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The appendix 255
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• Gynaecological emergencies in female patients.
The chest.
•
•
The central nervous system.
Gastrointestinal disease
The following commonly simulate appendicitis.
•
Non- specific mesenteric adenitis, particularly in
young children, following upper respiratory tract
infection. This may cothe diagnosis may be confirmed at the time of
appendicectomy.
Meckel’s diverticulitis, often indistinguishable
•
from appendicitis; the presence of an inflamed
Meckel’s diverticulum (see Chapter 25) should
always be excluded if the appendix is normal at
surgery.
•
Acute Crohn’s ileitis (see Chapter25) affects young
adults, usually with a long history of recurrent
pain.
Non- Crohn’s terminal ileitis due to yersinia
•
enterocolitica.
•
Intestinal obstruction, with colicky pain and
vomiting. Closed loop large bowel obstruction,
where there is a distal obstruction and the
ileocaecal valve is competent, results in the
colon and caecum distending. Where there is
impending caecal perforation there will be RIF
pain and tenderness.
• Gastroenteritis, with diarrhoea and vomiting but
more diffuse and less severe tenderness. Vomiting
usually precedes any colic.
•
Acute colonic diverticulitis usually affects the left
colon but may give RIF pain if the sigmoid colon is
sufficiently mobile, or if there is inflammation of a
solitary caecal diverticulum lying in the RIF. The
age group differs from the usually younger patient
with appendicitis.
• Caecal cancer may present with a mass and a his-
tory of RIF discomfort/pain for a few weeks/
months.
• Perforated peptic ulcer, normally a sudden onset
pain. RIF pain may occur as fluid tracks down the
right paracolic gutter.
•
Acute cholecystitis, in which the initial colicky pain
is foregut pain, experienced in the epigastrium. A
distended, inflamed gallbladder may descend to
the RIF.
• Pancreatitis, a central pain with central and some-
times RIF tenderness, diagnosed by a raised serum
amylase concentration.
exist with appendicitis, so
The urogenital tract
• Testicular torsion may occasionally present with
periumbilical pain and vomiting. It is mandatory
to examine the testes of all boys and young adults
with abdominal pain, to exclude both torsion and
maldescent (see Chapter48).
• Ureteric colic. The urine must be tested for blood
and pus cells in every case of acute abdominal
pain. The patient with ureteric colic is usually restless and moving about, with pain radiating from
loin to groin.
• Acute pyelonephritis. Typically associated with a
history of dysuria, loin tenderness and a high fever
(39 °C) with rigors. Note that an inflamed appendix adherent to the ureter or bladder may produce
dysuria and microscopic haematuria or pyuria.
Gynaecological emergencies
The most common gynaecological pitfalls are acute
salpingitis, ectopic pregnancy and ruptured cyst of
the corpus luteum.
•
A ruptured or torted ovarian cyst presents with
sudden severe RIF pain radiating to the loin. An
urgent pelvic ultrasound may reveal the diagnosis,
or it may be confirmed at laparoscopy.
• Pelvic inflammatory disease is a range of diseases
including acute salpingitis, endometritis and
tubo-
ovarian abscess. It is a more diffuse, bilateral, lower abdominal pain, usually accompanied
by a vaginal discharge with a history of dyspareunia and dysmenorrhoea.
• A ruptured ectopic pregnancy may present with
colicky RIF pain if the pregnancy is in the right fallopian tube, with peritonitis and shoulder tip pain
when it ruptures due to free blood irritating the
diaphragm. Diagnosis is suggested by a positive
pregnancy test.
Neurological causes
The pain preceding the eruption of herpes zoster affecting the 11th and 12th dorsal segments, the irritation of
these posterior nerve roots in spinal disease (invasive
tumour or tuberculosis) and the lightning pains of tabes
dorsalis all occasionally mimic appendicitis.
The chest
Basal pneumonia and pleurisy may give referred
abdominal pain, which may be surprisingly difficult
256 The appendix
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to differentiate, especially in children. Auscultation
may reveal a rub, and chest Xpneumonia.
ray may demonstrate
Management ofacute appendicitis
When the patient is diagnosed with acute appendicitis, a broadshould be commenced.
spectrum antibiotic, such as co- amoxiclav,
Appendicectomy
The mainstay of treatment of acute appendicitis is surgery and, therefore, appendicectomy should be offered
to the patient. Appendicitis when perforated and
complicated after delayed diagnosis leads to peritonitis, sepsis and ultimately death. Laparoscopic appendicectomy has become the surgical standard. Compared
to the open technique, it is associated with less postoperative pain, faster recovery and lower incidence of
wound infections and intra- abdominal abscesses.
