Operative Surgery and Topographic Anatomy - 2016

Content Module No. 3. Topographic Anatomy and Operative Surgery of the Abdominal Regions and Organs

Topic 18. Operations on the liver and biliary tract, closure of liver wounds, liver suturing. Cholecystectomy, choledochotomy. Surgical approaches to the pancreas. Splenectomy

1. Relevance of the topic: penetrating wounds and blunt abdominal trauma with injuries to the Liver, extrahepatic biliary tract, and Spleen, as well as Developmental anomalies of these Organs and surgical Diseases of the liver, Extrahepatic Bile ducts, Pancreas, and spleen, are frequently encountered in medical practice. Knowledge of the Anatomical and physiological features of these organs enables a deeper understanding of the specific nature of pathological processes and their complications, allowing for the provision of qualified primary and specialized medical care.

2. Specific objectives:

1. Analyze surgical approaches to the liver, extrahepatic biliary tract, pancreas, and spleen, identify potential intraoperative Errors and Complications, and determine ways to prevent them.

2. Explain how to perform the most common surgical Procedures on the liver, extrahepatic biliary tract, and spleen.

3. Explain the technique for performing cholecystectomy and splenectomy.

3. Tasks for independent work in preparation for the Class.

3.1. List of key terms, parameters, and characteristics that the student must master in preparation for the class:

3.2. Theoretical questions for the class:

1. Indications for surgery on The Liver and extrahepatic biliary tract.

2. Indications for splenectomy.

3. How is a liver wound closed?

4. How is liver resection performed?

5. How are retrograde and antegrade cholecystectomy performed?

6. How is choledochotomy performed?

7. What are the surgical approaches to the pancreas?

8. What is The sequence of ligation of the Vessels of the splenic hilum during splenectomy?

3.3. Practical skills to be acquired during the class:

1. Execution of surgical approaches to the liver, extrahepatic biliary tract, pancreas, and spleen.

2. Closure of a liver wound.

3. Ligation of the cystic artery and the neck of the gallbladder, and dissection of the gallbladder from its bed.

4. Incision of the common bile duct.

5. Ligation of the vessels at the splenic hilum and their isolation.

4. Topic Outline

For open and closed liver injuries, as well as gunshot wounds, an upper midline laparotomy is used. This incision may be supplemented with transverse incisions to the right and left. Surgical debridement of the liver wound is performed. To this end, the wound edges are excised, removing all damaged tissue. Bleeding from the wound during debridement is stopped by vessel ligation, suturing, or biological tamponade. Bile leakage is eliminated by ligating and suturing the intrahepatic bile ducts. In cases of extensive ruptures of a liver lobe, resection is performed; for marginal wounds, a wedge resection is indicated. It should be noted that Surgical Treatment of liver injuries primarily aims to stop bleeding and remove damaged tissue, potentially up to a near-total liver resection.

The surgeon approximates the wound edges after excising the damaged area and places simple interrupted sutures. The sutures are placed using a round, heavily curved needle, entering the parenchyma 2–3 cm away from the wound edge. To prevent the threads from cutting through the tissue, a bolster is used, made from the greater omentum or a separated patch of the falciform ligament of the Diaphragm. The surgeon also places a special Kuznetsov-Pensky suture using a blunt needle and a double thread. The loops of the thread are passed sequentially in a loop-like fashion, compressing the vessels in the damaged area of the liver. The application of U-shaped (mattress) sutures (Fig. 58) and X-shaped vessel transfixion is also possible.

Fig. 58. Most common liver sutures: A - X-shaped suture; B - suture with synthetic tissue bolsters.

The surgical team performs a marginal liver resection. U-shaped sutures or Kuznetsov-Pensky sutures are applied. Stepping back 0.5 cm outward from the placed sutures, the damaged area of the liver is excised with a scalpel. Large vessels and bile ducts are oversewn and ligated. Several drainage tubes are placed near the wound (Figs. 59, 60).

