ESOFAGECTOMIA TRASHIATAL

Current Procedures: Surgery > Chapter 5. Transhiatal Esophagectomy >

Indications Resectable esophageal carcinoma. Barrett esophagus with high-grade dysplasia. Carcinoma of the cardia or proximal stomach. Achalasia. Advanced disease (mega-esophagus). Failed esophagomyotomy. Benign (undilatable) stricture. Recurrent hiatal hernia or reflux esophagitis following multiple hiatal hernia repairs.

Contraindications Absolute Biopsy-proven distant metastatic (stage IV) esophageal cancer. Tracheobronchial invasion by upper or mid-third tumors visualized on bronchoscopy. Aortic invasion demonstrated on MRI, CT scan, or endoscopic ultrasound (EUS). Relative Cardiopulmonary comorbidities. Previous esophageal surgery causing excessive mediastinal adhesions. Previous radiation therapy (more than 6–12 months prior) causing mediastinal and esophageal radiation fibrosis.

Informed Consent In our series of patients, overall mortality is 1%, and more than 70% of patients experience no postoperative complications. Expected Benefits Resection of the intrathoracic esophagus and accessible associated adenopathy for definitive therapy or local management of disease, while restoring normal swallowing and digestive function as much as possible. Potential Risks Cervical esophagogastric anastomotic leak (5–10%). Cervical dysphagia or esophageal stricture requiring early postoperative dilation (50–60%). Postvagotomy dumping symptoms (25–50%). Recurrent laryngeal nerve injury (< 5%). Chylothorax (< 2%). Mediastinal hemorrhage (< 1%). Membranous tracheal injury (< 1%). Gastric tip necrosis (< 1%). Surgical site infections and systemic complications common to any major operation (eg, pneumonia, venous thromboembolism, and cardiovascular events).

Equipment A table-mounted "upper hand" retractor facilitates exposure of the operative field. Endoscope for preoperative visualization of the esophageal abnormality and to ensure an adequate normal proximal margin. 14-inch right-angle clamps. Extra-long 16-inch electrocauterizing device. Gastrointestinal anastomosis (GIA) stapler

Patient Preparation Preoperative Planning Thorough preoperative staging evaluation is essential before performing transhiatal esophagectomy for malignancy. Esophagoscopy and biopsy, to establish the location of the tumor and histology. CT scanning, to demonstrate the local extent of the tumor and presence of distant metastatic disease. EUS, to define the depth of tumor invasion within the esophageal wall and surrounding tissues. EUS can also identify dissemination of tumor into regional lymph nodes and can be combined with fine-needle aspiration for confirmation of malignancy. Positron emission tomography has recently become a standard part of the staging evaluation and determines occult distant metastatic disease. For patients with a history of gastric disease or previous gastric surgery, or patients with esophagogastric junction tumors that may necessitate resection of a major portion of the stomach, a barium enema should be performed to assess the colon as an alternate conduit if the stomach is not suitable. Maximizing the patient's preoperative cardiopulmonary status is paramount to successful recovery. Patients should abstain from cigarette smoking and alcohol use for a minimum of 3 weeks before the operation. Patients should use an incentive spirometer on a regular basis (10 deep breaths three times daily), and walk at least 1–3 miles per day. For patients with severe dysphagia, weight loss, or dehydration, liquid supplementation by either oral or nasogastric routes should be considered. Placement of percutaneous gastrostomy and jejunostomy tubes should be avoided for preoperative feeding as they increase the risk of surgical site infection, risk injuring the right gastroepiploic artery, and complicate subsequent mobilization of the stomach at the time of operation. Patients who may require colonic interposition should receive a preoperative bowel preparation. Anesthetic Management Continuous radial intra-arterial blood pressure monitoring. Two large-bore peripheral intravenous catheters. Epidural catheter for postoperative analgesia. Standard endotracheal tube. Foley catheter.

Patient Positioning After induction of general anesthesia, flexible endoscopy is performed by the operating surgeon to verify the exact location of the mass or abnormality and to ensure that there is an adequate normal length of proximal esophagus above for construction of a cervical esophagogastric anastomosis. Following completion of endoscopy, a 16 French nasogastric tube is placed to evacuate air from the stomach. Figure 5–1: The patient should be supine with a folded blanket under the shoulders to provide adequate neck extension. The head is turned to the right and supported on a padded head ring. The skin of the neck, chest, and abdomen is prepared and draped from the angle of the mandible superiorly to the pubis inferiorly, and from both midaxillary lines anteriorly. Both arms are padded and tucked at the patient's side following the placement of arterial and venous access lines. Figure 5–1