Laparoscopic appendicectomy is particularly
in obese patients and in young females. For the obese
patient, laparoscopic surgery may provide much better
views of the peritoneal cavity, in order to perform the
procedure as well as washout of any collection of pus,
compared with open surgery where the operation may
be technically challenging or result in a larger wound
(with the subsequent increased risk of wound infection)
due to the obesity. For women, laparoscopy may also be
diagnostic allowing examination of the ovaries and
the pelvis in order to exclude other causes of RIF pain
while avoiding the radiation risks of CT.
beneficial
Conservative treatment
Conservative management with antibiotics may be
considered in selected patients who present with
uncomplicated acute appendicitis and an operative
approach is best avoided or postponed, such as in the
presence of severe comorbidities or active SARSCoV- 2 infection, where a general anaesthetic would
pose a significant risk of death. Following this strategy, around a quarter of patients would need an
appendicectomy within a year.
Appendiceal abscess
Some patients may present late having had ongoing
pain in the RIF for 5–7days. In these cases, the appendix may have perforated already forming a
peri- appendiceal abscess walled off by omentum
and/or small bowel. Crossconfirm the diagnosis and assess the potential for
percutaneous drainage of the abscess. Nutritional
support may be needed with parenteral nutrition if
the patient has ileus, and intravenous antibiotics are
given following microbiology advice.
Radiological drainage is the best treatment to control infection. Surgery on the phlegmonous tissue is
not generally indicated due to the risk of bowel injury
resulting in enterocutaneous fistula or postoperative
intra-
abdominal sepsis, as well as the risk of more
extensive surgery such as a limited right hemicolectomy because of the unhealthy inflamed appendix
stump. If the appendix abscess is not amenable to
radiological drainage and antibiotics do not work,
surgery is the only option for drainage.
sectional imaging will
Appendix mass (Box26.2)
An appendix mass may form when the omentum and
adjacent viscera wall off the inflamed appendix and
no abscess forms. The patient may be well
Box 26.2 A mass inthe right iliac fossa (RIF)
The causes of a mass in the RIF are best thought of
by considering the possible anatomical structures in
this region.
•
Appendix abscess or appendix mass.
•
Carcinoma of caecum: differentiated from the
above by usually an older age group, a longer
history, often the presence of diarrhoea, anaemia
with positive occult blood and finally the barium
enema examination.
•
Crohn’s disease: always to be thought of when there
is a local mass in a young patient with diarrhoea.
•
A distended gallbladder, which may extend down
as far as the RIF.
•
Pelvic kidney (or renal transplant).
•
Ovarian or tubal mass.
•
Aneurysm of the common, internal or external iliac
artery.
•
Retroperitoneal tumour arising in the soft tissues
or lymph nodes of the posterior abdominal wall or
from the pelvis.
•
Ileocaecal tuberculosis (rare in the UK, common in
India).
•
Psoas abscess– now rare.
The appendix 257
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systemically but may have tenderness in the RIF with
a palpable mass. An appendix mass is also best managed conservatively with antibiotics as an operation
poses similar risks to those described for an appendix
abscess.
Interval appendicectomy
Following conservative management of an appendix abscess or mass, interval crosswill confirm resolution and exclude the presence of
an underlying neoplasm. An interval colonoscopy
may be undertaken to ensure the appendix orifice is
visualized endoscopically and no underlying neoplasm or other pathology (e.g. Crohn’s disease) is
identified. Recurrent abdominal pain, the risk of
recurrent appendicitis and the potential risk of an
underlying appendix neoplasm (see below) warrant
discussion of an elective interval laparoscopic
appendicectomy.
sectional imaging
Appendiceal neoplasms
Appendiceal neoplasms are not uncommon. There
are four broad categories of invasive neoplasm that
can potentially spread beyond the appendix:
Neuroendocrine neoplasms (NEN).
•
Mucinous neoplasms.
•
• Goblet cell adenocarcinomas.
•
Non- mucinous adenocarcinomas.
