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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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332 Atlas of Gastrointestinal Surgery: The Colon
Once complete mobilization of the right
colon is confirmed by gentle traction of the mobi-
lized bowel toward the pelvis, the abdomen is irri-
gated and evaluated for hemostasis. A laparoscopic
Babcock clamp is placed on the cecum. The pneu-
moperitoneum is released and a 4-cm vertical peri-
umbilical incision is made. A wound protector is
placed around this midline incision and the
right colon is removed by advancing the laparo-
scopic Babcock clamp through the midline
wound and grasping the bowel with a handheld
Babcock clamp (7).
Right colon
7
The terminal ileum, cecum, ascending colon, and
a portion of the transverse colon are retrieved
through the midline wound (8).
8
This allows both ends of bowel to be
available for division and creation of the
anastomosis. The remaining mesentery
Laparoscopic Right Hemicolectomy 333
and the small and large bowel are
divided extracorporally (9).
Mesentery
Transverse
colon
Right colon
Ileum
9
334 Atlas of Gastrointestinal Surgery: The Colon
A handsewn or sta-
End-to-end ileocolic anastomosis
pled anastomosis can be
performed. The commonly
employed handsewn tech-
niques include an end-to-
end, a side-to-side, or an
end-to-side anastomosis.
When performing an end-to-end
anastomosis (10), a size discrepan-
cy may exist between the lumen of the
small bowel and that of the colon.
Transverse
colon
Ileum
10
Ileum
11
To correct for this discrepancy, a small cut with
Tr. colon
the electrocautery (Cheatle maneuver) can be
made in the antimesenteric portion of the small
bowel (11).
Tr. colon
After the handsewn anastomosis is com-
pleted the bowel is placed back into the
peritoneal cavity. The mesenteric defect is
absorbable suture (12).
Ileum
12
13
Ileum
Laparoscopic Right Hemicolectomy 335
Alternatively, a stapled anastomosis may be performed. This can
be performed as a side-to-side or end-to-side anastomosis. The
side-to-side anastomosis is performed by aligning the antimesenteric
borders of the small bowel and colon and removing the abutting
corners of the staple lines. The linear stapler is introduced
through these openings (13). Avoiding the mesentery,
the stapler is closed and fired, connecting the two
Colon
lumens. The staple line is inspected for hemostasis.
The remaining enterotomy is
approximated with Allis clamps
(14). It is best to offset the
previous staple lines to
avoid overlapping them
in the final staple line.
The final closure is per-
formed by firing a linear sta-
pler just below the Allis
clamps. Heavy scissors are used
to remove the remaining bowel
along with the Allis clamps.
14
336 Atlas of Gastrointestinal Surgery: The Colon
The anastomosis can be further secured with a row
of Lembert sutures placed to bury the staple line.
Furthermore, a single stitch is placed to prevent ten-
sion at the apex of the anastomosis (15).
No drains are required for this procedure.
15
Ileum
Colon
The port sites are closed prior to closure of the
midline wound. A narrow malleable retractor
is placed through the midline wound to pre-
vent bowel injury while closing the port
sites. The midline wound is closed
with interrupted sutures. The
wounds are irrigated and
closed with a subcuticular
stitch. Subcutaneous 25%
Marcaine is injected for
additional pain control.
Dressings are applied.
Left Hemicolectomy
Operative Indications
The operation of choice for tumors involving the dis-
tal transverse colon, splenic flexure, or descending
colon is a left hemicolectomy. An anastomosis is
Omentum
typically created between the midtransverse and
the sigmoid colon (1, line A-B). The operation
includes division of the left colic artery with preser-
vation of the right branch of the middle colic
artery and the inferior mesenteric artery. In older
patients with sigmoid diverticular disease or ath-
erosclerotic disease, an anastomosis in the
sigmoid colon may not heal well; therefore an
anastomosis in the rectosigmoid should be per-
formed (1, line A-C). Preoperative prepara-
tion of the patient includes an optional mechan-
ical bowel preparation, intravenous antibiotics,
and prophylaxis for deep vein thrombosis.
Transverse
colon
Left br.
of middle
colic a.
IMA
Left
colon
Left
colic a.
Sigmoid colon
Rectum
1
338 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
The patient is positioned in the supine or lithotomy position,
with the left arm tucked. This allows for an additional assis-
tant to retract the abdominal wall to better expose the splenic
flexure. A midline incision is made in preparation for removal
of the left colon (2). A self-retaining retractor is used to
assist in exposure. The patient’s abdomen is thoroughly
explored for metastatic disease. The liver and periaortic
regions are palpated, and the small intestine and colon are
inspected in a systematic fashion. During exploration, the sur-
2
The procedure begins with careful midline
retraction of the small bowel and left colon by
the assisting surgeon. The operating sur-
geon mobilizes the attachments of the
left colon along the line of Toldt with
the electrocautery (3). When
mobilizing the left colon medially,
it is important to recognize the
position of the left ureter which
geon should assess for evidence of locally advanced disease
involving the omentum, stomach, small bowel, or spleen. If
locally advanced disease is found, every effort is made to
remove the involved structures.
Line of Toldt
Left
colon
3
Left ureter
Gonadal
vessels
lies medial to the gonadal ves-
sels and superior to the com-
mon iliac artery. Once the
ureter is visualized, the sig-
moid colon can be mobi-
lized to the level of the rec-
tosigmoid junction.
Left Hemicolectomy 339
A right-angle clamp may be placed under the peritoneal attachments by the assistant surgeon to prevent injury to under-
lying structures.
The splenic flexure attachments are released (4); electrocautery generally is sufficient to maintain hemostasis during this
step. However, care must be taken when applying traction to any attachments to the spleen so that the splenic capsule is
not injured. Further mobilization of the left colon occurs with the release of the attachments of the greater omentum from
the transverse colon. Often, the omentum will wrap itself around the colon preventing easy separation of the omental fat
from the mesenteric fat.
Stomach
Spleen
Colon
4
340 Atlas of Gastrointestinal Surgery: The Colon
IMA
Left
colon
Left colic a.
5
Sigmoidal br.
Sigmoid colon
Once the left colon is fully mobilized, ligation of the vascular supply is easily accomplished. First the left colic artery is
identified as it branches from the inferior mesenteric artery toward the descending colon (5). The left colic vessels are ligat-
ed with either a 2-0 nonabsorbable suture ligature or a second reinforcing tie. The mesentery can then either be divided to
the mid sigmoid colon or to the rectosigmoid junction.
Sigmoid colon
Left Hemicolectomy 341
A linear stapling device is used
either at the sigmoid or the recto-
6
sigmoid junction to divide the distal
bowel (6).
The left branch of the middle colic is identi-
fied more readily if the mesentery of the splenic flexure
and distal transverse colon is divided first. The middle
Rectosigmoid
colic artery is identified and followed to its branching
point. The left branch is then identified as it courses
toward the splenic flexure, divided, and ligated with
a 2-0 nonabsorbable tie. Division of the mesentery is
completed, and the proximal bowel is divided with with
a linear stapling device (7).
Transverse
colon
Middle
colic a.
7
Left
colon
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