Gastrointestinal Practicals - Peritoneal Lavage

C” Modul - Advanced Skills

C3 Lecture: GI practicals. Invasive diagnostic techniques. Abdominal drainage. Anastomosis techniques

Gastrointestinal practicals - peritoneal lavage

1. Acute abdominal lavage

History

1950: Four quadrant needle paracentesis

1965: Diagnostic Peritoneal Lavage (DPL - Root HD et al: Diagnostic peritoneal lavage. Surgery. 1965 ;57:633-7). Sensitivity: 98%; but: specificity: 80% (no information on retroperitoneum).

1990’: laparoscopy. Advantage: good visualisation of intraabdominal organs;

Disadvantage: no information on retroperitneum, ‘complicated’ closure

Indications

• Equivocal clinical examination

• Difficulty in assessing patient

• Persistent hypotension despite adequate resuscitation

• Multiple injuries

• Stab wounds where the peritoneum has been breached

• Lack of other diagnostic methods (UH, CT)

Open method

• Urinary catheter and nasogastric tube

• Local anesthesia

• Vertical, approx. 2 cm sub-umbilical incision, division of linea alba

• Incision on peritoneum and insertion of peritoneal dialysis catheter

• Aspiration of free blood or gastric content, etc.

• If no blood seen – infusion of 1L normal saline

• 3 min to equilibrate

• Placement of drainage bag on floor and allow to drain - “gravity is our friend”

• 20 ml sample is sent to laboratory for measurement of rbc, wbc and microbiological examination

Closure

- Peritoneum: purse-string suture

- Skin: interrupted suture

Closed method

• Urinary catheter and nasogastric tube

• Local anesthesia

• Guide-wire, blind introduction

• 9% morbidity: vessel damage

No. 3. choice - obes patient protocol for DPL

Indications

• CT is not possible (weight, diameter limits, poor image, higher radiation)
• Open DPL contraindicated
• Depth of puncture (peritoneum) can not be judged
• Complication rate of closed technique is much higher

Possibility

• Half closed/open/blind Seldinger or modified Seldinger technique

Acute peritoneal lavage - positive result

• Red cell count > 100,000 / mm3

• White cell count > 500 / mm3

• Presence of bile, bacteria or faecal material

Acute peritoneal lavage – next step

Damage control - surgery

Chronic lavage: peritoneal dialysis

Technique

Dialysate is injected into the peritoneal space through a two-way Tenckhoff catheter which remains permanently in place.

Peritoneal dialysate, made up mostly of salts and sugar (glucose), encourages ultrafiltration. The peritoneum allows waste and fluid to pass from the blood into the dialysate, which is pumped out..

Abdominal post. op. lavage /drainage

Abdominal drainage – main types

• Penrose

• Delbet (corrugated)

• Silicone tubes

• Suction drains

• Mikulicz-drain (gauze packs)*

• Continuous post-op. lavage in severe intra-abdominal sepsis:

• Simple
• Cheap
• Life-saving

Drainage problems

• Clotting

• Fibrin plug

• Cavity compartments, adherence

• Bacterial infections

Rules

• Cavity: should be open
• Closure: primary is forbidden

GI practicals - anastomosis

Anastomosis: late Latin (sec. Galen) from Greek (anastomoun = ana = up, + stoma = mouth; = opening up).

Types of anastomoses

• Side to side

• End-to-end

• End-to-side

Anastomosis healing

Lag phase (day 0-4)

• Acute inflammatory responses

• No intrinsic strength

Fibroplasia phase (day 3-14)

• Fibroblasts proliferate

• Immature collagen is laid down

Maturation phase (beyond 10 days)

• Collagen is remodelled

• Strength of anastomosis is increased

Goals of anastomosis surgery

– Promote primary healing by accurate alignment of the divided bowel

– Cause minimal disruption of the local vasculature

– Incorporate minimum amount of foreign material

Factors influencing anastomotic healing

• Good anastomotic technique (maintain apposition until collagen is laid down)

