Surgery

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Ростовский Государственный Медицинский Университет

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Медицина общая

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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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SURGERY

Whenapproachingalaparoscopiccolectomy,standardizingthesurgical techniquehelpsfacilitatetheoperation,allowingittobeperformedina quickandefficientmanner.Thismethodwilldecreasesurgeon frustrationandoperativetime.Eachstepmusthavespecifictargetsand thosetargetsshouldbereachedinatimelymanner.Ifthesurgeonisnot meetingthosegoalsandtheoperationisfailingtoprogress,early conversionisadvocatedandmayreducetheriskofintraoperative complications.Justasstandardizationfacilitatesperformingthe procedure,institutingstandardizedpreoperativeandpostoperativecare pathwayshaveshowntobesafeandcost-effective,reducingpatient lengthofstayanddecreasingcostsandcomplications.

Positioning

Thepatientisplacedinthemodifiedlithotomypositionwithcarefully paddedAllenstirrupsandwiththigh-highsequentialcompression stockingsutilized.Positioningofthepatientintheoperatingroomshould includetuckingoftheright(orboth)arm(s)bythepatient’ssidetoallow fullaccesstothatsideofthepatient,becausetheconductoftheoperation hastheoperatingsurgeonandassistantstandingontherightsideand alsointermittentlybetweenthelegstofacilitatesplenicflexure mobilization.

Themonitorsshouldbepositionedneartheleftshoulderandlefthip areaformaximalviewingcapabilityofthismultiquadrantoperation.The patientneedstobepaddedtoavoidanypressureinjuriesandsecuredto thebedtoallowextremepositioningchangesduringtheoperation.In particular,steepTrendelenburgpositionisutilizedand,therefore,gel padsplacedabovetheshoulderorsomeothermethodofsecuringthe patient(beanbagorfoampaddingunderneath)areessential.Thesepads orbeanbagsmustbethoroughlysecuredtothetable.Itisthepracticeof theauthorstotestthesecurepositioningofthepatientbymovingthebed intoextremeposition.Patientmovementcanbecorrectedbefore beginningtheoperation.Thepatient’sabdomenispreppedanddrapedto theanterioraxillarylineslaterally,theribcagesuperiorly,andthepubic area.

Technique

Afterdraping,a1-cmincisionismadeabovetheumbilicusinthemidline. A12-mmtrocarisplacedattheumbilicusincisionanda

pneumoperitoneumshouldbeestablishedtoapressureof15mmHg.The authorsutilizea10-mm,30-degreescopethroughthetrocarthroughout theprocedure.Followingthat,threeadditionaltrocarsareplaced,one5mmsizeintherightupperquadrant,a12-mmtrocarintherightlower quadrantjustmedialandslightlysuperiortotheanteriorsuperioriliac spine,anda5-mmsuprapubictrocar.Ifnecessary,afourth5-mmtrocar canbeplacedintheleftlowerquadrant2–4cmsuperiorandanteriorto theanteriorsuperioriliacspinedependingonthesizeofthepatient.

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Inthecaseofacancerdiagnosis,theinitialstepsaretoperforma staginglaparoscopybyfirstplacingthepatientinreverseTrendelenburg positiontoevaluatetheliverandperitonealsurfaceandthenreturningto aslightTrendelenburgtoevaluatetherestoftheabdominalperitoneal cavityandthepelvis.

Tobegintheleftcolonmobilization,thepatientisplacedinsteep Trendelenburgwithleftsidetiltedup;inthisway,weutilizegravityasa retractorandsweepthesmallboweloutofthepelvisandawayfromthe leftcolonmesenteryandduodenum.Thedegreeofthetabletiltis dependentonthemobilityofthesmallintestine.Notinfrequentlythere areadhesionsoftheterminalileumorcecumtotherightpelvisor sigmoidmesenterythatrestrictthemobilityofthesmallbowel;andthese adhesionsshouldbedividedtoensurethatthesmallbowelisfully mobilizedandoutofthepelvisandawayfromtheleftcolonmesentery. Unimpededvisualizationofthemesenteryisthekeytoasuccessful medial-to-lateralmobilization.Atthistime,anyattachmentsofthe sigmoidcolontotheleftpelvisorlateralpelvicsidewallareleftinplace becausetheyhelpelevateandretractthecolonoutoftheoperatingfield.

