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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Meckel’s Diverticulum
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Fig. 4 A GIA stapler can
be placed across the base
of the diverticulum for a
diverticular resection.
Surgeons should be
vigilant to avoid narrowing
of the bowel to avoid
stricture. (Credit: JF Burke
and CM Leys)
301
hand-sewn anastomosis. If a diverticulectomy is performed, one must look for and
ligate any mesentery vessels feeding the distal portion of the diverticulum (Fig.3
arrow). The decision between diverticulectomy and SBR is dependent on various
characteristics of the Meckel diverticulum. Factors favoring SBR include inammation, a thickened base, and/or ischemia [11], or a height-to-diameter ratio of less
than 2 (due to risk for incomplete excision of heterotopic tissue present at the base
of the diverticulum) [12]. In the absence of these characteristics, diverticulectomy is
safe, has a shorter operative time, and is usually associated with a lower risk of
future small bowel obstruction [13, 14].
An ongoing point of debate is the recommended management for incidentally
identied Meckel diverticulum seen during operation for trauma or any other unrelated pathology. Those who advocate for resection of incidental Meckel diverticulum cite the risk of future obstruction, bleed or diverticulitis. Additionally, there are
reports of incidentally-noted Meckel diverticulum having tumors found on histologic examination [15–17]. Those who argue against resection point to a higher risk
of complications in patients who underwent resection versus observation [18]. As in
many areas of surgery, the correct decision is dependent on the clinical situation; a
number of factors have been identied as increasing the risk of future complications
related to an untreated Meckel diverticulum. From a patient standpoint, male
patients and patients less than 50years of age are at higher risk of developing symptomatic disease [19]. Diverticular features that are more likely to lead to problems
later include narrow diverticular neck, diverticulum greater than 2cm long, brous
remnant connected to the umbilicus, and palpable heterotopic tissue [19]. Ultimately,
the surgeon must consider the overall goal of the intended operation and the condition of the patient (as in the trauma laparotomy) when making the nal decision for
resection of the incidental diverticulum.
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J. R. Julson and C. Onwubiko
6 Complications andPost-operative Care
Morbidity following Meckel diverticulum resection is reportedly quite low at 5.3%,
with wound infection and ileus accounting for 66% of post-operative complications
[18]. Patients are generally able to progress quickly post-operatively. In pediatric
patients, regardless of surgical approach, hospital length of stay is reported at 2–7
days [10] and, similarly, average length of stay for adults is 4days [20]. Though
rare, post- operative complications can arise and are similar to any patient who
undergoes small bowel surgery including a risk of infection, bleeding, future bowel
obstruction from post-operative adhesive disease, and anastomotic leak or stricture.
References
1. Meckel JF.Uber die divertikel am darmkanal. Arch Die Physio. 1809;9:421–53.
2. Stallion A.Surgical treatment: evidence-based and problem-oriented. In: Meckel’s diverticulum. Munich: Zuckschwerdt; 2001. https://www.ncbi.nlm.nih.gov/books/NBK6918/.
3. Hansen CC, Soreide K.Systematic review of epidemiology, presentation, and management of
Meckel’s diverticulum in the 21st century. Medicine (Baltimore). 2018;97(35):e12154. https://
doi.org/10.1097/MD.0000000000012154. From NLM Medline.
4. Schizas D, Katsaros I, Tsapralis D, Moris D, Michalinos A, Tsilimigras DI, Frountzas M,
Machairas N, Troupis T. Littre’s hernia: a systematic review of the literature. Hernia.
2019;23(1):125–30. https://doi.org/10.1007/s10029- 018- 1867- 0. From NLM Medline.
5. Poulsen KA, Qvist N.Sodium pertechnetate scintigraphy in detection of Meckel’s diverticulum:
is it usable? Eur J Pediatr Surg. 2000;10(4):228–31. https://doi.org/10.1055/s- 2008- 1072364.
