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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_841_Библиотеки_им_академика_М_И_Перельмана.pdf
A.J. Greenstein and A.J. Greenstein
194
25
25.1 Introduction
Surgery for ulcerative colitis and Crohn’s disease
has benetted immeasurably from the transition from open to laparoscopic surgery. While
traditional open surgery oen provides easy
visualization of the mesentery in relation to the
intestine with short operative times, its wellknown disadvantages include wound complications such as infection, disruption, and hernias,
as well as a larger incision, worse cosmesis, more
postoperative pain, more blood loss, later return
of bowel function, later oral intake, and longer
hospital stay [1].
Open surgery may also suer from dicult
visualization (specically in the le upper quadrant and pelvis)– especially in the obese patient.
On the other hand in laparoscopic surgery, special attention must be paid to correct orientation
of the mesentery to avoid rotation of the bowel or
of the mesentery. In particular, one must avoid
rotation of bowel with stomas, rotation of the
pouch, or herniation of bowel posterior to the
mesentery in laparoscopic pouch procedures.
Hand-assisted laparoscopic surgery (HALS) has
some of the advantages and disadvantages of both
and involves a relatively larger incision [2, 3].
Although there may be some diculty in orientation, HALS does allow for hand dissection of the
bowel hand dissection of the congenital adhesions,
retraction, and exposure of mesentery, particularly
when the bowel is fragile as in severe colitis. It also
allows for palpation of masses and/or ureteric
stents when the ureter cannot be visualized.
We will describe our technique in subtotal colectomy for ulcerative colitis using advanced laparoscopic methods with special emphasis on the
transverse colon and exures. We perform this
technique for nearly all of our patients with ulcerative colitis, even for most of those patients with
fulminant disease, and we rarely use hand assistance or a GelPort.
25.2 Preoperative Strategy
andPlanning
In general, surgery for UC is multistaged with
three-, two-, or on occasion one-staged procedures. Fulminating disease, with fever, tachycardia,
and elevated white cell count with a le shi, is in
general done in three stages. Patients with intractable steroid-dependent disease and on biologic
medications such as Remicade, Cimzia, and
Humira, with hypoalbuminemia, and with anemia
are preferentially done in three stages, but occasionally may be done in two stages in younger
patients. Surgery for patients with dysplasia/
DALM/ cancer, who are generally in better physical shape but usually older, may be done in two
stages. One-stage procedures have been recommended by some surgeons, but should be limited
to highly selected cases [1, 4, 5].
It is our preference to do a proximal defunctioning loop ileostomy in all J-pouch procedures.
An Isovue enema evaluation of healing of the
pouch prior to closure of the Turnbull-type loop
ileostomy is routine.
All patients are fully evaluated with regard to
ASA level, BMI, and comorbidities. e ileostomy site is always marked in the sitting position
if an ileostomy is planned. is must be done by
the surgeon or stoma nurse and future management and possible problems, such as hernias,
dehydration, and skin irritation discussed in
detail with the patient. Bowel prep is controversial, but it is our preference to use cathartics,
antibiotics, and high colonic tap water enemas
(except for fulminating disease with abdominal
tenderness).
In terms of technical approach, there is some
controversy regarding the medial to lateral
app roach vs. lateral approach which is the
standard approach in open surgery. Either
approach is appropriate provided careful visualization of retroperitoneal structures is carried
out and thedissection is done with preservation
of the continuity of the sympathetic nerves, the
preaortic plexus, the ureters, and the gonadal
vessels, all of which lie posterior to the embryonic retroperitoneal plane. Although the medial
to lateral approach is technically more demanding, it is probably somewhat faster and more precise, allowing for high/proximal ligation of the
colonic vessels when necessary. Obviously, if
there is a dysplasia-associated lesion or mass
(DALM) or cancer of the colon, vessels should be
taken at their origin while mesenteric transection should be close to the colon for benign disease.
Surgical Technique andDicult Situations forUlcerative Colitis
25.3 Laparoscopic Technique
25.3.1 Positioning
All patients requiring colonic resection should be
placed in stirrups. An orogastric tube is placed
and the stomach emptied; it is usually removed at
the end of the operative procedure. Care is taken
to position the patient using egg crates to protect
all pressure points of the arms and legs. Straps are
appropriately placed to prevent movement on the
operating table during the operative procedure.
A plastic warming blanket is placed over the
upperchest to maintain a constant temperature.
