List of products

Allis' clamps, Codman, Massachusetts, USA

Babcock's forceps, Codman, Massachusetts, USA

Dacron, Du Pont, Wilmington, USA Dexon, Davis & Geck, Gosport, UK/Davis & Geck International, c/o

Cyanamid International, Wayne, New Jersey, USA

EEA stapler, Auto Suture Co. UK, Ascot, UK/US Surgical Corporation, Connecticut, USA

Endo-Babcock, Auto Suture Co. UK, Ascot, UK/US Surgical Corporation, Connecticut, USA

Endo·Retract, Auto Suture Co. UK, Ascot, UK/US Surgical Corporation, Connecticut, USA

Ethibond, Ethicon, Edinburgh, UK!Ethicon Inc, Somerville, New Jersey, USA

Gastrografin, Schering Health Care, UK GIA stapler, Auto Suture Co. UK, Ascot, UK/US Surgical Corporation,

Connecticut, USA

U.S stapler, Ethicon Endosurgery, Edinburgh, UK!Ethicon Endosurgery, Cincinatti, Ohio, USA

Ligaclip, Ethicon Endosurgery, Edinburgh, UK!Ethicon Endosurgery, Cincinatti, Ohio, USA

Marlex, C P Bard, Massachusetts, USA Maxon, Davis & Geck, Gosport, UK!Davis & Geck International, c/o

Cyanamid International, Wayne, New Jersey, USA Mousseau-Barbin tube, Porges Catheter Corporation, New York, USA

Prolene, Ethicon, Edinburgh, UK!Ethicon Inc, Somerville, New Jersey, USA

Rigiflex dilator, Rigiflex Inc, Belmont, Massachusetts, USA

Satinsky clamp, Codman, Massachusetts, USA SGIA 50 stapler, Auto Suture Co. UK, Ascot, UK/US Surgical

Corporation, Connecticut, USA Shaw scissors, Hemostatic Surgery Corporation, San Francisco, USA

TA 55 stapler, Auto Suture Co. UK, Ascot, UK/US Surgical Corporation, Connecticut, USA

TA 90 stapler, Auto Suture Co. UK, Ascot, UK/US Surgical Corporation, Connecticut, USA

Thoracoports, Auto Suture Co. UK, Ascot, UK/US Surgical Corporation, Connecticut, USA

Vicryl, Ethicon, Edinburgh, UK!Ethicon Inc, Somerville, New Jersey, USA

607

Index

Abdominal fundoplication, 294-300 Abdominal incisions, 70-8

choice of, 71-2 exposure, 74-5 haemostasis, 72 method, 72 midline incision, 7 3 paramedian incision, 73 preoperative preparation; 72 principles and justification, 70 subcostal incision, 74 wound closure, 75-8

knots, 75-7 single-layer or mass closures, 77 suture materials, 77 two-layer closures, 78

wound protection/infection, 72 Abdominal vagotomy, see Vagotomy Achalasia

abdominal myotomy, 267-75 anaesthesia, 268 assessment, 268 history, 267 indications, 268 operation, 269-75

anterior partial fundoplication, 274-5 approximation ·of crura, 273 exposure of gastro-oesophageal

junction, 270 incision, 269 mobilization ofleft lobe ofliver, 269 mobilization of oesophagus, 270 myotomy, 271-3 wound closure, 275

outcome, 275 patient preparation, 268 postoperative care, 275 preoperative preparation, 268 principles and justification, 268

thoracic myotomy, 262-6 anaesthesia, 263 complications, 266 diagnosis, 263 history, 262 operation, 263-5 outcome, 266 postoperative care, 266 preoperative preparation, 263 principles and justification, 262

videoendoscopic surgery, 593-600 anaesthesia, 595 complications, 600 operations, 595-9

laparoscopic Heller myotomy, 598-9 thoracoscopic Heller myotomy, 596- 8

postoperative care, 599 preoperative preparation, 594-5

clinical, 594 endoscopy, 594 manometry, 595 radiology, 594

principles and justification, 59 3

Afferent limb syndrome, 412 Alcoholism, 513 Alkaline reflux gastritis, 391,413 Anaesthesia

achalasia abdominal myotomy, 268 thoracic myotomy, 263 videoendoscopic surgery, 595

extrarnucosal enucleation of oesophageal leiomyoma, 2 3 7

gastric restriction surgery, 550 intrathoracic fundoplication, 322 left posterolateral thoracotomy, 56 oesophageal perforation, 249 oesophageal replacement, stomach, 143 oesophageal strictures, resection of, 345 oesophageal varices, stapling procedures,

516 oesophagectomy

abdominal-right thoracic approach, 52 left thoracoabdominal approach, 62 transhiatal, 198

oesophagogastrectomy, 282 pyloroplasty, 395 rigid oesophagoscopy, 22 ulcer surgery, 482, 532

Anastomosis cervical

gastro-oesophageal, 207-9 left thoracic subtotal oesophagectomy,

194 duodenojejunal, 546 gastric

hand-sewn technique, 88-107,459-60 stapled, 108-19

gastroduodenal, 99-101,489-90 see also Billroth I gastrectomy

gastrojejunal, 103-7 Billroth II, 101-2

stapled, 116-17 Roux-en-Y, 101

gastric reconstruction, 163,433 transmesocolic, 339

stapled, 430-2 anastomotic reconstruction, 431 closure of mesocolon, 432 closure of stapler defect, 432 stapler application, 431

sutured, 429-30 anterior portion of anastomosis, 429 completion of anastomosis, 430 posterior inner suture, 429

gastro-oesophageal, 112-15 hand-sewn, gastric, 88-107 jejunogastric, 348 jejunojejunal, 411

end-to-side, 90-2 gastric reconstruction, 158-9 Roux-en-Y, 110-11 stapled, 159 terrninolateral, 3 39

laparoscopic gastroenterostomy, 578-82

Anastomosis- continued ·oesophageal

leakage, 41 stapled, 84-7 sutured, 79-83

oesophageal replacement small intestine, 12 3-5 stomach, 150-2

oesophagojejunal, 108-11 gastric reconstruction, 160-2 oesophageal stricture resection, 348 stapled, 108-11, 162

portacaval end-to-side, 508-9 side-to-side, 506-8

stapled gastric, 108-19 gastrojejunal, 101-2, 116-17 Heineke-Mikulicz pyloroplasty, 118 oesophageal, 84-7 oesophagojejunal, 108-11, 162

sutured, oesophageal, 84-7 see also Shunts, portasystemic

Anatomical repair for uncomplicated gastro­oesophageal reflux, 311

Anatomy oesophagus, 256-61

anatomical relations, 256-7 blood supply, 258 cervical, 170-2 mobilization of distal oesophagus,

