The gall-bladder, pancreas, and spleen

From Primary Surgery

Contents 1 Chapter 13 1.1 13.2 Biliary Colic 1.2 13.3 Acute Choleystitis 1.3 Acute Cholecystitis 1.4 13.4 Cholangitis 1.5 Choledochostomy 1.6 13.5 Cholangitis caused by Ascaris 1.7 13.6 Primary or Recurrent Pyogenic Cholangitis 1.8 13.7 Cholecystectomy 1.9 Elective Cholecystectomy 2 13.8 Obstructive Jaundice 2.1 Obstructive Jaundince 3 13.9 Pancreatitis 3.1 Acute Pancreatitis 4 13.10 Pancreatic Pseudocyst 4.1 Pancreatic Pseudocyst 5 13.11 The Surgery of the Spleen

Chapter 13

Most disease of the gall-bladder is due to stones, apart from the uncommon occasions when Ascaris invades it. Such is the lifestyle of most of your patients that you probably won't see it very often. In Africa it is unusual, but it is commoner in Northern India and Tibet. Disease of the pancreas is also uncommon in much of Africa, but calcified chronic pancreatitis and carcinoma of the pancreas are not uncommon in India. Many patients are found at postmortem to have gall-stones which have caused no symptoms. Stones may however obstruct the common bile-duct and cause biliary colic, or obstructive jaundice. They can promote infection of the gall-bladder and cause acute or chronic cholecystitis. They can also promote infection of the pancreas and cause pancreatitis. You can treat acute cholecystitis non-operatively, or if this fails, you can drain a patient's gall-bladder by doing a cholecystostomy. If he has chronic cholecystitis, you may sometimes be able to remove his gall-bladder. But if he has obstructive jaundice due to stones in his common duct, you should refer him to an expert. If he has obstructive jaundice due to carcinoma of the head of his pancreas, you may be able to relieve his symptoms by making an opening between his gall-bladder and his jejunum — a cholecysto-jejunostomy (13-6). You can treat acute pancreatitis (13.9), a pancreatic abscess (5.10b), and drain a pancreatic pseudocyst (13.10). There are also a few occasions when splenectomy is indicated, other than for trauma (13.11).

13.2 Biliary Colic

Biliary colic is due to a stone passing through the cystic duct or impacted in it. The patient has a severe colicky epigastric pain which radiates to his right subcostal region and right scapula. He wants to bend himself double, he rolls around, and rarely keeps still. Intense pain comes in waves against a background of severe pain, typically in attacks lasting about half an hour, one to three hours after a fatty meal. Pain makes his breathing difficult and may be accompanied by nausea and vomiting. Attacks occasionally last as long as 6 hours. If they last 24 hours, he has cholecystitis, not uncomplicated biliary colic. He may be tender in his hypochondrium or his right epigastrium, and have a positive Murphy's sign (see below).

BILIARY COLIC

MURPHY'S SIGN. Put your hand under the patient's ribs on the right side, and ask him to take a deep breath. If he feels pain as his gall-bladder moves down on to your hand, the sign is positive and indicates cholecystitis.

X-RAYS. Most gallstones don't show on an X-ray, so a plain film is unlikely to help. An oral cholecystogram will show 90% of stones, provided he is not jaundiced; if he is clinically jaundiced you won't get good X-rays. Look for: (1) the negative shadows of gallstones floating in the contrast medium, (2) no outline to his gall-bladder, showing that his cystic duct is blocked, or his gall-bladder is severely diseased. If his symptoms are suggestive, repeat the test with a double dose of contrast medium.

ULTRASOUND is a simple, cheap and accurate way of finding stones in the gall-bladder, whether or not he is jaundiced; it is better than a cholecystogram, but it needs skill.

SPECIAL TESTS. A slightly raised serum bilirubin may indicatesubclinical jaundice. Occasionally, only his serum alkaline phosphatase is raised when his bile duct is obstructed.

THE DIFFERENTIAL DIAGNOSIS OF BILIARY COLIC includes a perforated peptic ulcer (11.2), an amoebic liver abscess (31.12), and upper small gut obstruction (10.3). Suggesting ureteric colic — pain radiating towards the genitalia. Blood in the patient's urine on microscopic examination. Radioopaque shadows along the line of his ureter. Suggesting right basal pneumonia — cough, fever, and lung signs at his right base.

THE NON-OPERATIVE TREATMENT OF BILIARY COLIC. If necessary, give him pethidine 50 to 100 mg 4-hourly intravenously or intramuscularly, for 24 to 48 hours. An anticholinergic drug is optional. Give him only clear fluids by mouth. If he vomits, give him fluids intravenously. If he is fortunate, his pain will stop in 24 to 48 hours, and you can start to feed him cautiously, avoiding oily or fatty foods. Start to investigate him as soon as he has recovered from his pain. Advise him to take a low-fat diet. opening between his gall-bladder and his jejunum — a cholecysto-jejunostomy (13-6). You can treat acute pancreatitis (13.9), a pancreatic abscess (5.10b), and drain a pancreatic pseudocyst (13.10). There are also a few occasions when splenectomy is indicated, other than for trauma (13.11).

13.3 Acute Choleystitis

The patient's symptoms are those of biliary colic (13.2), but they last more than 24 hours. To begin with they are due to a chemical inflammation caused by concentrated bile under pressure, but bacterial infection may follow. He has a 95% chance of recovering in 10 days, even without treatment. There is a 5% chance that the infection will spread to his smaller bileducts (cholangitis), or that he will develop peritonitis from a perforation of his gall-bladder. Operate if: (1) he has cholangitis which is threatening his life, or (2) his gall-bladder forms a gradually enlarging acute inflammatory mass. It will be acutely inflamed, oedematous, and perhaps gangrenous, so don't try to remove it. Instead, drain it (cholecystostomy). This may save his life and is simple and safe, but it will seldom cure him permanently, so you will probably have to refer him for cholecystectomy later. Acute on chronic cholecystitis (relapsing cholecystitis, recurrent biliary colic) is usually less severe than a typical acute attack, and is one of the more common kinds of gall-bladder disease. His symptoms may subside without infection and leave his gall-bladder distended with mucus (mucocoele of the gallbladder), or it may distend with pus and perhaps burst (empyema of the gall-bladder).

• FORCEPS, gallstone, Desjardin's, one only. Use these long slender forceps for removing stones from the biliary system.

Acute Cholecystitis

SIGNS. The patient is febrile, looks sick, and lies still. Tenderness is well localized in his right upper quadrant. He may be exquisitely tender (unlike biliary colic), and show guarding and rigidity. Murphy's sign is usually positive (13.2). A well-localized mass usually forms a few days after the start of his attack, just below his right costal margin. Mild jaundice does not always mean that his common duct is obstructed by a stone. If he has jaundice, swinging fever, chills and rigors, suspect that his cholecystitis is complicated by cholangitis.