From NLM Medline.
6. Farrell MB.Meckel’s diverticulum imaging. J Nucl Med Technol. 2020;48(3):189–90. https://
doi.org/10.2967/jnmt.120.244137. From NLM Medline.
7. Kotha VK, Khandelwal A, Saboo SS, Shanbhogue AK, Virmani V, Marginean EC, Menias
CO. Radiologist’s perspective for the Meckel’s diverticulum and its complications. Br J
Radiol. 2014;87(1037):20130743. https://doi.org/10.1259/bjr.20130743. From NLM Medline.
8. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN,
Napolitano LM, Sawyer RG, Slain D, etal. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195–283. https://doi.org/10.2146/
ajhp120568.
9. Crosthwaite GL, Leather AJ.Laparoscopy: the ultimate diagnostic tool for a bleeding Meckel’s
diverticulum. Aust N Z J Surg. 1997;67(4):223–4. https://doi.org/10.1111/j.1445- 2197.1997.
tb01948.x.
10. Skertich NJ, Ingram MC, Grunvald MW, Williams MD, Ritz E, Shah AN, Raval MV.Outcomes
of laparoscopic versus open resection of Meckel’s diverticulum. J Surg Res. 2021;264:362–7.
https://doi.org/10.1016/j.jss.2021.02.028.
11. Duan X, Ye G, Bian H, Yang J, Zheng K, Liang C, Sun X, Yan X, Yang H, Wang X, et al.
Laparoscopic vs. laparoscopically assisted management of Meckel’s diverticulum in children.
Int J Clin Exp Med. 2015;8(1):94–100.
12. Varcoe RL, Wong SW, Taylor CF, Newstead GL. Diverticulectomy is inadequate treatment
for short Meckel’s diverticulum with heterotopic mucosa. ANZ J Surg. 2004;74(10):869–72.
https://doi.org/10.1111/j.1445- 1433.2004.03191.x.
Meckel’s Diverticulum
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13. Redman EP, Mishra PR, Stringer MD.Laparoscopic diverticulectomy or laparoscopic-assisted
resection of symptomatic Meckel diverticulum in children? A systematic review. Pediatr Surg
Int. 2020;36(8):869–74. https://doi.org/10.1007/s00383- 020- 04673- 5.
14. Brungardt JG, Cummiskey BR, Schropp KP.Meckel’s diverticulum: a national surgical quality
improvement program survey in adults comparing diverticulectomy and small bowel resection.
Am Surg. 2021;87(6):892–6. https://doi.org/10.1177/0003134820954820.
15. Mora-Guzman I, Munoz de Nova JL.Meckel’s diverticulum in the adult: prophylactic surgery.
J Visc Surg. 2018;155(2):167. https://doi.org/10.1016/j.jviscsurg.2018.01.005.
16. Caracappa D, Gulla N, Lombardo F, Burini G, Castellani E, Boselli C, Gemini A, Burattini
MF, Covarelli P, Noya G.Incidental nding of carcinoid tumor on Meckel’s diverticulum: case
report and literature review, should prophylactic resection be recommended? World J Surg
Oncol. 2014;12:144. https://doi.org/10.1186/1477- 7819- 12- 144.
17. Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H 3rd, Lee KK, Bartlett
DL.Meckel’s diverticulum—a high-risk region for malignancy in the ileum. Insights from a
population-based epidemiological study and implications in surgical management. Ann Surg.
2011;253(2):223–30. https://doi.org/10.1097/SLA.0b013e3181ef488d.
18. Zani A, Eaton S, Rees CM, Pierro A.Incidentally detected Meckel diverticulum: to resect or not
to resect? Ann Surg. 2008;247(2):276–81. https://doi.org/10.1097/SLA.0b013e31815aaaf8.
19. Zyluk A.Management of incidentally discovered unaffected Meckel’s diverticulum—a review.
Pol Przegl Chir. 2019;91(6):41–6. https://doi.org/10.5604/01.3001.0013.3400.
