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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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362 Atlas of Gastrointestinal Surgery: The Colon
Left
colon
pler in either an end-to-end (13 and 14) or side-to-end configuration (15).
Details of this anastomosis have been outlined in the Left Hemicolectomy
chapter. No drains are required for this procedure. The abdomen is irrigated,
the fascia is closed with interrupted nonabsorbable suture, and the skin is
Alternatively, a stapled anastomosis can be performed using a circular sta-
13
closed with a synthetic absorbable 4-0 subcuticular suture.
Rectum
End-to-end
anastomosis
Left
colon
Left
colon
Side-to-side
anastomosis
Rectum
15
Rectum
14
Laparoscopic Sigmoid Colectomy
Operative Indications
Laparoscopic resection has become the procedure of choice for the surgical management of uncomplicated sigmoid diver-
ticular disease. Other common indications for the laparoscopic approach include colorectal cancer and rectal prolapse.
Complicated diverticular disease such as a colovesicle fistula can be attempted laparoscopically but is associated with a
higher risk of conversion to an open procedure. Repair of sigmoid volvulus may also occasionally be performed laparo-
scopically. Preoperative preparation for a laparoscopic sigmoid colectomy includes an optional mechanical bowel prepa-
ration, intravenous antibiotics, and prophylaxis for deep vein thrombosis.
Operative Technique
Essential to the performance of a laparoscopic resection is
patient positioning. The patient is positioned in the low
lithotomy position with the right arm tucked at the patient’s
side. The abdomen is prepped widely. A nasogastric tube
and Foley catheter should be placed prior to trocar insertion.
The video monitors are placed near the head of the bed, and
the operating surgeon stands at the patient’s right side. A
laparoscopic sigmoid colectomy can be performed with four
ports: three 10-mm trocars and one 5-mm trocar. The cam-
era port is established first in the infraumbilical region using
the open Hasson technique. The camera port is inserted and
secured with a 2-0 nonabsorbable suture. The remaining
ports are positioned as demonstrated (1). A 30 degree
1
angled camera is used to perform the procedure.
364 Atlas of Gastrointestinal Surgery: The Colon
2
Left colon
Sigmoid colon
Laparoscopic removal of
the sigmoid colon begins with
mobilization of the lateral attach-
ments. The chronic inflammation associated
Rectosigmoid
with diverticular disease may make these
attachments difficult to release. The operating
table is placed in steep Trendelenberg with the
left side tilted up, and both the assistant and the
operating surgeon stand to the patient’s right. The assistant
retracts the colon medially and follows the operating surgeon’s instruments with the camera. The operating surgeon begins
with a laparoscopic grasper and electrocautery scissors to release the lateral attachments of the sigmoid colon (2). Care
must be taken to avoid deep dissection and injury to the iliac vessels. Once the colon is reflected medially, the left ureter
should be visualized crossing the iliac artery.
Sigmoid colon
Laparoscopic Sigmoid Colectomy 365
3
Left ureter
IMA
Once the bowel has been mobilized, if the
indication for resection is adenocarcinoma of the colon, it
is important to ligate the inferior mesenteric artery near its origin to obtain an appropriate lymphadenectomy. The colon is
retracted laterally and the vascular pedicle is identified. A window is created in the mesentery surrounding the vascular
pedicle with an electrocautery scissors. The ureter is identified running lateral to the vascular pedicle. The vascular pedicle
is either divided with an endovascular stapler or endoclips (3). The remaining mesentery can be divided with the LigaSure
or Harmonic scalpel.
366 Atlas of Gastrointestinal Surgery: The Colon
4
Sigmoid colon
Rectosigmoid
Tension is then applied to the colon to lift it out of the pelvis, and the distal bowel is divided using a laparoscopic linear
stapling device (4). It is important to clear the surrounding mesentery from the bowel wall so that the ends of the bowel
to be put together are free. Failure to do this may allow mesentery to be caught up in the anastomotic staple line. If the
mesentery has been adequately mobilized, only one or two applications of the laparoscopic linear stapling device will be
required to divide the colon. Once the bowel has been divided, the entire length of the proximal mobilized bowel should
be visualized to make certain that all mesenteric attach-
ments have been divided.
Mobilization of the splenic flexure may not be
necessary for a limited sigmoid resection. To
Sigmoid colon
assess the reach of the proximal bowel to the
divided rectosigmoid, a laparoscopic Babcock
clamp is placed at the point where the
proximal bowel is to be divided and an
attempt is made to bring this down
Proximal bowel
Rectosigmoid
to the rectal stump (5). If mobi-
lization of the splenic flexure is
necessary, please refer to the
description in the Laparoscopic
Left Hemicolectomy chapter.
5
Laparoscopic Sigmoid Colectomy 367
At this point the divided segment of bowel is ready to be
removed from the abdomen. Prior to opening the abdomen, the
distal staple line on the mobilized sigmoid colon should be
grasped with a laparoscopic locking Babcock clamp. A left
lower quadrant incision is made that is large enough to allow
Sigmoid
colon
the bowel to pass freely. A small wound protector is
placed. A small Richardson retractor is placed, the
abdominal wall is lifted up, and a handheld Babcock
clamp placed through the incision to grasp the end
of the mobilized colon. The laparoscopic Babcock
clamp is released, and the bowel should be
removed easily through the wound. Once the
bowel is removed from the abdomen to the proxi-
6
mal resection site, the remaining mesentery is divided.
