Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
.pdf
472 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
The patient is placed in the supine position. Tucking both arms provides addi-
tional room for retraction when mobilizing the hepatic and splenic flexures. A
midline vertical peri-umbilical incision is used, a self-retaining retractor is
placed, and the patient’s abdomen is explored. The liver is palpated and the
small intestines and colon are inspected in a systematic fashion. In many cir-
cumstances the colon is quite dilated and friable and care must be taken to
avoid perforation. The small bowel and its mesentery are gently retracted into
the left upper quadrant. Gentle traction is placed on the right colon, and the
lateral peritoneal attachments are released with the electrocautery. The operat-
ing surgeon assists by lifting up the attachments with forceps. A right-angle
clamp is placed under the peritoneal attachments by the assistant surgeon to
prevent injury to underlying structures such as the ureter and duodenum. The hepatic flexure may contain a few small ves-
sels, but the electrocautery device generally is sufficient to maintain hemostasis. Mobilization of the colon continues by
releasing the attachments of the greater omentum from the hepatic flexure and transverse colon.
Once the right colon mesentery is released from the retroperitoneum and the second and third portions of the duode-
num are free, the ileocolic vessels can be identified, doubly clamped and ligated with 2-0 silk ties. On the patient side,
the ligature is reinforced with a suture-ligature or a second tie. Complete mobilization of the duodenum prevents inadver-
tent injury to the ureter or duodenum during division of the mesentery. The mesentery between the ileocolic vascular pedi-
cle and the site of small bowel division is marked. At least 10 cm of distal ileum should be removed with the colon. The
few small vessels within this portion of the mesentery are clamped and ligated with 2-0 silk. The small bowel is divided
with a linear stapler. The middle colic artery is identified within the transverse mesocolon, doubly clamped and ligated with
2-0 silk ties. On the patient side, the ligature is reinforced with a suture-ligature or a second tie. If the middle colic artery
is divided proximally, there will be very few vessels within the remaining mesentery of the transverse colon and it can be
divided with the electrocautery.
The greater omentum is further mobilized off the splenic flexure, using the electrocautery. The lateral attachments of the
descending colon are mobilized in an identical fashion to the right colon attachments. One must be certain to identify the
left ureter through its entire course. Once the splenic flexure and left colon are mobilized, the mesentery can be divided.
The left colic artery is identified as it comes off the inferior mesenteric artery, and is doubly clamped and ligated with 2-0
silk ties. On the patient side, the ligature is reinforced with a suture-ligature or a second tie. The remaining mesentery is divid-
ed between Kelly clamps and ligated with 2-0 silks. The rectosigmoid is divided with a linear stapler and the specimen,
consisting of the terminal ileum, the right colon, the transverse colon, the left colon, and the sigmoid colon, is removed from
the operative field. The abdomen is copiously irrigated with antibiotic-containing solution and inspected for hemostasis.
Subtotal Colectomy for Ulcerative Colitis 473
Distal ileum
The ileostomy is created in the right lower quadrant at the pre-
viously marked site. A quarter-sized disc of skin is removed with the
electrocautery. The subcutaneous tissue is divided and separated
with hand-held retractors until the anterior fascia of the rectus
sheath is encountered. A disc of the anterior fascia of the rectus
sheath is excised, exposing the rectus muscle. The rectus muscle is
separated with a Kelly clamp. The posterior fascia is visualized and
a similar sized disc is excised. This opening through the right lower
quadrant abdominal wall should allow passage of two fingers.
Utilizing a Babcock clamp passed from outside in, the distal
ileum is brought through the ostomy opening. Care must be taken
to avoid rotation of the small bowel. The ileum should protrude
out from the skin for approximately 2 in. The small bowel is then
tacked to the abdominal wall fascia with several 3-0 nonab-
2
line incision is closed.
When the rectum is severely diseased, it is best to leave
a longer rectosigmoid remnant so the stapled end can be
brought through the lower midline fascia during closure, leav-
sorbable sutures. The mesentery of the terminal ileum is then
tacked to the abdominal wall with a running 3-0 synthetic
nonabsorbable suture. The ostomy is matured (2) after the mid-
Ileostomy
3
ing a small defect through which the bowel protrudes (3).
Rectosigmoid
474 Atlas of Gastrointestinal Surgery: The Colon
The fascia is re-approximated with 0 synthetic nonab-
sorbable suture. The skin can be closed over the bowel
with skin staples or left open to create a mucous fistula
(4). By doing this, should the staple line break down,
the contents of the rectosigmoid will drain without creat-
End
ileostomy
4
Rectosigmoid
remnant
ing an intra-abdominal abscess.
The rosebud, everted ileostomy is created by placing
eight sutures of 3-0 synthetic absorbable material. Each
suture goes full thickness through the end of the ileum,
part way through the ileal wall at the level of the skin, and
then through the subcutaneous layer of the skin. Eight
such sutures, equally spaced, are placed and when
secured will create an everted ostomy, approximately
1 inch high. The eversion process can be aided by the use
of a right-angle or gooseneck clamp.
Surgical Management of Sigmoid Volvulus
Operative Indications
Volvulus of the colon is the third most common
cause of large bowel obstruction, behind colon
cancer and diverticular disease. By far the
most frequent site of volvulus is the sigmoid
colon (1), with the cecum second.
