Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 7 • Open Total Abdominal Colectomy with Ileorectal Anastomosis 95
Left ureter
A
Figure 7-11A
A
Figure 7-12A
B
Figure 7-11B
Tail of pancreas
B
Figure 7-12B
Splenic flexure
attachments
C
Figure 7-12C
Tip of spleen
D
Figure 7-12D
96 Chapter 7 • Open Total Abdominal Colectomy with Ileorectal Anastomosis
u
After the left colon has been mobilized, the sigmoid colon can be transected anywhere along
its surface from rectum to descending colon that is appropriate for the disease process. The
rectosigmoid colon is transected in a mesenteric-to-antimesenteric direction with a linear
cutter stapler at the sacral promontory to provide the distal end of the anastomosis (Figure
7-13).
u
The IMA pedicle or the left colic vessels can be divided at their origin or along the vessel
pedicle at a point appropriate for the disease process as the left colon is mobilized from the
retroperitoneal structures (Figure 7-14). The IMV can be ligated at its origin adjacent to the
third portion of the duodenum with the left colon retracted anteriorly and the small bowel
and right colon retracted to the patient’s right (Figure 7-15).
u
The transverse colon is pulled inferiorly. The surgeon’s left hand is passed through the defect
of the ileocolic vessels and encircles the middle colic vessels. These vessels form a “V” and
can be easily identified and divided outside the pancreatic tissue to protect the anterior surface
of the pancreas (Figure 7-16).
Chapter 7 • Open Total Abdominal Colectomy with Ileorectal Anastomosis 97
Figure 7-13 Figure 7-14
Figure 7-15 Figure 7-16
98 Chapter 7 • Open Total Abdominal Colectomy with Ileorectal Anastomosis
u
The anastomosis is accomplished by opening the antimesenteric corner of the transverse
staple line on the sigmoid colon and the ileum. The small bowel is positioned to the left side
of the abdomen with the cut edge of the mesentery placed toward the midline. The terminal
ileum is allowed to fall to the left side of the pelvis, and the small bowel is brought up along
the edge of the left side of the rectum (Figure 7-17A). The sigmoid is positioned along the
right side of the pelvis, and the linear cutter stapler is placed down the open corners of the
transverse staple lines to create a side-to-side anastomosis (Figures 7-17B and 7-18).
u
The transverse opening of the anastomosis is opened widely, the longitudinal staple lines are
distracted as far as possible, and the opening is brought together with Allis clamps. The
transverse opening is closed with a second firing of the linear cutter stapler (Figure 7-19).
The mesenteric defect is closed by placing a running suture from the pelvic brim down the
mesentery of the sigmoid colon along the mesentery of the small bowel all the way up to the
base of the duodenum to prevent herniation and twisting (Figure 7-20). The transverse staple
line of the ileosigmoid anastomosis is oversewn with a running Lembert suture line of 3-0
absorbable suture to invert and protect the transverse staple line (Figure 7-21).
u
An adhesive barrier can be applied, and the abdomen is closed with a running No. 1 loop
absorbable suture.
Chapter 7 • Open Total Abdominal Colectomy with Ileorectal Anastomosis 99
Rectum
Ileum
A
Figure 7-17A
B
Figure 7-17B
Figure 7-18 Figure 7-19
Figure 7-20 Figure 7-21
100 Chapter 7 • Open Total Abdominal Colectomy with Ileorectal Anastomosis
Step 4: Postoperative Care
Patients are ambulated early. Intravenous fluid replacement is given to maintain a urine output
of greater than 30 mL/hr. Nasogastric decompression is not required unless the patient becomes
nauseated. Most patients tolerate clear liquids within 24 to 48 hours, and the diet can be
advanced as tolerated. Patients should be given prophylactic antibiotics for 24 hours, incentive
spirometry, and deep vein thrombosis prophylaxis and encouraged to ambulate as much as
possible during the early postoperative period. Usual hospital stay after an open right colectomy
is 4 to 5 days; the hospital stay is shorter when the patient is placed on a fast-track postoperative regimen. Postoperative analgesia is usually managed with patient-controlled analgesia followed by a switch to oral analgesics.