Fig. 59. Hemostatic sutures on the liver: A - Kuznetsov-Pensky suture; B - Labbé suture.

Fig. 60. Types of liver sutures. Technique for placing a simple interrupted suture on the liver.

The second surgical team performs gallbladder removal from the neck to the fundus (retrograde cholecystectomy). Two fenestrated clamps are applied to the gallbladder — one near the fundus and the second near the neck. Traction is applied to the neck of the bladder, and an incision is made along the right edge of the hepatoduodenal ligament to expose the cystic duct. It is isolated down to the common bile duct. The duct is transected between clamps, and a double ligature is applied to its stump. Traction on the neck allows Isolation of the cystic artery, which, after careful identification, is transected between clamps and its stump is ligated. Next, the gallbladder is mobilized from its hepatic bed. For this, the serosa is incised along the right and left edges of the gallbladder with a scalpel, connecting the incisions near the fundus. Using scissors and a sponge, the gallbladder is enucleated from its bed. The gallbladder bed is reperitonealized with a continuous suture. The wound of the anterior abdominal wall is closed tightly in layers.

It is emphasized that an antegrade cholecystectomy — removal of the gallbladder from the fundus to the neck — is also possible. It is performed in cases where technical difficulties arise during the isolation of the gallbladder neck and cystic artery (scar and infiltrative changes, adhesions, anatomical variations in THE POSITION OF the neck, cystic duct, and cystic artery).

The operation is performed by incising the common bile duct, which is indicated for obstructive jaundice, stones in the hepatic and common bile ducts, A large number of small stones in the gallbladder, and pathological Changes in the major duodenal papilla. The length of the incision in the common bile duct wall is up to 1 cm. The incision is made longitudinally between two stay sutures on the anterior wall of the duct, closer to its lateral edge, at a distance of 0.5 cm from the duodenal margin. A probe is passed through the major duodenal papilla. If the probe does not pass into the duodenum, the papilla must be incised, explored, and, if necessary, a sphincterotomy performed.

Indications for splenectomy include splenic trauma, hemolytic jaundice, Werlhof's disease, Splenomegaly in portal Hypertension, echinococcal cysts, infarctions, tumors, and abscesses.

If the surgery is performed for splenic trauma, stopping the Hemorrhage is the absolute priority. If adhesions are present (e.g., in splenomegaly), they must be divided between clamps, and the vessels transfixed and ligated. The phrenicosplenic ligament is identified and transected. After dividing the gastrosplenic ligament, access to the splenic hilum is achieved, making it possible to ligate its vessels. The Arteries are ligated directly at the splenic hilum, followed by the Veins; the vessels are then transected, the spleen is removed, and meticulous hemostasis is performed. A drain is placed near the splenic bed.

Upon entering the Abdominal cavity, to gain access to the pancreas, the surgeon must approach the posterior wall of the omental bursa. This can be accomplished by incising ligaments such as the hepatogastric, gastrocolic, or the transverse mesocolon. The preferred approach to the pancreas is through incision of the gastrocolic ligament. In purulent processes originating in the omental bursa and tending to extend posteriorly, the pancreas is approached via a lumbar incision.

5. Self-Assessment Materials

A. Self-Assessment Tasks

Test No. 1

A surgeon removed the gallbladder using a minimally invasive surgical approach that spares the intercostal neurovascular bundles. Which laparotomy was used?

a. Shalimov's incision

в. Upper midline

c. Middle midline

d. Oblique subcostal

e. Angular

Test № 2

A surgeon applied the Kuznetsov-Penssky suture to the liver. What type of needle should be used for this purpose?

a. Blunt with a double suture

b. Blunt with a single suture

c. Tapered with a single suture

d. Cutting with a single suture

e. Cutting with a double suture

Test № 3

A surgeon is performing a retrograde cholecystectomy. Which bile duct should be ligated during this Procedure?

