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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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352 Atlas of Gastrointestinal Surgery: The Colon
8
Sigmoid
colon
Mesentery
At this point, the mobilized segment of bowel is ready to be removed from the abdomen. Before opening the
abdomen, the proximal staple line on the mobilized sigmoid colon is grasped with a laparoscopic Babcock clamp. Either a
vertical midline incision or a left lower quadrant incision is made that is large enough to allow removal of the bowel. A
small wound protector is placed. The open wound is retracted with a small Richardson abdominal retractor in order to visu-
alize the end of the sigmoid colon grasped by the laparoscopic Babcock clamp. A hand-held Babcock clamp is passed
through the midline wound and placed on the specimen and the laparoscopic Babcock is released. With gentle traction,
the bowel should come up out of the wound easily. (8)
Rectosigmoid
(divided)
Laparoscopic Left Hemicolectomy 353
Sigmoid
Left colon
Transverse colon
divided extracorporeally
9
Once the bowel is removed from the abdomen and the
proximal resection site is identified, the remaining mesentery
is divided. A Babcock clamp is placed on the bowel prox-
imally, and the bowel is divided distally with the electro-
cautery, or a linear staple (9).
If an intracorporeal anastomosis is performed, a cir-
cular gastrointestinal stapling device is used. To deter-
mine the necessary staple size, a sizer is placed into the
proximal colon after the stapler line is removed. The same
sizer can also be introduced into the rectum through the
anus to ensure the stapling device will pass easily. A purs-
estring suture is then placed around the edge of the proxi-
mal bowel using 2-0 nonabsorbable synthetic suture, and
the anvil is inserted and secured (10).
10
Anvil in
transverse colon
354 Atlas of Gastrointestinal Surgery: The Colon
Circular stapler
The proximal end of the bowel is
returned to the abdominal cavity and a
pneumoperitoneum is re-established by
11
12
Rectum
occluding the wound protector. Under
visualization through the laparoscope, a circular sta-
pler is inserted into the rectum and gently rotated follow-
ing the curvature of the rectum (11 and 12). The stapler
is advanced until the trocar pierces the stapled end of the
rectosigmoid. The detachable introducer is removed
from the trocar and the abdomen through a 10-mm
port. The anastomosis is created by placing a
grasper on the proximal trocar and inserting it
onto the shaft attached to the circular stapling
device (13). The two ends of bowel are approx-
imated by rotating the handle on the end of the cir-
cular stapling device. The stapler is fired under visualization
through the laparoscope.
Anvil in
transverse colon
Circular
stapler in
rectum
13
14
Transverse colon
Laparoscopic Left Hemicolectomy 355
Rectum
To open the stapling device, the handle on the end of the circular stapler is rotated in the opposite direction, releasing the
stapler from the anastomosis (14). The stapling device is gently removed from the rectum, and the two “donuts” of bowel
tissue are examined for completeness.
Testing the anastomosis to insure that it is secure is accomplished by covering the anastomosis with saline, occluding the
bowel proximal to the anastomosis, and inserting air into the rectum. If the anastomosis is air tight, no air leakage should
be noted from the anastomosis. The abdomen is then irrigated with an antibiotic-containing solution, the pneumoperitoneum
is removed, and the wounds are closed with synthetic absorbable suture.
Sigmoid Colectomy
Operative Indications
The most common indication for a sigmoid
colectomy is involvement with diverticular dis-
ease (1). Diverticular disease is one of the
most common gastrointestinal disorders
requiring surgical care. Historically, surgical
treatment of this disease was indicated after
an initial presentation of complicated diver-
ticular disease or after a second hospitaliza-
tion for uncomplicated diverticular disease.
In the era of newer and more effective oral
antibiotics and the ability to determine sur-
gical outcomes from large patient databases,
the issue of when to operate on recurrent
uncomplicated diverticular disease is being
re-evaluated.
To confirm active diverticular disease and to
prevent resection for disorders such as irritable
bowel syndrome, active diverticular disease should be
documented on CT imaging prior to resection. In addition,
removal of the entire diseased sigmoid colon is imperative so that nor-
mal healthy descending colon can be anastomosed to normal rectum.
Left
colon
IMA
Sigmoid
mesentery
Rectum
1
Diverticula
Preoperative preparation of the patient includes an optional mechani-
cal bowel cleansing, intravenous antibiotics, and prophylaxis for deep
vein thrombosis.
Sigmoid Colectomy 357
Operative Technique
The patient is placed in the lithotomy position with the left
arm tucked at the patient’s side to allow room for an assistant
to retract the abdominal wall should the splenic flexure need
to be mobilized. A midline infra-umbilical incision (2) is made
and a self-retaining retractor is used. An abdominal exploration
will usually demonstrate an elongated sigmoid colon with a
thickened mesentery. Large palpable diverticula filled with
stool may be present. Palpation of the colon will usually reveal
2
normal bowel proximal and distal to the diseased segment. At
The procedure begins with careful retraction
of the small bowel and left colon to the
patient’s right side by the assisting surgeon.
The operating surgeon then mobilizes the
attachments of the left colon along the line
of Toldt. When mobilizing the left colon
medially, it is important to recognize the
this point, a decision usually can be made as to whether or not
the splenic flexure will need to be mobilized.
Left
colon
L. ureter
position of the left ureter, which lies
medial to the gonadal vessels and supe-
rior to the common iliac artery (3).
Sigmoid
colon
3
358 Atlas of Gastrointestinal Surgery: The Colon
4
Rectosigmoid
Once the ureter is visualized, the sigmoid
colon can be mobilized to the level of the
rectosigmoid junction (4).
Left ureter
Gonadal vessels
Left colon
For benign disease, the bowel is often divided prior
to dividing the mesentery. Small defects are created in
the mesentery adjacent to the bowel with the elec-
trocautery device, and the linear stapler is used
to divide the diseased segment from the proxi-
mal normal colon and the distal rectum (5).
IMA
Rectosigmoid
5
Sigmoid Colectomy 359
Mesosigmoid
6
The mesosigmoid is then divided and the mesenteric vessels are ligated with 2-0 nonabsorbable
suture material (6).
360 Atlas of Gastrointestinal Surgery: The Colon
Transverse
colon
Posterior
outer row
7
Posterior
inner row
(locking)
Rectosigmoid
8
Staple lines
excised
Anterior
inner row
9
10
In preparation to perform a handsewn coloproctostomy, it is important to clear the mesentery from around the ends of
the bowel to be anastomosed. At this time, the bowel proximal should be carefully inspected for any hidden diverticula
that may hinder the performance of the anastomosis. The two ends of the bowel must be brought together without ten-
sion. The anastomosis begins with a placing a posterior row of interrupted 3-0 silk Lembert sutures. Gentle traction on
the lateral sutures stabilizes the colon for placement of these stitches (7). The staple lines are then excised with electro-
cautery (8) and the posterior row of sutures are cut. The posterior inner layer consists of a continuous locking suture using
3-0 synthetic suture material (9) brought around anteriorly as a Connell stitch (10).
11
Sigmoid Colectomy 361
The outer anterior layer consists of
interrupted 3-0 silk Lembert sutures
(11 and 12).
12
L. colic a.
Rectosigmoid
Left
colon
Coloproctostomy
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