Step 5: Pearls and Pitfalls
The ileorectal anastomosis sometimes begins functioning rapidly and suddenly stops causing
nausea, vomiting, and general malaise. This “ileorectal syndrome” may be due to the small
intestine being exposed to a higher pressure created by the rectal vault. Placement of a 34-F
mushroom catheter in the rectum during the first week of recovery may alleviate this problem
or prevent it from occurring. The bowel slowly recovers over 7 to 10 days. An anastomotic leak
must be ruled out. Parenteral nutrition allows the patient time to recover normal bowel function. When feeding resumes, a liquid diet is usually best until function normalizes.
Chapter 7 • Open Total Abdominal Colectomy with Ileorectal Anastomosis 101
The rectum varies in length in individuals. The usual length of 12 to 15 cm is adequate to
provide a meaningful reservoir. Occasionally, the blood supply provided by the middle hemorrhoidal vessels via the internal iliac artery through the anterior lateral ligaments is inadequate.
If this inadequacy can be determined preoperatively or suspected intraoperatively, the superior
hemorrhoidal artery can be saved during sigmoid mesenteric dissection and good blood supply
guaranteed. If the IMA has been sacrificed, and blood supply fails to the upper rectum, the only
option is to resect more rectum to find well-vascularized tissue. Continued uncertainty regarding blood supply should lead to a decision to perform an end ileostomy and leave a Hartmann’s
stump at the level of reasonable blood supply.
The length of the rectal stump is also mandated by the need to perform long-term surveillance for malignancy. Patients with familial adenomatous polyposis, hereditary nonpolyposis
colorectal cancer, or Crohn’s disease require endoscopic surveillance. A short (12-cm) stump is
easy to follow in the office setting.
Selected Readings
Church J, Burke C, McGannon E, et al. Risk of rectal cancer in patients after colectomy and ileorectal anastomosis for familial adenomatous
polyposis: a function of available surgical options. Dis Colon Rectum 2003;46:1175–81.
Kalady MF, McGannon E, Vogel JD, et al. Risk of colorectal adenoma and carcinoma after colectomy for colorectal cancer in patients
meeting Amsterdam criteria. Ann Surg 2010;252:507–11.
C H A P T E R
8
Laparoscopic Total
Abdominal Colectomy and
Ileorectal Anastomosis
James W. Fleshman, Jr.
Step 1: Clinical Anatomy
The right colon lies on the patient’s right side suspended laterally by peritoneal attachments to
the right side of the abdominal wall, superiorly by attachments to the undersurface of the liver
and posterior diaphragm, and medially by its mesentery. The ileocolic artery and vein and the
right colic artery, if it is present, run through this leaf of mesentery. The colon is adherent to
the retroperitoneum on the right side of the abdomen and covers the right gonadal vessels and
right ureter. The inferior vena cava is the next most medial structure on the right side. The
hepatic flexure, the fold at the junction between the right colon and transverse colon, is adherent to the anterior surface of the kidney by avascular attachments to Gerota’s fascia. The first
and second portions of the duodenum are adherent to the undersurface of the mesentery of the
right colon and proximal transverse colon. The gallbladder is sometimes adherent to the cephalad surface of the transverse colon at the hepatic flexure.
The space behind the right colon is triangular shaped with the flat horizontal surface at the
hepatic flexure running from the abdominal side wall toward the midline along the line of the
greater curve of the stomach. The vertical axis follows the right lateral side wall of the abdomen.
The hypotenuse runs from the fusion plane of the cecum at the pelvic brim over the top of the
right iliac artery and vein at about the point where the ureter passes over the iliac vessels toward
the midline over the aorta up to the base of the pancreas along the third portion of the duodenum. This triangular retroperitoneal area is a potential space with avascular attachments and
allows the right colon to be lifted completely from the retroperitoneum during dissection.
Release of all suspensory attachments allows the right colon to be made into a midline structure.
The ileocolic artery and vein arise from the superior mesenteric artery (SMA) and superior
mesenteric vein in the midportion of the SMA below the duodenum. The right colic artery is
a variable structure and may be present as a separate structure or as part of the ileocolic trunk.
The right branch of the middle colic artery exits through the pancreatic tissue from its origin
on the SMA as a portion of the middle colic trunk at the base of the transverse mesocolon
(Figure 8-1).
