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Operative Surgery: Stomach, Colon, Appendix & Minimally Access Surgery (MAS)

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I. OPERATIVE SURGERY OF THE STOMACH

A. Gastrectomy-Based Procedures

1. Billroth I (Gastroduodenostomy)

• Lower half of the stomach is resected; cut stomach anastomosed to the first part of the duodenum
• Standard operation for gastric ulcer (ulcer excised to exclude malignancy)
• Preferred reconstruction after partial gastrectomy for distal gastric cancer
• 

2. Billroth II / Pólya (Gastrojejunostomy)

• Two-thirds of the stomach removed; duodenal stump closed; stomach anastomosed to jejunum
• Removes the gastric antrum → reduces acid load
• Diverts gastric secretions away from duodenum (Pólya)
• Still occasionally needed for complex emergency ulcer disease (e.g., giant perforated duodenal ulcer where Billroth I anastomosis under tension)
• No longer has an elective role for duodenal ulceration
• 

3. Total Gastrectomy (for Gastric Cancer)

• Approach: Long upper midline incision
• Stomach removed en bloc with entire greater and lesser omentum
• Steps:
  1. Transverse colon separated from greater omentum
  2. Subpyloric nodes dissected; duodenum divided with surgical stapler
  3. Hepatic nodes cleared along hepatic artery; right gastric artery divided at origin
  4. Left gastric artery divided at origin; nodes along splenic artery removed
  5. Spleen preserved if possible; oesophagus divided with right-angled clamp (>5 cm clearance from tumour)
  6. Frozen section of resection margins if in doubt
• Reconstruction: Roux-en-Y oesophagojejunostomy
  • Alimentary (Roux) limb ≥ 50 cm to prevent bile reflux oesophagitis
  • Circular stapler used via purse-string in oesophageal stump
  • End-to-side jejunojejunostomy at a convenient point
• Lymph node dissection:
  • D1: Perigastric nodes (N1 stations)
  • D2: Major arterial trunks cleared — standard at specialist centres, spleen and pancreas conserved, station 10 nodes spared

4. Subtotal Gastrectomy (Distal Tumours)

• Proximal stomach preserved; blood supply from short gastric arteries
• Reconstruction: Roux-en-Y jejunogastrostomy preferred over Billroth II (less enterogastric reflux and bile reflux oesophagitis)

5. Gastrojejunostomy (Bypass)

• Jejunum anastomosed to posterior, dependent wall of antrum — isoperistaltic
• Used for bypass of malignant obstruction (distal stomach, duodenum, pancreatic tumours)
• Poor results when used for duodenal ulcer alone (→ stomal ulceration from acid exposure)

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B. Vagotomy-Based Procedures

1. Truncal Vagotomy + Drainage

• Principle: Section of vagus at lower oesophagus → reduces maximal acid output by ~50%
• Gastric drainage procedure needed due to gastric stasis (vagal denervation of antropyloroduodenal segment)
• Drainage options:
  • Heineke–Mikulicz pyloroplasty (most popular): longitudinal incision through pylorus closed transversely
  • Gastrojejunostomy: alternative drainage
• 
• 

2. Highly Selective Vagotomy (HSV) / Parietal Cell Vagotomy

• Only the parietal cell mass is denervated; nerves to antrum (crow's foot of Latarjet) preserved
• No drainage procedure required (antropyloroduodenal innervation preserved)
• Lowest operative mortality (<0.2%), lowest side effects (<5%), but higher recurrence (2–10%)
• Does NOT increase risk of long-term gastric cancer (unlike other operations)
• 

3. Selective Vagotomy + Drainage

• Vagotomy of the gastric branches only (preserving hepatic and coeliac fibres)
• Similar side effects to truncal vagotomy

Comparison Table (Bailey & Love, p. 1183)

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II. POSTOPERATIVE COMPLICATIONS OF GASTRIC SURGERY

A. Early Complications (Post-Radical Gastrectomy)

1. Oesophagojejunal anastomotic leak — mainly saliva and food; often managed conservatively (Roux-en-Y limits contamination); drain placement if fistula develops
2. Duodenal stump leakage — usually due to distal obstruction; drained radiologically → controlled fistula; Foley catheter placed in duodenum to establish controlled fistula if bile peritonitis requires laparotomy
3. Secondary haemorrhage — septic collections + vascular dissection → catastrophic bleeding from exposed vessels; managed by re-operation or interventional radiology

