Anesthesiologist's Manual of Surgical Procedures, 4th ed.

General Surgery

Chapter 7.3

Intestinal Surgery

Jeffrey A. Norton MD

Surgeon

Harry A. Oberhelman MD, FACS

Surgeon

Kevin A. Malott MD

Anesthesiologist

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Duodenotomy

Surgical Considerations

Description: A duodenotomy is performed to ligate a bleeding vessel at the base of a duodenal ulcer or to perform some procedure on the ampulla of Vater or the duct of Santorini. It is important, therefore, to be familiar with the anatomy of the proximal duodenum in relation to the major and minor pancreatic duct orifices (Fig. 7.3-1). The duodenotomy may be made longitudinally or transversely, depending on the surgeon's preference. A transverse opening allows one to close the duodenotomy without tension; however, it must be made very accurately for the purpose of exposure. Bleeding vessels at the base of an ulcer must be secured with suture ligatures. Care must be taken to avoid perforating the duodenum when performing a sphincterotomy.

Usual preop diagnosis: Duodenal ulcer; impacted common duct stone; chronic pancreatitis 2° alcoholism, gallstones, pancreatic divisum, or other obstruction of the main pancreatic duct

Summary of Procedures

Position

Supine

Incision

Midline abdominal or subcostal

Unique considerations

Magnifying glasses, if operation involves lesser pancreatic sphincter

Antibiotics

Cefoxitin 1 g iv

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

1–2 h

Closing considerations

Secure closure of duodenum without tension

EBL

Minimal

Postop care

NG decompression

Mortality

< 0.5%

Morbidity

Duodenal leak: < 5%
Postop pancreatitis: < 3%

Pain score

6–8

Patient Population Characteristics

Age range

Any age

Male:Female

1:1

Incidence

Not uncommon

Etiology

Duodenal ulcer; impacted common duct stone; villous tumors of ampulla; chronic pancreatitis, pancreatic divisum

Associated conditions

Bleeding duodenal ulcer (50–60%); chronic pancreatitis (20–25%); impacted common duct stones (10–15%)

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Figure 7.3-1. Anatomy of pancreatic ductal system. In 30% of patients, the accessory duct ends blindly. (Reproduced with permission from Greenfield LJ, Mulholland MW, Oldham KT, et al: Surgery: Scientific Principles and Practice, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001.)

Anesthetic Considerations

See Anesthetic Considerations following Operations for Peptic Ulcer Disease, Stomach Surgery, p. 515.

Suggested Readings

  1. Cisco RM, Norton JA: Surgery for gastrinoma. Adv Surg2007; 41:65–76.
  2. Nora PF: Operative Surgery: Principles and Techniques,3rd edition. WB Saunders, Philadelphia: 1990.

Open Appendectomy

Surgical Considerations

Description: Open appendectomy is performed for appendicitis or suspected appendicitis; however, it has been largely replaced by the laparoscopic approach (see p. 591). The negative laparotomy rate has been reduced by the judicious use of preoperative CT examination. Through a RLQ (McBurney) or right paramedian incision, the cecum is exposed and pulled into the wound (Fig 7.3-2). The appendix is then delivered through the wound; and the mesoappendix is clamped, cut, and ligated. The appendix is removed by crushing, ligating, and then transecting the base. The appendiceal stump may be invaginated into the wall of the cecum or left alone. In some instances it may be easier to divide the base of the appendix before delivering the appendix into the wound. The wound should be left open and soft drains used in cases of perforated appendix. In children, the appendix may be inverted and allowed to slough off internally.

Variant procedure or approach: Laparoscopic appendectomy (see p. 592).

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Figure 7.3-2. Relevant anatomy for appendectomy. (Reproduced with permission from Scott-Conner CEH, Dawson DL: Operative Anatomy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2003.)

Usual preop diagnosis: Appendicitis

Summary of Procedures

Position

Supine

Incision

RLQ (McBurney's) or right paramedian

Unique considerations

Variation in stump closure; NG tube if prolonged ileus expected.

Antibiotics

Cefoxitin 1 g preop

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

1 h

Closing considerations

Skin wound should not be closed when appendix is perforated. Drain in presence of well-defined abscess cavity.

