Книга_861_Библиотеки_им_академика_М_И_Перельмана

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Ростовский Государственный Медицинский Университет

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Sub-InferiorMesentericVeinApproach

Becausecompletesplenicflexuremobilizationandhighligationofthe IMVisrequiredvirtuallyeverytimeacoloanalanastomosisisperformed, theauthorsfrequentlyutilizeasub-IMVmedial-to-lateralapproachto mobilizetheproximalleftmesocolonandsplenicflexureastheinitial stepinlaparoscopicLAR.Thepatientiskeptinarelativelyneutralor slightreverse-Trendelenburgpositionandisrolledsteeplytotheright. Theomentumisreflectedcephaladandthesmallbowelisswept medially,exposingtheduodeno-jejunaljunctionattheligamentofTrietz. Therearefrequentlyadhesionsofthefirstfewcentimetersofthejejunum totheleftcolonmesentery,whicharesharplydivided.TheIMVis identifiedjustlateraltotheligamentofTrietzandisgraspedandelevated offoftheretroperitoneum.AnavascularwindowbeneaththeIMVis identifiedandopenedwithmonopolarcautery.Thisincisioniscontinued caudallyalongtheanterioraspectoftheaortatowardtheoriginofthe IMA.AgrasperisinsertedbehindtheIMVandthemesocoloniselevated offtheretroperitoneum.Amedial-to-lateralmobilizationisthen performedheadingtowardtheleftupperquadrantandthencontinuing asfaraspossibletowardthepelvicbrim.PreservingtheIMVinitiallywill helpidentifytheappropriateplane;butonceitbeginstolimit visualization,itshouldbedivided.

ItisessentialtorememberthattheIMVeventuallycoursesbehindthe pancreastojoinwiththesplenicvein.Asaresult,continuingthe dissectioncephaladalongtheposterioraspectoftheveinwilleventually leadbehindthepancreas.Withtheupperaspectoftheleftmesocolon mobilized,thebulgeofthebodyofthepancreasandthejunctionwiththe rootofthetransversemesocolonbecomevisible(Fig.15-6).Atthispoint, itisnecessaryto“stepup”infrontofthebodyofthepancreasandgo throughtheavascularportionoftherootofthetransversemesocolonto enterthelessersacfrombeneath.Whencorrectlyexecuted,this dissectioncancontinueintothelessersacandwillallowcompletesplenic flexuremobilizationfrombeneaththecolon.Ifatanypointtheplane becomesunclear,thelessersaccanbeenteredfromaboveasdescribed previously.Havingcompletedtheposteriormobilization,theplane betweentherootofthetransversemesocolonandthebodyofthe pancreasistranslucentandcanberapidlydividedwithsharpdissection. Thetransversecolonwillthenrequireseparationfromtheomentumto completethemobilizationofthesplenicflexuremobilization.

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FIGURE15-6Sub-IMVdissectioniscontinued

laterallyunderthecolontothewhitelineofToldt,and superiortoandabovethepancreas.Caremustbe takentoensurethedissection“stepsup”overthe pancreastoenterthelessersac.IMV,inferior mesentericvein.

ProctectomywithTotalMesorectalExcision

ThepatientisplacedinsteepTrendelenburgpositionwiththerightside downtoallowthesmallboweltoretractoutofthepelvis.AfterIMA division,thepropermesorectalplaneisexposedbycephaladandanterior elevationoftherectosigmoidjunction.Themesorectaldissectionshould besharplyperformedsharplytopreventinjurytothehypogastricand parasympatheticnerves.Thehypogastricnerves,protectedduringIMA dissectionatthesacralpromontory,arepreservedbecausetheycourse laterallyintothepelvis(Fig.15-7).Mesorectaldissectionisperformed posteriorly,thenlaterally.Posteriordissectioncontinuesthroughthe avascularplaneoutsidethefasciapropriatoWaldeyer’sfasciaandthen tothelevatormuscles.Retractiononthemesocoloniscriticaltofacilitate thedissectionandshouldbeanteriorlyandcephaladtodemonstratethe planes.

FIGURE15-7Enteringtheappropriateplanefor

mesorectaldissectioniscriticaltooncologicresection. Byelevatingtherectosigmoidjunctionanteriorlyand superiorly(outofthepelvis),aplanemaybevisualized deeptothemesorectum.Sharpdissectionshouldbe performedinthisavascularplane.

