Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_917_Библиотеки_им_академика_М_И_Перельмана.pdf
4 Master Program Colorectal Pathway: Laparoscopic Splenic Flexure Release (Tips…
55
traction do not occur. The most common mechanism whereby the spleen is injured
during splenic mobilization involves excessive pulling on the descending or transverse colon when the greater omentum is attached to the splenic capsule. The result
is avulsion of capsule and subsequent bleeding. When this occurs, generally the best
approach is to pack the area and wait for hemostasis rather than resort to more
aggressive strategies. That being said, clearly the best way to treat a splenic injury
is to avoid it in the rst place [19].
Other areas of risk involve injury to the pancreas, particularly in the area of the
splenic hilum and the pancreatic tail. While mobilizing the splenic exure, one must
be certain to be anterior to the tail of the pancreas and away from the splenic hilum.
It is not difcult when fully mobilizing the mesentery of the distal transverse colon
and the proximal descending colon to delve too deep into the retroperitoneum and
inadvertently dissect posterior to the pancreatic tail. This, in turn, takes the surgeon
into the splenic hilum [19].
Lastly, a potential complication, which is unique to the inframesocolic approach,
includes carrying the dissection at the IMV to posterior and coming underneath the
inferior border of the pancreas. The real problem here is that if this is continued, one
can enter the splenic vein, which could result in major bleeding. By recognizing this
possibility, the surgeon should be able to avoid this issue entirely.
The inframesocolic approach is more difcult to adopt from a technical standpoint. It is the preferred approach during robotic dissection, when changes in table
positioning are much more restricted. It is our recommendation that surgeons
become facile with all three approaches. But while learning each technique, the
surgeon should be aware of the limitations and risks of each approach and have a
low threshold to convert to another approach or to an open approach.
Another area of difculty that can be encountered is when the greater omentum
is so prominent that it either entirely obscures the exure and/or is densely fused
with the mesentery (Fig.4.10). This needs to be carefully released to obtain adequate length that can be carried out for a safe colorectal anastomosis.
Fig. 4.10 Greater
omentum covering the
splenic exure
56
A. Caycedo-Marulanda and J. H. Marks
Outcomes
Literature comparing different approaches for SFR is scarce. Perhaps the most
signicant publication is from Benseler and colleagues. This retrospective study
compared the use of the three different approaches on 303 patients that underwent
laparoscopic surgery for rectal cancer at a single center over a 12-year period. The
authors identied a signicantly higher rate of intraoperative complications
(p=0.038), including dissecting in the wrong plane, organ injury, and bleeding, for
those patients that had SFR using the lateral approach. Postoperative morbidity
was also higher on the same group, secondary to increased wound infection
(p=0.001) [20]. We cannot provide any rational explanation for these results nor
would we allow this to factor into our decision-making for how to best approach
this operative step.
Conclusions
Splenic exure release is an integral part of the procedure for a multitude of colon
surgeries. The general and colorectal surgeon must be entirely comfortable with the
different approaches in order to carry this out in a routine fashion. In most cases, the
splenic exure can be released by using one of the above-described techniques.
However, on occasion, a combination of approaches is required. We recommend
that each surgeon develop their preferred technique which they use routinely but
also become facile with the other approaches as these will be helpful at times, and
it is best to be knowledgeable before trying a technique in a difcult situation.
We advocate the routine release of the splenic exure for a safe anastomosis. It
is the authors’ opinion that consideration to releasing the splenic exure be given
early on during the procedure in a proactive fashion, rather than reserving it for
when it is necessary in order to achieve adequate length for the anastomosis.
Delaying the decision to complete splenic exure takedown until the end of an otherwise difcult operation can complicate the procedure even further. Routine release
using a standardized approach will result in better outcome for patients with colorectal disease.
References
1. Goulder F. Bowel anastomoses: the theory, the practice and the evidence base. WJGS.
2012;4(9):208–6.
2. Chand M, Miskovic D, Parvaiz AC.Is splenic exure mobilization necessary in laparoscopic
anterior resection? Dis Colon Rectum. 2012;55(11):1195–7.
3. Brennan DJ, Moynagh M, Brannigan AE, Gleeson F, Rowland M, OʼConnell RP. Routine
mobilization of the splenic exure is not necessary during anterior resection for rectal cancer.