259-60 musculature, 258 nerve supply, 259 oesophageal hiatus, 260-1 phreno-oesophagealligarnent, 259

stomach fundus, 256-61 as oesophageal replacement, 143

vagus nerves, 354-9 abdominal, 356 angle of His, 359 anterior divisions, 3 57 central vagus complex, 355 cervical, 355 coeliac branches, 358 'criminal' nerve of Grassi, 359 distal oesophageal plexus, 358 gastric branches

anterior, 357 posterior, 358

gastroepiploic vagal innervation, 359 hepatic branches, 357 nerves of Latarjet

anterior, 357 crow's foot, 359 posterior, 358

posterior divisions, 358 thoracic, 356

Angelchikcollar, 311-12 Angle of His, 359 Antecolic gastrojejunostomy, 407-8

609

610 Index

Anterior gastropexy, 279 Antibiotic cover

left thoracoabdominal oesophagectomy, 62 oesophageal perforation, 248 oesophageal strictures, 30

Antiperistaltic jejunal interposition loop, 392 Antireflux surgery, 292-3

complicated gastro-oesophageal reflux, 350-3

antral patch, 351-2 fundic patch, 350-1 Schatzki's ring, 352-3

paraoesophageal hiatus hernia, 276 rationale for

contrast studies, 293 endoscopy, 292-3 histology, 293 objective assessment, 292-3 oesophageal manometry, 293 pH monitoring, 293 symptoms, 292

reoperative, 316-19 incision, 317-18 outcome, 319 principles and justification, 316

Roux-en-Y diversion and fundoplication, 335-44

anastomosis jejunojejunal terminolateral, 339 Roux-en-Y gastrojejunal

transmesocolic, 339 antireflux procedure, 338 antrectomy, 339 complications, 368 duodenal diversion

after partial gastrectomy, 341 after previous partial gastro­

oesophagectomy, 342 after total gastrectomy, 343 after total gastro-oesophagectomy and

colonic interposition replacement, 343

history, 335 indications, 335 normal technique, 336-9 outcome, 368 postoperative care, 367 preoperative preparation, 335 vagotomy, 336-7

problems of, 340-1 hiatal opening difficult or dangerous

to reach, 340-1 hiatal opening easily reached but

vagotomy difficult, 340 thoracic approach, 301-6

Belsey Mark IV procedure, 302-6 history, 30 1 outcome, 306 postoperative care, 306

uncomplicated gastro-oesophageal reflux, 307-15

anatomical repair, 311 circumferential prosthesis ( Angelchik ),

311-12 ligamentum teres fixation, 312 oesophageal extension, 308

and fundoplication, 309-10 posterior gastropexy, 314-15 postoperative care, 315 principles and justification, 307 supplemental proximal gastric

vagotomy, 313

Antral patch, 351-2 Antrectomy, 339

ulcers duodenal, 4 79-80 recurrent, 391

Balloon dilators, 29-30, 38 Balloon tube tamponade, 19 Belsey Mark IV procedure, 302-6 Billroth I gastrectomy, 414-19

history, 414 incision, 415-19 indications, 414 postoperative care, 419 wound closure, 419

Billroth II gastrectomy, 101-2 Roux-en-Y gastrojejunostomy after,

411-12 stapled anastomosis, 116-17

Biopsy endoscopic, 9 laparoscopic, 570 liver, 509

Bleeding, 388-9 Dieulafoy's lesion, 526 Mallory-Weiss tear, 525-6 ulcers, see Ulcers videoendoscopic surgery for achalasia, 600 watermelon stomach, 526

Carcinoma distal oesophagus, cardia and proximal

stomach, en bloc oesophagectomy for, see Oesophagectomy,

en bloc oesophagogastrectomy for, see

Oesophagogastrectomy Cardio-oesophageal junction, mobilization of,

68 Cardiovascular fitness, preoperative, 39-40 Celestin dilator, 27, 28, 29, 37 Chest drains, oesophageal surgery, 40 Circumferential prosthesis, 311-12 Collis gastroplasty, 331 Collis-Nissen combined operation, 327-34

complications, 334 postoperative care, 334 preoperative preparation, 327 principles and justification, 327 surgery, 328-33

dissection of oesophageal hiatus, 329 division of short gastric vessels, 330 exposure, 328 incision, 328 Nissen fundoplication, 332 placement of crural sutures, 330 reduction of wrap and closure of hiatus,

333 removal of gas teo-oesophageal fat pad,

331 uncut Collis gastroplasty, 331

Colonic interposition oesophageal replacement, 128-41

choice of colonic segment, 130 complications, 140-1 contraindications, 129 duodenal diversion, 343 history, 128 indications, 129 operation, 131-9

Colonic interposition oesophageal- continued outcome, 141 postoperative care, 140 preoperative preparation, 131 principles and justification, 129

Contrast studies, gastro-oesophageal reflux, 293,321

Cricopharyngeal myotomy, 173-7 incision, 173-7 patient position, 1 73 postoperative care, 177

'Criminal' nerve of Grassi, 359

Delirium tremens, 511-12 Diaphragm, division of, 66 Diarrhoea, postvagotomy, 368, 393 Dieulafoy's lesion, 526 Dilators, 26-30

balloon, 29-30, 38 mercury-filled, 27, 31-3

self-bougienage, 32-3 wire-guided, 27-9, 33-7 see also individual types

Distal oesophageal plexus, 358 Diverticula

duodenal, 537-47 operation, 539-46

diverticulectomy, 540-4 with reimplantation of ampulla of

Vater, 543-4 simple extraduodenal, 540-1 transduodenal, 541-2

duodenojejunostomy, 546 exposure, 539 extended sphincteroplasty, 545

postoperative care, 547 preoperative preparation, 538 principles and justification, 53 7

long oesophageal myotomy, 230-6 assessment, 230 indications, 230 operation, 231-6 patient preparation, 230 postoperative care, 236 principles and justification, 230

pharyngo-oesophageal, excision of, 173-7 incision, 173-7 patient position, 173 postoperative care, 177

