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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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the spike exit outside the side.
For end-to-side anastomosis, there should be a minimum of 2 cm
between the staple lines to avoid an ischemic intervening segment.
For low anastomosis, consideration is often given for a posterior
placement of the spike to give additional distance between anterior
structures (eg, vaginal wall).
Care is maintained to ensure the colonic conduit is not twisted (Fig. 2114B).
FIGURE 21-14 A. Laparoscopic colorectal anastomosis. B. Laparoscopic colorectal
anastomosis. Note how the spike comes out at or above the rectal staple line.
PEARLS AND PITFALLS
Difficulties in Reach
Proper reach of the colon into the pelvis may be difficult in certain
cases, such as due to variations in anatomy, vascular supply, and
body habitus.
If, after high ligation of the vessels, complete and full mobilization
of the left colon and splenic flexure, and along with removal of the
omentum from the transverse colon, there is still reach issues; several
maneuvers may be employed in order to have a tension-free
anastomosis.
Since the IMA and IMV have been ligated at their origin, blood
supply is based on the middle colic vessels.
The first maneuver involves creating a retroileal, transmesenteric
window through an avascular plane to the right of the superior
mesenteric pedicle near the terminal ileum (Fig. 21-15).
FIGURE 21-15 Retroileal window. A window is created to the right of the
superior mesenteric artery near the terminal ileum. The colon can be delivered
to anastomosis with the rectum. Middle colic vessels may need to be ligated.
Anastomotic rings are examined for completeness, and an air leak test is
performed with flexible sigmoidoscopy.
The author prefers to use flexible endoscopy in order to clearly view
the anastomosis intraluminally, to ensure hemostasis, integrity, and
perfusion of the bowel both proximal and distal to the staple line.
Small, pinpoint leaks are generally simply oversewn and re-tested.
Large defects are either repaired primarily or the anastomosis may
be redone completely.
Consideration should be given for diversion.
Surgical drains are rarely used.
The colon can be placed through this window and into the pelvis. If
this does not work, the surgeon must make the decision to transect
the root of the entire transverse colon, with high ligation of the
middle colic vessels.
Mobilization to the hepatic flexure and removal of the entire
omentum off the colon must be performed.
If this technique does not sufficiently provide the needed length, a
complete 180-degree counterclockwise rotation of the right colon
based on the ileocolic pedicle can be performed (Deloyer
procedure).
The hepatic flexure and right colon must be completely mobilized,
and all attachments released.
The right colic vessels and mesentery of the right colon are ligated,
and the colon is rotated in order to have the anterior wall of the
cecum/right colon against the retroperitoneum and the cecum is in
the right iliac fossa with the appendix pointing toward the hepatic
flexure (it is not necessary to perform an appendectomy) (Fig. 21-
16).
FIGURE 21-16 Deloyer procedure. The right colon and hepatic are mobilized,
and all mesentery is divided except the ileocolic pedicle. The colon is rotated
counterclockwise 180 degrees, and a right colon anastomosis is performed to the
rectum/anus.
If these maneuvers are unsuccessful, a cecal–rectal anastomosis may be
performed, or alternatively, a total colectomy with ileorectal
anastomosis can be used. These latter two should be used with caution
considering the function and other pre-operative considerations.
TIPS
A positive air leak tests are controlled on a case-by-case basis.
Postoperative Care
We follow our published standardized enhanced recovery perioperative
care plan.
Orogastric tubes are removed prior to extubation, intravenous fluids are
minimized, diet is given day 0, and urinary catheters are removed day 1.
Opioids are minimized, and patient-controlled analgesia is avoided.
Nonsteroidal anti-inflammatories are permitted and combined with oral
acetaminophen.
Subcutaneous heparin and intermittent pneumatic compression are
continued following surgery for deep vein thrombosis prophylaxis.
Suggested Readings
Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis.
ASCRS Standards Committee. Dis Colon Rectum. 2014;57(3):284-294.
Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz DJ. Anastomotic leak testing after
colo-rectal resection: what are the data? Arch Surg. 2009;144:407-411.
Chapter 22
Right Colectomy
PETER MARK NEARY
SHERIEF SHAWKI
CONOR PATRICK DELANEY
Perioperative Considerations
An oral polyethylene-based bowel preparation is given the day prior to
surgery. Patients with concern for bowel obstruction do not receive oral
bowel preparation.
Patients receive three doses of 1 g neomycin and 500 mg metronidazole
orally the day before surgery.
Tumors are generally visualized endoscopically by the operating surgeon
and tattooed (unless already visible on preoperative imaging).
Preoperative subcutaneous heparin is administered within 2 hours of
surgery, and sequential compression devices are used to help prevent deep
venous thrombosis prophylaxis.
Imaging is reviewed to look for relative anatomical landmarks and to
exclude involvement/invasion (eg, tumor, fistula) into adjacent organs (ie,
pancreas, duodenum, retroperitoneum) that may dramatically alter surgery.
Right-sided stents are infrequently, but selectively used (eg, phlegmon,
radiation, tumor involvement).
Equipment
Bean bag (if desired)
2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant
Carbon dioxide insufflator
Bipolar energy device
Wound protector
Laparoscopic instrument set (Fig. 22-1)
FIGURE 22-1 Laparoscopic equipment.
Suction
10-mm 0-degree laparoscope with high definition
Camera lead
Gas tubing
12-mm balloon port
20-mm syringe
5-mm blunt-tip trocar port ×3
Laparoscopic electrocautery lead
Monopolar food switch (if desired)
Open electrocautery device
Laparoscopic towers
16Fr rubber catheter
Fluid warmer
Sterile water
Scope warmer (Fig. 22-2)
FIGURE 22-2 Scope warmer with laparoscopic lens.
Blue-loaded linear gastrointestinal anastomosis (GIA) 80-mm stapler
TA 60- or 90-mm stapler with blue cartridge
60 mL 0.25% bupivacaine with epinephrine 1:100 000
Minilaparotomy set
Closing instrument tray
4/0 absorbable monofilament suture
3/0 polyglactin
1 Maxon
A 10-mm 0-degree laparoscope with high definition is preferred by the
senior author.
The authors find a 30-degree lens usually compromises the view often
provided by inexperienced camera holders and rarely improves
visualization.
A 30-degree lens is on standby if necessary for a very obese male with
a high hepatic flexure. A typical tray is shown in Figure 22-3.
FIGURE 22-3 Full equipment set.
This varies by individual surgeon preference.
Anesthesia
General anesthesia is typically utilized. Laparoscopic right hemicolectomy
via a medial-to-lateral method is the preferred approach.
Complete muscle relaxation is necessary for effective insufflation and
laparoscopic visualization.
Epidural anesthesia is unnecessary. Pain is generally well controlled using
multimodal analgesia with transversus abdominis plain block, oral and
intravenous analgesia.
Patient Positioning
The patient is placed in modified lithotomy. Legs are held in Yellowfins
stirrups (Fig. 22-4). Both arms are tucked, and the patient is secured on a
bean bag. Edges of the bean bag are flattened when being stiffened to
prevent interference with the instruments (Fig. 22-5). In patients who are
too obese to safely strap both arms, the right arm is kept out. Lithotomy
position gives the option to the surgeon to stand between the legs when
distal transverse colon mobilization is necessary.
FIGURE 22-4 Patient positioned in modified lithotomy.
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