Книга_861_Библиотеки_им_академика_М_И_Перельмана

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Ростовский Государственный Медицинский Университет

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theleftureterisoutofharm’sway.IftheIMAistobedividedlaterinthe case,asecondmesentericwindowismade,caudaltotheleftcolicvessels towardthebaseofthemesentery.Theretroperitonealavascular dissectionplanebetweentheToldtandGerota’sfasciacanthenbe extendedbeneaththedistaldescendingcolon.Theleftureterandgonadal vesselsarebluntlydissectedawayfromtheundersideofthecolon mesenterytowardtheleftiliacfossa.Aftercompletingthemedial-tolateralmobilization,thedescendingcolonismediallyretractedandthe remaininglateralattachmentsaredividedsharply.Theproximalleft colonisreleasedtocompletethisportionoftheprocedure.When possible,theleftcolicveinshouldbeidentifiedbeforeligatingtheIMV. TheIMVshouldbeligatedcephaladtowheretheleftcolicveindrains intotheIMVtogetmaximalmesentericlengthening.

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FIGURE19-5Visualizationoftheinferior

mesentericartery.

Medial-to-LateralStartingattheSacralPromontory

Thesurgeonstandsonthepatient’srightsidewiththecameraoperator whilethefirstassistantstandsonthepatient’sleft.Thepatientisplaced intheTrendelenburgpositionwiththerightsidedown,soastoshiftthe smallboweloutofthelowerabdomen.Thedissectionisinitiatedatthe

rightbaseoftherectosigmoidcolonatthelevelofthesacralpromontory. Thefirstassistantgraspsthesigmoidandrectosigmoidandretractsthem upandtotheleft,whichplacestherectosigmoidmesenteryonstretch andexposesthegroovebetweentheinferiormesentericvascularpedicle andtheretroperitoneum.Thesurgeonthenincisestheperitoneum immediatelybeneaththeIMAatthelevelofthesacralpromontoryand extendsthisopeningintothepelvisforadistanceandalsocephalad towardthetakeoffoftheIMA(Fig.19-6).Aplaneisdevelopedbetween thepresacralstructuresandthecolonmesenteryworkingfromtheright towardtheleft.Caremustbetakentoidentifytopreservetheright hypogastricnerve.Theleftureterandhypogastricnervecanusuallybe identifiedovertheiliacarteryanddissectedawayfromthe mesocolon.Thisposteriorplanedissectioniscontinuedcephaladbeneath theleftcolonmesenterytowardtheoriginoftheIMA.Theperitoneumat thebaseoftheleftcolicmesenterymustbescoredtoexposetheIMAand itsbranches.Theleftureterandnerveintheposteriorplanearedissected freeofthemesentery,andtheIMAisdivided.IftheIMAistransectedat thelevelofthebifurcationtotheleftcolicandsuperiorrectalartery,the IMVcanalsobemobilizedanddividedatthispoint.Anteroproximal transectionoftheIMVrequiresincisionoftheperitoneumanteriortothe aortatotheleveloftheligamentofTreitztoidentifytheveinadjacentto theduodenojejunaljunction.Afterdetachingthesevessels,themedial-tolateralmobilizationiscontinuedcephaladbeneaththesigmoidand descendingcolonmesenterytowardthesplenicflexure.

FIGURE19-6Therectosigmoidmesenteryon

stretchandexposesthegroovebetweentheinferior mesentericvascularpedicleandtheretroperitoneum. Thesurgeonthenincisestheperitoneumimmediately beneaththeinferiormesentericartery(IMA)atthe levelofthesacralpromontoryandextendsthis openingintothepelvisforadistanceandalso cephaladtowardthetakeoffoftheIMA.

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Lateral-to-MedialApproach

ThepatientisplacedinreverseTrendelenburgpositionwiththeright sidedown.Thefirstassistantstandsonthepatient’srightsidewiththe cameraoperatorwhilethesurgeonstandsbetweenthelegs.Thefirst assistant,usingtwoatraumaticgraspers,retractsthedistaldescending andproximalsigmoidcolonmediallyandupward,whichcreatestension onthelateralattachments.Thesurgeoninitiatesthedissectionby dividingthewhitelineofToldtwithascissorsorotherdeviceinserted throughthelowerleftport.Thedissectionbeginsatthepelvicbrimand continuescephaladtowardthesplenicflexure(Fig.19-7).Asthe mobilizationprogresses,themedialandupwardtractionprovidedbythe

firstassistantmustbeincreasedsoastomaintaintractiononthe attachments.ThecorrectdissectionplanebetweentheanteriorGerota’s fasciaandtheposterioraspectofthemesocolonmustbefoundand developedwithminimaltonobleeding.Thisplaneisoftennotevidentat thestart;butonceestablished,itisusuallyeasytomaintainthroughout tocompletethemobilization.Attheflexure,itisimportanttotransition fromthedeeperretroperitonealplanetoamoresuperficialplaneventral tothepancreas.Asonenearstheflexure,thereisoftenatendencytodrift lateralandcephaladtowardthespleen.Theflexureshouldberetracted caudalandmedialandthenliftedanteriortowardtheabdominalwallby theassistanttoexposetheembryologicavascularplanethatoftenlies wellbelowthespleen.