A Babcock clamp is placed on the proximal bowel and
the bowel is divided distal to the clamp (6).
The anastomosis is performed with a curved circular stapler (EEA). To determine the necessary size, both the proxi-
mal and distal ends of the bowel should be dilated with a sizer. A pursestring suture is placed around the edge of the
proximal bowel using a 2-0 nonabsorbable synthetic suture, and the anvil is inserted and secured (7). The proximal end
of the bowel is returned to the abdominal cavity and a pneumoperitoneum is re-established by occluding the skin protec-
tor. Under direct visualization, the stapler is inserted into the rectum and gently rotated with the curvature of the rectum
(8). The trocar is advanced through the stapled end of the rectosigmoid, and the detachable introducer is removed from
Proximal
bowel
Anvil
7
8
368 Atlas of Gastrointestinal Surgery: The Colon
9
Left colon
Rectosigmoid
the trocar and the abdomen through a 10-mm port. The anas-
tomosis is created by placing a grasper on the proximal trocar
and inserting it into the shaft attached to the circular stapling
device (9). The two ends are brought together by rotating the
handle on the end of the circular stapling device. The stapler is
fired (10). To open the stapling device, the handle on the end
of the stapler is rotated in the opposite direction, releasing the
stapler from the anastomosis. The stapling device is gently removed
from the rectum and the two “donuts” of bowel tissue are exam-
ined for completeness.
Testing the anastomosis to ensure that it is secure is accom-
plished by covering it with saline, occluding the bowel proximal
to the anastomosis, and inserting air into the rectum. If it is air
tight, no air leakage should be noted from the anastomo-
10
sis. The abdomen is then irrigated, the pneumoperi-
toneum is removed, and the wounds closed with
synthetic absorbable suture.
Sigmoid Colectomy with Rectal Stump
(Hartmann’s Procedure)
Operative Indications
The most common indication for performing a Hartmann’s
procedure is a patient with an unprepped bowel who
presents with colon obstruction or perforation.
Conditions that may lead to this circumstance include
an obstructing cancer (1), inflammatory bowel dis-
Rectum
Sigmoid
colon
sary dissection. Since the bowel is unprepped, an anasto-
Obstruction
1
mosis cannot be performed. Thus, the distal bowel is closed
and the proximal bowel is brought out as a colostomy.
ease, perforated diverticular disease, or ischemic
bowel secondary to a sigmoid volvulus. Often,
the patient may require resuscitation and broad-
spectrum antibiotics prior to surgery.
The goal of the operation is to remove the dis-
eased segment safely and quickly without any unneces-
370 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
The patient may be in the supine or lithotomy position with both
arms extended. The abdomen is prepped and draped widely. A
lower midline incision allows for the best exposure (2).
2
The diseased bowel is identified and
the necessary lateral attachments of the
bowel are released. Extra care should be
taken to identify the left ureter since it may
be caught up in the disease process. The
diseased sigmoid segment is removed by
creating small defects in the mesentery
adjacent to the healthy bowel so that the
linear stapler can be placed to divide the
bowel at the proximal and distal ends
(3). The mesentery is then divided
between Kelly clamps and ligated
with 2-0 silk ties.
Sigmoid
colon
Rectosigmoid
3
Once the diseased bowel is
removed, the distal staple line is
inverted with 3-0 silk Lembert
sutures. The ends of these
sutures can be left long to allow
for easier identification of the
distal bowel end when the time
Sigmoid Colectomy with Rectal Stump (Hartmann’s Procedure) 371
Colostomy
comes, weeks later, to reverse
the colostomy (4).
Rectum
4
Creation of the colostomy is
often the most difficult part of the
operation. In obese patients, it may
be necessary to extensively mobilize the
left colon in order to bring the colostomy out to the skin. It is important that the colostomy rests outside the abdominal
wall without tension. The colostomy site is created by excising a quarter-sized piece of skin in the left lower quadrant. The
subcutaneous fat is divided down to the anterior fascia using the electrocautery. The anterior fascia is visualized with the
assistance of thyroid retractors, then opened in a vertical direction using the electrocautery. The rectus muscle fibers are
separated and the posterior fascia is opened. An adequate colostomy site should allow the passage of two fingers.
A Babcock clamp is passed through the defect, and the end
of the descending colon is grasped and brought out through the
ostomy site. Care should be taken to avoid twisting the bowel. The
colostomy is secured to the posterior fascia from within the peri-
toneal cavity with 3-0 silk sutures. Once the abdominal incision has
been closed with interrupted nonabsorbable sutures and the skin is
closed, the colostomy is matured (5). The staple line is removed
and the bowel is approximated to the dermis using interrupt-
Colostomy
ed full-thickness 3-0 synthetic absorbable suture, as
described in the End Colostomy section.
Rectal stump
5
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