Dis Colon Rectum. 2007;50(3):302–7.
4. Tortorelli A, Aleri S, Sanchez A, Rosa F, Papa V, Di Miceli D, et al. Anastomotic leakage
after anterior resection for rectal cancer with mesorectal excision: incidence, risk factors, and
management. Am J Surg. 2015;81(1):41–7.
4 Master Program Colorectal Pathway: Laparoscopic Splenic Flexure Release (Tips…
5. Toh JWT, Matthews R, Kim SH.Arc of Riolan-preserving splenic exure takedown during
anterior resection. Dis Colon Rectum. 2018;61(3):411–4.
6. Jurowich CF, Germer CT.Elective surgery for sigmoid diverticulitis– indications, techniques,
and results. Visc Med. 2015;31(2):112–6.
7. Rullier E, Denost Q, Vendrely V, Rullier A, Laurent C.Low rectal cancer. Dis Colon Rectum.
2013;56(5):560–7.
8. Marks JH, Myers EA, Zeger EL, Denittis AS, Gummadi M, Marks GJ. Long-term out-
comes by a transanal approach to total mesorectal excision for rectal cancer. Surg Endosc.
2017;31(12):5248–57.
9. Marks JH, Salem JF.From TATA to NOTES: how taTME ts into the evolutionary surgical
tree. Tech Coloproctol. 2016;20(8):513–5.
10. Marks JH, Montenegro GA, Salem JF, Shields MV, Marks GJ.Transanal TATA/TME: a case-
matched study of taTME versus laparoscopic TME surgery for rectal cancer. Tech Coloproctol.
2016;20(7):467–73.
11. Caycedo-Marulanda A, Ma G, Jiang HY. Transanal total mesorectal excision (taTME)
in a single- surgeon setting: renements of the technique during the learning phase. Tech
Coloproctol. 2018;22(6):433–43.
12. Fukuoka A, Sasaki T, Tsukikawa S, Miyajima N, Ostubo T. Evaluating distribution of
the left branch of the middle colic artery and the left colic artery by CT angiography
and colonography to classify blood supply to the splenic exure. Asian J Endosc Surg.
2016;10(2):148–53.
13. Sakorafas GH, Zouros E, Peros G.Applied vascular anatomy of the colon and rectum: clinical
implications for the surgical oncologist. Surg Oncol. 2006;15(4):243–55.
14. Kawamoto A, Inoue Y, Okigami M, Yasuda H, Okugawa Y, Hiro J, etal. Preoperative assess-
ment of vascular anatomy by multidetector computed tomography before laparoscopic colectomy for transverse colon cancer: report of a case. Int Surg. 2015;100(2):208–12.
15. McDermott S, Deipolyi A, Walker T, Ganguli S, Wicky S, Oklu R.The role of preoperative
angiogram in colon interposition surgery. Diagn Interv Radiol. 2012;18(3):314–8.
16. Takeru M, Takeshi I, Kenro H, Daisuke T, Yutaka S, Yasuo S, et al. A three-step method for
laparoscopic mobilization of the splenic exure. Ann Surg Oncol. 2015;22(s335):1–1.
17. Garcia-Granero A, Sánchez-Guillén L, Carreño O, Sancho Muriel J, Alvarez Sarrado
E, Fletcher Sanfeliu D, et al. Importance of the Moskowitz artery in the laparoscopic
medial approach to splenic exure mobilization: a cadaveric study. Tech Coloproctol.
2017;21(7):567–72.
18. Blanco-Colino R, Espin-Basany E.Intraoperative use of ICG uorescence imaging to reduce
the risk of anastomotic leakage in colorectal surgery: a systematic review and meta-analysis.
Tech Coloproctol. 2017;22(1):15–23.
19. Merchea A, Dozois EJ, Wang JK, Larson DW.Anatomic mechanisms for splenic injury during
colorectal surgery. Clin Anat. 2011;25(2):212–7.
20. Benseler V, Hornung M, Iesalnieks I, Breitenbuch von P, Glockzin G, Schlitt HJ, etal. Different
approaches for complete mobilization of the splenic exure during laparoscopic rectal cancer
resection. Int J Color Dis. 2012;27(11):1521–9.
