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FIGURE8-1A.Thedescendingcolonisretracted
mediallyasdissectioncarriedthroughthewhiteline ofToldtwithanelectrosurgicalinstrument.B.The colonandsmallbowelarereflectedmedially, revealingtheleftureterhighlightedbyforcepsinthe retroperitoneum.Thesurgeon’sleftindexfinger indicatestheleftkidney.C.Thesplenicflexureofthe colonisheldontensionbythesurgeon’srighthand, whiletheindexfingerprotectsthecolonanddistracts thesplenocolicligamentfortransectionwithcautery.
Tocompletethereleaseofthesplenicflexurefromtheleftupper quadrant,theomentalattachmentstotheanteriorsurfaceofthe
transversecolonareincisedthroughthemidline.Beginninglaterally,an incisionismadeontheperitonealattachmentsofthesplenicflexure, usingthefingerasaguide,withtheintenttoenterthelessersacby separatingtheomentumfromthetransversecolon.Proceedingmedially, thecolonisreleasedfromtheomentum.Thekeyistostaysuperficial, dividingonlytheperitonealattachmentbetweenthem.Onceallofthe
omentalattachmentstothetransversecolonmesenteryaredivided,the lessersaciswidelyopened.Thethickerportionsoftheseattachments areclampedandsutureligated.Tofullyreleasethesplenicflexuretothe midline,attachmentstotheundersurfaceofthetailofthepancreasand theretroperitoneummustbeincisedtothemidlinetowardthe duodenumattheligamentofTreitz(Fig.8-2).Accordingly,thesplenic flexureispulleddownandtherighthandplacedintothe retroperitoneumtoexposetheplanebetweentheundersurfaceofthe spleentipandthelateralaspectoftheabdominalcavity.
FIGURE8-2Forcepsindicatecolonicattachments
totheligamentofTreitz;thesemustbecompletely incisedtomobilizethetransversecolontothe midline.
ExcisingtheSpecimen
Theleftcolonisliftedfromtheabdomenandispulledtothepatient’s left,exposingthemedialaspectoftheleftcolonmesenteryoverthe
sacralpromontory.Theperitoneumontherightsideofthemesenteryis incisedalongacourseallowingaccesstothepreviouslydevelopedlateral planeofdissection.Thesuperiorrectalarteryiselevatedfromthe retroperitoneum,andtheoriginoftheIMAisisolatedattheaortajust abovethebifurcationofthecommoniliacartery(Fig.8-3A).TheIMVis identifiedjustlateraltotheligamentofTreitzatthebaseofthe mesenteryoftheleftcolon,typicallyaboveawindowofclearperitoneum alongtheanteriorsurfaceoftheaorta(Fig.8-3B).Itisthenelevatedoff oftheretroperitoneumandencircledneartheinferiorborderofthe pancreas.TheIMAandIMVarethendividedbetweentiesafter confirmingtheleftureterissafelyintheretroperitoneum(Fig.8-3C).
FIGURE8-3A.Theinferiormesentericartery(IMA)
isdissectedattheaortaandencircledpriortoligation, demonstratedherebythesurgeon’sindexandmiddle fingers.B.Theinferiormesentericvein(IMV)is localizedlateraltotheligamentofTreitzandgrasped withforcepsinthisimage.C.Here,theIMVisdoubly clampedatthesplenicveininpreparationforligation.
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Theleftcolonisthencaudallydeliveredtothepelvis.Ifappropriately mobilized,thesplenicflexureshouldreachthepelvicbrim.Theproximal
pointoftransectionisthenchosen,takingcaretoremoveadequate proximalanddistalmarginswhileleavingenoughcolontoaccomplisha tension-freeanastomosis.Themesenteryisdivideduptothecolon,after whichthemarginalarteryisisolated,divided,andthenflashedto confirmpulsatileflow.Ifitisobviousthatarterialbleedingisnot present,thenamoreproximaltransectionsiteshouldbechosen.When possible,5-cmmarginsareobtained.
Theproximalportionoftheanastomosisispreparedbyplacingpurse
stringsuturebyhandorwithanautomaticinstrument.Thepursestring isplacedcarefullytoensureadequatebloodsupplyandpreventtension ortwistinthecolon.Thecircularstapleranvilandshaftarethensecured inthepursestringandreinforcedwithtiesasneededtocompletethe donutaroundthebaseoftheshaft(Fig.8-4).
FIGURE8-4Theproximalcolotomyisinspected
(A)andapursestringofProlenesutureisplaced circumferentially(B).C.Theanvilofthecircular staplerissecuredbytyingthesuture.
ColorectalAnastomosis
Thesigmoidorrectumisthentransectedattheleveloftheupperrectum usingeitheralinearcuttingstapleroratransverselinearstaplerto
createthetransversestapleline.Theinterveningmesorectumisthen dividedbetweenclampsandligated.Thecircularstapleritselfisthen introducedthroughtheanalcanaltothelevelofthetransversestaple line,andthepostisextendedthroughthemidportionoftherectalstump justanteriortothetransversestapleline.Beforedeployingthespike,the staplerheadmustbeflushandflatagainstthestaplelineintherectal stump.Attimes,thecircularstaplercanbecomecaughtonarectalfold, causingmisfiringofthestapler.Ifthestaplercannotbemaneuvered aroundthisfold,thentherectumshouldbeagaindividedbelowthefold, andthecircularstaplerreintroduced.Thecompromiseofacceptingan anteriorrectal-to-end-colonicanastomosisisnotthesolution.
Theleftcolonisbroughtintothepelviswithouttwistingitsmesentery. Thestaplerpostisthenconnectedtotheshaftoftheanvil,andthe
deviceisclosedunderdirectvisionwiththemesenteryoftheleftcolon directedposteriorly(Fig.8-5).
FIGURE8-5Afterdeploymentofthestaplerrod
throughtherectalcuff,theanviliscoupledtothe receptablepost.
Afterfiring,thestaplerisremovedfromtheanusandbothdonutsare checkedforacomplete,uninterruptedringoffullthicknessbowelon
both.Theringsshouldbesenttopathologyastruedistalandproximal margins.ThestaplelinemaybeoversewnwithinterruptedLembert stitchesbasedonsurgeonpreference.
Theanastomosisisthentestedforleakbyinsufflatingairthrougharigid proctoscopeplaced.First,thepelvisisfilledwithsaline.Withthebowel
proximaltothestapledanastomosisoccluded,airispumpedthroughthe proctoscopeintothecolon(Fig.8-6).Small“champagne”-typebubbles wouldindicatealeakatthestaplelineandshouldbeaddressedwith Lembertsuturesof3-0absorbablematerialorcompletereconstruction oftheanastomosis.Largerormorevigorousbubblingshouldprompt revisionoftheanastomosisorprimaryrepairwithproximaldiversion.
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FIGURE8-6Totesttheanastomosis,thepelvisis
filledwithwater.Alargebolusofairistheninjected viaproctoscope;bubblessignifyaleak.
Atthispoint,theentiresurgicalteamrescrubsanddonscleansurgical
garmentswhiletheoperatingroomstaffpreparesasteriletrayofclosing instruments.Theabdomenisthenclosedafterirrigationandreturning thesmallbowelingentleS-shapedcurves.Adrainisnottypicallyleft unlessthereisconcernforurologicinjury.
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