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Complications of open repair of unruptured abdominal aortic aneurysm
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
The abdomen is opened through a long xiphoid-to-suprapubic midline incision. The stomach, greater omentum, and transverse colon are retracted cephalad, and the small bowel is packed by warm saline soaked towels to the right. A self-retaining retractor such as a Bookwalter (Codman and Shurtleff Incorporated. Raynham, MA) or Omni (Integra) or Omni-Tract (Integra Life Sciences Corporation, Plains Borough, NJ), Thompson retractor (Thompson Surgical Instruments, Traverse City, MI) is applied.2 Ligament of Treitz is divided in a relatively avascular plane. The third and fourth portions of the duodenum are mobilized to the right periaortic lymphatics, and connective tissue containing small blood vessels are ligated and divided using 2-0 silk ties.2 Inferior mesenteric vein can usually be preserved unless the aneurysm involves the pararenal aorta. Left renal vein is mobilized and a Silastic vessel loop is passed around it. The dissection in the posterior peritoneum is carried caudally to the right of the midline to protect inferior mesenteric artery (IMA) and avoid injury to the sympathetic nerve plexus. The accessory renal arteries if present and gonadal arteries should be carefully dissected.2 Gonadal arteries are ligated and divided, but significant size accessory renal artery or abnormal origin of the main renal artery should be preserved with aortic cuff following the division of the anterior wall of the aorta and should be re-implanted into prosthetic graft as a Carrel patch.
Surgery for biliary atresia: Open and laparoscopic
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Mark Davenport, Atsuyuki Yamataka
The ligament of Treitz is identified and the proximal jejunum about 15 cm from this identified and exteriorized through the umbilicus. This is then divided and the length of the Roux loop calculated by bringing it to the xiphoid process on the anterior abdominal wall (i.e. length not actually predetermined as 30 cm or 40 cm, etc.) (Figure 55.17).
Anatomy
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
Ernest F. Talarico, Jalid Sehouli, Giuseppe Del Priore, Werner Lichtenegger
The duodenum is about 25 cm long, C-shaped, and aside from its ampulla, it is entirely retroperitoneal. The duodenum has four parts: superior, descending, horizontal, and ascending. The ligament of Treitz is a musculofibrous band that extends from the upper aspect of the ascending part of the duodenum to the right diaphragmatic crus and tissue around the celiac trunk (CT). Always remember that the head of the pancreas lies in the “C” of the duodenum.
Heterotopic gastric mucosa and intestinal atresia in a neonate
Published in Baylor University Medical Center Proceedings, 2021
Rachel Thompson, Sarah Glogowski, Alexia Ghazi, James Davis
A 2.3 kg black female was born at 35 weeks’ gestation. An ultrasound at 33 weeks’ gestation demonstrated an enlarged proximal small bowel and stomach concerning for intestinal atresia. A contrast study conducted on day of life 1 demonstrated proximal jejunal atresia (Figure 1a) prompting immediate operative exploration. Intraoperative findings included a type 1 atresia 8 cm from the ligament of Treitz. The distal bowel was investigated, revealing no further atretic segments or masses. Resection and anastomosis were performed. The anastomosis was tested and was found to be widely patent. On pathologic microscopic evaluation, sections showed scattered islands of gastric foveolar epithelium and mildly thickened muscularis propria. In conjunction with the clinical assessment, the overall gross and microscopic findings were compatible with gastric heterotopia in a setting of jejunal atresia (Figure 1b).
A Novel Method of Damage Control for Multiple Discontinuous Intestinal Injuries with Hemorrhagic Shock: A Controlled Experiment
Published in Journal of Investigative Surgery, 2020
Weihang Wu, Zhicong Cai, Nan Lin, Weijin Yang, Jie Hong, Li Lin, Zhixiong Lin, Junchuan Song, Yongchao Fang, Chen Lin, Hongwen Zhang, Dongsheng Chen, Yu Wang
Hemorrhagic shock was induced by controlled bleeding of the jugular artery, with the mean arterial pressure maintained at 40 mmHg for 20 min [11, 14]. Meanwhile, the abdomen was opened with a midline incision. The small intestine was severed at 50 and 105 cm below the ligament of Treitz. The intestinal ischemia model was established by ligating the mesenteric vessels with a small tertiary mesenteric vessel reserved. The free 55-cm small intestine was divided into 11 segments at 5-cm intervals. Adjacent segments were established into normal blood supply intestinal segments and suspected necrotic intestinal segments model. A total of six normal blood supply segments and five intestinal segments suspicious for necrosis were established. In the IR group, EET was performed by reconnecting the segmented intestines with BST. The intact proximal intestine and distal intestine were connected to the main tube, and the free 55-cm intestinal section was connected to the side tube. The tube was inserted 1–1.5 cm into the edge of resection and was secured with cable ties (Figures 2 and 3). In the IL group, the segmented intestine was ligated with silk threads. A proximal jejunostomy tube (16F) was placed for nutritional support later. Thereafter, the abdominal cavity was temporarily closed with TCC (Figure 4). Fluid resuscitation with Ringer’s solution was initiated 30 min after hemorrhagic shock was induced. During 72 h after the EET, all animals were injected with cephalosporin cefazolin sodium (0.5 g, bid) and piperidine (0.5 mg/kg) injection to minimize the infection and pain.
From Paris to Montreal: disease regression is common during long term follow-up of paediatric Crohn’s disease
Published in Scandinavian Journal of Gastroenterology, 2020
Mike Davies, Susanna Dodd, Morwenna Coultate, Andrew Ross, George Pears, Bruno Gnaneswaran, Christos Tzivinikos, Anastasia Konidari, Jeng Cheng, Marcus KH. Auth, Fiona Cameron, Sarang Tamhne, Elizabeth Renji, Manjula Nair, Colin Baillie, Paul Collins, Philip J. Smith, Sreedhar Subramanian
Ileocolonic disease location was the commonest (n = 70, 53%) followed by colonic (n = 39, 30%) and ileal (n = 23, 17%) location at diagnosis (Figure 1). In addition, 21 (16%) and 10 (7.5%) patients had disease proximal (L4a) and distal to the ligament of Treitz respectively at diagnosis and 38 (29.7%) had perianal disease. Of these, 13 patients (9.8%) had disease both proximal and distal to the ligament of Treitz. Growth status was only available in 67 patients, of whom 43 (64%) had impaired status. At maximal follow up, disease location remained broadly similar except for upper GI (L4) disease with fewer patients (n = 21, 15.9%, p = .0001) compared to diagnosis (Figure 1). There was a non-significant increase in the proportion of patients with perianal disease at diagnosis (20.4%) and maximal follow-up (23.5%). At diagnosis, 83 (62.9%) of patients had an extensive ‘pan-enteric’ phenotype but of these patients only 55 (66.3%) retained the phenotype at last follow-up (p = .0002). Disease extension was noted in 25 (18.9%) of patients and regression was noted in 47 (35.6%). The rate of exposure to biological therapy was similar in patients with disease regression (32/47, 68.1%) and disease extension (21/25, 84%).