Diverticulectomy, 540-4 with reimplantation of ampulla of Vater,

543-4 simple extraduodenal, 540-1 transduodenal, 541-2

Drainage chest, oesophageal surgery, 40 gastric interposition oesophageal

replacement, 152 total abdominal vagotomy, 364

Dumping syndrome, 368, 392, 491 Duodenal diversion

after partial gastrectomy, 341 after previous partial gastro­

oesophagectomy, 342 after total gastrectomy, 343 after total gastro-oesophagectomy and

colonic interposition replacement, 343

Duodenal diverticula, see Diverticula Duodenal obstruction/trauma,

gastroenterostomy in, 404

Duodenal stump blow-out, 387 Duodenal ulcers, 479-80

aims of surgery, 476 background, 476 choice of procedure, 480 giant duodenal ulcer, 480 oversewing with duodenotomy and

parietal cell vagotomy, 480 oversewing truncal vagotomy and

pyloroplasty, 479 oversewing with vagotomy and

antrectomy, 479-80 oversewing with vagotomy and

pyloroplasty anterior vagal trunk, 486 duodenotomy, 480, 483 incision and exposure, 483 oesophageal exposure, 485 posterior vagal trunk, 486 pyloroplasty, 485 suture ligation, 484

perforated, 531 definitive procedure, 534-5 with haemorrhage, 534 with obstruction, 534 simple closure, 532-4

predictors of continued bleeding! rebleeding, 476

Duodenojejunostomy, 546 Duodenotomy, duodenal ulcers, 480, 483

Eder-Puestow dilator, 27, 29,37 En bloc oesophagectomy, see

Oesophagectomy, en bloc Endoscope

injection sclerotherapy, 11 insertion

blind, 2 visual, 3

see also Endoscopy Endoscopic cautery, 478 Endoscopic heater probe, 4 78 Endoscopy

balloon dilators, 38 flexible, 1-9

examination of oesophagus, 4 examination of stomach, 5-8 introduction of endoscope, 2-3

blind insertion, 2 visual insertion, 3

passage into stomach, 5 patient preparation, 1 principles and justification, 1 recovery from, 9 taking tissue specimens, 9

gastro-oesophageal reflux, 292-3, 321-2 injection sclerotherapy

bleeding ulcers, 478 elective, 13-14 emergency, 17

oesophageal achalasia, 594 oesophageal perforation, 248 oesophagectomy, 601-6

history, 601 operation, 602-4 postoperative care, 606 preoperative preparation, 601 tumour dissection, 604-6

Enteroenterostomy, 434 Enterotomy, 581

Eversion extraction oesophagectomy, see Oesophagectomy, eversion extraction

Extended sphincteroplasty, 545

Finney pyloroplasty, 398-9 Fundic patch, 350-1 Fundoplication

abdominal, 294-300 complications, 300 history, 294 indications, 294 operation, 295-300

buttressing fundoplication, 300 crural plication, 298 distal oesophagus

final mobilization, 298 initial mobilization, 296

encircling oesophagus, 297 fixing fundoplication, 299 fundus

adequacy of mobilization, 299 further mobilization, 296 initial mobilization, 296

general exposure, 295 identification and preservation of

anterior/posterior vagal trunks, 297

incision, 295 local exposure, 295 wound closure, 300

postoperative care, 300 preoperative preparation, 295 principles and justification, 294

anterior partial, 274-5 gastro-oesophageal reflux, 339-44 intrathoracic (Nissen), 320-6, 332

anaesthesia, 322 complications, 326 history, 320 indications, 321 laparoscopic, 571-4

contraindications, 571 indications, 5 71 operation, 571-4 outcome, 574 postoperative care, 574

operation, 322-4 outcome, 325 patient preparation, 322 postoperative care, 325 preoperative assessment, 321-2

barium swallow, 321 oesophageal manometry, 322 upper gastrointestinal endoscopy,

321-2 with oesophageal extension, for

uncomplicated gastro-oesophageal reflux, 309-10

paraoesphageal hiatus hernia, 278

Gallstones, postvagotomy, 368 Gastrectomy

Billroth I, 414-19 history, 414 incision, 415-19 indications, 414 postoperative care, 419 wound closure, 419

Index 611

Gastrectomy- continued Billroth II, Roux-en-Y gastrojejunostomy

after, 411-12 distal, for gastric ulcers, 481, 487-90 limited total, 443-8 with oesophagojejunogastric

reconstruction, 465-71 operation, 466-70 outcome, 470-1 postoperative care, 470 preoperative preparation, 466 principles and justification, 466

partial, 420-35 anatomy, 421 complications, 434-5 duodenal diversion, 341 history, 420 operation

closure of duodenum, 427 closure of mesocolon, 432 division of duodenum, 426 division of gastrohepatic ligament, 422 division of left gastroepiploic vessels,

423 gastrojejunostomy

stapled, 430-2 sutured, 429-30

incision, 421 incision in transverse mesocolon, 428 lesser curvature neurovascular arcade,

425 ligation of right gastric vessels, 424 ligation of right gastroepiploic vessels,

424 mobilization of greater curvature, 422 position of gastrojejunostomy, 428 preoperative preparation, 420 preparation of greater curvature, 423 preparation of lesser curvature, 425 proximal division of stomach, 427 retractors, 4 21

postoperative care, 434 reconstruction, 96-102

enteroenterostomy, 434 gastroduodenal anastomosis, 99-101 gastrojejunal anastomosis, 433

Billroth II, 101-2 Roux-en-Y, 101

jejunal interposition, 102 'lesser curve', 97-9 Roux-en-Y, 101,433

with preservation of innervation, 474-5 incision and exposure, 474 isolation of jejunal segment, 474-5 postoperative care, 475 preservation of antral vagal innervation,

474 principles and justification, 474 proximal gastrectomy, 474

segmental resections, 472-3 exposure of stomach, 473 exposure of upper abdomen, 473 incision, 472 postoperative care, 473 preoperative preparation, 472 principles and justification, 472 problems of, 473

total, 92-5 duodenal diversion, 343 with lymph node dissection, 450-64

combined resection of spleen and distal pancreas, 463

612 Index

Gastrectomy- continued dissection around duodenum, 453-4 dissection around spleen and

oesophagus, 457-8 hand-sewn anastomosis (end-to-side),

459-60 incision, 452 lymph node dissection, 455-6 omentectomy, 452-3 postoperative care, 464 principles and justification, 450-1 reconstruction of gastrointestinal

continuity, 461-3 without lymph node dissection, 436-49

history, 436 postoperative care, 449 preoperative preparation, 436 reconstruction, 446-8

Gastric acid hypersecretion, 512 Gastric anastomosis

hand-sewn technique, 88-107 gastrojejunostomy, 103-7 partial gastrectomy, 96-102

gastroduodenal anastomosis, 99-101 gastrojejunal anastomosis

Billroth II, 101-2 Rouxloop,lOl

jejunal interposition, 102 'lesser curve' reconstruction, 97-9

Roux-en-Y loop, 89-92 end-to-side jejunojejunostomy, 90-2

single-layer serosubmucosal appositional, 88

total gastrectomy, 92-5 stapled, 108-19

gastrojejunostomy, 116-17, 119 closure of stab wound, 117 duodenal closure, 116 resection of stomach, 116 stapling technique, 117

gastro-oesophageal, 112-15 closure of gastrotomy, 114 construction, 112-13 GIA technique, 114-15 narrow oesophagus, 114

Heineke-Mikulicz pyloroplasty, 118 oesophagojejunal, 108-11

checking integrity of anastomosis, 110 construction ofRoux-en-Y

jejunojejunostomy, 110-11 firing EEA device, 110 insertion ofEEA device, 109 passage of anvil into oesophagus, 109 preparation of oesophagus, 108

