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Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis 35
A
Figure 3-9
B
Figure 3-10B
Figure 3-10A
C
Figure 3-10C
Incision line
in left gutter
Left Right
Left colon
Surgeon Assistant
Head
Figure 3-11
36 Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis
to enter an avascular plane from the pelvic brim all the way up to the splenic flexure (Figures
3-10B and 3-12). The areolar tissue plane is developed toward the midline to release the
mesentery and colon from the retroperitoneal structures, exposing the left ureter and gonadal
vessels (Figure 3-10C). As the left colon is pushed toward the midline bluntly, the left ureter,
gonadal vessels, and areolar tissue plane are dropped posteriorly all the way down to the
pelvic brim at the sacral promontory and up to the splenic flexure and all the way to the
midline at the aorta (Figure 3-13A and B).
Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis 37
Feet
Cut edge of
mesocolon
Left Right
Surgeon Assistant
Areolar tissue
plane
Identification of
left ureter
Head
Figure 3-12
A
Figure 3-13A
Left ureter
B
Figure 3-13B
38 Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis
u
The splenic flexure is released from the left upper quadrant by incising the lateral peritoneal
attachments with a finger placed in the avascular tissue plane posteriorly and extended up
toward the tip of the spleen. The peritoneum is incised over the finger using the finger as a
guide (Figure 3-14A). As the splenic flexure is released medially, the dissection turns toward
the pancreas, and the attachments of the splenic flexure to the undersurface of the tail of the
pancreas are incised using electrocautery over the finger as a guide (Figure 3-14B). The splenic
flexure attachments are occasionally very dense and attached to the spleen; these adhesions
are freed from the tip of the spleen and the vascular pedicle of the spleen to allow the splenic
flexure to move toward the midline (Figure 3-14C). The omental attachments along the
anterior surface of the splenic flexure and transverse colon are incised with electrocautery to
preserve the omentum and release the colon from the undersurface of the omentum toward
the previously dissected right colon (Figure 3-14D).
Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis 39
A
Figure 3-14A
Tip of spleen
Tail of pancreas
B
Figure 3-14B
Splenic flexure
attachments
C
Figure 3-14C
D
Figure 3-14D
40 Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis
u
When the left colon has been mobilized, the sigmoid colon can be transected at a point
appropriate for the disease process anywhere along its surface from the rectum to descending
colon. The sigmoid 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
(Figures 3-15 and 3-16).
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 now mobilized from
the retroperitoneal structures (Figure 3-17). 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 3-18).
Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis 41
Figure 3-15
Transverse colon
Cecum
Figure 3-16
Terminal
ileum
Inferior
mesenteric artery
hemorrhoidal artery
mesenteric
Left colic
Superior
Inferior
vein
artery
Tumor
Left colon
Descendingsigmoid
junction
Sigmoid colon
Figure 3-17
Figure 3-18
42 Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis
u
The final step is to divide the transverse colon mesentery and vessels at the middle colic
vessel origin over the anterior surface of the pancreas. The base of the right colon mesentery
is pulled to the patient’s right, and an incision is made across the base of the mesentery of
the left colon on the patient’s left. The transverse colon can be lifted anteriorly to reveal the
final attachments of the colon at the third portion of the duodenum. The base of the mesentery of the transverse colon, as the transverse colon is lifted anteriorly, reveals the middle
colic vessels as they form a “
V.” These vessels are divided outside the pancreatic tissue to
protect the anterior surface of the pancreas (Figure 3-19).
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 (Figure 3-20).
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 sigmoid colon. 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 3-21 and 3-22).
Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis 43
Small intestine
Figure 3-20 Figure 3-19
Ligament of
Treitz
Superior
mesenteric artery
Ileosigmoid
anastomosis
Sigmoid colon
Terminal ileum
Figure 3-21 Figure 3-22
44 Chapter 3 • Extended Right Colectomy with Ileosigmoid Anastomosis
u
The transverse opening of the anastomosis is opened widely, the GIA 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 75-mm linear cutter stapler (Figure 3-23). 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 to the base
of the duodenum to prevent herniation and twisting (Figure 3-24). 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 3-25). An adhesive barrier
can be applied, and the abdomen is closed with a running No. 1 loop absorbable suture.
Step 4: Postoperative Care
Patients are ambulated early. They are given intravenous fluid replacement 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 most commonly feared complication after an extended right colectomy and ileosigmoid
anastomosis is anastomotic leak. Anastomotic leak can be prevented by oversewing the transverse staple line and careful construction of the anastomosis without risk of twist, tension, or
ischemia. Closure of the mesenteric defect also prevents herniation and torsion. Occasionally,
patients develop a syndrome known as “ileosigmoid” or “ileorectal” syndrome, in which the
patient develops an ileus after the initial early return of bowel function. The small bowel
becomes distended, bowel function ceases, and the patient becomes nauseated with emesis. A
nasogastric tube is required as well as support with intravenous fluids and parenteral nutrition.
Decompression of the rectal or sigmoid stump with a 34-F mushroom catheter can sometimes
be helpful. This syndrome typically resolves over 4 to 5 days of bowel rest to allow slow resumption of enteral feedings. Most patients have 6 to 10 bowel movements a day at first; this can be
modified with the addition of fiber and antidiarrheals over time.
Selected Readings
Parry S, Win AK, Parry B, et al. Metachronous colorectal cancer risk for mismatch repair gene mutation carriers: the advantage of more
extensive colon surgery. Gut 2011;60:950-7.
You YN, Chua HK, Nelson H, et al. Segmental vs. extended colectomy: measurable differences in morbidity, function, and quality of life.
Dis Colon Rectum 2008;51:1036-43.