B. Sequelae / Long-Term Complications

1. Dumping Syndrome

2. Postvagotomy Diarrhoea

• Most devastating sequela; ~5% intractable
• Cause: rapid gastric emptying + denervation + exaggerated GI peptide response
• Management: dietary manipulation, antidiarrhoeals; octreotide NOT effective; revisional surgery results unpredictable

3. Bilious Vomiting / Bile Reflux Gastritis

• Follows operations diverting alkaline bile into gastric remnant
• Treatment: Roux-en-Y reconstruction (≥50 cm limb); first choice revisional surgery after Billroth I

4. Small Stomach Syndrome

• Reduced capacity → early satiety; managed with frequent small meals

5. Recurrent Ulceration & Gastrocolic Fistula

• Anastomotic ulcer at gastrojejunostomy penetrates transverse colon
• Presents with: profuse post-prandial diarrhoea, foul breath, faeculent vomiting, severe weight loss
• Diagnosis: CT with oral contrast, barium enema; endoscopy often non-diagnostic
• Caused largely by jejunal bacterial contamination, not direct colonic communication

6. Malignant Transformation

• Partial gastrectomy and vagotomy + drainage are independent risk factors for gastric cancer (bile reflux → intestinal metaplasia)
• Lag phase: minimum 10 years
• HSV not associated with increased cancer risk

7. Nutritional Consequences

• Weight loss common; vitamin B12 deficiency (loss of parietal cell mass/intrinsic factor) — requires routine replacement
• Other deficiencies: iron (poor absorption), folate, fat-soluble vitamins
• Advice: small, frequent meals; jejunum/small gastric remnant adapts over time

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III. OPERATIVE SURGERY OF THE COLON

A. Total Abdominal Colectomy (TAC)

1. 2 colonic segments involved with rectal sparing, where anastomosis is unsafe

2. Patient in extremis with pancolitis (where total proctocolectomy not indicated)
3. Indeterminate colitis (Crohn's vs. UC not established)

• Begin with ileocolic pedicle division; mobilise caecum off right iliac vessels (medial to lateral)
• Continue clockwise to hepatic flexure; divide gastrocolic ligament
• Splenic flexure: antegrade (right to left) preferred; retrograde if severely inflamed
  • Caution: arc of Riolan / IMV branches; avoid splenic capsule injury
• Left colon: divide lateral attachments; protect left ureter (stents if severe inflammation)
• Medial approach to sigmoid / left colon avoids inflammatory adhesions
• Distal transection: rectosigmoid junction — preserves adequate rectal length
• Extract through Pfannenstiel or ileostomy site incision
• End ileostomy or ileorectal anastomosis depending on clinical scenario

B. Right Hemicolectomy / Colectomy for Colon Cancer

• Medial-to-lateral dissection; high vascular ligation at origin of feeding vessels (ileocolic, right colic, middle colic)
• Duodenum protected during hepatic flexure mobilisation
• Ileocolic anastomosis (hand-sewn or stapled, end-to-end, end-to-side or side-to-side)

C. Colostomy / Ileostomy

• Stoma may be definitive, covering/diverting, or salvage
• Slow-transit constipation: ileostomy preferred over colostomy as definitive procedure
• If ileostomy output is unsatisfactorily high → avoid colectomy

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IV. OPERATIVE SURGERY OF THE APPENDIX

A. Laparoscopic Appendicectomy (Appendectomy)

• Veress needle technique or Hasson open technique through umbilicus
• CO₂ insufflation to 12–15 mmHg
• Umbilical camera port + working ports in RLQ/LLQ

1. Reverse Trendelenburg with right side up
2. Follow caecum to convergence of taenia coli to locate appendix base
3. Retrocaecal appendix: divide white line of Toldt to mobilise caecum
4. Create window through mesoappendix; divide with linear stapler (white load) or ligasure/cautery
5. Divide appendix at base with blue load stapler or Endoloop
6. Place in retrieval bag; extract through umbilical port
7. Inspect staple line; achieve haemostasis
8. If turbid fluid: send sample for culture and sensitivities