Procedure Overview Transhiatal esophagectomy is widely used for the resection of both benign and malignant esophageal disease. In experienced hands, it is a safe and well-tolerated alternative to transthoracic esophagectomy, and it avoids the morbidity of mediastinitis resulting from an intrathoracic anastomotic leak. Using this approach, the thoracic esophagus is resected through a widened diaphragmatic hiatus and a cervical incision. Alimentary continuity is restored with a gastric conduit anastomosed to the remaining cervical esophagus above the level of the clavicles. Abdominal Phase The abdomen is entered through a midline supraumbilical incision (see Figure 5–1). Exploration of the abdomen is performed to confirm that the stomach is an appropriate conduit and is not extensively replaced by tumor nor contracted from prior surgery or caustic ingestion. Mobilization of the stomach. Following exploration, the triangular ligament of the liver is divided using electrocautery. A self-retaining, upper hand, table-mounted retractor is used to facilitate exposure, and the left lobe of the liver is padded and retracted to the right with a liver blade. The greater curvature of the stomach is visualized, and the course of the right gastroepiploic artery is identified. Beginning at the midpoint of the greater curvature of the stomach, the greater omentum is separated from the stomach to the level of the pylorus between right-angled clamps, using 2-0 silk ties for hemostasis. Care is taken to apply the clamps 1–2 cm below the right gastroepiploic artery to avoid injury to this vessel. Attention is then directed to the superior aspect of the greater curvature of the stomach. The left gastroepiploic artery and short gastric vessels are identified and divided between right-angled clamps using 2-0 silk ties for hemostasis. To prevent gastric necrosis, it is important to avoid ligation of these vessels too close to the stomach. Additionally, the surgeon must take care to avoid injury to the spleen during this portion of the dissection. Figure 5–2: Mobilization of the lower esophagus. Following the division of these vessels, attention is turned to the diaphragmatic hiatus. The peritoneum overlying the esophageal hiatus is incised, and the esophagus is encircled with a 1-inch Penrose drain. The gastrohepatic omentum is then incised, taking care to preserve the right gastric artery. The left gastric artery and vein are divided between clamps and doubly ligated, avoiding injury to the celiac axis. The artery is ligated and divided at its origin from the celiac axis, sweeping any adjacent lymph nodes toward the stomach. Throughout this dissection, the surgeon should be mindful of aberrant vascular anatomy, particularly an aberrant left hepatic artery arising from the left gastric artery, which might need to be preserved. To maximize the reach of the stomach superiorly, a generous Kocher maneuver is performed, and the duodenum is mobilized sufficiently so that the pylorus can be grasped and moved to the level of the xiphoid process medially. Two traction sutures are placed, one at the superior and one at the inferior pole of the pylorus. A 2-cm long pyloromyotomy is created, beginning 1.5 cm on the gastric side and extending through the pylorus and onto the duodenum for 0.5–1 cm. This is performed using the cutting current of a needle-tipped electrocautery device and a fine-tipped vascular mosquito clamp to dissect the gastric and duodenal submucosa away from the overlying muscle. The pylorus is marked with two metallic silver clips on the traction sutures for future radiographic localization. Downward traction is placed on the Penrose drain encircling the esophagogastric junction. The diaphragmatic hiatus is progressively dilated manually until the surgeon's hand can be inserted into the posterior mediastinum through the hiatus. A narrow Deaver retractor is placed into the hiatus to allow visualization, division, and ligation of the lateral attachments of the distal half of the esophagus. Gentle blunt dissection is used in combination with electrocautery and a long right-angled clamp to expose the lateral esophageal attachments and mobilize the distal 5–10 cm of the lower esophagus. The low posterior mediastinum is gently packed with a gauze "lap pack" as attention is now turned to the neck. A feeding jejunostomy tube should be placed in all patients. A 14 French rubber jejunostomy tube is inserted approximately 8–10 inches beyond the ligament of Treitz. This is secured in place using two 4-0 polypropylene purse-string sutures and a 4-cm long Weitzel maneuver. The tube is clamped and anchored to the operative drapes until later in the procedure when the jejunostomy is brought out through the left abdominal wall. Figure 5–2 Figure 5–3 Cervical Phase Figure 5–3: Cervical incision and mobilization of the cervical esophagus. Palpation of the cricoid cartilage indicates the level of the cricopharyngeal sphincter, the beginning of the esophagus. A 5–7 cm incision is created along the left anterior border of the sternocleidomastoid (SCM) muscle from the sternal notch to the level of the cricoid cartilage. An incision superior to this point provides no added exposure of the cervical esophagus, which is located inferior to the cricoid cartilage. The platysma muscle is incised. The fascia along the anterior edge of the SCM muscle is incised in the direction of the wound, and the SCM muscle is retracted laterally to expose the omohyoid muscle. The omohyoid muscle and its contiguous fascial sheath are divided, exposing the underlying carotid sheath. The SCM muscle and carotid sheath and its contents are gently retracted laterally, while the larynx, thyroid, and trachea are retracted medially using only a finger. Hand-held retractors should not be used for this purpose to prevent injury to the recurrent laryngeal nerve lying in the tracheoesophageal groove. The middle thyroid vein is divided. The inferior thyroid artery, which is always found at the level of the cricoid cartilage and upper esophageal sphincter, is identified, divided, and ligated. The dissection is carried directly posterior until the prevertebral fascia is identified. Blunt finger dissection into the superior mediastinum separates the cervical and upper thoracic esophagus from the prevertebral fascia. Upward retraction on the cervical esophagus by a finger placed gently along the tracheoesophageal groove elevates the upper thoracic esophagus from the superior mediastinum into the cervical wound, and sharp dissection posterolateral to the tracheoesophageal groove is used to free the anterior surface of the esophagus away from the trachea. The cervical esophagus is encircled with a 1-inch Penrose drain. With upward traction on the Penrose drain, the cervical esophagus is mobilized circumferentially to the level of the carina by the surgeon's index finger, which is kept directly against the esophagus. Mediastinal Dissection Figure 5–4A: Posterior mobilization of the intrathoracic esophagus. Back in the abdomen, working through the diaphragmatic hiatus, the surgeon palpates the esophagus to assess its mobility and establish that transhiatal resection is feasible. The surgeon inserts one hand through the diaphragmatic hiatus posterior to the esophagus. The hand is advanced superiorly, keeping as close to the spine as possible along the prevertebral fascia. At the same time, the cervical esophagus is gently retracted anteriorly and medially using the rubber Penrose drain. A "sponge-on-a-stick" is inserted through the cervical incision behind the esophagus. By advancing the sponge stick inferiorly, the esophagus is dissected free from the prevertebral fascia. Working upward from the diaphragmatic hiatus and downward through the cervical incision, posterior mobilization of the esophagus is completed using a combination of finger dissection and dissection with the sponge stick. The sponge stick is advanced downward until it meets the surgeon's hand inserted through the diaphragmatic hiatus. At this point, a 28 French Argyle Saratoga sump catheter is placed through the cervical incision into the mediastinum along the dissected path to evacuate blood. Figure 5–4B: Anterior mobilization of the intrathoracic esophagus. While the esophagogastric junction is retracted inferiorly with its encircling Penrose drain, the surgeon places his or her hand against the anterior esophagus, palm downward. The hand is advanced into the mediastinum, gently dissecting the esophagus from the posterior pericardium and the carina. The cervical esophagus is retraced superiorly and laterally, and the surgeon places his or her hand against the anterior wall of the esophagus. The hand is advanced inferiorly with two fingers dissecting along the wall of the anterior esophagus to free the esophagus from the posterior membranous trachea. Care must be taken to avoid injury to the trachea during this process. With the anterior and posterior esophageal attachments divided, the cervical esophagus is gently retracted superiorly into the cervical wound as the lateral attachments of the upper esophagus are progressively swept away by blunt dissection. Approximately 5–8 cm of the upper thoracic esophagus is circumferentially mobilized in this fashion. Attention is then turned to the abdominal