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183
PLATE
83
A R R:
S--E A (B)
INDICATIONS e low-lying lesions of the rectum and rectosigmoid may
be resected and bowel continuity established anterior to the sacrum in a
variety of ways. Although the end-to-end anastomosis (Plate ) can be
used, side-to-end anastomosis is advantageous in cases with considerable
discrepancy in size between the resected bowel and the rectal stump, particularly in obese patients. When the lesion is so low that abdominoperineal
resection, with sacri ce of the rectum, ordinarily would be indicated, and
in the presence of distant metastases, or when the patient refuses to give
permission for a permanent colostomy, bowel continuity can be established
by a very low side-to-end anastomosis. is approach may occasionally be
needed in colostomy (Hartmann’s) closure, and a similar ileorectal anastomosis can be used in closing an ileostomy (e.g., a er total colectomy for
pseudomembranous colitis).
e principles of cancer surgery should be observed, including en bloc
excision of the lymphatic drainage area and early ligation of the inferior mesenteric vessels near the point of origin (figures 1 and 2). e blood supply
to the sigmoid will be sustained through the marginal artery of Drummond
via the middle colic artery arising from the superior mesenteric artery. e
malignant lesion of the rectosigmoid should be at least cm above the anus
unless the anterior resection is carried out for palliation alone. At least cm
and preferably more of the bowel should be resected below the malignant
tumor to assure removal of all adjacent lymph nodes. e continuity can
be reestablished a er the descending colon, the splenic exure, and the le
portion of the transverse colon are mobilized (figure 3).
e entire right colon can be freed from its lateral peritoneal attachments and rotated to its embryologic position on the le side of the abdomen, if more mobility is desired.
e advantages of the side-to-end anastomosis include assurance of a
larger and more secure anastomosis than may be possible by the end-toend method.
PREOPERATIVE PREPARATION A er the lesion has been proved to be
malignant by microscopic examination, and polyps or secondary lesions
ruled out by appropriate colonoscopic and barium studies of the colon, the
patient is shi ed to a clear liquid diet for a day or so before surgery. A preliminary computed tomography scan with IV contrast may reveal distal spread
and locate the courses of the ureters. For cancers below the peritoneal re ection, an endorectal ultrasound study will aid in the staging of the extent of
disease. Appropriate tumors should be evaluated for radiation therapy and
chemotherapy prior to operation. e rectum is irrigated with saline or a
povidine-iodine solution. e tube is le in place for rectal decompression.
An indwelling urethral catheter ensures a collapsed bladder, providing better exposure of deep pelvic structures. Systemic antibiotics are given.
ANESTHESIA General endotracheal anesthesia is satisfactory. Spinal anes-
thesia may be used.
POSITION e patient is placed near the le side of the table and so immo-
bilized that the Trendelenburg position can be assumed during the nal
anastomosis without di culty.
OPERATIVE PREPARATION e skin is prepared from the symphysis up
to the epigastrium. If a stapled anastomosis is planned, Allen stirrups are
used to create a modi ed lithotomy position allowing concurrent preparation and draping for later access to the rectum. e perineum and rectum
are prepared and included in the draping if stapling is planned.
INCISION AND EXPOSURE A midline incision is made, starting just
above the symphysis and extending down to the umbilicus and around it on
the le side. e height to which the incision is carried in the epigastrium
depends on the location of the splenic exure. Because it will be necessary
to detach the splenic exure, easy exposure of this area must be provided.
Undue tension of the le half of the colon and splenic exure will tear the
splenic capsule, causing blood loss and risking splenectomy.
A er the abdomen is opened, a self-retaining retractor is inserted, and
the liver is palpated for evidence of metastasis. Palpation should be carried
out well over the top of both lobes of the liver as well as on the undersurface.
Likewise, lymph nodes along the course of the inferior mesenteric artery
and at the bifurcation of the aorta are inspected for evidence of involvement. e position and xation of the tumor are ascertained by palpation.
