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Cross-Reference
Large bowel obstruction (LBO, 560.9) (Ch. 1), (Ch. 4)
Pain, abdominal (Ch. 1)
Polyps (211.3) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Colonic volvulus (560.2) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
RIGHT HEMICOLECTOMY (OPEN)
Principle
Oncologic resection of the right colon with ligation of the vascular pedicle and corresponding lymphadenectomy.
Setting
Inpatient, OR procedure.
Alternatives
Laparoscopic approach.
Extended right hemicolectomy (inclusion of distal transverse colon and splenic flexure).
Long Hartmann stump and end-ileostomy.
Indication
Right colon cancer, right-sided diverticulitis, cecal volvulus.
Preparatory Considerations
Full colonic evaluation for all elective cases, tattooing of small lesions is advisable.
Bowel cleansing (traditional) vs no bowel cleansing (evolving concept).
Ureteral stents for redo cases or extensive disruption of anatomy (eg, inflammation).
Marking of possible stoma sites.
Prophylactic antibiotics.
Surgical Steps
1. Patient position: supine or modified lithotomy position (surgeon's preference).
2. Laparotomy: periumbilical or epigastric midline, right transverse (from umbilicus), right subcostal incision.
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3. Placement of abdominal wall retractor or wound protector vs dynamic abdominal wall retraction with hand-held
retractor to expose right side of colon.
4. Abdominal exploration: local resectability, secondary pathology (liver/gallbladder, colon, female organs, small
bowel), other abnormalities.
5. Defining resection margins:
a. Cecum/ascending colon: right branch of mid colic artery.
b. Hepatic flexure: extended right hemicolectomy.
6. Mobilization of right colon from its retroperitoneal attachments, starting at ileocecal junction, moving along colonic
gutter to hepatic flexure. Landmarks: ureter, duodenum (avoid injury).
7. Development of lesser sac: oncologic resection requires at least half omentectomy—division of gastrocolic ligament
in several steps (alternative in proven benign disease: omental sparing with dissection of omentum off he transverse
colon).
8. Identification of ileocolic vascular stalk: becomes evident through slight traction of cecum to RLQ.
9. Oncologic devascularization of right colon with clamping and transecting major vascular stalks (ligature, suture
ligatures). Before dividing tissue, remote location of ureters to be verified.
10. Stepwise continuation toward right branch of mid colic artery.
11. Transection and ileotransverse anastomosis may either be performed in individual steps or combined through one
side-to-side linear stapler and one transverse closure/resection of specimen.
12. Macroscopic assessment of specimen: verification of pathology and resection margins.
13. Oversewing of staple lines with interrupted sutures.
14. Closure of mesenteric window.
15. Drains not indicated (unless specific indication). No need for NGT.
16. Closure of incision.
Anatomic Structures at Risk
Right ureter, duodenum, superior mesenteric vein, mid colic artery.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Complications
Bleeding (surgeon-dependent): traction on superior mesenteric vein, inadequate ligature of vascular stalk, mid colic artery.
Anastomotic leak (2%): most commonly due to technical error, tension, inadequate blood supply.
Ureteral injury (0.1–0.2%).
Cross-Reference
Large bowel obstruction (LBO, 560.9) (Ch. 1), (Ch. 4)
Pain, abdominal (Ch. 1)
Polyps (211.3) (Ch. 4)
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Colorectal cancer—colon cancer (153.X) (Ch. 4)
Colonic volvulus (560.2) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.IX) (Ch. 4)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
(SUB-)TOTAL COLECTOMY, ILEORECTAL ANASTOMOSIS (OPEN)
Principle
Resection of the whole (or most of the) colon while preserving the rectum (and a portion of the sigmoid colon) and avoiding
pelvic dissection:
Cancer/polyps: oncologic resection + reduction of mucosa at risk, facilitation of surveillance (flexible sigmoidoscopy
in the office), acceptable bowel function.
Slow-transit constipation: either total abdominal colectomy with IRA or subtotal colectomy with anastomosis to the
mid sigmoid: too little
constipation; too much 15% of unacceptable diarrhea.
IBD: total abdominal colectomy with IRA in highly selected cases depending on circumstances (30–60% requiring
later completion proctectomy).
Setting
Inpatient, OR procedure.
Alternatives
Laparoscopic approach.
Total abdominal colectomy with end-ileostomy.
Proctocolectomy with IPAA or end-ileostomy.
Indication
HNPCC with colorectal cancer proximal to rectum.
FAP and AFAP with relative rectal sparing (< 20 polyps in rectum).
Multiple synchronous colon cancers and/or polyps.
Treatment-refractory slow-transit constipation.
Ulcerative colitis with relative rectal sparing and preserved rectal compliance.
Crohn colitis: rectal sparing, good sphincter function, lack of active perianal manifestations.
Preparatory Considerations
Full colonic evaluation and histologic documentation for all elective cases, tattooing of most distal polyp site, rigid
sigmoidoscopy to rule out rectal cancer.
Bowel cleansing (traditional) vs no bowel cleansing (evolving concept).
Ureteral stents for redo cases or extensive disruption of anatomy (eg, inflammation).
