Transcript GI Surgery

GI Surgery
Gastrointestinal
Anatomy

Alimentary canal

Think two layers



Mucosa
Serosa
Really four




Mucosa
Submucosa
Muscularis
Serosa
Mouth

Frenulum

Small fold
 Fold of mucous
membrane
 Found on the
inner surface of
the upper and
lower lips, and at
the base of the
tongue
Mouth

Teeth

Organs of
mastication
 Deciduous


Baby teeth
Are shed and
replaced. 20 by
age 2½
Mouth

Teeth

Permanent


Permanent – 32
total
Digestion


Mechanical by
teeth
Chemical by saliva
Mouth

Tongue
 Muscular
organ,
partly in the
mouth and partly
in the pharynx
Mouth

Tongue
 Functions:



Manipulation
of food in
mastication and
deglutination
Speech
production
Taste
Pharynx

Naso, Oro, and
Laryngopharynx
 Laryngopharynx

Opens inferiorly
to the larynx
anteriorly and to
the esophagus
posteriorly
Esophagus



Extends from the
pharynx to the
stomach
10 inch long
musculomembranous tube
Joins the cardia of
the stomach
Esophagus

Posterior to the
trachea and heart,
and anterior to the
aorta

Through the
diaphragm slightly
to the left of midline
Esophagus

Blood supply is from branches of the
inferior thyroid, thoracic aorta, and celiac
arteries

Nerve supply from vagus nerve branches
and sympathetic chain
Stomach


Extends from the
esophagus to the
duodenum
Both chemical
and mechanical
digestion
principally
Stomach

Absorption

Some water,
electrolytes,
certain drugs
(especially
aspirin), and
alcohol
Stomach

Rugae
are the
folds in
the
stomach
lining
Stomach

Divided into 3
parts

Fundus or cardiac
portion

Uppermost
portion, above
the level of the
cardiac
(esophageal)
sphincter
Stomach

Divided into 3
parts

Body

Largest, central
portion of the
stomach
Stomach

Divided into 3
parts

Antrum or pyloric
portion

Lower portion of
the stomach
near the pyloric
sphincter
Stomach


Stabilized
indirectly by the
lower portion of the
esophagus
Stabilized directly
by its attachment
to the duodenum,
which is anchored
to the posterior
peritoneum
Stomach

Greater curvature


Convex lower
margin
Lesser curvature

Concave upper
margin
Stomach

Greater omentum

Attached to the
greater curvature
 Double fold of
peritoneum
containing fat
 Covers the
intestines, like an
apron
Stomach

Lesser omentum

Attached to the
lesser curvature
Small intestine

Extends from the pylorus to the ileocecal
valve

About 1 inch in diameter

Food is moved through by peristalsis,
created by waves of motion in the
muscles of its walls
Small intestine

Absorption of
nutrients takes
place here

Plicae circulares

Circular mucosal folds


For greater surface
area
Villi and microvilli

Minute projections of
the intestinal mucosa
Small intestine

Absorption of
nutrients takes
place here

Plicae circulares

Villi and microvilli


Increases surface
area for absorption
Contains a capillary
network
Small intestine

Divided into 3 parts

Duodenum


About 10 inches
long
Stabilized by a
fusion between
the pancreas and
the posterior
peritoneum
Small intestine

Divided into 3 parts

Duodenum


Common bile duct
enters intestine
here
Ligament of Treitz
 Suspends
the
duodenum from
the posterior
body wall
Small intestine

Divided into 3 parts

Jejunum


About 7½ feet long
Ileum


About 10½ feet
long
Empties into the
large intestine via
the ileocecal valve
Small intestine

Mesentery

Connects the
intestines to the
posterior
abdominal wall
Small intestine

Blood supply

Varies for the
duodenum
 For the jejunum
and ileum it’s the
superior
mesenteric
Large intestine

Extends from the
ileocecal valve to
the anus







Cecum
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anal Canal
Cecum

Attached to the
ileum and
extends about
2½ inches
below it

Appendix hangs
from the cecum
Ascending colon

About 6 inches
long

Extends upward
from the
ileocecal valve
to the hepatic
flexure
Transverse colon



About 20 inches
long
Extends from
the hepatic
flexure to the
splenic flexure
Attached to the
transverse
mesocolon
Descending colon