– Good blood supply

– Tension-free

• Causes of leak / failure

– Distal obstruction

– Perianastomotic sepsis

– Perianastomotic haematoma

– Hypotension

– Hypoxia

– Jaundice

– Corticosteroids

– Uraemia

Anastomotic techniques

• Conventional

– Hand-sewn

– Stapled

• Novel techniques

– Compression rings

– Tissue glues

No evidence that hand-sewn are superior to stapled anastomoses

Two layered technique

• Classic teaching of GI anastomoses

– Inner continuous all layer catgut suture

– Outer seromuscular interrupted silk

• Produces serosal apposition and mucosal inversion

• Inner layer is haemostatic but also strangulates mucosa

Single layered technique

• Modern teaching of GI anastomoses

• Interrupted, seromuscular, absorbable (e.g. 3/0 Vicryl + round bodied needle)

• Incorporates strong submucosal layer

• Minimal damage to submucosal vascular plexus

Stapled anastomoses

• Side to side anastomosis with linear staplers (e.g. GIA 60)

• End to end anastomosis with circular devices (e.g. CEEA)

• Reduced radiologically-detected anastomotic leaks

• Increased rate of anastomotic strictures

Drainage of anastomosis

• Controversial
• No evidence that the use of a drain reduced leak rate for anastomoses above pelvic brim
• May increase the risk of anastomotic leak

Other (non-GI) anastomoses

Biliary / urological

• Always absorbable sutures

• Non-absorbable sutures: risk of stone formation

Vascular

• Always non-absorbable sutures

• Prolene is most often used (2/0 on aorta, 4/0 on femoral artery, etc.)

GI practicals - intestinal anastomosis

Surgical intervention: special considerations

• Patient factors

- Intestinal antisepsis/bowel prep

• Room set-up

• Special bowel technique

 The intestinal tract is considered contaminated

 Second instrument set up after bowel is closed

 In all procedures involving the intestines, special precautions are taken to prevent contamination of the field by the bowel contents.

 Once the bowel has been opened, all contaminated instruments, sponges, and other equipment are kept separate from equipment that is used for closure.

 It is required in some facilities that you set up a separate Mayo stand for closure with needed instruments and suture. May need new draping materials. These items are not touched until the bowel has been closed and the team has been re-gloved and re-gowned according to the OR policy.

 During the procedure the area for anastomosis is isolated with lap sponges or drapes, or both, to minimize spillage of bowel contents.

Principles of resection and anastomosis

• Supine position

• Midline exposure

• Adequate retraction is a must

• General anesthesia

• Affected bowel must be mobilized (freed)

• Pathological tissue is removed with a margin of some healthy tissue

• An adequate blood supply to the remaining bowel must exist

• Relatively equal diameter segments of bowel should be sewn together.

• The anastomosis should be tension-free and leak-proof

• The mesenteric defect is closed

• Functional and anatomical continuity is maintained

Enterotomy - surgical intervention and procedure steps

1. Incision is made—usually midline for best exposure
2. Explore the loops of intestine to identify portion to be removed. If the lesion is cancerous, a wide margin of intestine on either side of the lesion is also removed.
3. To free the bowel from its peritoneal and mesenteric attachments, dissect them with Metzenbaum scissors. Péan clamps and ties are used for hemostasis.
4. Portions of the mesentery are double-clamped, divided, ligated. Large vessels are controlled with suture ligatures.
5. The bowel is freed up (mobilization procedure), along the full length of the bowel to be resected.
6. Once the bowel is isolated, the segment is double-clamped at each end with intestinal clamps. Using the cautery pencil, the bowel is divided between each set of clamps.
7. At this point, the bowel is open and there is great potential for fecal contamination. To help prevent this, place 2 lap sponges around the base of the intestinal stumps.
8. Next, to initiate anastomosis, the assistant places the 2 bowel ends in close approximation, and the first layer of interrupted sutures is placed.

