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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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Total Abdominal Colectomy with
Ileorectal Anastomosis
Operative Indications
Removal of the abdominal colon is performed for colonic polyposis, synchronous cancers, colitis resulting from inflammato-
ry bowel disease or infection, and slow transit constipation. Following resection of the abdominal colon, the ileum can be
anastomosed to the rectal remnant provided there is adequate rectum remaining and it is free of disease. The quality of life
following an ileorectosigmoid anastomosis is acceptable, with approximately three to six bowel movements a day. If the
ileal anastomosis is to the rectum, the number of bowel movements may be as high as eight to ten per day. When per-
forming a total abdominal colectomy, the ileocolic, middle colic, and the left colic arteries will be divided. The inferior
mesenteric artery, along with the superior rectal artery, may be preserved to ensure adequate blood supply for healing the
ileorectosigmoid anastomosis (1). Preoperative preparation of the patient includes an optional mechanical bowel prepara-
tion, intravenous antibiotics, and prophylaxis for deep vein thrombosis.
Operative Procedure
The patient is placed in the supine position. Tucking both arms pro-
vides additional room for retraction when mobilizing the hepatic and
splenic flexures. A midline abdominal incision is performed in prepa-
ration for removal of the colon. A self-retaining retractor is used to
assist in exposure. The patient’s abdomen is explored. The liver and
periaortic regions are palpated, and the small intestine and colon are
inspected in a systematic way. The small bowel and its mesentery
are gently retracted toward the left upper quadrant. Gentle traction
is placed on the right colon and the lateral peritoneal attachments
Total Abdominal Colectomy with Ileorectal Anastomosis 373
Transverse colon
Right colon
Ileocolic a.
Middle
colic a.
R. colic a.
Left colon
SMA
IMV
IMA
L. colic a.
Sigmoidal
branches
Sigmoid colon
Rectum
1
374 Atlas of Gastrointestinal Surgery: The Colon
are released with electrocautery (2). The
2
Lateral
attachments
operating surgeon assists by lifting up the
attachments with forceps. A right-angle clamp
may be placed under the peritoneal attach-
ments to prevent injury to underlying struc-
tures such as the ureter and duodenum.
Right
colon
Cecum
The attachments to the hepatic flexure
may contain a few small vessels, but electro-
cautery generally is sufficient to maintain
hemostasis (3). Mobilization of the colon
continues by releasing the attachments of the
omentum from the transverse colon.
Hepatic flexure
attachments released
3
Complete mobilization of the right colon and
hepatic flexure prevents inadvertent injury to
the ureter or duodenum during division of the
mesentery (4).
Total Abdominal Colectomy with Ileorectal Anastomosis 375
4
Duodenum
Right
colon
Right
ureter
Once the right colon mesentery is
released from the retroperitoneum and the
second and third portions of the duodenum are
free, the ileocolic vessels can be doubly clamped,
5
divided, and ligated with 2-0 silk sutures. On
the patient side, the ligature is reinforced with a
Cecum
suture-ligature or a second tie (5).
Ileocolic a.
Ileum
376 Atlas of Gastrointestinal Surgery: The Colon
The mesentery between the ileocolic vascular pedi-
cle and the site of small bowel division is scored and
divided. At least 10 cm of small bowel should be
removed with the colon. The small bowel is divid-
Right
colon
Terminal
ileum
6
In the absence of malignancy in
ed with a linear stapler (6).
the transverse colon, the omentum
should be preserved. The attachments
of the omentum to the transverse
colon are divided. This is best done
with the electrocautery, placing gen-
tle traction on the colon while ele-
vating the omentum (7).
Omentum
7
Transverse colon
Total Abdominal Colectomy with Ileorectal Anastomosis 377
In the event of a malignancy in the transverse colon, the omentum is
removed with the colon specimen. Once the mesentery of the transverse colon
is free, the middle colic artery can be identified, doubly clamped,
divided, and ligated with 2-0 silk
sutures. On the patient-side, the
ligature is reinforced with a
suture-ligature or a second tie.
If the middle colic is divided
proximally, there will be very
few vessels within the remain-
ing transverse mesocolon and
this can be divided with elec-
trocautery. More frequently, the
right and left branches of the
middle colic vessels are divided
Mesentery
8
Transverse
colon
Right branch of
middle colic a.
divided
separately (8).
378 Atlas of Gastrointestinal Surgery: The Colon
Left
colon
10
Left
gonadal
vessels
Left ureter
The attachments of the left colon are then mobilized so that the left ureter can
be visualized throughout its course (9).
Once the left colon has been fully mobilized, the attach-
ments of the splenic flexure are released with the electro-
cautery by placing gentle traction on the colon
(10). Care must be taken not to injure the
splenic capsule. Throughout the dissec-
tion, the small bowel must be packed
off to avoid inadvertent injury.
Total Abdominal Colectomy with Ileorectal Anastomosis 379
Stomach
Spleen
Colon
10
380 Atlas of Gastrointestinal Surgery: The Colon
Once the left colon and splenic flexure are mobilized,
the mesentery can be divided. The left colic artery is iden-
tified as it comes off the inferior mesenteric artery and
doubly clamped, divided, and ligated with 2-0 silk
sutures. On the patient side, the ligature is
reinforced with a suture-ligature or
a second tie. The superior rectal
artery is preserved to ensure heal-
ing of the ileorectal anastomosis.
The remaining mesentery of the
left colon and sigmoid colon is
mobilized to the peritoneal
reflection (11).
Superior rectal a.
Left colic a.
Left
colon
IMA
(preserved)
Rectosigmoid
11
Sigmoid colon
12
Total Abdominal Colectomy with Ileorectal Anastomosis 381
The rectosigmoid junction is divided with
a linear stapler and the specimen is removed
(12). The abdomen is irrigated and inspected
for hemostasis.
Rectosigmoid
A side-to-end anastomosis allows for correction of the
size discrepancy that exists between the small bowel and the
rectosigmoid. The stapled ends of the bowel are inspected to
In performing an ileorectal anastomosis, it is important
to correctly orient the small bowel mesentery. This is
accomplished by aligning the small bowel with the root
of the small bowel mesentery. The stapled end of small
bowel is then swung down so that the stapled end is to
the patient’s left of the rectal stump. A handsewn or sta-
pled anastomosis can be performed.
insure that the mesentery has been adequately removed. The
staple line on the end of the small bowel is inverted with a
row of 3-0 silk Lembert sutures. The posterior outer layer
of the anastomosis is performed using a row of interrupt-
ed 3-0 silk Lembert sutures. The rectosigmoid staple line
is removed with the electrocautery. The inner layer of
the anastomosis consists of continuous synthetic suture
placed in a locking fashion, brought around anteriorly
in a Connell stitch. The anastomosis is completed with
an outer layer of 3-0 silk Lembert sutures. The small
bowel mesentery may be tacked to the retroperitoneum
with interrupted sutures (13).
Small bowel
Ileorectal
anastomosis
Rectum
13
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