There are also noncolon, can be precursors of invasive tumours: sessile
serrated lesion and adenoma.
Appendiceal neuroendocrine
neoplasms
Appendiceal NENs (previously known as ‘carcinoids’)
comprise between 30 and 80% of all appendiceal neoplasms and are found, usually incidentally, in around
1% of appendicectomy specimens. Rarely, appendiceal NENs with extensive local disease and/or distant
metastases present with abdominal pain, bowel
obstruction, a mass in the RIF or symptoms consistent with carcinoid syndrome.
NENs arise from the enterochromaffin (Kulchitsky)
cells of the crypts of Lieberkuhn between villi.
The histopathological diagnosis of appendiceal
NENs includes immunohistochemical staining for
invasive lesions that, as in the
synaptophysin and Chromogranin A. The Kibased on the mitotic activity and appearance of the
cells, is used to determine the proliferative capacity of
the tumour and its overall grading as per the WHO
classification. The Kiappendiceal NEN, its localization within the appendix and the extent of vascular invasion and invasion
into the mesoappendix determine the need for further surgery.
67index as well as the size of the
67index,
Treatment
For small <1cm, well- differentiated tumours, appendicectomy alone may suffice whereas for larger or
more aggressive tumours a right hemicolectomy is
more appropriate in order to achieve cure.
Mucinous neoplasms ofthe
appendix
Mucinous neoplasms of the appendix are the most
frequent source of pseudomyxoma peritonei, a rare
syndrome that is characterized by a slow and relentless accumulation of mucinous tumour in the peritoneal cavity. Mucinous appendiceal neoplasms with
pushing- type invasion rather than infiltrative invasion are low- grade appendiceal mucinous neoplasms
(LAMN) and high- grade appendiceal mucinous neoplasms (HAMN), whereas a mucinous adenocarcinoma of the appendix exhibits the ability of infiltrative
invasion and is more likely to produce distant metastases. If there are signet ring cells in a mucinous
adenocarcinoma, the prognosis is worse.
Mucinous neoplasms may be identified on
cross- sectional imaging if the appendix appears
dilated or diagnosed histologically after a patient
presents with acute appendicitis and undergoes
appendicectomy. LAMN are the most common,
and an appendix containing LAMN is typically
dilated with fibrotic or calcified walls containing
intraluminal mucin. If a LAMN is removed intact
with appendicectomy then no further surgery is
required but subsequent follow- up to ensure no
disease recurrence occurs. If pushing invasion
leads to rupture then mucin can spread in the peritoneal cavity following the peritoneal fluid flow
(pseudomyxoma peritonei, see below). In other
words, although a LAMN has no infiltrative potential its rupture leads to disease spread anywhere in
the peritoneal cavity that can act as a nidus for
further disease development at that site.
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Pseudomyxoma peritonei
Deposition of mucin in different parts of the
peritoneal cavity alongside low- grade mucinous neoplastic cells leads to the formation of pseudomyxoma
peritonei in a prolonged and indolent course.
Surgery for pseudomyxoma peritonei is
performed in specialized centres and aims to clear
all visible disease with peritonectomy, omentectomy, bilateral salpingo resection, followed by heated intraperitoneal chemotherapy (HIPEC) to clear any cancer cells that were
not visible to the naked eye. Although patients with
LAMN who had cytoreductive surgery and HIPEC
have an 87% survival rate at 5 years, patients with
appendiceal HAMN or mucinous adenocarcinoma
have a more aggressive course of disease and poorer
prognosis.
oophorectomy, and bowel
Goblet cell adenocarcinomas
Goblet cell adenocarcinomas are rare tumours and
occur almost always in the appendix. Although goblet
cell adenocarcinoma was previously termed ‘goblet
cell carcinoid’, this is a misnomer as they are a type of
adenocarcinoma.
Appendiceal adenocarcinoma
An appendiceal adenocarcinoma that is not mucinous
is a form of adenocarcinoma resembling the
type. Treatment is similar to colonic adenocarcinoma
requiring a completion right hemicolectomy to ensure
regional lymph node clearance after the diagnosis is
made on an appendicectomy specimen. Despite right
hemicolectomy conferring an improved survival
advantage to appendicectomy alone, the overall prognosis of appendiceal adenocarcinoma is worse than
that of colonic adenocarcinoma.
colorectal
Additional resources
Case 65: Acute abdomen in a medical student
Case 66: Yet another mass in the right iliac fossa
The colon
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Justin Davies
Learning objectives
✓ To know the dierent manifestations of colonic diverticular disease and
its management.
