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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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L
aparoscopic Abdominoperineal Resection and Total Proctocolectomy with End Ileostomy
ig. 8–3
ig. 8–4
Op
erative Technique
141
5
Fig. 8–
1
42
L
6
aparoscopic Abdominoperineal Resection and Total Proctocolectomy with End Ileostomy
ig. 8–
Op
erative Technique
143
7
TOT
OCTOCOLECTO
Y
IN
with
m
N
.
S
.
E
t
T
-
T
b
A
Fig. 8–
AL PR
MY WITH
END ILEOSTOM
DICATIONS
Crohn’s disease of the rectu
PREOPERATIVE PREPARATIO
The preoperative preparation is the same as for
abdominoperineal resection
PITFALLS AND DANGER POINT
Pitfalls are similar to those for abdominoperineal
esection. In addition, duodenal injury may occur
during right colon mobilization
OPERATIVE TECHNIQU
Room Setup and Trocar Placemen
he room is set up in a similar fashion as for abdomi
noperineal resection. After insertion of the camera
port, four additional ports are generally required for
the procedure, two on each on the left and right side
Fig. 8 – 8) Similar to abdominoperineal resection, the
lower ports should be placed at the proposed ileostomy and potential drain sites. The position of surgical
team varies according to localization of the dissection.
he surgeon stands on the opposite side of the colon
eing mobilized or between the patient’s legs.
fter placement of the ports, the small bowel is
careful examined for evidence of Crohn’s disease
using two laparoscopic Babcock clamps. Dissection
can start from any segment of the colon. Some sur-
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L
F
f
cult retraction of these
W
l
Toldt, extending towards the hepatic fl
m
followed by mobilization of the splenic fl
h
j
v
p
-
aparoscopic Abdominoperineal Resection and Total Proctocolectomy with End Ileostomy
ig. 8–8a
geons prefer to mobilize the sigmoid and rectum as
ar as possible prior to the ascending, transverse, and
tructures from the pelvis once they are mobilized.
e usually start the dissection from the ileocecal
valve and ascending colon as in the open procedure.
The colon is retracted toward the midline and the
ateral peritoneum is divided along the white line of
exure. During
obilization, the spermatic vessels, the right ureter
edFig. 8 –9). The left
cation of the left ureter
exure wit
ivision of the phrenocolic, splenocolic and reno-
olic ligaments
Fig. 8 –10). The transverse colon is
en separated from the greater omentum by either
ividing the avascular plane along the omentocolic
unction or, alternatively, by transecting the omentum
Fig. 8 –11). At this point, if the procedure is contin-
ued totally laparoscopically, the rectum is dissected
as described for abdominoperineal resection and the
essels are ligated intracorporeally. After the terminal
leum is divided with an endoscopic linear cutter, the
ntire specimen is then extracted through a standard
erineal wound. Unlike peripheral excision for malig
nancy, the proctectomy is performed in an intersphincteric plane. The ileum is divided externally and
e remainder of the operation proceeds as described
Op
erative Technique
145
b
ig. 8–8
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6
L
9
aparoscopic Abdominoperineal Resection and Total Proctocolectomy with End Ileostomy
ig. 8–
Op
erative Technique
1
10
47
Fig. 8–
1
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L
11
aparoscopic Abdominoperineal Resection and Total Proctocolectomy with End Ileostomy
ig. 8–
Postoperative Care 149
for abdominoperineal resection. Alternatively, once
the colon has been mobilized, a small Pfannenstiel
incision is performed and rectal dissection is completed as in the open procedure. The colon is
exteriorized and the ileum and mesenteric vessels are
extracorporeally divided.
COMPLICATIONS
Stoma-related complications (retraction, stenosis,
prolapse, dehydration)
Postoperative small bowel obstruction
Nonhealing perineal wound
POSTOPERATIVE CARE
Postoperatively, the nasogastric tube is removed in
the operating room. A clear liquid diet is initiated
immediately after surgery, as tolerated, and advanced
to a regular diet once there is passage of fl atus or
bowel movement through the stoma. Patients can
often be discharged home after 3 to 4 days.