About 7 inches
long

Extends from
the splenic
flexure to the
sigmoid colon
Sigmoid colon

About 6 inches
long

Extends from
the descending
colon to the
rectum
Sigmoid colon

Lies on the inner
surface of the
iliac muscle,
passes over the
pelvic rim and
into the pelvic
cavity, forming an
S curve in the
pelvis
Rectum



About 6 inches long
Extends from the
sigmoid colon to the
anus
Dilates just before
it becomes the anal
canal
Rectum


Slightly curved
It lays on the
anterior surface of
the sacrum and
coccyx, and is
surrounded by
pelvic fascia
Anal canal


About 1 inch long
Surrounded and
controlled by 2
circular muscle
groups which form
the internal and
external sphincters
Large Intestine

Varies in
diameter

From about
3½ inches at
the cecum to
about ½ inch
at the sigmoid
Large Intestine

Taeniae coli

3 longitudinal
strips of
longitudinal
muscle
Large Intestine

Epiploic
appendices

Fatty
appendages
along the bowel
that have no
particular
function
Large Intestine

Haustra

Sacculations
or
outpouchings
of bowel wall
between the
taenai coli
Large Intestine

Functions

Absorb water
 Expel
indigestible
residue
Large Intestine

Several vitamins
needed for
normal
metabolism,
including some B
vitamins and
vitamin K, are
synthesized by
bacterial action
and absorbed
Liver



Located in the right
upper quadrant
Falciform Ligament
divides the liver into
right and left lobes
Right lobe is 6
times larger than
the left lobe
Liver

4 lobes

Right
 Left
 Quadrate
 Caudate
Liver

2 lobes

Right
Six times as large as
the left
 Separated from the
left lobe by the
falciform ligament

Liver

2 lobes

Left
Smaller and flatter
than the right
 Situated left of
falciform ligament

Liver

2 secondary lobes

Quadrate and
Caudate

Medial portions of
the right lobe,
between the
gallbladder and the
falciform ligament
Liver

Glisson’s capsule
 Dense
connective tissue covering the
external surface

Porta hepatis
 Location
of entry and exit for major vessels,
ducts and nerves on the inferior surface
Liver

Blood supply

Arterial


Hepatic artery
Venous

Portal vein and its
branches carry
blood from the
stomach,
intestines and
spleen to the liver
Liver

Blood supply

Venous

Hepatic venous
system returns
the venous blood
to the inferior
vena cava
Liver

Lobules

Functional units of the liver
 Each consists of:




Hepatic duct
Hepatic portal vein branch
Branch of the hepatic artery
Nerves and lymphatics
Liver

Lobules

A central vein is located in the center of each
lobule and provides for venous drainage into
hepatic veins
 Hepatocytes


Functional cells of the liver
Manufactures bile

Approximately 600 to 1000 ml per day
Liver

Bile is transported through ducts to the
hepatic ducts, which join to form the
common hepatic duct, which merges with
the cystic duct to form the common bile
duct, which opens into the duodenum

Bile contains bile salts which facilitate
digestion and absorption, and various
waste products
Liver

The opening at
the duodenum is
at the ampulla of
Vater and is
controlled by
relaxation of the
sphincter of Oddi
Liver

The liver is essential in the metabolism of
carbohydrates, proteins, and fats

The liver metabolizes nutrients into
glycogen stores

The liver plays an important role in the
blood clotting mechanism
Liver

The liver plays a major role in the body’s
response to foreign chemicals, such as
pollutants, drugs, and alcohol

The liver stores fat soluble vitamins
A,D,E, and K plus iron and copper
Gallbladder



Lays in a sulcus in the undersurface of
the right lobe of the liver
Receives bile from the liver via the
hepatic duct
Terminates at the cystic duct
Gallbladder

Stores and concentrates bile
 Capacity

– 40-70 ml
Cholecystokinin
 Released
by duodenal cells when food,
especially fats, enter the duodenum
Bile aids in digestion of fats
 Blood supply

 Cystic
artery, a branch of the hepatic artery
Pancreas


Lays transversely behind the stomach
Head of the pancreas is fixed to the curve
of the duodenum, the body lies across the
vertebrae, and the tail extends to the
hilum of the spleen
Pancreas