Gastric bypass, gastroenterostomy in, 404 Gastric outlet obstruction, 367, 389 Gastric reconstruction, 154-64,446-8

operations, 156-63 jejunal preparation, 15 7 jejunojejunostomy, 158-9

anterior wall, 159 posterior wall, 158-9 stapled, 159

jejunoplication, 162-3 pouch with orthograde duodenal

transit, 163 Roux-en-Y anastomosis, 163

oesophagojejunostomy, 160-2 anterior wall, 161 posterior wall, 160-1 stapled, 162

transposition of jejunum, 15 7

Gastric reconstruction- continued outcome, 164 principles and justification, 156 types of, 155

Gastric restriction surgery, 548-60 anaesthesia, 550 history, 548 indications, 549 operation, 550-9

gastric stapling, 554-6 hand position, 551 incision, 5 51 patient position, 550 placement of Marlex mesh, 558 pouch measurement, 557 preparation of stomach for stapling,

552-3 wound closure, 559

outcome, 559 postoperative care, 559 preoperative preparation, 549-50 principles and justification, 548-9

Gastric ulcers, 480-2 background, 477 choice of procedure, 482 distal gastrectomy with

gastroduodenostomy, 481,487-90 division of duodenum, 489 division of stomach, 488 duodenal mobilization, 488 gastric mobilization, 487 gastroduodenal anastomosis, 489-90 preparation of gastric remnant, 489 ulcer exposure, 487

giant gastric ulcer, 481 high-lying gastric ulcer, 481-2 and non-steroidal anti-inflammatory drugs,

477,481 oversewing alone, 481 oversewing or excision with vagotomy and

pyloroplasty, 481 perforated, 531, 535 types of, 477

Gastric vagotomy, see Vagotomy Gastric varices, stapling procedures, see

Stapling procedures, oesophageal varices Gastroduodenal anastomosis, 99-101, 489-

90 see also Billroth I gastrectomy

Gastroenterostomy, 403-13 complications, 412-13

afferent limb syndrome, 412 alkaline reflux gastritis, 413 early, 412 jejunogastric intussusception, 412 'Roux syndrome', 413 twisted gastrojejunostomy, 413

incision, 404 indications, 403-4

duodenal obstruction/trauma, 404 gastric bypass surgery, 404 gastric malignancy, 404 peptic ulcer surgery, 403

laparoscopic, 575-83 history, 575 indications, 576 instrumentation, 575-6

bowel occlusion, 576 grasping forceps, 575-6 needle holders and sutures, 576

jamming loop knot, 577 outcome, 583

Gastroenterostomy- continued patient positioning and port placement,

577 postoperative care, 583 preoperative preparation, 576 stapled and sutured anastomosis, 581-2

application of stapler, 581 external anchoring suture and

enterotomy, 581 suture of residual anastomotic defect,

582 sutured anastomosis, 578-80

anterior layer, 580 opening bowel, 580 posterior layer, 578-9

loop antecolic gastrojejunostomy, 406-7 retrocolic in peptic ulcer surgery, 404-6

postoperative care, 412 Roux-en-Y, 408-12

indications, 408 preoperative preparation, 408 technique, 409-12

closure of mesocolonic defect, 410 division of jejunum, 410 gastrojejunostomy after Billroth II

gastrectomy, 411-12 jejunojejunal anastomosis, 411 selection of jejunal segment, 410 take-down of previous anastomosis,

409 Gastroepiploic vagal innervation, 359 Gastrojejunostomy, 101-2, 103-7, 116-17

antecolic, 407-8 Billroth II, 101-2,411-12

stapled, 116-17 closure of stab wound, 117 duodenal closure, 116 position of, 428 resection of stomach, 116 Roux-en-Y, 101,408-12

gastric reconstruction, 163,433 indications, 408 preoperative preparation, 408 technique, 409-12

closure of mesocolic defect, 410 division of jejunum, 410 jejunojejunal anastomosis, 411 selection of jejunal segment, 410 take-down of previous anastomosis,

409 transmesocolic, 339

stapled, 430-2 anastomotic reconstruction, 431 closure of mesocolon, 432 closure of stapler defect, 432 stapler application, 4 31

sutured, 429-30 anterior portion of anastomosis, 429 completion of anastomosis, 430 posterior inner suture, 429

twisted, 413 Gastro-oesophageal anastomosis, 112-15

closure of gastrotomy, 114 construction, 112-13 GIA technique, 114-15 narrow oesophagus, 114

Gastro-oesophageal fat pad, 331 Gastro-oesophageal reflux

videoendoscopic surgery for achalasia, 600

see also Antireflux surgery

Gastro-oesophagectomy partial, and duodenal diversion, 342 total, and duodenal diversion, 343

Gastropexy anterior, 279 posterior, 314-15

Gastrostomy, high with peritoneal cuff, 527-9

incision, 528-9 indications, 527 outcome, 529 wound closure, 529

Grasping forceps, 5 75-6

Haemostasis, 72 Heineke-Mikulicz pyloroplasty, 347, 396-7

incision, 396-7 patient position, 396

Heller myotomy laparoscopic, 598-9 thoracoscopic, 596-7

Hepatic failure, 512 Hernia, see Paraoesophageal hiatus hernia Hiatus

anatomy, 260-1 closure of, 333

crural sutures, 330 dissection of, 329 hernia, see paraoesophageal hiatus hernia

Hurst dilator, 27 Hyperdynamic circulation, 511 Hypokalaemia, 496

Infection, 512 Injection sclerotherapy, see oesophageal

varices, injection sclerotherapy of Injectors, injection sclerotherapy, 11 Intercostal muscles, division of, 64 Intravariceal injection sclerotherapy, 10, 17

Jaboulay gastroduodenostomy, 400 Jaundice, postoperative, 367 Jejunogastric intussusception, 412 Jejunojejunal anastomosis, 411

end-to-side, 90-2 gastric reconstruction, 158-9 Roux-en-Y, 110-11 stapled, 159 terminolateral, 339

Jejunoplication, 162

Knots abdominal closure, 75-7 jamming loop, 577

Kocherprocedure,339,502

Laparoscopes, 566 Laparoscopy, 561-70

abdominal procedures, 564-5 completion of procedure, 5 70 dissection, 568 equipment, 562-3

instruments, 563 video cameras, 562

Laparoscopy- continued gastroenterostomy, 575-83

history, 575 indications, 576 instrumentation, 575-6

bowel occlusion, 576 grasping forceps, 575-6 needle holders and sutures, 576

jamming loop knot, 577 outcome, 583 patient positioning and port placement,

577 postoperative care, 583 preoperative preparation, 576 stapled and sutured anastomosis, 581-2

application of stapler, 581 external anchoring suture and

enterotomy, 581 suture of residual anastomotic defect, 582

sutured anastomosis, 578-80 anterior layer, 580 opening bowel, 580 posterior layer, 578-9

