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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 9 • Open Total Proctocolectomy and Ileal Pouch 145
Figure 9-22 Figure 9-23
Figure 9-24 Figure 9-25
Duodenum
Areolar tissue
IMV
Figure 9-26
146 Chapter 9 • Open Total Proctocolectomy and Ileal Pouch
9 o’clock all the way down to the pelvic floor (Figures 9-27 and 9-28). A complete and intact
mobilization of the mesorectum reveals its bilobed configuration (Figure 9-29).
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The lateral peritoneal attachments are incised down to the anterior peritoneal reflection. The
lateral dissection is performed by retracting the rectum medially and sharply dividing the
tissue in a posterior-to-anterior fashion (Figure 9-30). When adequate tension is created,
the plane of the mesorectal fascia can be seen ensuring that it is completely excised. The
Chapter 9 • Open Total Proctocolectomy and Ileal Pouch 147
Left ureter
Left pelvic nerve
Figure 9-27
Right pelvic nerve
and ureter
Mesorectum
Areolar tissue
Sacral promontory
Figure 9-28
Right anterior
lateral ligaments
Figure 9-29 Figure 9-30
Mesorectum
148 Chapter 9 • Open Total Proctocolectomy and Ileal Pouch
anterior peritoneum is incised, the prostate or cervix is retracted anteriorly, and the rectum
is retracted posteriorly (Figure 9-31). The anterior dissection is carried down to the pelvic
floor, and any remaining lateral attachments are divided.
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The rectum is divided with a linear stapler; the proximal rectum must be occluded to limit
spillage as the specimen is removed (Figure 9-32).
Chapter 9 • Open Total Proctocolectomy and Ileal Pouch 149
Figure 9-31
Prostate
Anterior peritoneal
reflection
Rectum
Figure 9-32
150 Chapter 9 • Open Total Proctocolectomy and Ileal Pouch
J Pouch Construction
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Construction of the 15-cm J pouch is accomplished by folding the terminal 30 cm of the
small intestine on itself to create a 15-cm “J” (Figure 9-33A-C). The apex of the “J” is opened
on the antimesenteric surface for a distance of 1.5 cm, and a 0 polypropylene (Prolene)
purse-string suture is placed around the opening (Figure 9-34). The 10-cm linear cutter
stapler is fired through the apical opening with the jaws down each limb of the “J” (Figure
9-35). Care must be taken to keep the jaws of the stapler as close to the antimesenteric border
as possible to avoid damaging the blood supply to the lateral wall of the pouch. The stapler
is fired twice through the apical purse-string to divide the septum completely between the
two limbs of the “J” and create a 15-cm-long opening. The transverse staple line of the blind
limb of the “J” is secured to the inlet of the pouch using interrupted absorbable suture to
invert the transverse staple line and prevent it from twisting (Figure 9-36).
Chapter 9 • Open Total Proctocolectomy and Ileal Pouch 151
Anterior view
Loop ileostomy
site
J pouch
Ileocecal valve
A
Figure 9-33A-C
Transection of terminal ileus
within 5 cm of IC valve
15 cm
2 firings of 10-cm GIA
7.5 cm
10 cm
7.5 cm
B
Mesentery
Rectum
C
Figure 9-34 Figure 9-35
Figure 9-36
152 Chapter 9 • Open Total Proctocolectomy and Ileal Pouch
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The anvil of the 29-mm circular stapler is secured in the apical purse-string as the last com-
ponent of constructing the J pouch (Figure 9-37). The J pouch is pulled down into the pelvis
with the cut edge of the mesentery to the patient’s right, the small bowel falling into the
patient’s left, the mesentery stretched across the anterior surface of the pelvis, and the posterior wall of the pouch falling into the curve of the sacrum (Figure 9-38). The staple
head is reconnected to the post of the stapler, which has been inserted through the anal canal
to the level of the transverse staple line. The stapler is closed and fired to create a circular
end-to-end, double-stapled, ileal pouch–anal anastomosis.
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The cut edge of the mesentery is secured along the retroperitoneal surface with a running
absorbable suture to close the potential internal hernia, prevent twisting of the pouch, and
to fix the pouch in the pelvis so that it cannot retract (Figure 9-39).
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A large Blake drain is placed in the pelvis and brought out through a stab wound in the left
lower quadrant, secured to the skin with 3-0 nylon, and hooked to suction bulb drainage.
The drain is placed behind the pouch all the way down to the level of the anal anastomosis
and left in place until drainage has decreased to less than 15 mL per shift. The right lower
quadrant ileostomy site is constructed by excising a 3-cm disk of skin and subcutaneous fat
in the right lower quadrant on the infraumbilical fat fold in a site previously marked by the
enterostomal therapist. The loop ileostomy is brought through the anterior abdominal wall
at a site 20 cm proximal to the inlet of the pouch. An adhesion barrier is placed throughout
the abdominal cavity and over the loop of small bowel brought out at the ileostomy to prevent
adhesion formation. The ileostomy is matured by incising 80% around the circumference of
the small bowel at the level of the skin on the distal limb, which is usually inferiorly placed
and maturing the mucocutaneous junction at the level of the skin (Figure 9-40). The proximal
limb is everted to create a 2.5-cm spigot using three-point sutures of absorbable suture around
the circumference of the bowel. A suspensory rod can be used if there is tension on the small
bowel or the abdominal wall is thick owing to obesity.
