Operative Checklist

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170

Fig. 40.1 Ureter anatomy

External iliac tery and vein

S. R. Steele and A . T. Schlussel

Gonadal vessel

Ureter

Common iliac artery and vein

2. The ureter courses over the pelvic brim and then crosses the bifurcation of the common

4. Emerging experience in ICG uorescence can help identify the ureter, where available.

iliac artery on the left and the external iliac on the right.

3. The gonadal vessels will cross the ureter ante-

Operative Techniques

riorly as it enters the pelvis.

4. The proximal ureter on the right is located posterior to the duodenum.

5. The proximal ureter on the left is lateral to the inferior mesenteric vessels.

6. The distal ureters are located medial to the gonadal vessels

7. Observe for Kelly’s sign (vermiculation of the ureter when it is pressed) as this will assist in differentiating the ureter from other structures.

1. Operative exposure and medialization of the left colon (a) Lateral-to-medial approach (Fig.40.2)

(i) Requires tension and counter

tension.

(ii) Can utilize the hook monopolar cau-

tery to allow for controlled and focused cauterization along the white line of Toldt and gentle tissue pushing with the heel of the hook. Dissecting the lmy attachments in the avascular plane will medialize

Operative Checklist

the colon (Fig.40.3).

(iii) Do not work in a hole. Continue the

1. Ensure the patient is in proper position on the table, and use table positioning/gravity to move the bowel out of the way.

2. Ureter stents can be used as indicated and should be planned ahead for placement.

3. Methylene blue given intravenously may help identify the ureter or injury site.

dissection proximally and then back down distally to widen the dissection eld and identify the ureter.

(iv) Controlled and focused cauterization

using the hook device in this region can limit thermal spread. Alternatively and to avoid using monopolar energy

colon mobiliz

40 Cannot Find theUreter

Fig. 40.2 Left-side ureter anatomy from a lateral approach

171

Descending

to the right

Left common

iliac artery

Ureter

Hypogastr nerves

Glonadal vessel

Fig. 40.3 Takedown of the lateral attachments of the left side of the colon to identify the ureter. (With permission. Leroy J, Henri M, Rubino F, Marescaux J.Sigmoidectomy.

In: Milsom JW, Böhm B, Nakajima K, editors. Laparoscopic colorectal surgery. New York: Springer;

2006. p.145–69)

172

Wrong plane

The correct plane

Fig. 40.4 Retroperitoneal window posterior to the inferior mesenteric vascular pedicle from a medial approach (arrows indicate the direction of the instrumentation). (With permission. Leroy J, Henri M, Rubino F, Marescaux J.Sigmoidectomy. In: Milsom JW, Böhm B, Nakajima K, editors.

Laparoscopic colorectal surgery. NewYork:

Springer; 2006. p.145–69)

S. R. Steele and A . T. Schlussel

in the abdomen, a bipolar energy device is commonly used for this dissection.

(b) Medial-to-lateral dissection.

(i) Elevate the inferior mesenteric vas-

cular pedicle to place the mesentery under tension.

(ii) Score the mesentery distal to the

inferior mesentery vascular pedicle (Fig.40.4).

(iii) A laparoscopic blunt grasper is

inserted into the plane between the mesentery and the retroperitoneum. The mesentery is then elevated toward the anterior abdominal wall.

(iv) This plane should be bluntly dis-

sected laterally toward the abdominal wall; the ureter will be identied and should be bluntly dissected posteriorly off of the mesentery.

(v) Ensure the dissection is not too deep

and the ureter is not adherent to the mesentery on the “ceiling” of the dissection (Figs.40.5 and 40.6).

(vi) The inferior mesenteric artery and

vein should be circumferentially iso-

Fig. 40.5 Wrong plane of dissection will lead behind the ureter and expose it to increased risk of injury

Fig. 40.6 The correct plane of dissection to keep the ureter in the retroperitoneum

lated to ensure it is completely mobilized off of the left ureter as to not inadvertently transect the ureter or cause thermal injury.

40 Cannot Find theUreter

173

Technical Pearls (Tips andTricks)

1. Consider a medial-to-lateral approach when

the colon is adherent to the abdominal wall due to a chronic or active inammatory process. This technique will allow the surgeon to develop a plane under the area of concern and identify the ureter prior to dissection through brotic tissue.

2. If the ureter is not identied in the retromes-

enteric space caudal to the inferior mesenteric artery (IMA), consider making a window in the mesentery cephalad to the main sigmoidal artery, and look for the ureter under the mesentery between the main sigmoidal and the left colic artery. The mesentery here is usually a thin, avascular bare area and can be opened up without using energy. When the mesosigmoid is post- inammatory, the mesentery above this level is healthier and easier to dissect. Once the ureter is found at the level above the IMA, it can be traced back to the retromesenteric dissection that started below the IMA.

