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338
11.1 Creation of an Intestinal Stoma
Sigmoid Colostomy
Operative Technique
T2
Fig. 11.1.6 Creation of a double-lumen colostomy of the sigmoid colon.
Assessing the mobility of the sigmoid colon.
With an atraumatic grasper (T2), expose the junction between the sig-
moid colon and the rectum and assess the mobility of the bowel. Separate
the sigmoid from the lateral gutter. Perform elevation and medial reflection of the sigmoid and mesosigmoid bluntly with a dissecting swab and
sharply with scissors after coagulating and incising the white line of Toldt
with bipolar electrocautery.
T3
T2
Fig. 11.1.7 Creation of a double-lumen colostomy. Opening a window in
the mesosigmoid.
Elevating the sigmoid colon on a rubber band requires opening a window
in the mesocolon. Locate a poorly vascularized area of the mesocolon approximately 1 cm wide, using transillumination to avoid vascular structures. Incise the peritoneal covering with scissors. Continue the dissection
bluntly using a grasper (T2). Use a second grasper to apply tension to the
intestinal segment being dissected (T3). Control any bleeding with bipolar
electrocautery or with laparoscopic clips or ligatures.
Fig. 11.1.8 Creation of a double-lumen colostomy. Looping around the
sigmoid colon.
Using a laparoscopic grasper, introduce a rubber band cut to size (approximately 30 cm) into the peritoneal cavity through the 10.5-mm instrument trocar and converter (T2). Pass the rubber band through the
mesosigmoid window to the grasper (T3).
T3
T2
T2
Complications
Fig. 11.1.10 Creation of a double-lumen colostomy. Exteriorizing the intestinal segment.
After extending the incision T2 to approximately 3 cm, pull the looped
sigmoid segment out through the abdominal wall. This maneuver
evacuates the pneumoperitoneum and allows the abdominal wall to return to a normal position and avoid tension on the bowel loop.
339
Fig. 11.1.9 Creation of a double-lumen colostomy. Exteriorizing the sigmoid colon.
After exteriorizing both ends of the rubber band through the 20-mm instrument trocar (T2), remove the trocar from the abdomen over both
ends of the rubber band, which are held securely with a clamp above the
trocar opening.
Complications
Intraoperative Complications
Bleeding from damaged vascular structures and the mesocolon
can usually be controlled with laparoscopic clips or sutures. If
this is unsuccessful, conversion to laparotomy is indicated.
Injuries to the ureter require treatment by laparotomy.
Fig. 11.1.11 Creation of a double-lumen colostomy. Completed stoma.
As in the open procedure, insert a spacer bar beneath the sigmoid. Then
open the intestinal lumen and attach its contours to the abdominal wall
with interrupted sutures.
Immediate Postoperative Complications
Complications in the laparoscopic creation of a stoma generally
involve the stoma itself. Necrosis, peristomal infections, prolapse of the intestine, acute invagination, internal hernia with
loop incarceration, and other complications are discussed elsewhere.
340
11.1 Creation of an Intestinal Stoma
Creation of a Terminal Colostomy
Operative Technique
T2
T3
Fig. 11.1.12 Terminal colostomy. Hartmann’s operation.
After incising the mesocolon and coagulating small vessels, divide the
bowel with a stapler (T3), simultaneously closing the proximal and distal
sections of the colon.
T3
Fig. 11.1.13 Terminal colostomy. Hartmann’s operation.
Using a swab (T3) and scissors (T2), dissect the proximal sigmoid colon
from the lateral gutter and free it sufficiently to reach the abdominal wall.
Fig. 11.1.14 Terminal colostomy. Hartmann’s operation.
After opening a channel through the abdominal wall at the level where
the proximal colon reaches the wall without tension, grasp the sigmoid
colon with an atraumatic grasper and exteriorize it for “maturing” the
colostomy on the skin. As the opening in the abdominal wall is made, the
pneumoperitoneum is evacuated.