Heller myotomy, 598-9 laparoscopes, 566 Nissen fundoplication, 5 71-4

contraindications, 571 indications, 571 operation, 571-4 outcome, 574 postoperative care, 574

placement of additional ports, 567 postoperative care, 570 retrieval of specimens, 570 suturing and stapling, 569 vagotomy, 584-92

complications, 592 highly selective, 587-8 history, 584-5 outcome, 592 patient position, 586 postoperative care, 592 preoperative preparation, 585 truncal, 590

thoracoscopic, 591 Laser therapy, bleeding ulcers, 478-9 Left thoracolaparotomy, 190 Leiomyoma, oesophageal, 237-43

anaesthesia, 237 complications, 243 operation, 238-42

exposure and mobilization of oesophagus, 239

extramucosal enucleation, 239-40 incision, 2 38 repair of mucosal defects, 241 repair of muscle coat defect, 242 underwater inflation test for mucosal

leakage, 241 wound closure, 242

outcome, 243 postoperative care, 243 preoperative preparation, 237 principles and justification, 23 7

ligamentum teres fixation, 312 Long oesophageal myotomy, 230-6 Lymph node dissection, 145,455-6

Mallory-Weiss tear, 525-6 Maloney dilator, 27

self-bougienage, 32-3

Manometry, oesophageal achalasia, 595

Index 613

gastro-oesophageal reflux, 293, 322 Mercury-filled bougies, 27, 31-3

self-bougienage, 32-3 Metabolic alkalosis, 496 Midline abdominal incision, 73 Musculature, hiatus and abdominal

oesophagus, 258 Myotomy

for achalasia abdominal approach, 267-75

anaesthesia, 268 assessment, 268 history, 267 indications, 268 operation, 269-75

anterior partial fundoplication, 274-5

approximation of crura, 273 exposure of gastro-oesophageal

junction, 270 incision, 269 mobilization ofleft lobe of liver, 269 mobilization of oesophagus, 270 myotomy, 271-3 wound closure, 275

outcome, 275 patient preparation, 268 postoperative care, 275 preoperative preparation, 268 principles and justification, 268

thoracic approach, 262-6 anaesthesia, 263 complications, 266 diagnosis, 263 history, 262 operation, 263-5 outcome, 266 postoperative care, 266 preoperative preparation, 263 principles and justification, 262

cricopharyngeal, 173-7 incision, 173-7 patient position, 173 postoperative care, 177

long oesophageal, 230-6 assessment, 230 indications, 230 operation, 231-6 patient preparation, 230 postoperative care, 236 principles and justification, 230

pyloromyotomy, 193

Needle holders, 576 Nerves of Latarjet

anterior, 358 crow's foot, 359 posterior, 358

Nerve supply, hiatus and abdominal oesophagus, 259

Nissen fundoplication, 320-6, 332 anaesthesia, 322 complications, 326 history, 320 indications, 321 laparoscopic, 571-4

contraindications, 5 71 indications, 5 71 operation, 571-4

614 Index

Nissen fundoplication- continued outcome, 574 postoperative care, 57 4

operation, 322-4 outcome, 325 patient preparation, 322 postoperative care, 325 preoperative preparation, 321-2

barium swallow, 321 oesophageal manometry, 322 upper gastrointestinal endoscopy,

321-2 see also Collis-Nissen combined operation

Non-steroidal anti-inflammatory drugs and duodenal ulcers, 477 and gastric ulcers, 481

Nutrition postoperative, in liver disease, 513 preoperative, 40

Obesity surgery, see Gastric restriction surgery

Oesophageal anastomosis leakage, 41 stapled, 84-7

principles and justification, 84 technique, 85-7

sutured, 79-83 operation, 80-3 outcome,83 postoperative care, 83 principles and justification, 79

Oesophageal extension for uncomplicated gastro-oesophageal reflux, 308

with fundoplication, 309-10 Oesophageal leiomyoma, see Leiomyoma,

oesophageal Oesophageal perforation, 244-61

aggressive resuscitation, 248 anaesthesia, 249 antibiotic therapy, 248 assessment of injury, 248 diagnosis

clinical, 245 endoscopic, 248 radiological, 245-7

indications for surgical intervention, 248-9

contained perforations, 248 free perforations, 248 location/extent of perforation, 249 patient's general health, 249 presence of underlying oesophageal

disease, 249 time elapsed since injury, 248-9

initial management, 248 late diagnosed, 254, 388

postoperative care, 255 operation

alternative approach, 254 late diagnosed perforation, 254 obstructed oesophagus, 251-3

perforation above fibrotic, benign or malignant stricture, 252-3

perforation from pneumatic dilatation, 251

unobstructed oesophagus, 250-1 postoperative care, 255 preoperative preparation, 245-9 principles and justification, 244

Oesophageal replacement, 134 colon, 128-41

choice of colonic segment, 130 complications, 140-1 contraindications, 129 history, 128 indications, 129 operation, 131-9 outcome, 141 postoperative care, 140 preoperative preparation, 131 principles and justification, 129

extra-anatomical, 165-9 anterior mediastinum, 166-8

patient position, 166 postoperative care, 169 prehilar route, 169 preoperative preparation, 165 prethoracic tubing, 169 principles and justification, 165 subcutaneous route, 169

small intestine, 120-7 free jejunal graft, 126-7 jejunal loop, 121 postoperative care, 127 principles and justification, 120 Roux-en-Y, 122-5

formation of anastomosis, 123-5 selection of small intestinal segment,

122 stomach, 142-53

anaesthesia, 143 anatomical points, 143 completion of abdominal operation,

152 complications, 153 drainage, 152 duodenal mobilization, 149 elevation of stomach and cervical

anastomosis, 150-2 elevation of stomach and intrathoracic

anastomosis, 152 formation of gastric tube, 146-8 history, 142 incision, 144 interposition of whole stomach, 149 lymph node dissection, 145 outcome, 153 patient position, 144 postoperative care, 153 preoperative preparation, 142-3 preparation of stomach, 144-5 preparation of tunnel for interposition,

149-50 principles and justification, 142

Oesophageal strictures dilatation, 26-38

balloon dilators, 29-30, 38 indications, 26 mercury-filled bougies, 27, 31 postoperative care, 38 preoperative preparation, 30 prophylactic antibiotics, 30 self-bougienage, 32-3 types of dilator, 26-30 wire-guided dilators, 27-9, 33-7

Celestin, 29, 37 Eder-Puestow, 29,37 Savary-Gilliard, 28, 3 7

resection, 345-9 anaesthesia, 345 history, 345

Oesophageal strictures- continued operation, 346-8

jejunogastric anastomosis, 348 oesophagojejunostomy, 348 passage of jejunal segment through

oesophageal hiatus, 347 preparation of jejunal segment, 346 resection of gastro-oesophageal

junction, pyloroplasty and gastrostomy tube, 347

selection of jejunal segment, 346 thoracotomy and oesophagectomy,

348 outcome, 349 postoperative care, 349 preoperative preparation, 345 principles and justification, 345