20. Ezekian B, Leraas HJ, Englum BR, Gilmore BF, Reed C, Fitzgerald TN, Rice HE, Tracy
ET.Outcomes of laparoscopic resection of Meckel’s diverticulum are equivalent to open laparotomy. J Pediatr Surg. 2019;54(3):507–10. https://doi.org/10.1016/j.jpedsurg.2018.03.010.
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Part V
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Colorectal Surgery
Right Hemicolectomy
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CyrusFeizpous, MeghanLark, andSanjayMohanty
1 Anatomy andIndications
The right colon extends from the cecum, which is typically xed in the right lower
quadrant, to the hepatic exure, where it transitions to the transverse colon. The
arterial supply to the right colon primarily comes from the ileocolic artery and the
right colic artery. The ileocolic artery supplies the terminal ileum and the cecum,
and the ascending colon is supplied by the right colic in 32–63% of people [1, 2].
The hepatic exure is supplied by branches of the middle colic artery and collateral
vessels between these branches and those from the right colic artery form the right
portion of the marginal artery of Drummond. The venous drainage of the right colon
typically mirrors the arterial supply as the ileocolic, right colic, and middle colic
veins drain into the superior mesenteric vein. The lymphatic supply to the colon
follows the blood supply through the mesentery. This becomes clinically signicant
when discussing margins of resection for malignancy.
Benign or malignant lesions of the cecum and right colon can be treated by right
hemicolectomy. Indications for benign processes involving the right colon include
inammatory bowel disease, ischemia, trauma, cecal volvulus, and more. Malignant
or premalignant lesions can also be appropriately managed with right hemicolectomy, including adenocarcinomas or colonoscopically unresectable adenomas. In
addition, appendiceal neoplasms such as adenocarcinoma or carcinoid tumors larger
than 2cm, those not conned to the appendix, or with positive lymph nodes require
right hemicolectomy [3].
The extent of resection for malignant lesions located within the cecum or ascending colon is dictated primarily by the blood supply and lymphatic drainage. Where
C. Feizpous · M. Lark · S. Mohanty (*)
Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
e-mail: cfeizpou@iu.edu; meglark@iu.edu; mohantys@iu.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_25
307© The Author(s), under exclusive license to Springer Nature
308
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formal oncologic resection is required, the extent of colon removed is based upon
the area supplied by the ileocolic and right colic artery and margin considerations.
If extended right hemicolectomy is warranted, removal of additional transverse
colon supplied by the middle colic artery may be required.
C. Feizpous et al.
2 Preoperative Preparation
Individual patient risk factors will determine what additional cardiac and pulmonary work-up is required preoperatively. Pertinent preoperative work-up is determined by the underlying diagnosis requiring right colon resection. Colonoscopy is
used to identify, obtain tissue diagnosis, and mark (tattoo) the location of an intraluminal lesion. This is particularly important when a laparoscopic approach is
planned. Using India ink, the endoscopist should tattoo immediately adjacent to the
lesion, preferably distal, allowing for intra-operative identication [4].
In cases where malignancy is proven or suspected, preoperative work-up should
also include computed tomography of the chest, abdomen, and pelvis for oncologic
staging [5]. Preoperative carcinoembryonic antigen (CEA) is obtained to facilitate
postoperative surveillance. Additional staging should include mismatch repair/microsatellite instability testing of any tumor tissue and, in appropriate patients, a discussion of fertility risk. Evidence of metastatic disease does not necessarily exclude
right hemicolectomy, especially when obstruction or refractory bleeding is present,
but may alter the treatment approach with use of neoadjuvant therapy, as per
National Comprehensive Cancer Network (NCCN) Guidelines [5]. Careful discussion with the patient about goals of therapy, patient preferences, and relative balance of risks and benets is required prior to performing any operative procedure.
