raise sus- Bimanual clinical examination: tender
picion, while laparoscopy with directed biop- adnexal mass may be palpated.
sies remains the golden standard for definitive Pelvic or transvaginal ultrasound is typi-
diagnosis. cally confirmatory, as is computed
• Positive laboratory findings include presence tomography.
of white blood cells on cervical wet prep, ele- If no response to trial of oral or intravenous
vated sedimentation rate and C-reactive antibiotics (third-generation cephalospo-
protein, or positive serological testing for gon- rins plus doxycycline with or without met-
orrhea and/or chlamydia. ronidazole for 14 days) within 48–72 h,
• Transvaginal ultrasonography and computed percutaneous or surgical drainage of the
tomography typically reveal thickened, fluid- abscess is mandated.
filled fallopian tubes with or without free pel- – May be necessary for ruptured abscesses
vic fluid and/or organized infected fluid High mortality rate if not recognized and
collections. managed promptly.
22 Gynecologic Considerations for the Acute Care Surgeon 205

In addition to management of sepsis, total

abdominal hysterectomy with bilateral sal-
pingo-oophorectomy is the procedure of
• However, a more conservative approach
can be attempted in young patients
desiring future fertility.
The abdomen should be explored for meta-
static abscesses and any suspicious areas
must be irrigated liberally and drained.
Laparoscopic approach may be attempted
by experienced minimally invasive sur-
geons in the hemodynamically stable

22.3.2 Bartholin’s Abscess

• Bartholin’s glands (great vestibular glands)

Fig. 22.3 Bartholin’s cyst
are located at 4 and 8 o’clock at the vaginal
– Rarely palpable in normal patients Debridement should always be accompa-
– Contains ducts lined with transitional epi- nied by appropriate antibiotic therapy.
thelium that lead to Bartholin’s cyst when Recurrent cysts or abscesses can be marsu-
obstructed from inflammation or abscess pialized or excised in their entirety
when cyst becomes infected (Fig. 22.3).
– Bartholin’s cyst
Typically affects women in their third decade
(2 % of women develop a Bartholin’s cyst or 22.4 Emergency General Surgical
abscess during their lifetime) Procedures in the Obstetric
May range in size from 1 to 3 cm Patient
Is detected on examination or recognized
by the patient The acute care surgeon is not infrequently called on
– Bartholin’s abscess to assess and treat general surgical problems in the
Typically results in discomfort and pregnant patient. Insightful knowledge of the nor-
dyspareunia. mal physiologic changes occurring during preg-
Most commonly polymicrobial, but sexu- nancy as well as the variations in presentation of
ally transmitted N. gonorrhea and C. tra- surgical disease is imperative. Similarly, in order to
chomatis are occasionally implicated. ensure safety and well-being of both the mother
Usually presents as acutely inflamed, tender and the fetus, the emergency surgeon should be
masses on the posterior vulvar vestibule, well versed in the safety and utility of diagnostic
with expressed or spontaneous purulent tests and imaging modalities (Table 22.1).
– Treatment:
Incision, drainage with a small balloon- 22.4.1 Appendicitis in Pregnancy
tip catheter, for a few weeks to allow for
formation and epithelialization of a new • Most common non-obstetric indication for
duct. operation during pregnancy.
206 G.C. Velmahos

Table 22.1 Physiologic changes due to pregnancy

Physiologic changes due to pregnancy
Cardiovascular changes
Increased cardiac output
Increased blood volume
Decreased systemic vascular resistance
Decreased venous return from lower extremities
Respiratory changes
Increased minute ventilation
Decreased functional residual capacity
Gastrointestinal changes
Decreased gastric motility
Delayed gastric emptying
Coagulation changes
Increased clotting factor levels (II, V, VII, VIII, IX,
Fig. 22.4 Typical ultrasonographic characteristics of
acute appendicitis: tubular structure with a diameter
Increased fibrinogen levels >7 mm and wall thickness >3 mm
Increased risk for venous thromboembolism
Renal changes
• Low-grade fevers and mildly elevated white
Increased renal plasma flow and glomerular
filtration rate cell count may also be present, but the physi-
Ureteral dilation ologic leukocytosis of pregnancy may mask
Increased bladder capacity early in pregnancy this finding.
• Risk of ruptured appendicitis increased
(because of delayed diagnosis related to atypi-
• Average incidence: 1 in 1500 deliveries, quite cal presentation of acute appendicitis as the
similar to that in the nongravid females, but pregnancy progresses).
the pregnancy-induced anatomic and physio- – 50% increased risk in the second trimester
logic changes can make the diagnosis and as high as 70 % in the third
difficult. – With subsequent preterm labor and poten-
tial of fetal loss
Symptoms and Signs
• Location of pain depends on uterus volume. Diagnosis
– Typical pain in the right lower quadrant is • Ultrasonography is the study of choice: visu-
often replaced by periumbilical pain, later alization of a tubular structure with a diameter
localized in the right lower quadrant, fol- >7 mm and wall thickness >3 mm is highly
lowed by nausea and vomiting during the suggestive (Fig. 22.4).
first trimester. • Increasing body of evidence supporting the
– Due to upward migration of the cecum use of CT:
later in pregnancy, the pain may be most – Performed 10–20 min after administration
prominent in the right upper quadrant, of rectal contrast.
mimicking biliary disease. – Appendiceal CT exposes the gravid abdo-
– Similarly, involuntary guarding of the men to only one third the radiation of a
abdominal wall musculature and tender- regular abdominal CT.
ness on rectal examination from a low- However, as the risk for teratogenesis, fetal
lying appendix may be less pronounced if loss, and subsequent carcinogenesis is not
appendicitis occurs later in pregnancy, due zero, its use is advocated only in high-risk
to displacement by the gravid uterus of the pregnancies with equivocal clinical presen-
abdominal wall anteriorly and the appendix tation, in which a negative laparoscopy
superiorly. might be detrimental.
22 Gynecologic Considerations for the Acute Care Surgeon 207

