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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presenceofanaccessorymiddlecolicarterymaybeseenin10%of patients.

Veins

Withtheexceptionoftheinferiormesentericvein,thecolon’svenous anatomyparallelsthearterialsupplyofthecorrespondingmidgut-or hindgut-derivedsegments.Drainageofthemidgut-derivedrightcolonis achievedbythesuperiormesentericvenoussystem,whichincludesthe ileocolic,rightcolic,andmiddlecolicveins.Thisconfigurationformsthe superiormesentericveinandjoinsthesplenicveintoemptyintothe portalvenoussystemasitsuperiorlyprogresses.

LymphaticDrainage

Lymphaticsupplyparallelsthebloodsupply.Lymphaticsoriginateinthe bowelwallasaplexusinthelaminapropriaanddrainintothe submucosallymphatics.Themostproximallymphnodestothebowel wallaretheepicolicnodes,locatedbetweentheintestinalwallandthe arterialarcades.Drainagecontinuesintotheparacolicnodes,which mirrorthemarginalarteries.Together,theepicolicandparacoliclymph nodesmakeupthemajorityofcoloniclymphnodesandarethemost likelysitesofregionalmetastaticdisease.Intermediatenodesarefound alongthemaincolicvessels,andtheydrainintotheprincipalnodes locatedattheoriginofthesuperiorandinferiormesentericarteries.

SURGERY

Themajorsurgicalproceduresfortherightcolonincludetheright hemicolectomyandextendedrighthemicolectomy(Table2-1,Fig.2-2). Tumorslocatedintheappendix,cecum,orascendingcolonrequirea righthemicolectomy,theanatomicboundariesofwhichspanthedistal terminalileumandcecumtotheproximalhalfofthetransversecolon.An extendedrighthemicolectomylengthenstheresectiontoalsoincludethe transversecolontothesplenicflexure,includingtheleftbranchofthe middlecolicartery.Theprocedureisappropriatefortumorsatthe hepaticflexureandinthetransversecolon.Manysurgeonsavoidisolated transversecolonresectionsbecauseahepaticflexuretosplenicflexure anastomosisisapotentiallyproblematiconebecauseofinconsistent bloodsupply.

TABLE2-1 StandardResectionsforRight-

SidedColonTumors

Tumorlocation Resection

Cecum/appendix Righthemicolectomy Ascendingcolon Righthemicolectomy Hepaticflexure Extendedright

hemicolectomy

Transversecolon Extendedright

hemicolectomy

FIGURE2-2Standardresectionsforright-sided

colontumors.A.Righthemicolectomywithileocolic anastomosisforatumorinthececum.B.Extended righthemicolectomywithileocolicanastomosisfora hepaticflexuremass.

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Positioning

Thepatientispositionedsupinewithpressurepointspaddedandasafety strapacrosstheanteriorthighs.Bilateralsequentialcompressiondevices shouldbeplacedonthelowerextremitiesbeforeinductionofgeneral anesthesia.Theselectiveuseofureteralstentsmaybeadvisablefor patientswithbulkytumors,ahistoryofradiation,orreoperativefields. Ureteralstentshavenotbeenshowntopreventinjuriesbutaidintheir intraoperativeidentification,enablingimmediaterepair.Inpractice, ureteralstentsforrightcolectomyareusedlessfrequentlythanforleft colonresections.Theabdomenisthenclearedofhairwithanelectric clipperandpreppedwithchlorhexidine.Patientsshouldreceivea prophylacticdoseofantibiotics30–60minutesbeforetheincisionis made.Choiceofantibioticsshouldbebasedonthehospital’sinfection nomogrambut,ingeneral,shouldcoverentericgram-negativebacilli, anaerobes,andenterococci.

