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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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Laparoscopic Total Proctocolectomy
with End Ileostomy
Operative Indications:
Removal of the entire colon and rectum (1)
with creation of an end ileostomy, whether
Transverse colon
performed laparoscopically or openly, is
indicated for a patient with the diagnosis
of polyposis or inflammatory bowel disease
who is not a candidate for an ileoanal
pouch. Common contraindications for cre-
ating an ileoanal pouch include poor
Right
colon
sphincter function, perianal inflammatory
disease, and low rectal cancer. When per-
forming a total proctocolectomy for inflam-
matory bowel disease with dysplasia, the
ileocolic, the middle colic, and the inferi-
or mesenteric arteries are divided at their
origin to allow the performance of an
adequate lymphadenectomy should cancer
be discovered in the final pathology specimen.
At the end of this procedure, an ileostomy is created in the
Middle
colic a.
R. colic a.
Ileocolic a.
SMA
IMV
IMA
Left
colon
L. colic a.
Sigmoidal
branches
Sigmoid colon
Rectum
right lower quadrant. Preoperative preparation of the patient includes
a visit with the enterostomal therapist for stoma marking, an optional
mechanical bowel preparation, intravenous antibiotics, and prophylaxis
for deep vein thrombosis.
1
Operative Technique
The patient is placed on the table in
the supine position. General endo-
tracheal anesthesia is induced and a
Laparoscopic Total Proctocolectomy with End Ileostomy 453
Patient secured to table
2
Foley catheter is placed. The patient
is then placed in the modified litho-
tomy position supporting the lower
Modified lithotomy position
extremities with padded stirrups. The
patient’s sacrum should be at the
edge of the table and the thighs must be kept as flat as possible, to avoid having elevated thighs interfere with manipula-
tion of the laparoscopic instruments during the dissection. Both arms must be padded and tucked at the patient’s side (2).
If the patient is obese, arm extensions can be placed and left at the side with the arms tucked. The patient must be secured
to the table to avoid shifting while in a steep Trendelenburg position during the procedure. Extreme tilt to the left and
right is often required. This is necessary to allow gravity to act as a retractor, keeping the small intestine out of the oper-
ating field. Securing the patient may be accomplished by placing a beanbag underneath the patient’s torso prior to posi-
tioning; by taping the patient’s chest to the table with foam egg crates and silk tape; or by securing both the chest and
the head to the table with padding and tape. After correct positioning, a tilt test is performed to ensure the patient does
not shift when in extreme positions. The patient’s abdomen is then prepped and draped. The video monitors are posi-
tioned on the left and right side of the patient to begin the procedure (3). The right-side monitor tower generally con-
tains the insufflator and camera equipment and therefore does not get repositioned during the procedure.
One 5/12-mm Hasson trocar and four 5-mm trocars are used. Either laparoscopic Babcock or nontraumatic bowel
graspers are used to retract the colon and manipulate the small bowel and omentum. Two graspers and an endoshears are
used to perform the dissection. Division of the mesentery is performed with either a vessel-sealing device, endovascular sta-
plers, clips, or endoloops. Vessel-sealing devices such as the Harmonic scalpel, LigaSure, or Enseal can facilitate dividing
the omentum, the colohepatic ligament, or the mesentery and can shorten the duration of the procedure. When mobiliza-
tion and division of the mesentery is complete, the ileum is divided intracorporeally and the specimen may be removed
through the perineum.
454 Atlas of Gastrointestinal Surgery: The Colon
3
To begin the procedure, a 1-cm supraumbilical incision is made and
dissection is carried down to the abdominal wall fascia. The fascia and
peritoneum are incised and 2–zero absorbable sutures are placed
through the fascia to act as stay sutures. A Hasson trocar is placed in
the supraumbilical position, pneumoperitoneum is established, and the
camera is inserted through the trocar. Under direct
5/12 trocar used
for ileostomy
vision, four 5-mm trocars are placed: one in
the left lower quadrant, one in the
suprapubic position, one in the right
upper quadrant, and one in the
right lower quadrant (3).
Ideally, but not always, this
right lower quadrant trocar is
placed through the site previ-
ously marked for the stoma.
Care is taken to avoid injuring the
inferior epigastic vessels by transillu-
minating the abdominal wall and by
visualizing each trocar as it is placed.
A general rule of thumb for the lower
quadrant port placements is to position
them four finger-breadths superior and
medial to the anterior superior iliac spine.
Once the ports have been placed, the abdomen is
systematically explored.
If the operation is performed on a female with a uterus, the uterus needs to be retracted superiorly and secured to the
anterior abdominal wall. A 2–0 non-absorbable suture is passed through the abdominal wall midline between the pubis
and the suprapubic port. The needle is passed through the body of the uterus, brought back out through the anterior
abdominal wall within 1 cm of where it entered, and the suture is tied to itself. A four-by-four pad, folded between the
tightened suture and the skin, can serve as a buttress.