In the presence of metastasis to the liver or seeding throughout the general
peritoneal cavity, a sleeve type of segmental resection is indicated. When a
palliative resection is carried out, wide dissection of the inferior mesenteric
blood supply up to the point of origin in the region of the ligament of Treitz
is not necessary.
DETAILS OF PROCEDURE A er it has been decided that the lesion is
resectable, that an anterior resection is warranted, and that adequate bowel
can be resected distal to the tumor, the small intestines are walled o and
the transverse colon and splenic exure are mobilized (figure 4).
While the omentum is held upward, sharp dissection is used to divide
the attachment of the omentum to the transverse colon. A few blood vessels may need to be ligated during this procedure. Opening into the lesser
sac above the transverse colon ensures an easier and safer separation of the
omentum from the splenic exure of the colon, particularly in the obese
patient. Again, great care must be exercised as the splenocolic ligament is
divided in order to avoid tearing the splenic capsule. Clamps should be
applied in this area so that the contents of the splenocolic ligament can be
carefully divided and ligated (figure 5).
CONTINUES
184
Inferior mesenteric artery
Superior
hemorrhoidal artery
Middle
colic artery
1
Lesion
Pouch of
Douglas
Middle
hemorrhoidal
artery
Pectinate line
Omentum
2
Inferior
mesenteric
vein
Inferior
mesenteric
artery
Superior
hemorrhoidal
artery
Marginal
artery of
Drummond
Middle
colic artery
Left
colic artery
Sigmoid arteries
3
Marginal artery
of Drummond
Lesser sac
4
Spleen
5
5
Colon
Transverse colon
Splenocolic
ligament
Line of division
185
PLATE
84
A R R:
S--E A (B)
DETAILS OF PROCEDURE e peritoneum over the region
of the le kidney is divided as gentle traction is maintained downward
and medially on the splenic exure of the colon. ere is a tendency to
grasp the colon and to encircle it completely with the ngers. is tends
to puncture the thinned out mesentery. Rents can be avoided if a gauze
pack is used to gently sweep the splenic exure downward and medially
(figure 6). Usually, it is unnecessary to divide and ligate any vessels during this procedure. e peritoneum in the le lumbar gutter is divided,
and the entire descending colon is swept medially.
e rectosigmoid is freed from the hollow of the sacrum as shown in
Plates and , Total Mesorectal Excision. e sigmoid is rst separated
from any attachments to the iliac fossa on the le side, and the le gonadal
vessels and the ureter are identi ed throughout their course in the eld
of operation (figure 7). O en, especially in the female, a very low-lying
lesion can be mobilized and li ed up well into the wound.
A er the bowel has been freed from the hollow of the sacrum, the ngers
of the le hand should separate the right ureter from the overlying peritoneum
by blunt dissection (figure 8). e peritoneum is incised some distance from
the tumor, and the rectum is freed further down to the region of the levator
muscles using the mesorectal dissection (Plates and ). Division of the
middle hemorrhoidal vessels with the suspensory ligaments may be necessary to ensure the needed length of bowel to be resected below the tumor.
e surgeon should not hesitate to divide the peritoneal attachments in the
region of the pouch of Douglas, to free the rectum from the prostate gland in
the male and from the posterior wall of the vagina in the female. e inferior
mesenteric artery is freed from the underlying aorta to near its point of origin
(figure 9). ree curved clamps are applied to the inferior mesenteric artery,
and the vessel is divided and ligated with silk. e inferior mesenteric
vein should be ligated at this time, before the tumor has been palpated and
compressed due to the manipulation required during resection.