3. Utilize the suction irrigator as a blunt dissec-

tor to further develop the plane between the retroperitoneum and mesentery. The blunt tip will help prevent inadvertent damage to the ureter.

4. Be mindful of misidentifying the psoas ten-

don (appropriately called “the fool’s ureter”).

5. Recognize the anatomy. If you identify the

gonadals at the level of the IMA pedicle, then you know the ureter is medial. If you observe the red bers of the psoas muscle, you are too deep in the retroperitoneum and need to adjust your dissection.

6. Be careful of extra-thin patients with mini-

mal mesenteric fat. In these cases, the embryonic fusion planes that are dissected during colectomy may not be as easy to follow as in patients with somewhat greater adiposity, and the ureter may be closer to your dissection than you would otherwise appreciate.

7. Change to a hand-assisted approach or con-

vert to laparotomy to improve exposure.

8. Intraoperative ureteral stent placement.

9. Call for assistance during the operation.

10. In hostile cases, though not ideal, it may be reasonable to dissect the mesosigmoid mid- mesentery rather than its base at the level of the retroperitoneum. In this approach, the ureter is usually well below the level of dissection, and dissecting the base of the mesentery is obviated.

11. Prophylactic ureteral stent placement: (a) Ureteral injury has a reported inci-

dence of 1.1/1000 cases following laparoscopic colorectal resections; this risk is greater in pelvic operations and in rectal cancer or diverticular case. This is a rare but dreaded complication, and the repair of an iatrogenic ureteral injury may be complex. While there are benets to stenting, routine use of stents is not recommended. Stents may assist in the recognition of a ureteral injury, yet they have not been demonstrated to result in prevention of this complication.

(b) The placement of ureteral stents is per-

formed using cystoscopy, and these procedures have inherent complications. There is a risk of iatrogenic ureteral perforation, transient hematuria, urinary tract infections, and possible hydronephrosis due to ureteral edema from trauma. In addition, stent placement incurs an additional cost to the patient as well as time under general anesthesia.

during laparoscopic procedures as these catheters have demonstrated an 83% success rate in ureteral identication with transillumination through the retroperitoneum alone with no required dissection. These devices may be useful given the loss of tactile feedback in laparoscopic operations.

(d) Ureteral stents should be placed

selectively.

174

S. R. Steele and A . T. Schlussel

Special Postoperative Care

1. If stents are placed, they are typically removed the following day.

2. If a Jackson-Pratt drain was placed, consider sending the drain uid for creatinine if there is suspected ureter injury.

Clinical Scenario

A 38-year-old woman is undergoing total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis refractory to medical management. The colorectal specimen was removed and J pouch was created. When attempting to perform double-stapled IPAA, the cut edge of the small bowel mesentery was noticed to be twisted. While trying to correctly orient the pouch mesentery, the pouch along with the distal small bowel starts to become ischemic (Fig.41.1).

Key Points

1. As soon as the terminal ileum and ileal mesentery are transected, place a series of markings along the anterior surface near the cut edge of the small bowel mesentery by using either a marker or sutures. The markings can help reorient the mesentery without causing further torsion.

2. Always conrm small bowel orientation before creating the IPAA.

3. To conrm orientation, follow the cut edge of the terminal ileal mesentery from the superior

S. W. Lee (*) Department of Surgery– Colon and Rectal Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA

mesenteric artery (SMA) at the level of the duodenum to the ileocolic pedicle to the stapled end of the ileum. It helps to have the patient tilted right side up for this maneuver. If this cut edge is observed without any small bowel crossing over it, then the orientation of the bowel is correct. If the orientation of the small bowel mesentery cannot be veried, the small bowel has to be untwisted starting at the ligament of Treitz. This is the only way to ascertain the correct orientation.

Operative Assessment

1. Always conrm small bowel orientation before creating the pouch-anal anastomosis. (a) The cut edge of the small bowel mesen-

tery has to be straight along the right side of the pelvis. Under no circumstances should the anastomosis performed without ascertaining the correct orientation.

2. What type of exposure is needed to reorient the small bowel? (a) For laparoscopic cases, re-establish pneu-

moperitoneum, and run the small bowel starting at the ligament of Treitz.

(b) For a low midline incision, a hand or sin-

gle access device could be placed through the incision, and the small bowel could be run laparoscopically. Additional laparoscopic ports can be placed, as needed.

https://doi.org/10.1007/978-3-030-11181-6_41

175

176

Fig. 41.1 Pouch ischemia from torsion (via endoscopy)

order to accomplish what is needed.

Operative Checklist

S. W. Lee

1. Lighted retractors or headlights for improved visualization in the pelvis are necessary.

2. Hand access device or single incision laparoscopic access device.

3. Laparoscopic setup.

4. Open laparotomy tray with pelvic retractors (lighted retractors, if available) and long pelvic instrument tray if performing open; if performing laparoscopically, have these trays available in case of conversion.