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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_861_Библиотеки_им_академика_М_И_Перельмана.pdf
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►Содержание►
FIGURE7-1Leftcolonbeingretractedwhilethe
peritoneumatthebaseofthemesenteryisincised, fromthelevelofthesacralpromontoryupward, exposingtheareolarplane.Dissectioniscontinued, liftingthemesocolonfromtheretroperitoneumand exposingtheureterandthegonadalvessels.IMA, inferiormesentericartery;IMV,inferiormesenteric vein.
Thebaseofthemesocolonisthusfreetobelifted,facilitatingfurther lateraldissectionintheavascularplanetowardthelineofToldt.Special attentionshouldbepaidtowarddissectionnearthetailofthepancreas andthelowerpoleofthespleen.Atthispoint,theToldtlineisincised, allowingfullmobilizationoftheleftcolonfromitsbed.Theexactborders ofcolonicresectionareevaluatedagainatthisstage,andtheextentof splenicflexuremobilizationisaddressedagaintoallowforatension-free anastomosis.
Whenapproachingthesplenicflexure,weusuallyrepositionthe retractionofthesmallboweltotherightlowerabdominalquadrant,to allowforeasieraccesstothetransversecolon.Thelessersacisenteredby dividingthegastrocolicligamentnearitsattachmenttothecolon.This allowsmobilizationofthesplenicflexurefrombothsides,which facilitatestakedownandreducestheriskforsplenicinjury.Dissectionin theareolartissueiscarriedonusingelectrocautery,withdivisionofthe lienocolicligamentcompletedbetweenties.Thesplenicflexureisthen furtherdissectedalongtheavascularplanefromtheretroperitoneumto allowforatension-freeanastomosis.Thecolonisthendivideddistally
andproximallydependingontheprimarypathologyandqualityofthe remainingcolonandbloodsupply.Weverifythattheproximalanddistal endsmaybebroughttogetherforatension-freeanastomosis.Weusually electtodividethecolonusingalinearstapler,withthemesocolonbeing dividedatthelevelofboweldivision,betweentiesorusinganysealing devicesuchasclips–LigaSure(tm)(Covidien,CO)orEnseal(R) (EthiconEndo-Surgery,Inc.,Cincinnati,OH).
Theauthors’preferenceistoperformaBaker(side-to-end) anastomosiswhenpossible.Theproximalstaplelineisreopenedandthe anvilisinsertedthroughthelateralwalloftheproximalcolonabout3–4 cmfromthestapleline,whichisnowresealedusinganotherlinear stapler.Ahemostaticrunningsutureisthenplacedoverthestapleline.A circularstaplerisintroducedthroughtheanusandguideduptothe staplelineandthetrocarintroducedthroughthemiddleofthestaple line.Theproximalcolonisguidedtowardtheanastomosissite,making surethatthemesocolonisnottwisted,andtheanvilisconnectedtothe pin.Thecircularstaplermaythenbeclosedandfiredunderdirectvision. Afterfiringthestapler,theanastomosisisinspectedandcheckedforleak. Theproximalbowelisoccludedwhiletheanastomosisisinflatedwith betadinesolution.Theanastomosisisthensubmergedinsalinesolution andinsufflatedagainusingair.Intheeventofaleak,theanastomosiscan bereinforcedwithsuturesandmaybedivertedorresectedand reperformed.
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Asurgicaldrainisleftneartheanastomosisfor3–4daystoevacuatea possiblehematoma.Abdominalwallclosureisperformedinstandard manner.
POSTOPERATIVEMANAGEMENT
Patientsbenefitfromanacceleratedperioperativecarepathwayaimingto enhanceearlyrecoveryandshortenhospitalstay.Patienteducationis essentialforreducedpostoperativecomplicationrateandaccelerated recovery.Mostofourpatientsreceiveanepiduralcatheterforenhanced postoperativepainmanagementviapatient-controlledanalgesia.Ifan epiduralcatheterisnotinstalled,anintravenouspumpisusedforthe first3dayspostoperativelyandsupplementedwithperipheral nonsteroidalanti-inflammatorydrugswhenrequired.Antibioticsare discontinued24hoursaftersurgery.