Asdissectioncontinues,posteriorretractionislimitedbylateral retraction.Whenthisproblemoccurs,thesurgeonmusttakelateral,and eventuallyanterior,attachmentstofacilitatedissectionintheplanejust lateraltothefasciapropria.Stayingclosetothemesorectumprotectsthe lateralstalks,whichareasiteofpotentialinjurytothenervesofthe pelvicplexus(Fig.15-8).

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FIGURE15-8Continuedtensionontherectumby

liftingtherectumanteriorlyandsuperiorlyallowsfor visualizationofthemesorectalplane.Posteriorly,the dissectionplaneshouldleavethenervesintact,with thepresacraltissue.Theplanecreatesa“U”shape, andtravelsanteriorasitisdevelopedlaterally,tothe lateralstalks.Unlessthereistumorinfiltration, preservationofthelateralstalksshouldbeperformed bystayingclosetothefasciapropriaoftherectum.

Asthedissectioncontinues,anteriordissectionisnecessary.Cephalad andposteriorretractionoftherectumwillplacetensionontheanterior planes.Asecondretractorcanbeusedtoplacetensionontheanterior pelvicstructures.Inmalepatients,caremustbetakentoavoidinjuryto theseminalvesicles.TheverythinavascularplaneofDenonvilliers’fascia existsbetweentheanteriormesorectumandtheseminalvesicles,and mustbecarefullydissectedtoavoidbleeding(Fig.15-9).Infemale patients,alargeuteruscanobstructvisualizationandtheabilityto appropriatelyretracttherectum.A2-0polypropylenesutureonaKeith needlecanbeintroducedthroughthesuprapubicabdominalwalland usedtofixtheuterustotheanteriorabdominalwalltoalleviatethis situation.Ifthepatienthashadapriorhysterectomy,thevaginamaybe fusedtotheanteriorrectum.Dissectionmaybefacilitatedbyhavingan assistantelevatethevaginawithasizerorwithatransvaginallyplaced malleableretractor.

FIGURE15-9Anteriorviewoflaparoscopic

dissection.Anopenretractorelevatestheanterior structuresawayfromthedissectionplanetoallowfor visualizationoftheappropriateplane.Caremustbe takentopreservetheseminalvesiclesanteriorand lateraltotheprostateinamaleortherectovaginal septumanteriorlyinafemale.

Afterlateralandanteriordissection,thesurgeoncanreturntothe posteriordissectionandobtainimprovedmobilizationtoreachdeeper intothepelvis.Whenposteriordissectioniscompletetothelevators,the mesorectumwilldissipate,eveninheavypatients.Adecisiontostartthe dissectionfromtheperinealphaseortolaparoscopicallytransectthe rectummustbemade.

Forlaparoscopictransectionoftherectum,oneportwillbeenlargedto a15-mmporttoinsertthestapler.Manylocationsincludingstomasite (rightlowerquadrant),leftlowerquadrant,periumbilical(camerasite), orPfannenstielincisionhavebeenusedonthebasisofindividualsurgeon preference.Theauthorsgenerallyusealeftlowerquadrantspecimen extractionsiteandstaplingport.Thekeytosuccessfultransectionisa staplerplacedperpendiculartotherectum(Fig.15-10).Thismethod minimizestheuseofmultiplestaplelinesanddecreasestheriskof devascularizedrectumordogearsattheanastomosis.Dependingonthe widthofthepelvis,atransversestaplelinemaybepossible,orthe surgeonmayhavetouseananterior-to-posteriorstaplelinetoobtain correctangles.

FIGURE15-10Laparoscopicstaplingofthe

rectum.Therectumshouldbestapledata perpendicularangle;thisiskeytodecreasingtheuse ofmultiplestapleloadsandhasbeenshowntoreduce theriskofanastomoticleak.

TransanalRectalTransectionandPerinealDissection

Thetransanaldissectionmaybeperformedbefore,during,orafterthe abdominalportionoftheprocedureandcontinuedproximallyfora variableextentdependingonstaffandequipmentavailabilityand surgeontraining.Furtherinformationonaso-calledbottoms-up approachisprovidedinthechapteronTATME.Forpurposesofthis chapteritisassumedthattherectaldissectionhasbeencompletedtothe fullestextentpossiblelaparoscopicallybeforebeginningthetransanal dissection.Aseparatechapterinthistextisdedicatedtothespecific technicaldetailsofintersphinctericdissectionfordistalrectalcancers.

