Abdomen

Abstract

In this chapter, the principles of abdominal surgery are indicated as well as the clinical anatomy on which they are based. In addition common bowel resection procedures are described as well as anastomosis procedures used in abdominal surgery. The particularities of the abdomen of children are also presented.

1 Principles of Surgery

• The knowledge of basic surgical principles is essential in order to be able to demonstrate competence in tissue dissection, principles of hemostasis etc. thus minimizing risk and optimizing the surgical outcome

• Excellent communication and teamwork are the cornerstones of performing safe and successful surgery

• The aim of any surgical procedure includes that:

  • Every operation should have a benefit for the patient

  • The benefit might be diagnostic or therapeutic

  • This benefit has to be achieved with the surgical procedure that provides maximal benefit with minimal risk

• Mutilating operations should be always avoided

2 Organ Anatomy

A good knowledge of the anatomy and recognize variants, which could make surgery more challenging, is a prerequisite for avoiding complications and contributes to the success of the procedure.

The normal anatomy for the following organs is shown in the figures below

• Stomach (Figs. 20.1 and 20.2)

• Small bowel (Fig. 20.3)

• Colon (Fig. 20.4)

• Rectum (Fig. 20.5)

• Liver (Fig. 20.6)

• Pancreas (Fig. 20.7)

• Adrenals (Fig. 20.8)

Fig. 20.1

Topographic anatomy of the stomach

Fig. 20.2

Vascular anatomy of the stomach, spleen, liver, and duodenum

Fig. 20.3

Topographic and vascular anatomy of the small bowel

Fig. 20.4

Topographic and vascular anatomy of the colon

Fig. 20.5

Topographic anatomy of the rectum

Fig. 20.6

Segmental arrangement of the liver

Fig. 20.7

Topographic and vascular anatomy of the pancreas

Fig. 20.8

Topographic and vascular anatomy of the adrenals

3 Age Related Anatomical Particularities

Age-related Differences in Anatomy

• Age-related differences in anatomy are listed in Table 20.1 and illustrated in Fig. 20.9

Table 20.1 Age-related differences in anatomy

Fig. 20.9

Differences in the abdomen of infants and adults

4 Abdominal Incisions

• Types of abdominal incision and their advantages and disadvantages are described in Table 20.2

Table 20.2 Types of abdominal incision, their advantages and disadvantages

5 Common Bowel Surgical Techniques

• Small bowel anastomosis

  • End-to-end ileo-ileostomy, side-to-side ileo-ileostomy, and ileoascendostomy (Fig. 20.10)

  • Diversion anastomoses: Y-Roux, and omega with a side-to-side anastomosis (Fig. 20.11)

  • Stricturotomy (Fig. 20.12)

• Colon

  • Right hemicolectomy (Fig. 20.13)

  • Left hemicolectomy (Fig. 20.14)

Fig. 20.10

Anastomoses techniques. (a) End-to-end ileoileostomy, (b) side-to-side ileo-ileostomy, (c) ileo-ascendostomy

Fig. 20.11

Diversion anastomoses. (a) Y-Roux anastomosis, (b) Omega anastomosis with a side-to-side anastomosis

Fig. 20.12

(a–c) Principle of stricturotomy

Fig. 20.13

Right hemicolectomy

Fig. 20.14

Left hemicolectomy

6 Types of Ostomies

• Ostomies are diversions of the intestine to an opening in the abdominal wall

• This procedures can be performed either in the small intestine or the colon

• Figure 20.15 shows the different possibilities to divert the intestine and create a stoma

• The indications for each one will be indicated in the different chapters

Fig. 20.15

(a) Chimney end stoma, (b) double barrel stoma, (c) end to side with distal vent (Bishop-Koop ostomy), (d) side to end with proximal vent (Santulli ostomy), (e) loop stoma (skin bridge), (f) end stoma with closure of the distal part (Hartmann pouch)

7 Special Bowel Surgical Techniques

• Noble plication

  • Indication for intestinal obstruction due to extensive adhesions resulting from numerous similar operations or extensive serosal damage following division of multiple adhesions

  • Fixation of loops causing adhesions to form in an orderly fashion without kinks

  • Fixation with serosal sutures between the intestinal loops with wide meanders (Fig. 20.16)

  • Alternatively the loops can be stuck with Fibrin glue

  • A modification is also possible with the insertion of a long tube (Baker tube) which is exteriorized through an appendicostoma (Fig. 20.17)

Fig. 20.16

Classical Noble plicature

Fig. 20.17

Plicature with along tube via appendicostoma

• Bishop Koop Anastomosis (Fig. 20.18)

  • Indicated in cases of meconium ileus, multiple intestinal atresia or stenosis, especially for the management of greatly different intestinal diameters

  • The intestine is divided at the site where the anastomosis is required

  • About 5 cm distal of the separation the distal intestine is incised antemesenterially

  • The proximal intestine is anastomosed end to side

  • The distal intestine is exteriorized as a chimney ostomy and serves as a vent

  • Extraperitoneal closure of the stoma is easy and safe

Fig. 20.18

Bishop Koop colostomy