Allpatientsshouldreceivevenousthromboembolismprophylaxisusing pneumaticcompressiondevicesthatareinplaceduringtheoperation andsubcutaneousfractionedheparininjectionsbeginning1dayafter surgery.
Postoperativerespiratorycomplicationsareminimizedusingearly ambulation,pulmonaryphysiotherapy,andincentivespirometry.
Surgicaldressingsareremovedonpostoperativeday2andthepatient isencouragedtoshower.
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NGTisnotrequiredroutinelyaftertheoperation,exceptwhenthe patientsuffersfromileus.However,inthesettingofalengthyoperation withsignificantadhesiolysisorbowelhandling,weprefertokeepthe NGTinplaceuntilthepatientpassesflatus.Withreturnofbowel function,thedietisadvancedfromclearliquidstoregularfood.
Patientsaredischargedhomewhentheyarefeelingwellandableto tolerateenteralfeeding.
RECOMMENDEDREFERENCESAND READINGS
ChenM,SongX,ChenLZ,LinZD,ZhangXL.Comparingmechanicalbowelpreparationwithboth
oralandsystemicantibioticsversusmechanicalbowelpreparationandsystemicantibiotics
aloneforthepreventionofsurgicalsiteinfectionafterelectivecolorectalsurgery:ameta-
analysisofrandomizedcontrolledclinicaltrials.DisColonRectum2016;59(1):70–78. GuenagaKF,MatosD,CastroAA,AtallahAN,Willie-JorgensenP.Mechanicalbowelpreparation
forelectivecolorectalsurgery.CochraneDatabaseSystRev2005;25(1):CD001544. SlimK,VicautE,PanisY,ChipponiJ.Meta-analysisofrandomizedclinicaltrialsofcolorectal
surgerywithorwithoutmechanicalbowelpreparation.BrJSurg2004;91(9):1125–30.
Chapter8
OpenLeftandSigmoid Colectomy—LateraltoMedial
WilliamC.ChapmanJrandMatthewG.
Mutch

INDICATIONS/CONTRAINDICATIONS

Leftandsigmoidcolectomyaremostfrequentlyperformedfor malignancyordiverticulardisease.Witheitherprocess,thelocationand extentofdiseasealongwithvascularanatomicconsiderationspredicate theextentofrequiredresection.Diverticulardisease,forexample,often requiresonlyacompletesigmoidresection,withdissectionoftheleft colonperformedtofacilitatetheprimaryanastomosisofthehealthy rectumtosoftdescendingcolon.However,inthesettingofmalignancy, completeresectionrequiresremovalofboththetumorandtheentire vascularandlymphatictissueofthecolonicportioninquestion.Because theleftcolonisproximallysuppliedbyarcadesofthemiddlecolic pedicle,namely,themarginalarteryofDrummond,anddistallybythe inferiormesentericartery(IMA),botharteriesandtheinferior mesentericvein(IMV)mustberesected.Thesigmoidcolon,also perfusedbytheIMA,mustthereforebetakenoutattimestofacilitate completeremovalofaleftcoloncancer.Finally,re-anastomosisoftheleft colontotherectumsometimesrequiresmobilizationofthesplenic flexureandhighligationoftheIMV.
Physiologically,resectionoftheleftorsigmoidcoloniseasily postoperativelytoleratedbymostpatients.Therefore,theonlytrue contraindicationtoeitherprocedureistheinabilityofthepatientto tolerategeneralanesthesia.
PREOPERATIVEPLANNING
Foraleftorsigmoidcolonresection,preoperativeplanninginvolves threetypicalconsiderations:additionalscreeningforconcomitant colorectaldisease,theuseofbowelpreparation,andtheinitiationofpain managementandvenousthromboembolismpreventiontechniques.In addition,aneoplasticlesionmustbeaccuratelylocalizedwithendoscopic tattooingorimagingsuchascomputedtomographyorcontrastenema.
Inthesettingofmalignancy,preoperativeaxialimagingtoadequately stagethecancerandexcludedistantmetastasisisamust.Colonoscopy, usuallyintheelectiveoutpatientsetting,shouldalsobeperformedbefore anyelectiveresectiontotattoolesionsandensuretheremainderofthe colonisdiseasefree.