Having a 5-mm camera available is beneficial if the patient has adhesions. This allows a camera to be placed through
any port, facilitating visualization around the adhesions and adhesiolysis. The surgeon stands on the patient’s left side to
begin the procedure by mobilizing the right colon. Placing the patient in the Trendelenberg position and rotating the right
side up will improve exposure.
Laparoscopic Total Proctocolectomy with End Ileostomy 455
4
Right colon mobilized
Cecum
A bowel grasper is
used to grasp the appendix
Peritoneal
attachments
divided
The hepatic flexure is mobilized using the
electrocautery device. Once the right colon
has been released, the surgeon’s attention is
turned to ligation of the vascular pedicle.
The right mesocolon is lifted anteriorly with
and gently retract it towards the
left upper quadrant, exposing the lat-
eral peritoneal attachments of the right
colon. These attachments are released with
endoshears, working in a cephalad direction
(4). Electrocautery is rarely needed for division
of the lateral peritoneal attachments.
5
Ileocolic
vessels
divided
a bowel grasper placed on the mesentery
directly above the origin of the ileocolic ves-
sels. The vessels are divided within the mesen-
tery using a vessel-sealing device. If the patient
has cancer or dysplasia, high ligation of the
ileocolic vessels is performed by creating
mesenteric defects and dividing the ileocolic
artery close to its origin, using a vascular lin-
ear stapler or endoclips (5). Care must be
taken when mobilizing the right colon out of
the retroperitoneum to avoid injury to the duo-
denum or right ureter.
Right colon
Ileum
Cecum
456 Atlas of Gastrointestinal Surgery: The Colon
6
Ascending
colon
mesentery
Divided
ileocolic
vessels
The remaining ascending colon mesentery is divided with a vessel-sealing device (6). The ileomesentery to the termi-
nal ileum is divided with a vessel-sealing device.
Laparoscopic Total Proctocolectomy with End Ileostomy 457
The terminal ileum is divided intra-
7
corporeally with an Endo GIA sta-
pler. To facilitate this, the 10-mm
camera is taken out of the Hasson
Terminal
ileum
Cecum
trocar and a 5-mm camera is insert-
ed through the left lower quadrant
port. The stapler is passed through
the Hasson trocar to divide the ter-
minal ileum (7). The stapler is
removed and the 10-mm camera is rein-
serted through the Hasson trocar.
Mesentery
Stomach
The decision to resect the omentum with the
colon is the based on the surgeon’s prefer-
ence. A vessel-sealing device can be used
to divide the omentum for an en bloc
resection. Alternatively, to preserve
the omentum, the transverse colon is
reflected inferiorly while the omen-
tum is lifted superiorly and the
avascular plane between the colon
and the omentum is divided using
the electrocautery scissors (8).
Tr. colon
Omentum preserved
(taken off transverse colon)
8
Tr. colon
458 Atlas of Gastrointestinal Surgery: The Colon
The middle colic vessels or their branches are divided with a
vessel-sealing device (9). If cancer is present in the transverse
colon, these vessels are ligated close to their origin. The
transverse mesocolon is mobilized to the point of maxi-
mum reach and visibility from the right.
Once the right colon and a portion of the
transverse colon have been mobilized and the
mesentery divided, both the operating and the
assistant surgeon move to stand on the
patient’s right side. The patient is placed in
the Trendelenberg position with the left side
tilted up. The small bowel and mobilized
portions of colon are gently swept out of the
pelvis and into the right upper quadrant.
To initiate the left colon mobilization, the
sigmoid colon mesentery is grasped and retracted
Tr. colon
Middle colic
vessels divided
9
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 direction exposing the
retroperitoneum (10).
Sigmoid colon
Sigmoid mesentery
Rectum
10
Sacral promontory
Laparoscopic Total Proctocolectomy with End Ileostomy 459
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
developed with a combination of sharp and blunt dissection. The inferior mesenteric
artery (IMA) and the sigmoid mesentery are retracted towards the ante-
rior abdominal wall, while the retroperitoneal structures, including the
left ureter, gonadal vessels, and iliac vessels, are
identified and kept posterior (11).
Sigmoid colon
11
Mesosigmoid
Left ureter
IMA
Jejunum
Rectum
Retroperitoneum
460 Atlas of Gastrointestinal Surgery: The Colon
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 either a
vessel-sealing device, vascular stapler, Endo GIA, or clips (12).
IMA
12
Ureter and
gonadal vessels
13
Laparoscopic Total Proctocolectomy with End Ileostomy 461
Left colon
After division of
Jejunum
Gerotaʼs
fascia
the IMA, extensive
mobilization of the left
colon mesentery is per-
formed (13).
14
Left colon
As the dissection contin-
ues superiorly, the base of the
IMV is identified, cleared, and
divided in a manner similar to
that of the IMA (14).
IMV
Ureter and
gonadal vessels
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