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 4 • Extended Left Colectomy with Right Colon–to–Rectal Anastomosis 55
A
Figure 4-12A
C
Figure 4-12C
B
Figure 4-12B
D
Figure 4-12D
Figure 4-13
56 Chapter 4 • Extended Left Colectomy with Right Colon–to–Rectal Anastomosis
u
The IMA pedicle is divided at its origin on the aorta (Figure 4-14). The IMV is 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 4-15).
u
The final step of the bowel resection is to transect the middle colic vessels at their origin over
the anterior surface of the pancreas. The base of the right colon mesentery and the base of
the mesentery of the left colon are lifted anteriorly, exposing the final attachments of the
colon cephalad to the third portion of the duodenum at the base of the mesentery of the
transverse colon. With the transverse colon retracted cephalad, these vessels form a “
can be easily identified and divided outside the pancreatic tissue protecting the anterior
surface of the pancreas (Figure 4-16).
u
After removing the transverse, left, and sigmoid colon as a specimen, the hepatic flexure is
rotated 180 degrees counterclockwise to place the right colon and terminal ileum in the
midline of the abdomen with a straight, untwisted edge of cut mesentery extending from the
duodenum to the pelvic brim (Figure 4-17A). The hepatic flexure and right colon fall to
the pelvis (with the cecum at the pelvic brim) to lie to the left of the midline rectal stump.
The staple line of the hepatic flexure is pulled up to lie adjacent to the cut end of the rectum.
A functional end-to-end, side-to-side anastomosis is accomplished with a firing of the 75-mm
linear cutter stapler through the open antimesenteric corners of the transverse staple lines
through the right colon and the rectum (Figure 4-17B). The resulting opening is closed using
a transversely placed staple line of the 75-mm linear cutter stapler, with the GIA staple lines
distracted as far as possible. The transverse staple line is inverted with a continuous 3-0
absorbable suture with Lembert sutures. The apex of the GIA staple line at the crotch between
V” and
Figure 4-14
Chapter 4 • Extended Left Colectomy with Right Colon–to–Rectal Anastomosis 57
Superior mesenteric artery
Ileocolic vessels
(preserved)
Figure 4-15
Right colon
Rectum
A
Right colon–to–rectal anastomosis
B
Figure 4-17A-B
Figure 4-16
58 Chapter 4 • Extended Left Colectomy with Right Colon–to–Rectal Anastomosis
the right colon and the rectum is protected with a 3-0 absorbable suture between the portions of bowel. The mesenteric defect is closed with a continuous absorbable suture from the
duodenum along the mesenteric edge of the terminal ileum and right colon down to the level
of the sacral promontory and the rectal stump; this may prevent volvulus and internal
herniation (Figure 4-18).
Step 4: Postoperative Care
The abdomen is closed with a running No. 1 loop absorbable suture and staples, and sterile
gauze is applied. 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 venous thrombosis prophylaxis and encouraged to ambulate as
much as possible during the early postoperative period. Usual hospital stay after an open
extended left 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 patientcontrolled analgesia followed by a switch to oral analgesics.
Step 5: Pearls and Pitfalls
The most commonly feared complication after an extended left colectomy and right colon-torectal anastomosis is anastomotic leak. These leaks can be prevented with oversewing of the
transverse staple line and careful construction without risk of twist, tension, or ischemia. The
closure of the mesenteric defect also prevents herniation and torsion. An incidental appendectomy may be prudent to prevent difficulty with diagnosis of acute appendicitis and its related
complications because the appendix may now reside in the left lower quadrant. 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. Preservation of the water-absorptive surface of the right colon
should yield improved bowel function over time.
Selected Readings
Adriano T, Gianluca M, Vittorio F. A technique for colorectal anastomosis after extended left colectomy. Eur J Surg 1998;164:627-8.
Le TH, Gathright JB Jr. Reconstitution of intestinal continuity after extended left colectomy. Dis Colon Rectum 1993;36:197-8.