Placement of ureteric catheters is dependent on
the discretion of the surgeon, but is advisable for
severe cases of ulcerative colitis with fulminating
disease and any patients with Crohn’s colitis. With
the patient in stirrups, we irrigate the rectum and
rectosigmoid with an irrigating suction system
(28 Foley catheter taped with Steri-Strips to a pool
tip suction) using up to 3000 ccs of saline.
Irrigation of the rectum is discretionary, but we
use this on an almost routine basis during the
course of rectosigmoid or rectal dissection prior
to transection of the large bowel. is is particularly important when bowel prep has failed to
adequately clean thecolorectum. Preparation of
the skin with ChloraPrep or Betadine is routine
for the abdomen and perineum, and per standard
technique, antibiotics are given within 30min of
incision.
25.3.2 Trocar Placement
To establish pneumoperitoneum, a 5 mm Fios
Optiview scope is passed through a small incision
in the umbilical region or le upper quadrant (if
there is a previous umbilical incision). If there is
distension, a 12 mm balloon Hasson trocar is
placed through a periumbilical incision. 5 mm
ports are then placed in the right upper quadrant,
and on the le side (and sometimes in the suprapubic position) with a 12mm port at the ileostomy site in the right lower quadrant. It is our
preference to use 5 mm instruments whenever
possible in order to minimize the chance of
herniation and reduce the need for fascial closure.
e future right lower quadrant ileostomy site can
be used for extraction of the bowel through a
wound protector and passage of the Endo GIA to
transect the colon when the 12 mm port is in
place. If it is deemed preferable to extract the
colon through the midline, the umbilical port site
can be extended up or down as a relatively short
incision. We generally do not advocate the use of
single incision laparoscopic surgery (SILS) for
this procedure. Placement of trocars varies considerably, but we have noted our suggested trocar
sites (. Fig.25.1).
25.3.3 Distal Left Colon
e dissection begins on the le side with the surgeon high on the right side and the assistant low
on the le side. e table is inclined with the le
. Fig. 25.1 Trocar Placement
andTransection
atRectosigmoid Junction
195
25
25
A.J. Greenstein and A.J. Greenstein196
side up in steep Trendelenburg. e small bowel is
swept to the right and cephalad. e mesenteric
dissection is carried out from medial to lateral
using a 5mm LigaSure or harmonic scalpel. We
transect the peritoneum over the medial side of
the mesocolon posterior to the marginal artery of
Drummond and cephalad to the superior rectal
artery in the relatively avascular plane. Aer
dening the plane, care should be taken in this
area to identify and visualize and preserve
the preaortic hypogastric plexus and nerves.
Subsequently, when the embryonic retroperitoneal plane is established by blunt dissection, the
ureter and the testicular or ovarian vessels should
be identied and preserved. In some patients,
these structures cannot be easily identied so it is
imperative that one stays anterior to the embryonic plane which is generally not dicult in IBD
cases. A blunt instrument is then passed through
to the lateral paracolic gutter anterior to the white
line of Toldt. e tip is visualized by retracting the
colon in an anteromedial direction aer which
the colon is retracted by the assistant once again
in an antero lateral direction with two graspers.
Transection of the sigmoid mesentery and vessels
is then continued in a cephalad direction.
Following this, the dissection is continued downward taking the mesentery to the rectosigmoid
colon using the 5mm LigaSure (. Fig.25.2), and
nally, the mesenteric fat is cleaned until the muscular layer of the bowel is visualized. A 60mm
Endo GIA staple load is then used to transect the
rectosigmoid colon (. Fig. 25.3) and the staple
line is air leak tested.
. Fig. 25.2 Distal Dissection
. Fig. 25.3 Stapling Rectosigmoid Junction
25.3.4 Proximal Left Colon
andSplenic Flexure
Following transection of the colon, the patient is
placed in reverse Trendelenburg position, and the
division of the mesentery is continued from the
site of initiation of the dissection backup in a
cephalad direction to the area of the splenic exure, transecting the le colic vessels (. Fig. 25.4)
and then the arc of Riolan at the splenic exure.
As the splenic exure is approached, the surgeon
moves to between the legs. Mesenteric transection is continued anteromedially to the ligament
. Fig. 25.4 Dissection Splenic Flexure
of Treitz, being careful to stay anterior to the
fourth portion of the duodenum and the pancreas. During the course of this dissection, the
lateral attachments of the le colon are taken
immediately anterior to the line of the fascia of
Toldt using either the 5 mm LigaSure or the
harmonic scalpel. e colonic attachments to the
diaphragm and spleen are taken down avoiding
Surgical Technique andDicult Situations forUlcerative Colitis
197
25
traction on the lamentous attachments to the
spleen and thus any capsular tears. Capsular tears
are not uncommon with open surgery but are rare
with the better visibility of laparoscopic surgery.