Table 22.2 SAGES guidelines for laparoscopy during

Guidelines for laparoscopic surgery during pregnancy 36
1. Defer operative intervention until the second trimester, 40
when the fetal risk is lowest, whenever possible
2. Pneumatic compression devices must be used 30
because of the enhancement of lower venous stasis
with pneumoperitoneum and pregnancy-induced 24
hypercoagulable state
3. Fetal and uterine status, as well as maternal 20
end-tidal CO2 and arterial blood gases, should be
4. Use fluoroscopy selectively and protect the uterus
with lead shield if intraoperative cholangiography is
possible 12
5. Given enlarged gravid uterus, abdominal access
should be obtained using open technique
6. Dependent positioning should be used to shift the
uterus off the inferior vena cava
7. Pneumoperitoneum pressures should be minimized
(to 8–12 mmHg) and not allowed to exceed 15 mmHg Fig. 22.5 Uterine size at various stages of pregnancy
8. Obstetric consultation should be obtained before
area should be avoided – the right upper
quadrant may be a reasonable substitute
• Magnetic resonance imaging for secondary trocar placement) (see
– Generally considered safe in pregnancy Fig. 22.5).
– Disadvantage: limited availability Lower levels of pneumoperitoneum
Sparse publications (8–12 mmHg) (to prevent altered hemody-
namics in the fetus).
Management Insufflation, adequate hydration, prudent
• Once the diagnosis has been established, maternal ventilation, and serial blood gas
appendectomy may be undertaken. monitoring (to prevent fetal acidosis with
– Laparoscopy the peritoneal CO2).
Pregnancy is no longer a contraindication External tocodynamometer placed on abdo-
to laparoscopy, provided one bears in mind men to monitor for uterine contractions
the physiologic and anatomic variations of (upon completion of the operation).
the gravid abdomen. Administer tocolytics only if uterine irrita-
– Precautions (specific to laparoscopy) (see bility or contractions are noted (never
Table 22.2): prophylactically).
Continuous transvaginal fetal heart rate Early administration of corticosteroids for
monitoring. lung maturation at the earliest sign of pre-
Evidence of fetal distress should prompt mature onset of labor.
desufflation. – The open approach
Rotation of mother to a left-sided position Preferred when laparoscopic approach
to decrease uterine compression on the might be difficult (later stages of gestation)
inferior vena cava. or nonavailability of experienced minimal
Open Hasson technique (do not use blind invasive team.
access or a Veress needle) and trocar A right-sided transverse incision over the
placement. area of maximal tenderness is best (inci-
• The latter has to be modified to account sions over McBurney’s point, even early in
for the enlarged uterus (the hypogastric pregnancy, are usually inadequate).
208 G.C. Velmahos