SPECIAL TESTS. His serum bilirubin and alkaline phosphatase will probably be slightly raised, and his total white count markedly so.

X-RAYS are less useful than ultrasound. Vomiting will make it impossible for him to take contrast medium by mouth.

THE DIFFERENTIAL DIAGNOSIS includes amoebic liver abscess (31.12), perforated peptic ulcer (11.2), acute pancreatitis (13.9), acute pyelonephritis, and volvulus of his small gut with strangulation (10.9).

NON-OPERATIVE TREATMENT FOR ACUTE CHOLECYSTITIS

This is only safe if you are sure of the diagnosis. Analgesics are needed, because his pain is severe. So give him enough pethidine (avoid morphine because it may increase the pain of biliary colic), if necessary 4-hourly for 24 hours. Nasogastric suction is not essential, but it will keep his stomach empty and so relieve his nausea and vomiting. Rehydration may be necessary. Correct his initial fluid loss with saline, and then give him his daily fluid requirements (A 15.3). Antibiotics are less necessary than you might expect, because the inflammation in his gall-bladder is predominantly chemical. Give him chloramphenicol, ampicillin, or tetracycline. Continue this treatment for 3 or 4 days, and then start to feed him. His symptoms should start to improve in 24 hours, and he should be symptom free in 3 weeks. Advise him to take a low- fat diet, and refer him for an interval cholecystectomy after about two months.

CHOLECYSTOSTOMY FOR ACUTE CHOLECYSTITIS

INDICATIONS. Drain his gall-bladder if: (1) intense pain persists, (2) swinging fever continues with tachycardia, (3) his abdominal tenderness gets worse, the area of guarding extends, or the mass increases in size, or (4) he has rigors and deepening jaundice, indicating cholangitis.

EQUIPMENT. If you don't have Desjardin's stone forceps, a Fogarty balloon catheter, pushed past the stone, inflated, and withdrawn is often effective. You may possibly be able to use a tiny Foley catheter. Sponge forceps are much less satisfactory. Find two assistants in addition to the trolley nurse.

ANAESTHETIC. (1) General anaesthesia, intubation, and relaxants. If he is very sick or very old you can operate under local anaesthesia.

INCISION. Feel for the area of maximum tenderness, an illdefined mass, or both (A, in Fig. 13-1). Centre the incision over this area, and cut through all layers of his abdominal wall. Or, do an upper median or paramedian incision. You will probably find his gallbladder easily. If you don't find it, carefully separate the adherent omentum and transverse colon by pushing them away with your finger. Pack large swabs ('lap pads') round his gall-bladder carefully; it easily ruptures and spills infected bile into his peritoneal cavity.

If the structures below the right lobe of his liver are matted together in an oedematous haemorrhagic mass, so that his gall bladder is difficult to find, insert your hand over the upper surface of his liver, and draw your fingers down until you reach its edge. Then move your hand medially over the convex surface of his liver until you reach his falciform ligament, joining his liver to his diaphragm. At its lower edge is his ligamentum teres. About 5 cm to the right of this, you should be able to feel the tense, turgid, elongated mass of his fiery-red, acutely inflamed, oedematous, and perhaps partly necrotic gall-bladder.

Try to expose enough of the fundus of his gall-bladder to allow you to drain it. Use your finger, or a 'swab on a stick' (4-8), to carefully 'peel' away his omentum, the hepatic flexure of his colon, and his transverse mesocolon. Avoid sharp dissection. If he bleeds, control it with packs.

If you don't find a tense inflamed gall-bladder when you operate, look for acute pancreatitis (13.9), a liver abscess (31.12) or a localised perforation of a peptic ulcer (11.2) etc. Surround the exposed area of his gall-bladder to minimize spillage. Insert a purse string suture of 2/0 chromic catgut (B). Plunge a trocar and cannula, attached (if you have the kind with a side tube) to a sucker, through the purse string (C). Withdraw the trocar far enough to allow you to aspirate his gall-bladder, milking any remaining exudate up towards the suction. When you have sucked his gall-bladder empty, take a swab from the wall for culture. Feel for gallstones. Expect to find them in Hartmann's pouch 13-3), near the point where his gall-bladder joins his cystic duct. Gently try to get your hand into a position where it can palpate this area comfortably, taking care not to tear his gall-bladder. Use scissors to enlarge the opening to 1.5 cm. Feel for stones with a pair of Desjardin's stone forceps or sponge-holding forceps. Guide the stones into the jaws of the forceps (D) with your fingers outside his gall-bladder.

CAUTION! Don't try to remove stones which are too tightly wedged lower down. You may do much damage. Leave them. They may free themselves later: if they don't they can be removed later at an interval cholecystectomy. Insert a 20 to 26 Ch Malecot, de Pezzer, or Foley catheter, into his gall-bladder. Tie the purse string snugly around it (E), and apply a second one 5 mm away from the first. Bring the tube out through a separate stab incision. Irrigate the wound with saline, close it in a single layer (9.8), and leave his skin unsutured for delayed primary closure. Pass a piece of silk around the catheter at least twice, and suture it to his skin. Attach it to a bottle for drainage.

POSTOPERATIVELY, expect bile to start draining in a day or two. Remove the tube in 10 to 15 days. If it is still discharging, he can go home for a few weeks with it in place. The fistula will slowly close unless a stone has been left in Hartmann's pouch (when a small mucous fistula will result). Warn him that his underlying disease has been relieved, not cured. Refer him to an expert for cholecystectomy about 2 months later.

13.4 Cholangitis

If a patient has a stone in his common bile-duct, it may promote ascending cholangitis. Untreated, this may be followed by multiple abscesses in his liver, or by septicaemia. Antibiotics are useful, but surgery may be necessary. Ideally, his common bileduct should be explored, and any stones removed. This is difficult and needs special instruments and X-rays. If it is impractical, you may be able to save his life by decompressing his common duct and inserting a T-tube (choledochostomy). This will be easier than trying to anastomose his gall-bladder to his jejunum (choledochojejunostomy), which will be difficult because his gall-bladder is diseased, and there may be a stone in his cystic duct. A patient with cholangitis usually has a history of gall- bladder symptoms. Typically, an attack of colic is followed the next day by fluctuating jaundice, dark urine, pale stools, nausea and vomiting, fever and rigors, and a leucocytosis. His gall-bladder and liver are tender, but his gall-bladder is not palpable.

Choledochostomy

ANTIBIOTICS. in order of preference give the patient: (1) Mezlocillin, piperacillin, or azlocillin. (2) Ampicillin with gentamicin or another aminoglycoside or a cephalosporin.

INDICATIONS. Cholangitis, as described above. If he is jaundiced, with rigors and spiking fever which fails to respond to antibiotics in 24 hours, operate. If you delay he will probably die.

