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

7 1 0 S E C T I O N I X • C O L O N

The remaining vascular pedicles of the ascending, transverse, and descending colon are sequentially visualized, clamped, divided, and ligated. Remaining proximal to the vessels decreases the number of vessels that need to be divided.

The specimen is removed from the table and opened off the field to confirm pathologic findings and rule out additional findings.

All laparotomy pads are removed from the abdomen, and the Bookwalter retractor is taken down. If a retraction stitch was placed in the uterus, the stitch should be tied down to prevent bleeding from the myometrium.

The abdomen is irrigated with warm sterile saline.

Brooke Ileostomy

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 out a circular disc. The ileostomy is placed through the summit of the infraumbilical bulge through the split thickness of the rectus muscle. Electrocautery is used to cut through the subcutaneous tissue down to the anterior fascia of the rectus muscle, 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 brought out of the abdominal cavity for a length of approximately 5 cm, taking care not to twist the mesentery. If the ileostomy is temporary, it should be wrapped in a sheet of Seprafilm to prevent adhesions and facilitate takedown in the future.

The abdomen is closed before the ileostomy is matured (see following section, Abdominal Closure), and the incision is protected with a clean, dry towel.

Stitches using 2-0 chromic are placed through the mucosa at points equidistant from each other and through the seromuscular layer proximally at the skin level. The ileostomy is everted so that the end falls away from the mucocutaneous junction. The appliance is cut to fit circumferentially so that there are no gaps exposing the skin.

Ileorectal Anastomosis

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

Dissection for ileorectal anastomosis differs in sequence from the previously mentioned steps in that the operation begins with takedown of the right colon and proceeds clockwise to the final step of division of the sigmoid colon from the rectum.

Preparation for open lumen of bowl mandates meticulous attention to detail to prevent fecal spillage into the abdominal cavity. A blue towel is folded and placed on the field, which will contain contaminated instruments: a metal pool sucker, Allys bowel clamps, and sponge stick. Moist laparotomy pads are packed around the rectum.

A Glassman clamp is placed across the distal sigmoid colon, and a knife is used to detach the colon. Allys clamps are placed on the mesenteric and antimesenteric edges of the open lumen of bowel, and a sponge stick is used to blot and clean the edges.

The terminal ileum is similarly divided off the Ochsner clamp and grasped with Allys clamps. Care is taken to place the Ochsner obliquely on the small bowel to match the size of the rectum. A Cheatle incision may be made on the antimesenteric border to enlarge the lumen.

The antimesenteric and mesenteric borders of each lumen are lined up. Care is taken to ensure that the small bowel is not twisted around its mesentery.

A double-armed 4-0 Maxon monofilament suture is used to create a single-layered running anastomosis.

The integrity of the anastomosis may be checked using the proctoscope to insufflate through the rectum while submerged under saline. Presence of bubbles requires single interrupted sutures to repair the leak.

The surgeons’ gloves are changed before skin closure.

4. ABDOMINAL CLOSURE

The omentum is moved to the side and placed in either paracolic gutter. One sheet of Seprafilm is cut in half and placed over the bowel under the incision. This minimizes adhesion formation and makes reentry easier for future operations.

The abdomen is closed using no. 1 polydioxanone (PDS) running suture.

The subcutaneous tissue is irrigated with bacitracin irrigation, and the skin is closed with staples.

The umbilicus is reapproximated. A bacitracin-soaked cotton ball wrapped in Adaptic is packed into the umbilicus as a bolster.

7 1 2 S E C T I O N I X • C O L O N

STEP 4: POSTOPERATIVE CARE

Adherence to a postoperative colorectal clinical pathway ensures standardization of care.

Adequate pain control is achieved using patient-controlled analgesia or epidural catheter.

Stress ulcer prophylaxis, such as famotidine (Pepcid) 20 mg IV every 12 hours, should be used if indicated.

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 within 24 hours of surgery. Dosing schedules should start on postoperative day 1 after results of morning laboratory tests are back to ensure that there is no significant drop in hemoglobin to suggest postoperative bleeding.

Adequate intravenous fluid should be administered with monitoring of urine output via urimeter on the Foley bag.

The diet may be limited to ice chips and sips of water in the postanesthesia care unit and on postoperative day 1. Return of bowel function is measured by the frequency and pitch of bowel sounds, lack of abdominal distention, and the patient’s subjective will to eat. A clear liquid diet may be offered as sips of clear liquids without carbonation and without a straw to minimize accumulation of air in the intestine. This may be advanced ad lib as bowel function returns.

Early ambulation is crucial for return of bowel function. Patients should be instructed to walk multiple times a day beginning on postoperative day 1, and should be encouraged to do so frequently.

