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

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Primary Anastomosis

The decision to restore bowel continuity depends on the primary diagnosis and clinical scenario.

The mesentery to the proximal end of the anastomosis is clamped, divided, and ligated. An Ochsner bowel clamp is then placed across the bowel, and the specimen is divided and passed off the field. The proximal lumen of the colon is inspected for abnormalities and irrigated with saline. Care is taken to ensure full sterile technique is maintained without fecal spillage.

A purse-string suture using 2-0 Prolene on an SH needle is taken circumferentially around the proximal end of the bowel. A 29-mm circular intraluminal stapler (ILS) is opened, and the anvil is placed in the lumen, synching the purse-string down (Figure 61-6, A).

The colon is replaced into the abdomen, and a pneumoperitoneum is recreated. An anvil grasper is used to pick up the anvil in the conventional laparoscopic technique. The left hand is used to guide the anvil to the pelvis in the hand-assisted technique.

The perineal operator places the circular stapler into the rectum and is directed to the stapled end of the bowel. The main rod is deployed so that it exits either above or below the staple line (Figure 61-6, B). The main rod and anvil are attached. The mesentery is checked for twists and for undue tension. The circular stapler is tightened and fired. The resulting rings are inspected for completion.

A leak test is performed by introducing air into the rectum while occluding the proximal bowel. The anastomosis is submerged in saline and placed under intraluminal air tension. Presence of bubbles suggests an incomplete staple line and should be addressed accordingly.

Loop ileostomy may be created to divert the fecal stream away from the distal anastomosis in the presence of unhealthy tissue or a tentative anastomosis.

Proximal colon

Main rod

Anvil

Intraluminal stapler

Purse-string suture

Rectum

FIGURE 61–6

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Protecting Loop Ileostomy

The following outlined steps may be done with the open abdomen using the Alexis wound retractor (Applied Medical) through the incision made to exteriorize the resected segment of colon.

Umbilical tape is passed between the mesentery and distal ileum. A Vicryl stitch may be used to mark the up side of the ileostomy to avoid confusion in which side to mature.

Two Ochsner clamps are placed on the anterior fascia of the rectus muscle, and an Allys clamp is placed on the skin between the two. The assistant maintains even traction so that all layers are parallel and aligned.

An Ochsner clamp is placed on the skin over the ileostomy site and pulled up. A no. 10 blade knife is used to cut a circular disc.

Electrocautery is used to cut through subcutaneous tissue down anterior rectus fascia, which is sharply divided. Muscle fibers are spread perpendicularly, and the peritoneum is cut longitudinally enough to snugly fit two fingers. Injury to the inferior epigastric vessels should be avoided.

The ileostomy is wrapped in Seprafilm and brought out of the abdominal cavity through the ostomy site on traction using the umbilical tape for a length of at least 4 cm, taking care not to twist the mesentery. This will minimize adhesions and facilitate ease of takedown at a later time.

The proximal limb is confirmed by visualizing the suture, and a transverse incision is made across the ileum using Bovie electrocautery.

Vicryl sutures are placed through the mucosa at points equidistant from each other on the proximal limb, then through the seromuscular layer proximally at the skin level, and then to skin. The proximal limb is everted to form a spicket-like protuberance that falls into the ileostomy bag, diverting the sulcus away from the level of the skin. The distal limb is sutured to the inferior portion of the skin edge without eversion.

The appliance is cut to fit circumferentially so that there are no gaps exposing the skin at the end of the procedure after skin is closed.

End Colostomy

A left lower colostomy site is created in a similar fashion to the aforementioned technique for creation of a loop ileostomy.

An Ochsner bowel clamp is passed through the aperture of the ostomy site and placed on the edge of the bowel to be exteriorized.

The clamp is pulled through, taking care that there are no twists in the mesentery and no tension on the colostomy.

The colostomy is matured in standard fashion after the abdomen is closed and the midline incision is protected.

4. CLOSING

Surgical gloves are changed, and the Alexis wound retractor is removed, as are all other ports. Seprafilm is placed, and the anterior rectus fascia 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 the 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. A nasogastric tube should be placed if there is extensive lysis of adhesions or other indication for maintenance of a nasogastric tube postoperatively.

STEP 4: POSTOPERATIVE CARE

The same principles of postoperative care followed for laparoscopic-assisted right colectomy apply to laparoscopic-assisted left and sigmoid colectomy, and can be referred to in Chapter 59.

STEP 5: PEARLS AND PITFALLS

Division of the left colic artery may be necessary for adequate mobilization in creating a tension-free anastomosis. The ascending branch of the left colic artery should be preserved, allowing collateral flow from the middle colic artery back to the ascending left colic artery through the marginal arteries.

Oncologic resection of the sigmoid colon mandates attention to preserve the meandering artery of Riolan during high ligation of the IMA for maintaining collateral blood flow to the proximal left colon.

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Consideration for placement of ureteral stents should be made for cases involving complicated diverticulitis or large bulky tumors. Although stents have not been shown to prevent injury, palpation of the stent may assist in timely recognition of ureteral location. In addition, injuries may be identified earlier during the intraoperative period by visualization of the stent, thus facilitating repair.

The left ureter should be visualized and swept laterally before division of the IMA pedicle. Failure to do this may involve inclusion of the ureter with the pedicle, leading to one of the most common causes of ureteral injury during this procedure.

High ligation of the IMA pedicle may injure the superior hypogatric (sympathetic) plexus because of entrapment and division of the nerves. This results in retrograde ejaculation. Care should be taken to identify the nerves and dissect them laterally before division of the pedicle.

A lip of omentum may be mobilized to buttress the anastomosis, a consideration to make if the tissues are inflamed or friable.

The inferior epigastric artery may be visualized and avoided before making the incision for an ostomy by transillumination of the anterior abdominal wall with the laparoscopic light.

Tension on the ileostomy due to foreshortened mesentery or large abdominal pannus may be relieved by mobilization of the right colon.

SELECTED REFERENCES

1. Aalbers AG, Biere SS, van Berge Henegouwen MI, Bemelman WA: Hand-assisted or laparoscopic-assisted approach in colorectal surgery: A systematic review and meta-analysis. Surg Endosc 2008; 22:1769-1780.

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

3. 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].