PREPARATION. If he has circulatory failure, give him 2 litres of 0.9% saline rapidly. If this does not soon improve him, give him blood. If he still does not improve, operate urgently; it is his only chance. Give him 10 mg of vitamin K1 twice daily intramuscularly. Insert a nasogastric tube.

EQUIPMENT. Desjardin's stone forceps. A T-tube or a 14 Ch urethral catheter.

INCISION. Make an upper median or paramedian incision and follow the initial steps for a cholecystostomy, as in Section 13.3, until you have exposed his subhepatic area and found his gallbladder, cystic-duct, and common bile-duct. The incision will have to be longer than that for a cholecystostomy, so extend that incision, cutting the muscles in line with the skin incision, parallel to his costal margin and about 3 cm below it. Place two large moist packs under his liver to get good exposure. Place another one deep in his right subhepatic space (Morrison's pouch), to absorb any of the infected bile which will later come gushing out. Use a small gauze swab on the end of a large curved haemostat to dissect in the triangle between his common bile-duct, his cystic duct, and his common hepatic duct. Feel for his hepatic artery; his bile-duct is the tube lying immediately to its right in the free edge of his lesser omentum. His portal vein lies behind both of them. As Fig. 13-3 shows, there is considerable anatomical variation in this region. Make sure you have found his bile-ducts before proceeding further. Palpate them to be sure none of them pulsates! Then expose 2 cm of his common duct, which will probably be dilated — even to 5 cm or more (A, Fig. 13-2).

If in doubt, aspirate his common duct to make sure it contains bile and not blood. Now place two 3/0 catgut stay sutures on its anterior surface about 4 mm apart (B). With the tip of the sucker close by, make a 2 cm longitudinal incision between the stay sutures (C). Suck out all the bile and exudate, and take a swab for culture and sensitivity. Using Desjardin's stone forceps, gently remove any stones that you easily can (D). The curve on the forceps may help you — the stones are probably well down his common duct at its lower end, where it enters his duodenum. Don't prolong this stage of the operation if it is difficult — you can do much harm. If there is much 'sludge', wash out his common duct by irrigating it with plenty of saline using a plain rubber catheter and a 20 ml glass syringe. Insert a T-tube. Failing this, insert a 14 Ch urethral catheter in his common bile-duct for about 4 cm (E), and suture it to the upper end of the incision in the duct with 3/0 chromic catgut (F). Close the opening in the duct snugly round the drainage tube with the same material. Bring the tube out through a stab incision, leaving some slack inside, in case it is pulled on. Anchor it securely to his skin with a non-absorbable suture. Close his abdominal wall carefully — his wound is likely to become infected, so don't close his skin (9.8).

POSTOPERATIVELY, connect the tube to a bedside bottle, and allow it to drain freely until his jaundice and fever subside. Refer him. If you cannot refer him, do a tube cholangiogram 7 to 10 days postoperatively using 'Hypaque' or similar aqueous contrast medium diluted one part to two parts of 0.9% saline. This will help in further management. It should show any residual stones. If you find any, try again to refer him. The stones can be removed by an expert through the T-tube tract by passing a fibre-optic endoscope into his duodenum and slitting his sphincter of Oddi, or by opening his duodenum at operation. This is very difficult surgery. Only a few patients need it.

If you see no stones, and the medium flows nicely into his duodenum, try clamping the tube. Provided that he has no pain, fever, or jaundice, remove the tube.

If you cannot do a tube cholangiogram, connect the tube to a vertical length of plastic tubing (as when measuring the CVP, A 19.2) to see what pressure builds up. It should not be higher than 8 to 10 cm of bile. If after 24 hours no higher pressure develops, try clamping the tube. Remove it after two weeks if no discomfort develops. If pressure does build up in the tube, don't remove it. He may need it for months, but try to refer him. If fever and jaundice reappear, unspigot the tube — he will need further surgery to remove his remaining stones.

13.5 Cholangitis caused by Ascaris

Ascaris worms sometimes crawl up into a patient's common bile-duct and gall-bladder, where they can cause biliary colic, acute cholecystitis, obstructive jaundice, and cholangitis. This most often happens when a child has been given an anti-helminthic. So, if a child has cholangitis, or if an adult does not fit the usual clinical picture for biliary disease, suspect Ascaria-sis. Finding Ascaris ova should arouse your suspicion, but does not confirm the diagnosis. Do an intravenous cholangiogram when the jaundice is ebbing — it may outline the worms. Don't operate, except on the indications below.

ASCARIS CHOLANGITIS

Nasogastric suction will rest the child's upper intestinal tract. Systemic antibiotics will help to control his cholangitis. Later, give him piperazine or mebendazole.

INDICATIONS FOR SURGERY. Deepening jaundice, spiking fever, chills and rigors which do not respond to antibiotics; nausea and vomiting, toxaemia, dehydration, tachycardia, and perhaps hypotension; together with a leucocytosis. If he has these symptoms, explore and drain his bile-ducts (choledocho-stomy), as in Section 13.4. Remove any worms you find.

13.6 Primary or Recurrent Pyogenic Cholangitis

This differs from 'secondary cholangitis' in that: (1) It has no known cause; it is not secondary to stones, strictures, carcinoma, or worms. (2) The primary pathology is not in the gall-bladder, but in the bile-ducts (intra- or extrahepatic), which contain sludge and pigment stones. (3) Treatment involves drainage of the bile-ducts, not removal of the gall-bladder, unless it is very distended and gangrenous. (5) Symptoms commonly recur (unusual in secondary cholangitis). This was one of the most common abdominal emergencies in East Asia — China, Korea, Taiwan, Hong Kong and Malaysia, but its incidence is now declining.

The patient, who is usually between 30 and 40 years (the sexes are affected equally) presents with a high swinging fever, chills, and rigors, a gnawing right upper abdominal pain, and mild jaundice (Charcot's triad), usually with a history of previous attacks. His liver is tender and enlarged and his gall- bladder may be palpable. His urine is dark, but his stools are seldom clay-coloured — complete obstruction of the common bile-duct is rare.

PRIMARY PYOGENIC CHOLANGITIS

SPECIAL TESTS. The patient's white count is raised, so is serum bilirubin (3 mg/dl or more). If infection is severe and liver cells are involved, his transaminases are raised. Measure serum amylase, because there is a 10% chance that he also has pancreatitis.

X-RAYS. A plain X-ray may show air in his biliary tract due to incompetent sphincter of Oddi. During an acute attack neither an oral nor an intravenous cholangiogram will demonstrate his biliary system. Four weeks later an intravenous cholangiogram may show filling defects in common bile-duct.

NON-OPERATIVE TREATMENT. If the disease is mild, take blood cultures and give him antibiotics (cephradine or gentamicin, 2.9). Give him 10 mg of vitamin K1. Give him intravenous fluids, and aspirate his stomach through a naso-gastric tube.