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An ostomy appliance is applied. Care is taken to avoid contamination of the skin sites. The
abdomen is closed with a running No. 1 absorbable suture; the subcutaneous tissue is irrigated with antibiotic solution and closed with skin staples; and dressing is applied.
Step 4: Postoperative Care
Patients undergoing open total proctocolectomy, ileal pouch–anal anastomosis, and diverting
loop ileostomy require patient-controlled analgesia and deep vein thrombosis chemical and
mechanical prophylaxis because of the high risk secondary to inflammatory bowel disease or
neoplasia. The patient should be ambulated frequently and given incentive spirometry, and a
bladder catheter should be left in place until the patient is fully ambulatory and it is deemed
probable that pelvic edema and nerve dysfunction have resolved. A large Blake drain is usually
present in the pelvis, and this should remain in place while the output is greater than 15 mL
in a shift. The loop ileostomy must be managed with routine emptying at least four times a day.
The faceplate adhesive surface must be changed every 4 days. Patient education and management of the ostomy is facilitated by input from an enterostomal therapy nurse.
As mentioned before, avoidance of dehydration and control of ostomy output are essential.
Enteral feedings may start as soon as ostomy output is verified. A low-residue postileostomy
diet is helpful to avoid a food bolus obstruction proximal to the ostomy. Most patients receive
preoperative antibiotics at the time of operation, and the antibiotics are routinely continued for
24 hours postoperatively. The risk of Clostridium difficile is low, but this infection is devastating
if present. The midline wound is at high risk for infection if there is spillage from the ostomy
appliance or leakage beneath the ostomy faceplate onto the midline wound. Caution is important during ostomy changes to prevent contamination and exposure. The patient should be told
that after surgery it is common to pass mucus and blood per anum, especially when the patient
attempts to empty the bladder on a regular basis.
Chapter 9 • Open Total Proctocolectomy and Ileal Pouch 153
Figure 9-37 Figure 9-38
Figure 9-39 Figure 9-40
Mesentery
Functioning limb
2.5-cm spigot
Defunctionalized limb
flush to skin
154 Chapter 9 • Open Total Proctocolectomy and Ileal Pouch
Step 5: Pearls and Pitfalls
The incidence of nerve damage and sexual dysfunction can be reduced by following the same
areolar tissue planes that are used for accomplishing total mesorectal excision for cancer.
However, in a patient with ulcerative colitis and extreme inflammation, this plane may be obliterated and may not be followed easily. In these cases, it may be important to dissect within the
mesorectal envelope in the fat, dividing vessels sequentially and leaving a rim of fat in the pelvis
that protects the nerves. The anterior lateral ligaments should be divided medially rather than
against the lateral side wall of the pelvis to avoid injuring the nerves.
When the pelvis is inspected as the pouch is pulled into the pelvis, the small bowel should
be placed to the patient’s left, and the cut edge of the mesentery should be placed to the right.
Construction of the pouch so that it lays in the curve of the sacrum and the mesentery suspended across the axis of the pelvis anteriorly may provide a better chance of the pouch reaching
the pelvic floor without tension. Construction of the J pouch should be designed to allow the
pouch always to fall into the pelvis and be suspended by the mesentery anteriorly. This design
ultimately causes the inlet of the pouch to be to the patient’s left and exit the left side of the
pelvis and the blind limb of the “J” to be to the right of the mesentery in the right side of the
pelvis.
When the pouch does not reach easily, several measures are possible to lengthen the mesentery. Cross-hatching or transverse incision along the SMA cutting the peritoneum over the fat
and preserving the artery gives 1 to 2 cm in length. Care must be taken to free the SMA pedicle
from the anterior surface of the duodenum. The ileocolic pedicle sometimes tethers the SMA.
Dividing the ileocolic vessel closer to the SMA may provide 1 to 2 cm of length. The window
of peritoneum in the terminal ileum mesentery along the terminal branch of the SMA can be
opened to allow the distal ileum to reach further. This maneuver relieves some tethering from
the apex of the J pouch.
The retention of the ileocolic vascular pedicle has been proposed to allow collateral blood
supply to the pouch. A 5-cm horizontal incision crossing several middle-level arcade blood
vessels, in the area of the 30 cm of terminal ileum that is used to construct the pouch, allows
the mesentery of the terminal ileum to open as the apex of the J pouch advances 5 to 6 cm
toward the anal canal. The decision to preserve the ileocolic vessel must be made early in the
procedure. It is not routine for our practice to preserve the ileocolic vessel because it causes
retraction on the pouch.
On rare occasions, there is a patient in whom the pouch does not reach the pelvis under any
circumstance. The pouch can be suspended from the diverting ileostomy in the pelvis with the
apex opening closed with either staples or a purse-string. Over time, the mesentery and the
bowel may stretch to reach all the way to the pelvic floor; this has occurred only rarely in our
25-year practice.