Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 106 • Thoracotomy for Trauma 1177

Left lung

Sternum

FIGURE 106 –3

FIGURE 106 –4

1178 Section XVI • Operations—Elective and Trauma

SELECTED REFERENCES

1. Wright C: Transverse sternothoracotomy. Chest Surg Clin N Am 1996;6:149-156.

2. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons, Committee on

Trauma: Practice management guidelines for emergency department thoracotomy. J Am Coll Surg

2001;193:303-309.

3. Baxter BT, Moore EE, Moore JB, et al: Emergency department thoracotomy following injury: Critical

determinants for patient salvage. World J Surg 1988;12:671-675.

4. Bifﬂ WL, Moore EE, Harken AH: Emergency department thoractomy. In Mattox KL, Feliciano DV,

Moore EE (eds): Trauma, 4th ed. New York, McGraw-Hill, 2000, p 245.

5. Feliciano DV, Mattox KL: Indications, technique and pitfalls of emergency center thoracotomy.

Surg Rounds 1981;4:32.

1179

STEP 1: SURGICAL ANATOMY

◆ Exposure of the retroperitoneal structures—duodenum, pancreas, kidneys, ureters, vena

cava, and aorta—may be required to address injury of these structures or other emergent

conditions.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ For trauma, wide preparation of the torso is necessary, including neck and groins.

Retroperitoneal Exposure

William J. Mileski

CHAPTER

107

1180 Section XVI • Operations—Elective and Trauma

STEP 3: OPERATIVE STEPS

◆ A full midline incision is made.

◆ Beginning on the right, the surgeon exposes the retroperitoneal structures by mobilization

of the cecum and ascending colon, releasing the lateral peritoneal reﬂ ection, the white line

of Toldt, from caudad and lateral to the cecum and extending the release cephalad, combin-

ing with mobilization of the lateral attachments of the duodenum (Figure 107-1).

FIGURE 107 –1

CHAPTER 107 • Retroperitoneal Exposure 1181

◆ This extended Kocher maneuver allows medial rotation of the colon and duodenum. It can

be further extended by mobilization of the mesentery of the small intestine to the ligament

of Treitz, the Cattell maneuver includes retraction of the entire right side of the colon, most

of the transverse colon, and the small intestine and left cephalad, which exposes the right

kidney, right adrenal gland, right ureter, entire duodenum, head of the pancreas, inferior

vena cava, and infrarenal aorta (Figure 107-2).

Pancreas

Cecum

Aorta

Inferior

vena cava

Duodenum

FIGURE 107 –2

1182 Section XVI • Operations—Elective and Trauma

◆ Exposure of the retroperitoneal attachments on the left can be accomplished in a mirrored

fashion, incising the left retroperitoneum from the lateral aspect of the sigmoid colon and

extending cephalad to incise the splenorenal ligament and splenophrenic attachments

(Figure 107-3).

◆ A plane of dissection is then bluntly developed between the spleen, pancreas, and colonic

mesentery anterior to Gerota’s fascia (Figure 107-4). With the left colon, spleen, and tail of

the pancreas retracted to the right, the left kidney, left adrenal gland, left ureter, and aorta—

from celiac axis to bifurcation—can be visualized.

Spleen

Aorta

FIGURE 107 –3

CHAPTER 107 • Retroperitoneal Exposure 1183

Stomach

retracted

Artery

Vein

Pancreas

Left kidney

Plane dissected

bluntly

Vasa brevia in

gastrocolic

ligament

FIGURE 107 –4

1184 Section XVI • Operations—Elective and Trauma

STEP 4: POSTOPERATIVE CARE

◆ Nasogastric decompression may be required for a prolonged period following this extensive

retroperitoneal dissection.

STEP 5: PEARLS AND PITFALLS

◆ Steady rotation and countertraction with blunt dissection (a sponge stick is often helpful) is

critical to maintaining the plane of dissection.

SELECTED REFERENCE

1. Cattell RB, Braasch JW: A technique for the exposure of the third and fourth portions of the duodenum.

Surg Gynecol Obstet 1960;111:378-379.