Approximately 25
cm in length

Is both and
endocrine and an
exocrine gland
Pancreas

Pancreatic secretions containing digestive
enzymes are collected in the pancreatic
duct (duct of Wirsung), which unites with
the common bile duct

Islets of Langehans
 Groups
of cells that secrete hormones into
the blood capillaries instead of into the duct
Pancreas

The hormones insulin and glucagon are
both involved in carbohydrate metabolism

Blood supply

Celiac and superior mesenteric artery
Spleen
Spleen

Protected by the
10th, 11th, and
12th ribs, near the
stomach and the
splenic flexure of
the colon
Spleen

Is covered with peritoneum that forms
supporting ligaments

Blood supply

Splenic artery

Splenic vein drains into the portal system
Spleen

Functions

Defense of the body by phagocytosis of
microorganisms
 Formation of nongranular leukocytes and
plasma cells
 Phagocytosis of damaged RBCs
 Acts as a blood reservoir
Considerations

The intestinal tract harbors many
microorganisms, and is considered a
contaminated area

Leakage into the peritoneal cavity can
cause peritoneal sepsis
 Acid
secretions from gastric resections can
be irritating and cause peritonitis
Considerations

Bowel technique should be employed to
prevent the spread of contamination

Bowel technique

Isolate instruments that come into contact
with GI secretions or mucosa
 Change gloves (and sometimes gown)
after anastomoses completion
Considerations

Bowel technique
 Clean
closure technique
 Drop technique
 Cancer technique

ex: breast biopsy and mastectomy
Considerations

Nasogastric tubes
are frequently
used to
decompress the
bowel and to
remove gastric
secretion
Considerations


Stapling devices
are used frequently
Anastomosis may
be:
 end-to-end
 side-to-side
 end-to-side
Considerations

Peptic ulcer
 Ulcer
occurring in
the lower end of
the esophagus,
stomach, or
duodenum
Considerations

Adhesions
 Holding
together
by new tissue,
produced by
inflammation or
injury, of two
structures that are
normally separate
Considerations

Diverticula
 Small,
blind pouches
that form in the lining
and wall of a canal or
organ, especially the
colon
 About 15% of people
with diverticula will
develop diverticulitis
Considerations

Meckel’s
diverticulum
 Pouch
caused
by continued
existence of the
omphalomesenteric
duct located on the
ileum close to the
ileocecal valve
Considerations

Meckel’s
diverticulum
 Occurs
in about
1-2% of the
population
 Is usually
asymptomatic
Considerations

Meckel’s
diverticulum
 If
symptomatic, can
present as signs of
appendicitis,
sudden bleeding, or
bowel obstruction

Then are usually
removed
Considerations

Meckel’s
diverticulum
 Many
are
discovered
incidentally during
surgery for other
causes or on post
mortem
examination
Considerations

Intussusception
 Invagination
of the
proximal intestine
into the lumen of
the distal intestine
causing intestinal
obstruction
Considerations

Volvulus
 Torsion
of a loop
of intestine
causing
obstruction

With or without
strangulation
Considerations

Polyp
 Outward
growth
from a mucous
membrane
Considerations

Strangulated
hernia
 Hernia
with
luminal viscera
entrapment that
compromises the
vascularity of the
viscera
Strangulated Hernia
Considerations

Cirrhosis
 Disease
of the liver
marked by scarred
or distorted liver as
a result of chronic
inflammation
Considerations

Cirrhosis
 Liver
cells are
replaced with
fibrous or adipose
connective tissue
Considerations

Cirrhosis
 Symptoms
include
jaundice, edema
in the legs,
uncontrolled
bleeding, and
increased
sensitivity to drugs
Considerations

Cirrhosis
 May
be caused by
hepatitis, certain
chemical that
destroy liver cells,
parasites that infect
the liver, and
alcoholism
Surgical Interventions
Esophagectomy

Removal of the esophagus
Esophagogastrostomy

Removal of the diseased portions of the
stomach and esophagus and
establishment of an anastomosis
between the stomach and the esophagus

Supine or modified supine
Esophagogastrostomy

May be performed through a
thoracoabdominal approach, including
resection of the 7th, 8th, or 9th rib