EBL

< 75 mL

Postop care

Wound care when left open

Mortality

Perforated: 2%
Nonperforated: < 0.1%

Morbidity

Pelvic, subphrenic, or intraabdominal abscess (perforation): 20%
Wound abscess: < 5%
Fecal fistula: < 1%
Wound hematoma: < 0.5%
Ileus: Variable

Pain score

5–7

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Patient Population Characteristics

Age range

Any age

Male:Female

1:1

Incidence

1/15 persons

Etiology

Obstruction (80–90%); fecaliths (75%); carcinoid tumors (< 5%)

Associated conditions

None

Anesthetic Considerations

See Anesthetic Consideration following Excision of Meckel's diverticulum, below p. 512.

Suggested Readings

  1. Nguyen NT, Hinojosa MW, Fayad C, et al: Laparoscopic surgery is associated with a lower incidence of venous thromboembolism with a lower incidence of venous thromboembolism compared with open surgery. Ann Surg2007; 246:1021–7.
  2. See Suggested Readings following Excision of Meckel's diverticulum, pp. 513–514.

Excision of Meckel's Diverticulum

Surgical Considerations

Description: Meckel's diverticulum is a true congenital diverticulum, usually arising within 100 cm of the ileocecal valve. It was first described by Meckel in 1809. Excision of a Meckel's diverticulum is indicated for bleeding, obstruction, perforation, inflammation, intussusception, and when there is a palpable mass near the base of the diverticulum. Ectopic mucosa is present in roughly 50% of symptomatic patients, with gastric mucosa the most frequent. After entering the peritoneal cavity, the distal ileum, along with the diverticulum, is delivered into the wound. The diverticulum is excised and the wound is closed in two layers. Following excision of the diverticulum, care must be taken not to narrow the bowel lumen during closure. If a diagnosis can be made preop, a laparoscopic approach may be used (see Laparoscopic Bowel Resection p. 588).

Usual preop diagnosis: Meckel's diverticulum

Summary of Procedures

Position

Supine

Incision

Midline abdominal or RLQ (McBurney's)

Antibiotics

Cefoxitin 1–2 g iv

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

1–1.5 h

EBL

< 100 mL

Mortality

< 0.5%

Morbidity

Wound infection: 5%
Pulmonary complication: < 5%
Anastomotic leak: < 1%

Pain score

6–8

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Patient Population Characteristics

Age range

< 40 yr

Male:Female

3:1

Incidence

0.3–2.5%

Etiology

Congenital

Associated conditions

Exomphalos; esophageal atresia; anorectal atresia; gross malformations of CNS or CV system

Anesthetic Considerations

(Procedures covered: open appendectomy; excision of Meckel's diverticulum)

Preoperative

This patient population is generally fit and healthy, apart from their acutely presenting illness. Full-stomach precautions are appropriate in these patients. Surgery for appendicitis is one of the most common nonobstetric procedures performed on the pregnant patient (~1/1,500 pregnancies). These patients often are more ill at the time of diagnosis, because early symptoms may be attributed to pregnancy, and the gravid uterus may hinder an accurate abdominal exam. Anesthesia management for the gravid appendicitis patient mirrors that of the nongravid patient (full-stomach precautions) with consideration of the maternal physiologic changes of pregnancy and the effects of anesthesia on the fetus and uteroplacental perfusion (See Anesthetic Considerations for Cervical Cerclage, Obstetric Surgery, p. 835.)

Respiratory

Respiratory impairment may occur 2° the acute abdominal pain and splinting. Tachypnea and hyperpnea can be heralding Sx of appendiceal perforation and sepsis. Patients with acute abdomen pain should be treated as if they have full stomachs. Consider administration of metoclopramide (10 mg iv), H2-antagonist (ranitidine 50 mg iv), and Na citrate 0.3 M 30 mL po.
Tests: As indicated from H&P.

Cardiovascular

May be dehydrated from fever, emesis, and ↓ oral intake → ↑ HR + ↑ BP (2° pain), or ↓ BP (sepsis, hypovolemia). Assess volume status appropriately and hydrate adequately prior to proceeding with anesthetic induction.
Tests: ECG, if indicated from H&P.