Thefulllengthofthemesenteryfromtheduodenumtothesacral promontoryisvisualized.Themesenteryorthecolonisgentlygrasped throughthesuprapubicportand,withtensionelevatingthemesentery anteriorlyandinferiorly,theinferiormesentericartery(IMA)isposed. Theiliacvesselsareoftenvisualizedatthistimethroughthe retroperitonealsurface,andinathinpatienttherighturetermayalsobe obvious.Dissectionisinitiatedatthesacralpromontorycaudaltothe IMA.TheIMAmaybeobviouswhenplacedundertensioninthin patients,becausewhenthemesosigmoidisgraspedandelevated anteriorly,thevesselistentedupandisquiteprominent.Inobese patients,itmaynotbesoobvious.

Theperitoneumoverlyingthedissectionplaneisscoredalongthe sacralpromontoryintothepelvisandalsocephaladtowardthe duodenum.Establishingthisdissectionplaneisanessentialfirststep;

andoftenoncetheperitoneumisincised,thepneumoperitoneumwill helpopenuptheplanes.Theplaneofdissectionmaybeextendedtoo deepintothetissue,therebymobilizingtheretroperitonealstructuresoff oftherectuswiththecolonicmesentery.

Dissectionshouldbeanteriortotheiliacvesselsandtothehypogastric nerves,andtheleftureterisoftenquicklyseen.Oncethisdissection planeisestablished,anatraumaticinstrumentcanperformablunt dissectionfreeingthemesenteryoffoftheretroperitoneum.Theleft uretershouldthenbeprotectedandallowedtoremaininthe retroperitoneum,andthedissectioncontinueduptotheoriginofthe IMA.Iftheuretercannotbequicklyandeasilyidentified,themostlikely conclusionisthatithasindeedbeenelevatedalongwiththemesocolon. Oncetheureterisidentifiedandtraced,dissectioniscontinuedonthe peritonealsurface,scoringanddissectingouttheIMAandinferior mesentericvein(IMV).Inabilitytoidentifythelefturetershouldthen leadthesurgeontomobilizethecolonalongthewhitelineofToldtto identifytheureter.Failuretoidentifytheleftureterbybothapproaches maybeanindicationtoconverttoanopenprocedure.

Oncethemesenteryisfreedfromtheretroperitoneum,theIMAis isolatedandmayundergoahighligationoraselectiveligationdepending ontheindicationfortheoperationatthesurgeon’spreference.Theartery isdividedusingeitheravessel-sealingenergydeviceorothertechniques includingclipsand/orstaples.Themesenteryisfurthermobilizedfrom theretroperitoneumextendingtowardthesplenicflexurefreeingitfrom Gerota’sfascia.TheIMVisthenextvesselencounteredandisisolated duringthiscephaladdissectionandmaybedividedviaasimilar technique.Ifalowanteriorresectionisbeingperformed,thendivisionis

Oncethemesenteryiscompletelyfreedtothesplenicflexureanddown tothesacralpromontory,thesurgeonturnshisorherattentiontoward thewhitelineofToldt.Thecolonisthenmediallyandsuperiorly retractedandtheperitoneumisincised,withanendoscopicscissorswith orwithoutcautery.Thepreviouslydissectedplaneiseasilyenteredand theperitonealattachmentsdivideduptothesplenicflexure.Careshould betakennearthesacralpromontorywhenperformingthisstepbecause theuretermaystillbeattachedtotheperitoneumandmaybeinjured. Typically,theretroperitoneumbehindthelateralaspectofthesigmoid anddescendingcolonisstainedapurplishcolor,whichisusefulto identifythecorrecttissueplane.Thisstainingisfromtheprevious medial-lateralretroperitonealdissection.Theproximallineofresectionis thenselectedlargelyonthebasisofthemesentericbloodsupplyand locationofpathology,butmayalsobedeterminedbythequalityofthe sigmoidcolonandthepresenceorabsenceofpreviousradiationtherapy. Inacaseofdiverticulardiseaseaffectingthesigmoidcolonorintheface

