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

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The right colic artery, if present, is isolated and divided, as is the hepatic branch of the middle colic artery.

The lateral attachment is divided and dissection is carried around the hepatic flexure, taking the hepatocolic ligaments down (Figure 59-5, A). The gastrocolic ligament is detached from the transverse colon just distal to the point where the colon will be divided (Figure 59-5, B).

For an oncologic resection, the omentum should be resected with the specimen, taking care to preserve the gastroepiploic artery.

The mesentery is divided to the point of vascular demarcation of the transverse colon.

Pneumoperitoneum is reversed and the mobilized segment is exteriorized.

Release of hepatocolic flexure

A

Release of gastrocolic ligament

Transverse colon

B

FIGURE 59–5

The mesentery to the terminal ileum is clamped, divided, and ligated to a point 5 to 15 cm away from the ileocecal valve. The mesentery is similarly cleared from the transverse colon.

Hand-sewn end-to-end anastomosis:

An Ochsner bowel clamp is placed obliquely on the small bowel to make up for the size difference between the small bowel and colon lumen.

An Ochsner bowel clamp is placed perpendicularly on the transverse colon.

The specimen is transected and removed from the table (Figure 59-6).

The two ends of bowel are positioned so that the antimesenteric and mesenteric ends are aligned.

Both lumens are inspected and irrigated, taking care to maintain sterile technique and minimize fecal spillage.

A double-armed 4-0 Maxon monofilament suture is used to create a single-layered running anastomosis. The serosal edge is grasped and the mucosa and submucosal edges are reapproximated. This is done by placing the knot on the outer portion of the bowel at the antimesenteric border. One arm of suture is passed under the knot and used to complete half of the anastomosis, as is the other arm on the other side. The suture line is inspected for integrity.

Stapled side-to-side anastomosis:

The exteriorized segment is laid out so that the antimesenteric limb of the small bowel is aligned with the antimesenteric limb of the transverse colon. A stay stitch using 2-0 Vicryl suture may be used to maintain alignment.

A colotomy and enterotomy are made on the antimesenteric side over the proximal and distal resection lines using Bovie electrocautery.

Deliver specimen

Wound protector

FIGURE 59–6

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A 75-mm blue load linear GIA stapling device is introduced through each opening, and a common wall is created between the two, taking care to ensure that the mesentery is away from the staple line.

The linear stapler is reloaded and fired perpendicularly to the staple line, closing the colostomy and releasing the specimen from the field (Figure 59-7).

The staple line is inspected for integrity. It is our preference to place a 2-0 Vicryl stitch between the colon and ileum to take tension off the staple line. The intersection of the staple line may also be reinforced with a figure-of-eight stitch, because this is a natural weak point.

The mesenteric defect may be closed according to the surgeon’s preference.

The completed anastomosis is dropped back into the abdominal cavity.

Surgical gloves are changed, and the Alexis wound retractor is removed. It is our preference to place Seprafilm over the midline incision to minimize postoperative adhesions. The abdomen is reapproximated using 0 polydioxanone (PDS) in figure-of-eight interrupted sutures.

The subcutaneous skin is irrigated with bacitracin antibiotic (50,000 U in 1 L saline).

Staples are used to close skin. A small umbilical bolster is created by placing a bacitracinsoaked cotton ball wrapped in Adaptic into the umbilical depression. This is left in place during the hospital stay and removed before discharge home.

The orogastric tube is removed before extubation, provided there is no extensive lysis of adhesions or indication for maintenance of a nasogastric tube postoperatively.

Transverse closure

Side-to-side anastomosis with GIA stapler

A B

FIGURE 59–7

STEP 4: POSTOPERATIVE CARE

Adherence to a postoperative colorectal clinical pathway ensures standardization of care and facilitates timely discharge from the hospital.

Adequate pain control is achieved using patient-controlled analgesia. Use of a nonopioid analgesic such as ketorolac (Toradol) should be considered. In our protocol, this is administered on postoperative day 1, provided there are no contraindications such as renal insufficiency, and given on a scheduled basis of 15 mg intravenously every 8 hours for 9 doses. Patients are transitioned to an oral analgesic on postoperative day 2.

Consideration for stress ulcer prophylaxis should be made for patients with symptoms or history of gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD).

All patients should receive prophylaxis for deep venous thrombosis, consisting of sequential compression devices while in bed, and heparin 5000 U subcutaneously every 8 hours or enoxaparin 40 mg subcutaneously every morning, starting within 24 hours after surgery.

Adequate IV fluid should be administered with monitoring of urine output. The Foley catheter may be removed on postoperative day 1.

The diet may be limited to ice chips and sips of water in the postanesthesia care unit. A clear liquid diet is started on postoperative day 1. Return of bowel function is measured by the frequency and pitch of bowel sounds, lack of abdominal distention, amount of belching, presence of nausea and vomiting, and the patient’s subjective will to eat. Diet may be advanced ad lib as bowel function returns.

Early ambulation is crucial for aid in return of bowel function. Patients should be instructed to walk multiple times a day beginning on postoperative day 1.

The dressing over the incision site is removed on postoperative day 2, and the incision is checked daily thereafter to ensure absence of infection. The umbilical bolster remains in place until the patient is discharged from the hospital.