Oesophageal varices bleeding

shunts, see Shunts, portasystemic stapling procedures, see Stapling

procedures, oesophageal varices injection sclerotherapy of, 10-20

combined technique, 10 emergency sclerotherapy, 17

elective, 12-16 endoscopy, 13-14 injection technique, 14-16 outcome, 20 patient preparation, 12 postoperative care, 20

emergency, 17-19 balloon tube tamponade, 19 combined injection, 18 endoscopy, 1 7 initial measures, 1 7 intravariceal injection, 1 7 outcome, 20 postoperative care, 20

endoscope, 11 injectors, 11 intravariceal technique, 10

emergency sclerotherapy, 17 outcome, 20 paravariceal technique, 10 postoperative care, 20 sclerosants, 11

Oesophagectomy, 348 abdominal-right thoracic approach, 52-5

abdominal operation, 53 anaesthesia, 52 postoperative care, 55 preoperative preparation, 52 principles and justification, 52 subtotal, 178-88

abdominal approach, 179-82 incision, 179-82 wound closure, 182

history, 178 postoperative care, 188 thoracic approach, 183-8

incision, 183-8 patient position, 183

thoracic operation, 54-5 en bloc, 214-29

extent of, 217-18 history, 214 operation, 218-28 outcome, 229 postoperative care, 228 preoperative preparation, 218 principles and justification, 215-18

Oesophagectomy- continued endoscopic, 601-6

history, 60 1 operation, 602-4 postoperative care, 606 preoperative preparation, 601 tumour dissection, 604-6

eversion extraction, 211-13 indications, 211 operation, 212-13 outcome, 213

left thoracic subtotal, 189-95 cervical anastomosis, 194 closure, 19 3 complications, 195 contraindications, 189 division and closure of stomach, 192 division of oesophagus, 192 indications, 189 left neck incision, 194 left thoracolaparotomy, 190 mobilization of stomach, 191 mobilization of thoracic oesophagus,

191 position of stomach in chest, 193 postoperative care, 195 preoperative preparation, 189 pyloromyotomy, 193

left thoracoabdominal, 61-9 abdominal dissection, 67 anaesthesia, 62 antibiotic prophylaxis, 62 division of diaphragm, 66 division of intercostal muscles, 64 exploration of abdomen, 64 incision, 63 indications, 61 laparotomy and left thoracotomy, 68 nasogastric intubation, 62 patient position, 63 postoperative care, 69 preoperative preparation, 62 rib resection, 65 thoracic dissection, 66 thoracic exploration, 66 thoracic incision, 64 wound closure, 68

transhiatal, 196-21 0 abdominal phase, 199 anaesthesia, 198 cervical gastro-oesophageal anastomosis,

207-8 cervical phase, 200-6 history, 196 outcome, 210 postoperative care, 209-10 preoperative assessment and

preparation, 197-8 principles and justification, 196-7

Oesophagogastrectomy, 280-91 anaesthesia, 282 classification of adenocarcinoma, 280 indications, 281 outcome, 290 postoperative care, 290 preoperative preparation, 282 principles and justification, 281 total, 287-90

extragastric extent of resection, 289-90 left pancreatic resection, 289 pancreas-preserving splenectomy,

289

Oesophagogastrectomy- continued retroduodenal and para-aortic lymph

nodes, 289 transmediastinal oesophagectomy,

290 patient position, 287

transmedial with proximal gastrectomy, 282-7

endoscopic dissection of cervical and intramediastinal oesophagus, 286

patient position, 283 preparation of distal oesophagus, 283 preparation of mediastinal oesophagus,

284 preparation of proximal oesophagus,

285-6 transmediastinal pull-through and

extirpation of oesophagus, 286-7 Oesophagogastroduodenoscopy, 495 Oesophagojejunogastric reconstruction,

465-71 operation, 466-70 outcome, 470-1 postoperative care, 470 preoperative preparation, 466 principles and justification, 466

Oesophagojejunostomy, 108-11 gastric reconstruction, 160-2 oesophageal stricture resection, 348 stapled, 108-11, 162

checking integrity of anastomosis, 110

construction ofRoux-en-Y jejunojejunostomy, 110-11

firing EEA device, 110 insertion ofEEA device, 109 passage of anvil into oesophagus, 109 preparation of oesophagus, 108

Oesophagoscopy, rigid, 21-5 anaesthesia, 22 contraindications, 21 equipment, 22 examination, 25 indications, 21 passage of oesophagoscope, 24 patient position, 23 patient preparation, 22 postoperative care, 25 tooth protection, 23

Oesophagus abdominal approach, see Abdominal

incisions achalasia, see Achalasia adenocarcinoma, oesophagogastrectomy,

280-91 anatomy, 256-61

anatomical relations, 256-7 blood supply, 258 mobilization of distal oesophagus,

259-60 musculature, 258 nerve supply, 259 oesophageal hiatus, 260-1 phreno-oesophagealligament, 259

cervical mobilization of, 172 surgical anatomy, 170-2

recurrent laryngeal nerves, 1 72 surgical approach, 45-51

incision, 46-51 patient position, 45

distal, mobilization of, 259

Oesophagus- continued examination of

endoscopic, 4

Index 615

rigid oesophagoscopy, 21-5 injury to, 366 major surgery, 39-42

complications of, 41-2 anastomotic leakage, 41 recurrent laryngeal nerve injury, 42 thoracic duct injury, 41-2

postoperative care, 40-1 chest drains, 40 feeding, 40-1

preoperative preparation, 39-40 cardiovascular fitness, 39-40 diagnosis and operative planning, 39 nutrition, 40 preoperative and perioperative

therapy,40 respiratory fitness, 40

myotomy, see Myotomy, long oesophageal replacement, see Oesophageal replacement resection, see Oesophagectomy strictures, see Oesophageal strictures varices, see Oesophageal varices see also Oesophagectomy;

Oesophagoscopy Omentectomy, 452-3

Pancreas, resection, 463 Pancreatitis, postoperative, 367 Paramedian abdominal incision, 73 Paraoesophageal hiatus hernia, 276-9

associated antireflux procedure, 276 asymptomatic patients, 276 operation, 277-9

anterior gastropexy, 279 closure and completion, 279 closure of hiatus, 278 fundoplication, 278 incision and exposure, 277 reduction and excision of sac, 277

outcome, 279 postoperative care, 279 preoperative preparation, 277 principles and justification, 276 surgical approach, 276

