7 0 0 S E C T I O N I X • C O L O N
STEP 2: PREOPERATIVE CONSIDERATIONS
Indications for total abdominal colectomy involve both emergent and elective scenarios for treatment of:
Ulcerative colitis
Crohn’s disease of the large bowel with sparing of the distal sigmoid colon and rectum
Attenuated familial adenomatous polyposis
Synchronous multiple cancers
Perforated cecum due to distal colon cancer obstruction
Constipation
Bowel continuity may or may not be restored depending on the clinical circumstance.
If temporary or permanent ileostomy is planned, the patient should be marked preoperatively for either an end or loop ileostomy and educated concerning the new ostomy.
Consideration for ureteral stenting should be made based on the extent of disease and prior abdominal operations.
Aspirin, other blood thinners, and vitamin E should be stopped for 10 days before the procedure.
Preoperative laboratory and cardiac evaluations should be obtained based on patient comorbidities.
Patients taking steroids preoperatively should receive a stress dose of hydrocortisone
100 mg intravenously (IV) before the operation. This should be continued postoperatively and tapered accordingly.
Consideration toward placing an epidural catheter preoperatively should be made for postoperative pain control and minimization of parenteral narcotic use and associated postoperative ileus.
Bowel preparation should include mechanical bowel preparation of the surgeon’s choice. Sodium phosphate bowel preparations should be used with caution because of acute phosphate nephropathy.
Appropriate preoperative antibiotics are administered parenterally within 1 hour before cut time, according to the Surgical Care Improvement Project (SCIP) quality measures defined for elective colorectal operations. We use ertapenem (Invanz) 1 g IV without redosing, because it has 24-hour duration of action.
C H A P T E R 62 • Total Colectomy |
701 |
STEP 3: OPERATIVE STEPS
1.POSITIONING
Proper positioning of the patient should be directed by the primary surgeon to ensure consistency and safety to the patient.
The patient should be placed supine on the operating table. After administration of anesthesia, sequential compression devices should be placed on the legs and a Foley catheter inserted. The legs are placed in low lithotomy position with Allen stirrups. The boots are adjusted so that each leg rests in a flexed position without pressure on the popliteal fossa. Padding is used to shield the skin from all hard objects.
Abdominal and pubic hair is clipped off.
A Bair Hugger Warmer is placed across the patient’s chest.
An orogastric tube is placed, to be removed after surgery unless a nasogastric tube is indicated, as in cases of extensive lysis of adhesions.
Rigid proctoscopy is performed to clean the rectum of residual stool and to confirm absence of pathologic findings in the rectum that may need to be addressed in the operating room.
The abdomen and perineum are prepped in standard fashion according to the surgeon’s preference. The scrotum should be positioned away from the perineum.
7 0 2 S E C T I O N I X • C O L O N
2. INCISION
The pubic symphysis and manubrial notch are palpated and marked. A line is drawn down the entire midline in case the incision needs to be extended during the later part of the procedure (Figure 62-2).
A no. 10 blade knife is used to make an incision from a point 2 cm above the umbilicus down to the pubic symphysis.
The abdomen is entered sharply. Care is taken to dissect around the bladder obliquely. The incision is extended through the pyramidalis muscle to the pubic symphysis.
The abdomen is explored for additional pathologic abnormalities. The terminal ileum is identified and the entire small bowel is run proximally to the ligament of Treitz. The liver is palpated for the presence of masses.
Transverse colon
Inferior mesenteric artery
Superior mesenteric artery
Middle colic artery 
Left colic artery
Right colic artery
Descending colon
Ileocolic artery |
Sigmoid arteries |
Ascending colon
Superior rectal artery
Sigmoid colon
Rectum
C H A P T E R 62 • Total Colectomy |
703 |
3. DISSECTION
A Bookwalter retractor is set up. Laparotomy pads are placed along each side of the abdominal wall. Two ratcheted short Richardson retractors are positioned opposite each other in lower oblique fashion, taking care not to impinge on the femoral canal.
The small bowel is packed upward using a moist blue towel with a radiopaque loop attached to it, and a wide Deaver ratcheted retractor is bent and placed to maintain exposure without compression of the aorta or inferior vena cava.
In female patients, the uterus should be retracted by placing a figure-of-eight stitch with 2-0 Vicryl through the posterior wall of the uterus as a retraction stitch. A ratcheted bladder blade is then placed to retract the uterus and bladder.