✓ To know the presentation and management of inammation of the
colon (colitis).
✓ To have knowledge of carcinoma of the colon, its aetiology, dierential
diagnosis, pathology, staging and treatment.
Constipation
anddiarrhoea
Constipation and diarrhoea are two symptoms frequently attributable to diseases of the large bowel.
There are, of course, many causes of these common
complaints, owing not only to lesions of the large
intestine but also to other parts of the gastrointestinal
tract being affected or to general diseases. It is useful
here to consider the more common causes of these
two symptoms.
Adynamic bowel:
3
a
Hirschsprung’s disease.
b Spinal cord injuries and disease.
c Hypothyroidism/myxoedema.
d Parkinson’s disease.
4 Drugs:
a
Opiate analgesics.
b Anticholinergics.
5 Habit and diet:
a Dehydration.
b
Starvation.
c Lack of fibre in diet.
d Lack of exercise.
27
1
Constipation
1 Organic obstruction due to a stricture:
a Carcinoma of the colon.
b Diverticular disease.
c Crohn’s disease.
2 Painful anal conditions:
a Anal fissure.
b Prolapsed haemorrhoids (piles).
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
Diarrhoea
1 Specific infections:
a Food poisoning (e.g. Salmonella).
b Dysentery (amoebic and bacillary).
c Cholera.
d Viral enterocolitis.
2 Inflammation or irritation of the intestine:
a Ulcerative colitis.
b Tumours of the large bowel.
1
Harald Hirschsprung (1830–1916), Professor of Paediatrics,
Queen Louisa Hospital, Copenhagen, Denmark.
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c Diverticular disease.
Crohn’s disease.
d
3
Drugs:
a
Antibiotics and antibiotic- induced colitis.
Erythromycin (stimulates the motilin receptor).
b
c
Laxatives.
d
Digoxin.
Orlistat (inhibits lipase and causes
e
steatorrhoea).
Loss of absorptive surface:
4
a
Bowel resections and bypass surgery (short
circuits).
Coeliac disease.
b
c
Idiopathic steatorrhoea.
5 Pancreatic dysfunction: steatorrhoea due to lipase
deficiency.
Post- gastrectomy and after bypass surgery for obe-
6
sity (see Chapter 24).
7
General diseases:
Anxiety states.
a
b Hyperthyroidism.
c Uraemia.
d
Carcinoid syndrome (see Chapter25).
e Zollinger–Ellison syndrome (see Chapter34).
Diverticular disease
Background (Table27.1)
Diverticula of the colon consist of outpouchings of
mucous membrane through the muscle wall of the
bowel. Because they lack the normal muscle coats, they
are examples of ‘false’ diverticula, in contrast to a
Meckel’s diverticulum of the small bowel, which is a
true diverticulum. They lie alongside the taenia coli,
often overlapped by the appendices epiploicae.
Diverticula are found most commonly in the sigmoid
colon, and in the Western world become increasingly
rare in passing from the left to the right side of the colon.
sided diverticula are more commonly found in
Rightpeople from Asia. They are unusual before the age of 40
years, although becoming more common in younger
people in recent years, but they are found in about 60%
of 70-
year- olds. The sex distribution is roughly equal.
Pathogenesis
The characteristic feature of diverticulosis (the presence of diverticula in the absence of any symptoms) is
hypertrophy of the muscle of the sigmoid colon, with
diverticula occurring at the sites of potential weakness
in the bowel wall, corresponding to the points of entry
of the supplying blood vessels to the bowel (Figure27.1).
Traditionally blamed on a lowgests a multifactorial cause of diverticulosis.
Diet and lifestyle: diverticula are less common in
1
individuals with a highvegetables, whole grains, poultry and fish).
Regular physical activity reduces the risk of
diverticulitis.
2 Structural abnormalities: diverticula are common
in patients with Marfan and Ehlers–Danlos
syndromes, as well as polycystic kidney disease. This suggests a potential role for dysfunctional connective tissue.