field. The previously placed lap pad is removed from the posterior mediastinum. The hand is inserted palm downward through the diaphragmatic hiatus and advanced along the anterior esophagus until the circumferentially mobilized upper thoracic esophagus can be identified by palpation. The remaining lateral esophageal attachments and vagal branches are gently avulsed by drawing the hand inferiorly along the esophagus in a "raking" motion. If difficulty is encountered in this dissection, the upper sternum can be divided to provide exposure of the upper thoracic esophagus in the superior mediastinum and division of its lateral attachments under direct visualization. Throughout the mediastinal dissection, intra-arterial blood pressure is monitored with a radial artery catheter to avoid prolonged hypotension due to displacement of the heart. Once the entire thoracic esophagus has been mobilized, the nasogastric tube is withdrawn to a level above the upper esophageal sphincter. The cervical esophagus is elevated out of the wound and divided approximately 8–10 cm distal to the upper sphincter using a GIA surgical stapler. Approximately 5 cm of excessive cervical length should be left to ensure a tension-free reconstruction. The thoracic esophagus and stomach are then delivered downward through the diaphragmatic hiatus, and the sump catheter is advanced down into the posterior mediastinum from the neck incision. A narrow Deaver retractor is inserted into the diaphragmatic hiatus to allow the surgeon to inspect the mediastinum for bleeding and the mediastinal pleura for injury that indicates the need for a chest tube. If the pleura has been violated, a 28 French chest tube is inserted in the appropriate anterior axillary line in approximately the sixth intercostal space, sutured in place, and connected to an underwater seal chest tube suction system. The posterior mediastinum is packed again with a large gauze abdominal lap pad to control minor bleeding, and the cervical wound is covered with a moist pack as the surgeon returns to the abdomen for preparation of the gastric conduit. Figure 5–4A Figure 5–4B Creation of the Gastric Conduit and Abdominal Closure Figure 5–5A: Preparing the gastric conduit. With the mobilized stomach and attached esophagus placed on the patient's anterior chest wall, the site along the greater curvature of the stomach that will reach most superior is identified by gently pulling the fundus toward the cervical incision. Once this point is identified, it is continuously retracted superiorly, as the fat along the lesser curvature is cleared between clamps and ligated at the level of the second "crow's foot." The upper stomach is progressively divided by sequential applications of the GIA stapler, starting at the lesser curvature and working toward the fundus. Traction on the fundus during this maneuver must be maintained to straighten the stomach sufficiently to reach the neck. The proximal stomach is divided approximately 5 cm distal to the esophagogastric junction, and the specimen is passed off of the field. The staple line along the lesser curve of the stomach is oversewn with a running 4-0 polypropylene Lembert stitch. Figure 5–5B: Completed gastric conduit. The completed gastric conduit should reach 4–5 cm above the left clavicle. Figure 5–6: Delivery of the gastric tip into the cervical wound in preparation for the anastomosis. Using a narrow Deaver retractor to expose the diaphragmatic hiatus, the superior tip of the gastric fundus is placed through the hiatus. The surgeon's hand should remain on top of the stomach, gently guiding it upward through the posterior mediastinum, underneath the aortic arch and into the superior mediastinum. When the gastric fundus can be palpated in the superior mediastinum with a finger inserted through the cervical incision, a Babcock clamp is inserted into the superior mediastinum and the gastric tip gently grasped. The jaws of the clamp are not completely closed to minimize trauma to the gastric tip. The gastric tip should not be pulled into the cervical wound, but rather the stomach pushed upward and the tip guided with the hand inserted through the diaphragmatic hiatus into the cervical wound. The surgeon should ensure that the stomach is not twisted by noting that the staple line along the lesser curvature of the stomach is facing toward the patient's right side and by palpating the stomach through the diaphragmatic hiatus and the cervical incision. The gastric tip should remain pink and without evidence of ischemia throughout the remainder of the procedure. The position of the stomach in the neck wound is maintained by packing a small moistened gauze pad into the thoracic inlet alongside the stomach to prevent it from retracting downward into the mediastinum. Attention is redirected to the abdomen, which is inspected for hemostasis. After delivery of the gastric conduit into the cervical incision, the pyloromyotomy will lie 3–4 cm below the level of the diaphragmatic hiatus. The diaphragmatic hiatus is closed loosely using one or two interrupted No. 1 silk sutures until three fingers slide easily alongside the stomach in the hiatus. Additionally, one or two interrupted 3-0 silk sutures are placed between the anterior gastric wall and the adjacent hiatus to discourage migration of a loop of small intestine through the hiatus into the chest. Finally, the left lobe of the liver is returned to its anatomic location, and the triangular ligament is sutured over the hiatus to prevent future herniation of abdominal contents. The jejunostomy tube is brought out of the left upper abdominal wall through a separate stab incision and tacked to the adjacent peritoneum using interrupted 3-0 silk sutures. The jejunostomy tube is secured to the skin using a 2-0 polypropylene suture. The abdomen is then closed using No. 1 looped PDS suture on the muscle fascia, running 2-0 chromic catgut suture on the subcutaneous tissue, and running 3-0 nylon suture on the skin. The abdominal incision is isolated from the field with a sterile towel to prevent wound contamination by oral flora, which can occur once the cervical esophagus is opened for performance of the anastomosis. A sterile drape is placed over the abdominal field. Figure 5–5A Figure 5–5B Figure 5–6 Cervical Esophagogastric Anastomosis Figure 5–7A-D, Figure 5–7E-F: Creation of the cervical esophagogastric anastomosis. After closure of the abdomen, attention is turned to the cervical wound. The tip of the divided cervical esophagus is grasped with an Allis clamp and retracted superiorly and to the right. The anterior wall of the stomach is grasped using a Babcock clamp, and the staple line is rotated more medially. A seromuscular traction suture is placed in the anterior gastric wall to elevate the stomach into the wound, the cervical esophagus is aligned with the stomach, and the site of the anastomosis selected. A 1.5-cm vertical gastrotomy is created in the anterior gastric wall to allow later insertion of a 3-cm Endo-GIA staple cartridge (Figure 5–7A). The cervical esophageal staple line is amputated obliquely, allowing for enough redundancy to accommodate later retraction of the stomach into the thoracic inlet (Figure 5–7B). The staple line is then sent for pathologic examination as the proximal esophageal margin. Two stay sutures are placed, one at the anterior tip of the divided esophagus and the other between the posterior end of the divided esophagus and the superior end of the gastrotomy (Figure 5–7C). These stay sutures align the back wall of the cervical esophagus and the front wall of the stomach for construction of the anastomosis. An Endo-GIA-30 stapler is placed in the stomach as the traction sutures are drawn inferiorly, gently pulling the stomach and esophagus downward as the stapler is advanced inward and closed (Figure 5–7D). Two lateral suspension sutures of 4-0 Vicryl are placed between the cervical esophagus and the stomach on either side of the anastomosis to alleviate tension on the anastomosis. The stapler is fired and removed, thereby creating a 3-cm-long side-to-side stapled esophagogastric anastomosis. The previously placed 16 French nasogastric tube is guided across the anastomosis and into the intrathoracic stomach. The gastrotomy and esophagotomy are closed in two layers of running and interrupted 4-0 monofilament absorbable suture, and each side of the anastomosis is marked with a hemoclip for future radiographic localization (Figure 5–7E, F). The wound is irrigated, and a 0.25-inch Penrose drain is placed adjacent to the anastomosis. The drain is sutured to the skin. The neck incision is closed loosely by reapproximating the SCM muscle fascia to the omohyoid muscle, fascia, and platysma using absorbable interrupted 3-0 Vicryl sutures, and the skin edges are reapproximated with running 4-0 nylon. Figure 5–8: Final anatomic position of the gastric conduit. Sterile dressings are applied, and the thoracostomy tubes are placed on suction. A postoperative chest radiograph should be obtained in the operating room to confirm full expansion of both lungs, absence of hemothorax or pneumothorax requiring an additional chest tube, and appropriate positioning of the tip of the nasogastric tube above the silver clips marking the pylorus. Figure 5–7A–D Figure 5–7E–F Figure 5–8