Gastrointestinal

Patient typically has abdominal pain with N/V. Muscular resistance to palpation of abdominal wall frequently parallels the severity of the inflammatory process. With spreading peritoneal irritation (as with perforation), patient will develop abdominal distension and paralytic ileus. Electrolyte abnormalities are common 2° N/V.
Tests: Electrolytes

Hematologic

Moderate leukocytosis (10,000–18,000) with moderate left shift. Hemoconcentration is probable if patient is dehydrated.
Tests: CBC

Laboratory

Other tests as indicated from H&P.

Premedication

Full-stomach precautions (see p. B-4). Consider midazolam 1–2 mg iv. Opiate medications (morphine 0.03–0.15 mg/kg iv) often delayed or minimized until diagnosis made. Opiate analgesics not contraindicated during the evaluation of an acute abdomen including appendicitis.

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Intraoperative

Anesthetic technique: GETA, with rapid-sequence iv induction, followed by ET intubation (see full-stomach precautions, p. B-4). If systemic sepsis is absent, hydration is adequate, the patient is cooperative, and high abdominal exploration is unlikely, then regional anesthesia may be considered.

Induction

Rapid-sequence induction of anesthesia (see p. B-4). Restore intravascular volume prior to anesthetic induction if patient is clinically hypovolemic.

Maintenance

Standard maintenance (see p. B-2), without N2O. Evacuate stomach with OG or NG tube. Maintain muscle relaxation based on nerve stimulator response.

Emergence

Patient should be extubated awake after return of airway reflexes.

Blood and fluid requirements

IV: 16–18 ga × 1
NS/LR @ 5–8 mL/kg/h

 

Monitoring

Standard monitors (see p. B-1).

Others, as indicated by patient's status.

 

Positioning

[check mark] and pad pressure points
[check mark] eyes

 

 

Complications

Sepsis

 

 

Postoperative

Complications

Sepsis (possible with appendiceal rupture)
Paralytic ileus
Atelectasis
PONV (see p. B-6)

Adequate antibiotic coverage

Adequate pain control, incentive spirometry, early ambulation

Pain management

PCA (see p. C-4).

 

Tests

As indicated clinically.

 

Suggested Readings

  1. McBurney C: Experience with early operative interference in cases of disease of the vermiform appendix. NY Med J1889; 50:676–84.
  2. Meckel JF: Ulcer die divertikel an darmkanal. Arch Physiol1809; 9:421–53.

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  1. Merritt WT: Anesthesia for gastrointestinal surgery. In: Principles and Practice of Anesthesiology,2nd edition. Longnecker DE, Tinker JH, Edward G, eds. Mosby-Year Book, St. Louis: 1998, 1881–903.
  2. Morgan EG, Mikhail MS, Murray MJ: Clinical Anesthesiology,4th edition. Lange Medical Books, Stamford: 2006, 919–20.
  3. Rosen MA: Management of anesthesia for the pregnant surgical patient. Anesthesiology1999; 91:1159–63.
  4. Way LW, Doherty GM, eds: Current Surgical Diagnosis Treatment. Appleton & Lange, Stamford: 1994, 610–13.
  5. Zani A, Eatons S, Rees CM, Pierro A. Incidentally detected Meckel diverticulum: to resect or not to resect? Ann Surg2008; 247:276–81.

Enterostomy

Surgical Considerations

Description: Enterostomy is performed for stenting the small intestine with a long tube for feeding purposes, for bypassing small or large bowel obstructions, and following total proctocolectomy. An intestinal tube is either purse-stringed into the small bowel and brought through the abdominal wall or the intestine itself is brought to the exterior and fashioned into a stoma. Different tubes are used for feeding, according to surgeon's preference. After purse-stringing the tube in the bowel, the seromuscular layer of the jejunum is sutured over the tube for a distance of 3–4 cm before exiting through the abdominal wall. The Brooke ileostomy is created by bringing a 2-inch segment of ileum through an abdominal wall stab wound. The ileum is folded back on itself and sutured to the skin edge or dermis (Fig. 7.3-3). Some surgeons secure the ileum to the underlying peritoneum and/or fascia, but this is not necessary.