Fig. 11.1.15 Terminal colostomy. Hartmann’s operation.
Attach the sigmoid aperture to the epidermis with a circle of interrupted
sutures after placing an additional four to six interrupted sutures from the
aponeurosis of the external abdominal oblique muscle to the sigmoid wall
to hold the stoma.
Late Complications
Late complications can occur. These include:
− Peristomal hernia (Fig. 11.1.16 a).
− Prolapse or invagination (Fig. 11.1.16 b).
− Stenosis (Fig. 11.1.16 c).
− Retraction (Fig. 11.1.16 d).
− Peristomal dermatitis (Fig. 11.1.16 e ).
− Peristomal infection (late abscess, fistulas, or ulceration).
− Bleeding.
− Tumor formation (granulation polyps, adenomas, or carcinomas).
− Mechanical ileus (for example internal incarceration, adhesions, or volvulus of a Kock pouch).
− Disturbed vascular supply due to surgical error.
Laparoscopic creation of a stoma appears to decrease the inci-
dence of these complications. The reason is that the stoma lies
in a planned incision through which the surgeon can exteriorize
the bowel at the site selected from within the peritoneal cavity
under laparoscopic visualization without tension or twisting.
Bibliography
341
a
b
c
Bibliography
Althaus RJ. Ein neuer Kontinenzverschluß für Kolostomieträger. Zbl. Chir.
1981; 160:241.
Englert G, Winkler R. Verbesserung der Lebensqualität von Stomaträgern.
Freising: Ilco; 1988.
Evers G. Allgemeine und örtliche Spätkomplikationen des Kunstafters. Zbl.
Chir. 1969; 94:83.
Feuster H, Hennig G. Kontinente Colostomie durch Magnetverschluß. Dtsch.
med. Wschr. 1975; 102:1063.
Harper PH, Truelove SC, Lee ECG, Kettlewell MGW et al. Split ileostomy and
ileocolostomy for Crohn’s disease of the colon and ulcerative colitis: a
20 year survey. Gut 1983; 24:106.
Kewenter J, Kock NG, Myrvold H, Philipson B. The continent ileostomy. In
Kremer K, Kivelitz H. Colitis ulcerosa. Stuttgart: Thieme; 1977.
Kivelitz K, Kremer K. Kontinenz und Stomata. Ingelheim: Deutsche Abbot;
1979.
Kock NG. Continent ileostomy. Prog. Surg. 1973; 12:180.
Kock NG. Kontinente Ileostomie. Chirurg 1982; 53:541.
Kuntzen H, Pitzler K. Der Anus praeternaturalis und seine Komplikationen.
Zbl. Chir. 1962; 87:67.
Lenneberg E, Rowbotham JL. The ileostomy Patient. A describe study of
1425 patients. Springfield Illinois: Thomas; 1970.
d
e
Fig. 11.1.16 a−e Creation of a terminal colostomy. Complications.
a Peristomal hernia.
b Prolapse.
c Stenosis.
d Retraction.
e Dermatitis and peristomal abscess.
Myrvold HE. The continent ileostomy. Wld. J. Surg. 1987; 11:720.
Plamu A, Sivula A. Kock’s continent ileostomy: results of 51 operations and
experiences with correction on nipple-valve insufficiency. Brit. J. Surg.
1978; 65:645.
Schmidt E. Spätergebnisse nach glattmuskulärem Sphincterersatz. Chirurg
1985; 56:305.
Schmidt E, Bruch HP, Greulich M, Rothammer A et al. Kontinente Colostomie
durch freie Transplantation autologer Dickdarmmuskulatur. Chirurg
1979; 50:96.
Schreiber HW, Rehner M, Merguet H. Anus praeternaturalis. In Baumgartl F,
Kremer K, Schreiber HW. Spezielle Chirurgie für die Praxis, vol. II/2, p. 435.
Stuttgart: Thieme; 1972.
