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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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Total Abdominal Colectomy
https://t.me/med1917
MaryG.Smithson andDrewGunnells
1 Anatomy andIndications
The colon begins at the cecum which is xed in the right lower quadrant. The small
intestine feeds into the cecum through the ileocecal value. The cecum continues as
the ascending colon which lies on the right side of the abdomen and transitions to
the hepatic exure near the liver. There the colon transitions to the transverse colon
which extends horizontally to the splenic exure. After this, the colon continues
down the left side of the abdomen as the descending colon. Lastly, the colon extends
into sigmoid colon which connects the colon to the rectum. The superior mesenteric
artery (SMA) and the inferior mesenteric artery (IMA) provide the blood supply to
the colon. The cecum and ascending colon are supplied by the ileocolic and right
colic arteries, both branches of the SMA.Arterial supply to the transverse colon is
from the middle colic, also a branch of the SMA.The descending and sigmoid colon
received their blood supply from left colic and sigmoid arteries, both are branches
of the IMA.There is an anastomotic arcade between the SMA and IMA allowing
communication between right and left colon via the arc of Riolan or the marginal
artery. This point also is the transition from midgut to hindgut. Venous drainage
mimics the arterial colon supply with the IMV draining into the splenic vein while
the SMV joins the splenic vein to form the hepatic portal vein. Lymphatics also
mimic arterial blood supply, ultimately draining lymph nodes into lymphatics that
run along the main vessels.
Indications for total abdominal colectomy (TAC) include both benign and malig-
nant reasons, with benign being most common. Malignant reasons include
M. G. Smithson (*) · D. Gunnells
Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama–
Birmingham, Birmingham, AL, USA
e-mail: mgrabowsky@uabmc.edu; dgunnells@uabmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_28
345© The Author(s), under exclusive license to Springer Nature
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synchronous lesions, cancer in setting of inammation bowel disease (IBD), as well
as prophylaxis for malignancy in patients with familial adenomatous polyposis (FAP)
and hereditary non-polyposis cancer (HNPCC). Benign reasons include Crohn’s disease with extensive colonic involvement refractory to medication as well as ulcerative
colitis if the rectum is spared. Other indications include lower GI bleed with no known
source, fulminant Clostridium difcile-associated colitis, and colonic dysmotility.
M. G. Smithson and D. Gunnells
2 Preoperative Preparation andAnesthesia Considerations
Preoperatively, patients will likely have undergone a CT abdomen/pelvis in workup
but if not, then one is indicated in order to delineate anatomy. For malignancy, a CT
chest will also need to be obtained for staging. For certain disease processes, colonoscopy can be useful preoperatively for diagnosis including malignancy, colitis,
and ischemia. For patients with hereditary concerns, they often undergo genetic
testing to conrm mutation which can inuence type of operation. If not urgent,
patient can undergo the normal preoperative preparations for colon surgery including bowel prep which can reduce risk of anastomotic leak [1], preoperative ostomy
marking and teaching, heparin administration for prevention of deep vein thrombus,
as well as enhanced recovery pathway (ERP) regional pain block.
Once in the operating room, patients will undergo general anesthesia with endotracheal intubation. Sequential compression devices should be placed on legs. A
foley catheter should be placed for urinary drainage and intraoperative monitoring.
Antibiotics are given within 60minutes of surgical incision. Choice of antibiotics is
based on type of operation and examples for TAC include cefazolin plus metronidazole, cefoxitin, or ertapenem. Additional antibiotics are based on hospital-specic
and patient-specic antibiotic resistance [2].
3 Operative Descriptions
The decision to perform minimally invasive or open total abdominal colectomy
depends on many factors including surgeon, hospital, and patient factors. While
both options are safe, there is lower mortality and morbidity in the minimally invasive approach compared to open. Robotic has lower conversion rate to open compared to laparoscopic but does have signicantly increased hospital charges [3].
3.1 Open TAC
An incision is made starting above the umbilicus to below through the midline. The
subcutaneous tissues are dissected down to the fascia until peritoneum is identied.
This is elevated and entered sharply. A wound retractor is placed. If operation is due
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to malignancy, it is important to survey the abdomen for metastasis. Dissection can
be started on either side of the colon but it is the author’s preference to start on the
left. The rst step is mobilizing the rectosigmoid and sigmoid colon off the left
pelvic brim, identifying the left ureter and gonadal vessel, and keeping these safe.