FIGURE19-7Lateral-to-medialdissectionofthe

descendingcolon.Itisimportanttocorrectlyidentify thedissectionplanebetweentheanteriorGerota’s fasciaandtheposterioraspectofthemesocolon.

OmentalPeel

Thisstepisthesameregardlessoftheorderofoperationorthechosen methodofdescendingcolonmobilization.Thegoalistoseparatethe

distaltransversecolonfromtheomentumandthestomach.Theauthors’ preferenceisto“peel”fromthecolonbydividingtheavascular attachmentsalongtheantimesentericsurfaceofthetransversecolon.The omentumisreflectedupandtowardtheheadwhilethetransversecolon isretractedcaudallyanddorsally.Thisdissectionisbeststartedjustto theleftofthemid-transversecolonsoastofacilitateentryintothelesser sacandaviewofthebackwallofthestomach.Thesurgeonmustbeware ofthepossibilityofinadvertently“overshooting”themarkandmakinga windowinthetransversecolonmesentery,whichisbothincorrectand dangerousbecausethemarginalarterymaybeinadvertentlydivided. Providedthatthedorsalwallofthestomachcanbeseenthroughthe windowbetweenthecolonandtheomentum,thedissectionplaneis correct.Afterenteringthelessersac,theremainingattachmentsbetween theomentumandthedistaltransversecolonaredivided.Theremaining splenicflexureattachmentsarethendivided.Thebaseofthedistal transversemesocolon,justlateraltothesiteoftransectionoftheIMV andventraltotheinferioredgeofthepancreas,isdividedtoreleasethe finalposteriorattachmentofthesplenicflexure.Atypicalmesenteric arteriesinthisareamayrequirehemostaticdivision.Alternatively,the gastrocolicligamentcanbetransectedoutsidethegastroepiploicarcade alongthegreatcurveofthestomachthatdetachesthestomachfromthe stilladherenttransversecolonandomentum.

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ProximalTransectionoftheColonandMesentery

Theproximalpointofboweltransectionshouldbechosenandthecolon andmesenteryintracorporeallydividedbeforeinitiatingtheopenportion oftheLAR.Accomplishingthistaskfacilitatestheopenpartofthecase. Itisimportanttoassessthemobilityofthedescendinganddistal transversecolontodeterminetheproximalmostpointthatwillreach intothedistalpelviswithouttension.Thebloodsupplyofthispartofthe colonshouldalsobeassessedtoensurethatitiswellvascularized.The mesenteryisthendividedstartingatthebasejustproximaltowherethe IMAwastransected.Greatcaremustbetakenatalltimestopreservethe marginalvesselsclosetothepointoftransection.Finally,thecolonis dividedwithanintracorporeallinearstaplingdevicecompletely detachingtheupperandlowerbowelandmesentericsegments.

InitialRectalMobilization

Theperitoneumoftheleftorrightpelvicguttercanbeeasilyscored

providedtherectosigmoidanddistalsigmoidcolonisretracted anteriorly,cephalad,andtowardtheoppositeside.Infact,severalofthe descendingcolonmobilizationmethodsdescribedintheprecedingtext (lateral-to-medialandmedial-to-lateralstartingatthesacral promontory)includescoringoftheiliacfossaperitoneumandpartial mobilizationoftherectosigmoidmesentery.Monopolar,bipolar,or ultrasonicshearscanbeusedtoscoretheperitoneumandtodissect beneaththerectosigmoidandproximalrectalmesentery.Tractionmust bemaintainedontherectosigmoidtofacilitatedissectionposteriorly;as thisplaneisdeveloped,thehypogastricnervesandtheuretersneedtobe identifiedandpreserved.Oncestarted,themostcaudalofthefirst assistant’sretractorsshouldbeplacedintheposteriorpocket,opened wide,andthenleveredsoastolifttheoverlyingmesorectumanteriorly andtowardthehead.Meanwhile,thefirstassistant’scephaladretractoris usedtoretractthemesorectummediallyandupwardatthelevelofthe sacralpromontory,thusprovidingmoretractionandimprovingthe surgeon’sviewofthedissectionfield.Theperitoneumcanbescoredto theanteriorreflection.Oncecompleted,theperitonealattachmentson theoppositesidearescoredinasimilarmanner.Itisusuallyarelatively simplemattertojointheleftandrightdissectionplanesbeneaththe rectosigmoidmesentery.Theanteriorperitonealreflectionshouldbe scored,ifpossiblelaparoscopically,andthedissectioninitiatedfor1–2 cm.