Variant procedure or approaches: There are various intestinal or drainage tubes that may be inserted into the bowel, depending on the function required. For example, certain tubes are used for feeding, while others may be used for drainage or decompression.

Usual preop diagnosis: Intestinal obstruction due to extensive adhesions; following removal of the large intestine (including the rectum); for enteral feedings

 

Figure 7.3-3. Brooke ileostomy. (Reproduced with permission from Hardy JD: Rhoad's Textbook of Surgery, 5th edition. JB Lippincott, Philadelphia: 1977.)

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Summary of Procedures

 

Enterostomy

Ileostomy

Position

Supine

Incision

Midline abdominal

Antibiotics

Cefoxitin 1–2 g iv preop

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

1–1.5 h

Closing considerations

Securing tube to abdominal wall

Viable stoma

EBL

< 100 mL

Postop care

Tube irrigation

Stoma care

Mortality

< 0.5%

Morbidity

Ileus: 60–70%
Wound infection: < 5%



Stoma necrosis: < 2%

Pain score

5–6

5–6

Patient Population Characteristics

Age range

20–65 yr

Male:Female

1:1

Incidence

Common

Etiology

Intestinal obstruction (60–70%); diseases resulting in total proctocolectomy (10–15%); inability to eat (5–10%)

Associated conditions

Inflammatory bowel disease (IBD); intestinal adhesions; inability to eat orally

Anesthetic Considerations for Ostomy Procedures

(Procedures covered: enterostomy; continent ileostomy; gastrostomy; gastrojejunostomy)

Preoperative

This patient population is very diverse and includes those with IBD, cancer, and those presenting post-CVA and trauma. Thus, the population ranges from the otherwise healthy to the critically ill. Many of these patients will have abnormal protective airway reflexes and are at risk of aspiration of gastric contents.

Respiratory

Patients post-CVA or head trauma may have abnormal laryngeal reflexes and difficulty swallowing, making them prone to aspiration of gastric contents and associated pneumonitis (evaluate gag reflex). Decreased pulmonary reserve and hypoxemia can be seen in patients with pulmonary infections.
Tests: Consider CXR to r/o pneumonia. Consider ABG.

Cardiovascular

Patients may be hypovolemic 2° chronically poor po intake.
Tests: ECG; orthostatic vital signs

Musculoskeletal

Patients often sick and debilitated (e.g., post-CVA).

Gastrointestinal

Patients often malnourished and prone to electrolyte abnormalities 2° poor po intake.
Tests: Electrolytes; BUN; Cr, consider PT/PTT.

Laboratory

CBC with differential; others as indicated from H&P.

Premedication

Depends on patient status. Titrate small doses of benzodiazepines (midazolam 0.25–0.5 mg iv) or opiate (fentanyl 25–50 mcg iv). Consider H2-antagonists (e.g., ranitidine 50 mg iv, 60 min preop) and metoclopramide (10 mg iv 20 min preop).

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Intraoperative

Anesthetic technique: GETA is appropriate for most ostomy procedures; MAC with local anesthesia may be appropriate in selected patients.

Induction

Patient may be at risk for pulmonary aspiration. If GA is planned, consider rapid-sequence induction with cricoid pressure. If patient is clinically hypovolemic, restore intravascular volume (colloid, crystalloid, or blood products) prior to induction and titrate induction doses of sedative/hypnotic agents.

Maintenance

MAC: Titration of sedatives (e.g., propofol 25–150 mcg/kg/min) and analgesics (fentanyl 25–50 mcg iv). GA: Standard maintenance (see p. B-2).

Emergence

Trachea should be extubated after return of protective laryngeal reflexes, if patient at risk for aspiration of gastric contents.

Blood and fluid requirements

Minimal blood loss
IV: 16–18 ga × 1
NS/LR @ 5–8 mL/kg/h

 

Monitoring

Standard monitors (see p. B-1).

Others as clinically indicated.

Positioning

[check mark] and pad pressure points
[check mark] eyes

 

Postoperative

Complications

Atelectasis
Aspiration
Hypoxemia
Hypercarbia
VTE (see appendix p. B-7)

Pain management

PCA (see p. C-3).