INDICATIONS FOR OPERATION. (1) the failure of non-operative treatment. (2) A palpable, tender, enlarged gall-bladder. (3) Septicaemia. (4) Peritonitis.

LAPAROTOMY. Aim to remove all biliary grit and mud by washing out his extra- and intrahepatic bile-ducts with copious amounts saline. If this is impossible, do a wide (>2.5 cm) choledochoduodenostomy so that stones that are left behind can pass into gut without totally obstructing his biliary tree. If he is very ill with septicaemia or peritonitis, do a cholecystostomy if his gall-bladder is enlarged. If it is shrunken and his common duct dilated, do a choledochostomy, and insert a T-tube. Refer him for a choledochoenterostomy or cholecystectomy 6 weeks later. If you cannot refer him and you are sufficiently skilled, do a choledochoduodenostomy, or a choledochojejunostomy (13.8) at that time.

13.7 Cholecystectomy

Removing a patient's gall-bladder is the standard method of treating chronic gall-bladder disease, but it is not an operation for the occasional surgeon, so if you do see a patient with cholecystitis, or gallstones, try to treat him non-operatively as in Sections 13.2 and 13.3.

If his symptoms persist, and you are experienced, you may feel justified in removing more normal-looking, easier gall-bladders on the indications given below. This is something which district hospitals in areas where gall-bladder disease is common, should be able to do. Even so, it is right at the edge of this particular system of surgery. Whatever you do, don't try to remove the more difficult fibrotic, contracted gall-bladders. These really are for the experts. Unfortunately, you will not know if a patient's gall-bladder is going to be easy or difficult, until you are inside his abdomen. So, be prepared to close it, or do a cholecystostomy, if you find that he has a difficult one. We describe the retrograde method of removing the gall-bladder in which you first dissect and tie its neck. An alternative method is to start at the fundus.

The main danger is injuring his common bile or hepatic ducts. But, provided you don't operate when chronic inflammation has scarred his gall-bladder and porta hepatis severely, you should be able to avoid this.

A patient's symptoms and your findings, when you operate, are likely to bear little relation to one another. A few small stones may give him severe colic, while a gangrenous gallbladder may cause him little distress. So don't let moderate symptoms lead you to expect an 'easy gall-bladder', and don't operate in a hurry. The commonest cause of an injured bile-duct or hepatic artery is an 'easy' gall-bladder done quickly. Another cause is the anatomical variability shown in Fig. 13-3.

Elective Cholecystectomy

INDICATIONS. (1) You must be fairly experienced. (2) You must be sure of the diagnosis. (3) The patient must have symptoms which justify the operation. (4) He must not be too fat. (5) There must be no complicating factors. (6) You must be unable to refer him. (7) You must be prepared to back out, or do a cholecystostomy, if you find that he has a difficult gall-bladder.

ANTIBIOTICS. The main cause of death in gall-bladder surgery is post-operative sepsis. Give him a perioperative antibiotic (2.9) if he is: (1) Over 50. (2) Actively infected. (3) Jaundiced. Or, (4) when you are likely to have to explore his bile-ducts.

ANAESTHESIA. (1) A general anaesthetic with good muscle relaxation. (2) Subarachnoid (spinal) anaesthesia.

EQUIPMENT. A general set. A self-retaining and a Deaver's retractor. You will need two assistants and a trolley nurse.

INCISION. Make a midline or upper right paramedian incision extending up to his costal margin (A, in Fig. 13-4). Feel for his gall-bladder. Feel for stones. Feel both lobes of his liver to be sure they are smooth and normal. If his gall-bladder seems far up under his rib cage, run your hand over its right lobe, divide his falciform ligament across the dome of his liver, and draw it down. Put some large packs between his diaphragm and his liver — don't forget to remove them afterwards! Insert a self-retaining retractor, and try to see his gall-bladder. Use long tissue forceps to place large moist abdominal packs over the hepatic flexure of his colon, his duodenum, and his stomach. Ask your first assistant to draw these downwards and medially. You should now be able to see under his liver clearly. Protect his liver with a pack, and ask your second assistant to retract it upwards and laterally with a large Deaver's retractor (B). Look at his gall-bladder. If his gall-bladder is acutely inflamed, do a cholecystostomy (13-1). If it is very small, shrunken, thick-walled, contains stones, and is firmly stuck to nearby structures, leave it alone, or take out the stones and do a cholecystostomy and close the wound. Removing such a gall-bladder will be very difficult. If it looks and feels reasonably normal, apart from a few stones, and is attached by fine adhesions only, it should be safe to proceed. Find his cystic duct, his common bile-duct, and his hepatic artery, in the free edge of his lesser omentum. His epiploic foramen (of Winslow) lies behind it; you should be able to pass one or two fingers through it into his lesser sac. Place a gall-bladder clamp, or sponge-holding forceps on Hartmann's pouch (C). This is a widened area in the lower part of the patient's gall-bladder, just before it tapers off into his cystic duct. Pull gently upwards on these forceps, so as to stretch the tissues and make dissection easier. Incise the triangle of peritoneum between Hartmann's pouch and the common bile-duct. This will appear when you apply traction to the sponge-holding forceps on Hartmann's pouch. It is a most important step. Start by making a small nick in the peritoneum with a long pair of Metzenbaum scissors. Carefully insert the tips of the scissors, then, using 'the push and spread technique' (4-8), or a Lahey dissecting swab, open up enough of the patient's peritoneum to expose the deeper structures.

CAUTION! Be careful not to cut any small blood vessels. Bleeding will make the operation difficult. By spreading the blades of the scissors (but not too far!) before you cut, or using a Lahey dissecting swab, you should be able to separate peritoneum only. Take a pledget of gauze in the beak of a pair of curved artery forceps (a 'peanut' or Lahey swab, as shown in C, and E, Fig. 13-4), and gently push apart the peritoneum, so that you see his common bile-duct. Now, use your left hand to try to feel his cystic duct as it leaves his gall-bladder to join his common bile-duct. It may be helpful lift up the clamp on his gall-bladder while you do this, so as stretch the ducts.