Performed to remove tumors in the distal
esophagus or cardia of the stomach, or
for strictures of the distal esophagus
Esophageal hiatal hernia repair
and antireflux procedures

Performed to restore the
cardioesophageal junction in its correct
anatomic position in the abdomen, secure
it firmly in place, and to correct
esophageal reflux
Esophageal hiatal hernia repair
and antireflux procedures

Hernia of the diaphragm which permits a
portion of the stomach to enter the
thoracic cavity
Esophageal hiatal hernia repair
and antireflux procedures

Symptoms vary from severe heartburn,
reflux, regurgitation, and dysphagia
(difficulty swallowing)

Repair is performed when symptoms are
severe
Esophageal hiatal hernia repair
and antireflux procedures

Nissen fundoplication

Mobilization of the
esophagus
 Pull the esophagus
downward out of the
hernia
 Place heavy sutures
close to the hiatal
aperture
Esophageal hiatal hernia repair
and antireflux procedures

Nissen fundoplication

Posterior wall of the
stomach is brought up
around the distal
esophagus
 The stomach walls
are wrapped and
sutured around the
esophagus
Esophageal hiatal hernia repair
and antireflux procedures

Nissen fundoplication

May be done
laparoscopically
Vagotomy

Excision of a segment, or segments, of
the vagus nerve branches
Vagotomy

Helps to reduce gastric acid secretion in
patients with duodenal ulcers
Gastrostomy

Establishment of a
temporary or
permanent
opening in the
stomach
Gastrostomy


Performed for gastrointestinal
decompression or to provide prolonged
nutrition
Uses a Foley, Malecot, Pezzer or
mushroom catheter inserted
percutaneously or through an incision into
the stomach
Gastrotomy

Opening of the anterior stomach wall with
exploration of the interior

Usually performed to explore for upper GI
tract bleeding, tissue biopsy, gastric
lesion, or foreign body
Gastrojejunostomy

Establishment of
a permanent
communication
between the
jejunum and the
stomach
Partial Gastrectomy

Billroth I

Resection of the diseased portion of the
stomach and the establishment of an
anastomosis between the stomach and the
duodenum
Billroth I
Billroth II
Partial Gastrectomy

Billroth I

Performed to remove a benign or malignant
lesion located in the pylorus
Billroth I
Billroth II
Partial Gastrectomy

Billroth II

Resection of the distal portion of the
stomach and establishment of an
anastomosis between the stomach and
the jejunum
Billroth I
Billroth II
Partial Gastrectomy

Billroth II

Performed to remove a benign or malignant
tumor in the stomach or the duodenum
Billroth I
Billroth II
Total Gastrectomy

Complete removal
of the stomach
and establishment
of an anastomosis
between the
jejunum and the
esophagus
Total Gastrectomy

Performed to
remove a
malignant lesion of
the stomach and
metastases in the
adjacent lymph
nodes
Excision of Meckel’s
diverticulum

Removal of the unobliterated congenital
duct at the umbilicus that is attached to
the distal ileum

The diverticulum may contain gastric
mucosa which may ulcerate, perforate, or
bleed
Appendectomy



Removal of the appendix from its
attachment to the cecum through a right
lower quadrant muscle splitting (McBurney)
incision
Performed to remove an acutely inflamed
appendix, thereby controlling the spread of
infection and reducing danger of peritonitis
May be performed laparoscopically
Appendectomy
Small bowel resection

Resection of the
diseased intestine,
usually followed
by an anastomosis
Ileostomy

Formation of a
temporary or
permanent
opening into the
ileum
Colectomy

Removal of
diseased colon
Colostomy


Mobilization of a
loop of colon (or
distal end in some
instances) through
the abdominal wall
May be permanent
or temporary
Low Anterior Resection

Anterior resection of the sigmoid colon
and rectosigmoidostomy

Resection of the lower sigmoid colon, with
end-to-end anastomosis of the rectum
and remaining sigmoid

Utilizes an EEA stapler
Low Anterior Resection
Abdominoperineal resection

Performed to remove malignant lesions or
for inflammatory diseases of the lower
sigmoid colon, rectum, and anus that are
too low for the use of EEA stapling
devices

Permanent colostomy and closure of the
anus
Abdominoperineal resection

Requires two separate set-ups
 One
for the abdominal mobilization
colostomy
 One for the perineal resection
with
Ileoanal Endorectal Pullthrough