Suggested Readings

  1. Cingi A, Solmaz A, Attaqllah W, et al: Enterostomy closure site hernias: a clinical and ultrasonographic evaluation. Hernia2008; in press.
  2. Zinner MJ, Schwartz SI, Ellis H, eds: Maingot's Abdominal Operations,Vol I, 10th edition. Appleton & Lange, Stamford, CT: 1997, 427–51.

Continent Ileostomy Pouch (Kock)

Surgical Considerations

Description: A Kock pouch consists of an internal reservoir fashioned from the distal ileum and an intussuscepted nipple valve used to provide continence. Approximately 45 cm of small bowel are required for construction of the

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pouch and valve. After suturing two limbs of the ileum together over a distance of 15 cm, the distal segment is intussuscepted over itself to form the nipple valve. The pouch is then sutured closed and mounted beneath the abdominal wall stoma site (Fig. 7.3-4). The stoma is made flush with the skin for cosmetic reasons and left intubated for 1 month with a special plastic catheter. The pouch remains decompressed for 1 month before intermittent catheterization is initiated. The continent ileostomy reservoir has been modified byBarnett to include the construction of an isoperistaltic valve with an intestinal collar around its base to prevent deintussusception and valve prolapse. These procedures are typically performed following a total proctocolectomy or to replace conventional ileostomies.

Usual preop diagnosis: Inflammatory bowel disease; familial polyposis or malfunctioning ileostomies

 

Figure 7.3-4. Continent ileostomy or Kock pouch. (Reproduced with permission from Hardy JD: Hardy's Textbook of Surgery, 2nd edition. JB Lippincott, Philadelphia: 1988.)

Summary of Procedure (Kock or Barnett Pouch)

Position

Supine

Incision

Midline abdominal

Special instrumentation

GIA or TA staplers

Antibiotics

Usual bowel prep with antibiotics; cefoxitin 1 g iv preop

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

3–4 h

Closing considerations

Valve vascularity

EBL

200–300 mL

Postop care

Maintain pouch decompression

Mortality

< 1%

Morbidity

Intestinal ileus: 5%
Wound infection: < 5%
Intestinal obstruction: 2–3%
Pouch fistula: 1–3%
Valve necrosis: < 0.5%

Pain score

6–8

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Patient Population Characteristics

Age range

18–80 yr

Male:Female

1:1

Incidence

Common

Etiology

Ileostomy (50%); proctocolectomy (5%)

Associated conditions

Extracolonic inflammatory bowel manifestations (10%)

Anesthetic Considerations

See Anesthetic Considerations for Ostomy Procedures, p. 515.

Suggested Readings

  1. Barnett WO: Modified techniques for improving the continent ileostomy. Am Surg1984; 50(2):66–9.
  2. Becker JM, Stuchni AF: Ulcerative colitis. In: Surgery: Scientific Principles and Practice,3rd edition. Greenfield LJ, Mulholland MW, Oldham KT, et al, eds. Lippincott Williams & Wilkins, Philadelphia: 2001, 1070–89.
  3. Little UR, Barboors RN, Shrock TR, et al: The continent ileostomy–long-term durability and patient satisfaction. J Gastrointest Surg1999; 3:625–32.
  4. Smith LE: Surgical therapy in ulcerative colitis. Gastroenterol Clin North Am1989; 18:99–110.

Small-Bowel Resection with Anastomosis

Surgical Considerations

Description: Resection of the small bowel is performed for a number of diseases (listed below). After entering the peritoneal cavity, the involved small bowel is delivered into the wound and the lesion resected between bowel clamps (Fig. 7.3-5). Varying amounts of mesentery are included, depending on the diagnosis. More extensive resections are indicated for malignant disease, including regional lymph nodes. Reanastomosis may be accomplished by various suturing techniques or stapling. The peritoneal cavity may be accessed through vertical or transverse incisions. Operative techniques include open end-to-end, closed end-to-end, side-to-side, or stapled, functional end-to-end anastomoses.

Variant procedure or approaches: Laparoscopic small-bowel resections are being performed more frequently (see p. 588).

