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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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432 Atlas of Gastrointestinal Surgery: The Colon
Colon
Mesentery
of colon
22
Terminal
ileum
Rectum and
mesorectum
After the rectum is divided, a ratcheted grasper is used to secure the sta-
pled end of the rectum and the pneumoperitoneum is evacuated through the trocars.
A paraumbilical incision is made, a wound protector is placed, and the terminal ileum, colon,
and rectum are brought out through the incision. The teminal ileum is divided with a linear stapler
just proximal to the ileocecal valve (22).
The J-pouch is created extracorporally. At the point of greatest mobility the terminal ileum is opened with a
2-cm transverse incision along the antimesenteric border. A linear gastrointestinal stapling device is introduced
through this enterotomy and the ends of the ileum are brought together in a “J” configuration (23). The recom-
mended pouch length is 15 cm; to accomplish this, two firings of the gastrointestinal stapling device are required
(24). A reinforcing suture is placed at the apex of this staple line, and the previously stapled line along the top
of the ileal pouch is reinforced with 3–0 interrupted non-absorbable sutures. To ensure hemostasis, the posterior
staple line in the lumen of the pouch is everted and oversewn with a 3–0 absorbable continuous locking suture.
A 2–0 non-absorbable purse-string suture is placed around the open end of the ileal pouch. The anvil of a cir-
cular stapling device is introduced and the purse string is secured (25).
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 433
23
Fiirst firing
of stapler
24
J-pouch
constructed
Second firing
of stapler
25
Anvil
434 Atlas of Gastrointestinal Surgery: The Colon
Ileal J-pouch
Rectal remnant
26
The pouch is returned to the abdominal cavity and the wound
protector is secured around the Hasson trocar, using a number one
silk tie to create a seal. The pnuemoperitoneum is re-established.
The ileal pouch–anal anastomosis is performed laparoscopically
under direct vision. The correct orientation of the ileal pouch and
mesentery is confirmed and a circular EEA stapler is gently introduced
through the anus. The pin from the stapler is advanced through the rec-
tal wall, just posterior to the linear staple line, and the anvil in the
pouch is attached to it (26). Great care must be taken to ensure that
no anterior or lateral structures are incorporated into the circular sta-
ple line. This requires anterior traction of the vagina in women or
anterior displacement of the tissue over the prostate in men.
The stapler is fired and removed, completing the anastomosis.
The stapler is inspected and the presence of two intact tissue
27
“donuts” is confirmed. The integrity of the anastomosis is tested.
The pelvis is filled with sterile saline solution and the ileum is
clamped, proximal to the pouch, with a laparoscopic bowel
clamp. A bulb syringe or rigid proctoscope is used to inject air
through the anus, inspecting for an air leak (27).
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 435
A temporary loop ileostomy is created at
28
Loop ileostomy
the previously marked right lower quad-
rant site to divert the fecal stream from
the ileoanal anastomosis. Through the
small midline incision, a segment of
ileum 40 cm from the J-pouch is
marked for proximal and distal orien-
tation. A disc of skin is excised at
the marked stoma site and the sub-
cutaneous fat is split to the anterior
rectus sheath. A vertical incision is
made in the rectus sheath and the rec-
tus muscle is spread. The posterior fas-
cia and peritoneum are vertically
incised. The ileum is brought
Distal ileum
(oriented towards feet)
Proximal ileum
(oriented towards head)
through the abdominal
wall with the distal por-
tion of the loop oriented
inferiorly (28).
436 Atlas of Gastrointestinal Surgery: The Colon
29
Stoma rod
Everted ileostomy
A stoma rod is secured to the skin after being passed
through a small defect in the ileal mesentery. The
supraumbilical incision is closed. Skin incisions are closed
and the loop ileostomy is matured, producing an everted
ileostomy (29 and 30).
Proximal ileum
Temporary loop
ileostomy
J-pouch
30
Total Proctocolectomy with End Ileostomy
Operative Indications
Removal of the entire colon and rectum (1) with creation of an end ileostomy is performed for a patient with the diagno-
sis of polyposis or inflammatory bowel disease who is not a candidate for an ileoanal pouch. Common contraindications
for creating an ileoanal pouch include poor sphincter function, perianal inflammatory disease, and
low rectal cancer. When performing a total proctocolectomy for inflammatory bowel disease
with dysplasia, the ileocolic, the middle colic,
and the inferior mesenteric arteries are divid-
ed at their origin to allow for an adequate
lymphadenectomy should cancer be dis-
Transverse colon
covered in the final pathology specimen.
At the end of this procedure, an ileosto-
my is created in the right lower quadrant.
Preoperative preparation of the patient
includes a visit with the enterostomal ther-
apist for stoma marking, an optional
mechanical bowel preparation, intra-
venous antibiotics, and prophylaxis for
deep vein thrombosis.
Right
colon
Middle
colic a.
R. colic a.
Ileocolic a.
SMA
IMV
IMA
L. colic a.
Sigmoidal
branches
Left
colon
Sigmoid colon
Rectum
1
438 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
The patient is placed in the supine position. Tucking both arms
provides additional room for retraction when mobilizing the
hepatic and splenic flexures. A midline incision is made from the
mid-abdomen to the pubis.
Ileostomy
site
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 retracted
toward the left upper quadrant. Gentle
traction on the right colon assists in
dividing the peritoneal attachments to the
Lateral
attachments
Right
colon
lateral abdominal sidewall (2).
Cecum
2
Hepatic flexure
attachments released
Total Proctocolectomy with End Ileostomy 439
The attachments of the hepatic
flexure may contain a few small ves-
sels, but electrocautery is generally
sufficient to maintain hemostasis.
Mobilization of the colon con-
tinues 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).
4
Duodenum
Right
ureter
Right
colon
440 Atlas of Gastrointestinal Surgery: The Colon
Once the mesentery of the right
colon is completely free from the
underlying duodenum, the ileocolic ves-
5
sels can be doubly clamped, divided, and lig-
ated with 2–0 silk sutures (5). On the
patient’s side, the ligature is reinforced
with a suture ligature or a second tie. The
mesentery between the ileocolic vascu-
lar pedicle and the site of small bowel
division is scored and divided.
Ileocolic a.
Cecum
Ten centimeters of small bowel can be
removed with the colon to ensure ade-
quate blood supply to the remaining
small bowel. The small bowel is divid-
ed with a linear stapler (6).
Ileum
Right
colon
Terminal
ileum
6
Total Proctocolectomy with End Ileostomy 441
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 of the omen-
tum by placing gentle traction on the
colon while elevating the omentum (7).
Once the transverse colon is free from
the omentum, the middle colic artery can
be identified, clamped, divided, and
Omentum
ligated with a 2–0 silk suture. The lig-
ature placed on the patient’s side is
reinforced with a suture ligature or a
second tie. If the middle colic artery
is divided proximally, there will be
Transverse colon
Next, the left colon is mobilized. To do this, the
peritoneal attachments are freed from the left
abdominal sidewall. As the left colon is
mobilized the left ureter should be visual-
ized throughout its course (8). Gerota’s
fascia should be separated from the left
colon mesentery.
no large vessels in the remaining
transverse colon mesentery and it can
be divided with electrocautery.
Left
colon
8
Left ureter
Left
gonadal
vessels
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