Beforebeginningtheopenportionoftheprocedure,theproximal bowelshouldonceagainbeassessedforadequatelengthtoreachthelow pelvis.Occasionally,additionalmobilizationwillbeneededanditisbest laparoscopicallyperformed.Intheauthors’experience,retroperitoneal nonvascularattachmentsthathavenotbeenfullytransectedcanlimitthe downwardreachoftheproximalbowel.Moreover,iftheIMAwas transecteddistaltothetakeoffoftheleftcolicartery,theIMAmayneed tobere-transectednearitsoriginattheaortatogainadditional mesentericlength.Formaximallength,theIMVshouldalsobeligated neartheinferiorborderofthepancreas,cephaladtowheretheleftcolic veindrainsintoit.

OpenPortionoftheCase

Asoriginallydescribed,aftercompletingtheclosedportionofthe operation,theabdomenisdesufflatedandthelaparoscopicports removed.Itisadvisedthatbeforedesufflation,thefascialsuture(s)for the12-mmrightlowerquadrantportbeplacedlaparoscopicallywitha laparoscopicsuturepasserorsimilardevice.Next,eitheralowermidline oraPfannenstielincisionismade.Ifamidlineincisionismade,itshould startjustabovethepubicsymphysisandextendcephalad.Ifa

Pfannenstielincisionismade,itshouldbeplacedabouttwo fingerbreadthsabovethepubicsymphysisandbecenteredonthe midline.Inbothcases,theincisionshouldbebetween8and10cmin length.Thislengthwillvarydependingonthesizeofthesurgeon’shand, thebodyhabitusofthepatient,andthesizeofthetumor.Ifneedbe,the incisioncanbeenlarged.

p.158

p.159

Theuseofawoundprotectorisadvised.Asmentioned,prior intracorporealdivisionoftheproximalbowelandmesenteryfacilitates retractionoftheproximalcolonandsmallbowel.Tostart,theproximal endofthebowelspecimenisidentifiedandretractedupandoutofthe wound.Allotherbowelinthefieldisthenretractedlaterallyorcephalad afterplacingmoistlaparotomypads.Abladderretractoristhenplaced andtheopenrectalmobilizationcommencedusingstandardopen instrumentsandretractors(St.Mark’s,wideandnarrowDeaver;wehave foundalighted,narrowSt.Mark’sretractorveryusefulforthisportion) (Fig.19-8).Atotalmesentericexcisionisthencarriedoutandtherectum divideddistallywithatransverselinearstapler(Fig.19-9).Ifthecanceris locatedintheproximalrectumorproximalmidrectumandthedecision hasbeenmadenottodividetherectumclosetothelevatormuscles,then therectalmesenterywillalsoneedtobetransectedinadditiontothe rectumitselfatalevel5cmbelowthelowestborderofthetumor.The specimenisremoved.Theproximalcolonisbroughtintothefieldandthe proximalanvilofthecircularend-to-endstaplerplacedintothecolon andsecuredwithapursestring.Thecompletedanastomosisischecked forleaksandadecisionmadeaboutproximaldiversion.Ifanileostomyis plannedpreoperatively,oneoftheright-sidedportscanbeplacedatthe sitechosenfortheileostomy.Theskinandfascialwoundsareenlarged andthebowelexteriorizedtocreatethestoma.Thelowerabdominal incisionisthenclosedintheusualmanner.

FIGURE19-8Retractionandexposureofthe

rectumafterwoundprotectorisplacedintothe incision.

FIGURE19-9A30-mmlinearstaplercoming

acrosstherectumaftertherectumhasbeendissected.

AUTHORS’CURRENTAPPROACH

Exceptforpatientswithverylargetumors,ortheveryobese,thecaseis initiatedbyplacingacameraportperiumbilicallyandtwo5-mmworking portsontherightside.Athoroughexplorationisthenundertaken.If afterlaparoscopicevaluation,thepatient’sanatomyappearstobe amenabletoalaparoscopicapproach,oneortwoadditional5-mmports areplaced,oneinthesuprapubicmidlineandoneintheleftlower quadrant.If,however,afterexplorationtheattendingsurgeonjudgesthat bytheendofthecaseanincisionof8cmorlargerislikelytobeneeded despitetheuseoflaparoscopicmethods,thenahanddevicecanbeplaced inthelowerabdomenandthemobilizationcarriedoutusinghandassistedlaparoscopicmethods.Ifitprovesimpossibletofinishthe mobilizationviaahand-assistmethodlaparoscopically,thenthecaseis completedthroughanextendedincision.Thesafestmethodshould alwaysbeutilized;thelengthoftheincisionissecondary.

INCISIONLENGTH

Skinincisionlengthisoneoftheonlyobjectiveparameterswehavethat canbeusedtoassesstheabdominaltraumaincurredduringanoperation apartfromoperativelength.Itisunderstoodbyallthatthefascial incisionlengthislongerthantheskinincisionlength.Thefinalskin incisionlengthshouldbemeasuredatthetimethedressingisbeing appliedintheoperatingroomandthenrecordedonthewrittenand dictatedoperativereports.Routinemeasurementandreportingoflargest incisionlengthwillfacilitatemeaningfulcomparisonoftheseriesof operationsbothwithinandbetweeninstitutions.

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