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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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262 Atlas of Gastrointestinal Surgery: The Small Bowel
The illustrated lesion involves only a small
segment of the small bowel mesentery, allow-
Desmoid
tumor
Superior
mesenteric
artery
Small
bowel
ing resection of that segment of small bowel
and complete resection of the desmoid tumor
with a surrounding wedge of mesentery (1).
The bowel is divided proximally and distally
with a linear stapler. The mesentery is divid-
ed between Kelly clamps and ligated with
2-0 silks. An end-to-end anastomosis
is performed with an inner continuous
layer of 3-0 synthetic absorbable
suture and an outer layer of inter-
rupted 3-0 silk Lembert sutures.
1
The defect in the mesentery is closed with inter-
rupted 3-0 silks (2). The abdomen is copiously
irrigated with an antibiotic-containing solution,
and the wound is closed in layers.
2
Bypass of Unresectable Small Bowel
Desmoid Tumor
Operative Indications
In some instances, a desmoid tumor is so extensive, spanning the root of virtually the
entire small bowel mesentery, that it is not resectable without resecting the entire
small bowel (1). In such cases, if there
is sufficient proximal small bowel
free to perform a side-to-side
anastomosis with the
colon, that is the pre-
ferred treatment.
Desmoid
tumor
Superior
mesenteric
artery
Transverse colon
Small
bowel
Jejunum
1
Ileum
264 Atlas of Gastrointestinal Surgery: The Small Bowel
Such patients generally have been tried on the various agents used to treat unresectable desmoid tumors, such as sulindac,
tamoxifen, and a variety of chemotherapeutic agents. In the case illustrated here, high-grade partial small bowel obstruction
is present; the patient can only be treated with a bypass procedure.
Operative Technique
The patient is explored though a midline incision. The patient illustrated here
has virtually the entire root of the small bowel mesentery involved with the
extensive desmoid tumor. Approximately 5 ft of proximal small bowel is free
prior to involvement by the desmoid tumor; this free small bowel is anastomosed
side-to-side to the midtransverse colon. This is performed with an inner contin-
uous layer of 3-0 synthetic absorbable suture material and an outer interrupted
layer of 3-0 silk Lembert sutures (2). The abdomen is copiously irrigated with
an antibiotic-containing solution, and the
wound is closed in layers.
Side-to-side
anastomosis
(bypass)
Transverse
colon
Small bowel
Small bowel
involved with
desmoid tumor
2
End Ileostomy
Operative Indications
An end ileostomy is usually created following a colectomy or
proctocolectomy for infectious, neoplastic, or inflammatory dis-
eases of the large bowel. It is important to have an enterostomal
therapist meet with the patient prior to surgery to mark the stoma
site. (1). The proper location of an ileostomy can prevent stoma
prolapse, hernia, or skin irritation. This procedure can be per-
formed laparoscopically or through an open wound. The open
procedure is described below.
Operative Technique
As previously mentioned, an end ileostomy is usually performed
in conjunction with another abdominal procedure. If no incision
has been made, a 7 cm periumbilical midline incision is used.
1
266 Atlas of Gastrointestinal Surgery: The Small Bowel
Skin
2
Rectus m.
and
fat
Subcutaneous fat
Using right angle retractors, the skin edges are retracted allowing
the anterior fascia of the rectus muscle to be visualized. The
anterior fascia is opened vertically with the electrocautery at
least 3–4 cm to the right of the midline incision (3). If this
Prior to closure of the abdomen, an elliptical
disk of skin and subcutaneous tissue is
removed with the electrocautery device from
the abdominal wall at the site where the
stoma marking was placed (2).
Anterior fascia
of
rectus muscle
distance is not preserved, it will be more difficult for closure
of the midline abdominal wound. The underlying rectus mus-
cle is gently spread with a large Kelly clamp and the posteri-
or fascia is opened with the electrocautery. To prevent injury
to underlying structures, a Mikulicz pad is placed in the
abdomen directly underneath the stoma site.
3
Once all layers have been opened, the stomal opening
should allow passage of one fingerbreadth easily (4).
4
Caudad Cephalad
End Ileostomy 267
A large Babcock clamp is then placed through the ostomy
site, and the end of the ileum is grasped and gently brought
through the stomal opening (5). The ileum should come
through the ostomy site without undue compression.
Careful attention should be given to the orientation of the
small bowel mesentery so that it does not twist. Correct
orientation places the ileal mesentery in the cephalad
Ileum
5
Mesentery
Seromuscular tacking sutures of 3-0 silk are placed
position as it passes through the stomal opening.
a
between the ileum and the peritoneum of the abdominal
wall. The mesentery of the ileum is tacked to the posterior
abdominal wall in a cephalad direction to prevent an inter-
nal hernia. The midline incision is closed. The staple line on
the bowel is removed with the electrocautery device.