B. Open Appendicectomy (McBurney's Approach)

1. External oblique aponeurosis — split in direction of fibres
2. Internal oblique — bluntly split
3. Transversus abdominis — split
4. Peritoneum — elevated and sharply incised

1. Caecum identified and delivered into wound
2. Appendiceal base at convergence of taenia coli
3. "Classic" technique: divide mesoappendix between Kelly clamps + ligate with 3-0 silk
4. Crush appendix at base with Kelly clamp → relocate clamp 1 cm distal to crush zone (CZ)
5. Ligate at CZ with 0 chromic suture; divide just proximal to clamp
6. Stump: cauterise or invaginate with purse-string / Z-stitch

• Peritoneum + transversus: running absorbable suture
• Internal + external oblique: interrupted absorbable sutures
• Skin: subcuticular absorbable suture
• If perforated: skin left open or loosely approximated

C. Management of Perforated/Complicated Appendicitis

• Antibiotic choice: Piperacillin-tazobactam alone OR ceftriaxone + metronidazole
• Once tolerating diet: oral amoxicillin/clavulanate for 5-day total course (equally effective to 7 days)

• Antibiotics-only viable alternative; ~25% failure rate requiring appendicectomy
• Appendicectomy remains the treatment of choice

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V. MINIMALLY ACCESS SURGERY (MAS)

A. Definition & Philosophy

• MIS / MAS: Major operations through small incisions using miniaturised imaging systems, minimising access trauma without compromising surgical quality
• Term "minimal access surgery" (Wickham) emphasises small incisions; "minimally invasive surgery" (MIS) is more widely used

B. Types of MAS

C. Physiology of CO₂ Pneumoperitoneum

• CO₂ rapidly absorbed into circulation → carbonic acid → respiratory acidosis
• Body buffers (largest reserve in bone) absorb up to 120 L CO₂
• Once buffers saturated: hypercarbia develops; anaesthesiologist must increase ventilation
• Risk of barotrauma if excessive tidal volumes used

• Reduced venous return (inferior vena cava compression)
• Reduced cardiac output
• Increased systemic vascular resistance
• Caval compression → risk of DVT/PE (combined with reduced lower limb perfusion)
• Raised diaphragm → reduced FRC, atelectasis

• Hypercarbia masked by adequate ventilation
• Cardiac patients at risk of decompensation
• Pregnancy: use lowest effective pressure; second trimester safest

D. Access Techniques

Veress Needle (Closed Technique)

1. Umbilical skin elevated; stab incision made
2. Veress needle inserted perpendicular to skin until two clicks (fascial + peritoneal entry)
3. Drop test confirms entry into peritoneal cavity
4. Insufflate to 12–15 mmHg
5. Insert trocar (blind or optical — Optiview / Visiport)

Hasson (Open) Technique

1. Infra- or supraumbilical incision down to external oblique
2. Vertical incision through fascia (elevated with retention sutures)
3. Peritoneum entered bluntly; Hasson port inserted under direct vision
4. Anchored with stay sutures; insufflation begun

E. Laparoscopic Advantages vs Open Surgery

F. Special Considerations

• Laparoscopy in pregnancy: Best performed in 2nd trimester; lowest effective intra-abdominal pressure; fetal monitoring required; left lateral tilt to avoid aorto-caval compression
• Cancer surgery: Appropriate if good tissue-handling maintained; avoid tumour morcellation; N₂O pneumoperitoneum avoided (unknown effect on port-site metastasis)
• Robotic surgery: Most valuable in urologic, gynaecologic, colorectal, and complex abdominal wall reconstruction
• Cirrhosis/Portal hypertension: Increased risk of haemorrhage; reduced pneumoperitoneum tolerance

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VI. GENERAL POSTOPERATIVE COMPLICATIONS (Abdominal Surgery)

A. Early (<72 hrs)

B. Intermediate (3–10 days)

C. Late (>10 days)

D. Specific Postoperative Complications by Operation

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Transplantation, Immunosuppression, AIDS & Universal Precautions