Paravariceal injection sclerotherapy, 10 Parenteral fluid therapy, 510-11 Partial pylorectomy, 401 Peptic ulcers

gastroenterostomy in, 403, 404-6 perforated, see Ulcers, perforated see also Duodenal ulcers; Gastric ulcers

Perforation of oesophagus, see Oesophageal perforation

Pharyngo-oesophageal diverticulum, excision of, 173-7

incision, 1 73-7 patient position, 173 postoperative care, 1 77

Phreno-oesophagealligament, 259 Portasystemic encephalopathy, 496 Portasystemic shunts, see Shunts,

portasystemic Position of patient

cervical approach to oesophagus, 45 cricopharyngeal myotomy, 1 73 gastric restriction surgery, 550 Heineke-Mikulicz pyloroplasty, 396 injection sclerotherapy, 12

616 Index

Position of patient- continued left posterolateral thoracotomy, 57 oesophageal replacement

extra-anatomical, 166 stomach, 144

oesophageal varices portacaval anastomosis, 500-1 stapling procedures, 517

oesophagectomy abdominal-right thoracic subtotal, 183 left thoracoabdominal, 63

oesophagogastrectomy total, 287 transmedial with proximal gastrectomy,

283 rigid oesophagoscopy, 23 vagotomy

laparoscopic, 586 total abdominal, 361

Posterior gastropexy, 314-15 Postgastrectomy syndrome, 491 Postvagotomy syndrome, 491 Pouches, see Gastric reconstruction Pulmonary complications, 511 Pyloric reconstruction, 368, 392 Pyloromyotomy, 193,402 Pyloroplasty, 118, 394-402

anaesthesia, 395 duodenal ulcers, 479,485 Finney, 398-9 gastric ulcers, 481 Heineke-Mikulicz, 347,396-7 history, 394 Jaboulay gastroduodenostomy, 400 leaking, 367 outcome, 402 partial pylorectomy, 401 postoperative care, 402 preoperative preparation, 395 principles and justification, 395 pyloromyotomy, 402

Radiology oesophageal achalasia, 594 oesophageal perforation, 245-7

Recurrent laryngeal nerves anatomy, 172 injury during oesophageal surgery, 42

Renal failure, 512 Respiratory fitness, preoperative, 40 Retractors, 421 Rib resection, 65 Roux-en-Y loop

construction, 89-92 gastric reconstruction, 163

partial gastrectomy, 96-102, 433 total gastrectomy, 92-5

gastrojejunal anastomosis, 101,433 transmesocolic, 339

gastrojejunostomy, 408-12 Billroth II gastrectomy, 411-12 closure of mesocolic defect, 410 division of jejunum, 410 indications, 408 jejunojejunal anastomosis, 411 preoperative preparation, 408 selection of jejunal segment, 410 take-down of previous anastomosis, 409

gastro-oesophageal reflux, 335-44 complications, 344 history, 335

Roux-en-Y loop- continued indications, 335 operations, 336-43

antireflux procedure, 338 antrectomy, 339 duodenal diversion

after partial gastrectomy, 341 after previous partial gastro­

oesophagectomy, 342 after total gastrectomy, 343 after total gastro-oesophagectomy

and colonic interposition replacement, 343

gastrojejunal transmesocolic anastomosis, 339

jejunojejunal terminolateral anastomosis, 339

vagotomy, 336-7 problems of, 340-1

outcome, 344 postoperative care, 343 preoperative preparation, 335

jejunojejunostomy, 110-11 end-to-side, 90-2

oesophageal replacement, 122-5 'Roux syndrome', 413

Savary-Gilliard dilator, 27, 28, 3 7 Savary guidewire, 27, 28 Schatzki's ring, 352-3 Sclerosants, 11 Sclerotherapy

bleeding ulcers, 478 oesophageal varices, see Oesophageal

varices, injection sclerotherapy of Segmental resections, 472-3

exposure of stomach, 473 exposure of upper abdomen, 473 incision, 4 72 postoperative care, 473 preoperative preparation, 472 principles and justification, 4 72 problems of, 473

Self-bougienage, 32-3 Sepsis, 384-8

operative management, 386-8 duodenal stump blow-out, 387 subphrenic abscess, 386-7 suture line dehiscence, 387 unrecognized oesophageal perforation,

388 prevention, 384-6

Shunts, portasystemic, 493-515 choice of, 497-9

end-to-side portacaval, 497 interposition mesocaval H graft, 498 mesocaval, 498 selective distal splenorenal, 499 side-to-side portacaval, 497 splenorenal, 499

direct portacaval anastomosis, 500-10 anaesthesia, 500 assessment of venous pressures, 506 determination of adequacy of

mobilization, 505 end-to-side portacaval anastomosis,

508-9 exposure of inferior vena cava, 502 exposure of operative field, 502 exposure of portal vein, 504 incision, 501

Shunts, portasystemic- continued incision of posterior peritoneum, 502 isolation of inferior vena cava, 503 liver biopsy, 509 mobilization of portal vein, 505 patient position, 500-1 side-to-side portacaval anastomosis,

506-8 wound closure, 510

elective therapeutic, 494 emergency therapeutic, 494 indications, 494 outcome, 513-15 patient preparation, 495-6 postoperative care, 510-13

alcoholism, 513 delirium tremens, 511-12 follow-up, 513 gastric acid hypersecretion, 512 hepatic failure, 512 hyperdynamic circulation, 511 infection, 512 monitoring, 510 nutrition, 513 parenteral fluid therapy, 510-11 pulmonary therapy, 511 renal failure, 512

preoperative preparation, 494-6 blood studies, 495 diagnosis, 494 history and physical examination, 494 nasogastric aspiration and stool

examination, 494-5 oesophagogastroduodenoscopy, 495

prophylactic, 494 Small intestine as oesophageal replacement,

120-7 free jejunal graft, 126-7 jejunal loop, 121 postoperative care, 127 principles and justification, 120 Roux-en-Y, 122-5

formation of anastomosis, 123-5 selection of segment, 122

Spleen injury to, 366-7 resection, 463

Stapling procedures gastric anastomosis, 108-19 gastric restriction, 552-6 gastrojejunal anastomosis, 116-17, 430-2 jejunojejunal anastomosis, 159 laparoscopic gastroenterostomy, 581-2 laparoscopy, 569 oesophageal anastomosis, 84-7 oesophageal varices, 516-24

anaesthesia, 516 circular stapler, 517-21

devascularization of lower oesophagus, 518

division of perforating veins, 519 exposure of left gastric pedicle, 517 insertion of stapling gun, 520 ligation of left gastric pedicle, 517 mobilization of oesophagus, 518 modifications of, 521 placement of encircling ligature, 519 position of patient and incision, 517 transection, 520-1

history, 516 linear stapler, 522-3

cardiofundectomy for gastric varices, 523

Stapling procedures- continued transabdominal subcardiac, 522

outcome, 523 postoperative care, 523 preoperative preparation, 516 principles and justification, 516