The umbilical bolster should be removed before the patient leaves the hospital. Skin staples are removed on postoperative day 10.

STEP 5: PEARLS AND PITFALLS

Placement of deep ratcheted Richardson retractors may impinge on the femoral nerve against the psoas muscle, causing compression and femoral nerve neuropathy. The short ratcheted retractors should be used to avoid this, even in patients with thick body walls.

The use of ertapenem 1 g IV for prophylaxis of surgical site infections after colon surgery has the advantage of once-a-day dosing so that therapeutic levels persist throughout the surgery without need for additional doses during long cases. Ertapenem is a broad-spectrum

antibiotic covering enteric flora and has been approved by the SCIP as an acceptable prophylactic antibiotic for elective colorectal surgery.

Visualizing the left ureter before dividing the inferior mesenteric artery will decrease the probability of inadvertent ureteral ligation. This step should be done every time after clamps are placed across the pedicle, before the artery is cut.

In patients who may need future completion proctectomy, such as those with ulcerative colitis, care should be taken not to enter the avascular mesorectal plane after division of the mesosigmoid. This preserves the integrity of the tissue plane and improves the relative ease of future dissection.

Every measure should be taken to preserve the ileal blood supply in patients with ulcerative colitis for potential future ileal pouch creation.

Care should be taken not to twist the small bowel mesentery when bringing out an ileostomy or creating an ileorectal anastomosis. This can be done by identifying the superior mesenteric artery at the root and “shaking hands” with the mesentery to feel for twists.

The use of Seprafilm underneath the incision minimizes abdominal adhesions and improves ease of entry on subsequent laparotomies. In addition, wrapping a temporary ileostomy with Seprafilm allows for easier takedown later.

SELECTED REFERENCES

1Beck DE, Opelka FG: Perioperative steroid use in colorectal patients. Dis Colon Rectum 1996;39: 995-999.

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

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].

4. 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.

5. 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.

Temporary loop ileostomy is used to protect the ileal pouch anal anastomosis (IPAA), and should be strongly considered in this operation. The patient should be marked preoperatively and educated concerning both the new ostomy and pouch.

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 the patient’s 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 as per the surgeon’s preference. Caution should be taken when using sodium phosphate preparation because of the risk of acute phosphate nephropathy.

Appropriate antibiotics should be given parenterally within 1 hour of the incision.

7 1 6 S E C T I O N I X • C O L O N

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. A thromboembolism-deterrent (TED) hose and sequential compression devices should be placed on the legs, and a Foley catheter should be inserted.

The legs are placed in low lithotomy position using Allen stirrups (Figure 63-1). 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 warmer is placed appropriately on the patient to ensure normothermia during the procedure.

An orogastric or nasogastric tube is placed after induction of anesthesia.

A small roll is placed under the patient’s lower back.

Rigid proctoscopy is performed to clean the rectum of residual stool and to confirm absence of pathologic abnormalities in the rectum that may need to be addressed in the operating room.

The premarked ileostomy site is scored using a needle to avoid losing the mark during the skin preparation.

The abdomen and perineum are prepped. The scrotum should be positioned away from the perineum.

Draping the patient:

The patient is draped in standard fashion according to the surgeon’s preference.

An under buttocks drape should be included, because there will be work from the perineal side.

Low lithotomy position

Allen stirrups

FIGURE 63–1

7 1 8 S E C T I O N I X • C O L O N

STEP 3: OPERATIVE STEPS

1.INCISION

A standard midline incision is made using a no. 10 blade knife from a point 2 cm above the umbilicus, through midline, and down to the pubic symphysis.

The abdomen is entered sharply and dissection is carried around the bladder obliquely. The pubic symphysis is palpated, and the incision is extended through the pyramidalis muscle as the inferior boundary of the incision.

The abdomen is explored for additional pathologic findings. 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.

Exposure

A Bookwalter retractor is set up so that the arm attaches to the right side of the table.

Moist laparotomy pads are folded in half and placed along the length of each side of the abdominal wall. Two ratcheted 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.

2. DISSECTION

Total abdominal colectomy is performed according to the steps outlined in Chapter 62. Please refer to that chapter for procedural details.

The recess at the base of the mesosigmoid, called the intersigmoid fossa, is identified and delicately incised. The left ureter lies just deep to intersigmoid fossa and is identified and mobilized laterally. The ureter courses medially and parallel to the gonadal vessels, another important landmark to identify.

The inferior mesenteric pedicle is isolated. This is done by identifying the avascular window at the base of the mesosigmoid while tenting the mesentery up. The window is incised and extended proximally to the pelvic brim and distally down to the level of the sacral promontory bilaterally.