CONTINUES
186
Splenic exure
6
Stomach
7
Spleen
Pouch of Douglas
Peritoneal
reection
Left ureter
Gonadal
vessels
Line of incision
Lesion
8
9
Line of incision
Lesion
Right ureter
Bifurcation
of aorta
Inferior
mesenteric artery
187
PLATE
85
A R R:
S--E A (B)
DETAILS OF PROCEDURE A er the mesenteric vessels have
been ligated and the rectum has been mobilized adequately, a Pace-Potts
noncrushing clamp is applied across the bowel at least to cm below
the tumor (figure 10a). e position of both ureters should once again
be identi ed before the clamp is applied. A straight clamp is applied cm
proximal to the noncrushing clamp, and the bowel is divided (figure 10b).
As soon as possible the specimen is wrapped in a large pack held in place by
encircling ties (figure 11).
It is reassuring for the surgeon, especially in obese patients, to see
active pulsations at the anastomotic site, and the surgeon should take the
time to free the mobilized colon and to loosen any tension on the middle
colic vessels. Procaine, percent, can be injected into the mesentery to
strengthen pulsations in elderly patients or in the presence of large fat
deposits in the mesentery (figure 11). e Doppler apparatus may be
used to verify the adequacy of the blood supply. e small bowel should
be returned to the abdomen from the plastic bag, since the base of the
mesentery of the small intestine can compress the middle colic vessels,
particularly if the small intestine is placed on the abdominal wall above
and to the right of the umbilicus (figure 12). e blood supply improves
as the colon resection nears the middle colic vessels, since the descending
colon is now dependent upon the marginal vessels of Drummond arising
from the middle colic vessels (figure 12). e entire transverse colon as
well as the right colon may be mobilized by detaching the omentum and
the peritoneal attachments as indicated by the dotted line (figure 12).
e mesentery is divided up to the bowel wall (figure 13) where active
pulsations have been identi ed. e mesentery to the sigmoid is further
mobilized and divided until a su cient amount of bowel has been isolated
proximal to the lesion.
e remaining colon must be su ciently mobilized then to reach the
rectal stump loosely and without tension. Extra mobility is mandatory,
since postoperative distention of the bowel and subsequent tension on the
suture line must be anticipated.
A decision is made for an end-to-end anastomosis with or without a stapling
instrument or a side-to-end anastomosis. e adequacy of the exposure, the
amount of omental fat, and nally, the discrepancy between the sizes of the upper
and lower lumens may in uence the nal technical approach.
CONTINUES
188
10a
11
Noncrushing
clamp
Procaine 1%
10b
Tumor
12
Middle
colic artery
Marginal
artery of
Drummond
Line of
resection
Inferior
mesenteric vein
Lahey bag
Rectal stump
13
Line of
resection
Ligament
of Treitz
Marginal artery
of Drummond
Inferior
mesenteric vein
Line of division
189
PLATE
86
A R R:
S--E A (B)
DETAILS OF PROCEDURE e bowel is divided obliquely
a er the mesentery has been cleared o to about cm from the clamp
(figure 14). e mobility of this segment of bowel is tested by bringing it down to the region of the rectal stump to be absolutely certain that
side-to-end anastomosis can be carried out without tension. If the initial
segment is too tight, additional transverse colon may be mobilized. e
hepatic exure can be freed as well as the entire right colon. Any attachments constricting the mesentery of the descending colon can be divided.
e presence of active arterial pulsations should be determined while the
closed end of the colon is held deep in the pelvis. e end of the bowel is
closed using a running absorbable suture followed by interrupted silk
Halsted mattress sutures. Alternatively, a stapled closure and division with
a GIA instrument can be used. Some surgeons oversew this staple line with
interrupted silks for better security and inversion.
e taenia adjacent to the mesentery along the inferior surface of the
mobilized segment is grasped with Babcock forceps, and traction sutures
(A and B) are placed at either end of the proposed opening (figure 15).
ese sutures keep the inferior taenia under traction during the subsequent
placement of the posterior serosal row of interrupted silk sutures (fig-
ure 16). e traction suture (B) should be within cm of the closed end of
the bowel, since it is undesirable to leave a long blind stump of colon beyond
the site of the anastomosis. A er this, the Pace-Potts clamp is removed. e
margins of the rectal stump are protected by gauze pads to avoid gross spilling and contamination. It is advisable to excise the edge of the rectal stump
if it has been damaged by the clamp. e color of the mucosa and viability
of the rectal stump should be rechecked. Any bleeding points on the edge
of the rectal stump are grasped and ligated with absorbable sutures.
