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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 105
Omentum
Right middle
colic vessels
Superior
mesenteric
artery
Duodenum
Figure 8-2
Transverse colon
Left middle
colic vessels
Pancreas (behind
transverse mesocolon)
Jejunum
IMV
Window
IMA
Aorta
106 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
the expected functional outcome of an ileorectal anastomosis. They can expect to have four to
five semisolid, pasty bowel movements a day with good bowel control after a period of accommodation (usually 6 months).
Step 3: Operative Steps
Right Colon
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The patient is positioned in the modified lithotomy position with the legs in Allen’s stirrups
and sequential compression leggings in place. A beanbag, attached directly to the operating
table with Velcro, is folded around the patient, including the shoulders, and deflated to fix
the patient in position. This beanbag keeps the arms at the patient’s side and allows the table
to be placed in steep Trendelenburg and airplaned to the left and right during the operation.
The trocar site placement is typically at the umbilicus, right upper anterior axillary line, right
lower anterior axillary line, suprapubic, and left flank positions. The camera operator stands
to the patient’s left shoulder and operates the camera through the umbilical port. The operating surgeon stands at the patient’s left hip or between the legs as needed and operates instruments through the left flank and suprapubic ports (Figure 8-3).
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A 15-mm Hg pneumoperitoneum is maintained with a pressure-controlled insufflator. The
camera cord, light cord, and carbon dioxide cord are passed off of the table from the patient’s
left shoulder to the instrumentation tower. A monitor is placed opposite the operating surgeon
and camera operator. If two monitors are available, one is at the right shoulder, and one is
at the right hip. The liver should be evaluated, the omentum should be placed over the
stomach to the left upper quadrant, and the small bowel should be retracted from the pelvis
to lie in the left upper quadrant. The 5-mm wavy grasper is a good instrument to flip the
small bowel up into the left upper quadrant with a reverse “C” motion; the principle should
be to avoid grasping any individual piece of bowel on the bowel itself. Using mesenteric fat
or epiploic fat to move portions of intestine is appropriate.
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The cecum is lifted to the anterior abdominal wall using the 5-mm grasper through the
suprapubic port in the operator’s left hand. An instrument with a surgeon-controlled energy
source can be used to incise along the base of the peritoneum from the pelvic brim over the
iliac vessels toward the duodenum at the midline of the abdominal cavity (Figure 8-4A). This
incision allows a plane to be developed in the retroperitoneum over the structures that are
found posteriorly (Figure 8-5). The right ureter is identified crossing the iliac vessels close
to the bifurcation of the aorta; the gonadal vessels are further lateral and run parallel to the
iliac vessels (Figure 8-4B). The psoas muscle lies posteriorly and should be a boundary of
dissection. The avascular plane that is encountered is used as the dissection plane and can
be bluntly dissected in a posterior sweeping direction to allow the mesentery and cecum to
separate anteriorly from the posterior structures.
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 107
Mesentery of right colon
Camera tower,
insufflator,
Monitor
Monitor
light source
Camera
driver
Figure 8-3
A
Figure 8-4A
Monitor
Surgeon
Assistant
Scrub
nurse
To suprapubic trocar
Areolar tissue
behind right colon
B
Figure 8-4B
To left
flank trocar
Figure 8-5
Psoas muscle Iliac artery
Ureter
108 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
u
The cecum should be completely mobilized from the retroperitoneum all the way out to the
side wall of the abdomen using the left-hand grasper for retraction upward and the right-hand
instrument to develop the plane. The dissection is carried in this posterior plane up to and
around and on top of the surface of the duodenum (Figure 8-6). The duodenum should be
separated from the overlying mesentery of the right colon using the left hand for anterior
retraction all the way up to the hepatic flexure peritoneal attachments, exposing the entire
sweep of the duodenum, a portion of the head of the pancreas, and the lateral aspect of the
middle colic vessels (Figure 8-7). The anterior portion of the kidney is exposed with this
same maneuver with upward traction and downward countertraction. The mesentery and
right colon are lifted toward the anterior abdominal wall, while pulling the avascular tissue
posteriorly with the blunt dissection using the instrument in the operator’s right hand. Most
of the retraction is accomplished with the left hand on the grasper through the suprapubic
port.
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The patient is placed in reverse Trendelenburg position. The attachments of the hepatic
flexure to the retroperitoneum are lifted anteriorly and divided with an energy source along
the line between the liver and the transverse colon (Figure 8-8); this allows entry in the
previously dissected plane of the right colon posteriorly in the area of purple hue in the
posterior peritoneum (Figure 8-9A).