Preoperative patient preparation usually involves full mechanical bowel preparation with oral antibiotics. An updated Cochrane Review concluded that there is no
evidence that preoperative mechanical bowel preparation alone (without antibiotics) decreases rates of anastomotic leak, mortality, peritonitis, need for reoperation,
wound infection, or morbidity. Additionally, there is some suggestion that inadequate bowel preparation which leaves liquid stool within the colon may be associated with poorer outcomes [6]. However, a Veteran’s Administration study noted
that mechanical bowel preparation with oral antibiotics may decrease rates of surgical site infections [7]. Our practice is to administer a preoperative mechanical bowel
preparation with oral antibiotics.
3 Anesthesia andPositioning
General anesthesia is utilized for open and minimally invasive right hemicolectomy.
Spinal blocks, transversus abdominus plane blocks, or thoracic epidural catheters
may be utilized to help with pain control and reduce narcotic requirements postoperatively [8].
Right Hemicolectomy
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The patient is positioned supine on the operating room table. The left arm is
tucked at the patient’s side for a minimally invasive approach. In open cases, arms
are left out. DVT prophylaxis is provided with sequential compression devices and
subcutaneous unfractionated heparin given prior to beginning the case. Preoperative
antibiotics with gram positive and gram negative coverage are given within 60min
of making incision and re-dosed as needed throughout the case [9]. An indwelling
urinary catheter is placed for monitoring during the procedure.
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4 Operative Descriptions
4.1 Open Right Hemicolectomy
The decision to perform an open or minimally invasive right hemicolectomy will
depend on patient factors and the surgeon’s familiarity with the minimally invasive
approach. We will begin with a description of the open approach.
A midline laparotomy incision in made extending just above and below the
umbilicus. The subcutaneous tissues and linea alba are divided with either the scalpel or electrocautery until the peritoneum is identied. This is elevated and entered
sharply with Metzenbaum scissors. Adhesions are taken down off of the abdominal
wall until there is enough space circumferentially to place a wound protector. A self
retaining retractor is placed, and the liver, peritoneum and other organs are inspected
for evidence of metastatic disease in the case of malignancy.
The omentum is displaced cephalad towards the stomach. In the open approach
a lateral to medial dissection is generally utilized. The lateral dissection is performed by incising the peritoneal reection, or the white line of Toldt, just lateral to
the cecum. The right ureter must be identied and preserved as it crosses anteriorly
over the right common iliac bifurcation. This dissection is carried superiorly toward
the hepatic exure of the colon with use of either the right angle or the surgeons left
hand. Care must be taken to stay high on the colon to avoid injury to retroperitoneal
structures and to avoid carrying the dissection posteriorly behind the duodenum or
kidney. Retraction of the colon medially via the surgeons right hand is important to
gain adequate countertraction for mobilization. The mesentery of the right colon is
separated from the retroperitoneum at the embryonic fusion plane. This should be
an avascular plane and continued bleeding during the course of this dissection
should lead the surgeon to believe they are progressing into the mesentery. As the
dissection progresses superiorly and medially, the second portion of the duodenum
must be identied and protected from injury (Fig.1). The duodenum is kept posteriorly while the colon is brought anteriorly off the retroperitoneum (Fig.2). The
hepatic exure is mobilized as the colon is retracted caudad once again paying close
attention to the location of the duodenum, gallbladder, and porta hepatis. The lesser
sac is then entered between the omentum and the attachments to the transverse
colon to allow mobilization of the proximal transverse colon. This is performed as
the surgeon retracts the transverse colon caudad while the assistant pulls anteriorly
and cephalad on the omentum. The omentum is then separated off of the transverse
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Fig. 1 The right colon is
retracted medial while
dividing the lateral
peritoneal attachments,
taking care to identify and
preserve the right ureter.