Postoperative Care Immediate postoperative chest radiograph while the patient is in the operating room to exclude unrecognized pneumothorax or hemothorax. Extubation in the operating room and initiation of epidural anesthesia. Early use of an incentive spirometer within several hours of awakening from anesthesia. Early ambulation beginning on postoperative day (POD) 1. Ice chips by mouth (not to exceed 30 mL/h) for throat comfort until the nasogastric tube is removed on POD 3. Initiation of oral liquids on POD 4, with progressive daily advancement to full liquids, then mechanical soft (pureed) diet, and a soft diet by POD 7. Initiation of jejunostomy tube feedings on POD 3 and tapering as oral intake increases. Monitoring for resolution of ileus. Barium swallow examination on POD 7 to document integrity of the anastomosis, adequate gastric emptying through pylorus and hiatus, and absence of obstruction at the jejunostomy site. If oral intake is poor, nocturnal jejunostomy tube feeding supplementation can be used. If the patient is eating well and has no complications, the jejunostomy tube can be removed 4 weeks postoperatively during follow-up examination.

Potential Complications Intraoperative Pneumothorax. Hemothorax. Uncontrollable mediastinal bleeding (< 1%). Need for thoracostomy tubes due to entry into pleural cavity (75%). Iatrogenic splenectomy (3%). Membranous tracheal laceration (< 1%). Injury to the gastric or duodenal mucosa during pyloromyotomy (< 2%). Early Postoperative Recurrent laryngeal nerve injury (< 1–2%) causing hoarseness and difficulty swallowing. Chylothorax (1%). Cardiac arrhythmia (atrial fibrillation). Sympathetic pleural effusion. Pneumonia and atelectasis (2%). Cervical esophagogastric anastomotic leak (4%). Gastric tip necrosis (1%). Dysphagia. Regurgitation. Postvagotomy "dumping." Anastomotic stricture requiring dilation. Delayed gastric emptying due to incomplete pyloromyotomy, narrowing of the diaphragmatic hiatus, or jejunostomy tube site obstruction. Late Cervical anastomotic stricture. Diaphragmatic hernia. Small bowel obstruction due to torsion at the jejunostomy tube site (< 1%).

Pearls and Tips Marking the pyloromyotomy and cervical esophagogastric anastomosis with hemoclips allows for visualization on postoperative imaging to assess the position of the stomach in the chest and gastric emptying. Use only a fingertip to retract the cervical esophagus, thyroid, and trachea medially during mobilization of the cervical esophagus. To minimize the chance of injury to the recurrent laryngeal nerve, do not place metal retractors against the tracheoesophageal groove. Minimize gastric trauma during mobilization and particularly to the gastric tip so that a healthy stomach can be anastomosed to the esophagus, reducing the risk of postoperative anastomotic leak. When creating the gastric conduit, preserve as much of the stomach as possible to maximize collateral circulation. Repeatedly assess the color and viability of the stomach after mobilization of the stomach, when the gastric tube is delivered into the cervical wound, and after the closure of the diaphragmatic hiatus to be certain that there is no venous congestion or ischemia from mechanical causes. Avoid use of suspension sutures to tack the gastric tip to the prevertebral fascia because of the risk of vertebral osteomyelitis. Use a radial artery catheter to monitor for intraoperative hypotension, particularly during the mediastinal dissection. Hypotension can be caused by cardiac displacement or hemorrhage from injury to mediastinal structures. Aggressive preoperative conditioning with abstinence from cigarette smoking, regular use of an incentive spirometer, and walking are rewarded by a less complicated postoperative course.

References Orringer M. Transhiatal esophagectomy without thoracotomy. Operative Techniques in Thoracic and Cardiovascular Surgery. 2005;10:63–83. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363–372.[PubMed: 17717440] [Full Text] Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg. 2000;119: 277–288.[PubMed: 10649203] [Full Text]

TECNICAS DE CIERRE DE HERIDA

Indications Surgical wounds. Traumatic wounds.

Contraindications Absolute Multiple comorbidities precluding safe intervention. Active infection. Foreign body (except surgical implants). Active bleeding. Relative Impaired healing (corticosteroids, malnutrition, radiation, chronic disease).