Anastomosis - procedure steps

• The two bowel ends are put in close approximation and the first layer of interrupted sutures is placed. The surgeon continues until the two intestinal lumens are joined.

• The intestinal clamps are then removed and a final reinforcing suture layer of interrupted sutures is placed.

• The final step is to close the mesentery. Usually interrupted sutures of size 3-0, are used.

(see details in video)

Postoperative care - potential complications

• Hemorrhage

• Infection—greater chance of sepsis and obstruction

• Key: ureteral injury, thromboembolism

• Other: depends on type of colectomy

• Right hemicolectomy: damage to right ureter, duodenum, inferior vena cava, common bile duct

• Tranverse colectomy: damage to stomach, pancreas, spleen, superior mesenteric vessels

Lecture C4 – Thoracic practicals. Thoracocentesis. Thoracic drainage

Content

• Thoracic trauma

• Iatrogenous trauma

• Thoracic fluid, effusion

• Haemothorax

• Pneumothorax

• Invasive techniques

- needle thoracocentesis

- thoracic drainage

- thoracic suction

• Flail chest

• Pericardial drainage, pericardiocentesis

Thoracic trauma

• Sudden and dramatic

• 25% of traumatic death

• 2/3 in hospital

• Severe consequences: hypoxia, hypovolemia, respiratory and cardiovascular dysfunction

• Blunt, non-penetrating

– MVAs

– Kicks

– Falling from a height

• Penetrating

– Gunshot wounds

– Punctures

Localization

• Chest wall

• Pleural space

• Pulmonary parenchyma

• Upper airway/mediastinum

• Cardiac

Blunt trauma

• Direct hit (e.g. rib fracture)
• Deceleration injury
• Compression injury
• Most common sign: rib fracture
• Fracture of the scapula, sternum or 1. rib: extreme forces = vascular injury is likely

Penetrating trauma

• Peripheral lung parenchyma
• Haemothorax, pneumothorax
• Heart, large vessels, esophagus

Thoracic trauma - general principles

• ABC first

• If patient is unstable, always consider tension pneumothorax, pericardiac tamponade, massive haemothorax

• Pathway of trauma drives the diagnosis

• Additional diagnostic tools are often needed: echocardiography, bronchoscopy, esophagography, oesophagoscopy, aortography

Iatrogenous trauma

NG tubes

Endobronchial

PTX

Thoracic tubes

Subcutaneus

Intraparenchymal

Intrafissural

CV catheters

Neck

Sinus coronarius

PTX

Pleural effusion

• Transudate (protein content < 3.0 g/ml), serosus fluid (pl. malignancies)

• Exsudate (protein content > 3.0 g/ml), inflammation

• Haemothorax (blood)

• Empyema (pus in pleural sac), fibro-purulent exsudate

• Chylothorax (lymph)

Mechanism/causes

• Increased hydrostatic pressure – CHF
• Increased capillary permeability – inflammation
• Decreased colloidal oncotic pressure – nephrotic syndrome, liver disease
• Decreased lymphatic drainage – metastatic obstruction

Diagnosis

• History + chest X-ray

Pleural effusion – therapy - general principles

• Find the cause
• Analgestics for pleurisy
• Thoracentesis
• Thoracic tube
• Pleurodesis – closure of pleural sac

Hemothorax- definition

Blood in pleural sac, usually caused by penetrating trauma.

