Operative Surgery and Topographic Anatomy - 2016

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

Topic 19. Operations on the Large Intestine. Appendectomy. Methods of Managing the Appendiceal Stump. Retrograde Appendectomy. Creation of a Fecal Fistula. Hemicolectomy (Surgical Principles)

1. Relevance of the Topic: A significant proportion of all large bowel diseases involve pathologies that do not respond to conservative Treatment and require surgical intervention. In addition to acute appendicitis—for which nearly one million appendectomies are performed annually—this group includes Hirschsprung's disease in children, idiopathic megacolon in adults, Ulcerative Colitis, and colorectal tumors.

2. Specific Objectives:

1. To explain the General Principles of operations on the Large Intestine.

2. To explain how to perform an appendectomy.

3. Tasks for Independent Work in Preparation for the Class.

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

3.2. Theoretical questions for the class:

1. Surgical technique for accessing the appendix via the McBurney (Volkovych-Dyakonov) incision.

2. Technique of appendectomy.

3. Methods of managing the appendiceal stump.

4. Indications and technique for creating a fecal fistula.

5. Principles of large bowel resection.

3.3. Practical skills to be acquired during the class:

1. Accessing the appendix via the McBurney (Volkovych-Dyakonov) incision.

2. Mobilization and removal of the appendix.

3. Management of the appendiceal stump using a purse-string suture.

4. Creation of a transverse colostomy.

4. Subject Matter

Appendectomy. The Volkovych-Dyakonov (McBurney) abdominal wall incision. Layer-by-layer tissue dissection. Careful Separation of the fibers of the internal oblique and transversus abdominis Muscles. When incising the Peritoneum, it must be elevated to avoid injuring underlying Organs. The ileocecal junction is identified, and the Characteristic Features of the large intestine are located. The Base of the appendix always lies on the free taenia of the colon, along its posteromedial margin, 2–2.5 cm from the ileocecal junction. The appendix typically courses downward and medially. The surgeon mobilizes the appendix by dividing its mesoappendix and ligating its vessels, frequently utilizing transfixion sutures. After dividing the appendix between a ligature and a clamp, the stump—tied with catgut—is cauterized with an alcoholic solution of iodine and invaginated using a purse-string suture. Alternative methods for managing the appendiceal stump are also possible, such as non-ligation with invagination into a purse-string suture. The anterolateral abdominal wall wound is closed tightly in layers (Fig. 61).

Fig. 61. Appendectomy (Stages of the operation): a, b — ligation of vessels and division of the mesoappendix; c, d, e, f — technique of appendix removal using the ligature-invagination method.

In cases of intestinal obstruction requiring urgent evacuation of intestinal contents when a radical operation is unfeasible, a fecal fistula is created. The Procedure can be performed on any mobile segment of the large intestine, including caecostomy, transversostomy, and sigmoidostomy.

An incision is made in the anterolateral abdominal wall, and the parietal peritoneum is sutured to the edges of the Skin wound. A segment of the large intestine is delivered into the wound and stitched along its entire circumference to the parietal peritoneum and transversalis fascia. After adhesions form between the parietal and visceral peritoneum within 3 to 4 days, the intestinal lumen is opened longitudinally and sutured to the edges of the skin wound (Fig. 62).

Fig. 62. Stages of creating an artificial anus.

General principles of large bowel resection include: thorough mechanical cleansing of the intestine prior to surgery; performing the resection in areas where the large intestine is covered by peritoneum; striving to remove segments with compromised Blood supply; and restoring bowel continuity using an end-to-end anastomosis.

5. Self-Assessment Materials

A. Self-Assessment Tasks

Test No. 1

The surgeon performed a surgical approach to the vermiform appendix via the McBurney (Volkovych-Dyakonov) incision. What type of laparotomy was performed in this situation?

а. Transrectal

в. Pararectal

c. Oblique Muscle-splitting

d. Median

e. Lower transverse

Test No. 2

A 6-year-old child was hospitalized on the third day of illness with severe generalized abdominal pain that initially localized to the right iliac region, accompanied by recurrent vomiting of stagnant contents. The condition is severe, Temperature is 39°C, skin is pale, and pronounced tachycardia is present. The anterior abdominal wall does not participate in Respiration; diffuse tenderness, significant muscular rigidity, and positive peritoneal signs are detected. The provisional Diagnosis is appendicular Peritonitis. What should be the management strategy?

а. Preoperative preparation, surgical intervention

в. Antibacterial therapy, followed by surgery if necessary

c. Emergency surgical intervention

d. Infusion therapy and physiotherapy, followed by surgery if necessary

e. Dynamic observation, followed by surgery if necessary

Test No. 3

The surgeon is performing an antegrade appendectomy. Following surgical access, the cecum with the vermiform appendix was identified and delivered to the anterolateral wall, and surrounded with gauze Sponges. What is the initial step of the operative procedure in this surgery?

а. Tying the purse-string suture on the cecum

в. Ligation and transection of the appendix

c. Division of the appendix between clamps

d. Peritonization

e. Mobilization of the appendix

B. Self-Assessment Questions

Task 1. Two hours after an appendectomy, a patient experienced weakness, dizziness, and fainted once. The general condition is of moderate severity. Pulse 110 bpm, BP — 70/40 mm Hg. Heart sounds are muffled. Palpation of the abdomen reveals rigidity and tenderness in the area of the surgical wound. Percussion of the abdomen reveals areas of dullness. What postoperative complication has developed in this case, and what should be the surgeon's tactical approach?

Task 2. What method of stump management of the appendix should be used in severe typhlitis?

Task 3. What should be the surgical tactics for mobilizing the appendix in its retrocecal position?

References

Required

1. Operativna khirurhiia i topohrafichna anatomiia; ed. by M.S. Skrypnikov. — Kyiv: Vyshcha Shkola, 2000. — P. 312-332.

2. Operativna khirurhiia i topohrafichna anatomiia; ed. by M.P. Kovalsky. — Kyiv: Medytsyna, 2010. — P. 237-272.

Supplementary

1. Kovanov V.V. Operativnaya khirurgiya i topograficheskaya anatomiya / V.V. Kovanov. — M., 2001. — P. 334-364.

2. Operativnaya khirurgiya i topograficheskaya anatomiya; ed. by Skrypnikov M.S. — Poltava, 2001. — P. 202-246.

3. Operativnaya khirurgiya i topograficheskaya anatomiya; ed. by Kulchitsky K.I. — K., 1994. — P. 207-240.

4. Elizarovsky S.I. Operativnaya khirurgiya i topograficheskaya anatomiya / S.I. Elizarovsky, R.N. Kalashnikov. — M., 1979.

5. Matyushin I.F. Vvedeniye v kurs operativnoy khirurgii i topograficheskoy anatomii / I.F. Matyushin. — Gorky, 1976.

6. Tomashuk I.P. Rukovodstvo po operativnoy tekhnike dlya nachinayushchikh khirurgov / I.P. Tomashuk, I.I. Tomashuk. — K.: Iz-vo Evropeyskogo universiteta, 2001. — 860 p.

7. Frauchi V.Kh. Kurs topograficheskoy anatomii i operativnoy khirurgii / V.Kh. Frauchi. — M., 1976.