Any accessory spleens, which are not uncommon,
should be preserved if the dissection does not
compromise the vascular supply to the spleen.
25.3.5 Completion ofSplenic
Flexure andLateral
Dissection ofTransverse
Colon
Both surgeon and assistant may work from the
right side for this part of the dissection. e assistant elevates the gastrocolic omentum either by
liing it upward from within the lesser sac just to
the le of midline and the lesser sac is entered.
Ideally, transection is continued below the greater
gastroepiploic arcade toward the splenic exure
transecting the epiploic vessels in the avascular
plane, meeting our prior dissection of the splenic
exure from the le side (. Fig. 25.5). At this
point, the mesentery of the splenic exure has
been transected until its junction with the mesentery of the transverse colon. e surgeon and
assistant now move to the le side and continue
transection of the gastrocolic omentum from the
midline toward the hepatic exure as the patient is
placed right side up. e plane of the mesentery
superior to the hepatic exure is dened and transected carefully down to the colon. e colon is
lied anteriorly and dissection continued separating the apex of the exure from the posterior
attachments below the gallbladder and proceeding
through the peritoneal reexion to separate the
colon from the proximal duodenum.
25.3.6 Right Hemicolectomy
At this point, we commence with a standard
medial to lateral dissection of the right hemicolon
with both the surgeon and assistant on the
patient’s le-hand side. e cecum and ascending
colon are elevated by the assistant anteriorly and
to the right, and the ileocolic vessels and the right
colic vessels are transected with preservation of
the branches to the terminal ileum, once again
being careful to enter and remain in the embryonic plane and to display and preserve the ureter
and gonadal vessels. e mesenteric transection is
now continued (completed) past the lower part of
the descending duodenum and the proximal part
of the third transverse portion of the duodenum
(. Fig.25.6). Aer successful medial mesenteric
dissection, the posterior peritoneal abdominopelvic attachments of the distal ileum and cecum
(cecum and distal ileum) should be taken down.
On occasion it may be preferable to take down the
lateral attachments anterior to the fascia of Toldt
prior to dissection of the ileocecal area, and this is
clearly at the discretion of the surgeon.
25.3.7 Completion ofTransection
oftheMesentery
oftheTransverse Colon
At this point, we are le with just the mesentery
of the transverse colon. Ideally, it is possible to
. Fig. 25.5 Opening Lesser Sac . Fig. 25.6 Dissection Right Colon
25
A.J. Greenstein and A.J. Greenstein198
a
b
. Fig. 25.7 Dissection Transverse Colon
orient the bowel in such a way as to clearly visualize mesentery. In some cases, it is easier to li it
anteriorly and superiorly, while in other cases, it
is better to let the transverse colon hang inferiorly from its mesentery (. Fig.25.7). In addition,
placement of the 5mm camera through a rightsided port may provide better visualization of the
mesentery as the umbilical port is oen directly
anterior to the transverse colon. Once the mesentery is clearly and safely visualized, one simply
advances from proximal to distal along the mesentery until the mesenteric dissection of the
splenic exure is encountered. A #7 JP is placed
in the pelvis adjacent to the stapled o rectal
stump.
. Fig. 25.8 Final Specimen
accommodate two ngers and a small wound
protector has been placed to stretch the site. e
colon is extracted in a distal-to-proximal direction. In cases of very edematous, fragile, dilated
colon, it is important to ensure that the size of
the ileostomy canal is adequate even if it needs
to be enlarged at both the skin and fascial levels.
If the cecum enlarges and becomes lled with
liquid stool, an opening may be made in the
colon and a pool suction introduced into the
cecum to aspirate the liquid. e mesentery to
the terminal ileum is carefully examined. e
cockscomb is excised, the ileum is transected
1 cm proximal to the ileocecal valve, and the
specimen is removed (. Fig. 25.8). e open-
ings in the fascia of the ileostomy canal are
sutured as needed to tighten the area, and an
end Brooke ileostomy is created. It is critical to
conrm that the mesentery is oriented correctly
prior to creation of the ileostomy, and reinsufation of the abdomen must be performed if
there is any doubt.