Sigmoid volvulus can occur when substan-
tial elongation of the sigmoid colon occurs,
Sigmoid colon
in right upper quadrant
with a redundant mesosigmoid. Sigmoid
volvulus is seen slightly more commonly in
men, in the elderly, in institutionalized
patients, in individuals with chronic constipa-
tion, and in patients with frequent use of laxatives
or enemas. Patients generally present with obstipa-
tion and a distended abdomen.
The diagnosis generally is suspected, or even con-
firmed, by flat and upright abdominal x-rays. A marked-
ly dilated colonic loop is seen projecting from the pelvis
into the right upper quadrant with what is described as an
“omega loop,” or a bent inner tube. The diagnosis can be
absolutely confirmed with a CT scan, which shows a “whirl” sign if the
axial cuts transect the site of volvulus perpendicularly.
Rectum
Left colon
1
476 Atlas of Gastrointestinal Surgery: The Colon
If there are no signs of ischemia or impending
gangrene, and the abdomen is soft and non-
tender, and there is no leukocytosis or fever,
then an attempt at detorsion can be made
with a flexible sigmoidoscope (2). This is
often successful and avoids the need for emer-
gency surgery. The recurrence rate is anywhere
from 30% to 80%, and depending upon the
clinical circumstances, a decision can be made
De-torsed sigmoid
colon
whether to proceed with sigmoid colectomy. After
endoscopic decompression, a soft rectal tube can
be inserted to allow adequate bowel preparation.
Operative Technique
2
Flexible sigmoidoscope
The patient is explored through a midline incision. If the operation is being
performed as an emergency, with a suspicion of ischemic or gangrenous bowel,
one should be prepared to do a sigmoid resection with a proximal colostomy
and a distal Hartmann’s pouch. If ischemic bowel is found, a proximal left
lower quadrant colostomy should be performed, and the distal rectosigmoid
oversewn after resection of the redundant sigmoid colon. In most instances,
however, with successful nonoperative detorsion of the sigmoid loop and elec-
tive bowel preparation, the patient can be explored under elective circum-
stances and an elective colon resection is performed.
Surgical Management of Sigmoid Volvulus 477
At the time of the laparotomy, if the bowel is still
volvulated, it is devolvulated, and the sigmoid colon
is resected proximally and distally by firing a linear sta-
pler (3). The amount of bowel resected should just
allow easy approximation of the descending colon to the
rectosigmoid, eliminating all redundancy. The mesentery
to the sigmoid colon is doubly clamped with
Kelly clamps, divided, and ligated with
2-0 silks. An end-to-end colocolosto-
my is performed with an inner con-
tinuous layer of 3-0 synthetic
absorbable suture and an outer
interrupted layer of 3-0 silk
3
Sigmoid
resected
Lembert sutures.
The rent in the mesentery should be closed
with 3-0 silk sutures (4). The abdomen is copi-
ously irrigated with an antibiotic-containing solu-
tion and closed in layers.
Colocolostomy
4
Surgical Management of
Cecal Volvulus and Cecal Bascule
Operative Indications
Failure of attachment of the cecum and right colon to the
retroperitoneum is quite common and has been estimated to
be present in up to 25% of the population. This allows the
ileocecal region to be very mobile and to become a potential
site of volvulus. The cecum and terminal ileum can rotate clock-
wise around the ileocolic vascular pedicle and present a picture
Right colon
Ileum
1
Cecum
of small bowel intestinal obstruction (1, 2). Abdominal flat and
upright films will show the cecum in the left upper quadrant,
leading one to suspect the diagnosis of cecal volvulus. Unlike
in the case of sigmoid volvulus, the likelihood of detorque-
ing a patient with cecal volvulus with colonoscopy is low. In
addition, ischemia and necrosis of the cecum are more com-
mon than with sigmoid volvulus. Therefore, all patients
should be explored.
Surgical Management of Cecal Volvulus and Cecal Bascule 479
Cecal volvulus Cecal bascule
Distended
cecum
2
Cecum
3
A second form of cecal volvulus can occur that does not involve a rota-
tion of the cecum, but merely a bending of the cecum up into the right upper
quadrant, resulting in what is called a “cecal bascule” (3). This is more diffi-
cult to diagnose on flat and upright abdominal films than is true cecal or sig-
moid volvulus, and can be mistaken for a sigmoid volvulus because of the right
upper quadrant air shadow.
Operative Technique
The patient is explored through a midline incision. At the time of laparotomy,
if there is no indication of ischemia or gangrene in the cecum, detorsion should
be carried out.
480 Atlas of Gastrointestinal Surgery: The Colon
There are a variety of techniques to prevent recurrence of cecal
volvulus, but in our experience all that is necessary is to tack the
right colon and cecum back into the retroperitoneum with a
series of interrupted 3-0 silk sutures (4). Others have suggest-
ed a cecostomy (5), or even cecal resection.
4
Omentum
Cecum
5
Surgical Management of Cecal Volvulus and Cecal Bascule 481
If at the time of laparotomy, changes consistent with
ischemia or gangrene are seen, resection of the cecum
should be performed. Often a primary anastomosis can
be performed, if the patient is stable and there is no
contamination. This can be performed in a variety of
Ileocolostomy
6
ways, but since the small bowel is often dilated from the
obstruction, an end-to-end ileocolostomy can be per-
formed with an inner continuous layer of 3-0 absorbable
synthetic suture material and an outer layer of interrupt-
ed 3-0 silk Lembert sutures. The defect in the mesen-
tery is closed with interrupted 3-0 silk sutures (6).
The abdomen is copiously irrigated with antibiotic-
containing solution and closed in layers.
Соседние файлы в папке Библиотека им академика М.И. Перельмана