STEP 5: PEARLS AND PITFALLS

The use of SCIP approved prophylactic antibiotic for colorectal surgery, ertapenem (Invanz) 1 g intravenously, before surgery, requires only a single dose for 24-hour coverage. Furthermore, it lasts for the duration of the procedure and does not require additional dosing.

The hepatic flexure suspensory ligaments should be divided with caution, because there are often large veins here. Careful dissection and the use of energy ligatures should strongly be considered to avoid uncontrollable bleeding and subsequent conversion to open laparotomy.

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Smaller lesions in the colon should be marked with tattoo ink for confirmation of location, which will assist in removal of the primary lesion with adequate 5-cm margin and areas of lymphatic drainage.

Placement of Seprafilm under the midline incision minimizes adhesions on reentry for subsequent operations. This should be considered, especially for indications such as Crohn’s disease and colon cancer.

SELECTED REFERENCES

1. Tinley HS, Constantinides VA, Heriot AG, et al: Comparison of laparoscopic and open ileocecal resection for Crohn’s disease: A meta-analysis. Surg Endosc 2007;20:1036-1044.

2. Kaban GK, Novitsky YW, Perugini RA, et al: Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries. Surg Innov 2008;15:26-31.

3. Kang JC, Chung MH, Yeh CC, et al: Hand assisted laparoscopic colectomy versus open colectomy: A prospective randomized study. Surg Endosc 2004;18:577-581.

4. Itani KMF, Wilson SE, Awad SS, et al: Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med 2006;355:2640-2651.

5. Guidelines from the Joint Commission on Surgical Care Improvement Project Core Measurement Set. Available on Internet: www.jointcommission.org/PerformanceMeasurement.

6. Law WL, Bailey HR, Max E, et al: Single-layer continuous colon and rectal anastomosis using monofilament absorbable suture (Maxon): Study of 500 cases. Dis Colon Rectum 1999;42:736-740.

7. Max E, Sweeney WB, Bailey HR, et al: Results of 1,000 single-layer continuous polypropylene intestinal anastomoses. Am J Surg 1991;162:461-467.

8. Zeng Q, Yu Z, You J, Zhang Q: Efficacy and safety of Seprafilm for preventing postoperative abdominal adhesion: Systematic review and meta-analysis. World J Surg 2007; 31:2125-2131;2132 [discussion].

C H A P T E R60

LEFT AND SIGMOID

COLECTOMY

Celia Chao

STEP 1: SURGICAL ANATOMY

The left colon begins at the mid-transverse colon and includes the splenic flexure, left (descending) colon, and sigmoid colon. The marginal artery of Drummond provides a vascular anastomosis between the superior and inferior mesenteric arteries. The blood supply to the left colon is derived from the inferior mesenteric artery. The first branch, the left colic artery, supplies the splenic flexure and descending colon. The sigmoid arteries and the superior rectal artery are the most distal branches of the inferior mesenteric artery and supply the sigmoid colon. The lymphatics follow its arterial blood supply. A minimum of 12 lymph nodes within the mesentery is considered an adequate resection when performing a left hemicolectomy or sigmoidectomy for cancer.

STEP 2: PREOPERATIVE CONSIDERATIONS

Indications: Tumors of the left colon can be resected with a left hemicolectomy, which involves sacrificing the inferior mesenteric blood supply, along with its branches (left colic artery and sigmoid arteries), which supply the splenic flexure to the proximal sigmoid colon. Tumors of the sigmoid colon can be removed with a sigmoid resection, encompassing the distal descending colon and the sigmoid colon, sacrificing the sigmoid and superior rectal arteries (Figure 60-1).

Preoperative planning: Evaluation of the entire colorectal lumen is necessary to rule out synchronous lesions before surgical intervention. This can be accomplished with either colonoscopy or barium enema, assuming that the patient does not have an obstructing or near-obstructing lesion. An adequate mechanical bowel preparation is generally performed the day before surgical resection, but is not considered necessary. Preoperatively, intravenous antibiotics must be administered before the skin incision. A preoperative dose of subcutaneous heparin (5000 U) or a low-molecular-weight heparin is recommended to prevent deep venous thrombosis. Before induction of general anesthesia, pneumatic compression boots are placed on both lower extremities and continued postoperatively until the patient ambulates on the first postoperative day. A Foley catheter is placed after induction of general anesthesia. Stress ulcer prophylaxis may be given until the patient tolerates oral intake.

Anesthesia: General anesthesia is used.

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STEP 3: OPERATIVE STEPS

1.INCISION

A midline incision is made. A Thompson retractor is used to retract the abdominal wall, particularly the left costal margin, which is necessary to facilitate adequate exposure of the splenic flexure.

Transverse colon

Descending colon

Inferior mesenteric artery

Superior rectal artery

Sigmoid artery

FIGURE 60–1

2. DISSECTION

An intra-abdominal exploration is performed to determine the extent of disease and resectability. The small bowel is packed and tucked away to the right upper quadrant of the abdominal cavity. The left colon is mobilized from its retroperitoneal attachments by incising the white line of Toldt (Figure 60-2).

White line of Toldt

Lateral peritoneal attachment

FIGURE 60–2

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The sigmoid and descending colon is retracted medially, exposing the left ureter and gonadal vessel (Figure 60-3).

Continuing cephalad along this retroperitoneal plane, divide the renocolic and splenocolic ligament to release the splenic flexure (Figures 60-4 and 60-5).

Gonadal vessels

Ureter

FIGURE 60–3