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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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422 Atlas of Gastrointestinal Surgery: The Colon
Stom
7
Tr. colon
Omentum preserved
(taken off transverse colon)
Tr. colon
The decision to resect the omentum
with the colon is the based on the surgeon’s
preference. A vessel-sealing device can be
used to divide the omentum for an en bloc resec-
tion. Alternatively, to preserve the omentum, the trans-
verse colon is reflected inferiorly while the omentum is lifted
superiorly and the avascular plane between the colon and the
omentum is divided using the electrocautery scissors (7).
The middle colic vessels or their branches
are divided with a vessel-sealing device (8).
If cancer is present in the transverse colon,
these vessels are ligated close to their ori-
gin. The transverse mesocolon is mobilized
to the point of maximum reach and visibil-
ity from the right.
Once the right colon and a portion of
the transverse colon have been mobilized
and the mesentery divided, both the operat-
ing and the assistant surgeon move to stand on
Tr. colon
Middle colic
vessels divided
the patient’s right side. The patient is placed in
the Trendelenberg position with the left side tilt-
ed up. The small bowel and mobilized portions of
colon are gently swept out of the pelvis and into the
right upper quadrant.
8
Sigmoid colon
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 423
Sigmoid mesentery
Rectum
9
Sacral promontory
To initiate the left colon mobilization, the sigmoid colon mesentery is
grasped and retracted superiorly and towards the left anterior superior iliac
spine. The peritoneum of the sigmoid mesentery is incised over the sacral
promontory to the right of midline. The incision is extended in a cranial direc-
tion exposing the retroperitoneum (9).
424 Atlas of Gastrointestinal Surgery: The Colon
The avascular plane between the left colonic mesentery and the retroperitoneum
becomes apparent as the pneumoperitoneum is forced into the space between the
mesosigmoid and the retroperitoneum. The lateral attachments of the colon to the left
sidewall (the white line of Toldt) are kept intact to provide retraction, keeping the left
colon out of the area of dissection. The avascular plane in the retroperitoneum is devel-
oped with a combination of sharp and blunt dissection. The inferior mesenteric artery
(IMA) and the sigmoid mesentery are retracted towards the anterior abdominal wall
while the retroperitoneal structures including the left ureter, gonadal vessels, and
iliac vessels are identified and kept posterior (10).
IMA
Jejunum
Sigmoid colon
10
Mesosigmoid
Left ureter
Rectum
Retroperitoneum
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 425
Once the ureter is identified and freed from the mesentery, the origin of the IMA is
cleared of the surrounding lymphatic and nerve tissue. Care is taken to ensure that the
ureter and other retroperitoneal structures are freed from the base of the IMA. The IMA
is ligated using a vessel-sealing device, vascular stapler endo GIA, or clips (11).
IMA
Ureter and
gonadal vessels
11
426 Atlas of Gastrointestinal Surgery: The Colon
12
Left colon
Gerotaʼs
fascia
After division of the IMA,
extensive mobilization of
the left colon mesentery
is performed (12).
Jejunum
As the dissection continues
superiorly, the base of the IMV
is identified, cleared, and divid-
13
Left colon
IMV
ed in a fashion similar to that of
the IMA (13).
Ureter and
gonadal vessels
Left colon
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 427
White line of Toldt
Rectum
After complete mobilization of the left colonic
mesentery from the retroperitoneum, endoshears are
used to incise the white line of Toldt on the lat-
eral aspect of the left colon (14). Putting the
patient in a steep reverse Trendelenburg
position helps with retraction as the
mobilization is continued cephalad
towards the spleen. The splenic
flexure is mobilized, dividing the
Sigmoid colon
Omentum
14
15
Spleen
omental attachments to the
spleen and transverse colon, and
entering the lesser sac. The
stomach should be visualized so
as not to injure it. The remaining
transverse colonic mesentery is
divided (15).
Tr. colon
Left colon
428 Atlas of Gastrointestinal Surgery: The Colon
When the colon is completely mobilized, attention is returned to the pelvis and the patient is placed in a steep
Trendelenburg position with no lateral tilt. The operating surgeon and assistant now stand on opposite sides of the patient,
facing the left-side monitor that has been moved to between the patient’s legs. The small intestine and colon are again gen-
tly swept out of the pelvis into the upper abdomen. A total mesorectal dissection is performed, beginning posteriorly, tak-
ing the rectum and the perirectal tissue directly off of the presacral fascia. The presacral space is entered and the rectal dis-
section is begun with the endoshears or hook cautery. Care is taken when initiating this dissection to identify and careful-
ly preserve both branches of the hypogastric nerve. The operating surgeon and
assistant utilize the right and left lower-quadrant trocars and the suprapubic tro-
car. Traction and counter traction are very important to open the correct dissec-
tion plane. As with an open total mesorectal dissection, every attempt is made
to ensure the integrity of the mesorectal fascia (16).
Sigmoid colon
Rectosigmoid
Mesentery of
the rectum
Hypogastric n.
Presacral
fascia
16
The dissection is extended laterally to the
pelvic sidewalls (17).
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 429
17
Lateral
attachments
18
The peritoneum anterior to the
rectum is opened (18) and the ante-
rior rectal wall dissection is then per-
formed, using posterior retraction of
the rectum and anterior retraction of the
vagina or prostate.
430 Atlas of Gastrointestinal Surgery: The Colon
19
Uterus
suspended
Posterior traction
on rectum
Anterior traction
on vagina
Rectum
If there is difficulty gaining adequate traction and count-
er traction with respect to the vaginal wall, EEA sizers
may be introduced into the anus and the vagina by a
second assistant who applies posterior and anterior
traction, helping define the plane between the rectum
and the vagina (19). Mobilization is continued
circumferentially to the anal ring. The complete proc-
tocolectomy reaches the base of the pelvic floor at
the level of the levators (20). This requires mobiliz-
ing the pelvic floor musculature off of the distal
rectum as it enters the anal canal. The inferior extent
of the mobilization is confirmed by digital rectal exam.
20
21
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 431
Rectum
Rectosigmoid
Mesorectum
When the rectum has been completely
mobilized, the distal rectum can either 1) be
divided with a gastrointestinal 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 rectum can be removed by performing a mucosectomy. The
technique for mucosectomy and with a handsewn anastomosis is the same as described for the
open procedure in the previous section.
If the stapling technique is employed, an Endo GIA stapler is used for division of the rec-
tum (21). A reticulating stapler is required and often only the 30-mm cartridge will fit into the
distal pelvis, requiring multiple firings for division of the rectum. When this is the case, it is impor-
tant to ensure the staple lines do not cross with each new firing. The rectum is divided 1 to 1.5
cm proximal to the maximum point of mobilization to ensure the anterior and lateral structures,
primarily the vagina in women, are not incorporated into the staple lines.
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