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primary anastomosis is what I want to do, then I perform intraoperative colonic lavage. It allows decompression of the colon and
makesbowelanastomosiseasier.Ifyouarenotplanningintra-operative
lavage(somethink itis agimmick…)youcanjust mobilizethecolonto
ensurethat you have adequate lengthoncethe resection is performed,
anddoa primary anastomosis.Thismay need to include take down of
thesplenicflexurewithhighligationofthemesentericvesselstoprovide
anadequatelengthofcolontoperformatension-freeanastomosis.
Asmentionedpreviously,alesionproximaltothesplenicflexure
or at the splenic flexure should undergo resection with primary
ileocolicanastomosis.
Youshouldensurethataproper canceroperationwithadequate
lymph node removal is performed if the lesion is an obstructing
cancerorsuspectedofbeingso.
Mobilizationandresection
The entire colon, both right and left, needs to be mobilized to
perform an effective lavage. The decompression of colon you have
already done will help with this. Great care should be taken not to
injureretroperitonealstructureson theleftsidesuchastheureter
orgonadalvessels.Identifyingthesestructuresawayfromtheinflamed
or obstructed portion of the colon and then ensuring that they are
mobilizedlaterallyisrecommended.Onceyou have full mobilization,
decideon thelevelof distalresection.Ifthis is a leftcoloniccancer,
performing a high ligation of the inferior mesenteric artery (IMA) will
ensurethatadequatelymphnoderemovalandretrievalisundertaken.(If
the patient does not have a significant history of peripheral vascular
disease,thentherectumshouldbewellperfuseddespitehighligationof
the IMA.) If the lesion is in the descending colon or proximal sigmoid
colonandthesurgeonthinksitnecessarytopreservemorecolon,thena
moreisolatedselectiveligationofthebloodvesselssupplyingthelesion
shouldbeperformed.A7-8cmproximalmarginisrequiredbutIwouldbe
happywitha 5cm distal margin. Ialsoincludeanother 3cm of proximal
colontobeusedas thesite tosecure exittubing forthe lavage.Once
thecolonicsegmentismobilizedanddevascularizedIdivideitdistally—
whichusuallyisattherectosigmoidjunction—withalinearstapler.Now
wearereadyforthelavage…
Intra-operativelavage
If you have decided before the operationthat you mightdo this then
you should speak with your circulating nurse to get all the equipment
needed.Thiswillpreventannoyingdelaysandswearingbyyourselfas
you wait for various items to be brought in. Some wealthy institutions
havededicated‘lavagekits’—Idonot workatone oftheseinstitutions
andthereforedo notknowhowtoeitherassembleor utilizethem.ButI
doknowhowtodothiswithsimplepiecesofkit.
Theequipmentneededisasfollows:
•
3L bags of warm normal saline (utilized by the urologist for
cystoscopies). Ask the circulating nurse to get two bags and put
theminthefluidwarmerbeforestartingthecase.
•
Sterilecorrugatedtubing(fromtheanestheticmachine).
•
Twopiecesofumbilicaltape.
•
A16-gaugeFoleycatheter.
•
0silkties.
•
Cystotubingtoconnectthe3LbagtotheFoleycatheter.
Withthissimplearray of equipment( Figure27.2) youcan proceed
withthecoloniclavage.
Figure27.2.Equipmentneededforintra-operativecoloniclavage:seetext.
Inowidentifyanddividethecolonattheproximalmarginandremove
thespecimen. Priorto doing thisI milkthestool awayfrom thepointof
divisionandplaceasoftbowelclampacrossthecolon—atleast10cm
proximal to the site of transection — so I don’t have stool spilling
everywhere when the colon is opened, and there is enough room to
insert the corrugated tubing that acts as our sewer pipe. The sterile
corrugatedtubingis insertedintotheendof thecolonandsecuredwith
two umbilical tapes — tying them around the colon tightly so that the
colonisdimpledinthegroovesofthetubing.Theotherendofthetubing
isthenpassedofftothenurse.Ifyoulikethecirculatoryouinstructherto
placeitinalargeplasticbagwithinabucketplacedonthefloornearthe
operatingfieldandtapethebagaroundthetubing(thislastmaneuverwill
helptokeepthestinkintheORatanacceptablelevel).Ifyoudon’tlike
thecirculatoryoucanhaveherplaceitwherevershewants,butit’sbest
nottomakeamess.
Nowwe need to take the 16FrFoley and insertit either through
theappendixortheterminalileum.Ifthepatienthasanappendix,then
use it: divide the mesoappendix and make an enterotomy at the midappendix.Gently dilate theappendixand passthecatheter through the
appendiceallumen;onceitenters thececum blowup theFoley balloon
with10ccofwaterandpullitbacksothatitabutstheappendicealorifice
andthenusea0silktietosecureittothedevascularizedappendix.