The peritoneal reection or white line of toldt is incised and taken superiorly up to
the splenic exure and the colon and mesentary are mobilized off the left retroperitoneum. Attention is turned to the lesser sac, which is entered superior to the transverse colon. The gastrocolic attachments are taken down to the splenic exure. The
splenocolic and renal colic attachments are taken down as well, freeing the splenic
exure. The gastrocolic attachments are taken down to the hepatic exure, being
careful to identify the duodenum and keep this safe. The peritoneal reection is then
taken down along the ascending colon, again identifying the right ureter and keeping this safe, then medializing the mesentery off the right retroperitoneum. Once the
colon is fully mobilized, the terminal ileum is divided just proximal to the ligament
of Treves. The mesentery is taken using the LigaSure device or clamps and ties,
starting at the ileocolic pedicle, all the way around to the IMA pedicle and rectosigmoid junction. The rectosigmoid junction is then divided using a linear stapling
device. At this point, an ileorectal anastmaosis is performed, or depending on the
indication for the TAC, an end ileostomy may be appropriate. Fascia, subcutaneous
tissues, and skin are then closed in an appropriate manner.
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3.2 Laparoscopic or Robotic TAC
The principles of a minimally invasive TAC are similar to an open procedure. Patient
is positioned supine with arms tucked. There are multiple port placement options
but author’s preference is a diamond approach with a supraumbilical 5mm port, a
right and left lower quadrant 5mm port, as well as a suprapubic 5mm port. Entry
into the abdomen is dependent upon surgeon preference either hasson technique,
varess needle, or gasless optiview. Once pneumoperitoneum is established, the additional trocars are placed. The dissection for laparascopic approach is very similar to
open approach. Differences include using a endoscopic stapling device as well as an
endoscopic liagsure. Extraction site is chosen based on indication for surgery, usually Pfannenstiel or periumbilical, or if an ostomy is being created, the ostomy site
can be used for extraction. For robotic operations, ports are placed in a straight line
across the mid-abdomen. This allows for access to all areas of the abdomen but does
require undocking and redocking the robot. If there are plans for an end ileosotmy,
the 12mm trocar site is placed in the future ostomy site, and an assitant port is
placed in right upper quadrant. Dissection principles are slightly different than open
or lap approach. The robot is initially docked towards the head and patient placed in
reverse Trendelenburg. Dissection begins by getting into the lesser sac and then
dividing the gastrocolic attachments all the way to the splenic exure. The splenocolic and renocolic ligaments are taken down, completely freeing the splenic exure
and mobilizing it off the left retroperitoneum. The peritoneal reection is divided as
far down the descending colon as possible. The descending colon is elevated, and a
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window is made through the mesentery allowing for the vessel seal to take the mesentary back up to the transverse where the original dissection began. Dissection is
continued taking down the gastrocolic attachments toward the hepatic exure, identifying the duodenum and keeping this safe. The hepatocolic and renal colic attachments are taken down and the dissection is taken down the peritoneal reection to
the cecum. The remaining mesentary is then taken with the vessel sealer. At this
time, the robot is de-docked and ipped towards the pelvis and patient is placed in
Trendelenburg. The rectosigmoid junction is identied and circumferentially dissected, identifying the ureter and keeping this safe. This junction is divided using a
robotic stapler. The sigmoid and descending colon mesentary are taken down all the
way up to previous dissection plane. At this point, the terminal ileum is either exteriorized for end ileostomy or used for ileorectal anastomosis.
M. G. Smithson and D. Gunnells
3.3 End Ileostomy Versus Anastomosis Considerations
After removal of the colon, two options remain for completion of the operation.
First is the end ileostomy with second being the ileorectal anastomosis with or without a diverting ostomy. Restoration of bowel continuity with an anastomosis will
largely depend on the indication for surgery as well as preoperative and intraoperative factors. Preoperatively, factors include patient’s nutrition, steroid use, and functional status. In fact, preoperative clinical deterioration such as low BMI and low
albumin as well as high steroid use, are associated with postoperative morbidity in
patients undergoing TAC [4]. Intraoperatively, one needs to consider technical
aspects of the anastomosis including tension and blood supply as well as clinical
condition of the patient during the operation. Overall, there are multiple patient factors that play into the decision to make an end ileostomy versus anastomosis. These
factors must be carefully considered to make the best decision for the patient.
4 Postoperative Considerations
Postoperative care is dependent on patient factors and surgical indications. For stable patients enhanced recovery pathway (ERP) has become standard of care in
patients undergoing colorectal surgery, including TAC.ERP includes multimodal
pain management, preoperative reginal pain black, early diet, and early ambulation.
