clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

The French position is one possible patient position for a laparoscopic cholecystectomy (the “American” supine position with both arms tucked alongside the body being the other).

■The patient’s legs are placed in stirrups or supported under the knee

■Legs need to be placed horizontally or slightly declining to allow free movements with laparoscopic tools

■Avoid any pressure on the peroneal (lateral popliteal) nerve

Beach Chair Position

The beach chair position is used for most laparoscopic obesity surgery procedures

■Requires a special weight-bearing table

■The patient is “sitting” on the table

■Avoid any pressure on arms, the brachial plexus, and the peroneal (lateral popliteal) nerve

8 SECTION 1 General Principles

Positioning for Esophageal Surgery

For esophageal resection and reconstruction, several approaches can be used. Depending on the location of the disease and the surgical approach, the positioning is adapted accordingly.

The positions used are:

a)Supine position with overextended thoracic spine, the head rotated to the right and extended. The right arm is left out and the left arm is tucked alongside the body (A) . This position is commonly used for transhiatal esophagectomies enabling:

–Good exposure of the upper abdomen

–Good exposure for the cervical anastomosis

b)Right or left lateral decubitus (B)

–For the intrathoracic anastomosis

–Procedures on the upper thoracic esophagus are approached via a right posterolateral thoracotomy, and similar procedures on the lower esophagus are best approached through the same incision on the left side

–The table is slightly kinked at the thoracic level, further opening the thoracic cavity after thoracotomy

c)45° lateral decubitus or screw position (C)

–An advantage is that the abdominal, the thoracic, and/or cervical phase of the procedure can be performed without changing the position

–For optimal access, the operating table can be tilted

–The main disadvantage is a more limited exposure

A

B

C

10 SECTION 1 General Principles

Incisions

Abdomen

The choice of the approach for entering the abdominal cavity depends upon:

■The accuracy of the preoperative diagnosis

■The location and extent of the disease

■Previous scars

■The requirement of a possible extension of the incision

■Anatomic structures, such as skin, fascia, muscles, nerves, and blood vessels.

The abdominal wall should stay functional. Whenever possible, incisions are placed along the skin split lines, also called the lines of Langer, and muscles and fascia are divided along their fibers

Mark the incision prior to cutting to prevent malpositioning

Midline Incision

The midline incision is the most expedient choice for opening the abdomen and provides unrestricted access, regardless of the patient’s size or shape (including exposure of the pelvis). The advantages of a midline incision are:

■Can be extended into a median sternotomy

■Minimal blood loss

■No muscle fibers are divided

■No nerves are injured

■Is suitable for repeated celiotomies

■Offers best exposure in an emergency situation with unclear diagnosis

The Steps

■Place skin incision exactly in the midline, above and below the umbilicus from the tip of the xiphoid to the pubis (extension as needed) (A-1)

■Deflect the incision around the umbilicus to the left or the right. The evasion of the umbilicus on the left side is preferred, because of possible rudimentary umbilical vessels. In general, use the opposite side of the umbilicus if an ostomy is planned

■The scalpel or the cautery can be used all the way

■By pulling the wound, the fat spreads and the midline plane separates down to the fascia (A-2, A-3)

■Apply digital pressure to minimize bleeding

■Incise the fascia with the scalpel or cautery just above or below the umbilicus, as the linea alba is widest around the umbilicus

■Gently lift up the peritoneum with pickups before opening to avoid small bowel lesions (A-4)

■Care to incise the linea alba without exposing the rectus muscles markedly facilitates the closure

12 SECTION 1 General Principles

Subcostal Incision (A-1)

The subcostal incision is usually made for cholecystectomy or common bile duct exploration (right subcostal incision) and for elective splenectomy (left subcostal incision). The major advantage of the subcostal incisions over the upper midline incision are greater lateral exposure and less pain. The disadvantage is that the operation takes longer, because there are more layers to close. The subcostal incision generally heals well with little risk of hernia formation.

The Steps

■Place skin incision two finger breadths below the costal margin. This facilitates closure so that the incision line is not on or over the costal margin

■Incise the anterior and posterior sheet of the rectus muscle. The muscle is cut slowly with the cautery (A-2); care should be taken to ligate or cauterize the inferior epigastric vessels

■Laterally, the fascia of the transverse muscle may need to be cut

■Try not to incise the fascia in the midline, but if necessary, extend the incision medially

Bilateral Subcostal Incision

The bilateral subcostal incision is used to access the liver for transplant and major liver resections. Also, most pancreas resections are performed with this incision. The exposure is often helped with a vertical extension to the xiphoid (the so-called “Mercedes star” incision).

The Steps

■Incision of skin and fascia as described above

■For pancreas resections, the incision is generally placed three to four finger breadths below the costal margin

■Mobilization of the liver begins with the division of the falciform ligament (the liver’s reflection of peritoneum with the anterior wall)

■Division of the round ligament (a fibrous cord resulting from the obliteration of the umbilical vein), which should be ligated to avoid bleeding, particularly in the presence of portal hypertension

■It is preferable to mobilize the liver prior to the use of stationary retractors to reduce the necessity of frequent repositioning

J-shaped Incision

The J-shaped incision is used most frequently for surgery on the right liver (see page 374 ). This incision provides a particularly good access to the area between the inferior vena cava and the right hepatic vein. The J-shaped incision can be extended laterally to a thoracotomy for better exposure.

Like the various positions used in esophageal surgery, there are different incisions used depending on the location of the disease, the level of the anastomosis, and the surgeon’s preference. Most of the time, a combination of two or more of the following incisions are used:

a)Upper midline laparotomy

–As described in the previous section on the abdomen

–Can be combined with a transverse laparotomy for better exposure

b)Thoracotomy

–Anterolateral: skin incision usually in the fourth or fifth intercostal space

–Posterolateral: skin incision in the seventh intercostal space at the angle of the scapula (A-1). A paravertebral or anterior extension is possible

–The intercostal muscle is freed from the upper border of the rib (avoids damaging the intercostal nerve and blood vessels, which lie behind the inferior border

of the rib) (A-2)

–The parietal pleura is opened with scissors, and the ribs are separated with a retractor

c)Cervical incision (B-1)

–Incision along the anterior border of the sternocleidomastoid muscle (B-2)

–Division of the platysma in the direction of the incision

–The omohyoid muscle (B-3) and, if necessary, the inferior thyroid artery and/or middle thyroid vein are divided to provide clear exposure

–The sternocleidomastoid muscle and carotid sheath and its contents are retracted laterally, and the trachea and larynx are retracted medially

–No retractor should be placed against the recurrent laryngeal nerve in the tracheoesophageal groove during the entire cervical phase of the procedure

–For better exposure, the medial part of the sternocleidomastoid muscle can be cut inferiorly close to the clavicle bone

–Identification of the flat, decompressed esophagus can be helped by inserting a large tube into the esophagus by the anesthesiologist

–In patients with a “bull neck” habitus or with osteoarthritis preventing extension of the neck, a partial upper sternal split can provide the prerequisite access to the high retrosternal esophagus