Removal of the entire colon and the
proximal ⅔ of the rectum and creation of
a pouch from the distal small bowel, and
anastomosis of that pouch to the anus
Performed for ulcerative colitis, familial
polyposis, and to prevent malignancies
Temporary colostomy (loop)
Hemorrhoidectomy

Excision and
ligation of dilated
veins in the anal
region to relive
discomfort and
control bleeding
Cholecystectomy


Removal of the
gallbladder
Performed for
cholecysitis,
cholelithiasis,
polyps, or
carcinoma
Cholecystectomy

Requires the dissection of the triangle of
Calot
 Border
defined by the 3 C’s
Cystic duct
 Cystic artery
 Common Bile duct


The cystic duct and cyst artery must both
be ligated and divided
Cholecystectomy

May be performed open (right subcostal),
but is usually performed laparoscopically
Open Cholecystectomy





Harrington Retractor
Right angle and peanut dissectors used to
dissect Calot’s triangle
Silk free ties used to ligate and divide the cystic
duct and cystic artery
ESU to dissect gallladder from the liver bed
Hospital stay of 2-3 days
Laparoscopic Cholecystectomy
Verres needle to insufflate
 4 Disposable trocars and sheaths

 10mm
x2- umbilical and subxiphoid
 5mm x2- RUQ midclavicular and anterior
axillary

Disposable graspers and hooks to dissect
Calot’s triangle
Laparoscopic Cholecystectomy

Disposable clip appliers and scissors to
ligate and divide the cystic duct and cystic
artery
3
clips each- 2 on the side that stays in
Disposable endoscopic ESU to dissect the
gallbladder from the liver bed
 Same Day Surgery

Cholecystectomy

Intraoperative
cholangiogram

X-ray
visualization of
the common bile
duct, using dye to
visualize the
filling of the ducts
and duodenum
Cholangiogram
Cholangiocath
 Irrigate catheter
 Bubbles look like stones on x-ray
 Dye

Choledochotomy
Incision into the common bile duct
 Performed to treat choledocholithiasis or
to relieve an obstruction in the common
bile duct

Choledochoscopy

Direct visualization of the common bile
duct by means of a choledoscope

Provides a means of extraction for stones
that are difficult to remove
Cholecystostomy

Establishment of an opening into the
gallbladder to permit drainage and removal
of stones
Chole-related Procedures

Cholecystoduodenostomy
 Anastomosis
between the gallbladder and
the duodenum

Cholecystojejunostomy
 Anastomosis
the jejunum
between the gallbladder and
Chole-related Procedures

Choledochoduodenostomy


Anastomosis between the common duct and
the duodenum
Choledochojejunostomy

Anastomosis between the common duct and
the jejunum
Pancreatic cysts

Drainage or excision of pancreatic cysts

May be drained internally into the small
intestine or the stomach, or may require
excision or external drainage
Pancreatoduodenectomy

Also known as the
Whipple
procedure

Performed for
carcinoma of the
head of the
pancreas
Pancreatoduodenectomy

Removal of:
 The
head of the pancreas
 The entire duodenum
 A portion of the jejunum
 The distal third of the
stomach
 The lower half of the
common bile duct
Pancreatoduodenectomy


Reestablishment of
the biliary, pancreatic,
and GI tract systems
Technically hazardous
procedure because it
involves many vital
structures and organs
Pancreatic transplantation

Implantation of a pancreas from a donor
into a recipient

Considered a possible treatment for type I
diabetes

Indicated for long established, totally
insulin-deficient (dependent) diabetics
with end-stage renal disease
Pancreatic transplantation

May interrupt the progression of
nephropathy, retinopathy, and neuropathy

Frequently performed in conjunction with
a kidney transplant
Drainage of abscess

Drainage of intrahepatic, subhepatic, and
subphrenic abscess

Incision and drainage of abscesses of the
liver
Hepatic resection

Resection of lobes
or segments of the
liver
Liver transplantation

Implantation of a
liver from a donor
to a recipient

Indicated for
patients with endstage liver disease
Splenectomy

Removal of the
spleen

Usually performed
for trauma to the
spleen, tumors,
cysts, or
splenomegaly
THE END 