Complications

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Ростовский Государственный Медицинский Университет

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FIGURE3-15Theilealattachmentstothe

retroperitoneumaredivided,connectingwiththe dissectionfromsuperiorly.Continuethismobilization overtherightiliacvessels.

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Exteriorization,BowelDivision,andAnastomosis

Aftertheintracorporealdissectioniscomplete,therightcolonisready forexteriorization,boweltransection,andextracorporealanastomosis. Usingalockingbowelgrasperthroughtheleftlowerabdominalport,the fatoftheileocecalregionisgraspedforidentificationthroughthesmall incision.

Beforemakingtheincision,onemustensureadequatereachofthemid transversecolontotheproposedincisionsite;ifnot,onerisksan unnecessarilydifficultanastomosis,orunduetensionandtearingofthe middlecolicvessels.Thisincisionisusuallyperiumbilical,andextending thecameraportincisionaroundtheumbilicusfor3–5cmisgenerally adequate;however,theincisionmayneedtobelargerinobesepatients and/orpatientswithlargetumors(Fig.3-16).

FIGURE3-16Fortheexteriorizationofthe

specimen,amini-laparotomyisusuallycreatedasa superiorextensionofaverticallyplacedinfraumbilical portwound.

Awoundretractorisplacedtoavoidaportsiterecurrenceincasesof malignancy.Thegraspedileocecalregionisbroughtintoviewthrough thesmallincision,andthedissectedrightcolonisexteriorizedandplaced initsnativeconfiguration(Fig.3-17).Theremainderoftheileal

mesenteryandmarginalarteryofthetransversecolonaredissected towardthebowelwall.Thebowelisdividedandanileocolicanastomosis iscreated.Thetypeofanastomosisdependsonsurgeonpreference: hand-sewn,stapledfunctionalend-toend,orstapledend-to-side(Fig.3-

18).

FIGURE3-17Theexteriorizedrightcolonlaidout

anatomically,readyfordivisionandanastomosis.

FIGURE3-18Afunctionalend-to-end

anastomosis.Itiscriticaltokeeptheileumfrom twisting360degreesarounditsmesentery.

Aftertheanastomosisisintracorporeallyreduced/returned,thefascia ofthemini-laparotomyisclosed.Weroutinelyretaintheportsduring fascialclosure,andthenreinsufflatetheabdomenfora“finallook”after themini-laparotomyisclosed.Thisstepassureshemostasis,notwisting oftheanastomosis,andnomigrationofthesmallbowelintothe mesentericdefect.

CommonPitfallsandSolutions

DifficultyinIdentifyingtheIleocolicPedicle

Theileocolicarteryexistsin100%ofanatomicspecimens,andalways coursesdistaltotheduodenumtotheileocecalarea.Theduodenalsweep mustbeidentifiedthroughthethinnedareaofthetransversemesocolon. Thereisoccasionallyacongenitalfusionofthetransversemesocolonand therightcolonmesenterythatneedstobefirstreleased.Inobese patients,theamountoffatmayobscurevisualizationoftheduodenum.If theduodenumishiddenunderneaththickfat,startthedissectionofthe ileocolicpediclesuperiortoit,andidentifytheduodenum.Theileocecal regionmustbeplacedonenoughtensiontotentupthepediclethrough thethickmesentericfat.Forpersistentdifficulty,aninferiorapproach withthepatientinasteepTrendelenburgpositionandtheentiresmall

bowelsuperiorlyretractedmaybeuseful.Underneaththeilealmesentery closetothemidline,theduodenumshouldbecomevisible,andfrom theredissecttheilealmesenteryoffoftheretroperitoneum.Theileocolic pediclewillbefreedfromitsattachmenttotheretroperitoneumwiththis maneuver,andshouldbeidentifiedreadilyfromthemedialapproach.