Informed Consent Usually implied with consent for major procedure, must obtain consent otherwise. Potential Risks Scarring (normal and abnormal). Bleeding (may require reoperation or transfusion). Infection (may require antibiotics or reoperation). Failure of operation or need for secondary intention healing. Need for revision.

Equipment Instruments Appropriate instruments vary by wound type but include at a minimum a needle driver and tissue handling forceps. Sutures Consist of both a needle and suture material, each with multiple subtypes and characteristics. The needle and suture material may vary widely based on different types of wounds in different locations. Needle Table 42–1: Point characteristics. Swage: the method of attaching the suture material to the needle. Channel swage: a channel is crimped over suture material (swage diameter > body diameter). Drill swage: suture material is placed in the drill hole at the rear of needle, which is then crimped (swage diameter < body diameter). Nonswaged: eyed needle (similar to sewing needle). Closed-eye needles require suture material to be passed through the eye each time it is threaded. French eye needles have a posterior slit allowing suture to be placed in the eye without direct threading; this causes more tissue trauma and reduced suture integrity (eye > body diameter). Pop-off: swage is designed to allow suture material to be gently removed from the needle with traction. Table 42–2: Needle body characteristics. Designed to transmit the penetrating force to the point. Varied alloy characteristics can make a needle soft or firm (ductility). Diameter: gauge or thickness of needle. Table 42–1. Needle characteristics—point. Category Type Description Tissue Use Diagram   Conventional cutting Triangular point that changes to a flattened body with one cutting edge on the concave surface of the needle (surface seeking) Skin and tendon     Reverse cutting Cutting edge on convex curvature of the needle (depth-seeking) Stronger than conventional cutting Dense tissue, including skin, oral mucosa, and tendon   Cutting Side-cutting (spatula) Flat with 2 cutting edge to reduce tissue injury and improve depth control Ocular tissues     Taper-point (round needle) Stretches tissue without direct cutting action to minimize tearing Sharpness increases with taper ratio (slope) (8–12:1) and decrease with tip angle (20–35 degrees) Easily penetrated tissues, including abdominal viscera, dura, and peritoneum   Blunt Blunt Dissects through tissue rather than cutting it Friable tissue, including kidney and liver   Table 42–2. Needle Characteristics—body. Type Notes Diagram Straight Used in easily accessible tissue   Tissue is manipulated to allow passage of needle (eg, Keith needle) Curved Most common Chord length: linear distance between tip and swage (bite width)   Needle follows predicable path through tissue with even tension distribution Needle length: distance between tip and swage along curvature of needle   Radius: distance form center of arc of rotation of needle to needle itself—determines bite depth Compound Compound curved: variable radius   Used in ophthalmologic and microsurgical procedures

Patient Preparation Nothing by mouth the evening before surgery if the patient will be undergoing general anesthesia. Preoperative antibiotics per institutional policy and based on wound characteristics. Anesthesiology consultation as needed. Anesthesia Under general anesthesia, no additional preparation is necessary. In a conscious patient, local anesthetic (lidocaine, bupivacaine, etc) must be used. Wound Preparation Wound must be clean. Clean wounds may need no specific preparation prior to closure. Highly contaminated wounds should be irrigated (bulb, pulse-lavage, etc). Lacerations. May use a prefabricated syringe-mounted ocular flushing system. A saline bottle with 5–10 needle punctures provides a low-cost, effective irrigator in the acute setting. Skin edge. Complex lacerations and damaged skin edges should be resected to healthy tissue where possible. "Freshen" skin edges to allow more accurate apposition of wound margins. Hair is generally removed to fully expose wounds and reduce infection.

Patient Positioning The wound should be fully exposed and at comfortable working distance from the surgeon. A light source is often necessary in the emergency department setting.