As the dissection is carried
superiorly, the duodenum
must be identied and
protected
Fig. 2 As the right colon
is mobilized and rotated
medially, the second and
third portion of the
duodenum should be
identied and kept
posterior
C. Feizpous et al.
colon using electrocautery. Alternatively, our practice in the case of proximal transverse tumors is to include the involved portion of omentum in the specimen. At this
point the terminal ileum up to the transverse colon should be fully mobilized and
Right Hemicolectomy
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able to be brought toward the midline. The proximal and distal transections points
are then identied. If the operation is performed for malignancy, these points should
be chosen to ensure a luminal margin of at least 5cm, both proximally and distally
[10, 11]. A window is made in the mesentry at both points just off the bowel edge
and the mesentery in between is divided by use of a vessel sealer or by ligation
between clamps and ties. In the setting of a suspected or conrmed malignancy the
mesentery should be divided in a “V” shape aiming towards the base of the ileocolic
artery at its junction with the superior mesenteric artery, to ensure a high ligation.
An adequately high ligation of the ileocolic artery ensures adequate nodal sampling
(at least 12 lymph nodes is generally recommended) for proper staging [5, 12]. If
present, the right branch of the middle colic is additionally divided at its origin
while the left branch is preserved (Fig.3). If the lesion is at the hepatic exure or
proximal transverse colon, the specimen can be extended by dividing the middle
colic vessels at their base. If the right colic vessels are present, these are also divided
at their origin. We then begin our anastomosis via the surgeon’s preferred technique.
Our practice is to use the a Barcelona technique [13]. The edges of the cut mesentery are brought side by side and a small enterotomy and colotomy are made on the
antimesenteric border at a level just beyond the mesenteric edges on the specimen
side. These are held open with Allis clamps. The 75mm GIA stapler is then passed
through the enterotomy and colotomy. One must ensure no mesenteric tissue is
caught within the stapler and that both ends are aligned evenly. A 3-0 Vicryl suture
is placed as a reinforcing crotch stitch at the far edge of the stapler. The stapler is
then red and brought out slowly to ensure no intraluminal bleeding. Another load
of the GIA stapler is used to divide the specimen just off the common enterotomy,
forming a side-to-side, functional end-to-end anastomosis in an anti-peristaltic conguration. The specimen is then passed off and sent to pathology. The stapled edge
of the side to side anastomosis may then be oversewn at the surgeon’s discretion.
The ileocolic anastomosis can alternatively be created either in a hand-sewn or
Fig. 3 The mesentery of
the right colon and, if
necessary, the transverse
colon is ligated. When
malignant disease is
resected, the ileocolic and
right colic (if present)
vessels are identied and
divided near their origin to
allow for adequate lymph
node sampling. The right
branch of the middle colic
is usually divided at its
bifurcation from the left
branch
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C. Feizpous et al.
alternative, stapled fashion (Figs.4 and 5). The abdomen is irrigated, inspected for
bleeding, and the fascia is closed with running, slowly absorbable suture. The subcutaneous tissue is again irrigated, and the skin is closed.
4.2 Laparoscopic Right Hemicolectomy
Laparoscopic right hemicolectomy can be performed under general anesthetic with
similar preparation and positioning as described above. Because of the reduction of
tactile sensation during the laparoscopic portion of the case, tattooing of the lesion
colonoscopically takes on increased importance.
The abdomen can be entered using a Veress needle technique, via optical entry,
or the open Hasson technique. We perform this operation using optical entry via a
Fig. 4 The side-to-side
stapled anastomosis is
constructed after resecting
the specimen. Each half of
the linear cutting stapler is
passed through
enterotomies in the
terminal ileum (left) and
transverse colon (right).
Firing the stapler creates a
lumen through the
antimesenteric borders of
the intestine
Fig. 5 The common
enterotomy from the
side-to-side stapled
anastomosis is closed using
the transverse non-cutting
stapler. Care is taken not to
narrow the newly created
lumen, and the staple line
can be oversewn
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