Usual preop diagnosis: Intestinal obstruction, complicated by intestinal gangrene due to adhesions, internal hernia, volvulus, intussusception, mesenteric vascular occlusion, Crohn's disease, radiation enteritis, intestinal fistulae, small bowel tumors, and trauma

Summary of Procedures

Position

Supine

Incision

Vertical or transverse

Unique considerations

Adequate fluid resuscitation; NG tube

Antibiotics

Cefoxitin 1–2 g iv preop

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

1–3 h

EBL

50–100 mL

Postop care

NG or long intestinal tube decompression

Mortality

Varies according to etiology: 1–5%

Morbidity

Atelectasis: < 10%
Intestinal ileus: < 10%
Wound infection: < 5%
Intestinal leak, fistula: < 3%

Pain score

7–9

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Patient Population Characteristics

Age range

20–90 yr

Male:Female

1:1

Incidence

Common

Etiology

Interference with blood supply (obstruction, strangulated hernia, volvulus, mesenteric thrombosis); trauma; tumors; Crohn's disease

Associated conditions

Multiple, depending on etiology (see Preop diagnosis, above).

 

Figure 7.3-5. Block-Potts bowel clamps are applied from the antimesenteric to mesenteric border to avoid twisting. A Kocher clamp is applied on the specimen side, and the bowel is transected with a scalpel. (Reproduced with permission from Baker RJ, Fischer JE, eds: Mastery of Surgery, Vol II, 4th edition. Lippincott Williams & Wilkins, Philadelphia: 2001.)

       

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Anesthetic Considerations

See Anesthetic Considerations for Intestinal and Peritoneal Procedures, p. 522.

Suggested Readings

  1. Chaiyasate K, Jain AK, Cheung LY, et al: Prognostic factors in primary adenocarcinoma of the small intestine. World J Surg Oncol2008; 31:6–12.
  2. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations,7th edition. MacMillan, New York: 1993.

Enterolysis

Surgical Considerations

Description: Enterolysis consists of separating loops of bowel adhesed to other loops or the abdominal wall by sharp dissection, and by excising adhesive bands. Care must be taken to avoid producing enterotomies. Covering potential adhesion sites with a hyaluronic carboxymethylcellulose membrane may lessen the formation of intraperitoneal adhesions.

Usual preop diagnosis: Intraabdominal adhesions; intestinal obstruction

Summary of Procedures

Position

Supine

Incision

Midline abdominal

Special instrumentation

A long intestinal tube may be necessary for decompression and fixation of bowel loop.

Unique considerations

Bowel decompression

Antibiotics

Cefoxitin 1 g iv preop

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

1–4 h

Closing considerations

Adequate decompression to permit wound closure

EBL

150–500 mL

Postop care

PACU; continued intestinal decompression 2–5 d

Mortality

1–3%

Morbidity

Wound abscess: 15–20%
Prolonged ileus: 10–20%
Fistula formation: < 10%
Pulmonary complications: 5–10%
Recurrent intestinal obstruction: 5–8%

Pain score

5–7

Patient Population Characteristics

Age range

Any age

Male:Female

1:1

Incidence

Common

Etiology

Previous intraabdominal operative procedure (> 90%); malignant tumors (15–20%); hernias (10–15%); volvulus (5–10%); inflammatory bowel disease (5%); gallstone ileus (< 5%); intussusception (< 5%)

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Anesthetic Considerations

See Anesthetic Considerations for Intestinal and Peritoneal Procedures, p. 522.

Suggested Readings

  1. Aydeniz B, Teppey-Wessels K, Honig A, et al: Laparoscopic enterolysis before adjuvant radiotherapy in a case of endometrial cancer. Gynecol Oncol2004; 92:331–3.
  2. Close MB, Christensen NM: Transmesenteric small bowel plication or intraluminal tube stenting. Indications and contraindications. Am J Surg1979; 138(1):89–96.
  3. Vrijland WW, Tseng LN, Eijkman HJ, et al: Fewer intraperitoneal adhesions with use of hyaluronic acid-carboxymethylcellulose membrane: a randomized clinical trial. Ann Surg2002; 235:193–9.