The surgeon on the right side of the patient pulls up on the sigmoid colon so that the lateral peritoneal attachment is on tension (Figure 62-3). Electrocautery is used to divide the attachment.
White line of Toldt
Lateral peritoneal attachment
7 0 4 S E C T I O N I X • C O L O N
The recess at the base of the mesosigmoid, called the intersigmoid fossa, is identified and delicately incised. The left ureter lies just deep to it and is identified and mobilized laterally. The ureter courses medially and parallel to the gonadal vessels, another important landmark to identify (Figure 62-4).
The surgeon to the left of the patient isolates the inferior mesenteric pedicle. This is done by identifying the avascular window at the base of the mesosigmoid while tenting the mesentery up. The window is incised against the surgeon’s finger from the right with electrocautery, and is extended proximally to the pelvic brim and distally down to the level of the sacral promontory bilaterally.
The peritoneal covering of pedicle is cut, and excess mesenteric fat is thinned in preparation for ligation.
Seurat clamps are used to divide the pedicle. A 2-0 Vicryl tie is used to ligate both the base and specimen side of the pedicle. If the artery feels calcified or has atherosclerotic plaque visibly extruding from the vessel after clamping, a 2-0 Vicryl stick tie should be placed to ensure hemostasis of the pedicle base (Figure 62-5).
The rectosigmoid mesentery is sequentially clamped, divided, and ligated to the serosal edge of the colon. The surface is cleaned of excess mesenteric and epiploic fat in preparation for division.
Before division, the left colon is mobilized as much as possible by being divided from its retroperitoneal lateral attachments upward toward the spleen (Figure 62-6).
Gonadal vessels
Ureter
C H A P T E R 62 • Total Colectomy |
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Inferior mesentery artery
7 0 6 S E C T I O N I X • C O L O N
Method of division of the rectosigmoid depends on whether intestinal continuity will be reestablished. Either a linear stapler or division between two Ochsner bowel clamps may be used to divide the bowel at the level of the sacral promontory (Figure 62-7). The proximal rectosigmoid end is wrapped with a laparotomy pad and may be clamped if there is concern for fecal leakage through the staple line during mobilization. The distal stump is marked with a 2-0 Prolene suture for future recognition if reversal is a possibility.
The Deaver blade is removed along with the blue towel. The transverse colon is pulled downward, and the lesser sac entered by incising the filmy attachment of the gastrocolic ligament to the colon (Figure 62-8).
The splenic flexure is mobilized by the surgeon standing on the patient’s right side. The assistant may move to the position between the patient’s legs for improved visualization. The splenocolic ligament is divided close to the bowel wall to avoid injury to the spleen
(Figure 62-9).
Once the splenic flexure is down, the remainder of the gastrocolic ligament is detached from the transverse colon.
Attention is then turned to the right colon. The small bowel may be loosely packed away, once again, depending on the surgeon’s preference.
Division of the |
rectosigmoid |
C H A P T E R 62 • Total Colectomy |
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Gastrocolic ligament incised
FIGURE 62–8
Splenocolic ligament
FIGURE 62–9
7 0 8 S E C T I O N I X • C O L O N
The cecum is retracted up away from the pelvic brim. The lateral peritoneal attachment is divided, and gentle blunt dissection is used to separate the ascending colon from the retroperitoneum. The duodenum is identified and dissected downward and away from colonic mesentery (Figure 62-10).
The phrenocolic and hepatocolic ligaments are clamped, divided, and ligated using 2-0 Vicryl suture.
The ligament of Treves is identified and divided along with the parietal peritoneum of the terminal ileum. The ileocolic vascular pedicle is identified, clamped, divided, and ligated in similar fashion, as mentioned earlier (Figure 62-11).
The mesentery is scored to the point of ileal resection. The vascular arcades are clamped, divided, and ligated, and the ileum is divided between two Ochsner clamps.
It is important to note that the method of pedicle ligation and mesenteric division will vary drastically for patients with ulcerative colitis. The possibility of having an ileal anal pouch in the future mandates that ileal length and vasculature be preserved. In this circumstance, the ileocolic artery is preserved, and the mesentery is divided close to the right colon (Figure 62-12).
Division of lateral peritoneal attachment
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