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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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462 Atlas of Gastrointestinal Surgery: The Colon
Left colon
White line of Toldt
Rectum
15
After complete mobilization of the left colonic
mesentery from the retroperitoneum, endoshears
are used to incise the white line of Toldt on
the lateral aspect of the left colon (15).
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
Sigmoid colon
Omentum
16
Spleen
mobilized, dividing the omen-
tal 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 (16).
Tr. colon
Left colon
Laparoscopic Total Proctocolectomy with End Ileostomy 463
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, which has been moved to between the patient’s legs. The small intestine and colon are again
gently swept out of the pelvis into the upper abdomen. The presacral space is entered and the rectal dissection is begun
with the endoshears or hook cautery. A total mesorectal dissection is performed, beginning posteriorly, taking the rectum
and the perirectal tissue directly off of the presacral fascia. Care is taken when initiating this dissection to identify and care-
fully preserve both branches of the hypogastric nerve. The operating surgeon and assistant utilize the right and left lower
quadrant trocars and the suprapubic trocar. Traction and counter traction are very important to open the correct dissection
plane. As with an open total mesorectal dissection, every attempt is
made to ensure the integrity of the mesorectal fascia (17). The
dissection is extended laterally to the pelvic sidewalls.
Sigmoid colon
Rectosigmoid
Mesentery of
the rectum
Hypogastric n.
Presacral
fascia
17
464 Atlas of Gastrointestinal Surgery: The Colon
The peritoneum anterior to the rectum is
opened (18) and the anterior rectal wall dis-
section is performed, using posterior retraction
of the rectum and anterior retraction of the vagi-
na or prostate. If there is difficulty gaining ade-
quate traction and counter traction with respect
18
to the vaginal wall, EEA sizers may be intro-
duced into the anus and the vagina by a second
assistant, who applies posterior and anterior trac-
tion, helping define the plane between the rectum
and the vagina (19). Mobilization is continued cir-
cumferentially to the anal ring.
Uterus
suspended
Posterior traction
on rectum
19
Anterior traction
on vagina
Rectum
The complete mobilization for the proctocolectomy
reaches the base of the pelvic floor at the level of the
levators (20). This requires mobilizing 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.
Laparoscopic Total Proctocolectomy with End Ileostomy 465
20
The legs are elevated to expose the perineum and
the Lone Star retractor is sutured to the buttocks. The
interspincteric groove is palpated and a circumferential
skin incision is made with the electrocautery between the
internal and external anal sphincters (21).
21
Skin incision
around anus
466 Atlas of Gastrointestinal Surgery: The Colon
External
sphincter
Internal
sphincter
22
The Lone Star retractor hooks are placed circumferentially, exposing the intersphincteric space. Dissection is continued cra-
nially in the avascular intersphincteric plane (22) until the previous pelvic dissection is reached. The pelvic cavity is initial-
ly entered posteriorly and the dissection is completed as the dissection is continued laterally and anteriorly. When this mobi-
lization is complete, the rectum and colon are brought through the perineal defect and removed from the field (23).
Anterior
rectal
attachments
divided
Laparoscopic Total Proctocolectomy with End Ileostomy 467
Bowel
delivered
through
perineum
Rectum
Anus
23
Sigmoid colon
468 Atlas of Gastrointestinal Surgery: The Colon
24
Close perineum
The pelvis is irrigated through the perineal wound. The levator muscles are reapproximated with
interrupted zero absorbable synthetic sutures. The external sphincter is plicated in a similar fashion
(24). Interrupted 3–0 synthetic absorbable sutures are used to close the subcutaneous tissue and
the skin is closed with 4–0 subcuticular absorbable sutures.
Laparoscopic Total Proctocolectomy with End Ileostomy 469
Pneumoperitoneum is re-established to create the end ileostomy. With the
camera in the Hasson trocar and the surgeon working through the left lower
quadrant and suprapubic ports, the small bowel is run and the staple line on
the terminal ileum is identified and grasped. The cut
edge of the mesentery is inspected along its length
to insure it is not twisted.
Terminal
25
ileum
A disc of skin is excised at the previously
marked stoma site. Ideally, this was the site of the
right lower quadrant trocar. Dissection is continued
down to the anterior rectus sheath fascia. The fas-
cia is vertically incised, the rectus muscle is split,
and the posterior fascia and peritoneum are verti-
cally divided. The ileum, correctly oriented, is
passed from the laparoscopic ratcheted grasper to
a handheld Babcock clamp inserted through the stom-
al incision (25). The end of the ileum is brought out
through the abdominal wall.
470 Atlas of Gastrointestinal Surgery: The Colon
End
ileostomy
26
Pneumoperitoneum is again re-established. The
5-mm camera is placed through the right upper quad-
rant trocar and the mesentery is inspected a final time
to ensure it is not twisted. The cut edge of the ileal
mesentery is visualized along its length from the
ileostomy to its root near the duodenum. The other
trocars are removed under direct vision through the
5-mm scope. The umbilical fascia is closed with a
zero absorbable suture. The skin incisions are closed
and the end ileostomy is matured (26 and 27) as
described in the End Ileostomy chapter.
End
ileostomy
27
Subtotal Colectomy for Ulcerative Colitis
Operative Indications
The first stage of the three-stage procedure for severe ulcerative colitis is the subtotal colectomy. The subsequent stages
include a mucosal proctectomy, creation of an ileoanal pouch, and pouch-anal anastomosis with a diverting ileostomy; and
then subsequent closure of the ileostomy. The purpose of the staged procedures is to perform the more difficult second
portion of the three stages when the patient is in a more healthy state. Therefore, patients with severe colitis on high dose
steroids, anemic, and malnourished do better with a staged procedure beginning with a
subtotal colectomy. Once the colectomy is performed (1),
the patient can be weaned off steroids and can be
built up nutritionally in preparation for the more
difficult second stage. With appropriate patient
selection, this procedure can be done laparo-
scopically. Preoperative preparation of the
patient includes an optional mechanical bowel
preparation, intravenous antibiotics, and pro-
phylaxis for deep vein thrombosis. Prior to sur-
gery, an ostomy nurse should place a mark on
the patient’s right lower quadrant indicating
the best site for an ileostomy appliance.
Right
colon
Transverse colon
Left
colon
Sigmoid colon
Rectum
1
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