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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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392 Atlas of Gastrointestinal Surgery: The Colon
Stomach
Spleen
Omentum
ing the patient in steep reverse Trendelenberg
position and applying gentle traction to the
colon while the electrocautery scissors are
used to free omental attachments (10).
The stomach should be visualized so as
not to injure it.
Once the left colon
has been mobilized, the
mesentery is divided. If the
Left colon
indication for resection is
adenocarcinoma of the
colon, it is important to
ligate the left colic
10
branches at their origin
from the inferior mesenteric
artery to insure an appropriate
lymphadenectomy. For benign dis-
ease, the mesentery can be divided closer to the bowel edge with the LigaSure or Harmonic scalpel. The left colon mesen-
tery is elevated and the vascular pedicles are identified. A window is created in the mesentery on both sides of the vas-
cular pedicles. The ureter is identified through this window in the mesentery to assure it has not been accidentally mobi-
lized with the mesocolon. The vascular pedicles are divided with either an endovascular linear stapler or endoclips (11).
The remaining mesentery can be divided with the LigaSure or Harmonic scalpel. Once the mesentery is free, the distal
bowel is grasped and elevated at the intended resection line at the rectosigmoid junction and any remaining mesentery is
gently freed from the bowel wall. Failure to do this may result in mesentery caught up in the staple line and potentially
lead to anastomotic complications. The distal bowel is again grasped just proximal to the line of resection, and tension is
applied to lift the colon out of the pelvis. A laparoscopic linear stapling device is used to divide the bowel (12). Once
the rectosigmoid colon has been divided, the entire length of the mobilized bowel should be visualized to make certain
that all attachments have been divided.
Sigmoid
colon
Laparoscopic Total Abdominal Colectomy 393
11
IMA
Left ureter
Rectosigmoid
Sigmoid colon
12
394 Atlas of Gastrointestinal Surgery: The Colon
Sigmoid colon
13
Mesentery
Prior to opening the abdominal wall, the proximal staple line on the divided rectosigmoid colon should be grasped with
a laparoscopic Babcock clamp. Either a vertical midline incision or a Pfannenstiel incision is made that is just large enough
to accommodate removal of the bowel. A small wound protector is placed. The open wound is elevated with a small
Richardson abdominal retractor in order to visualize the rectosigmoid colon held by the Babcock clamp. A second hand-
held Babcock clamp is placed on the specimen through the abdominal wound and the laparoscopic Babcock clamp is
released. With gentle traction, the bowel can be extracted easily through the abdominal wound (13).
Colon
Mesentery
Laparoscopic Total Abdominal Colectomy 395
Rectosigmoid
Terminal
ileum
Cecum
14
Once the bowel is removed from the abdomen to the proximal resection site on the ileum, the remaining ileal mesen-
tery is divided. A Babcock clamp is placed on the ileum just proximal to the line of resection to prevent the ileum from
slipping back into the wound. The ileum is divided with a linear stapler (14).
A side-to-end anastomosis can be handsewn extracorporeally or performed with a circular stapler intracorporeally, as
described here. The small bowel staple line is inverted 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 pursetring fashion. The anvil is introduced, and the pursestring is secured.
In performing an ileorectal anastomosis, it is important to correctly orient the small bowel mesentery. This is accom-
plished by aligning the small bowel with the root of the small bowel mesentery.
396 Atlas of Gastrointestinal Surgery: The Colon
15
Often the anastomosis can be performed
under direct vision through a Pfannenstiel inci-
sion. If not, the pneumoperitoneum is reintro-
duced by clamping closed the wound pro-
tector. The patient is positioned in steep
Trendelenberg position and the correct ori-
16
Rectum
entation of the mesentery is confirmed. The
circular stapler is inserted into the rectum and
gently rotated with the curvature of the rectum
toward the staple line (15 and 16). Under visu-
alization through the laparoscope, the trocar is
advanced through the rectosigmoid wall and posi-
tioned in the anvil. This is facilitated by the oper-
ating surgeon controlling the anvil grasper with one
hand and the circular stapler with the other hand.