Procedure Suture Closure Techniques Figure 42–1: Running continuous stitch. Widely used technique to close many wounds varying from lacerations to midline laparotomy wounds. Depth of bite and layers of tissue incorporated are dependent on site and tissue characteristics. Advantages of running technique. Allows expeditious wound closure. Closure is completed with one continuous length of suture material. Achieves approximation of wound margins. Disadvantages of running technique. Less reliable than interrupted closure. Wound edge eversion is difficult and there is greater potential for misalignment of wound edges, particularly if the tissue is pliable and the wound is long. Figure 42–2: Simple interrupted suture. Most common and basic suturing technique. Depth of bite and layers of tissue incorporated are dependent on site and tissue characteristics. Advantages of interrupted technique. Closure is completed suture by suture. The depth of bite, layers of tissue incorporated, and tension on the closure can be carefully adjusted for each individual stitch. Achieves accurate approximation of wound margins with optimal control. More reliable closure than continuous stitch. Disadvantages of interrupted technique. Time consuming. Multiple knots may contribute to foreign body response and additional scarring. Additional suture material may contribute to infections in the wound (suture abscess). Mattress suture: interrupted suturing technique in which the needle is passed through tissue multiple times. Figure 42–3: Horizontal mattress technique. The initial simple suture is placed perpendicular to the wound. Instead of tying the suture, the needle is advanced parallel to the wound margin and passed back through the tissue at an equal bite depth to a point on the initial wound edge equidistant to the length of advance on the opposite wound edge. The suture is tied and now lies parallel to the wound edge. Figure 42–4: Vertical mattress technique. The initial simple suture is placed perpendicular to the wound using a large bite depth. Instead of tying the suture, the needle is returned to the side of the initial bite at a smaller bite depth and without any advancement down the length of the wound. The suture is tied and now lies perpendicular to the wound edge. Figure 42–5: Half-buried horizontal mattress technique. Similar to the horizontal mattress technique, but the suture does not pass out of the tissue on the edge opposite the initial bite. The suture remains buried. Advantages of mattress suture techniques. Tissue eversion is easily controlled. Wound tension is distributed in friable tissue to prevent the suture from tearing through the tissue. Strong closure. Disadvantages of mattress suture techniques. Can create ischemic tissue either directly under the suture (vertical mattress) or constrict tissue within the confines of each suture leading to tissue ischemia (horizontal mattress). Figure 42–6: Purse-string suture. Used to close wounds by circumferential constriction of the wound edge. Commonly used in closing the end of a hollow viscus such as bowel or appendiceal stumps, around a catheter, or in reconstructive and cosmetic surgery. Uses a running suture technique. The suture is passed in and out of tissue around the circumference of the wound without entering the lumen of the viscera. As the suture reaches the origin, it can be tightened to reduce the circumference of the initial wound in a manner similar to the leather strings on a pliable "purse." If the technique is executed properly, the viscera can be reduced into the wound as the suture is tightened, creating a seal. Advantages of purse-string technique. Provides equal wound tension distribution around the circumference of the wound. Rapid closure. Disadvantages of purse-string technique. Creates pleating, which may lead to a poor seal, unfavorable scarring, or both. When used on skin, may lead to scar-widening as tissue stretches. Figure 42–7: Subcuticular suture. Used to close superficial skin edges to achieve accurate wound margin approximation. Sutures are not placed through the epidermis, thus avoiding potential scarring related to suture placement. The suture is introduced through normal skin and brought out of the deep tissue into the epidermal-dermal junction. The suture is then passed back into tissue and out of tissue at this same level, alternating edges of the wound (the suture should not penetrate epidermis). The suture exits deep tissue through the epidermis just distal to the wound. The tails are trimmed so they may be accessed to pull the suture out after several days (some prefer to tie or bury the suture). Advantages of subcuticular technique. Excellent control of wound margins increases the likelihood of a cosmetically pleasing outcome. May help avoid transverse "railroad track" scarring since sutures do not pass through the epidermis. Suture can be pulled out of the wound to reduce inflammatory response or suture erosion through the skin (spitting). Disadvantages of subcuticular technique. Closure is more time consuming than either staples or tissue glue. Figure 42–1 Figure 42–2 Figure 42–3 Figure 42–4 Figure 42–5 Figure 42–6 Figure 42–7 Nonsuture Closure Techniques Figure 42–8: Stapled closure. Used to close superficial skin edges. Skin edges are held up and everted using tissue forceps. A staple is deployed at this site. The process is repeated down the length of the wound. Advantages of stapled closure. Rapid skin edge closure. Individual staples can be removed in the event of wound infection. Disadvantages of stapled closure. May contribute to transverse hatching of the scar in a "railroad track" pattern. Staple removal can be uncomfortable. Tissue glue. Used to close superficial skin edges to achieve close edge approximation. Skin edges are approximated manually or with pull-out sutures. The wound is cleaned of necrotic debris, foreign material, and dried blood. A bed of glue is applied down the length of the wound, typically in one pass. Advantages of tissue glue. Rapid skin edge closure. Minimal tissue handling. Disadvantages of tissue glue. Glue cannot be removed easily if need be (eg, opening an infected wound). Expensive. Figure 42–8

Postoperative Care Wound edges should remain clean. Sutures should be removed several days (typical in face) or weeks following repair, depending on the location of the wound and characteristics of the tissue. Pain control with analgesics is appropriate. Antibiotics are not necessary for most wounds but may be recommended in contaminated wounds following closure.

Potential Complications Wound infection. Infected wounds, particularly those involving deep spaces, are typically opened to prevent systemic spread. Unfavorable scarring. Some scarring is expected, but hypertrophic scars, keloids, or wound contraction leading to functional limitation may occur, often without a known cause. Some wounds with unfavorable scarring may require scar revision. Figure 42–9: Standing cutaneous deformities ("dog ears") may be a result of individual wound length differences leading to excess tissue on one side of the wound, or occur in cases in which tissue rearrangement is necessary to achieve closure. These cutaneous deformities may persist and can often be addressed at primary closure. To remove a standing cutaneous deformity, the tissue leading to the deformity can be lifted away from the plane of tissue and resected in an elliptical fashion. If executed properly, the dimensions of the newly created ellipse will allow primary closure without a standing cutaneous deformity. Figure 42–9

Pearls and Tips Remember that not all wounds require or are well-managed by primary closure. To prevent injury to yourself and others, never handle needles directly. Returning suture by grasping the suture material instead of the needle will reduce the risk of the needle ejecting out of the needle holder. Use instruments appropriate for both the needle and the tissue you are suturing.

References Aston SJ, Beasley RW, Thorne CH, et al. Grabb and Smith's Plastic Surgery, 5th ed. Philadelphia, PA: Lippincott-Raven Publishers; 1997. Baker SR, Swanson NA. Local Flaps in Facial Reconstruction. St Louis, MO: Mosby-Year Book; 1995. Evans GRD. Operative Plastic Surgery. Stamford, CT: Appleton & Lange; 2000. Johnson & Johnson. Ethicon Wound Closure Manual, 2001. Available at: http://www.orthonurse.org/portals/0/wound%20closure%20manual.pdf. Accessed August 12, 2008. McGregor IA. Fundamental Techniques of Plastic Surgery and Their Surgical Applications, 10th ed. Edinburgh, New York: Churchill Livingstone; 2000. Sanders RJ. Subcuticular skin closure—description of technique. J Dermatol Surg. 1975;1:61–64.[PubMed: 770536] [Full Text]

MANEJO OPERATIVO DEL TUMOR RECTAL

Indications Transanal Excision of Tumor Stage T1 tumors: Mobile and < 4 cm in diameter. Involving < 40% of the rectal wall circumference. Located within 6 cm of the anal verge. Well or moderately differentiated histology only. Absence of vascular and lymphatic invasion. No evidence of nodal involvement on preoperative rectal ultrasound or MRI. Low Anterior Resection (LAR) with Total Mesorectal Excision Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained within 2 cm of the anal sphincter in moderately or well-differentiated tumors or within 5 cm for poorly differentiated tumors. Abdominoperineal Resection (APR) with Total Mesorectal Excision Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors.

Contraindications Transanal Excision of Tumor Tumors stage greater than T1N0M0. Fixed tumors. Tumors > 4 cm in diameter or involving > 40% of the circumference of the rectal wall. Tumors located > 6 cm from the anal verge. Tumors with poorly differentiated histology or angiolymphatic invasion, or those that show evidence of nodal involvement on preoperative rectal ultrasound or MRI. LAR with Total Mesorectal Excision Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors. APR with Total Mesorectal Excision Malignant lesion of the lower rectum diagnosed by evaluation of a tissue biopsy specimen showing local invasion into the pelvic sidewall or pelvis that could benefit from neoadjuvant treatment to facilitate possible curative resection.