1185

Abdominal aorta, 953f

Abdominal aortic aneurysm repair

anastomoses, 887-888

aortocaval ﬁ stula, 890

closure of, 889

dissection, 884-889, 884f-888f

horseshoe kidney, 881, 890

hypogastric aneurysm, 890

incision, 882, 883f

inﬂ ammatory aneurysm, 890

juxtarenal aneurysm, 890

pearls and pitfalls of, 890-891

postoperative care, 890

preoperative considerations for, 881

retroperitoneal approach, 882

surgical anatomy of, 880, 881f

suturing/sutures, 886, 886f-887f, 889, 889f

transperitoneal approach, 882

Abdominal hysterectomy

closure of, 1082, 1083f

dissection, 1076-1082, 1077f-1081f

incisions, 1072-1075, 1072f-1075f

pearls and pitfalls of, 1084

postoperative care, 1084

preoperative considerations for, 1070

surgical anatomy of, 1068-1070, 1069f

suturing/sutures, 1082, 1083f

vagina, 1082, 1082f

Abdominal surgery

appendectomy. see Appendectomy

Billroth I. see Billroth I

Billroth II. see Billroth II

duodenal ulcer, bleeding, 324-327

gastrectomy. see Gastrectomy

gastric banding, laparoscopic, 386-393

gastrojejunostomy. see Gastrojejunostomy

intussusception, 411-415, 412f-414f

malrotation, 416-420, 417f-419f

Meckel’s diverticulectomy,

394-398, 395f-397f

midgut volvulus, 416-420, 417f-419f

percutaneous gastrostomy feeding tube

placement. see Percutaneous gastros-

tomy feeding tube placement

pyloromyotomy. see Pyloromyotomy

pyloroplasty. see Pyloroplasty

Roux-en-Y gastric bypass. see

Roux-en-Y gastric bypass

Stamm gastrostomy, 240-245

Witzel jejunostomy, 246-252

Accelerated partial breast radiotherapy, 109

Accessory nerve, 29f, 37f

Acetabulum, 1063f

Achalasia, 230

Acute adrenal insufﬁ ciency, 104

Acute necrotizing pancreatitis, 600

Adductor longus muscle, 1059f, 1123f

Adductor magnus muscle, 1061f

Adenoma

parathyroid, 45-46

pleomorphic, 51

Adjustable gastric band, laparoscopic place-

ment of, 386-393

Adrenal artery, 89f, 94f, 895f, 1135

Adrenalectomy

bilateral, 90, 104

closure of, 104

complications of, 104

dissection, 92-103

incision, 90, 91f

indications for, 88

laparoscopic

incisions, 90

left-sided, 92-94, 93f

postoperative care, 104

right-sided, 95-96, 95f-96f

open

left-sided anterior, 97-98, 97f-98f

posterior, 101-103, 101f-103f

right-sided anterior, 99-100, 99f-100f

patient positioning for, 90, 91f

pearls and pitfalls of, 105

pheochromocytomas, 90, 105

postoperative care, 104

preoperative considerations for, 88, 90

surgical anatomy, 88, 89f

unilateral, 90

Adrenal glands, 88, 89f

Adrenal vein, 88, 89f, 94f, 96f,

1134f, 1135

Air embolus, 39

Allen’s test, 982

Allen stirrups, 716, 717f

Allis clamps, 24, 25f, 646

Allis forceps, 112, 113f

American Society of Anesthesiologists, 510

Ampulla of Vater, 453, 455f, 457f, 461

Amputation

below-knee

closure of, 1038, 1039f

dissection, 1032-1038, 1033f-1038f

incision, 1030, 1031f

pearls and pitfalls of, 1041

postoperative care, 1040

preoperative considerations for, 1030

surgical anatomy of, 1030, 1031f

hip disarticulation. see Hip disarticulation

supracondylar

closure of, 1048, 1049f

dissection, 1044, 1046, 1047f

incision, 1044, 1045f

indications for, 1042

myodesis/myoplasty, 1046

pearls and pitfalls of, 1050

postoperative care, 1050

preoperative considerations for, 1042

surgical anatomy of, 1042, 1043f

wound hematoma after, 1050

transmetatarsal

closure of, 1054, 1055f

dissection, 1053-1054, 1053f-1055f

incision, 1052, 1052f

indications for, 1051

Amputation (Continued)