Sources of bleeding, characteristics

• Blood will compress heart and great thoracic vessels

• Lungs contain approx. 1.5 l blood each

• Clinically significant bleeding is rare

• One or two sided

• Respiratory distress +/- (circulatory failure is more common)

• Tachycardia, weak pulse, shock-like state

• Diagnosis: X-ray: pleural effusion; diagnostic thoracocentesis

Treatment

• ABC
• Volume and oxygen
• Small (300-500) – left alone; reabsorbed
• Moderate (500-1000) – CT, drainage required
• Large (> 1000) – CT, drainage and surgery (control arterial bleed)

Pleural Injury

• Respiratory distress: tachypnoea, dyspnoea, orthopnoea

• Circulatory dysfunction: shock-like state. Intrapleural pressure increase → decrease of venous return → cardiovascular dysfunction, hypotension, tachycardia

Pneumothorax

• Condition in which air or gas exists in the pleural space

• Normally negative pressure (suction) between the visceral and parietal pleura → any injury that allows air or positive pressure to enter pleural space prevents the lung from remaining inflated

• Air in pleural space → increased intrapleural pressure → partial or total collapse of the lung

Etiology

• Blunt chest trauma (MVAs and falls)
• Penetrating traumas (gunshot and knife injuries), rib fractures, flail chest
• Assessment: questions to ask

- Are you having difficulty breathing?

- Do you have pain in your chest? Point to your pain with one finger.

Clinical manifestations

• Tachypnea, tachycardia
• Cyanosis
• Diminished breath sounds, hyper-resonance on affected side
• Neck vein engorgement
• Paradoxical movement of the chest
• Deviated trachea
• Anxiety
• Cardiogenic shock

Types

• Closed vs open
• Traumatic vs spontaneous
• Simple vs tension
• Primary vs secondary

Closed Pneumothorax

• Blunt trauma, abrupt pressure rise (blast, diving) or spontaneous

• Thin, smoker, male, 20-40 yrs old

• Most resolve after 1-2 days, < 10% require chest tubes, rarely require surgical repair

Treatment

• Oxygen
• Fluid iv
• Circulatory monitoring
• Chest tube

Open pneumothorax

Definition

A hole in the chest wall allows atmospheric air to flow into the pleural space. Air in the pleural space → increased intrapleural pressure → resulting in partial or total collapse of the lung.

Cause

• Results from a penetrating injury
• Side-effect of therapeutic procedure, insertion of a CVC or pulmonary artery catheter

Signs

• A sucking or hissing sound audible on inspiration as the chest wall rises
• Caughing up blood
• Frothy blood coming from wound
• Shortness of breath / difficulty breathing
• Pain in shoulder or chest that increases with breathing
• Respiration: bluish tint of lips, inside of mouth, fingertips, or nail beds (cyanosis)
• Circulation: HR increase, rapid and weak pulse (shock)

Open pneumothorax treatment

• Wound toilette – larger wounds first

• Check for entry and exit wound (look and feel)

• Air-tight, complete cover at least 5 cm beyond the edges of the wound

• Tape down three edges of airtight material (top edge and two sides) to create a “flutter valve” effect that allows air to escape from but not enter the chest cavity

• Place the casualty in the recovery position with the injured side to the ground

• Continuous check for: tension PTX and shock

• USA: Petroleum Gauze; Asherman Chest Seal (flutter-valve seal)

Tension pneumothorax

Definition: tension PTX = accumulation of air under pressure in the pleural space. Injured tissue forms a one-way valve, allowing air to enter the pleural space and preventing the air from escaping naturally → collapse of ipsilateral lung → hypoxia.

Increased thoracic pressure → pushes the heart, vena cava, and aorta out of position (mediastinum shift) → poor venous return to heart → decreased CO → hypoxia

Tension pneumothorax - etiology

• 33% of preventable thoracic deaths

• Iatrogenic or related to trauma (blunt or penetrating), rib fractures

• Barotrauma secondary to positive-pressure ventilation (PEEP)

• CV catheter placement, usually subclavian or internal jugular

• Conversion of idiopathic, spontaneous, simple PTX to tension PTX

• Unsuccessful attempts to convert an open PTX to a simple PTX in which the occlusive dressing functions as a 1-way valve

• Chest compressions during cardiopulmonary resuscitation (CPR)

• Pneumoperitoneum

• Fiberoptic bronchoscopy with closed-lung biopsy

• Markedly displaced thoracic spine fractures

Tension pneumothorax – signs, symptoms

• Early findings

– Chest pain

– Dyspnea

– Anxiety

– Tachypnea

– Tachycardia

– Hyperresonance of the chest wall on the affected side

– Diminished breath sounds on the affected side

• Late findings

– Decreased level of consciousness

– Tracheal deviation toward the contralateral side

– Hypotension

– Distension of neck veins (may not be present if hypotension is severe)

– Cyanosis

Pneumothorax - treatment

• Important questions:

– How much air?

