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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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442 Atlas of Gastrointestinal Surgery: The Colon
The splenic flexure is mobilized by placing the operat-
ing surgeon’s index finger or a right-angle clamp
under the attachments to the spleen. While
retracting the left colon, the electro-
cautery is used to divide these
attachments (9).
Stomach
Spleen
Colon
9
Total Proctocolectomy with End Ileostomy 443
Once the left colon and splenic flexure
are mobilized, the left colonic mesentery
is divided. The inferior mesenteric artery
is identified and then clamped, divided,
10
IMA
Left colic a.
Sigmoid
and ligated (10). The ligature placed on
the patient’s side is reinforced with a
suture ligature or a second tie.
colon
Left colic a.
Alternatively, the left colic, sigmoidal
branches, and superior rectal arteries
can be divided separately (11).
Superior rectal a.
Sigmoidal
branches
Sigmoid colon
Rectum
11
444 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 posi-
tion. 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
Rectosigmoid
rectum in the midline between the fas-
cia propria of the rectum and the pre-
sacral fascia (12).
Mesentery of the rectum
Presacral fascia
12
Total Proctocolectomy with End Ileostomy 445
13
Once this plane has
been developed, the rec-
tum is mobilized laterally
using a right-angle clamp
(13). Mobilization is best
performed with strong traction
away from the plane of dissection.
This will allow visualization of the
pelvic sidewall nerves, which must
not be injured so that sexual function
can be preserved.
Mesorectum
Nerves
preserved
446 Atlas of Gastrointestinal Surgery: The Colon
The anterior mobilization of
the rectum is done last.
Peritoneum
Electrocautery is used to open
the peritoneum and begin to
establish a plane between the
prostate or vagina and the rec-
tum (14). It is important to
use strong posterior retraction on
the rectum along with anterior
retraction on the prostate or vagina,
employing a deep pelvic retractor to
facilitate this dissection (15 and 16).
14
Sigmoid
mesentery
Sigmoid
colon
15 16
MALE FEMALE
Prostate
Rectum
Vagina
Rectum
Total Proctocolectomy with End Ileostomy 447
Sigmoid colon
Mesorectum
Coccyx
Right ureter
Inf. hypogastric nerve
Sacrum
17
The rectum is mobilized to the anal ring (17). The entire dissection can be accomplished with electrocautery. When
the dissection is complete, a Mikulicz pad can be packed into the posterior pelvis to assist in the perineal dissection.
448 Atlas of Gastrointestinal Surgery: The Colon
18
The patient is then placed in steep
Trendelenberg position with the legs extended in
high lithotomy. The perineum is prepped with
Skin incision
around anus
19
Betadyne. A curvilinear incision is made around
the anus with electrocautery (18). The dissec-
tion of the anus is begun in the posterior loca-
tion. The anus is grasped with Allis clamps and
retracted anteriorly. A self-retaining Gelpi
retractor is placed in the perineal wound. The
dissection with electrocautery is continued
until the levator muscles are identified posteri-
orly and laterally (19).
Skin incision
around anus
Total Proctocolectomy with End Ileostomy 449
The pelvis is entered just anterior to the coccyx
and the Mikulicz pad placed earlier should be
identified. Attempts should be made to preserve
as much of levator muscle as possible for better
20
Levator m.
closure of the perineum. The dissection of the
lateral levator muscle can be facilitated by
placing the index finger in the free pelvic
space and pulling the levator muscle towards
the perineum (20).
Anterior rectal
attachments divided
The anterior dissection is completed last. At this point, it is
helpful to bring the entire bowel through the posterior
space and into the perineum. The rectum is pulled
down while the prostate or posterior vaginal wall is
lifted up from within the pelvis. Care is taken to
avoid injury to either structure when dividing the final
anterior rectal attachments (21). Once the entire
specimen is freed, it is passed off the table.
Bowel delivered
through perineum
Rectum
Mesorectum
21
Sigmoid colon
450 Atlas of Gastrointestinal Surgery: The Colon
The abdomen and pelvis are irrigated with antibiotic-con-
taining solution. The levator muscles are reapproximated with
2–0 interrupted absorbable synthetic suture material, begin-
ning at the coccyx. The perineal subcutaneous tissues are irri-
gated and closed with 3–0 synthetic absorbable interrupted
sutures (22). The skin of the perineum is reapproximated
with a running subcuticular 4–0 absorbable suture. Dry dress-
ings are applied. If there is no large defect within the per-
22
The pelvic peritoneal edges are
brought together with a 4–0 run-
ning synthetic non-absorbable
ineum, a drain is not necessary.
Bladder
suture, beginning at the base of the
bladder and ending up over the
sacral promontory (23).
23
Total Proctocolectomy with End Ileostomy 451
An end ileostomy is created in the previously
marked site in the right lower quadrant (24
and 25) as described in the End Ileostomy
section of the Small Bowel chapter. The mid-
line abdominal wound is closed with number one
interrupted synthetic absorbable sutures. The sub-
cutaneous tissues are irrigated with an antibiotic-containing solu-
tion. The skin is reapproximated with a running subcuticular 4–0
synthetic absorbable suture. Dressings are applied.
End
ileostomy
24
25
End
ileostomy
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