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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_602_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Preface
- •Ulcerative Colitis
- •Indeterminate Colitis
- •Polyps
- •MALIGNANT CONDITIONS
- •Colorectal Cancer
- •Extent of Resection
- •Colorectal Cancer with Synchronous Pathology
- •Synchronous Benign or Premalignant Conditions
- •Contributors
- •BENIGN CONDITIONS
- •Diverticular Disease
- •Volvulus
- •Ischemic Colitis
- •Rectal Prolapse
- •Familial Polyposis and Hereditary Colon Cancer Syndromes
- •Crohn’s Colitis
- •Synchronous Cancer
- •Preoperative Evaluation
- •Neoadjuvant Therapy for Rectal Adenocarcinoma
- •Squamous Carcinoma of the Anus
- •Surgical Approach and Strategy
- •Strategies for Complex Situations
- •Primary Anastomosis versus Staged Procedures
- •Technical Factors for Safe Anastomosis
- •Other Factors Affecting Anastomotic Healing
- •Technical Considerations and Adjuncts
- •INTESTINAL POUCH RESERVOIRS
- •INTESTINAL STOMAS
- •POSTOPERATIVE CARE
- •Management of Altered Sphincter Function
- •Urogenital Function
- •CANCER SURVEILLANCE
- •POUCH SURVEILLANCE
- •REFERENCES
- •2 Right Colectomy for Cancer
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE (Right and Transverse Colectomy)
- •Division of Ileum and Colon
- •Ileocolic Two-Layer Sutured End-to-End Anastomosis
- •COMPLICATIONS
- •REFERENCES
- •3 Laparoscopic Right Hemicolectomy
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Mobilization of the Hepatic Flexure
- •4 Left Colectomy for Cancer
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Extent of Dissection
- •Liberation of Splenic Flexure
- •No-Touch Technique
- •Technique of Anastomosis
- •OPERATIVE TECHNIQUE
- •Incision and Exposure
- •Liberation of Descending Colon and Sigmoid
- •Division of Renocolic Ligament
- •Ligation and Division of Mesorectum
- •Stapled Colorectal Anastomosis
- •Closure
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCES
- •5 Laparoscopic Left Hemicolectomy
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •Mechanical Bowel Preparation
- •Administration of Prophylactic Antibiotics
- •Other Perioperative Steps
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Room Setup and Patient Positioning
- •Exteriorization of the Left Colon
- •Performing the Anastomosis
- •Closure of the Wound
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Prevention of Anastomotic Complications
- •Which Colorectal Anastomosis: Sutured, Circular Stapled, or Double Stapled?
- •Extent of Lymphovascular Dissection
- •Indications for Complementary Colostomy or Loop Ileostomy
- •Presacral Dissection: Prevention of Hemorrhage
- •Presacral Dissection: Preservation of Hypogastric Nerves
- •Ureteral Dissection
- •Incision and Position
- •Presacral Dissection
- •Pelvic Hemostasis
- •Mobilization of Proximal Colon
- •Selection of Anastomotic Technique
- •Wound Closure and Drainage
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCES
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Abdominal Phase
- •Colostomy
- •Pelvic Floor
- •Perineal Phase
- •Position
- •Closure of Perineum
- •Dissection of Perineum
- •Hemostasis
- •OPERATIVE TECHNIQUE
- •Position
- •Incision and Exploration: Operability
- •Mobilization of Sigmoid, Lymphovascular Dissection, and Presacral Dissection
- •POSTOPERATIVE CARE
- •Perineal Care
- •Colostomy Care
- •COMPLICATIONS
- •REFERENCES
- •ABDOMINOPERINEAL RESECTION
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE TECHNIQUE
- •Room Setup and Trocar Placement
- •Exploration of the Abdominal Cavity
- •Mobilization of the Sigmoid/Rectosigmoid Colon
- •Division of the Inferior Mesenteric Vessels
- •Division of the Sigmoid/Descending Colon
- •Rectal Mobilization
- •Perineal Dissection and Specimen Removal
- •COMPLICATIONS
- •POSTOPERATIVE CARE
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Placement of Ileostomy
- •Operative Position
- •Incision
- •Dissection of Left Colon
- •Division of Mesocolon
- •Needle-Catheter Jejunostomy
- •Closure of the Abdominal Incision
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCES
- •INDICATIONS
- •CONTRAINDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Mucosectomy
- •Abdominal Dissection
- •Rectal Dissection