Theappropriateroleofmechanicalandchemicalbowelpreparationis controversialandlikelysurgeondependent.Widelyrecognizeddatahave demonstratednoreductioninsurgicalsiteinfectionswiththeuseofa mechanicalpreparationalone.However,morerecentdatafromlarge populationdatabases,suchastheNationalSurgicalQualityImprovement Program(NSQIP)andtheMichiganSurgicalQualityCollaborative,have demonstratedthatcombinedmechanicalandoralantibioticpreparations havereduceddeepandsuperficialwoundinfections.Inourpractice,all patientsscheduledforelectiveleftandsigmoidresectionsundergoa combinedoralpreparationconsistingofpolyethyleneglycolsolution, neomycin,andmetronidazoleadministeredinthe12hoursbefore surgery.Onceintheoperatingroom,1gofertapenemorintravenous(IV) ciprofloxacinandmetronidazoleinpenicillin-allergicpatientsisgivenfor perioperativeinfectionprophylaxis.
Amultimodalpainmanagementprogramandvenousthrombus prophylaxisisutilizedinthepreoperativeperiodforallelectivecolon resections.Eachpatientreceivesagramoforalacetaminophenand12 mgofalvimopan,alongwithplacementofanepiduralanalgesicinfusion catheterbytheanesthesiateam.Adoseofsubcutaneousheparinisalso administeredbeforeenteringtheoperatingroom.
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Itisunusualtorequireproximaldiversionafteraleftcolectomy;butif theplanistoincludeastoma,thepreoperativemarkingofthesitecan
improvefunctionaloutcomesforthepatient. Thepatientshouldbeinformedofthepostoperativebowelfunction
expectedaftersegmentalresectionoftheleftand/orsigmoidcolon. Bowelfunctionissomewhatlessthannormal,influencedbythepatient’s ageandrejectedbymultiplebowelmovementsthatoccurrapidlyand urgently.
Patientsinwhomdenseadhesionsorinflammatoryprocessesare expected,cystoscopyanduretericstentplacementmaybeindicated
typicallyatthestartoftheoperation.

SURGERY

Ourstandardapproachforstandardopenleftorsigmoidcolectomiesisa lateral-to-medialcolonicdissectioncombinedwithhighligationofthe IMVandIMA.
Positioning
Thepatientisplacedinmodifiedlithotomypositionusinglithotomy stirrupswithsequentialcompressiondevicesinplace.Abladdercatheter issterilelyinserted,andtherectumisirrigatedwithabetadinesolution toclearanyremainingsolidstool.Thearmsareplacedwiththeleftarm extendedandtherightarmtuckedtoallowforpositioningofaMayo standoverthepatient’schest.Havingthescrubassistantabovethehead allowsadirectvisuallineintotheoperatingfield.IftheMayostandisnot placedabovethehead,botharmsmaybeleftout.Theabdomenis clippedandprepped,andthepatientisthendrapedinstandardmanner withsterilelegcoversandbodydrapeallowingforabdominaland perinealaccess.
Technique
MobilizationoftheColon
Theabdomenisenteredthroughaverticalmidlineincisionfrompubis toasfarabovetheumbilicusasneededtomobilizethesplenicflexure,
andacircumferentialplasticwoundretractorisplaced.TheBookwalter self-retainingretractoristhensecuredoverthelaparotomyandopened widely.Thesmallbowelispackedintotherightupperquadrantusinga damplaparotomytowelandretractors.
Anincisionismadeatthebaseofthelateralaspectoftheleftcolon mesenteryalongthewhitelineofToldtwiththeleftcolonretracted
mediallyandanteriorly(Fig.8-1A).Theincisionisextendedfromthe pelvistotheleftupperquadrant.Undertension,thecolonandits mesenteryareelevatedanteriorlyandmediallywhiletheretroperitoneal tissueisretractedlaterally.Theexposedareolartissueplaneanteriorto theretroperitoneumisdissectedoffofthemesenterywith electrocautery,exposingtheureterandgonadalvessels(Fig.8-1B).This planeisextendedmediallytothebaseoftheaortaandcephaladtothe levelofthesplenicflexure,freeingtheleftcolonfromtheanterior
surfaceofthekidney
(Fig.8-1C).
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