25.3.8 Intestinal Extraction
andTransection
oftheTerminal Ileum
Extraction of the colon may be carried out
through a midline incision at the umbilicus, a
Pfannenstiel incision, or an oblique right or le
lower quadrant incision. We prefer to extract
the colon or rectum through the ileostomy site
aer the 12 mm ports have been enlarged to
25.4 Conclusions
Laparoscopic surgery has improved our management of ulcerative colitis. Results are dependent
upon surgical expertise, training, and experience.
Nevertheless, most procedures in this country
continue to be done via traditional open techniques. e training and number of experienced
laparoscopic colorectal surgeons must be
increased to meet the challenge of transition to
laparoscopic colorectal surgery.
Surgical Technique andDicult Situations forUlcerative Colitis
199
25
References
1. Tjandra JJ, Fazio VW, Milsom JW, et al. Omission of
temporary diversion in restorative proctocolectomy
–is it safe? Dis Colon Rectum. 1993;36:1007–14.
2. Meijer DW, Bannenberg JJ, Jakimowicz JJ. Handassisted laparoscopic surgery: an overview. Surg
Endosc. 2000;14:891–5.
3. Meshikhes AW. Controversy of hand-assisted
laparoscopic colorectal surgery. World J Gastroenterol.
2010;16:5662–8.
4. Weston-Petrides GK, Lovegrove RE, Tilney HS,
et al. Comparison of outcomes after restorative
proctocolectomy with or without defunctioning
ileostomy. Arch Surg. 2008;143:406–12.
5. Davies M, Hawley PR. Ten years experience of onestage restorative proctocolectomy for ulcerative
colitis. Int JColorectal Dis. 2007;22:1255–60.
201
Surgical Technique
and Difficult Situations
for Crohn Disease
from Adrian Greenstein
AlexanderJ.Greenstein andAdrianJ.Greenstein
26.1 Introduction – 202
26.2 Subacute Perforation: Abscess and Mass – 202
26.3 Duodenal Fistula – 205
26.4 Sigmoid and Rectal Fistulae – 205
26
26.5 Stricturing Disease – 206
26.6 Conclusion – 207
References – 207
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_26
26
202
A.J. Greenstein and A.J. Greenstein
26.1 Introduction
Crohn’s disease is a nonspecic transmural inammatory bowel disease that may aect the intestinal tract from the mouth to the anus. e areas
of maximum prevalence are Northern Europe
and America. It is also characterized by multiple
extraintestinal manifestations which may be colon
related (mouth, eye, joint, skin, or liver) or small
bowel related (urinary stones, fat- soluble vitamin
deciencies) [1]. ere are two major forms of
presentation of the intestinal form of the disease:
“obstructing or stricturing” and “perforating or
penetrating.” “Inammatory” is now considered
to be a third group or a subtype of the non-perforating group [2, 3].
Stricturing disease generally aects the terminal ileum and is most commonly single. However,
multiple strictures may present as jejunoileitis and
occasionally also aect the duodenum and large
bowel. Perforating or penetrating disease may be
subdivided into three forms: acute free perforation with peritonitis, subacute perforation with
abscess formation (pelvic, pararectal, paraintestinal, mesenteric, retroperitoneal or psoas, and
lumbar), and the more chronic form of stulizing disease (ileocolic, ileosigmoid, coloduodenal,
cologastric, colojejunal, ileorectal, rectovaginal,
ileocolovesical, enterocutaneous, and rectovesical
in addition to other rare stulae). is chapter will
concentrate on the more complex forms such as
ileocolic disease with abscess, various forms of stulizing disease, and multiple stricturing disease.
26.2 Subacute Perforation: Abscess
and Mass
Intraperitoneal, pelvic, or retroperitoneal abscess
formation remains a serious complication of perforating disease and may originate from any part
of the bowel from the ligament of Treitz to the
rectum. e patient presents with localized pain
or change in the nature of the pain from central
cramping pain to more severe sharp pain localized to the site of the perforation, usually right
lower quadrant, but the le lower quadrant or
pelvis is not uncommon. Remittent fever with elevated white cell count and “a shi” are the usual
conrmatory features, and localization is by CT
scan and/or sonography. Percutaneous drainage
under radiological control is the standard of care,
. Fig. 26.1 27-year-old male with retroperitoneal Crohn’s
abscess and preoperative drainage
provided there is a reasonable sized collection and
the radiologist does not have to traverse loops of
bowel. If percutaneous drainage is not possible,
laparotomy or laparoscopy with aspiration of
the infected purulent uid and drainage may be
necessary. Eventually the diseased segment from
which the abscess originated must be resected.