Closure of Enteric Fistulae

Surgical Considerations

Description: Enteric fistulae may occur between the bowel and abdominal wall (enterocutaneous), between loops of the intestine (enteroenteric or enterocolic), or between the bowel and bladder or vagina (enterovesical or enterovaginal). Surgical repair is usually reserved for fistulae to the abdominal wall, bladder, and vagina, and consists of excising the fistula and repairing the bowel and the other organ separately. Most fistulae are characterized by the adherence of the two visceral organs with a communication between their lumens.

The organs involved are separated by blunt-sharp dissection and repaired locally after excision of the indurated margins of the defect. In the case of both the small and large intestines, it may be necessary to resect a segment of bowel with the defect and to perform an end-to-end anastomosis. If the repair sites involved lie close together, it is important to interpose tissue, such as the omentum, between the viscera to minimize chance of recurrence. Occasionally, a fistula may be bypassed rather than surgically resected.

Usual preop diagnosis: Enteric fistula

Summary of Procedures

Position

Supine

Incision

Midline abdominal

Unique considerations

Preop nutritional support and fistula wound care

Antibiotics

Cefoxitin 1–2 g iv preop

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

2–4 h

Closing considerations

Separation of repairs by interposition of omentum and other tissue

EBL

50–300 mL

Postop care

NG decompression until bowel function returns; TPN support

Mortality

0–5%

Morbidity

Ileus: 60–70%
Pulmonary complications: 10%
Recurrent fistula: 5–10%
Wound infection: 5–10%

Pain score

6–8

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Patient Population Characteristics

Age range

Any age

Male:Female

1:1

Incidence

Common

Etiology

Anastomotic leaks (60–70%); carcinoma (10–15%); Crohn's disease (5–10%); iatrogenic bowel injury (5–10%); perforative diverticulitis (5–10%); radiation enteritis (5%); foreign body perforation (< 5%)

Associated conditions

Malnutrition (30%); inflammatory bowel disease (25%); cancer (15%)

Anesthetic Considerations for Intestinal and Peritoneal Procedures

(Procedures covered: small-bowel resection; enterolysis; closure of enteric fistulae; excision of intraabdominal and retroperitoneal tumor; drainage of subphrenic abscess)

Preoperative

Patients requiring exploratory laparotomy present both electively and emergently for a very wide range of disorders. As a result of their abdominal pathology, these patients are often at high risk for the pulmonary aspiration of gastric contents. Precautions to prevent this are necessary to help assure safe patient outcome (see p. B-4).

Respiratory

Respiratory insufficiency can be present due to intraabdominal pathology (e.g., ascites, large tumor, free blood, bowel distension, pain); ↓ FRC →↑ A-a gradient and arterial hypoxemia; diaphragmatic impairment and splinting →↑ respiratory insufficiency.
Tests: Consider CXR; ABG.

Cardiovascular

Patients for emergency surgery often critically ill and unstable, and should be evaluated for presence of hypovolemia (hypotension, tachycardia) and should receive adequate volume replacement before anesthetic induction. Elective patients may be hypovolemic 2° bowel prep.
Tests: ECG; consider orthostatic vital signs

Musculoskeletal

Abdominal rigidity may be present; abdominal pain is common.

Gastrointestinal

Diarrhea, vomiting, and prolonged npo status can lead to electrolyte abnormalities. Malnutrition may be present.
Tests: Electrolytes, consider PT/PTT

Renal

Renal insufficiency/failure may be present, especially in elderly and/or chronically ill patients, and in those who are hypovolemic.
Tests: Consider BUN; Cr; electrolytes.

Laboratory

CBC with differential; Plt count

Premedication

Standard premedication (see p. B-1). Consider H2-antagonists (e.g., ranitidine 50 mg iv 1 hr preop), metoclopramide (10 mg iv 30 min preop; although contraindicated in bowel obstruction/perforation), and Na citrate (30 mL po 10 min preop).

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Intraoperative

Anesthetic technique: GETA ± epidural for postop analgesia. If postop epidural analgesia is planned, placement of catheter prior to anesthetic induction is helpful to establish correct placement in the epidural space (accomplished by injecting 5–7 mL of 2% lidocaine via the epidural catheter, and confirming segmental block).