3
Abnormal motility and increased intraluminal pres-
sure: patients with diverticulosis may have abnormal motility, with chronic and excessive segmental
contractions producing high intraluminal pressure.
The dysmotility may also be related to an enteric
neuropathy since a reduced number of pacemaker
cells in the myenteric plexus has been observed.
4 Genetics: genes are thought to contribute to 40–
50% risk of diverticulitis.
5 Obesity increases the risk of diverticulitis.
fibre diet, evidence sug-
quality diet (high in fruit,
Table27.1 Diverticulum terminology
True diverticulum An outpouching covered by all the layers of the bowel wall (e.g. Meckel’s diverticulum,
False diverticulum Lacking the normal muscle coat of the bowel (e.g. colonic diverticula).
Diverticula Plural of diverticulum.
Diverticulosis The presence of (usually, colonic) diverticula without symptoms.
Diverticular disease Diverticula that cause symptoms, usually due to inflammation.
Diverticulitis Inflammation of a diverticulum.
jejunal diverticulum).
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epiploica
Mesocolon with
blood supply
Taenia coli
The colon 261
Diverticulum
(a)
Figure27.1 The relationship of diverticula of the colon to the taenia coli and to the penetrating blood vessels.
(a)Normal colon. (b) Colon with diverticula. Both shown in transverse section.
6 Non- steroidal anti- inflammatory drugs: regular
use increases the risk of diverticulitis.
7
Immunosuppression: patients who are immuno-
suppressed are at higher risk of acute diverticulitis, complicated diverticulitis and mortality from
diverticulitis.
Complications ofdiverticula
Diverticular disease may manifest in one of three ways.
1
Diverticulitis, that may result in perforation into:
a
The general peritoneal cavity, to cause peritonitis.
b The pericolic tissues, with formation of a
pericolic abscess.
c Adjacent structures (e.g. bladder, small bowel,
vagina), forming a fistula.
2 Large bowel obstruction, due to muscular hyper-
trophy and inflammatory fibrosis leading to a
stricture.
3 Haemorrhage, as a result of erosion of a vessel
within the fundus of the diverticulum. The bleeding varies from acute and profuse to a chronic
occult loss, and is more common in patients with
hypertension, diabetes and those on NSAIDs.
(b)
(LIF) accompanied by fever, vomiting, local tenderness
and guarding. A vague mass may be felt in the LIF
and occasionally also on rectal examination.
Acute complicated diverticulitis
This is diverticular inflammation combined with
obstruction, abscess, fistula or perforation. Perforation
into the general peritoneal cavity produces the
signs of general peritonitis. A pericolic abscess is comparable to an appendix abscess but on the left side: a
tender mass accompanied by a swinging fever and
leucocytosis.
Recurrent diverticulitis
This is diverticulitis that resolves completely but then
abruptly returns.
Smouldering diverticulitis
This is an uncommon presentation that persists for
weeks to months.
Other presentations of diverticular disease include
the following:
Clinical features
Acute uncomplicated diverticulitis
This is characterized by an acute onset of low central
abdominal pain, which shifts to the left iliac fossa
Profuse rectal bleeding
Bleeding from a diverticulum is the most likely cause
of a sudden, profuse, bright red bleed in an elderly,
often hypertensive patient.
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Colovesical stula
Diverticulitis may result in a fistula into the bladder
with the passage of gas bubbles (pneumaturia) and
faecal debris in the urine (faecaluria). Diverticulitis is
the most common cause of a colovesical fistula, others being carcinoma of the colon, carcinoma of the
bladder, Crohn’s disease and trauma.
Ongoing chronic gastrointestinal
symptoms
Ongoing abdominal pain is seen in around one in
four patients 12 months after an acute episode of
diverticulitis. This may be related to increased visceral hypersensitivity following inflammation.
Special investigations
• Computed tomography (CT) scan is the investigation of choice in the acute stage and can help
exclude other causes of lower abdominal pain in
difficult cases.
• Endoscopy: if the affected segment is low in the
colon, there may be an oedematous block to the
passage of the instrument beyond about 15 cm.
Rigid sigmoidoscopes view only the rectum, and so
do not visualize colonic diverticula. Flexible endoscopes are longer, and do allow full visualization of
the sigmoid colon (flexible sigmoidoscopy) or the
entire colon (colonoscopy).