It has been found useful for exposure to insert a traction suture (C) in the
midportion of the anterior wall of the rectum (figure 17). is keeps the
bowel under modest traction and aids in subsequent placement of mucosal
sutures. A noncrushing clamp may be applied across the colon to avoid the
possibility of gross contamination. An incision is made between the traction
sutures (A and B) along the taenia, and the lumen of the proximal bowel
is opened (figure 15). All contamination is removed in both angles of the
openings. e same type of traction suture (C) can be placed in the midportion of the wall of the sigmoid. Interrupted silks are placed full thickness
through the posterior edges of both the descending colon and rectal stump
(figure 16). e knots are tied within the lumen and then cut. is layer
provides absolute full thickness control for the posterior suture row. A
double-ended running absorbable suture is tied in the posterior midline. is proceeds laterally as a running, locking, continuous suture until
each suture line reaches the corner. A Connell inverting suture is then used
as the closure proceeds from both corners to the midline. erea er, an
interrupted row of nonabsorbable sutures are placed in a submucosal
mattress manner for inversion and security of the completed anterior anastomosis (figure 18).
is provides a large stoma. e patency of the stoma is determined by
palpation and the integrity of the anastomosis can be checked by lling the
pelvis with saline and then insu ating the rectum with air using an Asepto
syringe. e appearance of air bubbles signals the needs to reevaluate the
suture line or even in the entire anastomosis.
A er completing the anastomosis, the surgeon should recheck the adequacy of the distal blood supply and be certain that the proximal colon is
not under tension. e hollow of the sacrum is irrigated with saline and the
placement of a closed-system Silastic catheter in this region is optional.
To release tension from the suture line as the bowel becomes dilated in the
early postoperative period, it is useful to anchor some fat pads to the peritoneal re ection in the iliac fossa. is seals o entrance into the pelvis as it
anchors the bowel in this area. Likewise, the free medial edge of the mesentery should be approximated to the right peritoneal margin in order to cover
all raw surfaces. As this peritoneum is closed, the course and location of both
ureters must be identi ed repeatedly to avoid including them in a suture.
ALTERNATE STAPLED TECHNIQUE e Baker’s side-to-end anastomosis
as illustrated is a very safe approach when the surgeon must perform a handsewn anterior or low anterior resection. Most surgeons, however, have access
to and pro ciency with stapling instruments. In these circumstances, the
proximal descending colon is transected with a cutting linear stapler (GIA)
while the rectal stump is divided between a pair of suture lines created with
a noncutting linear stapler (TA) stapling device (figure 19). e rectum is
divided between the staple lines and the specimen removed. e staple line
of the proximal colon is partially resected along the antimesenteric border so
as to create an opening that allows passage of a circular stapler (EEA) anvil,
whose sha will exit through the taenia, approximately cm proximal to this
opening. A purse string is then applied about the anvil sha and tied in a
snug manner (figure 20). e open cut end of the proximal colon is closed
with the noncutting linear stapler. e main circular stapler (EEA) instrument is passed, with its disposable trocar retracted within, until it reaches
the staple line of the rectal stump. Under direct vision, the surgeon guides
the circular stapler (EEA) trocar out through the posterior rectal bowel wall
about ½ cm behind the suture line. A purse string is carefully placed about
the penetrating trocar. e trocar is removed and the anvil inserted into the
circular stapler (EEA) instrument within the rectum. e rectal purse string
is tightened and both purse strings are inspected. e two segments of bowel
are carefully brought together and the instrument is red. e ring and
release require adherence to the manufacturer’s instructions to verify correct
tightness or compression of the tissue before ring and the correct amount
of loosening for the cap to tilt before careful removal. e surgeon veri es
the presence of two intact tissue rings (donuts) containing the purse strings
of both the proximal and distal colon walls. A er inspection of the anastomosis, the air bubble test described above is most useful, as the surgeon cannot always see fully around the anastomosis. An advantage of bringing the
circular stapler (EEA) stapler trocar out posterior to the rectal stump staple
line is that it places the junction of the two staple lines (corners) somewhat
anteriorly, where they may be most easily reinforced with interrupted
nonabsorbable mattress sutures.
