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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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382 Atlas of Gastrointestinal Surgery: The Colon
14
Rectum
An alternative is to perform the anastomosis
with a circular stapler. The small bowel is posi-
tioned in the same side-to-end configura-
tion as for the handsewn anastomosis.
The small bowel staple line is invert-
ed with a row of 3-0 silk Lembert
sutures. An enterotomy is created
on the antimesenteric border of the
small bowel, 5 cm from the staple
line. A 2-0 continuous nonabsorbable
suture is placed around the enterotomy in a
15
To air test the anastomosis, the bowel
is clamped with a linen-shod clamp
pursetring fashion. The anvil is introduced, and
the pursestring is secured.
The circular stapler is introduced into
the rectum (14) and gently rotated with
the curvature of the rectum toward the sta-
ple line (15). The trocar is advanced
through the rectosigmoid wall, positioned in
the anvil, and the stapler is fired (16). The two
“donuts” of ileal and rectosigmoid tissue are examined
for completeness.
proximal to the anastomosis and the
pelvis is irrigated with saline. An
assistant insufflates the rectum
using a rigid proctoscope and the
saline is observed for the pres-
ence of air bubbles. The mesen-
teric defect can be closed with
3-0 absorbable suture. The
abdomen is irrigated with an
antibiotic-containing solution, and
the wounds are closed.
Ileum
Rectum
16
Laparoscopic Total Abdominal Colectomy
Operative Indications
Laparoscopic removal of the abdominal colon is performed for colonic polyposis and synchronous right and left colon can-
cer, colitis resulting from inflammatory bowel disease or infection, and slow transit constipation. Following resection of the
colon, the ileum can be anastomosed to the rectosigmoid 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 performing a laparoscopic total abdominal colectomy, the ileocolic, the middle colic, and left colic arteries
will be ligated intracorporeally. The inferior mesenteric artery along with the superior rectal artery may be preserved to ensure
adequate blood supply exists for healing of the ileorectosigmoid anastomosis (1). The anastomosis can be performed intra-
corporeally using a circular stapler or extracorporeally through a small Pfannenstiel incision. Preoperatively, the patient under-
goes an optional mechanical bowel preparation, intravenous antibiotics, and prophylaxis for deep vein thrombosis.
384 Atlas of Gastrointestinal Surgery: The Colon
Transverse colon
Right colon
Ileocolic a.
Middle
colic a.
R. colic a.
Left colon
SMA
IMV
IMA
L. colic a.
Sigmoidal
branches
Sigmoid colon
1
Rectum
Laparoscopic Total Abdominal Colectomy 385
Operative Techniques
As in all laparoscopic procedures, positioning of the patient is paramount. Gastric and bladder decompression are per-
formed to minimize the risk of bowel or bladder injury and to maximize visualization. The patient is placed in the lithoto-
my position with both arms tucked. The abdomen is prepped and draped widely. The video monitors are placed near the
head of the operating table, and the surgeon stands on the patient’s left side. A laparoscopic total abdominal colectomy
can be performed with five ports; four 10-mm ports and one 5-mm port. The VeraStep ports are inserted with an expand-
able sleeve that holds the trocar in place and creates a smaller fascial defect that does not require closure. The camera port
is created first. A vertical midline incision to accommodate a 10-mm port is made below the umbilicus. A Veress needle
is inserted and, when intra-abdominal position is confirmed, the abdomen is insufflated. Alternatively, entrance into the
abdominal cavity can be obtained by dissecting down to the peritoneum and entering the abdomen under direct vision
(Hasson technique). The Hasson technique is favored over the blind insertion of the Veress needle and trocar in patients
who have had previous abdominal surgery. The Hasson port can be secured with a 2-0 nonabsorbable suture to prevent
accidental withdrawal. Once the abdomen has been insufflated, a 30 degree angle camera is placed through this trocar,
and the abdomen is systematically explored.
The remaining 10 mm trocars are inserted: one in the right
lower abdomen, one in the left lower abdomen, and one in
the suprapublic position. A 5 mm trocar is placed in the
epigastic region (2).
The procedure begins with mobilization of the lateral
peritoneal attachments of the right colon. This is best done
with the operating surgeon and the assistant standing on the
patient’s left side facing the video monitor. Placing the
patient in the Trendelenberg position and rotating the right
side up will improve exposure. For the initial dissection, an
atraumatic bowel grasper is used through the left port and
the endoshears are used through the suprapubic port.
2
386 Atlas of Gastrointestinal Surgery: The Colon
Grasping the appendix and gently retracting it toward the left upper
quadrant assists in exposure of the lateral peritoneal attachments.
These are divided up to the hepatic flexure with endoshears
(3). Electrocautery is rarely needed for this mobilization.
Appendix
Cecum
Mobilized
right colon
3
Laparoscopic Total Abdominal Colectomy 387
Once lateral mobilization is complete and
the right colon has been released from its
retroperitoneal attachments, the sur-
geon’s attention is turned to ligation of
the vascular pedicle. The right meso-
Right
mesocolon
Ileocolic vessels
colon is lifted anteriorly with a
bowel grasper placed on the
mesentery directly above the ori-
gin of the ileocolic vessels.
Mesenteric defects are created,
and the ileocolic vessels are
skeletonized.
They are then divided with
a vascular linear stapler or endo-
clips brought through the left
port (4).
4
388 Atlas of Gastrointestinal Surgery: The Colon
The remaining ascending colon mesentery is
divided with a LigaSure or Harmonic scalpel
introduced through the left or suprapubic port
(5). To prevent difficulties in finding the
proximal small bowel staple line after the
specimen is removed, the small bowel
Right
colon
should remain attached to the colon until
the specimen is removed.
Ileocolic
vessels
(divided)
Mesentery
Ileum
5
Laparoscopic Total Abdominal Colectomy 389
If the disease involves the omentum, it should be taken en bloc with
the colon (6). The LigaSure or Harmonic scalpel can be used to
divide the omentum for an en bloc resection.
Stomach
Transverse
colon
Omentum
Alternatively, to preserve the omentum, the trans-
Stomach
Tr.
colon
6
Omentum
Stomach
verse colon is reflected downward while the omen-
tum is lifted up and the avascular plane between
the colon and the omentum is divided using
electrocautery scissors (7).
Tr.
colon
Transverse
mesocolon
7
Omentum
Tr. colon
390 Atlas of Gastrointestinal Surgery: The Colon
Transverse
colon
Right colon
Middle
colic a.
The middle colic vessels are identi-
fied and the remaining transverse mesocolon
is divided with the LigaSure or Harmonic
scalpel. Utilizing the upper midline and left
lower quadrant ports, the middle colic
vessels or their branches are dissected
free of the mesentery and divided with
an endovascular linear stapler or endo-
clips (8).
8
Laparoscopic Total Abdominal Colectomy 391
Left colon
Sigmoid colon
Rectosigmoid
9
Once the right and transverse colon have been mobilized, the operating and assistant surgeons move to the patient’s
right side. The patient is placed in the Trendelenberg position with the left side rotated up. Utilizing the right lower quad-
rant and the suprapubic ports, the lateral attachments of the left colon are released with the electrocautery endoshears. The
assistant retracts the colon medially with a grasper placed through the upper midline port and follows the operating sur-
geon’s instruments with the camera (9). In a patient with limited laparoscopic exposure, it may be easier to mobilize the
left colon before dividing the transverse mesocolon to avoid redundant colon obscuring the view. The ureter can be visu-
alized crossing the common iliac artery after the colon is reflected. Mobilization of the splenic flexure is facilitated by plac-
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