• CT colonography demonstrates diverticula as
globular outpouchings. Diverticular strictures
may closely simulate an annular carcinoma. The
length and density of the stricture can help with
differentiation: diverticular wall thickening typically involves a long segment and is low density
and smooth whereas carcinoma is higher density
and involves a shorter segment. The presence of
nodes in the adjacent fat (often the sigmoid mesentery) is also more common in carcinoma. A
stricture identified on imaging will require direct
visualization and biopsy at endoscopy in order to
confirm the diagnosis.
Insufflation of gas required for endoscopy or colonography carries a risk of perforation of the inflamed,
friable bowel if performed in the acute stage of diverticulitis, and if possible should be deferred until the
acute inflammation has settled. Colonoscopy remains
the gold standard and should be considered once an
episode of acute diverticulitis has settled, as colorectal cancer is subsequently identified in 1% of those
after uncomplicated and 7% of those after complicated
acute diverticulitis.
Differential diagnosis
The important differential diagnosis is from neoplasm of the colon. It is impossible to be certain of
this differentiation clinically or even on special
investigations, unless a positive biopsy is obtained
by endoscopy to definitively establish the diagnosis
of carcinoma. Even at surgery, it may be difficult to
be sure whether one is dealing with carcinoma or
diverticular disease; indeed, these two common
conditions may co-
exist.
Treatment
Acute diverticulitis
When uncomplicated (i.e., no evidence of perforation,
stricture or abscess), it is managed conservatively; the
patient is usually placed on antibiotics (coor ciprofloxacin and metronidazole, are the combinations of choice). The great majority will settle on this
regimen. There are some emerging data from randomized controlled trials that antibiotics may not be
necessary in radiologically confirmed cases of acute
uncomplicated sigmoid diverticulitis.
•
A pericolic abscess is diagnosed by CT scan, and may
be drained percutaneously if over 3 cm in size.
Drainage may occasionally be complicated by formation of a faecal fistula. Once the sepsis is controlled,
surgery with resection of the diseased segment
should be considered but is not always necessary.
• General peritonitis from rupture of an acute diverticulitis is a dangerous condition. When peritonitis
is the result of perforation of a diverticular abscess,
laparoscopic lavage and drainage may suffice but is
not commonly performed due to concerns that an
underlying carcinoma may not be detected and that
lavage alone may not be adequate to resolve the
symptoms. Ideally, surgical resection is performed,
either open or laparoscopic. A primary anastomosis, with or without a defunctioning loop ileostomy
to divert the faecal stream until the anastomosis has
healed, may be considered; the ileostomy is subsequently closed. Alternatively, an end colostomy is
fashioned, usually as a Hartmann’s procedure
(Figure27.2). Full antibiotic therapy is given.
2
Henri Hartmann (1860–1952), Professor of Surgery, Hôtel
Dieu, Paris, France.
amoxiclav,
2
The colon 263
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• Acute obstruction due to diverticulitis is often evi-
Chronic gastrointestinal symptoms
dent when a CT scan is performed in the emergency
setting. It is important to determine whether or not
the obstruction is caused by an adherent loop of
small intestine, which is not uncommon. Surgical
options are the same as for general peritonitis.
Right colon: ulcerating lesions Left colon: stenotic lesions
Superior
mesenteric
artery
Marginal
artery
If the diagnosis is made with considerable certainty
and symptoms are mild, this can be treated conservatively. The bowels are regulated by means of a regular
stool softener. A high-
roughage diet (fruit, vegetables,
Watershed area:
between superior
and inferior
mesenteric
artery supply
Inferior
mesenteric
artery
Right hemicolectomy
Figure27.2 Typical colonic operations. For a lesion in the right colon, a right hemicolectomy is performed, with an
ileocolic anastomosis. For a lesion in the left colon, a left hemicolectomy or sigmoid colectomy is performed, with
anastomosis of the colon to the rectum; in an emergency situation, with unprepared bowel, a Hartmann’s operation can
be performed with the proximal bowel end exteriorized as a colostomy and the rectum oversewn. At a second stage,
the continuity of the bowel can be restored by colorectal anastomosis.
Ileocolic anastomosis
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Left hemicolectomy
Figure 27.2 (Continued)
Sigmoid colectomy
Primary
anastomosis
Primary anastomosis
Hartmann’s
procedure
End stoma
Rectum oversewn or
brought to surface
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