ofpreviousradiationtherapy,theauthorspreferadescendingcolonto rectalanastomosis.Thisfeaturemayaffectthedegreeofsplenicflexure mobilizationnecessarytoresultinatension-freeanastomosis.

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Splenicflexuremobilizationbeginsbyputtingthepatientintoaslight reverseTrendelenburgpositionwithleftsideelevated.Theomentumis graspedandelevatedcraniallywhilethecolonisretractedinferiorlyto identifytheavascularplanebetweenthetransversecolonandthe omentum.Theomentumismobilizedoffofthecolonandthelessersacis entered.Thesurgeonmaychoosetocontinuedissectionaroundthe splenicflexurefromthelateraspectofthecolontoenterthelessersacif thelateralplaneisobvious.Careshouldbetakennottoinjurethe pancreasduringthismobilizationbecauseitcanbedifficulttoidentifyat times.Alternatively,thesplenicflexurecanbeposteriorlymobilized. Enteringintotheretroperitonealtissueplanebehindthemesocolon,the windowoverthetailofthepancreasisincisedtoenterthelessersac extendinguptowardthespleen.Themaneuverrequirestheuseofa45degreeangledorflexibletiplaparoscope.

Oncethesplenicflexureisfullymobilized,theproximalsiteofplanned resectionisgentlygraspedandbroughtdownintothepelvistoinsure thatthereisadequatemobilityforatension-freeanastomosisatthedistal plannedlineofresection.ThislengthshouldbeadequateiftheIMVwas dividedatthelevelofthepancreas.Fullmobilizationoftheomentum fromthetransversecolonandincisioncolonicmesenterymediallytothe edgeofthemiddlecolicvesselsmaybeneededtogainfurthermoliletyof thesplenicflexuralandsiteofproximaltransection.Oncemobilizationof thecoloniscomplete,thepatientisplacedbackintoTrendelenburg positionandthedistallevelofresectioninthecolonorrectumischosen, eitherbasedonanatomiclandmarksoronendoscopicconfirmationin thecaseofaneoplasm.Tattooingisofvaluebutcannotbefullyreliedon becauseofthenon-specificityoftheexactlocationwhendealingwith rectalneoplasmsandanticipatedmarginsof2cmorevenless.The authorsstronglypreferCO2insufflationfortheirintraoperative

colonoscopyforlocalizationandconfirmationofmarginstoavoid troublingcolonicdilation,whichcanimpairtheconductoftheremainder oftheoperation.Itisimperativetohaveadequateproximalclampingof thecolonifintraoperativeendoscopyisemployedtopreventexcessive colonicdistension.Foranteriororlowanterioranastomoses,oncethe coloniscompletelymobilizedandtheresectionmarginsdefined,the colonmesenteryisdividedwithavesselsealertothelocationofplanned colonorrectaldistalmargin.Thecolonisdividedusinganendoscopic

staplerplacedthroughtheleftlowerquadrantport.Thedistalstapleline onthecolonisthengraspedwitharatchetedgraspertoensureitisnot lostandthepneumoperitoneumisdeflatedthroughthetrocars.

