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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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402 Atlas of Gastrointestinal Surgery: The Colon
The splenic flexure is mobilized by placing
the operating surgeon’s index finger or a
right-angle clamp under the attachments to
the spleen (9).
Stomach
Spleen
Colon
9
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 403
While retracting the left colon, the
electrocautery is used to divide
these attachments. Once the left
10
IMA
Left colic a.
Sigmoid
colon
colon and splenic flexure are mobi-
lized, the left colonic mesentery is
divided. The inferior mesenteric
artery is identified and then clamped,
divided, and ligated (10). The liga-
ture placed on the patient’s side is
reinforced with a suture lig-
ature or a second tie.
Alternatively, the left colic, sigmoidal
branches, and superior rectal arteries
can be divided separately (11).
Superior rectal a.
Left colic a.
Sigmoidal
branches
Sigmoid colon
Rectum
11
404 Atlas of Gastrointestinal Surgery: The Colon
The rectal dissection is performed next. To facilitate midline
mobilization of the rectum, the patient is placed in the Trendelenberg
position; the surgeon's view is now into the pelvis (inset).
Sigmoid colon
Rectosigmoid
The small bowel is packed into the upper
part of the abdomen. The sigmoid colon and
rectum are retracted out of the pelvis and
anteriorly. Electrocautery is used to mobilize
the mesentery of the rectum in the midline
between the fascia propria of the rectum
and the presacral fascia (12).
Mesentery of the rectum
12
Presacral fascia
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 405
13
Once this plane has been developed,
lateral mobilization of the rectum is per-
formed with the assistance of a right-angle
clamp (13). Mobilization is best performed
with strong traction away from the plane of dis-
section. This allows visualization of the pelvic
side wall nerves, which must not be injured to
preserve sexual function.
Mesorectum
Nerves
preserved
406 Atlas of Gastrointestinal Surgery: The Colon
The anterior mobilization of the
rectum is done last. Electrocautery
is used to extend the peritoneal
opening anterior to the rectum
(14), and to begin to establish
a plane between the prostate
or vagina and the rectum. It is
important to emphasize the
need for strong posterior
retraction on the rectum, along
with anterior retraction on the
prostate or vagina using a deep
pelvic retractor, to facilitate this dis-
section (15 and 16).
Peritoneum
14
Sigmoid
mesentery
Sigmoid colon
MALE FEMALE
Prostate
Vagina
Rectum
15 16
Rectum
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 407
Sigmoid colon
Mesorectum
Right ureter
Inf. hypogastric nerve
Coccyx
Sacrum
17
The rectum should be mobilized to the anal ring. The entire pelvic dissection can be accomplished with
electrocautery (17). When the dissection is complete, a Mikulicz pad can be packed into the posterior pelvis
to assist in the perineal dissection if a mucosectomy is being performed.
408 Atlas of Gastrointestinal Surgery: The Colon
When the rectum has been completely mobilized, the distal rectum can either 1) be divided with a linear stapling
device or 2) a mucosectomy can be performed through the anus. Use of the gastrointestinal stapling device results in the
retention of 1 to 2 cm of distal rectal mucosa that the ileal pouch is connected to. Alternatively, the entire rectal mucosa
can be removed by performing a mucosectomy.
Mesorectum
Stapler
Rectum
1. Stapled Anastomosis
Once the stapling device has been
positioned across the distal rectum, tak-
ing care not to incorporate the levators,
18
prostate, or vagina, it is fired. The proximal
bowel is removed by clamping the distal rec-
tum with an intestinal clamp and dividing the
rectum above the staple line with a long-han-
dled scalpel (18). The entire colon and rectum
should be free of attachments and can be
passed off the operating room table.
An ileoanal J-pouch is then constructed.
With complete mobilization of the distal ileal
mesentery already performed, the pouch should
easily reach down to the anus. To check the length
prior to construction of the pouch, the most mobile seg-
ment of the ileum is brought to the anus with a
Babcock clamp. If additional length is necessary,
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 409
19
Peritoneum
of mesentery
the peritoneum along the edge of the small
bowel mesentery can be released (19).
J-pouch
constructed
Terminal ileum
At the point of greatest
mobility, the terminal ileum is
opened with a 2-cm transverse
incision along the antimesenteric
20 21
border. A linear gastrointestinal
stapling device is introduced through
this enterotomy and the ends of the ileum are
brought together in a “J” configuration (20).
The recommended pouch length is 15 cm; to
accomplish this, two firings of the gastrointestinal
stapling device are required (21).
410 Atlas of Gastrointestinal Surgery: The Colon
22
A reinforcing suture is placed at the distal end of this staple line. The sta-
pled line where the ileum was previously divided is inverted with 3–0 interrupt-
ed silk Lembert sutures. To ensure hemostasis, the pouch is everted and the pos-
terior staple line in the lumen is oversewn with a 3–0 absorbable continuous lock-
ing suture. A 2–0 non-absorbable purse-string suture is placed around the open
end of the ileal pouch. The anvil of a circular stapling device is introduced and the
purse string is secured (22).
The anus is gently dilated and the circular stapler device is introduced through
the anus into the very short rectal remnant. The trocar is advanced through the rem-
nant with the tip exiting just posterior to the previously placed staple line. The anvil
tip is positioned into the trocar, with attention given to the position of the pouch
and its mesentery. Upon confirmation that the mesentery is oriented posterior to the
pouch, the stapler is fired (23). The two “donuts” of ileum and rectum are
Anvil
examined for completeness.
Rectal remnant
Ileal J-pouch
23
24
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 411
Oversewn
posterior
staple line
Anus
Ileal
J-pouch
To air-test the ileal pouch–anal anastomosis the small
bowel is occluded proximal to the staple line with a
linen-shod clamp and the pelvis is filled with saline solu-
tion (24). An assistant insufflates the rectum with a rigid
proctoscope while the fluid in the pelvis is evaluated for
the presence of air bubbles.
Saline solution
to air-test the
staple line
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