pearls and pitfalls of, 1056

postoperative care, 1056

preoperative considerations for, 1052

surgical anatomy of, 1051, 1051f

Anal ﬁ stulas, 776-780

Anal sphincter muscle, 1093f, 1101f

Anastomoses

abdominal aortic aneurysm repair, 887-888

aortofemoral bypass graft, 900-902, 901f

bilioenteric, 532

Billroth I. see Billroth I

Billroth II. see Billroth II

bubble test for, 745

choledochoduodenostomy, 440-442,

440f-442f

colorectal, 740, 740f, 742, 744

end-to-end

aortofemoral bypass graft, 900, 901f

esophagogastrectomy, 216, 216f

gastrectomy, 312, 312f

left colectomy, 682, 682f, 684

right colectomy, 671, 671f

right hemicolectomy, 658, 658f

sigmoid colectomy, 682, 682f, 684

esophagogastrectomy, 216, 216f, 220,

223f-224f

esophagogastric, 211, 211f

esophagojejunal, 313, 313f

femoropopliteal bypass, 926, 927f

Finney pyloroplasty, 268, 270f

gastroduodenal, 283-284, 285f

gastrojejunal, 299f, 300, 301f

gastrojejunostomy, 336, 336f, 341f

Heineke-Mikulicz pyloroplasty, 264, 265f

hepaticojejunostomy, 446-450, 447f-449f

ileal pouch anal, 715

ileorectal. see Ileorectal anastomosis

jejunojejunal

in hepaticojejunostomy, 448, 449f

in Roux-en-Y gastric bypass, 360,

374, 374f

in total gastrectomy, 310, 310f, 313f

left and sigmoid colectomy

, 682, 682f, 684,

690, 691f

low anterior resection–total mesorectal

excision, 740, 740f, 742

right colectomy, 671-672, 671f

right hemicolectomy, 658, 658f-659f,

660-661

Roux-en-Y, 203, 214f, 215f

splenorenal, 957f

transhiatal esophagectomy, 184, 184f, 186,

188, 192

transthoracic esophagectomy, 198-200,

202

Anconeus muscle, 939f

Anesthesia

for carotid endarterectomy, 910, 917

for esophagogastrectomy, 204

for inguinal hernia repair in infants and

children, 843

Page numbers followed by f indicate ﬁ gures.

Index

1186 Index

Anesthesia (Continued)