A meta-analysis has shown ERP reduces overall morbidity and shortened hospital
length of stay without increasing readmission rates [5]. There is also evidence that
ERP in TAC is benecial to patients undergoing nonelective surgery with decreased
length of stay as well as decrease costs without an increase in complications [6].
Return of bowel is variable among patients. If an end ileostomy has been created,
patient will need proper ostomy education. Wound care and ostomy nurses are
essential tools for teaching patients and have been associated with quicker time to
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349
independence and decreased unscheduled visits [7]. Patients will also require follow- up exible sigmoidoscopies to survey rectum remaining in many cases. If end
ileostomy was chosen, reversal is dependent on the reason for an ostomy as well as
patient factors including medications (steroids and chemotherapy) and nutrition.
References
1. Castagneto-Gissey L, Russo MF, Casella-Mariolo J, Serao A, Marcellinaro R, D’Andrea V,
Carlini M, Casella G.The role of antibiotic prophylaxis in anastomotic leak prevention during
elective colorectal surgery: systematic review and meta-analysis of randomized controlled tri-
als. Antibiotics (Basel). 2023;12(2):397. https://doi.org/10.3390/antibiotics12020397.
2. Crader MF, Varacallo M. Preoperative antibiotic prophylaxis. [Updated 2023 May 29]. In:
StatPearls [Internet]. Treasure Island: StatPearls Publishing; 2023 Jan-. Available from: https://
www.ncbi.nlm.nih.gov/books/NBK442032/.
3. Moghadamyeghaneh Z, Hanna MH, Carmichael JC, Pigazzi A, Stamos MJ, Mills S.Comparison
of open, laparoscopic, and robotic approaches for total abdominal colectomy. Surg Endosc.
2016;30(7):2792–8. https://doi.org/10.1007/s00464- 015- 4552- 8. Epub 2015 Oct 20.
4. Gu J, Stocchi L, Remzi F, Kiran RP.Factors associated with postoperative morbidity, reopera-
tion and readmission rates after laparoscopic total abdominal colectomy for ulcerative colitis.
Color Dis. 2013;15(9):1123–9. https://doi.org/10.1111/codi.12267.
5. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery pro-
gram in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg.
2014;38(6):1531–41. https://doi.org/10.1007/s00268- 013- 2416- 8.
6. Liska D, Novello M, Cengiz BT, Holubar SD, Aiello A, Gorgun E, Steele SR, Delaney
CP.Enhanced recovery pathway benets patients undergoing nonelective colorectal surgery.
Ann Surg. 2021;273(4):772–7. https://doi.org/10.1097/SLA.0000000000003438.
7. Millard R, Cooper D, Boyle MJ.Improving self-care outcomes in ostomy patients via educa-
tion and standardized discharge criteria. Home Healthc Now. 2020;38(1):16–23. https://doi.
org/10.1097/NHH.0000000000000816.
Stomas (Colostomy andIleostomy)
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DavidHabib andFadyElabbasy
1 Introduction
The term “stoma” or “ostomy” refers to a surgically created opening in the gastrointestinal tract that communicates with the outside world. Stoma creation is usually
a small portion of a larger operation. Stomas are most often created to temporarily
divert the fecal stream away from a newly constructed anastomosis or to permanently divert the fecal stream away from an ill-functioning or absent rectum and/or
anus. Sometimes stomas are also created for the purpose of urinary diversion [1].
2 Types ofStomas
Stomas are dened by the segment of intestine used in their creation.
• Ileostomy: stoma using the ileum
• Colostomy: stoma using the colon
Stomas can also be dened by the way they are constructed (Fig.1).
• End ileostomy/colostomy: stoma using the cut end of a segment of ileum/colon
• Loop ileostomy/colostomy: stoma using a loop of ileum/colon allowing two
openings to be brought up to the skin surface
D. Habib
Advent Health Medical Group, Orlando, FL, USA
F. Elabbasy (*)
Department of Surgery, College of Medicine, University of Florida, Jacksonville, FL, USA
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_29
351© The Author(s), under exclusive license to Springer Nature
352
ab
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Fig. 1 Stoma types. (a) End ostomy. (b) Loop ostomy
D. Habib and F. Elabbasy
Moreover, the construction type of a stoma is independent of the segment of intestine used in its creation. Urostomies are stomas created for the purpose of urinary
diversion. This usually involves using a segment of intestine as a urinary reservoir
to which the ureters are anastomosed.