CLOSURE e routine closure is performed.
POSTOPERATIVE CARE e Foley catheter is removed in to days,
depending upon how much bladder and presacral dissection was performed. Careful observation of the voiding pattern, volumes, and residual volumes determines successful recovery. e initial liquid diet is
advanced as tolerated. e presacral drain is monitored for output and
blood content. It is usually removed in a few days unless a urine leak is
suspected on the basis of a large output of clear uid with an elevated
urea content. ■
190
191
PLATE
87
INDICATIONS A permanent ileostomy following removal of the colon can
be avoided in selected patients by removing all diseased colon down to the
top of the columns of Morgagni or the pectinate line, followed by construction of an ileal reservoir, with anastomosis of the anal canal (figure 1).
Patients with ulcerative colitis and polyposis are candidates for this procedure, but those with Crohn’s disease are not, because of the potential for
involvement of the small intestine. e patient must have an adequate anal
sphincter by digital examination or, better yet, by manometry. e rectum
should be free of ulcerations, abscesses, stricture, ssures, or stulae. is is
especially important in patients with ulcerative colitis (UC). is procedure
can be considered in patients who are strongly opposed to an ileostomy
and who are available for prolonged close follow-up. e patient should
thoroughly understand the uncertainties of postoperative anal control
and the need to have patience during the early months a er the operation.
e procedure is not recommended for patients older than years and
those who have fecal incontinence. Obesity may make it impossible to perform the anal pouch anastomosis. In patients with Familial Adenomatous
Polyposis (FAP) desmoids tumors involving the small bowel mesentery can
make it di cult to obtain adequate length to reach the anus with the pouch.
All patients should realize that a permanent ileostomy can sometimes be
required due to factors not known until the procedure is underway.
Various surgical procedures have been used in an e ort to improve longterm anal continence. It is questionable whether any procedure currently
used is always completely successful, and the patient should be informed of
this uncertainty. Increasing experience suggests the use of some type of anal
pull-through procedure has a reasonable chance of providing more comfort
than the terminal ileostomy or the ileal abdominal pouch.
A prolonged period of preoperative hyperalimentation or nonalimentation with catabolism may be avoided by a staged procedure, especially in
the presence of toxic megacolon, poor general condition, or rectal disease.
A permanent ileostomy is performed with subtotal colectomy, leaving the
rectum in place, and the superior hemorrhoidal vessels undivided. is also
o ers the chance to review the pathology of the colon to further exclude
Crohn’s disease. A er several months, an ileoanal anastomosis is considered
and a diverting ileostomy is created at the time of the pouch. A er a suitable recovery the temporary ileostomy is closed making this a three-stage
procedure. Various pouches have been advocated. ey include the J pouch
(figure 2, a), the three loop S pouch (figure 2, b), the lateral isoperistaltic
ileal reservoir (figure 2, c), and the four-loop W reservoir (figure 2, d).