Thelocationofspecimenextractionisdependentonthepreferenceof thesurgeon.Aleftlowerquadrant,asuprapubicPfannenstielincision,or aperi-umbilicalincisionismadeandawoundprotectorisplaced.The specimenisextractedthroughthisincisionandanastomosisisperformed usingacircularstapler.IfaPfannenstielincisionismade,theresection andanastomosismaybeperformedunderdirectvision.Anyother incisionrequiresreturningthecolontotheabdominalcavity,reinsufflatingthepneumoperitoneum,andlaparoscopicallyperformingthe anastomosis.BothaleftlowerquadrantandthePfannenstielincisions arebelievedtohavelowerincisionalherniarates.Whetherperforming theanastomosisunderdirectvisionorwiththelaparoscope,itis importanttoensurethecolonicmesenteryisstraightandnottwistedon itself.Thecolonshouldbecarefullyinspectedandthetaeniaandcutedge ofmesenterymustbefollowedalongtheentirelengthofthecolonbefore firingthestaplertoavoidtwistingofthecolon.Anairtestisperformed, withendoscopy(rigidorflexible)ifavailable,toassesstheintegrityofthe anastomosis.Thesurgeonthenclosesthefacialincisionsandskin accordingtopersonalpreference.

POSTOPERATIVEMANAGEMENT

ImplementationoftheERASpathwayaimstodecreasepostoperative ileus.Withrapidrecoveryofgastrointestinalfunction,patientscan transitiontooraldietandhydration,oralpainmedication,andearly discharge.Preoperativeeducationofthepatientisanessentialelementof theERASpathway.Supplementarybookletsorvideosshouldbepartof thepatient’spreoperativepreparation.Educationofthenursingstaff caringforthepatientisalsorequired.Earlyoralfeeding,early ambulation,standardizedpostoperativeantiemeticagents,andlimiting excessivefluidadministrationintra-andpostoperativelyhaveallbeen showntoenhanceearlygastrointestinalfunctionrecovery.Eachofthese itemsisusuallyincorporatedintostandardizedpostoperativecare,or ERASpathway.Theseperioperativecareplanshaveshownsignificant improvementinpostoperativepreventionofileusanddecreasinglength ofstay.Othercommonlyincludedtacticsincludeeliminationof nasogastrictubes,limitingoreliminatingnarcoticintakewiththeuseof nonsteroidalanti-inflammatoryagentsandepiduralcathetersorlocal blocks(TAPblocks)forpaincontrol.

COMPLICATIONS

Anastomoticleakisthemostdreadedcomplicationfollowingleft colectomywhetheritisperformedbylaparoscopicoropenapproach.To decreasetheriskofanastomoticleak,itiscriticaltoperformatensionfree,well-vascularizedanastomosis.Duringsurgery,atemporary divertingloopileostomyshouldbeconsideredifriskfactorsfor anastomoticleakarehigh.Someoftheserisksincludealowanastomosis, ahistoryofradiationtherapytotherectum,prolongeduseofsteroids, malnutrition,presenceofintra-abdominalsepsis,orthepresenceof significantcomorbidities.Ifthesurgeonquestionstheanastomotic integrity,thetensionpresent,ortheperfusionoftheintestineinvolved, theanastomosismustberevisedorredone.

RESULTS

Studieshaveshownthatlaparoscopicleftcolectomywasassociatedwith longeroperativetimewhencomparedtoopenprocedure;however,ithas beenshowntoresultinearlierreturnofbowelfunctionandshorter hospitalstay.Furthermore,laparoscopicleftcolectomyresultsinsimilar oncologicoutcomesintermsofnumberoflymphnodesharvested, negativemargins,overallsurvival,anddisease-freesurvivalwhen comparedtoopenprocedures.

CONCLUSIONS

Withadequatelaparoscopicskills,laparoscopicleftcolectomyperformed byamedial-to-lateralapproachisextremelyusefulinthepresenceof inflamedtissueandallowsearlyidentificationoftheureterandiliac vessels,allowingforasaferlateraldissection.Ithasbeenshowntobea safeandeffectiveapproachforleftcolonresectionwhencomparedto openprocedures.Patientstendtohaveearlierreturnofbowelfunction andlowerlengthsofstay,butoverallmorbidityhasneverbeenshownto bedifferentbetweentheopenandlaparoscopicgroupsinmost randomizedcontrolledtrials.