CAUTION! There are some important anatomical variations: (1) The common bile-duct and the cystic duct may join high or low, as in G, to L in Fig. 13-3. (2) The right hepatic artery may pass behind the common hepatic duct (A,and B, more common) or front of it (C, less common). (3) The cystic artery may be closely bound to the common hepatic duct. (4) The cystic artery usually 64%) arises from the right hepatic artery. It may cross behind usually) or in front of (unusually) the common hepatic and cystic ducts to reach the gall-bladder. Sometimes, it arises from the common hepatic (27%) or the left hepatic artery (5%), or from other arteries in the region (rare). (5) Be sure of your landmarks before you start to divide anything. (6) Use a Lahey swab and dissect by the 'push and spread' method. Find the junction of the patient's cystic and common bile ducts, as described above. Be sure to identify 2 cm of his common duct, both proximal and distal to the junction. This will give you an idea of its course and direction. The common bile-duct lies to the right of the structures going to the porta hepatis, and is a greenish colour — identifying it is one of the keys to safe gall-bladder surgery. If you have found the junction of his cystic and common bile ducts, and you are sure that what you presume is his cystic duct is going to his gallbladder, and nowhere else, define it further, using blunt dissection. Then tie it off, by the following method, close to his common bileduct, but not too close. Using a long pair of Lahey forceps, gently open up the cleft between his cystic and common hepatic ducts. Pass a tie of '0' chromic catgut through this cleft, and around his cystic duct, and tie F). Place another Lahey clamp on his cystic duct just above the tie close to his gall-bladder. Cut his cystic duct between the two ties close to the gall-bladder.

CAUTION! Only divide and tie structures that are passing to his gall-bladder. A long stump to the cystic duct is not important, unless it contained an obvious stone. If his cystic artery runs posterior to his common hepatic and cystic ducts (usual), take extra care. Using Lahey's forceps on his divided cystic duct, and traction with your left hand, feel carefully with your right thumb and index finger for any bands or structures that are still tethering his gall-bladder. One of these is probably his cystic artery, or a branch of it. Don't cut these structures; isolate them with finger dissection. Don't expect to feel any pulsation such a small vessel. If a strand of tissue runs to his gall-bladder, assume it is his cystic artery, tie, and divide it. Expect to find other branches and deal with them in the same way. If his cystic artery runs anterior to his common hepatic and cystic ducts (unusual), define it by blunt dissection, and make sure that it is indeed going to his gall-bladder. CAUTION! Don't tie his right hepatic artery by mistake. If you are sure you have found his cystic artery, tie it close to his gall-bladder with 2/0 black silk, leaving a long tail, so that you can easily find it if it bleeds. Leave a short cuff of tissue, distal to the tie. You should now be able to strip his gall-bladder from its bed by pulling it gently upwards on the clamps. Cut any peritoneal bands that join it to his liver, but tie off anything else — there may be vessel or an anomalous bile-duct inside a band. If the bed of his gall-bladder oozes, press a warm pack into it. If small veins continue to bleed, cauterize them. It is unnecessary and dangerous to close the peritoneum over the bed of the gall-bladder as in I, Fig. 13-4.

CAUTION! Check to make sure that the stump of his cystic duct secure and that no bile is leaking.

CLOSING THE WOUND. Either leave no drain, or place a soft rubber drain through a stab wound down to his porta hepatis. Close his abdominal wound as in Section 9.8.

DIFFICULTIES REMOVING THE GALL-BLADDER

If, when you open his abdomen, you find an INFLAMMATORY MASS or an unrecognizable mass of tissue, withdraw and close the wound. If you cannot refer him, consider operating later, when the inflammation has subsided. If you INJURE HIS CYSTIC DUCT early on, tie it between ligatures and divide it. If you injure it very near its union with the common bileduct, divide it carefully, tie it, and close the common duct opening with interrupted 3/0 catgut sutures. If you find that you have DAMAGED HIS COMMON BILE-DUCT you will have done so in one of three ways: (1) By ligature; undo the ligature. (2) By clamp; take off the clamp and inspect the damage. Do a choledochostomy higher up, and pass a fine catheter through the damaged area. Proceed as for a choledochostomy (13-2). (3) By partly dividing it. Leave a T-tube threaded up and down the duct and proceed as for choledochostomy. Refer him. If this is impossible, keep the T-tube in for 3 months, and then do a T-tube cholangiogram and remove it. Learn from your mistakes, learn to be able to forgive yourself, and carry on. If his CYSTIC ARTERY BLEEDS from the depths of his wound, this can be alarming. Don't clamp blindly. (1) Insert warm moist packs, apply pressure and wait 5 minutes by the clock. The spurting vessel will then be easier to find and control. Or, (2) put your index finger into the epiploic foramen (of Winslow) and squeeze the structures (portal vein, bile-ducts, and hepatic artery) in the free edge of the lesser omentum between your index finger and your thumb. This will control bleeding from the stump of the cystic artery. Transfix it carefully with 3/0 silk. If FRESH BLOOD DISCHARGES from the drain, his pulse rises, his blood pressure falls, and he has signs of a haemoperitoneum, his cystic artery is probably bleeding. Reopen his abdomen and control it. If BILE COMES FROM THE DRAIN, his temperature and white count rise, and he has pain, suspect that infected bile and exudate are pooling under his liver. Give him an antibiotic. If he does not improve reopen his abdomen and make sure the area is adequately drained.

13.8 Obstructive Jaundice

When jaundice is due to an obstruction in the flow of bile: (1) The patient's stools are pale. (2) His urine is dark, and contains little or no urobilinogen. (3) His skin itches. These features are most marked in complete obstruction, as when carcinoma blocks the common duct. Stones typically cause an intermittent obstruction, and a less characteristic picture. If a stone impacts in Hartmann's pouch or in the cystic duct, it causes pain but does not impede the flow of bile down the common duct, so jaundice is absent or is mild (due to associated cholangitis). If a an older patient has a steadily deepening and usually painless obstructive jaundice, and his gall-bladder is palpably enlarged, some tumour is probably obstructing his common duct. He is probably incurable, but a cholecystojejunostomy to decompress his gall-bladder, by diverting his bile into his jejunum, may make his last days more bearable. So make the best of such means of diagnosing him as you may have, and don't necessarily give him up as hopeless. In East and Central Africa, for example, obstructive jaundice is most commonly caused by: (1) Secondary carcinoma of the liver. (2) A secondary tumour in the porta hepatis, usually from a primary in the stomach. (3) Carcinoma of the head of the pancreas. (4) Gall-stones. (5) Hepatoma; although this is a common disease, presentation as obstructive jaundice is unusual. (6) Carcinoma of the extrahepatic bile-ducts. (7) Carcinoma of the gall-bladder. This is rare in Africa, but is the most common cause of malignant obstructive jaundice in India. With the exception of gallstones, in which the jaundice may be intermittent, all these diseases present with progressively deepening jaundice over weeks or months, usually without the fever and rigors of cholangitis that so often complicate the jaundice of gallstones. The patient may have no pain, but if he has, it is usually not severe; it is deep, penetrating, and present most of the time — quite unlike the agonizing episodic biliary colic that gallstones cause. He is anorexic, and nauseated, and may lose so much weight that he becomes severely emaciated, with no other symptoms than jaundice. First exclude hepatocellular jaundice, which has 'obstructive' features at first, although these diminish later. Then, if you decide that his jaundice is obstructive, weigh the evidence for malignancy or stones. If his jaundice continues to deepen, he needs surgery, if he is fit enough.

