Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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Reapproximating the mesenteric defect must be performed with care to ensure that the underlying vessels supplying the bowel are not compromised. This can be sutured using a continuous absorbable stitch (Figure 58-17).

Closure of mesentery

FIGURE 58–17

3.CLOSING

The abdominal cavity is irrigated with copious warm saline. The omentum can be overlaid on top of the newly formed anastomosis. After ensuring hemostasis, sponge counts, and instrument counts, close the abdomen using a no. 1 polydioxanone (PDS) suture. The subcutaneous tissue is irrigated again and the skin is closed with skin clips (see Figure 58-17).

STEP 4: POSTOPERATIVE CARE

A nasogastric tube is generally not required for a routine right hemicolectomy. Patients can generally tolerate sips of clear liquids and progress to a regular diet over the next few postoperative days.

STEP 5: PEARLS AND PITFALLS

Be careful of injury to retroperitoneal structures such as the duodenum and right ureter.

When performing the operation for cancer, it is important to ensure that the pathologists process and look at an adequate number of lymph nodes. This will ensure more accurate nodal staging, which is essential for the decision to treat with adjuvant chemotherapy.

SELECTED REFERENCES

1. Wille-Jørgensen P, Rasmussen MS, Andersen BR, Borly L: Heparins and mechanical methods for thromboprophylaxis in colorectal surgery. Cochrane Database Syst Rev 2004(4):CD001217.

2. Stahl TJ, Gregorcyk SG, Hyman NH, et al: Practice parameters for the prevention of venous thrombosis. Dis Colon Rectum 2006;49:1477-1483.

3. Docherty JG, McGregor JR, Akyol AM, et al: Comparison of manually constructed and stapled anastomoses in colorectal surgery. Ann Surg 1995;221:176-184.

4. LeVoyer TE, Sigurdson ER, Hanlon AL, et al: Colon cancer is associated with increasing number of lymph nodes analyzed: A secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21:2912-2919.

penetrating abdominal trauma and repair of endoscopically created perforations. Other indications include:

Benign polyps or lesions not amenable to endoscopic resection

Malignant lesions located in the appendix, cecum, ascending colon, and hepatic flexure

Crohn’s disease of the terminal ileum and ascending colon

Cecal volvulus

The hand-assisted technique allows for use of one hand in the abdomen while maintaining pneumoperitoneum. Advantages include preservation of tactile sensation and ease of dissection and should be considered for potentially difficult cases such as those having anticipated adhesions or inflammatory conditions as in cancer and inflammatory bowel disease (IBD). Operative times are shorter and the benefits of the laparoscopic approach are preserved.

Informed consent should address such complications as anastomotic stricture or leak, bowel obstruction, wound infection at the port sites, intra-abdominal infection, hematoma, injury to adjacent bowel or mesentery, injury to adjacent structures such as the ureter and great vessels, port site hernias, and the need for creation of an ostomy.

Preoperative evaluation of the patient’s comorbidities should be obtained, including determination of nutritional status, evidence of anemia, and cardiac risk factors. Appropriate laboratory and cardiac evaluations should be obtained.

Patients undergoing resection for malignant or potentially malignant pathologic conditions should have preoperative staging computed tomography (CT) scan of the chest, abdomen, and pelvis, with oral and intravenous (IV) contrast, and a baseline carcinoembryonic antigen (CEA) level drawn. In addition, a complete colonoscopy should be performed to confirm location of the lesion and to rule out synchronous lesions.

Aspirin, other blood thinners, and vitamin E should be stopped for 10 days before the procedure.

A mechanical bowel preparation may be given based on the surgeon’s preference.

An accepted parenteral antibiotic is given within 1 hour of the incision to prevent surgical site infection on colorectal cases in accordance with the Surgical Care Improvement Project (SCIP) guidelines. Ertapenem is given once a day and covers the 24-hour postoperative period.

Prophylaxis for thrombophlebitis is administered either preoperatively or within 24 hours from surgery in accordance with the SCIP guidelines.

Patients on steroids preoperatively should get a stress dose of IV hydrocortisone 100 mg before the operation. This should be continued postoperatively and tapered accordingly.

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Implementing a postoperative colorectal pathway facilitates timely recovery and decreased length of hospital stay. The pathway is reviewed with the patient to outline expectations for ambulation and pain control after surgery. It is imperative that patients understand the importance of ambulation on postoperative return of bowel function.

STEP 3: OPERATIVE STEPS

1.POSITIONING

The patient is placed supine on the operating table on a deflated bean bag covered with two hospital sheets.

After general endotracheal anesthesia is administered, a Foley catheter is placed along with sequential compression devices on the lower extremities.

Depending on the surgeon’s preference, the patient may remain supine or be placed in low lithotomy using Allen stirrups. Lithotomy allows for additional mobility for the assistant or the surgeon, should an alternative position be needed.

The arms are padded and tucked so that the top sheet comes over and underneath the bottom sheet. Care is taken to ensure that all IV lines are padded away from the skin to prevent pressure necrosis. The hands are placed in slightly flexed position with circular roll to prevent intraoperative movement.

Abdominal and pubic hair is clipped off as needed.

A warmer is placed appropriately to ensure normothermia during the surgery.

An orogastric tube is placed by the anesthesia team for the duration of the procedure, to be removed upon completion of the procedure.

The surgeon will stand on the patient’s left, with the assistant between the legs or next to the surgeon on the left.

Monitors are placed on the upper and lower right side of the patient.

2. INCISION

The abdomen is prepped and draped in standard fashion according to the surgeon’s preference.

Using a marking pen, mark the midline from pubic symphysis to xiphoid process to aid midline entry if rapid conversion to an open procedure is needed.

The laparoscopic instruments are positioned accordingly on the operative field to include a

30-degree laparoscope, two insufflation tubing devices attached to CO2 tanks, electrocautery, suction, and consideration for harmonic scalpel or LigaSure device.

Port placement

Hand-assisted laparoscopic technique

A vertical midline incision is made 1 cm less than the width of the hand. I prefer to carry the incision through the center of the umbilicus, which will make up for the difference in length.

The abdomen is entered sharply. The midline fascia is divided beyond the limit of the skin incision both proximally and distally. Visible adhesions are taken down in standard fashion.

The GelPort (Applied Medical) is used by placing the Alexis retractor into the wound and rotating the outer ring inward, thus tightening the fit. A 5-mm blunt-tipped port is placed through the GelPort, which is attached to the outer ring. Insufflation is initiated on high flow to 15 mm Hg.

The left hand is introduced through the GelPort and the laparoscope through the 5-mm port.

A 12-mm port is placed in the upper midline.

The patient is placed in steep Trendelenburg position and airplaned to the right.

Conventional technique

The Veress needle or Hassan technique may be used to access the abdomen below the umbilicus. A 12-mm port is placed in the left upper quadrant and a 5-mm port is placed at the upper midline. A second 5-mm port may be placed in the right lower quadrant for traction.

The liver is visualized and inspected along with the peritoneal cavity for evidence of metastatic disease. Laparoscopic intraoperative ultrasound may be performed at this time.