Precautions include perioperative fetal

monitoring and early involvement of an Pitfalls
obstetrician, as well as early administration • Any woman of childbearing age pre-
of corticosteroids as above. senting with abdominal or pelvic pain
should be considered pregnant until
proven otherwise.
22.4.2 Pregnancy and Biliary Disease • Any woman presenting with pain and
bleeding in early pregnancy should be
Acute cholecystitis is the second most common considered to have an ectopic pregnancy
disease process requiring surgical intervention until proven otherwise.
during pregnancy, with an incidence of approxi- • In pregnant women, clinical signs of
mately 1–8 in 10,000 pregnancies. shock are initially subtle.
• Ovarian torsion is a surgical emergency;
Symptoms and Signs laparoscopy confirms the diagnosis and
• Symptoms similar to nonpregnant women: permits the treatment in time. CT is
– Colicky right upper quadrant or epigastric another high-achieving diagnostic tool
pain typically after fatty meals often accom- that delays surgery and increases the
panied by severe nausea and vomiting. workload of the pathologist.
– Murphy’s sign. • Dealing with appendicitis or cholecysti-
– Low-grade fever. tis in pregnant women, the risk of mis-
– Laboratory workup may be obscured by carriage is higher with ongoing
the normal leukocytosis and elevated alka- intra-abdominal infection or peritonitis
line phosphatase of gestation. than with early laparoscopy.
• Abdominal ultrasound confirms the diagnosis • A pregnant woman on the operation
typically showing gallbladder wall thickening table should be rotated on the left side to
and pericholecystic fluid in the presence of decrease uterine compression on the
cholelithiasis. inferior vena cava.
• Open laparoscopy is the gold standard.
Management Pregnancy modifies abdominal anatomy;
• Should the pregnant patient present with therefore, in pregnant women, open lap-
symptomatic cholelithiasis (without acute aroscopy is the platinum standard and
cholecystitis), conservative management can any blind access a malpractice.
be entertained to allow progression of the
pregnancy into the second trimester (organo-
genesis is complete but the gravid uterus is not
yet large enough to obstruct the critical view
or hinder operative maneuvers). 22.5 Summary
• Laparoscopic cholecystectomy is safe in preg-
nancy and preferable to an open approach for • Gynecologic causes of acute abdomen include
acute cholecystitis, allowing earlier oral intake ruptured ectopic pregnancy, ovarian torsion,
and mobilization, better pain control, shorter pelvic inflammatory disease, and tubo-ovarian
hospital stays, and, perhaps most importantly, abscess.
less frequent preterm labor from less manipu- • Whenever a female of reproductive age pres-
lation of the gravid uterus. ents with abdominal or pelvic pain, pregnancy
• Again, should be ruled out.
– Open Hasson technique for access • Ectopic pregnancy may present as a surgical
– Supraumbilical incision to avoid pressure emergency in case of rupture or uncontrolled
on the enlarged uterus bleeding; however, in carefully selected
22 Gynecologic Considerations for the Acute Care Surgeon 209

females with the condition, a conservative Guidelines Committee of the Society of American
Gastrointestinal and Endoscopic Surgeons, Yumi
approach could be attempted.
H. Guidelines for diagnosis, treatment, and use of lapa-
• Ovarian torsion represents a surgical emer- roscopy for surgical problems during pregnancy: this
gency with high morbidity if not treated statement was reviewed and approved by the Board of
promptly. Should the cause of the torsion not Governors of the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES), September 2007.
be treated in the same setting, follow-up
It was prepared by the SAGES Guidelines Committee.
should be established to address the issue. Surg Endosc. 2008;22(4):849–61.
• Tubo-ovarian abscesses may be managed with Huchon C, Fauconnier A. Adnexal torsion: a literature
oral or intravenous antibiotics first in the review. Eur J Obstet Gynecol Reprod Biol. 2010;150(1):
nontoxic patient. Patients who are not improv-
Kamaya A, Shin L, Chen B, et al. Emergency gynecologic
ing should be offered surgical exploration. imaging. Semin Ultrasound CT MR. 2008;29(5):
• Laparoscopy is typically safer than the open 353–68.
approach in the treatment of acute appendici- McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY,
Cryer HM. Negative appendectomy in pregnant
tis and cholecystitis during pregnancy in expe-
women is associated with a substantial risk of fetal
rienced centers. Fetal monitoring and early loss. J Am Coll Surg. 2007;205:534–40.
obstetrician involvement should be the main- Moawad NS, Mahajan ST, Moniz MH, et al. Current diag-
stay of any surgical condition for which the nosis and treatment of interstitial pregnancy. Am J
Obstet Gynecol. 2010;202(1):15–29.
gravid female seeks surgical attention.
Oxford CM, Ludmir J. Trauma in pregnancy. Clin Obstet
Gynecol. 2009;52(4):611–29.
Practice Committee of the American Society for
Bibliography Reproductive Medicine. Early diagnosis and man-
agement of ectopic pregnancy. Fertil Steril. 2004;82:
Becker JH, de Graaff J, Vos CM. Torsion of the ovary: a
Disease Control and Prevention (2006, updated 2007).
known but frequently missed diagnosis. Eur J Emerg
Pelvic inflammatory disease section of sexually trans-
Med. 2009;16(3):124–6.
mitted diseases treatment guidelines, 2006. MMWR,
Brown JJ, Wilson C, Coleman S, et al. Appendicitis in
55(RR-11): 56–61.
pregnancy: an ongoing diagnostic dilemma. Colorectal
Trigg BG, Kerndt PR, Aynalem G. Sexually transmitted
Dis. 2009;11(2):116–22.
infections and pelvic inflammatory disease in women.
Butala P, Greenstein AJ, Sur MD, et al. Surgical manage-
Med Clin North Am. 2008;92(5):1083–113.
ment of acute right lower-quadrant pain in pregnancy:
Wilasrusmee C, Sukrat B, McEvoy M, Attia J,
a prospective cohort study. J Am Coll Surg. 2010;
Thakkinstian A. Systematic review and meta-analysis
of safety of laparoscopic versus open appendicectomy
Gilo NB, Amini D, Landy HJ. Appendicitis and cholecys-
for suspected appendicitis in pregnancy. Br J Surg.
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Acute Proctology
Korhan Taviloglu