57
Bibliography
Atallah S, Albert M, Monson JRT.Critical concepts and important anatomic landmarks encoun-
tered during transanal total mesorectal excision (taTME): toward the mastery of a new opera-
tion for rectal cancer surgery. Tech Coloproctol. 2016;20(7):483–94.
Deijen CL, Tsai A, Koedam TWA, Veltcamp Helbach M, Sietses C, Lacy AM, etal. Clinical out-
comes and case volume effect of transanal total mesorectal excision for rectal cancer: a system-
atic review. Tech Coloproctol. 2016;20(12):811–24.
58
Koedam TWA, van Ramshorst GH, Deijen CL, Elfrink AKE, Meijerink WJHJ, Bonjer HJ, etal.
Transanal total mesorectal excision (TaTME) for rectal cancer: effects on patient-reported
quality of life and functional outcome. Tech Coloproctol. 2017;21(1):25–33.
Lee L, De Lacy B, Gomez Ruiz M, Liberman AS, Albert MR, Monson JRT, etal. A multicenter
matched comparison of transanal and robotic total mesorectal excision for mid and low-rectal
adenocarcinoma. Ann Surg. 2018; https://doi.org/10.1097/SLA.0000000000002862. [Epub
ahead of print]
Pasam RT, Trejo DE, Murray A, Lee-Kong S, Feingold D, Kiran RP. PTU-223 Conversion
to open surgery from laparoscopy: to ‘try and fail’ or ‘not try at all’? Gut. 2015;64(Suppl
1):A161.1–A161.
Sylla P, Rattner DW, Delgado S, Lacy AM.NOTES transanal rectal cancer resection using trans-
anal endoscopic microsurgery and laparoscopic assistance. Surg Endosc. 2010;24(5):1205–10.
Wong-Chong N, Caycedo-Marulanda A. Transanal total mesorectal excision with retroileal
colorectal anastomosis: combining old and new techniques. Color Dis. 2018;20(7):642–3.
A. Caycedo-Marulanda and J. H. Marks
Masters Program Colorectal Pathway:
Laparoscopic Left Colon Resection
forComplex Inflammatory Bowel
Disease
AnuradhaR.Bhama andConorP.Delaney
Introduction andRationale
Crohn’s disease can be a challenging disease process for surgeons to treat. Patients
often present with obstruction, an abscess, or stula, frequently with septic complications of their disease [1]. When possible, these are initially treated nonoperatively
with image-guided drainage procedures and antibiotics in order to stabilize the
patient and clear the sepsis. This then allows for time to hold immunosuppressive
medications and optimize nutritional parameters to allow for an elective resection.
Less frequently, nonoperative preparation and preoperative optimization may not be
possible, and the patient will require a more emergent operative procedure. This is
usually related to intestinal obstruction or perforation of a previously contained
abscess.
This chapter will focus on the specic considerations regarding stula and
abscess necessary in patients with CD.Fistulas can occur between the small bowel
and colon with any adjacent structure including the bladder, the vagina, other gastrointestinal sites, or, more rarely, the skin (Figs. 5.1a, b and 5.2). In situations
involving a stula between the left colon and the small intestine, it is necessary to
determine the segment of the diseased intestine that is the origin of the stula, as the
diseased segment is the portion of the bowel that should be resected. If the small
intestine is diseased, then frequently only the small intestine requires resection, provided the sigmoid colon is free of disease and the stulous opening is small and
amenable to primary repair, as described below (Figs.5.3, 5.4, 5.5, and 5.6a–c).
Regardless, a laparoscopic approach can usually be utilized safely to perform a
5
A. R. Bhama
Department of Surgery, Division of Colorectal Surgery, Rush University Medical Center,
Chicago, IL, USA
C. P. Delaney (
Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
e-mail: delanec@ccf.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_5
*)
59
60
A. R. Bhama and C. P. Delaney
ab
Fig. 5.1 (a, b) Examples of colocutaneous stula in patients with inammatory bowel disease
Fig. 5.2 CT scan of
patient with colovesical
stula. Note air in the
bladder
Fig. 5.3 Fistula between
healthy small bowel and
diseased segment of colon
ab
5 Masters Program Colorectal Pathway: Laparoscopic Left Colon Resection…
Fig. 5.4 Luminal view of
enteric stula in setting of
active inammatory
Crohn’s disease
61
Fig. 5.5 (a, b) Laparoscopic views of stulizing Crohn’s disease
left-sided colon resection in most situations [2, 3]. Some patients with chronic complex diverticular disease may present with stulas and abscesses that require similar
management [4].