Chapter 4 • Extended Left Colectomy with Right Colon–to–Rectal Anastomosis 59
Figure 4-18
Step 1: Clinical Anatomy
C H A P T E R
5
Open Left and
Sigmoid Colectomy
Matthew G. Mutch
The left colon lies along the left side of the abdomen suspended from the splenic flexure to the
pelvic brim by lateral peritoneal attachments. The mesentery of the left colon arises from the
midline of the abdomen along the aorta. The sigmoid colon has no lateral peritoneal attachments
other than some congenital adhesions, which fix the apex of the sigmoid to the pelvic brim and
the iliac fossa. Otherwise, the sigmoid colon is attached to the retroperitoneum through a
midline mesentery arising from the inferior mesenteric artery (IMA) and extending down into
the pelvis to the mesorectum. The splenic flexure is attached to the undersurface of the tip of
the spleen, the lower edge of the tail of the pancreas, and the anterior surface of the left kidney
by various levels of suspensory ligaments and peritoneal extensions. The blood supply to the
left colon is based on the IMA, which arises from the anterior surface of the aorta just above
the bifurcation of the common iliac arteries. The IMA extends anteriorly and bifurcates to
produce the superior rectal artery feeding the sigmoid colon and the rectum. The left colic artery
extends cephalad to provide the left colon and distal splenic flexure with blood supply through
the arcade at the mesenteric edge known as the marginal artery of Drummond. The retroperitoneum behind the left colon contains the left ureter and the gonadal vessels lying over the
psoas muscle. The ureter crosses the iliac vessels at the bifurcation of the iliac vessels into the
external and internal iliac branches (Figure 5-1).
Step 2: Preoperative Considerations
60
A mechanical bowel preparation may be beneficial because it eliminates formed stool in the
distal colon and improves handling and anastomosis formation. However, it is not required,
and enemas may suffice. Antibiotic prophylaxis begun preoperatively and continuing for 24
hours postoperatively is recommended. Deep vein thrombosis prophylaxis by means of sequential compression devices is required and may be supplemented with subcutaneous heparin.
Preoperative tattooing of a neoplastic lesion is very helpful to identify a small lesion
intraoperatively.
Pancreas
Spleen
Chapter 5 • Open Left and Sigmoid Colectomy 61
Left kidney
Transverse
colon
Splenic
flexure
Duodenum
Figure 5-1
IMV
IMA
Left ureter
Left colon
62 Chapter 5 • Open Left and Sigmoid Colectomy
Step 3: Operative Steps
u
The patient is placed in lithotomy position using Allen’s stirrups with sequential compression
devices and bladder catheter in place. The rectum is irrigated to clear the rectum of any solid
stool. The patient’s arms are placed with the left arm extended and the right arm tucked to
allow an overhead Mayo stand placed for draping. The abdomen is entered through a vertical
midline incision from xiphoid to pubis, and the Bookwalter retractor (Codman, Raynham,
Mass.) is placed for exposure and opened widely. The small bowel is retracted to the right
upper quadrant and upper midline.
u
An incision is made at the base of the lateral aspect of the left colon mesentery along the
white line of Toldt with the left colon retracted medially and anteriorly (Figure 5-2). The
incision is extended from the pelvis to the left upper quadrant. The exposed areolar tissue
plane allows dissection anterior to the retroperitoneum (Figure 5-3). Blunt dissection frees
the left colon from the retroperitoneum and exposes the ureter and gonadal vessels within
the retroperitoneum (Figure 5-4). The blunt dissection is carried medially to the base of the
aorta and cephalad to the splenic flexure level, freeing the left colon from the anterior surface
of the kidney (Figure 5-5).
Chapter 5 • Open Left and Sigmoid Colectomy 63
Figure 5-2
Figure 5-4
Figure 5-3
Figure 5-5
64 Chapter 5 • Open Left and Sigmoid Colectomy
u
An incision is made on the peritoneal attachments of the splenic flexure using the finger as
a guide, incising lateral to medial to release the splenic flexure from the undersurface of the
tip of the spleen, the lateral aspect of the abdominal cavity, and the anterior surface of
the kidney (Figure 5-6). The tip of the spleen is freed from the splenic flexure, releasing the
multiple congenital adhesions and incising the omental attachment to release the splenic
flexure toward the midline (Figure 5-7). The attachments of the splenic flexure to the undersurface of the tail of the pancreas and the retroperitoneum are incised all the way to the
midline toward the duodenum at the ligament of Treitz (Figure 5-8).
u
The omental attachments to the anterior surface of the transverse colon are incised, releasing
the splenic flexure from the left upper quadrant. The omental attachments to the transverse
colon are incised all the way to the middle of the transverse colon or to the right colon itself
(Figure 5-9).