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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_602_Библиотеки_им_академика_М_И_Перельмана.pdf
60
L
eft Colectomy for Cancer
0
r
.
D
m
pply
-
p
ne PG or PDS sutures to control any
-
Insertion of Wound Protecto
Insert a Wound Protector ring drape or moist laparotomy pads into the abdominal cavity to protect the
ubcutaneous panniculus from contamination when
e colon is opened
ivision of Colon and Rectu
Expose the point on the proximal colon selected for
ivision. Apply an Allen clamp to the specimen side.
Fig. 4–1
Divide the colon after a
f nontraumatic clamp to avoid contamination. Com
letely clear the areolar tissue and fat from the distal
entimeter of the proximal colon so the serosa is
xposed throughout its circumference. Handle the
istal end of the specimen in the same manner by
applying an Allen clamp to the specimen side. Now
ivide the upper rectum and remove the specimen.
uction the rectum free of any contents. Apply no
bleeding from the rectal wall. Completely clear sur
ing a Doyen or other type
ounding fat and areolar tissue from a cuff of rectum
d
Check the
both ends of the bowel. Confi
.
-
fi
cantly narrower than the
Insert the fi
rst layer of seromuscular sutures
cient
.
rst to the lateral border
U
fi
rst two (Fig. 4–11). Each stitch takes
and cut all
ail
ostats
h
)
–
1
2
Op
6
cm in width so seromuscular sutures may be
nserted accurately.
End-to-End Two-Layer Anastomosis,
Rotation Metho
There are eight steps to the end-to-end two-layer
anastomosis, rotation method.
1.
east
cm of serosa has been cleared to the areolar
issue and blood vessels at both ends of the bowel
. Rotate the proximal colonic segment so the
mesentery enters from the right lateral margin of the
anastomosis. Leave the rectal segment undisturbed
(Fig. 4 –11).
3. If the diameter of the lumen of one of the seg
ments of bowel is signi
ther, make a Cheatle slit 1–2 cm long, on the
antimesenteric border of the narrower segment of
bowel (see Figs. 2–10, 2–11).
dequacy of the blood supply
rm that a
cuff of at
f
erative Technique
1
Fig. 4–1
Fig. 4–1
4.
.
f the rectal stump is not bound to the sacrum and if
rst
step of the anastomosis
5. Insert interrupted 4-0 silk atraumatic Lembert
of the anastomosis and then to the medial border.
sing the technique of successive bisection, place
the third Lembert suture on the anterior wall halfway
between the
about 5 mm of tissue (including the submucosa) from
the rectum and then from the descending colon.
. After all the anterior sutures have been inserted,
tie them
the suture t
s
xcept for those
of the two end guy sutures, which should be grasped
n hem
Fig. 4 –12). Pass a hemostat under-
neath the suture line, grasp the right lateral stitc
(Fig. 4 –13, A), and rotate the anastomosis 180°
(Fig. 4 –14
. Place a double-armed 5-0 Vicryl or PG suture
he middle of the deep mucosal layer (Fig.
5a). Complete this layer with a continuous locked
suture through the full thickness of the bowel
(Fig. 4 –15b)
Then, with the same two needles and
62
L
eft Colectomy for Cancer
Fig
F
4
4
-
p
fi
nal seromuscular layer
p
A
e
ig. 4–15a
. 4–13
–15b
Fig.
using a continuous Connell or Cushing suture, com
lete the remainder of the mucosal approximation
(Fig. 4 –16)
8. Approximate the
with interrupted 4-0 atraumatic Lembert silk sutures
(Fig. 4 –17). After all the suture tails are cut, permit
e anastomosis to rotate back 180° to its normal
osition.
End-to-End Anastomosis,
lternative Techniqu
When the rectum and colon cannot be rotated 180°
ig. 4–1
as required for the method described above, an alter-
-
rst. To do this,
A
6
7
8
9
Op
erative Technique
63
Fig. 4–1
native technique must be used in which the poste
nsert a seromuscular suture of 4-0 silk into the left
side of the rectum and the proximal colon. Do not
ie this suture; grasp it in a hemostat and use it as the
left guy suture. Place a second, identical suture
on the right lateral aspects of the rectum and proximal colon and similarly hold it in a hemostat
(Fig. 4 –18).