for percutaneous gastrostomy feeding tube

placement, 255

for pyloromyotomy, 345

for sentinel lymph node biopsy, 134

for Shouldice inguinal herniorrhaphy, 822

for skin grafts, 1146

for transhiatal esophagectomy, 173

for wide local excision, 110

Aneurysms

abdominal aortic. see Abdominal aortic

aneurysm repair

hypogastric, 890

inﬂ ammatory, 891

juxtarenal, 890

Angle of His, 388, 389f

Ankle-brachial indices, 904, 926

Ansa cervicalis muscle, 21f, 907f, 1019f

Ansa hypoglossi nerves, 6, 7f, 36f

Antecolic gastrojejunostomy, 334-335, 337f

Antecubital arteriovenous ﬁ stula, 989-992

Antegrade aortomesenteric bypass, 974-976

Anterior choledochotomy, 438, 439f, 442f

Anterior facial vein, 907f, 911f

Anterior jugular vein, 7f, 21f, 65f, 1019f

Anterior pancreaticoduodenal artery, 551f,

579

Anterior scalene muscle, 1019f, 1172f

Anterior sternoclavicular ligament, 1167f

Anterior superior iliac spine, 803f, 1123f

Anterior tibial artery, 929, 932, 933f, 1031f

Anterior vagus nerve, 329f-331f

Antibiotic prophylaxis

in cholecystectomy, 423

in Finney pyloroplasty, 271

in Jaboulay side-to-side gastroduodenos-

tomy, 273

in laparoscopic adjustable gastric

banding, 386

in left colectomy, 675

in pyloroplasty, 266

in sigmoid colectomy, 675

in skin grafts, 1146

Anuria, 962

Aorta, 509f

Aortic bifurcation graft, 900

Aortocaval ﬁ stula, 890

Aortofemoral bypass graft

abdominal aorta exposure, 896, 898, 899f

anastomoses, 900-902, 901f

ankle-brachial indices, 904

aortic anastomosis, 900, 901f

closure of, 902

complications of, 904

dissection, 896-902, 897f-901f

femoral artery exposure, 896

incision, 896, 897f

indications for, 894

pearls and pitfalls of, 904-905

postoperative care, 904

preoperative considerations for, 894

surgical anatomy of, 892-894, 893f, 895f

tunnel, 898, 899f

Aortomesenteric bypass, antegrade, 974-976

Aortorenal bypass, 946-952

Aortorenal endarterectomy, 952-954

Aortorenal plaque, 953f

Apex suture, 457f

Appendectomy

in intussusception repair, 414, 414f

laparoscopic, 399-403, 400f-402f

open, 404-410, 405f-409f

Appendiceal artery, 408, 409f

Arc of Riolan, 686

Areolar margin incision, 144, 145f, 150, 151f

Areola-sparing mastectomy, 117

Army-Navy retractor, 27, 27f

Arteriovenous ﬁ stula

antecubital, 989-992

radiocephalic, 986-988, 986f-988f

Arteriovenous grafts, 998-1003, 999f-1003f

Ascending colon

anatomy of, 664, 669

graft, 225-227

Ascites

left hepatic lobectomy and, 504-505

right hepatectomy and, 490-492

segmental hepatic resection and,

474-475

Axillary artery, 119f, 125f, 127f, 985f,

1111f, 1117f

Axillary node dissection

closure of, 1118, 1118f

dissection, 1114-1117

drains, 1119

incision, 1112, 1113f

lumpectomy with, 118

patient education after, 1120

pearls and pitfalls of, 1120

postoperative care, 1119-1120

preoperative considerations for, 1112

surgical anatomy of, 1110, 1111f

suturing/sutures, 1118, 1118f

Axillary vein, 127f, 1000f, 1111f, 1117f

Babcock clamps, 8, 9f, 242f-243f, 245, 248f,

622, 631

Babcock for

ceps, 6, 7f, 274f-276f

Balloon trocar, 853

Bariatric surgery, 386. see also Gastric banding;

Roux-en-Y gastric bypass

Basilic vein, 939f, 983f, 991f, 994-995, 997f,

999f-1000f

Bassini inguinal herniorrhaphy

closure of, 808, 809f

dissection, 804-808, 804f-808f

incision, 802

pearls and pitfalls of, 810

postoperative care, 810

preoperative considerations for, 802

surgical anatomy of, 802, 803f

suturing/sutures, 808, 808f-809f

Beger procedure

bilioenteric anastomosis, 532

dissection, 526, 527f

electrocautery, 532, 533f

end-to-side pancreaticojejunostomy

in, 535f

incision, 525, 526f

indications for, 523-524

lesser sac, 522

pancreaticojejunostomy in, 534, 535f

pearls and pitfalls of, 543

peritoneal dissection, 528-529

postoperative care, 543

preoperative considerations for, 524

surgical anatomy of, 522-524

suturing/sutures for, 530, 531f, 536

technique for, 528f-535f, 528-536

Below-knee amputation

closure of, 1038, 1039f

dissection, 1032-1038, 1033f-1038f

incision, 1030, 1031f

pearls and pitfalls of, 1041

postoperative care, 1040

preoperative considerations for, 1030

surgical anatomy of, 1030, 1031f

Benign breast lesion excision, 144-149

Biceps brachii muscle, 985f

Biceps femoris muscle, 1061f

Bicipital aponeurosis, 991f

Bilateral salpingo-oophorectomy

abdominal hysterectomy and, 1070

closure of, 1091

dissection, 1086-1090, 1087f

incision, 1086

pearls and pitfalls of, 1091

postoperative care, 1091

preoperative considerations for, 1086

surgical anatomy of, 1085, 1085f

Biliary radicals, 473, 486

Bilioenteric anastomosis, 532

Billroth I

closure of, 291

contraindications, 278

dissection, 280-290, 281f-290f

incision, 278, 279f

pearls and pitfalls of, 291

postoperative care, 291

preoperative considerations for, 278

surgical anatomy of, 278, 279f

sutures/suturing in

Connell, 288, 289f

Lembert, 283f, 283-284, 285f, 288, 289f

Billroth II

closure of, 303

dissection, 292-302, 293f-302f

Hofmeister method, 299f, 303

incision, 292

pearls and pitfalls of, 303

Polya method, 303

postoperative care, 303

preoperative considerations for, 292

surgical anatomy of, 292

sutures/suturing in, 302f

Cornell, 298, 298f, 300, 301f

Lembert, 297, 297f, 299, 299f

Biopsy

parotid tumors, 52

sentinel lymph node. see Sentinel lymph

node biopsy

Bleeding duodenal ulcer, 324-327

“Bloody gulch,” 32

Bookwalter retractor, 703, 718

Bougie

in open Heller myotomy, 235, 235f

in Zenker’s diverticula surgery, 166, 169

Bovie electrocautery, 722, 722f, 1134

Brachial artery, 983f-985f, 991f, 997f, 1000f

Brachial axillary nodes, 119f

Brachial nodes, 133f

Brachial plexus

injury to, 39

in modiﬁ ed radical mastectomy, 126,

126f-127f

in modiﬁ ed radical neck dissection with

spinal accessory nerve preservation,

21f, 31f, 37f

Brachialis muscle, 991f

Brachiobasilic upper arm transposition,

993-997, 993f-997f

Brachioradialis muscle, 939f, 984f

BRCA1, 109

BRCA2, 109

east

anatomy of, 108, 117, 119f, 1111f

lymphatic system of, 117, 119f

Breast cancer

description of, 109

sentinel lymph node biopsy for. see Sentinel

lymph node biopsy

Breast conservation, 110, 114

Breast surgery

axillary node dissection.

see Axillary node

dissection

benign breast lesion excision, 144-149

intraductal papilloma, 155-160