Induction

The patient with abdominal pathology is often at risk for pulmonary aspiration and the trachea should be intubated with patient awake or after rapid-sequence iv induction with cricoid pressure. (See Rapid-Sequence Induction, p. B-4.) If patient is clinically hypovolemic, restore intravascular volume (colloid, crystalloid, or blood products) prior to induction and titrate induction dose of sedative/hypnotic agents.

Maintenance

Balanced anesthesia without N2O (see Standard Maintenance Techniques, p. B-2): Maintain neuromuscular blockade based on nerve stimulator response. Place OG or NG tube to evacuate stomach contents.
Combined epidural and GA: Local anesthetic (2% lidocaine with 1:200,000 epinephrine 5–15 mL initial dose, then 3–5 mL q 60 min) can be injected into the epidural catheter to provide both anesthesia and optimal surgical exposure (contracted bowel and profound muscle relaxation). A continuous infusion of local anesthetic (e.g., 2% lidocaine or 0.25% bupivacaine) at 3–5 mL/h may be used in place of bolus redosing. Be prepared to treat hypotension with fluid and vasopressors. GA is administered to supplement regional anesthesia and for amnesia. If epidural opiates are used for postop analgesia, a loading dose (e.g., hydromorphone 0.5–1.0 mg) should be administered at least 1 h before the conclusion of surgery. Use of systemic analgesics may be minimized during this type of anesthetic with the benefit of decreasing the likelihood of postop respiratory depression.

Emergence

The decision to extubate at the end of surgery depends on the patient's underlying cardiopulmonary status and the extent of the surgical procedure. Patients should be hemodynamically stable, warm, alert, cooperative, and fully reversed from any muscle relaxants prior to extubation. If the above criteria are not met, consider postop ventilation in ICU setting.

Blood and fluid requirements

Anticipate large fluid shift.
IV: 14–16 ga × 1–2
T&S, consider T&C
NS/LR @ 10–15 mL/kg/h
Fluid warmer

Plts, FFP, and cryoprecipitate should be administered according to lab tests (Plt count, PT, PTT, DIC screen, thromboelastography [TEG]). Strive to maintain euvolemia based on estimated blood loss and fluid shifts, HR, BP, UO, ABG, and invasive monitors when used.

Monitoring

Standard monitors (seep. B-1).
UO
± Arterial line
± CVP/PA catheter
± TEE

Invasive monitors, as indicated by patient's status. Prevent hypothermia: use forced-air warmer; consider warming blanket, warming iv fluids, warm room temperature, keeping patient covered until ready for prep, etc.

Positioning

[check mark] and pad pressure points
[check mark] eyes

 

Complications

Hemorrhage
Sepsis

Acute septic shock may require aggressive hemodynamic support; PA catheter or TEE may help guide management in the unstable patient.

Postoperative

Complications

Sepsis
Hemodynamic instability
Atelectasis
Hypoxemia
VTE (see p. B-7)
Hemorrhage
Ileus
PONV (see p. B-6)

Pulmonary function abnormalities may persist for 1 wk postop (↓ vital capacity and ↓ FRC).

Pain management

Epidural analgesia (see p. C-2).
PCA (see p. C-3).

Patient should be recovered in ICU or ward accustomed to treating the side effects of epidural opiates (e.g., respiratory depression, breakthrough pain, nausea, pruritus).

Tests

CBC; CXR (if central line placed); electrolytes; glucose

Others as directed by intraop course.

P.524

Suggested Readings

  1. Aguirre A, Fischer JE, Welch CE: The role of surgery and hyperalimentation in the therapy of gastrointestinal-cutaneous fistulae. Ann Surg1974; 180(4):393–401.
  2. Becker HP, Willms A, Schwab R: Small bowel fistulas and the open abdomen. Scand J Surg2007; 96:263–71.
  3. Merritt WT: Anesthesia for gastrointestinal surgery. In: Principles and Practice of Anesthesiology,2nd edition. Longnecker DE, Tinker JH, Edward G, eds. Mosby-Year Book, St. Louis: 1998, 1881–903.
  4. Zinner MJ, Schwartz SI, Ellis H, eds: Maingot's Abdominal Operations,10th edition, Vol. I. Appleton - Lange, Stamford, CT: 1997, 593–616.