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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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242 Atlas of Gastrointestinal Surgery: The Small Bowel
Long
enterotomy
Side-to-side
anastomosis
8
9
10
Occasionally the stricture is too long to be managed with a Heineke–Mikulicz strictureplasty, and a long side-to-side
anastomosis may be performed. One suture is placed at the midpoint of the long stricture, and a second suture is placed
approximating the two ends of the bowel just proximal and distal to the stricture. A long U-shaped enterotomy is creat-
ed through the long strictured portion of bowel (8). A long side-to-side anastomosis is performed, much in the fashion
of a Finney pyloroplasty. This is carried out with an inner continuous layer of 3-0 synthetic absorbable suture material (9)
and an outer interrupted layer of 3-0 silk Lembert sutures (10). This results in elimination of the obstructing point in the
bowel, without the sacrifice of any normal or diseased bowel. The clinical course following strictureplasty has been demon-
strated to be similar to that following resection of diseased segments.
Some surgeons prefer to mark the area of strictureplasty with ligaclips, so that on subsequent barium studies the areas
of strictureplasty can be monitored for further narrowing. The peritoneal cavity is copiously irrigated with an antibiotic-con-
taining solution and closed.
Enteric Fistulas in Crohn’s Disease
Operative Indications
One of the propensities of Crohn’s disease, which is a transmural, full-thickness idiopathic inflammatory disease involving
the entire gastrointestinal tract, is to form fistulas into other loops of small bowel or other adjacent structures such as the
colon, the bladder, or the vaginal cuff in a female post-hysterectomy. In addition, a loop of diseased bowel caught up by
adhesions to the undersurface of an abdominal incision may become a site of fistulization through the old incision out onto
the skin. Although enteric fistulas are not, in and of themselves, an indication for surgery, in most instances they are an
indication of active disease, and surgery will often be required.
Crohn’s Disease of the Terminal Ileum
Involving the Sigmoid Colon
Operative Technique
The patient is explored through a midline abdominal incision. The entire
gastrointestinal tract is examined to evaluate the extent of disease. In the
patient illustrated here, approximately 1 foot of terminal ileum is involved
with Crohn’s disease, and the patient has not undergone prior surgery.
A redundant sigmoid
colon, stuck to the diseased
segment of terminal ileum
(1), can easily be dissected
Ascending
colon
Cecum
Fistula
site
Terminal ileum
Sigmoid colon
1
free. However, after separating
the sigmoid colon from the terminal
ileum, one could take a small clamp and enter
both the terminal ileum and the sigmoid colon through small fistula sites.
Ascending
colon
Crohn’s Disease of the Terminal Ileum Involving the Sigmoid Colon 245
2a
Fistula
site closed
2b
Distal ileum
Since the sigmoid colon is otherwise
normal and not involved with Crohn’s dis-
ease, the site into the sigmoid colon is
merely closed with a layer of 3-0 silk
Lembert sutures (2a). The terminal ileal dis-
ease is resected. Utilizing a linear stapler the right
colon is divided just beyond the cecum. The ileum is
Sigmoid colon
divided 3 or 4 cm proximal to the gross disease in the
ileum. The segment of mesentery to the diseased bowel is divided between Kelly clamps and ligated with 2-0 silk. The
specimen is removed from the operative field. The end of the ileum is inverted with a layer of 3-0 silk Lembert sutures. A
side-to-end ileocolostomy is performed with an inner continuous layer of 3-0 synthetic absorbable suture material and an
outer interrupted layer of 3-0 silk Lembert sutures (2b). The rent in the mesentery can be closed with either continuous
or interrupted sutures. After irrigation of the abdominal cavity with antibiotic-containing solution, the abdomen is closed.
Crohn’s Disease of the Terminal Ileum with
a Sigmoid Fistula into the Sigmoid Colon,
Also Involved with Active Disease
Operative Technique
The patient is explored through a midline incision. The entire gastrointestinal
tract is run to evaluate the extent of disease. The patient illustrated has involve-
ment of approximately 1 foot of terminal ileum and has not previously been
operated upon for Crohn’s disease. There is also obvious gross involvement of
The sigmoid colon and terminal
ileum are tightly adherent, with
inflammatory disease (1). In
separating the terminal ileum
from the midsigmoid colon, a
large fistula between the ileum
the midportion of the sigmoid colon with Crohn’s disease.