Occasional patients refusing reoperation have
survived without recurrence of the abscess for
many years, but ultimately the patient will present
with obstruction, recurrent abscess, or stula.
Aer successful drainage of intra-abdominal
or retroperitoneal abscess (
. Fig. 26.1), resec-
tion of the perforating segment of bowel may
be attempted laparoscopically. ese cases usually involve dicult adhesiolysis requiring both
blunt and sharp dissection. Conversion or handassisted laparoscopy with a smaller incision may
be necessary, but we typically begin with a pure
laparoscopic approach even in the setting of a
large phlegmon. Aer Hasson entry to the abdomen adjacent to the umbilicus, two to three 5mm
ports are placed in a standard fashion for laparoscopic ileocolic resection. e ultimate goal in
these cases is to mobilize the phlegmonous mass
in order to exteriorize it through a small midline
incision. We generally approach this in a lateral to
medial dissection given the very thick mesentery
that tends to accompany a Crohn’s mass.
Aer mobilizing the hepatic exure, we turn
our attention to the ileocolic angle. Unfortunately,
the area with greatest inammation oen tends
to be adjacent to the conuence of the ureter and
Surgical Technique and Difficult Situations for Crohn Disease from Adrian Greenstein
203
26
a
c
e
b
d
f
. Fig. 26.2 a–f Blunt dissection technique for ileocolic
Crohn’s mass: we proceed in a lateral to medial manner,
using primarily blunt dissection to mobilize the mass
iliac vessels. Preoperative ureteral stent placement
should be considered prior to any laparoscopic
approach. Appropriate use of blunt dissection is
paramount to a successful medial mobilization
of the mass and avoidance of collateral damage.
Our instrument of choice is the suction irrigating
device which serves well as a laparoscopic replacement for nger fracture dissection. A LigaSure
or ultrasonic scalpel should be available to lyse
scar tissue. Eventually, the scar will be penetrated
leaving the mesentery of the ileocolic region and
allowing the entire mass to be mobilized medially
(pls. see . Fig. 26.2a–f). Occasionally, a retroperitoneal plane is created, allowing for easier mobilization, but one must be careful to remain very
supercial and anterior within this plane. At this
point, a decision is made whether to transect the
mesentery intracorporeally or extracorporeally. If
medially and access the underlying abscess. Once the mass
is fully mobilized, we turn to mesenteric dissection prior to
exteriorization, resection, and anastomosis
the mesentery appears to be very bulky and at risk
for bleeding aer LigaSure transection, we place a
wound protector and exteriorize the entire mass.
Occasionally, the Crohn’s mass is too large to t
through the small midline extraction site. In this
case, it is necessary to exteriorize the colonic portion of the mass rst and transect at the normal
distal margin and then march proximally along
the mesentery of the diseased terminal ileum,
slowly extracting the mass through the midline
wound as its bulk allows. Ultimately, we are le
with clear margins on both sides.
In my experience, even in the setting of
abscess, we do not nd it necessary to create a
diverting loop ileostomy for these cases. In order
to minimize anastomotic leak rates, we believe
in “oversewing” of the anastomotic staple lines. I
rst lay down a posterior continuous 3-0 silk back
204
cd
ef
A.J. Greenstein and A.J. Greenstein
26
a
b
. Fig. 26.3 a–f Oversewing technique for ileocolic anas-
tomosis. After the two limbs are lined up, a back row of 3-0
silk is placed juxtamesenteric a and pulled posteriorly b.
row adjacent to the mesentery. is row of silk
sutures is then pulled posteriorly as the GIA stapler is placed to create the common enterotomy. A
second GIA load is used to close the enterotomy
and then all staple lines are oversewn and covered
with running 3-0 silk suture. Although there is no
objective evidence that oversewing the staple lines
reduces anastomotic leak rates, we have found this
A stapled anastomosis is created c, d. All staple lines are
oversewn with 3-0 silk and buried e, f
technique to be very satisfying and has resulted in
very low leak rates for our Crohn’s patients (pls.
see . Fig. 26.3a–f for technique).
Aer the anastomosis is placed back in the
abdomen, a drain may be placed in the right
gutter if there is residual abscess or if a large
amount of dissection has been performed in
that area.