102
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 103
Transverse colon
Straight arteries
Middle colic artery
Tumor
Right colic artery
Ileocolic artery
Ascending colon
Anterior cecal
artery
Posterior cecal
artery
Appendicular artery
Appendix
Figure 8-1
Marginal
artery
Jejunum
Superior
mesenteric
artery
Ileum
104 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
The left branches of the middle colic artery and vein exit adjacent to the right branch of the
middle colic and are found at the third portion of the duodenum over the pancreas. The inferior
mesenteric vein (IMV) travels along the window of the base of the mesentery of the colon and
enters the portal vein adjacent to the ligament of Treitz at the base of the splenic flexure mesentery. This area of the vasculature to the colon is extremely complex and should be studied
carefully before mobilization of the transverse colon. The mesentery of the transverse colon
itself is sometimes attached to filmy attachments of the posterior aspect of the stomach. The
omentum falls from the gastroepiploic artery along the greater curve of the stomach over the
transverse colon where it attaches tangentially to the antimesenteric surface of the transverse
colon and then continues to the lower aspect of the abdomen free-floating over the surface of
the small bowel.
The splenic flexure of the colon sits in the left upper quadrant with a surface adherent to the
undersurface of the tip of the spleen, the anterior surface of the left kidney, and the anterior
surface of the tail of the pancreas. A portion of the base of the mesentery of the transverse colon
is attached to the undersurface of the tail of the pancreas starting at the level of the IMV and
extending laterally toward the left side of the abdomen (Figure 8-2). These attachments can be
released by developing avascular planes given knowledge of the peritoneal windows, areolar
tissue planes, and structural relationships. The left colon itself is adherent to the retroperitoneum
in the left gutter via an avascular filmy tissue plane that attaches the mesentery and left colon
to the posterior abdominal wall where the ureter and gonadal vessels are found. The peritoneal
attachments along the left gutter of the abdomen suspend the left colon from the left side of
the abdomen from the pelvic brim all the way up to the splenic flexure. The splenic flexure is
a fold of the colon with its apex attached to the tip of the spleen by omental congenital
adhesions.
The splenic flexure is usually covered by the omentum as it falls over the top of the transverse
colon along the left gutter, and numerous embryologic attachments can occur between the
antimesenteric surface of the proximal left colon and the omentum at the splenic flexure. The
left colon descends along the left gutter to the level of the pelvic brim where the colon becomes
free from the pelvic side wall and falls into a sigmoid-appearing structure known as the sigmoid
colon. The sigmoid colon lies free in the pelvis, attached only posteriorly to its vascular attachments at the midline over the sacral promontory.
The inferior mesenteric artery (IMA) arises from the anterior surface of the aorta proximal to
the origin of the common iliac vessels. The IMA branches to give the superior hemorrhoidal
artery descending into the posterior mesorectal vessel and the ascending left colic vessel, which
sweeps up toward the splenic flexure. The IMV runs across the base of the mesentery of the
left colon, crossing the superior hemorrhoidal and left colic vessels on its way to the duodenum.
There is a clear peritoneal window between the aorta and the IMV, which can be used to enter
the avascular plane behind the left colon mesentery and the retroperitoneum.
Step 2: Preoperative Considerations
Common indications for a laparoscopic total abdominal colectomy with ileorectal anastomosis
are the same as for an open procedure and include synchronous colon cancers, familial cancer
syndromes (hereditary nonpolyposis colorectal cancer, familial adenomatous polyposis with
rectal sparing, and cancer in patients <40 years old), colonic inertia, Crohn’s colitis with rectal
sparing, and gastrointestinal bleeding. The preparation of the patient is dictated by the specific
indication, and the appropriate evaluations should be undertaken. A mechanical bowel preparation with oral agents is not necessary but is frequently performed to reduce stool in the colon.
If the patient has a history of constipation, the colon can be too heavy with retained stool to
allow a safe laparoscopic approach. The left side of the colon can be adequately cleansed with
several enemas before surgery. Routine deep vein thrombosis prophylaxis, prophylactic antibiotics, and instructions on postoperative care are required. Patients should receive education on