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DifficultyintheDissectionoftheMiddleColicVessels

Themiddlecolicvesselsneedtoberetractedawayfromthe retroperitonealstructuresusingtwopointsofretraction,asverticallyas possible.Imagininga“Y”configurationofthemiddlecolicvesselsin one’smindisimportant.However,duetoobesityorshortlengthofthe middlecolicvessels,thismedialapproachmaybedifficult.Asuperior approachshouldthenbeundertaken.Withthetransversecolonretracted inferiorly,thegastrocolicligamentisopened,andthetransverse mesocolonshouldbedissectedfreefromtheposteriorleafofthe omentum.Therightmiddlecolicbranchcanthenbeidentifiedand dividedfromthedorsalsideofthetransversemesocolon,orthe transversecoloncanbeplacedbackintoitsoriginalpositionandamedial approachtaken.Byfreeingtheposterior(ordorsal)attachmentsofthe middlecolicvessels,thevesselsareeffectivelyelongated,allowingthe rightbranchtobemorereadilyidentified.Ifthisapproachstillisnot adequate,usethe“openbook”method.Themidtransversecolonisfirst dividedusinganintracorporealstapler,andthetransversemesocolonis thendividedinacentraldirectiontowardthebifurcationofthemiddle colicvesselsasthetwoendsofthecolonareseparated.

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PoorReachoftheTransverseColontotheUmbilicus

Thisoccursmostcommonlyinobesity,wherethetransversemesocolon canbeshort.Theoptionsherearetotakethedissectionofthetransverse colonfurthertothelefttoincreaseitsreach,ortomakeaminilaparotomyintheepigastricareaclosetothedistaltransectionpointof thetransversecolon.Itissimplertoaltertheplacementofthesmall incisiontoamorecephaladsite.

AnastomoticTwistingandMesentericHernia

Aftertheilealmesenteryandileumaredivided,theileumcanbe inadvertentlytwisted360degreesduringthetransversecolondivision. Avoidanyconfusionbyplacingtwostaysutures,oneattheendofthe ileumandoneproximaltoit,withthesuturesclampedandseparated. Withthismaneuver,itisevenpossibletoplacetheileumbackintothe abdomenwithoutlosingitscorrectorientationincaseswherethe transversecolondoesnotexteriorizewellthroughthemini-laparotomy.

Itisgenerallynotnecessarytoclosethemesentericdefectafteraright hemicolectomy.Perhapsbecausethedefectislarge,itisuncommonthat amesentericherniadevelopsresultinginincarceration;overtime,this defectclosesbyreperitonealization.Inarecentretrospectivestudyof530 patients,theincidenceofcomplicationsassociatedwithanunclosed mesentericdefectwas0.8%.Byreinsufflatingtheabdomenafterthe anastomosisiscompleted,onecanassessforanymesenterictwisting and/orsmallbowelherniationintothemesentericdefect.

POSTOPERATIVEMANAGEMENT

Postoperatively,patientsaremanagedusinganacceleratedcarepathway (ERASpathway).ImportantERASelementsincludepreoperative education,settingofexpectations,limitationofsurgicalstressincluding minimallyinvasivesurgery,earlyenteralfeeding,earlyambulation, judiciousintravenousfluidresuscitation,aggressivepostoperative nausea/vomitingprophylaxis,andopiate-sparinganalgesia,withor withoutaperipheralμ-opioidantagonist.

TheestablishmentofameaningfulandsuccessfulERASprogramis actuallyquitechallengingandrequiresthededicatedcoordinationofa multitudeofdisciplines,includingthesurgicalteam,anesthesiateam, painmanagementteam,outpatientnurses,perioperativeservices, recoveryroomnurses,inpatientnurses,dietitian,pharmacy,and institutionalleadership.Whenpatientsarecompliantwithpre-,intra-, andpostoperativeERASelements,dischargeofpatientsonpostoperative day(POD)2or3afterelectivecolectomybecomespossible.