Informed Consent Transanal Excision of Tumor Expected Benefits Removal of tumor with preservation of anus. Avoidance of radical surgery. Potential Risks Bleeding requiring reoperation. Rectal stricture. Need for further resection based on pathologic findings. Fistula to prostate or vagina. Injury to the urethra for distal anterior tumors in men. LAR or APR with Total Mesorectal Excision Expected Benefits Treatment of rectal cancer. Potential prevention of colonic obstruction, tenesmus, and invasion of adjacent pelvic structures. Potential Risks Bleeding requiring reoperation from presacral or splenic injuries (LAR or APR) or from the anastomosis (LAR). Infection, including intra-abdominal or pelvic abscesses resulting from anastomotic leaks (LAR) or infected intra-abdominal or pelvic fluid collections (LAR or APR). Fistula formation from anastomotic leak (LAR). Postoperative ileus (LAR or APR). Ureteral injury (LAR or APR). Need for a permanent or temporary stoma (LAR). Bladder or sexual dysfunction (LAR or APR). Fecal incontinence (LAR). Clustering of bowel movements (LAR).

Equipment Transanal Excision of Tumor Self-retaining (Ferguson) anoscope. Lone Star retractor (for more proximal lesions). LAR or APR with Total Mesorectal Excision Self-retaining retractors. Bookwalter abdominal retractor with a lighted St. Mark's retractor. Lone Star retractor (for perineum). Handheld lighted St. Mark's retractor and long instruments (crucial for delicate dissection in the pelvis). Gastrointestinal anastomosis (GIA) stapler. End-to-end anastomosis (EEA) stapler (LAR). Thoracoabdominal (TA) stapler (LAR).

Patient Preparation Clearance of bowel for synchronous lesions by colonoscopy. CT scan of the chest, abdomen, and pelvis to evaluate for metastatic disease of the lungs, liver, or peritoneum. Endorectal ultrasound or endorectal MRI for local staging (T and N staging). Patients with uT1N0 tumors may be appropriate candidates for transanal excision. Patients with uT3NX or uTXN+ disease should be considered for possible neoadjuvant chemoradiation therapy. Consider preoperative tattooing of the lesion with permanent ink, especially if the lesion is small or the patient will receive neoadjuvant chemoradiotherapy. Preoperative carcinoembryonic antigen level. Nothing by mouth the evening before surgery. Mechanical bowel preparation according to surgeon's preference. Preoperative antibiotics and preoperative subcutaneous heparin. Anesthesiology consultation as needed. Stoma marking by an enterostomal therapist for patients undergoing LAR or APR.

Patient Positioning Transanal Excision of Tumor For posterior lesions, the patient should be in a supine lithotomy position in gentle Trendelenburg using well-padded stirrups. For anterior lesions, the prone jackknife position is preferred. Sequential pneumatic compression devices should be applied. LAR or APR with Total Mesorectal Excision The patient should be in a supine lithotomy position in gentle Trendelenburg using well-padded stirrups. Sequential pneumatic compression devices should be applied. A Foley catheter and nasogastric or orogastric tube should be placed, especially if mobilization of the splenic flexure is contemplated. Consideration should also be given to the placement of a left ureteral stent if a difficult pelvic dissection is anticipated.