3 Preoperative Preparation
Living with a stoma has variable and complex psychosocial implications for patients
[2]. Therefore, careful preoperative discussion and education are crucial in preparing patients to cope with a new temporary or permanent stoma. Although the bulk
of stoma education takes place in the postoperative period, preoperative education
has been found to be associated with shorter hospital length of stay, decreased time
to stoma prociency, and decreased unplanned provider encounters [3]. An essential
part of preoperative preparation is stoma marking which involves carefully and strategically choosing a site on a patient’s abdomen where a stoma is to be constructed.
This is usually done by an experienced wound, ostomy, and continence nurse
(WOCN). However, it is important for surgeons who create ostomies to be familiar
with ostomy marking procedures in case a WOCN is not available [4]. Important
factors to be considered for ostomy marking are the planned operation and type of
stoma anticipated as well as the patient’s body habitus including skin folds, creases,
contours, and scars. The patient’s abdomen should be examined in multiple positions including sitting and standing.
The following are factors to consider when choosing a stoma site:
• Within the borders of the rectus abdominis muscle
• At least two inches away from the midline, bony prominences, and the umbilicus
• Within the patient’s eld of vision
• Away from the site of any devices like belts or braces
Preoperative stoma site marking has been shown to decrease postoperative stoma
complications [5].
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353
4 Procedure Description
Stoma creation is often the last step of a larger operation. End or loop stomas may
be constructed using open or minimally invasive techniques. The target segment of
bowel is adequately mobilized to ensure that it reaches several centimeters above
the skin level without tension while carefully preserving perfusion.
A stoma trephine is created by excising a disk of skin at the previously marked
site while preserving subcutaneous tissue. This is usually 2cm for end small bowel
stomas, 2.5cm for loop small bowel stomas and end colostomies, and 3cm for loop
colostomies (Fig.2).
During open surgery, the surgeon’s hand is placed on the peritoneal side under
the intended stoma site to guide dissection and protect intra-abdominal viscera
(Fig.3)
The subcutaneous tissue is split to expose the anterior rectus sheath. A 3cm vertical incision is made in the anterior rectus sheath exposing the rectus abdominis
Fig. 2 The anterior rectus
sheath is incised
Fig. 3 Intra-abdominal
viscera are protected
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D. Habib and F. Elabbasy
muscle. The bers of the rectus abdominis are bluntly separated to expose the posterior rectus sheath through which a 3 cm vertical incision is made to enter the
peritoneal cavity (Fig.4).
Two ngers are passed through the trephine to ensure adequate size. The target
segment of bowel is then gently pulled through the trephine using a Babcock clamp
(Fig.2). A penrose drain or umbilical tape passed through a window created at the
bowel wall-mesentery interface may be used to pull a loop stoma through the trephine (Fig.5).
Fig. 4 Rectus bers are
split
ab
Fig. 5 (a) The trephine admits two ngers. (b) The segment of bowel is pulled through using a
Babcock clamp
ab
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355
It is important at this point to ensure adequate perfusion at the tip of the bowel
segment to reduce the risk of ischemic complications. This can be accomplished by
palpating a pulse at the mesenteric edge, observing pulsatile bleeding at the cut edge
of the mesentery, or by using near-infrared uorescence with indocyanine green
(ICG) infusion. A stoma that appears dusky or lacks adequate perfusion by uorescence assessment must be revised. Venous outow obstruction may also cause a
stoma to appear dusky and is often caused by an overly tight trephine, in which case
the trephine should be slightly enlarged. All other abdominal wounds should be
closed and protected before a stoma is matured to reduce the risk of contamination.
In the case of an end stoma, the staple line is excised, whereas for a loop stoma, an
incision is made on the antimesenteric wall of the bowel to open the lumen. An end
small bowel stoma is matured in Brooke fashion to facilitate pouching and protect
the peristomal skin from the caustic small bowel efuent. This involves everting the
bowel and using absorbable sutures that incorporate the full thickness of the bowel
edge, a seromuscular bite of the bowel wall where it meets the skin edge, and the
dermis (Fig.6).
After three to four circumferential sutures are placed as described, the remainder
of the bowel edge is secured to the skin using simple interrupted absorbable sutures.
c
Fig. 6 Maturation of an end ileostomy. (a) A tension-free segment of bowel is pulled through the
trephine. (b) Ileostomy maturation in Brooke fashion. (c) The matured stoma protrudes 2–3cm
above the skin level
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