Indications andContraindications
A laparoscopic approach is indicated in almost all patients. Inability to tolerate
pneumoperitoneum and steep Trendelenburg position because of medical comorbidity or massive obesity are rare in this population. The primary contraindication
is a prior history of multiple surgeries with obliterative adhesions. Anatomical considerations that may complicate laparoscopy include large hernias, dense adhesions
from prior surgery, or enterocutaneous stulas that require resection of the abdominal wall. Patients who are hemodynamically unstable generally cannot tolerate laparoscopy, as the positioning is typically more exaggerated, the operative times may
be longer, and the pneumoperitoneum causes a decrease in cardiac preload. Patients
62
A. R. Bhama and C. P. Delaney
a
b
c
Fig. 5.6 (a–c) Crohn’s ileosigmoid stula. After conrming that the sigmoid is not primarily
involved with active inammatory Crohn’s disease, the endoscopic stapler is used to transect
across the stula followed by resection of the disease terminal ileum and preservation of the sigmoid colon. (All: Courtesy of Daniel Popowich, MD)
must be able to tolerate the physiologic changes associated with laparoscopy in
order to undergo this approach. This includes patients with severe pulmonary disease as well. In the vast majority of cases, however, laparoscopy can be attempted
and if the patient does not tolerate a trial at positioning, or adhesions are too severe,
conversion to an open procedure may be indicated. Other contraindications include
lack of surgeon experience or lack of appropriate equipment.
There are some situations in which a large stula is present that may require
assistance from other subspecialty surgeons, such as a low bladder stula or rare
ureteric stula. In such cases, it is necessary to coordinate preoperative planning
with the assisting surgeons. Especially for the sigmoid colon, if it is possible to do
the majority of the procedure laparoscopically and a portion of the procedure
through a small Pfannenstiel incision, many of the benets of laparoscopy may be
provided to the patient by minimizing the size of the denitive incision. Careful
preoperative planning in a team-based approach and clear communication with the
operating room staff is necessary in these situations.
Segmental colon resection in the setting of CD remains somewhat controversial
[5–10]. Although a full discussion of this topic is outside the connes of this chapter, a total colectomy is usually indicated for CD-related dysplasia or pancolitis,
considering ileorectal anastomosis for those with rectal sparing and good continence [11]. Segmental colectomy, with or without a temporary diverting ileostomy,
can be considered for those with short segment disease in whom the rectum, anus,
and proximal colon appear salvageable.
5 Masters Program Colorectal Pathway: Laparoscopic Left Colon Resection…
63
Principles andQuality Benchmarks
The rst principle of treating IBD associated with stula and abscess is to ensure
that the source of sepsis has been controlled, and the patient has been stabilized
hemodynamically. These patients rarely present acutely. When possible, treatment
with antibiotics and utilization of radiologic drainage as a bridge to surgery is advocated to clear sepsis and allow the patient to recover from systemic sepsis and allow
for preoperative optimization. Nutritional optimization may need to be considered
as well, and we primarily base assessment on weight loss, using prealbumin in those
otherwise suspected to be malnourished. Patients are frequently evaluated by dieticians on the multidisciplinary team. If patients can tolerate enteral diets, they are
educated on dietary choices and supplements that optimize their protein and calorie
needs. If patients cannot tolerate oral intake, they are evaluated and followed carefully by members of a multidisciplinary nutritional support team to manage enteral
or total parenteral nutrition. Ideally patients will demonstrate weight gain or stabilization of weight loss and normal serum markers of nutrition including albumin and
prealbumin. There are instances where the disease severity is so great that surgical
resection is necessary prior to improvement in nutritional status. For that reason, we
generally are more concerned about getting 7–10days of adequate nutrition, rather
than waiting for laboratory values to normalize.
When proceeding with the operation, it is important to remember to evaluate the
entire bowel for active disease, even if the indication for operation is colonic disease. The extent of disease is not always accurately identied preoperatively.