- •Division of Waldeyer’s Fascia
- •Temporary Loop Ileostomy and Ileostomy Closure
- •Ileoanostomy
- •Constructing the Ileal Reservoir
- •OPERATIVE TECHNIQUE
- •Mucosal Proctectomy Combined with Total Colectomy
- •Perineal Approach
- •Constructing the Ileal Reservoir
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCES
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Abdominal Incision and Position
- •Closure of Pelvic Floor
- •POSTOPERATIVE CARE
- •12 End-Ileostomy
- •INDICATIONS
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Preoperative Selection of Ileostomy Site
- •Incision
- •Fashioning the Ileal Mesentery
- •Mucocutaneous Fixation of Ileostomy
- •13 Loop Ileostomy
- •INDICATIONS
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCES
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Skin-Sutured Cecostomy
- •Incision
- •Exploration of Cecum
- •Cecal Fixation
- •Mucocutaneous Suture
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCE
- •15 Transverse Colostomy
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Impending Rupture of Cecum
- •Diversion of Fecal Stream
- •OPERATIVE TECHNIQUE
- •Incision
- •REFERENCES
- •16 Closure of Temporary Colostomy
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Incision
- •Fascial Dissection
- •Closure of Colon Defect by Suture
- •Closure of Colonic Defect by Staples
- •Management of Skin Wound
- •REFERENCES
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Loop Ileostomy
- •Room Setup and Trocar Placement
- •Room Setup and Trocar Placement
- •Testing the Anastomosis
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •General Complications
- •Complications Related to Stoma Construction
- •Complication Related to Stoma Closure
- •REFERENCES
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Primary Resection and Anastomosis
- •Incision
- •Liberation of Sigmoid and Left Colon
- •Anastomosis
- •Abdominal Closure
- •Operative Technique
- •REFERENCES
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Incision
- •Presacral Dissection
- •Closure of Pelvic Peritoneum
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCES
- •CLINICAL CONDITIONS: SYMPTOMS AND MANAGEMENT CONCEPTS
- •REFERENCES
- •INDICATIONS
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •COMPLICATIONS
- •REFERENCES
- •22 Hemorrhoidectomy
- •INDICATIONS
- •CONTRAINDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Avoiding Anal Stenosis
- •Achieving Hemostasis
- •Intravenous Fluids
- •Positioning the Patient
- •Incision and Dissection
- •Radical Open Hemorrhoidectomy
- •Incision
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Choice of Anesthesia
- •Localizing Fistulous Tracts
- •Goodsall’s Rule
- •Physical Examination
- •Injection of Dye or Radiopaque Material
- •Preserving Fecal Continence
- •Fistulotomy Versus Fistulectomy
- •Combining Fistulotomy with Drainage of Anorectal Abscess
- •OPERATIVE TECHNIQUE
- •Anorectal and Pelvirectal Abscesses
- •Perianal Abscess
- •Ischiorectal Abscess
- •Intersphincteric Abscess
- •Pelvirectal Supralevator Abscess
- •Suprasphincteric Fistula (Extremely Rare)
- •Extrasphincteric Fistula (Extremely Rare)
- •Technical Hints for Performing Fistulotomy
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCES
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Anesthesia
- •Closed Sphincterotomy
- •Open Sphincterotomy
- •REFERENCES
- •25 Anoplasty for Anal Stenosis
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •OPERATIVE TECHNIQUE
- •Sliding Mucosal Flap
- •Incision
- •Internal Sphincterotomy
- •Advancing the Mucosa
- •Sliding Anoderm Flap
- •Incision
- •REFERENCE
- •INDICATIONS
- •PREOPERATIVE PREPARATION
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Selecting Proper Suture or Banding Material
- •Achieving Proper Tension of the Encircling Band
- •OPERATIVE TECHNIQUE
- •Fabricating the Encircling Band of Mesh
- •Incision and Position
- •Inserting the Mesh Band
- •Adjusting Tension
- •POSTOPERATIVE CARE
- •COMPLICATIONS
- •REFERENCES
- •27 Operations for Pilonidal Disease
- •INDICATIONS
- •PITFALLS AND DANGER POINTS
- •OPERATIVE STRATEGY
- •Acute Pilonidal Abscess
- •Marsupialization
- •Excision with Primary Suture
- •OPERATIVE TECHNIQUE
- •Pilonidal Excision with Primary Suture
- •REFERENCES
- •Index