Attachthe3LbagviathesterilecystotubingtotheFoleycatheterand
let it flow! Now startgently milking thestool-irrigant cocktail,starting at
thececum,aroundthetransversecolonand thenoutofthedescending
colon into the sterile tubing and out into the collection bag. Stop the
lavagewhentheeffluentisclear—no,youdonotneedtobeablereada
newspaper through the fluid… Now remove the Foley catheter and
complete the appendectomy. If the patient previously had an
appendectomy and you have placed the catheter through a small ileal
enterotomy—removetheFoleyandclosetheenterotomy.Idon’tbother
tryingtoextricatethetubingfromthecolon;Ijustresectthe2or3cmof
colonthatwereneededtosecurethetubingandhanditallofftothevery
happynursewho now has to deal with10poundsof stool! Apicture is
worth a thousand words and a diagram of the set-up is depicted in (
Figure27.3).
Figure27.3.Intra-operativecoloniclavage.
Afinal note about the lavage… I know that some surgeons would
simply milk out/suck out the stool from the colon and proceed with a
primary anastomosis — without the lavage. I contend, however, that
mobilizing the whole colon is required for any adequate colonic
decompression — I just can’t get the colon decompressed without full
mobilization.Ifindthelavagedoesnotaddmuchintimetotheprocess
andisamuchcleanerprocedure.Ifyouaregoingtodecompressthe
colonpriortodoingananastomosis,Iwouldlavageitaswell.Tryit!
Anastomosis
Igenerallyprefertheside-to-endanastomosisfor these patients
becausethereisasignificantsizediscrepancybetweenthedilatedcolon
andrectum.Inmyhandstheanastomosisisusuallystapled: Iinsert
the anvil of an EEA™ stapler into the open end of the colon and out
throughastabwound—securedwithapurse-stringsuture—attheantimesenterictaenia.Iclosetheopenendofthecolonwithalinearstapler
or two layers of sutures. I then bring the EEA™ stapler up through the
stapled-off rectum and perform the anastomosis. In a complete
obstructionthere israrelystool withinthe rectum.Asan alternativeyou
canperformahand-sewnanastomosis,butagainIwouldrecommenda
side-to-end anastomosis as opposed to an end-to-end given the size
discrepancythatisoftenseenwiththesepatients.
Divertornot?
Thedecisiontoperformaproximaldiversion,regardlessofintraoperative lavage, should be based on the patient’s overall health
andthe condition ofthebowelat the time ofsurgery. Patients with
multiple comorbidities who are ‘stable’ during the operative procedure
canstillundergoaprimaryanastomosisbutaproximaldiversionmaybe
recommendedespeciallyifthebowel thatis remainingis distendedand
edematous.Thecrucialfactoriswhetherthepatientwilltoleratean
anastomoticleakand its sequelae. As you know,diverting stomas
do not prevent anastomotic leaks but reduce their morbid
consequences,makingthemeasiertomanage—preventing‘failure
to rescue’. Which means — as the adage goes: if you think about
diverting,thendivert!
Youmayask:if Iplantodivert,whybotherwithcoloniclavage?
Well,having a columnofstool proximal to an anastomosis,evenif it is
divertedmoreproximally,canoftenleadtosignificantproblemsifaleak
develops.So—lavageisgood!
My favored diversionis aloop ileostomy. It is easier to construct
andclosethanacolostomy,althoughassociatedwithmorecomplications
suchasdehydrationandskinirritation.
Volvulusofthecolon
Thoughsometimesinapersonwhoisfat
Thediagnosisisnotclearasthat
‘TisthenyougethelpfromplainX-ray
Whichgaswithinthegutshouldwelldisplay
Sothatthecoilyouseeintheradiogram
Reachingfrompelvistothediaphragm.
ZacharyCope,TheAcuteAbdomeninRhyme
While volvulus accounts for onlyone-tenth of all instances ofcolonic
obstruction,wetendto rememberthosepatients.It isprobablybecause
of the spectacular appearance on abdominal X-rays and the equally
spectacular way it is treated. Volvulus of the sigmoid colon is much
more common than cecal volvulus. There is also volvulus of the
transverse colon but it isso rare that you willprobably notsee acase
duringyoursurgicallife.
Volvulusofthesigmoidcolon
In affected patients the sigmoid is long, with a redundant mesentery
that allows the sigmoid to rotate around its mesenteric axis, usually
counter-clockwise. It commonly occurs after patients have reached
seniority. It does happen in younger ages but then typically in an
institutionalized patient. The rotation must be at least 180° to be
symptomaticforobstruction,butiftherotationis360°thereisalsoarisk
ofstrangulation.Thesecircumstancesaccountfortwotypesofvolvulus:
a ‘slow’ form where obstruction develops gradually and a ‘rapid’ form
wherestrangulationdominates.Astheobstructingpointisdistallyatthe
rectosigmoid junction, the propulsion ofthe proximalcolon will blow up
theobstructedsigmoidlooptoimpressivedimensions.
Thetypicalpatientpresentswithahistoryofrecentonsetconstipation
and lack of flatus and a grossly distended belly. Because half of the
patients have recurrent episodes of volvulus the diagnosis may
alreadybeknown.Aplainabdominalfilmwillsuggestthediagnosis—
atremendouslylargeloopofcolonfillstheabdomenfromthepelvisto
theupper abdomen. Acontrastenemawith Gastrografin®willshow the
obstructionattherectosigmoidjunction.Typically,thecontrastendsina
characteristic‘bird’sbeak’sign.Thelowertwistcausesthisimage.Andof
course, a CT would show the huge loopof sigmoid, including the
whirl sign — typical for an intestinal volvulus — developing at the
twistingpointofthemesentery.