WeaverRM, Alexander-Williams J, Keighly MRB. Indications and outcome of
reoperation for ileostomy complications in inflammatory bowel disease.
Int. J. Colorect. Dis. 1988; 3:38.
Wedell HJ, Banzaf G, Meier zu Eisen P, Schlageter M. Erfahrungen mit einem
subcutanen, voll resorbierbaren Reiter bei der Anlage einer doppelläufigen Ileo- und Colostomie. Chirurg 1990; 61:36.
Winkler R. Stomaanlage. In Kremer K, Lierse W, Platzer W, Schreiber HW,
Weller S. Chirurgische Operationslehre, vol. 6, p. 439. Stuttgart: Thieme;
1992
Winkler R. Stomatherapie. Stuttgart: Thieme; 1983.
342
11.2 Laparoscopically-Assisted Right Hemicolectomy
L. U. Jung, C. A. Schneider, H. Yang, A. E. Roth
Objectives and Methods
In view of the good results obtained with laparoscopic cholecystectomy, the minimally invasive technique has been taken one
step further and has been applied to other gastrointestinal pro-
cedures such as laparoscopically assisted right colon resection.
This laparoscopic approach enjoys less complications, such as
wound infection and the potential for ventral hernia. It also
decreases hospital stay, postoperative ileus, and postoperative
pain.
Indications
− Most benign pathological conditions (diverticulitis, hemorrhage, etc.).
− Selected malignant conditions:
− Patients who need palliative surgery only because of dis-
tant metastases,
− High risk patients,
− Localized T1 N0 tumors.
Contraindications
− Severe coagulopathy.
− Respiratory failure.
− Cardiac failure.
− Extensive local and regional malignancy.
Trocar Placement
(See Fig. 11.2.5).
The camera port is placed at the umbilicus. Two trocars are
placed lateral to the left rectus muscle, one above and one
below the umbilical level. Two other trocars are placed lateral to
the right rectus muscle; one above and one below the umbilical
level.
Intraoperative Risks
− Subcutaneous emphysema from CO2insufflation into the
subcutaneous space.
− Trocar injury
− Bowels,
− Solid organs,
− Vascular structures.
Postoperative Risks
− Anastomotic leak.
− Wound infection.
− Bleeding.
− Trocar site recurrence (controversial and needs further evaluation).
Postoperative Course
Special Preparation
− Standard preoperative work up same as for open procedure.
− Patients should be informed that a small incision will be made
for delivery of specimen and formation of anastomosis.
− Patients should be informed that open operation may be
needed if laparoscopic attempt fails.
Anesthesia
General endotrachal.
Instrumentation
− General purpose laparoscopic setup.
− 2 12-mm trocars,
− 3 10-mm trocars,
− 2 laparoscopic Babcock clamps,
− 1 TA stapler,
− 1 GIA stapler.
Operative Positioning
Supine with arms tucked in on the side. The surgeon stands on
the left side of the patient and assistant on the right. The monitors are placed cephalad to the shoulder on the either side.
Nasogastric tub e is used during the intra- and postoperative period until bowel function returns. Diet is then started slowly.
The patient is also encouraged to ambulate as early as possible.
A urinary catheter is used only for a short period of time, if used
at all.
Complications
Postoperative Complications
Bleeding
Corrective action: Intraluminal bleeding, usually from the
wound boundaries of the anastomosis, can be managed endoscopically. Conventional laparotomy is indicated for intraperitoneal hemorrhage.
Suture Breakdown in the Anastomosis
Corrective action: Laparotomy is indicated for suture breakdown
in the anastomosis; the leak is closed by sutures, larger defects
and cyanotic wound margins are resected and the anastomosis
reconstructed.
Peritonitis
Infection of the Abdominal Wounds
Corrective action: Open wound treatment is indicated for infections of the abdominal wall.