Chassin’s Operative Strategy
in Colon and Rectal Surgery

Carol E.H. Scott-Conner, MD, PhD
Professor of Surgery
University of Iowa Carver College of Medicine
Iowa City, Iowa
Editor
Chassin’s Operative
Strategy in Colon
and Rectal Surgery
Illustrations by Casper Henselmann

Carol E.H. Scott-Conner, MD, PhD
Professor of Surgery
University of Iowa Carver College of Medicine
Iowa City, IA 52242
USA
Library of Congress Control Number: 2006930265
ISBN-10: 0-387-33043-7
ISBN-13: 978-0387-33043-3
Printed on acid-free paper.
© 2006 Springer Science+Business Media, LLC
Reprinted from Carol E.H. Scott-Conner: Chassin’s Operative Strategy in General Surgery, third edition, copyright
2002 Springer Science+Business Media, LLC.
All rights reserved. This work may not be translated or copied in whole or in part without the written permission
of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except
for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now
known or hereafter developed is forbidden.
The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not
identifi ed as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.
While the advice and information in this book are believed to be true and accurate at the date of going to press,
neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material
contained herein.
Printed in the United States of America. (BS/MVY)
9 8 7 6 5 4 3 2 1
springer.com

To Harry
Carol E.H. Scott-Conner

To Charlotte
Jameson L. Chassin

More than half of the fi rst volume of Chassin’s Operative Strategy in General
Surgery, introduced in 1980, was devoted to surgery of the small and large
intestine and anorectum. This unusually rich and detailed coverage was
maintained and even expanded in subsequent editions. The “big” Chassin’s
has become an invaluable resource for the surgical community.
In recent years, colorectal surgery has become a specialty unto itself,
practiced by both colorectal and general surgeons. This volume, Chassin’s
Operative Strategy in Colon and Rectal Surgery, seek to provide the gold
standard content of the large volume with the focus and specifi city needed
by colorectal surgeons. Practiced clinicians, fellows, and residents will all
fi nd valuable clinical guidance in these chapters.
Colorectal surgery is a rapidly-evolving surgical fi eld. Since the last edition
of the full volume of Chassin’s, laparoscopic colon surgery has become the
new standard of care for many patients. Thus, we have added four new,
previously unpublished chapters to this new volume:
• laparoscopic right hemicolectomy
• laparoscopic left hemicolectomy
• laparoscopic abdominoperineal resection and total proctocolectomy
with end ileostomy
• laparoscopic stoma construction and closure
Preface
Written by Steven D. Wexner, these new chapters provide the reader with
the latest techniques in colorectal surgery. In addition to the clear, comprehensive text, these new chapters are enhanced by 52 lavish new illustrations
by Caspar Henselmann, the skilled artist whose work has illuminated every
edition of this text.
It is our hope that the reader will fi nd Chassin’s Operative Strategy in
Colon and Rectal Surgery a useful distillation of the best of the “old” and
the “new” strategies and techniques in colorectal surgery.
Carol E.H. Scott-Conner, MD, PhD
ix

Contents
Preface ix
Contributors xv
Part I
Large Intestine
1
Concepts in Surgery of the Large
Intestine 3
Danny M. Takanishi and Fabrizio Michelassi
Benign Conditions 3
Malignant Conditions 9
Intestinal Pouch Reservoirs 17
Intestinal Stomas 17
Postoperative Care 19
Cancer Surveillance 20
Pouch Surveillance 20
References 21
2
Right Colectomy for Cancer 25
Indications 25
Preoperative Preparation 25
Pitfalls and Danger Points 25
Operative Strategy 25
Operative Technique (Right and Transverse Colectomy) 29
Postoperative Care 37
Complications 41
References 41
3
Laparoscopic Right Hemicolectomy 42
Steven D. Wexner and Susan M. Cera
Indications 42
Preoperative Preparation 42
Pitfalls and Danger Points 42
Operative Strategy 42
Operative Technique 43
Postoperative Care 49
Complications 49
References 49
4
Left Colectomy for Cancer 50
Indications 50
Preoperative Preparation 50
Pitfalls and Danger Points 50
Operative Strategy 50
Operative Technique 53
Postoperative Care 73
Complications 73
References 73
5
Laparoscopic Left Hemicolectomy 74
Steven D. Wexner
Indications 74
Preoperative Preparation 74
Pitfalls and Danger Points 74
Operative Strategy 74
Operative Technique 74
Postoperative Care 85
Complications 85
References 85
6
Low Anterior Resection for Rectal Cancer 86
Indications 86
Preoperative Preparation 86
Pitfalls and Danger Points 86
Operative Strategy 86
Operative Technique 91
Postoperative Care 117
Complications 117
References 118
7
Abdominoperineal Resection for Rectal
Cancer 119
Indications 119
Preoperative Preparation 119
Pitfalls and Danger Points 119
Operative Strategy 119
xi