Typically, preoperative evaluation includes colonoscopy and one or more means of
small bowel assessment, such as CT or MR enterography. If no recent endoscopic
assessment is available, preoperative colonoscopy should be performed to assess for
the extent of colitis or proctitis and for any underlying malignancy, as it allows more
accurate surgical planning and a better discussion with the patient. If patients are
very symptomatic and/or preoperative colonoscopy cannot be completed, this can
be performed intraoperatively. Even so, it is important to visually inspect the entire
intestine for active disease and in our practice, we generally exteriorize and “run” or
sequentially palpate the entire small intestine. At a minimum this can be done laparoscopically with a hand-over-hand technique of running the small bowel, with care
taken to avoid injuring the bowel, although generally the small bowel can be exteriorized and palpated when a specimen is being removed.
When performing a resection for CD, it is important to preserve as much bowel
as possible, though this is less directly relevant for colonic disease. Surgical margins
should be grossly negative for active disease for 2cm, as dened by the normal
appearing bowel with absence of mesenteric inammation. It is not necessary to
have frozen section assessment of surgical margins. An anastomosis should not be
created if there is active purulence in proximity to the anastomosis, such as a large
pelvic abscess with resultant thickening and secondary inammation of the distal
rectum. A proximal diverting loop ileostomy should be considered if there are concerns about the quality of the remaining intestine for anastomosis, patient nutrition,
or immunosuppression.
64
A. R. Bhama and C. P. Delaney
Preoperative Planning, Patient Workup, andOptimization
Except in the relatively rare situations of bleeding or acute perforation, preoperative
optimization is essential for patients with IBD.Abscesses that can be drained are
dealt with using image-guided techniques, including retroperitoneal abscesses,
unless small. Smaller abscesses and some intramesenteric abscesses may be best left
undrained and treated with antibiotics. Holding any immunosuppressive agents, such
as biologic agents, is also recommended. Steroids are tapered if possible but can
rarely be stopped in patients with these types of symptoms. There are no set guidelines for the duration of time of biologic agents to be held, though we generally wait
6–8weeks prior to proceeding with an operation. The nutritional status of the patient
should be assessed to determine the safety of proceeding with an operation and the
likelihood of successful healing postoperatively. Evaluation of serum levels of albumin, prealbumin, and transferrin is useful. In patients who are malnourished, preoperative supplemental nutrition may be necessary. This can be done orally with
high-protein supplements but may require enteral or parenteral nutrition, particularly
in those who are chronically partially obstructed with their disease, or who have
high-output or symptomatic stulas which preclude intestinal feeding. Postoperative
supplemental enteral or parenteral nutrition is generally unnecessary. Many patients
are also routinely seen by our enterostomal team and given a temporary mark for a
stoma. In cases requiring intraoperative decision-making, both left and right-sided
marks are placed, taking care to be away from old scars and skinfolds.
Once surgery is scheduled, standard enhanced recovery protocols are applied
[12]. Patients should be encouraged to stop smoking and limit alcohol intake, as
these have been shown to have improved postoperative outcomes when done for
greater than 4weeks prior to operation. Patient education and setting clear postoperative expectations are paramount in preparation for surgery. This discussion
includes expected goals regarding pain control, postoperative diet advancement,
patient participation in recovery, and discharge criteria and planning.
In preparation for the operation, all patients who are not obstructed should
undergo mechanical bowel preparation. Bowel preparation is commonly utilized as
it provides several benets in the laparoscopic setting. The decompressed bowel
after mechanical bowel preparation allows for easier manipulation and specimen
extraction. Particularly important is that the addition of oral neomycin and metronidazole with the mechanical bowel appears to be associated with a signicant
decrease in rate of postoperative surgical site infection.
Preoperative diet remains controversial, as patients traditionally fast from midnight the night prior to surgery. In our practice, consistent with anesthesia guidelines,
patients are allowed to continue to consume clear liquids up until 2hours prior to
surgery. Some enhanced recovery protocols also provide patients with carbohydrate
loading uids to drink the morning of surgery. Patients with chronic obstructive disease who will not tolerate a bowel preparation are kept on a liquid diet for 48hours
and given two bottles of magnesium citrate, a milder preparation that is usually tolerated reasonably well. For more details on preoperative preparations, please refer to
the chapters on enhanced recovery protocols in colorectal surgery (Chaps. 7 and 8).