RECOMMENDEDREFERENCESAND READINGS

AlthumairiAA,CannerJK,PawlikTM,etal.Benefitsofbowelpreparationbeyondsurgicalsite

infection:aretrospectivestudy.AnnSurg2016;264(6):1051–7. BagshawPF,AllardyceRA,FramptonCM,etal.Long-termoutcomesoftheAustralasian

randomizedclinicaltrialcomparinglaparoscopicandconventionalopensurgicaltreatments

forcoloncancer:theAustralasianLaparoscopicColonCancerStudytrial.AnnSurg

2012;256(6):915–9. BuunenM,VeldkampR,HopWC,etal;ColonCancerLaparoscopicorOpenResectionStudy

Group.Survivalafterlaparoscopicsurgeryversusopensurgeryforcoloncancer:long-term

outcomeofarandomisedclinicaltrial.LancetOncol2009;10(1):44–52. GuillouPJ,QuirkeP,ThorpeH,etal.Short-termendpointsofconventionalversuslaparoscopic-

assistedsurgeryinpatientswithcolorectalcancer(MRCCLASICCtrial):multicentre,

randomizedcontrolledtrial.Lancet2005;365:1718–26. GustafssonUO,TiefenthalM,ThorellA,LjunggvistO,NygrensJ.Laparoscopic-assistedandopen

highanteriorresectionwithinanERASprotocol.WorldJSurg2012;36(5):1154–61. HewettPJ,AllardyceRA,BagshawPF,etal.Short-termoutcomesoftheAustralasianrandomized

clinicalstudycomparinglaparoscopicandconventionalopensurgicaltreatmentsforcolon

cancer:theALCCaStrial.AnnSurg2008;248(5):728–38. JacobBP,SalkyB.Laparoscopiccolectomyforcolonadenocarcinoma:an11-yearretrospective

reviewwith5-yearsurvivalrates.SurgEndosc2005;19(5):643–9. JayneDG,GuillouPJ,ThorpeH,etal.Randomizedtrialoflaparoscopic-assistedresectionof

colorectalcarcinoma:3-yearresultsoftheUKMRCCLASSICtrialgroup.JClinOncol

2007;25:3061–8. LiangJT,HuangKC,LaiHS,etal.Oncologicresultsoflaparoscopicversusconventionalopen

surgeryforstageIIorIIIleft-sidedcoloncancers:arandomizedcontrolledtrial.AnnSurg

Oncol2007;14(1):109–17. NelsonH,SargentDJ,WieandHS,etal.Clinicaloutcomesofsurgicaltherapystudygroupofthe

laparoscopiccolectomytrial:acomparisonoflaparoscopicallyassistedandopencolectomyfor

coloncancer.NEnglJMed2004;350:2050–9. NelsonRL,GladmanE,BarbateskovicM.Antimicrobialprophylaxisforcolorectalsurgery.

CochraneDatabaseSystRev2014;9:CD001181. PatankarSK,LarachSW,FerraraA,etal.Prospectivecomparisonoflaparoscopicvs.open

resectionsforcolorectaladenocarcinomaoveraten-yearperiod.DisColonRectum

2003;46(5):601–11. VeldkampR,KuhryE,HopWC,etal.Laparoscopicsurgeryversusopensurgeryforcoloncancer:

short-termoutcomesofarandomisedtrial.LancetOncol2005;6(7):477–84. VlugMS,WindJ,VanDerZaagE,UbbinkDT,CenseHA,BemelmanWA.Systematicreviewof

laparoscopicvs.opencolonicsurgerywithinanenhancedrecoveryprogramme.ColorectalDis

2009;11(4):335–43.

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