a. Right hepatic

b. Left hepatic

c. Common hepatic

d. Common bile

e. Cystic

Test № 4

During surgery for gallstones, the surgeon needs to locate the common hepatic duct. Between the layers of which ligament is it situated?

a. Hepatoduodenal

b. Hepatogastric

c. Hepatorenal

d. Round ligament of the liver

e. Ligamentum venosum

Test № 5

During a cholecystectomy (gallbladder removal) performed from the fundus, calculi (gallstones) may migrate through a wide cystic duct into other PARTS OF THE biliary tract. Where should the surgeon perform an inspection?

a. Ductus choledochus

в. Ductus hepaticus communis

c. Ductus hepaticus dexter

d. Ductus hepaticus sinister

e. Ductulus bilifer

B. Self-assessment tasks

Task 1. During the exploration of the abdominal cavity, the surgeon discovered that the source of internal bleeding is a traumatic rupture of the right lobe of the liver. What should be the surgeon's further tactical steps in this case?

Task 2. During the abdominal exploration in a patient after blunt abdominal trauma, the surgeon revealed massive bleeding from the liver. How to temporarily stop the bleeding in this case?

Task 3. A 60-year-old patient suffering from biliary colic attacks experienced a bout that did not completely subside. For two months, the man felt a dull, aching, constant pain in the right hypochondrium. Palpation in the same area reveals a large, dense, elastic mass with a smooth surface. There are no signs of peritoneal irritation. The Temperature is normal, with mild leukocytosis. What is your Diagnosis and treatment strategy?

Task 4. A 78-year-old obese female patient was hospitalized on the third day of an acute cholecystitis attack. She has been suffering from Calculous Cholecystitis for over 30 years. The attacks are frequent and severe. However, considering the patient's age and, most importantly, such contraindications as pulmonary insufficiency, circulatory failure, and obesity, surgery was not offered to her. Despite intensive conservative treatment, the inflammatory process progressed, and the threat of gallbladder perforation arose. What should be the surgeon's tactics?

Task 5. A 50-year-old female patient underwent surgery for acute cholecystitis. The operation went well. The gallbladder was removed subserosally from the neck. The cystic artery and duct were securely ligated. The cystic stump and gallbladder bed were reliably reperitonealized. The common bile duct is patent. How will you close the abdominal cavity?

Task 6. A 64-year-old patient with obstructive jaundice was operated on for suspected common bile duct stones. During the surgery, it was found that he has Cancer of the major duodenal papilla extending to the wall of the common bile duct. The cystic duct is patent, and the gallbladder is markedly distended and tense. What operation can be performed in this case?

References

Essential

1. Operative Surgery and Topographic Anatomy; ed. by M.S. Skrypnikov. — Kyiv: Vyshcha Shkola, 2000. — P. 312-332.

2. Operative Surgery and Topographic Anatomy; ed. by M.P. Kovalsky. — Kyiv: Medytsyna, 2010. — P. 237-272.

Supplementary

1. Kovanov V.V. Operative Surgery and Topographic Anatomy / V.V. Kovanov. — M., 2001. — P. 334-364.

2. Operative Surgery and Topographic Anatomy; ed. by M.S. Skrypnikov. — Poltava, 2001. — P. 202-246.

3. Operative Surgery and Topographic Anatomy; ed. by K.I. Kulchytsky. — K., 1994. — P. 207-240.

4. Elizarovsky S.I. Operative Surgery and Topographic Anatomy / S.I. Elizarovsky, R.N. Kalashnikov. — M., 1979.

5. Matyushin I.F. Introduction to the Course of Operative Surgery and Topographic Anatomy / I.F. Matyushin. — Gorky, 1976.

6. Tomashuk I.P. Guide to Surgical Technique for Beginner Surgeons / I.P. Tomashuk, I.I. Tomashuk. — K.: European University Publishing House, 2001. — 860 p.

7. Frautschi V.Kh. Course of Topographic Anatomy and Operative Surgery / V.Kh. Frautschi. — M., 1976.