– Source?

– Clinical condition?

– Severity of other injuries?

– Critical care resources

Therapy in general: thoracocentesis ! Contraindication: relative only!

• previous thoracotomy
• previous pneumonectomy
• presence of a coagulation disorder

Treatment of simple pneumothorax

• <20% PTX: bed rest, limited physical activity
• 20% PTX: thoracocentesis, or insertion of a chest tube attached to an underwater seal

Treatment of simple pneumothorax - needle thoracocentesis

• Needle: 22 – 20 gauge
• Extension tubing
• Three way stopcock
• Syringe – 20 to 60 cc

 Supplemental oxygen

 +/- iv fluids

 Analgesics

Emergency needle decompression

This procedure is not the definitive treatment for tension PTX, but it arrests its progression and serves to restore cardiopulmonary function (slightly)

Indication

Tension PTX dg with any of 2 signs:

• Respiratory distress and cyanosis

• Mental alterations

• Non palpable radial pulse (hypovolemia)

Therapy

• Administration of 100% oxygen, ventilation if necessary, continuous monitoring, pulse oxymetry – if possible.

• Locate anatomic landmarks. Surgical chest prep (Betadine, alcohol), local anesthetics (if pt is awake or if time / situation permits).

• Trauma: supine, head tilt

• Other pts: 450 sitting position

• Place decompression catheters in the 2nd rib interspace in the midclavicular line. Placement in the middle third of the clavicle minimizes the risk of injury to the internal mammary artery.

• Puncture through the skin, 1-2 cm from the sternum.

• Needle (14-16-gauge) or needle catheter (Braunüle; 2 inch/5 cm) is used, perpendicular to skin just above the cephalad border of the 3rd rib (the intercostal vessels are largest on the lower edge of the rib).

• Once the needle is in the pleural space, listen for the hissing sound of air escaping, and remove the needle while leaving the catheter in place.

• A. Secure the catheter in place.

• B. Install a flutter valve (e.g. glove, condom).

• C. Prepare the patient for tube thoracostomy.

Percutaneous thoracocentesis

Instruments

• 18 G Braunüle

• Pneumocath (9 F)

• Seldinger catheter (6-16 F)

• Chest tube (18-36 F)

• Water seal

Complications

• Injury of intercostal vessels, nerves

• PTX (if the procedure is performed in patients without having PTX, the risk rate of lung injury and PTX is 10-20%)

• Infection

Chest drain - chest tubes

Indications

• Evacuate fluid and air from pleural space

• Reestablish negative intrapleural pressure to reexpand lung

• Tube thoracostomy is the definitive treatment for tension PTX, and needle decompression mandates an immediate follow up with a tube thoracostomy

Therapy

• Sedation; narcotics are optional and may not be necessary.

• Location of anatomic landmarks, administration of local anesthetic.

• Preparation the area with Betadine, draping (optional).

• 3-cm horizontal incision over the 5th or 6th rib along the midaxillary line.

• Using a curved hemostat (Péan) dissection down to the rib, just over the superior portion (avoiding the intercostal neurovascular bundle), then, puncture the intercostal muscles and parietal pleura

• Inserting a finger along side of the hemostat.

• Insertion the chest tube over the finger into the pleural space.

• Look for condensation in the tube as a sign of correct placement and air evacuation.

• Connect the thoracostomy tube to an underwater seal apparatus and suction.

• Suture the tube in place, dress the wound, and tape the tube to the chest.

• Chest X-ray to assess tube positioning and lung reexpansion.