Treatmentofsigmoidvolvulus
As opposed to cecal volvulus (see below), sigmoid volvulus is
initiallytreatedwithanattemptatendoscopicdecompression. This
is usually feasible and allows the surgeon to visualize the mucosa to
ensurethebowelisviable.Thismaybedonewitharigidproctoscope
(historically,atthebedside—and,whensuccessful,witharushof
s**thitting the surgeon’sface), butsuccessrates,and patient and
surgeon comfort, are best when this is done with a flexible
sigmoidoscopy in the endoscopy suite. Other methods of non-
operativemanagement(e.g.hydrostaticdecompressionwithbarium)now
belongtohistory( Figure27.4).
Figure27.4.Non-operativemanagementofsigmoidvolvulus.
When scoping the volvulus there are two points of obstruction
that the endoscopist must pass to ensure the blockage is
completely relieved. The first twist of the bird’s beak gets the
endoscopeinto thedilatedand twistedsigmoid colon.Thesecond twist
orpointofblockageneedstobepassedtoensurethecolonisuntwisted
andtheobstructionrelieved.Oncethecolonisdetorted,andthebowelis
seentobeviable,thepatientcanbeadmittedand‘prepped’toundergoa
semi-electivesigmoidresection.
If the colon cannot be untwisted, then the patient requires an
immediate operation with resection and stoma formation
(Hartmann’s)orprimaryanastomosis—again,thedecisionwhether
toanastomoseornotdepends on the condition of the patient, his
bowelandyourexpertise.
Aftersuccessfulnon-operativedecompression
There is no general agreement when patients should be offered a
sigmoidectomy to prevent a recurrence. About half of the patients will
haveonlyoneepisodebutthosewithtwoepisodeswillfrequentlyhavea
third.Mostsurgeonsthereforeofferresectionafterthesecondepisode—
Iofferitafterthefirstepisode!
Elective sigmoid resections for volvulus may be performed with
minimal mobilization of the colon, resecting just the redundant sigmoid
that has an elongatedmesentery. It can be completed through a small
lowermidlineincision,aPfannenstielincision,orasmallLLQtransverse,
muscle-splittingincision. Once theincisionis made, thecolon just pops
out, and because we aren’t mobilizing much, I find really no need to
utilizethelaparoscopeforthisresection.Placingalaparoscopeforthis
reallyjustwastestimeandmoney.
Finally,sigmoidopexy(i.e.fixingtheviablesigmoidanditsmesentery
totheabdominalwalltopreventrecurrence),whichhasbeenadvocated
by some authors over the years, should be relegated to the history
books.
Volvulusofthececum
Thisisarelativelyrarecondition—youprobablywon’tseemorethan
afewcasesduringyourcareer—butitwillusuallyrequireanoperation.
It can cause intermittent symptoms that are vague and not easily
identified until the patient presents with features suggesting intestinal
obstruction.
Theunderlyingcauseisaredundantmesenteryandlackoffixationof
the cecum: it flips and twists (usually) clockwise, which results in
obstructionand compromiseof theblood supply.Ararevariantofcecal
volvulusiscecalbascule—involvingupwardsandanteriorfoldingofthe
rightcolon.
These patients have clinical and radiographic signs of small
bowel obstruction. In addition, typically, the cecal ‘shadow’ is
absentfrom the right lowerquadrant. Instead,the poorlyattached
andredundantcecum—whichhasflippedtotheleftandupwards
—isvisualizedintheepigastriumorthelefthypochondrium,with
its concavity pointing to the right lower quadrant. On abdominal
radiographsasinglefluidlevelmaybeseen,representingthedislocated
cecumandisoftenconfusedwiththegastricshadow.Ifindoubt(thereis
always some ‘doubt’) and in the absence of peritoneal signs, you may
order a Gastrografin® enema, whichwill demonstrate the characteristic
‘beak’ in the right colon. But today a CT is the easiest and most
accurateroutetoadiagnosis.
There are isolated reports of colonoscopic decompression of
cecal volvulus but the complexity of such a procedure and its
doubtful results suggest that an operation is the treatment of
choice.
Whattodo?Thereis aneternalcontroversy— probablynevertobe
solved— between theproponentsof cecal fixation(cecopexy), and the
advocates of mandatory resection. This is our selective approach: first
detortthececum;ifafterdetorsionthe bowelappears gangrenousorof
doubtful viability, thenproceed with a righthemicolectomy. A primary
anastomosis should usually be permissible but occasionally
circumstances suggest that a stoma ispreferable. Ifso, bringout the
smallbowel asanendileostomyand acornerofthe closedcolon
end through the same hole. This ‘double-barrel’ stoma allows simple
closureandrestorationofbowelcontinuitythroughthesiteofthestoma.
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