Complications
343
Step-by-Step Procedure (Figs. 11.2.10 to 11.2.16)
1. The patient is placed on the operating table in the supine
position. The surgeon stands at the left and first assistant
stands at the right side of the table. The monitors are at the
shoulder level of the patient on the either side.
2. A 2 cm vertical incision is made in the skin inferior to the
umbilicus. The fascia is incised vertically through the linea
alba and peritonium is entered under the direct vision and secured. Pneumoperitonium to 15 mm Hg ist then established.
3. The 0 degree camera is inserted through the umbilical port
and the survey of the abdominal cavity is performed. Other
trocars are inserted under direct vision. Two trocars on the
left side of left rectus muscle and two trocars on right side of
right rectus (Fig. 11.2.1).
4. Using an Endo Babcock, the right colon is retracted medially.
Right colon is then mobilized starting at the cecum. Tilting
the operating table to the left facilitates the dissection
(Fig. 11.2.2).
The hepatic flexure is mobilized by pulling the hepatic flexure
inferiormedially using an Endo Babcock. A laparoscopic fan re-
tractor may be used to retract the liver and the operating
table placed in reverse Trendelenberg position (Fig. 11.2.2).
6. Mobilization of the right colon is completed by mobilizing the
proximal transverse colon and the distal portion of the terminal ileum.
7. The bowel is divided with the linear/cutter device such as the
Endo GIA.
8. Once the bowel is transected, the mesentery of the bowel is
divided by clipping individual vessels or using an Endo GIA sta-
pler (Fig. 11.2.3).
9. A collecting bag is introduced into the abdominal cavity and
specimen is placed in the bag. One of the right lateral ports is
made larger and the specimen is removed through the enlarged trocar site.
10. For a side to side anastomosis, one arm of the GIA stapler is
placed into one bowel limb each, through the excised an-
timesenteric corner of the respective bowel limb (Fig. 11.2.4).
11. The instrument halves and bowel limbs are matched and the
instrument is activated (Fig. 11.2.4).
12. The GIA introduction site is closed using the TA stapler
(Fig. 11.2.5).
13. The bowel can also be transected outside the abdominal cavity if the mesocolon is thick and difficult to handle in-
traabdominally. The pneumoperitonium is released and
through the enlarged port site, bowel that needs to be resected is exteriorized (Fig. 11.2.6).
14. Using the GIA stapler, side to side anastomosis is performed
(Fig. 11.2.7).
15. The specimen is then transected using the TA stapler
(Fig. 11.2.8).
16. After the staple line is inspected, the bowel is returned to the
abdominal cavity (Fig. 11.2.9).
17. The enlarged port site is closed and the pneumoperitonium is
reestablished. Final inspection of the abdominal cavity if per-
formed laparoscopically, then the pneumoperitonium is re-
leased and the trocar sites are closed (Fig. 11.2.9).
Operative Technique
Fig. 11.2.1 After insertion of the umbilical trocar, the abdomen is insuf-
flated with CO
serted. Three to four other trocars are then placed. One or two 10-mm
trocars are placed lateral to the left rectus muscle for Endo Babcocks and
two 12-mm trocars are placed lateral to the right rectus muscle to acco-
modate Endo GIA staplers and dissection-hemostasis instruments.
to a pressure of 15 mm Hg and the 0 degree scope is in-
2
344
11.2 Laparoscopically-Assisted Right Hemicolectomy
6
Fig. 11.2.2 Using Endo babcocks the right colon is retracted medially, exposing the right paracolic gutter. Special care must be given when using
the Endo Babcock as this instrument may perforate the colon if excessive
force is used to retract the colon. Mobilization of the right colon is best
started at the easily identifiable cecum and the operating table is tilted to
the left to facilitate dissection. The paracolic gutter is opened by dividing
the white line using scissors and electrocoagulation. The hepatic flexure
dissection is helped by inferiormedial traction of the colon and placing the
operating table in reverse Trendelenberg position. A laparoscopic fan retractor might be required to retract the liver at this point.