Ascending
colon
Sigmoid
colon
Cecum
Distal ileum
and colon is evident. The grossly
involved segment of sigmoid colon
is resected by firing the linear stapler 3
or 4 cm proximal to and distal to the gross
disease. The mesosigmoid to this area of bowel is divided
between Kelly clamps and ligated with 2-0 silks.
1
Crohn’s Disease of the Terminal Ileum with a Sigmoid Fistula into the Sigmoid Colon, Also Involved with Active Disease 247
Ascending
colon
End-to-end
colocolostomy
2b
Distal ileum
An end-to-end colo-
colostomy is performed
with an inner continuous layer of
3-0 synthetic absorbable suture material
and an outer interrupted layer of 3-0 silk Lembert
sutures (2a). The rent in the mesentery is closed
with either continuous or interrupted sutures.
The ascending colon is divided just above the
cecum with a linear stapler. The distal ileum is divid-
ed 3 or 4 cm proximal to the gross disease, again
with a linear stapler. The mesentery to this segment of dis-
eased bowel is divided between Kelly clamps and ligated with
Sigmoid
colon
2a
2-0 silks. An end-to-end ileoascending colostomy is performed in two layers. The inner layer consists of a continuous syn-
thetic absorbable suture, and the outer layer consists of multiple interrupted 3-0 silk Lembert sutures. The rent in the small
bowel mesentery is closed with either interrupted or continuous sutures (2b). The abdomen is copiously irrigated with
antibiotic-containing solution and closed.
Crohn’s Disease of the Distal Ileum with
Enterovesical Fistula
Operative Technique
The patient is explored through a midline abdominal incision and the entire gas-
trointestinal tract is evaluated for the extent of disease. In the illustrated patient,
who has not been operated upon previously, only the distal ileum is involved,
with a fistula between the bladder and a segment of ileum (1 and 2). The dis-
tal ileum is dissected off of the dome of the bladder and, after separating the
two organs, a small clamp can easily be passed into the bladder, and into ileum,
at the sites of the fistula. The bladder is closed in two layers using interrupted
3-0 synthetic absorbable sutures. A Foley catheter,
placed preoperatively, is left in for 1
week postoperatively.
Distal
ileum
Fistula site
Ascending
colon
Proximal
ileum
Bladder
1
Crohn’s Disease of the Distal Ileum with Enterovesical Fistula 249
Mesentery
Normal
ileum
Diseased
ileum
Fistula
Bladder
2
A segment of ileum may be involved with gross disease. This segment of bowel is resected by firing the linear stapler
both proximally and distally, 3 or 4 cm from gross disease. The mesentery to this segment of bowel is divided between
Kelly clamps and ligated with 2-0 silks.
250 Atlas of Gastrointestinal Surgery: The Small Bowel
An end-to-end ileocolostomy is performed with an inner continuous layer
of 3-0 synthetic absorbable suture material, and an outer layer of interrupt-
ed 3-0 silk Lembert sutures. The rent in the mesentery is closed with either
interrupted or continuous suture. An omental flap is constructed to cover the
bladder closure and separate it from the intestinal anastomosis (3).
The abdomen is copi-
ously irrigated with antibi-
otic-containing solution
and closed.
End-to-end
ileocolostomy
Mesentery
Ileum
Omental
flap
Bladder
3
Crohn’s Disease of the Distal Ileum
with a Fistula into the Vaginal Cuff
Operative Technique
The patient is explored through the old lower midline abdominal incision. The entire
gastrointestinal tract is examined for evidence of Crohn’s disease. This illustration repre-
sents a patient who has previously undergone an abdominal hysterectomy, but has not
had prior surgery for Crohn’s disease. Involvement of a midsegment of ileum only is
depicted here, with the ileum tightly adherent to the vaginal cuff (1).
Bladder
Ileum
Peritoneal flap
Fistula
Vagina
Rectum
1
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