Stomach cancer

en bloc oesophagectomy, see Oesophagectomy, en bloc

gastroenterostomy, 404 oesophagogastrectomy, see

Oesophagogastrectomy endoscopic examination of, 5-8 fundal anatomy, 256-61

blood supply, 258 mobilization of distal oesophagus,

259-60 musculature, 258 nerve supply, 259 oesophageal hiatus, 260-1 phreno-oesophageal ligament, 259

lymph nodes, 451 major surgery, 42-4

postoperative care, 43-4 preoperative preparation, 42-3

elective duodenal ulcer surgery, 42 gastric malignancy, 43 urgent/emergency ulcer surgery,

42-3 see also Gastrectomy; Gastric

reconstruction as oesophageal replacement, 142-5 3

anaesthesia, 143 anatomy, 143 completion of abdominal operation,

152 complications, 15 3 drainage, 152 duodenal mobilization, 149 elevation of stomach

and cervical anastomosis, 150-2 and intrathoracic anastomosis, 152

formation of gastric tube, 146-8 history, 1 4 2 incision, 144 interposition of whole stomach, 149 lymph node dissection, 145 outcome, 153 patient position, 144 postoperative care, 15 3 preoperative preparation, 142-3 preparation of stomach, 144-5 preparation of tunnel for interposition,

149-50 principles and justification, 142

passage of endoscope into, 5 see also Gastric anastomosis

Stomal ulcers, perforated, 531, 535 Subcostal abdominal incision, 74 Subphrenic abscess, 386-7 Supplemental proximal gastric vagotomy,

313 Suture line dehiscence, 387 Suturing procedures

abdominal incisions, 77-8 Collis-Nissen combined operation, 330 duodenal ulcer surgery, 484 gastrojejunal anastomosis, 429-30 laparoscopy, 569 oesophageal anastomosis, 79-83 suture line dehiscence, 387

Thoracic duct injury, oesophageal surgery, 41-2

Thoracotomy, left posterolateral, 56-60, 348

anaesthesia, 56 closure of incision, 59 complications, 60 extensions to abdomen, 59 incision, 57 intercostal division, 58 mobilization of oesophagus, 58-9 patient position, 57 postoperative care, 60 preoperative preparation, 56

Tooth protection, rigid oesphagoscopy, 23 Transhiatal oesophagectomy, 196-210

anaesthesia, 198 history, 196 operation, 198-208

abdominal phase, 199 cervical gastro-oesophageal anastomosis,

207-8 cervical phase, 200-6 mediastinal dissection, 200-6

outcome, 290 postoperative care, 209-90 preoperative preparation, 197-8 principles and justification, 196-7

Trocars, placement of, 565

Ulcers bleeding, 476-92

anaesthesia, 482 competing therapies, 477-9

endoscopic cautery, 478 endoscopic heater probe, 478 endoscopic injection/sclerosis, 478 laser, 478-9

complications, 491-2 postvagotomy and postgastrectomy

syndromes, 491 recurrence, 491

indications for surgery, 479-82 outcome, 491 perforated, 5 34 postoperative care, 491 preoperative preparation, 482

duodenal, see Duodenal ulcers gastric, see Gastric ulcers peptic, see Peptic ulcers perforated, 5 30-6

anaesthesia, 532 conservative management, 5 30 future developments, 535 operations, 532-5

duodenal ulcer definitive procedure, 534-5 with haemorrhage, 534 with obstruction, 534 simple closure, 532-4

gastric ulcer, 535 incision, 532 stomal ulcer, 535

postoperative care, 535 preoperative preparation, 532 surgical management, 5 30-1

recurrent, 367-8, 389-91, 491 after proximal gastric vagotomy, 390 after vagotomy and antrectomy, 391 after vagotomy and drainage, 391

Index 617

Ulcers-- continued reoperative surgery, 382-93

early complications, 384-9 bleeding, 388-9 gastric outlet obstruction, 389 sepsis, 384-8

operative management, 385-8 prevention, 384-6

late complications, 389-93 alkaline reflux gastritis, 391 dumping syndrome, 392 postvagotomy diarrhoea, 393 recurrent ulcer, 389-91

principles and justification, 382 techniques, 383

stomal, see Stomal ulcers Underwater inflation test for mucosal leakage,

241

Vagotomy, 336-7 duodenal ulcers, 479-80, 483-6 gastric

proximal, 373-81 indications, 374 operation, 375-80

anterior vagotomy of proximal stomach, 3 77

exposure, 3 75 inspection of completed vagotomy,

379 mobilization of oesophagus and

vagal trunks, 376 oesophageal skeletonization, 3 78 posterior vagotomy of proximal

stomach, 3 78 potential pitfalls, 380

postoperative care, 380 preoperative preparation, 3 7 4 principles and justification, 3 73-4 recurrent ulcers after, 390-1

total, 369-72 anterior selective, 3 70 complications, 3 72 exposure, 3 70 history, 369 incision, 3 70 indications, 369 posterior selective, 3 71 postoperative care, 3 72 pyloroplasty, 3 72 skeletonization of distal oesophagus, 3 72

gastric ulcers, 481 laparoscopic, 584-92

complications, 592 highly selective, 587-8 history, 584-5 outcome, 592 position of patient, 586 postoperative care, 592 preoperative preparation, 585 truncal, 590

thoracoscopic, 591 problems of

hiatal opening difficult or dangerous to reach, 340-1

hiatal opening easily reached but vagotomy difficult, 340

possible previous inadequate surgery, 340

total abdominal, 360-8 closure, 366

618 Index

Vagotomy- continued complications, 366-8

dumping syndrome, 368 gallstone formation, 368 gastric outlet obstruction, 367 leaking pyloroplasty, 367 oesophageal injury, 366 postoperative jaundice, 367 postoperative pancreatitis, 367 postvagotomy diarrhoea, 368 recurrent ulcer, 367-8, 391 splenic injury, 366-7

exploration, 361 exposure, 361 history, 360 incision, 361 indications, 360 modified techniques, 365-6

Vagotomy- continued patient position, 361 postoperative care, 366 truncal technique, 362-4

anterior, 363 modified, 365

drainage procedure, 364 posterior, 363-4

modified, 366 Vagus nerves, anatomy, 354-9

abdominal, 356 angle of His, 359 anterior divisions, 357 central vagus complex, 355 cervical, 355 coeliac branches, 358 'criminal' nerve of Grassi, 359 distal oesophageal plexus, 358

Vagus nerves, anatomy- continued gastric branches

anterior, 357 posterior, 358

gastroepiploic vagal innervation, 359 hepatic branches, 357 nerves ofLatarjet

anterior, 357 crow's foot, 359 posterior, 358

posterior divisions, 358 thoracic, 356

Video cameras, 562

Watermelon stomach, 526 Wire-guided dilators, 27-9, 33-7