A standard Brooke ileostomy (6) is created by placing a full-
thickness 3-0 absorbable suture through the open end of the
ileum (a), followed by a more proximal seromuscular tacking stitch
in the ileum at the level of the skin (b), and finally through the der-
mis (c). Four such sutures are placed, one in each quadrant.
cb
6
268 Atlas of Gastrointestinal Surgery: The Small Bowel
Prior to securing the sutures, a right-angle
clamp is used to help evert the ileum to form
a rosebud ileostomy (7). One or two 3-0
absorbable sutures are placed between each
of the four quadrant sutures to approximate
the ileum to the skin.
An end ileostomy should extend 1.5 to
2 cm above the skin because the effluent is
corrosive (8). A transparent ostomy appli-
7
End ileostomy
ance is placed.
Mesentery
tacked to
posterior
abdominal
wall
8
Loop Ileostomy
Operative Indications
The purpose of a loop ileostomy is to temporarily divert the fecal stream while a portion of the intestine beyond the ileosto-
my heals; as in the case of a distal intestinal anastomosis or perianal fistulae. The diverting loop ileostomy is made by bring-
ing a loop of terminal ileum through the abdominal wall. Typically, the right lower quadrant is used for ileostomy place-
ment. This procedure can be done open or laparoscopically. The benefit of a loop ileostomy over an end ileostomy is that
both ends of the bowel are brought through the abdominal fascia, and therefore, it is easier to reverse the stoma. However,
a loop ileostomy may not protrude from the abdominal wall as much as an end ileostomy, and therefore, irritation of the
skin around the stoma is a frequent problem. In this chapter, some tips for avoiding this will be demonstrated. It is impor-
tant to have an enterostomal therapist meet with the patient prior to surgery to mark the stoma site. Perioperative antibi-
otics and prophylaxis against deep vein thrombosis should be used.
Operative Techniques
Often a loop ileostomy is made in combination with a bowel resection and the
abdominal incision has already been made. If no incision has been made, a
7-cm periumbilical midline incision is used with the patient in the supine posi-
tion. The terminal ileum is identified and the portion of the bowel with the
best likelihood of reaching the stoma site is identified. Often little or no mobi-
lization of the right colon is required.
Once a loop of bowel is identified, a defect is created in the mesentery and
an umbilical tape is passed through this window. This facilitates bringing the stoma
through the abdominal wall. It is important to mark the orientation of the bowel,
since twisting during the creation of the stoma can occur easily. One stitch is placed
to mark the proximal limb, and two stitches are placed to mark the distal limb.
270 Atlas of Gastrointestinal Surgery: The Small Bowel
Attention is turned to creating the
opening in the abdominal wall. The first
step is to remove a disk of skin. A #15
blade scalpel is used to cut a circle of skin
approximately 2 cm in diameter. If the
patient has abdominal wall fat, a cylinder
of fat can be excised with the skin (1).
This aids in visualization of the fascia. A
laparotomy pad is placed underneath the
fascia at the stoma site to avoid injury to
the underlying bowel.
Skin
and
fat
Rectus m.
1
The right lower quadrant is elevated by the
Distal
limb
Proximal
limb
Ileum
operating surgeon’s left hand to facilitate iden-
tification of the fascia. The fascia is opened
transversely to expose the rectus abdominis
muscle. The rectus muscle is split using a
large Kelly clamp. The posterior fascia is
then opened. It is important to check for
hemostasis prior to bringing the bowel
through the stoma opening. The umbilical
tape is grasped with a large Kelly clamp,
and the bowel should come through the
stoma opening with minimal diffi-
culty (2). The orientation of
the bowel is confirmed and
the stoma rod placed. The
midline abdominal inci-
sion is irrigated and
closed in layers. Dressings
are applied.
2
Loop Ileostomy 271
The ileum is opened in a manner so that the bowel
lumen can be everted. The technique used is a modifi-
cation of the original Turnbull ileostomy. The distal
bowel is opened transversely approximately 2/3 the
circumference of the bowel, at a distance of about
5 mm above and parallel to the skin (3).
Stoma rod
3
The distal end of the ileum is secured directly to the dermis, while the proximal end is everted over the remaining bowel
and secured with 3-0 absorbable sutures (4 and 5). This secures the stoma rod without suturing the rod itself. Securing
the rod with sutures can make replacement of the appliance more difficult and painful for the patient. The appliance is
placed over the stoma opening.
Proximal
ileum
Distal
4 5
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