Technique

Abdominalincisionsusedtoperformarighthemicolectomymayvary, withchoicesincludingamidline,paramedian,transversesupraumbilical, orevenaPfannenstielincision.Wepreferthestandardmidline,withthe surgeonstandingtothepatient’sleft.Theperitonealcavityshouldfirstbe inspectedforgrossmetastases.Thesmallbowelshouldbeevaluatedfrom theligamentofTreitztotheileocecalvalveandtheliverclosely examined.Asolitaryhepaticmetastasismayberesectedatthesametime, butwithappropriatepresurgicalevaluation,thisoccurrenceisgenerally anticipatedratherthanunexpected.Theuterusandovariesshouldbe identifiedandexamined.Themassshouldbeidentifiedandthe surroundingtissueassessedforextensionbeyondthecolonbecausein mostcases,anenblocresectionisplanned.Ifacompleteresectionisnot possible,theprimarytumorisoftenresectedtoavoidthecomplications ofobstructionandhemorrhage.Aself-retainingabdominalretractoris thenplacedandthebedtiltedslightlytowardthesurgeon,allowingfor gravityretractionofthesmallbowel.

Theplannedresectionforarighthemicolectomyincludesthefinal6– 10cmoftheileumandtheproximaltransversecolon.Tumorsofthe cecum,alsoincludingappendicealmasses,shouldinclude10–15cmof theileum.

MobilizationoftheColon

Mobilizationoftherightcoloncanbeginfromthececumtowardthe hepaticflexure.Inthismanner,theperitonealattachmentstothececum areincisedwithelectrocautery.Thecolonisretractedanteriorlyand mediallysothatelectrocauterycanbeusedtofurtherreleasethelateral

peritonealattachmentsuptherightgutter.Thiscanbeaccomplishedby placingtheleftindexfingerbehindtheperitonealattachmentswhile usingelectrocauteryabovethefinger(Fig.2-3).Bluntdissectionwitha spongecanbeusedtodivideanyremainingthinattachmentstothe retroperitoneum.Thismaneuverwillaidinensuringthegonadalvessels, andureterremainsposteriortothespecimen.Awarenessofthecourseof theureterandgonadalvesselsiscrucial.Therighturetercanbe visualizedasitcoursesfromtheposterioraspectoftheduodenumtoward thebifurcationoftheiliacvessels.Mobilizationoftherightcolonis completedwhenthehepaticflexureisfreedsuperiorlyfromtheliverand posteriorlyfromtheduodenum.Theduodenumandheadofthepancreas canbevisualizedwhenthehepaticflexuredissectioniscompleted.The renocolicligamentthatanchorsthehepaticflexuremaybethick, requiringligationwithsuturetiesordivisionwithultrasonicshearsor electrothermalbipolardevice.Medialmobilizationalongthetransverse colonisthenaccomplishedbydivisionofthegastrocolicligamentjust belowthegastroepiploicarcadeofthestomachusingthesameenergy sources.Theomentumattachedtothefuturespecimencanalsobetaken. Threeareasrequirecautionduringcephaladmobilizationoftheright colon:(1)excessivemobilizationdeeptotheretroperitoneumand enteringGerota’sfascia,(2)avulsionofacollateralvenousbranch betweentheinferiorpancreaticoduodenalandmiddlecolicveins,and(3) injurytothesecondandthirdportionsoftheduodenum.

FIGURE2-3Releaseofthelateralperitoneal

attachmentstothececumusingtheleftindexfinger andelectrocautery.

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VesselLigationandDivisionoftheMesentery

Theileocolic,rightcolic,andrightbranchofthemiddlecolicvessels requireligationattheiroriginfromtheSMAtoperformanadequate oncologicresection.Toidentifytheileocolicpedicle,therightcolonis retractedcaudallyawayfromthemidline;theileocolicpediclebecomes visibleasapulsatileridge.Themesentericwindowatthevascularbaseis openedoneithersideofthepediclebeforedividingthepedicle.Once divided,theileocolicpedicleisliftedanteriorlylikeahandle,andblunt dissectionalongtheavascularretroperitonealplaneisachievedbylifting themesenteryandsimultaneouslysweepingtheretroperitoneum posteriorly.Themesenteryandcecumshouldbefreefromposterior attachments.

