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    none: Fig. 1. - Pièce opératoie
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    none: Fig. 2 et Fig. 3 Whipple, à la cholécysto-gastrostomie, a reproché de dévoriser la stase et l'infection, donc l'angiocholite : aussi a-t-il eu recours, chez son deuxième et son troisième opéré, à une cholécysto-jéjunostomie antérieure précolique type Roux, avec implantation jéjuno-jéjunale à 12 centimètres environ au-dessous de l'anastomose
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    none: Schéma 1 Pour faciliter l'exérèse lors du temps abdominal de libération, l'idée est venue de longue date de diviser totalement l'intestin lors de la réalisation de la colostomie par incision sus-iliaque gauche, d'aboucher l'extrémité terminale du segment colique supérieur à la peau de la fosse iliaque, puis, après dégagement plus ou moins poussé, de fermer l'extrémité supérieure du segment recto-colique en cul-de-sac, de l'abandonner librement dans la cavité abdominale, réalisant ainsi une exclusion unilatérale ouverte au canal anal
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    none: Schéma 2 Ici, c'est au cours du temps abdominal d'exérèse qu'on sectionne le sigmoïde non loin de l'anus artificiel. Il reste entre la section colique et la colostomie un court segment attenant à la paroi. On enferme l'extrémité abdominale en cul-de-sac sous plusieurs bourses d'enfouissement, rélaisant une brève exclusion unilatérale ouverte, elle, dans la colostomie. Moins dangereux que le précédent, ce procédé comporte cependant, comme lui, un assez gros pourcentage de risques de désunion, d'accidents péritonéaux ou occlusifs. Nous croyons sage de tout faire pour éviter également d'y recourir / Schéma 3 Supprimer toute la portion du côlon sous-jacente à la colostomie en la désinsérant par voie médiane de l'incision latérale où elle est amarrée serait une façon élégante d'éviter tous les écueils. La chose n'est pas impossible, mais, même lorsqu'on a pris soin de séparer par un pont cutané les deux orifices de l'anus iliaque gauche, cette libération pariétale par voie médiane est laborieuse, difficile, aléatoire pour la vascularisation de la branche supérieure afférente. S'il faut s'aider au cours de ces manoeuvres de l'excision directe de la brèche iliaque gauche, on ajoute alors à l'intervention un temps septique qui l'allonge et l'aggrave. Une telle pratique est aussi préjudiciable que les deux autres et constitue, avec elles, la triade des artifices que nous estimons dangereux et qu'il faut savoir rejeter / Schéma 4 Nous avons suivi deux fois cette technique avec succès ; mais, dans un cas, l'inoculation septique de l'incision médiane retarda beaucoup l'intervention seconde du fait d'une suppuration prolongée. Sans doute, cet accident doit-il être évité par une technique impeccable. Il n'en est pas moins vrai que, s'il survient, il constitue un reproche assez sérieux à la méthode. Par ailleurs, il enlève à la colostomie le caractère de simplicité qu'on aime à lui garder
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    none: Schéma 5 Cette manœuvre ingénieuse est quand même un peu complexe et assez délicate. Elle amène au dehors le segment exclu, qui pourra se rétracter peu à peu, mais qu'il est parfois nécessaire (inconvénient mineur, à dire vrai) de réséquer secondairement. Bien exécuté, ce procédé met sûrement à l'abri de toutes les complications péritonéales ou occlusives que peut engendrer la présence d'un cul-de-sac, d'un vase clos. Il est légitime de lui conserver une place de choix / Schéma 6 Notons que la même technique peut être suivie dans une opération d'Hartmann, purement abdominale, faite sous couvert d'anus iliaque. Il est même logique de se demander si la portion du côlon ainsi respectée, et sans doute capable d'allongement ne serait pas susceptible d'être utilisée secondairement pour un éventuel rétablissement de la continuité, qui n'aurait paru ni logique ni possible d'emblée, par intubation sous couvert de la colostomie persistante
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