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PART I: TRANSPLANTATION

A. Definitions & Types of Grafts

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B. The Immunological Basis of Rejection

Major Histocompatibility Complex (MHC) / HLA System

• HLA antigens (Human Leukocyte Antigens) are the main alloantigens responsible for rejection
• Encoded on chromosome 6 (short arm)
• Class I (HLA-A, B, C): expressed on all nucleated cells; recognised by CD8+ cytotoxic T cells
• Class II (HLA-DR, DP, DQ): expressed on APCs (dendritic cells, B cells, macrophages); recognised by CD4+ helper T cells
• ABO blood group antigens: also expressed on endothelium; mismatch → hyperacute rejection

Allorecognition Pathways

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C. Types of Rejection

• Occurs when donor immunocompetent T cells attack a relatively immunocompromised host
• Seen in: bone marrow / haematopoietic stem cell transplantation (HSCT), small bowel transplant, blood transfusion in immunocompromised
• Acute GvHD (<100 days): skin rash, diarrhoea, hepatitis
• Chronic GvHD (>100 days): resembles autoimmune disease (scleroderma-like)
• Treatment: high-dose corticosteroids, ciclosporin, mycophenolate

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D. Tissue Matching / Pre-Transplant Workup

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E. Brain Death & Organ Donation

1. Irreversible structural brain damage from known cause
2. No sedatives/metabolic cause
3. Tests performed by 2 senior doctors on 2 separate occasions:
   • Absent brainstem reflexes (pupillary, corneal, oculovestibular/caloric, gag, cough, oculocephalic)
   • Apnoea test: PaCO₂ rises to ≥6.65 kPa with no respiratory effort

• DBD (Donation after Brain Death): heart-beating donor; optimal oxygenation of organs
• DCD (Donation after Circulatory Death): controlled (Maastricht III) or uncontrolled; higher rates of primary non-function (ischaemia)

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F. Individual Organ Transplants

1. Renal Transplantation

• Most common solid organ transplant
• Recipient's native kidneys NOT removed (unless symptomatic - hypertension, recurrent infection, polycystic disease)
• Site: Heterotopic - iliac fossa (extraperitoneal)
• Anastomoses: Renal artery to external iliac artery; renal vein to external iliac vein; ureter to bladder (ureteroneocystostomy)
• Early complications: acute tubular necrosis (ATN), acute rejection, renal artery thrombosis, ureteric obstruction/fistula
• Late complications: chronic rejection, calcineurin inhibitor nephrotoxicity, opportunistic infections, post-transplant lymphoproliferative disorder (PTLD), recurrent original disease

2. Liver Transplantation

• Indications: cirrhosis (alcoholic, viral, NAFLD), acute liver failure, cholestatic disease (PBC, PSC), hepatocellular carcinoma (Milan criteria: 1 lesion ≤5 cm or 3 lesions ≤3 cm, no vascular invasion, no extrahepatic spread)
• Orthotopic (native liver removed); caval replacement or piggy-back technique
• MELD score used to prioritise allocation
• Split liver / living donor (right lobe)
• Complications: primary non-function, hepatic artery thrombosis (most feared early complication), biliary leak/stricture, acute/chronic rejection

3. Heart Transplantation

• Indications: end-stage heart failure (NYHA class IV), ischaemic/dilated cardiomyopathy, refractory arrhythmias
• Orthotopic; bicaval technique now preferred
• Denervated heart: resting HR ~100 bpm; no angina with ischaemia; relies on Frank-Starling and circulating catecholamines
• Complications: primary graft failure, acute rejection (Rx: OKT3/ATG), cardiac allograft vasculopathy (chronic rejection - obliterative coronary disease; diagnosed by annual coronary angiography), accelerated atherosclerosis

4. Lung Transplantation

• Indications: COPD, IPF, cystic fibrosis, pulmonary hypertension
• Single or bilateral sequential
• Primary graft dysfunction (reperfusion injury): most common early cause of death
• Bronchiolitis obliterans syndrome (BOS): manifestation of chronic rejection; progressive airflow obstruction; azithromycin may slow progression