Theremainderofthemesenterycanbedividedfromtheileocolic

pedicledowntotherightbranchofthemiddlecolicartery.Therightcolic vesselcommonlyemanatesfromtheileocolicarteryand,therefore,may notneedtobeindividuallyligated.Theextentofthemesentericresection variesdependingontheindicationforsurgery.Oncologicindications warrantligationofthemesentericvesselsclosetotheirrootforoptimal lymphnodeharvest,whereasbenignpathologyallowsfordivisioncloser tothemesentericborderofthecolon.Theultimatelandmarkofthe cephaladdissectionistoidentifytheduodenumandremainanteriortoit. Therightbranchofthemiddlecoliccanbesutureligatedatthisjunction, orabipolarcuttingandsealingdevicecanbeused.Careshouldbetaken topreservethemainmiddlecolicarterywhenperformingaright hemicolectomy.Fortumorslocatedinthehepaticflexureortransverse coloninwhichanextendedrighthemicolectomyiswarranted,themiddle colicvesselshouldbeligatedbeforethebifurcationattheinferiorborder ofthepancreas.Itisprobablybesttoavoiddirectmanipulationofthe tumorduringthedissection,butthistechniqueismoreasurgeon preferencethansupportedbydata.

ResectionandAnastomosis

Thetransversecoloncanbedividedwithalinearcuttingstapler,typically withablueorwhitecartridge.Similarly,theappropriatesiteoftheileum isdividedwiththesamestapler.Resectionmarginsshouldbegreater than5cmwhenperformingresectionforcancer.Intestinalcontinuitycan berestoredbythehand-sewn(one-ortwo-layer)orstapledtechnique withequivalentfunctionalresults;however,thestapledtechniquedoes savesometime.

Thestapledanastomosisbeginsbyaligningthetwoendsofthebowel alongtheendoftheantimesentericborders.Thegeneralspillageofbowel contentisminimalduringthisprocedure,anditisthereforeunnecessary toplacebowelclampsproximalanddistaltotheanastomosis.The antimesentericcornerofthestaplelineisexcisedonbothendsofthe bowel,andtheforksofthelinearcuttingstaplerareinsertedintothe ileumandcolon.Afterfiringwithabluecartridge,theinternalstapleline ischeckedforbleeding,andtheresultantileocolostomyedgesarealigned usingAllisclampsoranchoredwithstaysutures.Theopeningofthe ileocolostomycanbeclosedwithanotherapplicationofthelinearcutting stapler.Itisalsoacceptabletoclosethecommonopeningusing interrupted3-0silksuturesorrunning3-0vicrylsuturesfollowedby Lembertsutures.Themeritsofclosingthemesentericdefectare unknown,butarunningsutureshouldsufficeifclosureisdesired(Fig.2-

4).

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

FIGURE2-4A.Vesselligation,divisionofthe

mesentery,andresectionofanascendingcolonmass. B.Side-to-sidefunctionalend-to-endstapledileocolic anastomosis.

Forextendedrighthemicolectomy,weprefertobringtheileum directlytotheproximaldescendingcolonandnottothesplenicflexureto avoidtheriskofinvolvingthewatershedarea.

Thefascialincisionisclosedwithheavyabsorbablesuturessuchasa running1-0polydioxanonesuture.

POSTOPERATIVEMANAGEMENT

Mostpatientsundergoingelectiverighthemicolectomywillbemanaged postoperativelyonanenhancedrecoveryprotocol.Nasogastrictubesare notusedroutinely.Patientsarestartedonaclearliquiddietwithin24 hoursofsurgery,duringwhichtimetheymaybegivenperioperative antibioticprophylaxis.Urinarycathetersareremovedassoonaspossible —manytimesintheoperatingroom—toencourageearlyambulation, whichisakeycomponentinpreventingvenousthrombosisand postoperativepneumonia.Intravenousfluidsshouldbegivensparinglyto targetaurineoutputof0.5–1.0ml/kg/hr.Multimodalpainmanagement, includingtransversusabdominisplane,blockspreoperatively,andthe earlyinstitutionoforalanalgesicspostoperatively,suchasnonsteroidal anti-inflammatories,isencouraged.Theaimofenhancedrecovery pathwaysistoshortentheintervaltoresumptionofnormalactivities.

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