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Thepatient’slegsareliftedandspreadinlithotomystirrupstoallow theoperatingsurgeonandassistanttoaccesstheperineum.Aseparate setofoperativeinstrumentsshouldbeusedtopreventcontamination fromtheperineumtotheabdomen.Asmall,sterilelydrapedMayostand canbepositionedbeneaththepatient’sbuttockstouseasaworking surface.TheanusiseffacedbyuseoftheLoneStar(CooperSurgical, Trumbull,CT)retractororanaleffacementsuturesof1-0polyglactin.A lightedHill-Fergusonretractormaybeinsertedintotheanalcanalto

furtherflattenthemucosaandimprovevisualization,androtatedto exposethecircumferenceofthelumen(Fig.15-11).

FIGURE15-11Perinealdissection:Dissection

planeisbegunatthedentatelineusingeithera LoneStarretractororeffacementsutures.Alighted Hill-Fergusonretractormayhelpfacilitate visualization.Dissectioniscarriedproximallyina posterior,lateral,andthenananteriormanner.

Dissectionbeginswithacircularincisionatleast1cmdistaltothe furthestextentofthetumor.Ifnecessary,thedissectionwillbeinthe intersphinctericplanetoachieveanappropriateoncologicmargin.This dissectionistypicallyperformedusingelectriccauterytominimize bleeding.Asolutionof1/200,000epinephrinecanbeusedtoelevatethe mucosaandsubmucosaandtofurtherdecreasebleedingduringthe dissection.Operatingintheposteriorquadrantinitiallyispreferred becauseitiseasiertoidentifytheintersphinctericplaneinthislocation andavoidsrunofffromthesuperiorandlateraldissection.Placingan Allisclamponthecutedgeoftherectumallowsitberetracteddistallyfor betterexposure.Anteriorly,caremustbetakentoavoidinjurytothe vaginainfemales,ortotheprostateandurethrainmales.Towardthat goal,atransvaginallyplacedfingercanhelpelucidatetheappropriate plane.Excessivebleedingmaybeasignofinadvertententryintothe vaginalwallorprostateandtheappropriateavascularplaneshouldbe reestablished.Atthetopoftheanalcanal,superiortothepuborectalis, thedissectionplanewidensandentersthepelvis,throughthefullthicknessrectalwalltoconnectwiththeabdominaldissection.Theplane isenteredposteriorlyinitially,andthencontinuedlaterally.Dissectionis

directedjustanteriorlytothecoccyx,aspalpatedtransrectally.This dissectionwillallowthesurgeontoenterthemesorectalplaneandjoin thelaparoscopicandtransanalportionsofthesurgery.Oncetheplanes havebeenentered,acurvedfingerintothepelviscanhelpidentifyand isolateadditionalattachments.

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p.121

Oncethedissectioniscomplete,therectallumenissuturedclosed beforeaplannedtransabdominalextraction.Ifresectionisperformed laparoscopically,therectumispushedupoutofthepelvis.Amoist laparotomyspongeisplacedinthepelvicspacetopreventlossof insufflationbeforereturningtothelaparoscopicabdominalfield.

Ifahand-sewnanastomosisisplanned,thisperiodwhenthepelvisis emptyisanexcellenttimetoplacetheanastomoticsuturesintheopen rectalstump.Generally,sixtoeightsuturesof2-0polyglactinareplaced intotherectalmucosaandsubmucosa,incorporatingsomeofthedeeper sphinctermuscleandexitingextraluminallyabovethecuff.Theseare taggedwithhemostats,withtheneedlestillon,tobeusedoncethe proximalsegmentispreparedanddelivered.

SpecimenExtraction

Aftercompletingthedistalrectaltransectionandconnectingthe abdominalandtransanaldissections,thespecimenmaybeextracted throughavarietyofsitestoallowextracorporealproximaltransection andpreparationoftheproximalcolonicsegment.Optionsfor transabdominalextractionincludeextendingtheperiumbilicalorleft lowerquadrantportsites,creatingtheileostomyaperturewithvertical extensionoftheinferioraspect,ormakingaseparatePfannenstiel incision2cmabovethepubicsymphysis.Thedistalendoftherectumis laparoscopicallysecuredwithalockinggrasper.Themobilizedcolonic segmentispositionedintothepelvistoassureadequatereach.Amark maybeplacedwithelectrocauteryontheplannedpointofproximal transectionandthemesenterymaybelaparoscopicallydividedtoward thispointwithanenergydevice.Themarginalarteryispreservedand extracorporeallyinspectedforbleeding.Maintaininginsufflationwhile openingtheextractionsitecanhelppreventinadvertentinjurytothe viscerawhenenteringtheperitoneum.Awoundprotectorisplacedto flattentheabdominalwall,widentheincision,andpreventfecalortumor contaminationoftheextractionsite.