Obstructive Jaundince

DIFFERENTIAL DIAGNOSIS. First try to decide what kind of jaundice the patient has.

Haemolytic jaundice. His stools are dark. There is no bilirubin in his urine, but his urinary urobilinogen is increased. His blood shows increased levels of unconjugated prehepatic bilirubin (leading to high readings on the indirect van den Bergh test). His transaminases (GPT and GOT) are normal, and so is his alkaline phosphatase.

Obstructive jaundice. His stools are pale (clay-coloured if obstruction is complete), and show no improvement in colour in 10 days. There is bilirubin in his urine, but little or no urobilinogen. He has high blood levels of conjugated (posthepatic) bilirubin (giving high readings on the direct van den Bergh test). His alkaline phosphatase is very high. His transaminases are normal.

Hepatocellular jaundice. This is commonly viral hepatitis with an obstructive phase lasting 7–10 days, but sometimes much longer. At this stage his stools are pale. His urine contains bilirubin but little urobilinogen. His serum bilirubin is moderately increased mostly conjugated). His alkaline phosphatase is usually only moderately increased, but if cholestasis is a prominent feature it can rise to levels seen in obstructive jaundice. His transaminases are increased. As the oedema of his cells settles, his stools become normal or even dark, his serum bilirubin falls, his urinary urobilinogen rises or reappears, and his transaminases fall gradually. The return of stool colour is the most important sign. This form of jaundice is not common in most developing countries after the age of 35.

CAUTION! You may have difficulty distinguishing the obstructive phase of hepatocellular jaundice from surgical obstructive jaundice. Do try to make the distinction. A laparotomy for stone may be life saving, but anaesthesia and the trauma of surgery may cause hepatocellular jaundice to deteriorate, perhaps fatally. Ultrasound is very useful. An intravenous cholangiogram is not helpful in the presence of jaundice. The ducts will not be outlined. Suggesting malignancy — (1) Relentlessly progressive steadily deepening obstructive jaundice, weight loss. (2) A palpable gallbladder which you can feel as an elongated, smooth, non-tender mass, normal in contour, and slightly mobile, which may extend to the patient's umbilicus or even below it. If you can feel his distended gall-bladder, it strongly suggests a malignant obstruction at the lower end of his common bile-duct, but its absence does not exclude this. Suggesting secondary deposits in his liver — a large, knobbly liver. Suggesting a carcinoma of his stomach with secondaries in his porta hepatis — pain, anorexia, vomiting, an upper abdominal mass, and the visible peristalsis of pyloric stenosis. Anaemia is common. Suggesting carcinoma of the head of his pancreas — vague epigastric pain, and weight loss. Suggesting gallstones — a long history of intermittent varying jaundice, severe intermittent colicky pain, a non-palpable gall-bladder, fever, chills, and rigors (suggesting cholangitis), little or no weight loss, flatulent dyspepsia. A raised white count suggests cholecystitis. Suggesting hepatoma — a large, hard, irregular liver. A bruit is often present, ascites is common, and is often bloodstained. Suggesting stenosis of his bile-ducts, either malignant or benign — a tender, enlarged liver. His gall-bladder may or may not be palpable. Suggesting carcinoma of the gall-bladder — the patient is a woman with an enlarged liver and a hard, irregular mass in her right hypochondrium.

MANAGEMENT. If the patient has gall-stones, try to refer him to an expert. If he has malignant disease with obstruction at the lower end of his common bile-duct, a cholecystojejunostomy may help.

CHOLECYSTOJEJUNOSTOMY FOR OBSTRUCTIVE JAUNDICE

INDICATIONS. In practice the presence of a smooth enlarged gall-bladder is the only clear indication to operate. Its absence does not exclude the possibility of doing the operation.

CONTRAINDICATIONS. Cachexia, debility, a hard irregular gallbladder mass, a hard, craggy liver due to secondary deposits, hepatoma, a large gastric tumour, ascites etc.

PREPARATION. Give him vitamin K1 (water-soluble) 10 mg intramuscularly daily for 3 days preoperatively. This will reduce his tendency to bleed.

HYDRATION. Patients with jaundice are prone to acute renal failure if their glomerular filtration rate falls. So make sure he is well-hydrated preoperatively. Give him plenty of saline during the operation, catheterize his bladder, and leave the catheter in. Also give him frusemide.

INCISION. Open his abdomen through an upper midline or an upper right paramedian incision. Expose his liver and subhepatic area as in Section 13.7. Good exposure is essential. Inspect and feel his upper abdominal viscera carefully. Is his gallbladder normal in size and appearance? If it is a hard, irregular mass which is fixed to the surounding organs, it is probably malignant. Feel his pancreas, especially its head. (1) Lift his transverse colon upwards and forwards out of the wound with your left hand, while you feel his pancreas at the base of his transverse mesocolon. Its head lies to the right of his vertebral column at this level. A hard, knobbly, craggy mass suggests a tumour. (2) You can also feel the head of his pancreas from above. Stand on the left side of the table and feel with your right hand while you pull the hepatic flexure of his colon medially. Place your thumb anteriorly and your fingers posteriorly. Feel the head of his pancreas lying in the concavity of his duodenum. If necessary, Kocherize it (66.16), so that you can feel it properly.

CAUTION! Don't biopsy his pancreas. Unless you use special methods you will cause pancreatitis and a fistula. Feel his porta hepatis and the structures lying in the free edge of his lesser omentum. Can you feel any craggy, fixed, indurated masses, suggesting primary carcinomas of his bile-ducts or secondary deposits? Feel his stomach.

THE INDICATIONS FOR PROCEEDING FURTHER can only be decided at this stage. A bypass is indicated if he has an enlarged and distended but otherwise normal gall-bladder, showing that he has an obstruction in his common bile-duct, proximal to or within the head of his pancreas, with no obstruction to his cystic duct. If you find any gallstones, remove them. Then make sure that his jaundice is not caused by stones. If it is, do a choledochostomy as in Fig. 13-2. A bypass is contraindicated if: (1) He has multiple liver secondaries, a hepatoma, or a carcinoma of his gall-bladder. (2) The tumour involves his gall-bladder or porta hepatis. (3) He has an advanced tumour of his stomach, or colon, etc. Most of these conditions make the operation impossible.

CAUTION! (2) If his gall-bladder is diseased, or contains many stones, abandon the operation. Don't try to anastomose a thick walled, inflamed, oedematous gall-bladder.