xii Contents
Operative Technique 121
Postoperative Care 134
Complications 134
References 135
8
Laparoscopic Abdominoperineal
Resection and Total Proctocolectomy
with End Ileostomy 136
Steven D. Wexner and Giovanna M. DaSilva
Abdominoperineal Resection 136
Indications 136
Preoperative Preparation 136
Pitfalls and Danger Points 136
Operative Technique 136
Total Proctocolectomy with End Ileostomy 143
Indications 143
Preoperative Preparation 143
Pitfalls and Danger Points 143
Operative Technique 143
Complications 149
Postoperative Care 149
9
Subtotal Colectomy with Ileoproctostomy
or Ileostomy and Sigmoid Mucous
Fistula 150
Indications 150
Preoperative Preparation 150
Pitfalls and Danger Points 150
Operative Strategy 150
Operative Technique 150
Postoperative Care 158
Complications 158
References 158
10
Ileoanal Anastomosis with Ileal Reservoir
Following Total Colectomy and
Mucosal Proctectomy 159
Indications 159
Contraindications 159
Preoperative Preparation 159
Pitfalls and Danger Points 159
Operative Strategy 159
Operative Technique 161
Postoperative Care 169
Complications 169
References 169
11
Abdominoperineal Proctectomy for
Benign Disease 170
Indications 170
Preoperative Preparation 170
Pitfalls and Danger Points 170
Operative Strategy 170
Operative Technique 170
Postoperative Care 174
Complications 174
References 174
12
End-Ileostomy 175
Indications 175
Pitfalls and Danger Points 175
Operative Strategy 175
Operative Technique 175
Postoperative Care 179
Complications 179
Reference 179
13
Loop Ileostomy 180
Indications 180
Pitfalls and Danger Points 180
Operative Strategy 180
Operative Technique 180
Postoperative Care 182
Complications 182
References 182
14
Cecostomy: Surgical Legacy Technique 183
Indications 183
Preoperative Preparation 183
Pitfalls and Danger Points 183
Operative Strategy 183
Operative Technique 183
Postoperative Care 185
Complications 185
Reference 185
15
Transverse Colostomy 186
Indications 186
Preoperative Preparation 186
Pitfalls and Danger Points 186
Operative Strategy 186

Contents xiii
Operative Technique 186
Postoperative Care 188
Complications 188
References 189
16
Closure of Temporary Colostomy 190
Indications 190
Preoperative Preparation 190
Pitfalls and Danger Points 190
Operative Strategy 190
Operative Technique 190
Postoperative Care 194
Complications 194
References 194
17
Laparoscopic Stoma Construction and
Closure 195
Dan Enger Ruiz and Steven D. Wexner
Indications 195
Preoperative Preparation 195
Pitfalls and Danger Points 195
Operative Strategy 195
Operative Technique 195
Postoperative Care 211
Complications 211
References 211
Complications 222
References 222
Part II
Anus, Rectum, and Pilonidal Region
20
Concepts in Surgery of the Anus,
Rectum, and Pilonidal Region 225
Amanda M. Metcalf
Clinical Conditions: Symptoms and Management
Concepts 230
References 231
21
Rubber Band Ligation of Internal
Hemorrhoids 232
Indications 232
Pitfalls and Danger Points 232
Operative Strategy 232
Operative Technique 232
Postoperative Care 233
Complications 234
References 234
22
18
Operations for Colonic Diverticulitis
(Including Lower Gastrointestinal
Bleeding) 212
Indications 212
Preoperative Preparation 212
Operative Strategy 212
Operative Technique 212
References 216
19
Ripstein Operation for Rectal Prolapse 217
Indications 217
Preoperative Preparation 217
Pitfalls and Danger Points 217
Operative Strategy 217
Operative Technique 217
Postoperative Care 222
Hemorrhoidectomy 235
Indications 235
Contraindications 235
Preoperative Preparation 235
Pitfalls and Danger Points 235
Operative Strategy 235
Operative Technique 236
Postoperative Care 243
Complications 243
References 243
23
Anorectal Fistula and Pelvirectal Abscess 244
Indications 244
Preoperative Preparation 244
Pitfalls and Danger Points 244
Operative Strategy 244
Operative Technique 246
Postoperative Care 254
Complications 254
References 255
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