Insomecases,thespecimenmaybedeliveredthroughtheanus;yeta largetumor,bulkymesorectumorIMApedicle,oranarrowpelviswill

makethisdifficultandriskdamagetothesphinctermuscles.Iftransanal extractionisattempted,theentireIMApedicleandanadequatelengthof descendingcolonshouldbedrawnthroughtheanusbeforetransection. Themesenterytotheproximalresectionmarginshouldbecompletely transected.Staysuturesmaybeplacedtopreventthecolonfrom retractingintothepelvisortwistingduringconstructionofaneorectum andanastomosis.

Theproximalresectionmarginisselectedontheleftcolonbasedonan appropriateoncologiclymphadenectomyandconfirmationofadequate bloodsupply.Thesigmoidcolonisnottypicallyusedsecondaryto potentialischemiaafterhighligationoftheIMA.Thebowelwallis skeletonizedandthemarginalarteryisisolatedandcheckedforpulsatile arterialbleeding.Thecolonistransectedwithalinearcuttingstapler. Fluorescenceimagingperfusionassessmentmaybeusedtoassistwith selectionoftheproximalmargin.

CreationofaNeorectum

Comparedtostraightend-to-endcoloanalanastomosis,creationofa colonicJ-pouchresultsinsuperiorfunctioninthefirst6–18months postoperatively,bydecreasingfrequencyofbowelmovements,urgency, andfecalseepage.ComparativestudiesofcolonicJ-pouchhaveshown similarresultsfortransversecoloplastyandside-to-end(Baker) anastomosis,eachofwhichmayhavebenefitsoverend-to-endcoloanal anastomosis.TheauthorsprefertoperformaBakeranastomosisifreach isadequate;acoloplastymaybeperformedinpatientswithoutthe necessaryreach.However,theratesofpostoperativeanastomoticleak andpelvicsepsisarehigheraftercoloplastythanafteranyoftheother techniques.Inmaleswithnarrowpelvis,orlimitedreach,astraight coloanalmaybenecessary.Anyoftheseconfigurationsmaybeusedfora stapledorahand-sewnanastomosisandtheuseofaneorectumshould beconsideredwithanyanastomosisattheleveloftheanalcanal,notonly forthoserequiringtransanaltransection.

p.121

p.122

AcolonicJ-pouchisextracorporeallycreatedwiththedistal6cmof sigmoidordescendingcolonfoldeduponitself(Fig.15-12).Ananchoring stitchof3-0polyglactinisplacedtoapproximatetheantimesenteric bordersofthecolonandtopreventtwistingduringmanipulation.Pouch lengthsgreaterthan6cmhavebeencorrelatedwithincreasedevacuation difficulty.A60-mmlinearcuttingstaplerisinsertedintoanenterotomy createdattheapexoftheJ.Careshouldbetakentostaplealongthe

antimesentericborderoftheJ-pouchtopreventbleedingfromthestaple lineandpreservebloodsupply.Thedistalcolotomyshouldbeclosedand thesuturetaggedbeforereturningthepouchtotheabdomenfor anastomosis.Alternatively,abladdercatheterballoonmaybeinserted intothepouchandthenpulledthroughtheanustoguidethepouchinto position.Ifastapledanastomosisistobeperformed,theanvilwillbe placedinthedistalcolon,beforeclosureoftheJ-pouch,andsecureinto placewitha2-0polyglactinsuture.TransanalcolonicJ-pouch constructionisanotheroption,whichispreferredbyoneoftheeditors (SDW).

FIGURE15-12ColonicJ-pouch:AcolonicJ-pouch

iscreatedontheantimesentericsideofthecolonwith asinglefiringofalinear60-mmstapler.Pouchlength shouldbelimitedto60mmtopreventdifficultywith pouchemptying.

Coloplastyisconstructedwithalongitudinalincisionapproximately4– 6cmfromthedistalresectionmargin,alongtheantimesentericborder. Theincisionisextended8–10cmproximally(Fig.15-13).The longitudinalincisionisclosedtransverselytoenlargethecolonic reservoirinamannersimilartoaHeineke-Mikuliczpyloroplasty.A singlelayerof3-0polyglactinsuturesistypicallyused.Asmentioned

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