Insert interrupted 4-0 silk seromuscular Lembert
sutures (Fig. 4 –19) to complete the posterior layer
by successive bisection. As each suture is inserted,
attach it to a hemostat until the layer is completed.
t the conclusion of the layer, tie all the sutures and
Fig. 4–1
Fig. 4–1
Fig. 4–1
64
L
eft Colectomy for Cancer
F
Fig
p
,
p
h
-
)
-
-
ig. 4–22
ig. 4–20
ut all the tails except for those of the two lateral
guy sutures. Begin the posterior mucosal layer with
double-armed atraumatic suture of 5-0 Vicryl. Insert
e suture in mattress fashion in the midpoint of the
osterior layer of mucosa and tie it
Fig. –20). Use
ne needle to initiate a continuous locked suture
aking bites averaging 5 mm in diameter and going
hrough all coats of bowel
Fig.
–21). Continue this
in a locked fashion until the left lateral margin of the
nastomosis is reached (Fig.
–22). At this point
ass the needle from the inside to the outside of the
ectum and hold it temporarily in a
Grasp the remaining needle and insert a continu
us locked suture of the same type, beginning at the
midpoint and continuing to the right lateral margin
f the bowel. Here, pass the needle through the
ectum from inside out (Fig. 4 –23
tanding on the left side of the patient, use the
needle on the right lateral aspect of the anastomosis
o initiate the anterior mucosal layer. Insert con
inuous sutures of either the Cushing or Connell
ype to a point just beyond the middle of the ante
ior layer. Then grasp the needle emerging from the
left lateral margin of the incision and insert a similar
. 4–21
ig. 4–23
Fig. 4–2
4
5
)
-
lumen gently with the thumb and forefi
6
To construct a stapled colorectal anastomosis, fi
pply
fl
ush with the stapler. Remove the stapler
-
-
U
b
w
pp
Op
65
continuous Connell or Cushing stitch. Complete
e anterior mucosal layer by tying the suture to its
mate and cutting the tails of these sutures (Fig.
–24,
–25
Complete the anterior seromuscular layer by
nserting interrupted 4-0 silk atraumatic Lembert
sutures
Fig. 4 –26) Now carefully rotate the anas
omosis to inspect the integrity of the posterior layer.
Test the diameter of the lumen before closing the
mesentery by invaginating the colon through the
nger. Then
close the mesentery with continuous 2-0 PG sutures
(Fig. 4 –27) Leave the peritoneal defect in the left
paracolic gutter unsutured.
Fig. 4–2
erative Technique
Fig. 4–2
Stapled Colorectal Anastomosis
rst
close the proximal descending colon with a
5/3.5 mm linear stapling device
n Allen clamp to the specimen side and divide the
lon
Fig. 4 –29) and replace the Allen clamp with an
umbilical tape ligature covered with a sterile rubber
glove
Figs. 4 –30, 4 –31). Alternatively, divide the
colon with a cutting linear stapler. Then direct atten
tion to the rectum, a segment of which was previ
ously cleared of surrounding fat and vascular tissue.
se the 55/3.5 mm linear stapling device (Fig. 4–28)
to apply a layer of staples to this segment of rectum.
o not remove the specimen; retain it so mild upward
traction on it can stabilize the rectum during application of the stapling device (Fig. 4–29).
Make a stab wound on the antimesenteric border
of the proximal colon at a point 5–6 cm proximal to
the staple line. A scalpel blade or electrocautery may
e used to make this incision. Make a second stab
ound in the anterior wall of the rectal stump at a
point 1 cm distal to the staple line already in place
Fig. 4 –32)
osite each other, placing the proximal colonic
o
Approximate the two stab wounds
segment anterior to the rectal stump. Insert the
linear cutting stapling device, with one fork in the
rectal stump and the other in the proximal colonic
Fig. 4 –28). A
66
L
eft Colectomy for Cancer
ig. 4–27
8
Op
erative Technique
6
7
Fig. 4–2
68
L
eft Colectomy for Cancer
ig. 4–29
0
1
2
Op
erative Technique
69
Fig. 4–3
Fig. 4–3
Fig. 4–3