METHOD. Decompress his distended gall-bladder as for a cholecystostomy in Figure 13-1. Remove the purse string suture, and extend the opening with scissors to a length of 1.5 cm. Apply Babcock clamps to the fundus of his gall-bladder about 1 cm from each end of the incision. Lift his transverse colon upwards and look for the ligament of Treitz. This is the point where the retroperitoneal 4th part of his duodenum emerges to become his jejunum slightly to the left of his vertebral column, and distal to the attachment of the mesentery of his transverse colon. Choose a loop of jejunum 30 cm distal to the ligament of Treitz, and draw it up towards his open gall-bladder. Apply two Babcock clamps 3 cm apart on the antimesenteric border of his jejunum, to match those on the fundus of his gall- bladder. Bring these clamps alongside one another, making sure that there is no tension on the jejunal loop. Aim to make a 1.5 cm stoma.

CAUTION! Make the anastomosis neatly and carefully: it must not leak, because bile easily escapes, and a pool of bile is a serious complication. The anastomosis is similar to that for a gastroenterostomy (11.6) or ileotransversostomy. Make the seromuscular first layer of interrupted sutures of 3/0 silk on an atraumatic needle. Insert five sutures, which should ideally pick up only the seromuscular layer of his jejunum, but which will probably be of full thickness, in the wall of his gall-bladder. Place them about 2 mm away from the cut edge of the incision, and on the gut side about 2 cm back from the antemesenteric border of his jejunum. Incise his jejunum 3 mm back from the suture line. Trim away redundant mucosa with fine scissors. Apply Babcock's forceps temporarily over any bleeding points. Insert a continuous 'all coats' posterior layer of 3/0 atraumatic chromic catgut sutures, starting at one end; then continue to close the anterior layer with the same sutures. Finally, use 3/0 silk to insert an anterior layer of seromuscular interrupted Lembert sutures. Close his abdominal wall as soundly as you can, as in Section 9.8.

13.9 Pancreatitis

Both acute and chronic pancreatitis are not uncommon in India, but are seldom seen in Africa. You may have to treat them, or drain a pancreatic abscess (5.10b), or a pancreatic pseudocyst. Pathologically, acute pancreatitis varies from oedema and congestion of a patient's pancreas to its complete autodigestion, with necrosis, haemorrhage, and suppuration. Less severe forms may go on to form a tender, ill-defined mass in his epigastrium. His main symptom is pain, which can vary from moderate epigastric discomfort to an excruciating, penetrating agony, which bores through to his back, and needs high doses of pethidine to relieve it. He is tender in his epigastrium, perhaps with guarding. Later, his abdomen distends, and he vomits. Vomiting, and the outpouring of fluid into his retroperitoneum, sends him into shock and his gut into ileus. You may diagnose pancreatitis clinically, or you may only find it when you do a laparotomy for an acute abdomen. Estimating the serum amylase is not difficult, and your laboratory should be able to do it. Chronic relapsing or recurrent pancreatitis is one of the causes of a severe chronic upper abdominal pain. It is quite common in the states of Kerala and Orissa in India, and in alcoholics anywhere. It only needs surgery if the pain is debilitating, or if it constricts the common bile-duct, so that it causes jaundice and produces a syndrome which resembles carcinoma (13.8). A bypass (cholecystojejunostomy) will relieve a patient's jaundice, but this is not common.

Acute Pancreatitis

THE DIFFERENTIAL DIAGNOSIS includes perforated peptic ulcer (11.2), acute cholecystitis (13.3), biliary colic (13.2), rupture of an amoebic abscess (31.12), and strangulating upper small gut obstruction (10.3).

SPECIAL TESTS. The patient's serum amylase rises within a few hours of the start of his pain, and remains high for about 2 days. A level of more than 1000 Somogyi units is almost diagnostic. A peritoneal tap in his right lower quadrant will confirm the diagnosis — the aspirate may be straw-coloured, or reddish-brown, but its amylase is always high. In the severest haemorrhagic form of the disease the serum calcium is low.

X-RAYS may show pancreatic calcification, if he has had previous attacks; gallstones, a left pleural effusion, or distended loops of gut (ileus).

TREATMENT. Treat his shock energetically with large volumes of 0.9% saline, Ringer's lactate, or a plasma expander. Monitor his urinary output, his haematocrit, and if posssible, his central venous pressure (A 19.2). His pain may be overwhelming. Give him large doses of pethidine, supplemented by diazepam or promethazine. Keep his stomach empty with nasogastric suction. Antibiotics are useless. If you are reasonably sure of the diagnosis, don't operate; but it is better to operate unnecessarily, than not to operate on a case of strangulated gut, for example. If you do open his peritoneum, you will know that he has pancreatitis, because you will see areas of whitish-red fat necrosis on his transverse mesocolon, or omentum, and the exudate described above. His pancreas feels swollen and oedematous, and may contain greenish-grey necrotic areas. Don't insert drains: there is no evidence that they help.

DIFFICULTIES WITH ACUTE PANCREATITIS

If you find that he also has GALLSTONES, consider doing a choledochostomy (13-2). Don't be tempted to remove his gall-bladder, or a stone in his common bile duct, which may have precipitated the attack. Theoretically, this might be beneficial; but practically it is very difficult. If, during the course of 2 or 3 weeks, he develops the signs of SEPTICAEMIA, suspect that he is developing a pancreatic abscess. If his pancreatitis has progressed to form an ABSCESS (uncommon,5.10b), you will need to do a laparotomy to drain it, and a jejunostomy (9.7) to feed him while 'resting' his pancreas. If he develops RESPIRATORY OR RENAL FAILURE, usually in the first 48 hours (5-10% chance), he will probably die. There is little you can do except give him oxygen, plenty of intravenous fluids, and plasma expanders, together with frusemide to stimulate his urine flow. If necessary, ventilate him (A 19.4).

13.10 Pancreatic Pseudocyst

A large watery pancreatic exudate sometimes collects in patient's lesser sac. This has no epithelial lining, hence the term pseudo'cyst. He usually presents some weeks after an abdominal injury, or an attack of acute pancreatitis, with a mass in his abdomen and epigastric discomfort or pain. He may be toxic with fever and tachycardia, but he is not nearly as ill as he would be if he had acute pancreatitis, or a pancreatic abscess. The mass usually distends his abdomen: it may extend right across his epigastrium, and reach down to his umbilicus or beyond it. It is tender, tense, immobile, and is often not fluctuant. Sometimes, he has symptoms of pancreatic insufficiency, with steatorrhoea. If you make an opening between the cyst and his stomach, it will drain, without, surprisingly, the food in his stomach causing problems inside the cyst. You will have to open the anterior wall of his stomach, and then make another opening through its posterior wall into the cyst (cystogastrostomy). The correct timing of this is important (see below). Draining it is less urgent than operating on a pancreatic abscess (5.10b), and there is less chance of complications.

Pancreatic Pseudocyst

SPECIAL TESTS. The patient's serum amylase is usually raised. If he is jaundiced (unusual), liver function tests will show the changes of obstructive jaundice.