PREOPERATIVE PREPARATION Documentation of the pathologic pro-
cess involved is done with biopsies taken from the anal canal as well as the
rectum or colon. e stomach and duodenum are inspected by gastroduodenoscopy. Patients with polyposis and UC patients with high-grade dysplasia should be informed of the potential for malignancy. It is important
to have medical and surgical agreement that surgical removal of the entire
colon is in the best long-term interest of the patient. Time is usually required
for the patient to accept the recommendation and the patient can bene t
from talking with another patient who has undergone this procedure. e
patient’s medications, including steroid therapy for ulcerative colitis, must
be considered, and steroid therapy continued. Intravenous antibiotics are
given before operation, and any major blood volume de cit is corrected.
Patients receive a clear liquid diet for a day or two and an oral bowel preparation the day before.
In severe cases, some prefer a -week period of intense medication to
keep the colon at rest permitting the in ammatory reaction to subside.
I A
Such patients may be placed on total parenteral alimentation, systemic steroids and steroid enemas, and systemic antibiotics when ulcerative colitis
is present. e rectal mucosa is evaluated by sigmoidoscopic examination
immediately prior to the operation. A large rectal tube is placed for irrigation with saline and povidone-iodine antiseptic solution.
ANESTHESIA General endotracheal anesthesia is preferred.
POSITION e patient is placed in the modi ed lithotomy position using
Allen stirrups. is allows the abdominal as well as perineal dissections to
be performed without repositioning of the patient.
OPERATIVE PREPARATION e rectum is given a very limited low-
pressure irrigation, and the perianal skin and buttocks are given the routine
skin preparation. Constant bladder drainage is instituted and a nasogastric
tube is inserted. e pubis and abdominal skin are also prepared in the
routine fashion, and sterile drapes are applied.
INCISION AND EXPOSURE A lower midline incision that extends to the
le of the umbilicus is made, and the abdomen is explored. Particular attention is given to the entire small intestine to make certain there is no evidence of Crohn’s disease, which would contraindicate the operation. e
involvement of the colon with in ammation or polyposis is evaluated. In
the presence of polyposis, the possibility of encountering an unsuspected
site of malignancy or metastases to the liver is ever present. If there is any
question of Crohn’s colitis, the colon is resected and sent to the pathologist
for gross and microscopic veri cation.
DETAILS OF PROCEDURE e colon may be constricted, friable, and
quite vascular, with rm attachments to the omentum. Gentle traction is
applied to avoid tearing the friable bowel with resulting gross contamination. e mesentery of the colon can be divided and blood vessels ligated
relatively near the bowel wall, except in di use polyposis, where there is
always a possibility of metastases to regional lymph nodes. It is judicious to
have the pathologist evaluate the entire specimen as soon as possible.
Before proceeding with the removal of the mucosa from the lower segment and before constructing the ileal reservoir, it is essential that su cient
ileum has been mobilized to construct the pouch. Approximately cm of
terminal ileum is required for the construction of the ileal reservoir. Such
mobilization is accomplished by dividing the ileocolic vessels and the mesentery down to near the arcade of vessels at the very end of the ileum, but none
of the latter is ligated (figure 3). It may be necessary to evaluate the mobility
of the small bowel all the way up to the ligament of Treitz with division of any
bands that tend to limit the mobility of the small intestine (figure 4). Incisions within the posterior peritoneum may be worthwhile to provide added
mobility. Some divide the last ileal arcade (figure 4). e adequacy of the
blood supply involved should be evaluated frequently to be certain a vigorous
blood supply is sustained to the end of the mobilized ileal terminal. e end
of the proposed pouch should reach at least to the pubis, and preferably to the
edge of the Bookwalter ring being used for retraction.
e dissection below the rectosigmoid junction is carried out close
to the bowel wall to avoid damage to the presacral and parasympathetic
nerves. e rectal stump is washed out with povidone-iodine, and the
bowel divided at the anorectal junction. is leaves a stump about to cm
in length (figure 5). Some prefer to have a longer rectal anal stump, which
requires resection of the rectal mucosa from above rather than entirely
through the anus. Others use a stapling instrument for closure of the rectal
stump.
CONTINUES
192
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