5. Pancreas Transplantation

• Usually combined with kidney (SPK - simultaneous pancreas kidney)
• Indications: Type 1 diabetes with end-stage renal disease
• Exocrine drainage: bladder (older) or enteric (newer preferred)
• Monitoring rejection: serum amylase/lipase rise indicates graft pancreatitis; urinary amylase (if bladder drainage)

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PART II: IMMUNOSUPPRESSION

A. Goals

1. Prevent acute rejection
2. Prevent chronic rejection
3. Maintain adequate immune function to fight infections
4. Minimise drug toxicity

B. Immunosuppressive Drugs - Mechanism & Side Effects

1. Calcineurin Inhibitors (CNIs)

2. Antiproliferative Agents

3. mTOR Inhibitors

4. Corticosteroids

• Mechanism: Broad anti-inflammatory and immunosuppressive; inhibit NF-κB, reduce cytokine production (IL-1, IL-2, IL-6, TNF-α), impair APC function
• Uses: Maintenance (low dose prednisolone), acute rejection (IV methylprednisolone 500 mg–1 g/day × 3 days)
• Side effects: Diabetes, osteoporosis, hypertension, weight gain, adrenal suppression, cataracts, avascular necrosis of hip, poor wound healing, susceptibility to infection

5. Biological Agents

6. Standard Triple Therapy Protocol

CNI + Antiproliferative + Corticosteroid

e.g., Tacrolimus + MMF + Prednisolone

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C. Complications of Immunosuppression

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PART III: AIDS IN SURGICAL CONTEXT

A. Pathophysiology Review

• HIV (Human Immunodeficiency Virus) - RNA retrovirus; predominantly HIV-1
• Targets CD4+ T cells (also macrophages, dendritic cells) via gp120-CD4 binding + co-receptor (CCR5 or CXCR4)
• Reverse transcriptase converts RNA → DNA → integrates into host genome
• Progressive CD4+ depletion → AIDS when CD4 count <200 cells/μL (or AIDS-defining illness)

B. AIDS-Defining Conditions (Surgical Relevance)

C. Surgical Considerations in HIV/AIDS Patients

• CD4 count and viral load (guide surgical risk)
• Full medication history (ARTs, interactions)
• CD4 >200/μL: most elective surgery safe
• CD4 <50/μL: high perioperative risk; consider deferring elective surgery

• Poor wound healing
• Higher rates of infection (including resistant organisms)
• Higher recurrence of anorectal conditions
• Increased risk of post-op opportunistic infections
• Drug interactions between ARTs and anaesthetic agents

• Anorectal surgery (most common): condylomata, fissures, abscesses, fistulae
  • Surgery not significantly different but expect impaired healing and higher recurrence
• Splenomegaly/hypersplenism: splenectomy may be required
• Kaposi sarcoma: intestinal (bleeding, obstruction, perforation)
• Lymphoma: abdominal (obstruction, perforation, staging)
• CMV colitis: perforation → emergency surgery (high mortality)

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PART IV: UNIVERSAL PRECAUTIONS

A. Definition

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B. Components of Standard/Universal Precautions

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C. Bloodborne Pathogen Risks to Healthcare Workers

• Needlestick: 0.3%
• Mucous membrane splash: 0.09%
• Intact skin: negligible
• Risk increased by: hollow bore needle, deep puncture, visible blood on device, terminal illness in source patient (high viral load)

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D. Post-Exposure Protocol (Needlestick)

1. Encourage bleeding from wound; wash thoroughly with soap and water (do NOT suck wound)
2. Splash to eyes/mouth: irrigate copiously with water
3. Report immediately to occupational health / A&E
4. Risk-assess the source patient (HIV, HBV, HCV status; consent for urgent testing)
5. Assess baseline serology of exposed worker (HIV, HBV, HCV)

• Start PEP within 1 hour, no later than 72 hrs
• Standard PEP regimen: Truvada (tenofovir + emtricitabine) + raltegravir (or dolutegravir) × 28 days
• Follow-up HIV test at 6 weeks and 3 months

• If worker vaccinated and known responder → no action needed
• If unvaccinated or non-responder: HBIG + vaccine within 48 hours

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E. Additional Precaution Categories (Beyond Standard)

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F. Surgical Team Protection - Theatre Precautions

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G. Sterilisation & Disinfection

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