Once the right colon is fully mobilized, the division sites for the ileum and
transverse colon are selected. One must make sure that the distal ileum is
fully mobilized and pay special attention not to injure the right ureter. Division is best done with the linear stapler/cutter device such as the Endo
GIA.
Fig. 11.2.3 Once the bowel is transected, the mesentery can be divided
by clipping individual vessels or by using the Endo GIA stapler. We prefer
dividing the mesentery with Endo GIA staples as this saves a significant
amount of time.
Once the specimen is ready to be delivered out of the abdomen, one of
the right lateral ports is made larger. The specimen is removed through
the enlarged trocar site within a collecting bag and anastomosis is performed using the GIA stapler extraabdominally.
Fig. 11.2.4 For a side-to-side anastomosis, one arm of the GIA stapler is 컄
placed into one bowel limb, each through the excised antimesenteric
corner of the respective bowel limb. The instrument halves and bowel
limbs are matched, the instrument is locked and activated.
Complications
345
Fig. 11.2.5 The GIA introduction site is closed transversely using the TA
stapler.
Fig. 11.2.6 In patients in whom the mesocolon is thick and difficult to
handle intraabdominally, the bowel can also be transected outside the
abdominal cavity. The pneumoperitonium is released and through the enlarged port site, bowel that needs to be resected is exteriorized.
Fig. 11.2.7 Using the GIA stapler, an extraabdominal side-to-side anastomosis is performed, before the bowel is resected, at the preselected site
for anastomosis. The mesocolon supporting the specimen is separated
from the remaining mesocolon.
Fig. 11.2.8 The specimen is then transected using the TA stapler to close
both bowel lumina, central to the GIA introduction site. The mesocolic defect is then closed.
346
11.2 Laparoscopically-Assisted Right Hemicolectomy
컅 Fig. 11.2.9 After inspection, the anastomosed bowel is returned into the
abdominal cavity. The fascia is closed and the pneumoperitonium is reinstituted. Final survey of the abdominal cavity is performed laparoscopically, then the pneumoperitonium is released and trocar sites are closed.
3
6
7
5
1
4
2
6
Fig. 11.2.10 Step-by-step procedure:
1 Elevate right colon and mesocolon towards midline.
2 Start mobilization at cecum.
3 Incise peritoneal reflection along right paracholic gutter to and including
hepatic flexure.
4 Transect right mesocolon and insure vessel hemostasis.
5 Place small incision at appropriate level in RUQ and remove specimen in-
side bag.
6 Divide terminal ileum and proximal transverse colon.
Fig. 11.2.11 Step-by-step procedure:
7 Exteriorize both bowel ends. Excise antimesenteric corners of each. Place
GIA instrument and perform side-to-side ileo-colostomy.
Complications
8
7
347
8
Fig. 11.2.12 Step-by-step procedure:
8 Close GIA introduction site with linear stapler.
9 Excise excess tissue peripheral to linear stapler.
10 Afferent loop: Anastomosis functions in an end-to-end fashion.
79
9
7
Fig. 11.2.13 Step-by-step procedure:
7 In patients with a thick right mesocolon exteriorize the specimen intact.
Perform side-to-side anastomosis at appropriately selected level.
10
Fig. 11.2.14 Step-by-step procedure:
7 The GIA introduction site is part of the specimen.
8 Both the ileum and transverse colon are closed with a linear stapler at the
preselected resection level.
9 Both bowel ends are transected, using the stapler as a guide for the scal-
pel.
10 Anastomosis functions in end-to-end fashion after removal of specimen.
8
10
8/9
7
Fig. 11.2.15 Step-by-step procedure:
7, 8, 9 Anastomosis first-resection second is complete (“Anastomose-résec-
tion intégrée” of Welter-Ravitch).
10 Specimen is removed after corresponding mesocolon and vessels have
been transected.
11 Functional end-to-end anastomosis.
11