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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 115
IMV
IMA
Figure 8-16
Figure 8-17
Figure 8-18 Figure 8-19
IMV
Ureter
First branch
of IMV
Left kidney
Figure 8-20
116 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
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The patient is placed in reverse Trendelenburg, still airplaned to the right, and the splenic
flexure attachments are incised along the left side wall of the pelvis up to the level of the
spleen (Figures 8-21 and 8-22). The tip of the spleen and the anterior surface of the kidney
are exposed as the suspensory ligaments are divided, and the splenic flexure is mobilized
medially (Figure 8-23). The right upper quadrant trocar provides access for the assistant to
place a 5-mm grasper and pull the splenic flexure toward the midline. The operating surgeon
stands between the legs and uses the 10-mm grasper through the suprapubic midline and
the 5-mm port in the left lower quadrant to place the energy source to allow the instrument
to reach closer to the splenic flexure. The tail of the pancreas and tip of the spleen and anterior surface of the kidney are exposed (Figure 8-24).
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Finally, the omentum is released from the antimesenteric surface of the splenic flexure and
transverse colon to enter the lesser sac around the corner of the splenic flexure (Figure 8-25).
The right upper quadrant trocar site provides retracting access to lift the omentum anteriorly
and cephalad, while the suprapubic trocar site provides access for retracting the splenic
flexure toward the feet, and the left lower quadrant trocar site provides access for the energy
source to divide the attachments of the omentum to the colon. The pancreas is exposed in
the base of the lesser sac, and its lower edge is freed from the attachments of the splenic
flexure all the way to the stump of the IMV at the ligament of Treitz. The posterior wall of
the stomach, the anterior surface of the pancreas, the tip of the spleen, and the anterior
surface of the kidney are clearly visualized with this technique (Figure 8-26).
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 117
Descending
mesenteric vein
Figure 8-21
Transverse
Figure 8-22
Stomach
Pancreas
Spleen
colon
colon
Sigmoid colon
Spleen
Kidney
Inferior
Figure 8-23 Figure 8-24
Figure 8-25
Figure 8-26
Stomach
Pancreas
118 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
Isolation of Middle Colic Vessels
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After the left and right colon have been completely mobilized and the transverse colon com-
pletely freed from the gastrocolic ligament, the pedicle of the middle colic vessels can be
identified at the inferior margin of the pancreas and the anterior surface of the third portion
of the duodenum. In a hand-assisted approach, this pedicle is most easily identified by placing
the left hand through the hand-access port with the operator standing between the legs. The
operator identifies the windows of the mesentery on both sides of the vessels on either side
of the midline (Figures 8-27A and B and 8-28); this allows the middle colic vessels to be
lifted anteriorly, and the SMA and SMV are protected (Figure 8-27A). The flexible tip camera
is turned to the right upper quadrant and flexed to the right to give a transverse view of the
vessels as they are stretched and lifted. An endoscopic linear cutter stapler can be inserted
through a 10-mm trocar placed in the right upper quadrant (Figure 8-29), or the bipolar
sealing instrument can be used through the right upper quadrant to divide the base of the
middle colic vessels carefully. Time should be taken to ensure adequate hemostasis because
these vessels bear the pressure of aortic flow.
A
Figure 8-27A
Middle colic
vessels
Duodenum
SMA
B
Figure 8-27B
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 119
Stomach
Incision at base of
transverse mesocolon
Pancreas
Stump of inferior mesenteric vein
Duodenum (3rd portion)
Duodenum
(2nd portion)
Superior
mesenteric vessels
in edge of small
bowel mesentery
Figure 8-28
Pedicle of transverse
colon mesentery
Vessels of middle colic pedicle
Transverse colon
Small intestine
Figure 8-29
120 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
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The suprapubic incision is extended, and a wound protector is placed, or in a hand-assisted
case, the cap of the gel port is removed, and the carbon dioxide is deflated. The colon and
terminal ileum are extracted (Figure 8-30A). The mesentery of the sigmoid colon is identified,
and the mesentery is divided at the level of the sacral promontory using either a clamp and
tie technique or radiofrequency sealing with an appropriate device. The rectum can be divided
at the level of the sacral promontory with a transverse stapler, endoscopic stapler, or linear
cutter stapler through the suprapubic incision (Figure 8-30B).
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The terminal ileum is divided at the ileocecal valve using another firing of a GIA stapler
(Covidien, Mansfield, Mass.). The colon and its mesentery from the right colon all the way
to the top of the rectum are passed off as specimen.
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The terminal ileum is returned to the abdomen. The small bowel is allowed to fall to the
patient’s left, and the rectum is pulled to the right side of the pelvis. The ileum is allowed to
loop down into the pelvis along the left side of the rectum and then curve back up along the
antimesenteric border of the rectum to the level of the staple line (Figure 8-31). The two
transverse staple lines are aligned; the corners of the staple lines are opened, and a linear
cutter stapler is placed between the rectum and the terminal ileum to create a side-to-side
anastomosis when fired (Figure 8-32).
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 121
Cecum Sigmoid
A
Figure 8-30A
Point of transection of terminal ileum
B
Figure 8-30B
Rectum
Figure 8-31
Rectum
Ileum
Ileum
Figure 8-32
122 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
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The transverse opening is closed with another firing of the GIA stapler (Figure 8-33). The
transverse staple line is inverted with a running monofilament absorbable suture. The apex
of the GIA staple line is protected with an interrupted absorbable suture. The cut edge of the
mesentery in the small bowel can usually be secured to the retroperitoneum along the side
of the aorta on either side of the aorta using a running absorbable suture; this has the benefit
of preventing internal herniation and guarantees that the small bowel is lying in an unrotated
or twisted manner.
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The inner aspect of the umbilical trocar is closed with a figure-eight suture of 0 absorbable
suture. The Pfannenstiel incision is closed with a running monofilament absorbable suture
in the fascia. Subcutaneous tissue is irrigated with antibiotic solution at all sites. The skin is
closed with skin staples, and adhesive bandages are applied.
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 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.
Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis 123
Figure 8-33
124 Chapter 8 • Laparoscopic Total Abdominal Colectomy and Ileorectal Anastomosis
Step 5: Pearls and Pitfalls
Patients have a fairly rapid return of bowel function because of the laparoscopic approach. A
large fluid shift is likely to occur because of the raw surfaces created. Adequate fluid replacement can avoid acute renal failure, dehydration, and an ileus.
As we have performed more ileorectal anastomoses for familial adenomatous polyposis and
Crohn’s disease, the frequent development of a delayed ileus has led us to describe a syndrome
known as “ileorectal syndrome.” This syndrome is possibly caused by the terminal ileum facing
new high pressure intraluminally because of its attachment to the rectum with an intact sphincter only 12 cm away. The ileum interprets this high pressure as small bowel obstruction, and
a high volume of intraluminal fluid is created that causes diarrhea, a bloating sensation, and
nausea and vomiting. Treatment is best accomplished with a nasogastric tube, bowel rest,
and total parenteral nutrition. This syndrome develops even when a 34-F mushroom catheter
is left in the rectum in the early postoperative period to decompress and equalize the pressures
in the rectum. The terminal ileum responds as if it were a blocked ileostomy with high outpouring of fluid; distention; and a syndrome of nausea, vomiting, and diarrhea. The patient should
be reassured and supported, and the possibility of an anastomotic leak should be ruled out with
a computed tomography (CT) scan.