The stapler is fired while being visualized through
the laparoscope (17). The circular stapler is
removed from the rectum, and the two “donuts”
of ileal and rectosigmoid tissue are examined for
completeness.
To air test the anastomosis, the bowel is
clamped with a linen-shod clamp proxi-
mal 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 presence of air
bubbles. The mesenteric 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
17
Total Proctocolectomy with
Ileal Pouch–Anal Anastomosis
Operative Indications
Removal of the entire colon and rectum (1) is performed for colonic polyposis or ulcerative colitis that is either refractory
to medical therapy or shows intestinal dysplasia on biopsy. Following resection of the colon and rectum, the ileum is used
to create a pouch of intestine that is anastomosed to the anus. The quality of life following an ileal pouch–anal anastomo-
sis is very manageable with the patient having approximately 5 to 6 bowel move-
ments a day. When total proctocolectomy is per-
formed for dysplasia, the ileocolic, the middle
colic, and the inferior mesenteric arteries are
divided at their origin to provide an adequate
lymphadenectomy should cancer be discov-
ered in the pathology specimen. At the end
of the procedure, a temporary diverting
loop ileostomy is created in the right lower
quadrant. Preoperative preparation of the
patient includes a visit with the enteros-
tomal therapist for stomal marking, an
optional mechanical bowel preparation,
intravenous antibiotics, and prophylaxis
for deep vein thrombosis.
Right
colon
Sup. rectal a.
Middle
colic a.
R. colic a.
Ileocolic a.
Transverse colon
SMA
IMV
IMA
L. colic a.
Sigmoidal
branches
Sigmoid colon
Left
colon
Rectum
1
398 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
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 incision is made from the mid-abdomen to
the pubis.
A self-retaining retractor is used to assist in exposure.
After an initial exploration of the patient’s abdomen,
the small bowel and its mesentery are gently retract-
ed toward the left upper quadrant. Gentle traction
on the right colon with the assistant’s left
hand assists in dividing the peri-
toneal attachments to the later-
Lateral
attachments
al abdominal sidewall (2).
Right
colon
Cecum
2
Hepatic flexure
attachments released
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 399
The attachments of the hepatic flexure
may contain a few small vessels, but elec-
trocautery is generally sufficient to main-
tain hemostasis. Mobilization of the
colon continues with release of
these attachments (3).
3
Complete mobilization of the
right colon and hepatic flexure
prevents inadvertent injury to the
ureter or duodenum during divi-
sion of the mesentery (4).
Kidney
Duodenum
Right
colon
Right
ureter
4
400 Atlas of Gastrointestinal Surgery: The Colon
5
Once the mesentery of the right colon
is completely free from the underlying
duodenum, the ileocolic vessels can be dou-
bly clamped, divided, and ligated with 2–0 silk
sutures (5). On the patient’s side, the liga-
ture is reinforced with a suture ligature or a
second tie. The mesentery between the
Cecum
ileocolic vascular pedicle and the site
of small bowel division is scored
and divided.
Ileocolic a.
Ileum
At least 10 cm of small bowel should
be removed with the colon to ensure
adequate blood supply to the remain-
ing small bowel. The small bowel is
divided with a linear stapler (6).
Right
colon
Terminal
ileum
6
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 401
7
In the absence of malignancy in the trans-
verse colon, the omentum should be pre-
served. Electrocautery is used to create a
window into the lesser sac by placing gen-
tle traction on the transverse colon while
elevating the omentum (7). Once the
transverse colon is free from the omentum,
the middle colic artery can be identified,
Omentum
clamped, divided, and ligated with a
2–0 silk suture. The ligature placed
on the patient’s side is reinforced
with a suture ligature or a second tie.
If the middle colic artery is divided
Transverse colon
Next, the left colon is mobilized. To do this, the
peritoneal attachments are freed from the left
abdominal sidewall. The left colon should
be mobilized and the left ureter visualized
throughout its course (8). Gerota’s fas-
cia should be separated from the left
proximally, there will be no large ves-
sels in the remaining transverse colon
mesentery and it can be divided with
electrocautery.
Left
colon
8
colon mesentery.
Left
gonadal
vessels
Left ureter
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