Ifutilized,theorogastric/nasogastrictubeshouldberemovedatthe timeofextubation.Urinarycathetersshouldberemovedwithin24hours ofsurgery.AclearliquiddietisstartedadlibonthefirstPOD,and patientsareadvancedtoatransitionalorsoliddietonPOD2inthe absenceofsignificantnauseaordistension.Postoperativemaintenance fluidsaregivenjudiciously(e.g.,1ml/kg/hr),andstoppedevenonPOD1 ifpossible.Aggressivenarcotic-sparinganalgesia(whichisactually startedpreoperatively)iscontinued,withthearound-the-clockuseof acetaminophen,gabapentin,andNSAIDssuchasketorolac(ifwithout contraindications).Patientsaredischargedhomewhentoleratinganoral diet,andhavingsomereturnofbowelfunction(flatusorbowel movement)withoutsignificantnauseaordistension,abdominalpain,or fever.

COMPLICATIONS

A2009comparisonoflaparoscopicandopencolectomyof8,660patients utilizingtheACSNSQIPprogramshowedthattheuseoflaparoscopy decreasedtheincidenceofrisk-adjustedcomplicationscomparedtoopen surgery.Theoverallcomplicationrateforpatientsundergoing laparoscopicileocolectomywas15%comparedwith24%foropen ileocolectomy(P<0.05%).Theratesofspecificcomplicationsafter laparoscopicileocolectomyweresepsis(4–5%),woundcomplications (8%),cardiopulmonarycomplications(3%),vascularcomplications (1.5%),andneurologic/renalcomplications(3–4%).

RESULTS

Thereisvariationinrecoveryafterlaparoscopicrightcolectomy accordingtotheperioperativecarepathwayutilizedandthecriteriafor discharge.In2010,aprospectivemulticenterobservationalstudyof148 patientswasperformedtodeterminethe“benchmark”ofrecoverywhen patientsundergoinglaparoscopicrightandleftcolectomyaremanaged withastandardizedacceleratedcarepathway.Theresultsspecificto laparoscopicrightcolectomywereasfollows:aconversionrateof15%, meantimetogastrointestinalrecoveryasdefinedbypassingstooland toleratingsolidfoodof4.2days,andmeantimetodischargeorder writtenof4.5days.Prolongedpostoperativeileusoccurredin10.1%of patients,with4.7%requiringanasogastrictube.Thereadmissionrate was2%.

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MorerecentmodificationsinERASpathwayshavefurtherimproved uponpostoperativerecoverybytheincorporationofaggressive nonnarcoticanalgesia,furtherlimitationsonintravenousfluids,and aggressivemanagementofpostoperativenausea/vomiting.Arecent Mayoclinicreportofpatients(n=541)undergoinglaparoscopic colorectalsurgerymanagedwithsuchanERASpathwaydemonstrateda medianlengthofstayof3days(interquartilerange2–5days)after laparoscopicbowelresection,with25.9%ofpatientsdischargedwithin 48hours.

Laparoscopicsurgeryformalignancyisoncologicallysafe.Multiinstitutionalrandomizedcontrolledtrialshavedemonstratedequivalency betweenthelaparoscopicandopenapproachesforcoloncancer.These includetheClinicalOutcomesofSurgicalTherapyStudyGroup(COST) trial(n=872),EuropeanCOloncancerLaparoscopicorOpenResection (COLOR)trial(n=1,076),andtheUKMedicalResearchCouncil (CLASICC)trial(n=794).

CONCLUSION

Themedial-to-laterallaparoscopicrighthemicolectomyallowsforhighqualityoncologicsurgery,includingearlyhighligationofmesenteric vessels.Thelateralattachmentsactasanexcellentnaturalbowel retractor,facilitatingthisapproach.Thesurgicalexposureissomewhat reversedcomparedwithopensurgery,wherealateral-to-medial mobilizationisusuallyperformed.Thus,surgeonswillneedtobefamiliar withthevascularanatomyandtheirrelationshiptotheretroperitoneal structurestoperformasafeoperation.However,evenforthose beginningtolearnlaparoscopiccolectomy,thisoperationwilllikelybe oneofthefirsttobeattemptedandlearned.Whenpatientsaremanaged withamultidisciplinaryandcomprehensiveERASpathway,discharge fromthehospitalwithin48–72hoursbecomespossible.

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Соседние файлы в папке Библиотека им академика М.И. Перельмана

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