IMAGING. Ultrasound is much better than X-rays. If you are using X-rays: (1) Give him some barium. A lateral film of his stomach will show a mass bulging into the barium shadow from behind. A barium meal shows gross widening of the normal contour of his duodenum. You may see patches of calcification in his pancreas. Or, (2) insert a nasogastric tube. Inject 200 ml of air into his stomach and take a lateral supine view of his abdomen. In a pancreatic pseudocyst the stomach is displaced forwards, in an amoebic liver abscess, backwards.

THE DIFFERENTIAL DIAGNOSIS includes an amoebic abscess 31.12), hepatoma (32.26), an infected hydatid cyst (31.13), a hydro-nephrosis, pyloric stenosis (11.6), Burkitt's lymphoma 32.3), abdominal tuberculosis (29.5), gastric carcinoma (32.25), and an aortic aneurysm.

CYSTOGASTROSTOMY FOR A PANCREATIC PSEUDOCYST

WHEN TO OPERATE. Don't operate until 6 weeks after an attack of pancreatitis, by which time the cyst wall will be mature enough to take sutures. Once a pancreatic pseudocyst is palpable it rarely disappears spontaneously. Operate as soon as possible after 6 weeks; if you leave it too long it may bleed, rupture, become infected, or destroy much of his pancreas. However, if after an attack of pancreatitis the cyst is enlarging rapidly, and rupture is imminent (rare), drain the cyst to the exterior with a large Malecot catheter — even before 6 weeks have elapsed. Don't try to do an anastomosis. Some sur-geons consider external drainage disastrous.

RESUSCITATION. If he is dehydrated, wasted, or toxic, prepare him suitably. He may need parenteral fluids for a few days. Insert a nasogastric tube the previous evening, and wash out his stomach thoroughly.

INCISION. Make a median or paramedian incision (9.2). Choose an area on the anterior wall of his stomach that is overlying the cyst. Use a knife to start a 6 cm incision in the long axis of his stomach between 2 Babcock forceps. Enlarge it with scissors. Clamp any briskly bleeding vessels, and retract the edges of the incision, so that you can inspect the posterior wall of his stomach. Suck it empty. After opening his stomach, cautiously insert a needle connected to a syringe through its posterior wall into the mass (this is your last chance if you find it is an aortic aneurysm!). Expect to find a mildly opaque straw-coloured, or murky brownish fluid. If so, insert a small haemostat through the hole in his stomach into the cyst, and open it so as to enlarge the opening. Then insert forceps to enlarge the opening gently a bit more to 5 cm. Suck out the fluid, expect to aspirate up to 4 litres.

CAUTION! Don't incise the cyst, it may bleed severely. Lift up the cyst wall on sponge forceps and enlarge the incision until it is 6 cm long. There is no need to suture the stomach wall to the cyst, because they are already tightly stuck together. You will need to control brisk bleeding, so quickly oversew the opening all round with a continuous interlocking haemostatic stitch of 2/0 silk. Lock it (G, 4-7) because if one bite goes the whole must not collapse. Use silk, because pancreatic juice digests catgut. Reinforce the continuous suture with four interrupted 1/0 silk sutures at the ends and the middle of the elliptical incision. When you are sure the posterior opening in the stomach is no longer bleeding, close the anterior one in two layers, the first a full-thickness haemostatic continuous layer of 3/0 chromic catgut sutures, and the second one a seromuscular Lembert layer of continuous catgut, silk, or cotton. Close his abdominal wall in the usual way.

POSTOPERATIVELY, 'suck and drip' him for 4 to 5 days (9.9, A 15.5), until his suture lines are well-healed, and he has bowel sounds. Then start a fluid diet. Postoperative complications are unusual.

13.11 The Surgery of the Spleen

One of the few things you can do to a spleen surgically is to remove it. The indications for doing so (apart from trauma, 66.6) must be good, because the spleen of a tropical patient is commonly large, and is so firmly stuck to his diaphragm that: (1) Exposing it is difficult. (2) If he has portal hypertension he is likely to bleed from the vascular adhesions that join it to his diaphragm, and through which high pressure venous blood will be escaping into his systemic circulation. A further danger is the increased risk of subsequent infection (see below). A Splenic abscess occurs occasionally. It starts acutely, it may become chronic, and it shows up radiologically as a fluid level in an irregular space. The pus is sterile, and he may have sickle cell disease. Drain it, don't try to remove his spleen. Torsion of the spleen occurs when it has an exceptionally long pedicle, and is one of the rare indications for splenectomy. You are unlikely to make the diagnosis before you operate. The tropical splenomegaly syndrome, which is an immune response to recurrent attacks of malaria, is responsible for nearly all large spleens in malarious areas. It responds to long courses of antimalarials — pyrimethamine or chloroquine weekly, or paludrine daily. Don't remove such spleens. This is only indicated if hypersplenism is a complication. Sickle-cell anaemia in children sometimes benefits from splenectomy. This is rarely necessary, it is not urgent, and it is dangerous in an SS patient. If you really think it is indicated refer him.

KASHY (20 years) complained of a swelling in his right iliac fossa. Ordinarily, it was painless but during attacks of 'fever' it became painful and tender. At laparotomy, his whole spleen was found to be in his right iliac fossa, but his splenic vessels crossed his abdomen to their normal position. His 'wandering spleen' was removed easily. LESSON Some rare conditions have easy solutions.

SPLENECTOMY OTHER THAN FOR TRAUMA

INDICATIONS. The strong indications are conditions in a patient's spleen itself, as: (1) Spontaneous rupture. (2) Torsion. (3) Wandering spleen. (4) Hydatid disease (31.13). (5) Tumours (very rare). Splenectomy may also be indicated in: (6) Hypersplenism. (7) Idiopathic thrombocytopenia. (8) Myeloid leukaemia. (9) Congenital spherocytosis. (10) Sickle-cell disease (rarely). (11) As part of surgical operations which you are unlikely to do.

CAUTION! (1) Don't operate lightly, your only definite indications for doing so are the first four. (2) If a patient's spleen is huge, think seriously about referring him: it may need a thoracoabdominal approach.

METHOD. Follow the method for the removal of the spleen for trauma in Section 66.6.

SPLENIC IMPLANTATION. Depending on the indications for splenectomy, consider the advisability of a splenic implant. Unless, there is: (1) an obvious accessory spleen, (2) malignant disease, or (3) hypersplenism. Keep some slices of spleen, say 5×3×0.5 cm, and implant them under the peritoneum in the side wall of his abdomen, or in his anterior abdominal wall (66.6). Or, place some 1 cm cubes of spleen on his omentum. They will usually take, and will reduce the severity of attacks of malaria and the danger of septicaemia, especially that due to pneumococci. In a malarious area, he must take prophylaxis against malaria for the rest of his life.