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 109
Transverse colon
To suprapubic trocar
Right colon
and terminal
ileum mesentery
Middle colic
vessels
Head of
pancreas
Figure 8-6 Figure 8-7
Release of
hepatocolic flexure
Gallbladder
Liver
Transverse colon
Stomach
A
Duodenum
(2nd portion)
Figure 8-8
Figure 8-9A
110 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
u
The omentum attached to the transverse colon is detached to enter the lesser sac (Figure
8-9B). The transverse colon is released from the lesser sac, head of the pancreas, and under-
surface of the antrum of the stomach all the way out to the right side wall of the abdomen
(Figure 8-10). The hepatic flexure is completely mobilized from the undersurface of the liver,
and the posterior dissection is connected to the right upper quadrant dissection.
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The patient is returned to Trendelenburg position, and the cecum is grasped at the ileocecal
valve and lifted anteriorly to the abdominal wall. This maneuver provides the tension needed
to expose the ileocolic vessel in the mesentery of the right colon (Figure 8-9C).
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Dissection on either side of the ileocolic vessel provides windows to allow transection of the
ileocolic vessels at their origin along the SMA (Figures 8-9D and 8-11).
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The right colon is released from the lateral attachments of the colon from the right side wall
of the abdomen (Figure 8-12). The cecum is grasped and lifted anteriorly. The cecum is
retracted toward the midline to facilitate the division of the lateral attachments with the energy
source. This maneuver allows the right colon to become a midline structure from the middle
of the transverse colon all the way to the terminal ileum.
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 111
B
Figure 8-9B
D
Figure 8-9D
C
Figure 8-9C
Release of
gastrocolic
ligament
Transverse colon
Figure 8-10
Superior mesenteric artery
Figure 8-11
Window in ileocolic
mesentery
Ileocolic vessels
within mesentery
Cecum
Lateral attachments
Figure 8-12
112 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
Left Colon
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The patient is placed in steep Trendelenburg and airplaned to the right. The surgeon stands
to the right of the patient. The small bowel is swept from the pelvis into the right upper
quadrant with grasping instruments, and the base of the mesentery of the left colon is
exposed. The IMA is identified at its origin on the aorta proximal to the sacral promontory
(Figure 8-13). The space posterior to the superior hemorrhoidal artery and anterior to the
sacral promontory is exposed. Anterior traction is exerted on the superior hemorrhoidal artery
with a clamp through the suprapubic port. An energy source is introduced through the right
lower quadrant trocar site, and a 5-mm bowel grasper is introduced through the right upper
quadrant trocar site. The presacral window is easily seen with this retraction plan (Figure
8-14).
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The peritoneum is incised along the base of the triangle to expose the areolar tissue plane
behind the superior hemorrhoidal artery but anterior to the retroperitoneum where the
gonadal vessels and the ureter are found along the left iliac artery and vein (Figure 8-15).
This avascular plane is bluntly developed all the way out to the left abdominal side wall
behind the mesentery of the sigmoid and left colon.
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 113
Superior hemorrhoidal
IMA
Aorta
Sacral
promontory
Figure 8-13
Figure 8-14
mesenteric vein
mesenteric artery
Inferior mesenteric vein
Inferior vena cava
Inferior
Inferior
Ureter
Aorta
Mesentery
Ureter
Inferior
mesenteric artery
Figure 8-15
114 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
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The dissection is carried around the IMA to the peritoneal window beneath the IMV and
anterior to the aorta. The window is incised, and the opening is developed cephalad to the
IMA (Figure 8-16). The IMA is skeletonized and divided at its origin with an energy source
(Figure 8-17). The artery may be divided at the bifurcation of the left colic and superior
hemorrhoidal artery if the disease is benign to prevent all risk of injuring nerves of sexual
function in the preaortic plexus.
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Blunt dissection of the avascular plane is carried from the pelvic brim to the tail of the pan-
creas and laterally to the side wall of the abdomen beneath the left colon and its mesentery
(Figure 8-18). The right upper quadrant trocar site provides access for the retracting blunt
instrument, and the right lower quadrant trocar site provides access for the energy source or
dissecting instrument. The suprapubic site allows the second retracting grasper to lift the
edge of the mesentery anteriorly to provide a tenting effect, while the camera (in the umbilical port) looks beneath and laterally.
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The IMV is exposed at its origin at the level of the ligament of Treitz, proximal to the first
branch of the IMV, which travels to the splenic flexure. The vein is transected with an energy
source or stapling instrument to release the base of the mesentery of the left colon (Figure
8-19). The left colon is released from the lateral side wall of the abdomen from the pelvic
brim to the splenic flexure, exposing the previously dissected retroperitoneum with the protected structures posteriorly (Figure 8-20).