Contents For all patients presenting with swelling, pain,

23.1 Lower Gastrointestinal Bleeding 211 tenderness, itching, and bleeding symptoms of
the anal region:
23.2 Anal Pain 212
23.3 Acute Anal Fissure 212 • Take a thorough history.
23.4 Acute Hemorrhoidal Disease 212 • After obtaining informed consent, examine
23.5 Strangulated Hemorrhoids 212
the patient usually in the left lateral or the
Sims position, and more rarely in prone jack-
23.6 Hemorrhoids in Pregnancy 213
knife position.
23.7 Hemorrhoids and Portal Hypertension 213 • Rectal examination should detect external hem-
23.8 Hemorrhoids in Inflammatory Bowel orrhoids, fistula, anal carcinoma, anal condylo-
Disease 213 mas, anorectal abscess, and anal discharge.
23.9 Hemorrhoids in Leukemia 213 • Anorectal examination may reveal anal steno-
sis, anal sphincter problems, gross blood, and
23.10 Proctitis 213
anorectal abscess.
23.11 Anorectal Abscess 213
23.12 Fournier’s Gangrene 214
23.13 Perianal Sepsis in
23.1 Lower Gastrointestinal
Immunocompromised Patients 214 Bleeding
Bibliography 214
• Incidence: assumed to be 20/100,000 and con-
stitutes 25 % of all gastrointestinal bleedings
with a male predominance
• Defined as bleeding from the bowel distal to
the ligament of Treitz
• Usually manifests with maroon stools or
bright red blood per rectum
– Bright red blood per rectum strongly suggests a
lower gastrointestinal (GI) source of bleeding.
K. Taviloglu, MD
– However, hemorrhage may originate from a
Taviloglu Proctology Center - Abdi Ipekci Cad,
Nişantasi, Istanbul, Turkey source proximal to the ligament of Treitz in
e-mail: which case the patient is usually unstable.

© Springer International Publishing Switzerland 2016 211

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_23
212 K. Taviloglu

• Diagnosis Table 23.1 Grading of hemorrhoids

– After digital rectal examination. Degree Description
– Place a nasogastric tube to rule out an I Hemorrhoids prolapse beyond the dentate
upper GI source of bleeding. line on straining
– Order immediate colonoscopy, the urgency II Hemorrhoids prolapse through the anus on
straining but reduce spontaneously
depending on the degree of hypovolemia.
III Hemorrhoids prolapse through the anus;
Should detect the source of bleeding in
require manual reduction
69 % (48–90 %) of patients IV Prolapsed hemorrhoids cannot be manually
– Elderly (older than 65 years) and the reduced
patients with comorbidities warrant hospi-
talization because of high morbidity and
mortality rates (10–20 %).
– It is strongly recommended to carry out an • If untreated, prolapsed hemorrhoids may end
upper gastrointestinal endoscopy if a bleeding up with ulceration and necrosis.
site cannot be detected during colonoscopy. • Presentations and treatment.
– Thrombosed external hemorrhoids
Cause unknown
23.2 Anal Pain Usually preceded by abrupt onset of anal
mass and pain within 48 h
• Causes: acute anal fissures, thrombosed • Pain diminishes after the fourth day and
hemorrhoids, herpesvirus infection, anal if left alone dissolves spontaneously in a
condylomas, anorectal abscess, and proctal- few weeks.
gia fugax Treatment:
• Treatment: warm sitz baths, diltiazem, glyc- • Pain relief
eryl trinitrate ointment, and nonsteroid anti- • Excision under local or general
inflammatory drugs (NSAIDs) (helpful in anesthesia
60–70 % of cases) – Quicker recovery than with medical
– Prevention of recurrent thrombosis
23.3 Acute Anal Fissure – Prevention of residual skin