Procedure Transanal Excision of Tumor Regional anesthesia may be adequate, although general anesthesia is sometimes required. A self-retaining retractor is placed and a 1:100,000 epinephrine solution is infiltrated into the submucosa to facilitate dissection. Figure 24–1: Stay sutures are placed circumferentially 1 cm from the gross margin of the lesion. Figure 24–2: Full-thickness excision of the lesion is performed down to the level of perirectal fat using electrocautery. The specimen is carefully marked to delineate the correct orientation for the pathologist. Figure 24–3: The defect in the rectal wall is closed transversely with absorbable suture. Proctoscopic examination of the rectum is performed at the conclusion of the procedure to ensure patency of the rectum. Figure 24–1 Figure 24–2 Figure 24–3 LAR or APR with Total Mesorectal Excision General anesthesia is required. The patient should be in the lithotomy position with the legs elevated at approximately 15 degrees and spread at 45 degrees. Positioning of the anus and buttocks at the end of the table is important for access. A median laparotomy incision from the pubis symphysis to above the umbilicus is performed. For an LAR or APR, a self-retaining retractor is placed and the small intestine is retracted superiorly and to the right under a moistened towel. The left colon is freed from its lateral peritoneal attachments along the avascular line of Toldt, and the splenic flexure is mobilized (see Chapter 23) as needed for a tension free anastomosis. The peritoneum of the pelvic colon is opened using electrocautery. Care must be taken to identify the ureters, on the left in particular. The left ureter is identified as it crosses the pelvic brim over the left common iliac artery. Especially in patients with a significant amount of adipose tissue, widely encircling the ureter with a vessel loop can aid in safe mobilization of the distal rectum. The inferior mesenteric artery is identified at its origin and suture-ligated. The distal descending colon is then divided with a GIA-60 stapling device at least 5 cm proximal to the tumor. Figure 24–4: The distal rectum is then sharply mobilized posteriorly to remove the mesorectum intact with its fascial envelope (see also Figures 24–7A and 24–7B). The bladder is retracted superiorly and the anterior rectal wall is separated from the seminal vesicles and the posterior capsule of the prostate in a man. The lateral dissection encompasses the lateral peritoneal reflections, and middle hemorrhoidal vessels are ligated and divided. Figure 24–5: The proximal rectum is then clamped and a linear stapling device is applied across the rectum at least 2 cm distal to the tumor. The proximal rectum is divided and the specimen is removed. Figure 24–6A, B: Creation of the stapled LAR anastomosis. The staple line of the descending colon is opened and a nonabsorbable purse-string suture is placed. The anvil of a circular stapler is placed within the descending colon through the purse-string suture, and the suture is tied. The assistant then passes the circular stapler through the anus, deploying the "spike" just anterior to the staple line on the rectum. The anastomosis is completed as the surgeon marries the anvil placed in the end of the divided descending colon to the stapler exiting the rectum. The surgeon guides the end of the stapler together, taking care that no other tissue (ie, bladder or vagina) is intervening in the anastomosis, and the assistant fires the stapler. The rings of tissue ("donuts") are inspected for any defect. The assistant then inspects the integrity of the anastomosis by insufflating the rectum using a rigid sigmoidoscope, while the surgeon manually occludes the distal colon with the anastomosis submerged in sterile saline. The presence of any bubbling from the anastomosis suggests an anastomotic leak. Figure 24–4 Figure 24–5 Figure 24–6A–B Total Mesorectal Excision Care must be taken with lower lying rectal cancers to perform a total mesorectal excision to prevent leaving nodal tumor deposits behind. The superior hemorrhoidal artery is identified and ligated. Figure 24–7A-C: There should be wide incision at the peritoneal reflection and sharp division of the Waldeyer's fascia posterior to the fascia propria of the rectum, as well as incision of Denonvilliers' fascia and separation of the rectal wall from the seminal vesicles and the posterior capsule of the prostate anteriorly. Figure 24–8A, B: The correct and incorrect dissection planes for total mesorectal excision are depicted. Figure 24–7A–C Figure 24–8A–B Coloanal Anastomosis If it is not possible to obtain a distal rectal margin of at least 2 cm, a coloanal anastomosis may be contemplated. Figure 24–9A-C: The distal rectum is divided proximal to the dentate line following rectal dissection and total mesorectal incision. A 5–6-cm colonic J pouch can be fashioned using a GIA stapler. The end-to-side J pouch coloanal anastomosis is then created by sewing the full-thickness colon to the mucosa and internal sphincter of the anus. Absorbable sutures are used to create this anastomosis, and the colotomy created to allow admission of the GIA stapler when creating the J pouch is used for the anastomosis (Figure 24–9A, Figure 24–9C). If there is insufficient length for a colonic J pouch, an end-to-end anastomosis can be fashioned using a circular stapler or hand-sewn anastomosis as outlined above (Figure 24–9B, C). Figure 24–9A Figure 24–9B–C Abdominoperineal Resection for Low-Lying Rectal Cancers This procedure requires the same attention to obtaining adequate radial margins via total mesorectal excision. Figure 24–10: The sigmoid artery proximal to the takeoff of the superior hemorrhoidal artery is ligated. Figure 24–11A, B: The distal margin of resection should include the levators, as visualized from the perineal portion of the operation. Figure 24–12: The closure of the perineal incision should be in layers, beginning with the levators followed by the deep tissues and skin. Drains are placed in the deep space and are brought out through the lower abdominal wall. Figure 24–10 Figure 24–11A–B Figure 24–12

Postoperative Care Early ambulation is encouraged and diet is advanced as soon as tolerated. Patients requiring abdominal incision receive epidural analgesia and are transitioned to oral pain medications as soon as they can tolerate solids. Patients with ileostomies may require aggressive management of fluid status after the resumption of bowel function. We promote aggressive isotonic liquid consumption by the patient, with avoidance of caffeine and chocolate, and prefer first to use fiber bulking agents, followed by the addition of the antimotility agent loperamide. Daily examination of the perineal wound is mandatory following APR, and sitting should be discouraged for the first 5 postoperative days. Walking, however, should be aggressively encouraged. Pelvic drains are generally removed on postoperative day 5.

Potential Complications Transanal Excision of Tumor As excision of the rectal wall is carried out below the peritoneal reflection, intra-abdominal leak is generally not a problem. Deep space infections can occur and should be treated by local drainage. More commonly, pathologic evaluation reveals more extensive disease than was appreciated preoperatively, necessitating further local or more radical resection. LAR and APR with Total Mesorectal Excision Postoperative ileus is common, usually lasting 2–3 days and rarely requiring nasogastric decompression. Colonic ileus lasting longer than 2–3 days after LAR should prompt suspicion of an anastomotic hematoma, mechanical obstruction, or peritonitis associated with an anastomotic leak. Anastomotic leak is a potentially devastating complication following LAR and typically occurs 5–7 days following resection. Fever, leukocytosis, ileus, and distention may be early signs of a leak. Peritonitis mandates exploration with proximal diversion if a leak is discovered. More subtle clinical presentations may require imaging with water-soluble contrast enema for identification. Intra-abdominal abscesses from breaks in surgical technique may require intravenous antibiotics, bowel rest, and percutaneous drain placement. Splenic injury can occur when mobilization of the splenic flexure is necessary to perform a tension-free anastomosis (LAR), or as necessary for the colon to be easily brought up for end colostomy (APR). Ureteral injury can result from altered rectosigmoid anatomy associated with malignancy, inflammation, and neoadjuvant radiotherapy. Bladder or sexual dysfunction can occur due to injury of the sympathetic or parasympathetic nerves in the pelvis.

Pearls and Tips Transanal Excision of Tumor Pin the specimen out on suture card or cardboard and deliver it to the pathologist with correct orientation. Perform proctoscopy at the end of the procedure to ensure that the rectal lumen has not been sutured closed. Patients are usually hospitalized overnight for observation. Fever > 38.8°C is not uncommon in the immediate postoperative period, but if fever continues through the first postoperative night, blood and urine cultures as well as plain films of the chest should be ordered to evaluate for other, treatable sources of infection. LAR and APR with Total Mesorectal Excision For low rectal anastomosis, fill the pelvis with sterile saline and insufflate the rectal stump before reanastomosis with the circular stapler. If a leak is identified in the linear staple line on the rectum, posterior dissection should extend posteriorly to the level of the coccyx to identify the site of leakage. The circular stapler can then be brought out through the defect, a purse-string suture placed around the spike, and the purse-string suture excluded after firing the circular stapler. During perineal dissection, maintain constant attention to palpation of the Foley catheter to avoid inadvertent urethral injury.

References Chang AE, Morris AM. Colorectal Cancer. In: Mulholland MW, Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific Principles & Practice, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1103–1128. Huang EH. Complications of Appendectomy and Colon and Rectal Surgery. In: Mulholland MW, Doherty GM, eds. Complications in Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:498–522.