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Marking of possible stoma sites.
Prophylactic antibiotics.
IBD cases: Anophysiology studies for rectal compliance; small bowel follow-through or CT enterography to rule out small
bowel involvement, steroid stress dose (if needed), discontinuation of other immunosuppressives.
Surgical Steps
1. Patient position: modified lithotomy position.
2. Laparotomy:
a. Periumbilical or lower midline: infraumbilical incision sufficient if stomach can be reached, otherwise
extension above umbilicus.
b. Alternative access: transverse suprapubic (transection of rectus muscle), Pfannenstiel incision (transverse
incision to skin and anterior rectus sheath with midline rectus-saving celiotomy).
3. Dynamic abdominal wall retraction to expose right side, then left side of colon.
4. Abdominal exploration: local resectability, secondary pathology (liver/gallbladder, colon, female organs, small
bowel), other abnormalities.
5. Defining distal resection margin:
a. Total abdominal colectomy: upper rectum (confluence of teniae).
b. Subtotal colectomy (HNPCC, slow-transit constipation): sigmoid colon, ie, either proximal sigmoid or where
most distal polyp tattooed (HNPCC), or mid sigmoid colon (slow-transit constipation).
6. Mobilization of right colon from its retroperitoneal attachments, starting at ileocecal junction, moving along colonic
gutter to hepatic flexure. Landmarks: ureter, duodenum (avoid injury).
7. Development of lesser sac: oncologic resection requires at least half omentectomy on side of tumor: division of
gastrocolic ligament in several steps (alternative in proven benign disease: omentum-sparing, ie, dissection of
omentum off transverse colon).
8. Retrograde dissection from sigmoid toward splenic flexure along white line of Toldt. Opening of retroperitoneum,
identification of areolar tissue. Firm pressure against sigmoid mesentery to bluntly reflect retroperitoneal tissues and
expose left ureter. Incision of peritoneum is continued into pelvis.
9. Completion of splenic flexure mobilization by retraction of distal transverse and proximal descending colon and
conjoining the two in stepwise ligation. Avoid splenic tear.
10. Once retroperitoneal mobilization is complete from ileum to sigmoid: stepwise devascularization of colon with
clamping and transecting of major vascular stalks (ligature, suture ligatures). Before dividing tissue, remote location of
ureters to be verified.
11. Transection of terminal ileum with 75-mm linear stapler.
12. Distal resection point: stepwise division of mesentery or mesorectum between clamps and ligatures.
13. Transection at distal resection point: depending on exposure and mobility either with reload of 75-mm linear
stapler or transverse cutter/stapler.
14. Removal of complete specimen, macroscopic examination: confirm diagnosis. Frozen sections if uncertain
pathology or margin.
15. (A) Stapled end-to-end ileorectal anastomosis (IRA) or ileosigmoidal anastomosis (ISA): purse-string (hand-
sewn, device with Keith needle, or all-in-one device. Insertion of largest possible circular stapler anvil. Insertion of
stapler through anus and tension-free anastomosis. Assessment of donut completeness.
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(B) Functional end-to-end ISA: parallel alignment of distal ileum and mid sigmoid. Small antimesenteric
enterotomy on both sides, insertion of 75-mm linear stapling device. Closure of residual opening: hand-sewn,
reload of linear stapler, transverse (cutting) stapler.
16. Testing of anastomosis: submerging under water, finger compression of bowel proximal to anastomosis, and
insufflation of air through proctoscope.
17. Drains or NGT commonly not needed.
18. Closure of laparotomy incision.
Anatomic Structures at Risk
Both ureters, duodenum, spleen, mesenteric blood supply, gonadal vessels.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated. Steroid
taper if needed.
Complications
Bleeding (surgeon-dependent): inadequate ligature of vascular stalks, splenic tear, gonadal vessels.
Anastomotic leak (2%): most commonly due to technical error, tension, inadequate blood supply, high-dose steroids,
malnutrition.
Ureteral injury (0.1–0.2%).
Cross-Reference
Large bowel obstruction (LBO, 560.9) (Ch. 1), (Ch. 4)
Pain, abdominal (Ch. 1)
Hereditary nonpolyposis colon cancer (HNPCC, 153.8, V84.09) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
Functional disorders—chronic constipation (564.Ox) (Ch. 4)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
TOTAL ABDOMINAL COLECTOMY WITH END-ILEOSTOMY (OPEN)
Principle
The operation of choice for all nonelective cases of colitis regardless of underlying etiology (IBD, infectious, ischemic, etc):
ie, (emergency) resection of the whole colon while preserving the rectum and avoiding complex pelvic dissection. This
approach is fast, eliminates the majority of diseased bowel, avoids anastomosis, avoids difficult pelvic dissection, and
preserves pelvic space for later reconstruction, ie, "it does not burn any bridges."
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Setting
Inpatient, OR procedure.
Alternatives
Proctocolectomy with IPAA or end-ileostomy.
Total colectomy with end-ileostomy and distal mucous fistula.
Turnbull blowholes: only extremely rarely indicated.
Indication
Fulminant colitis or toxic megacolon.
Colitis with complication, eg, spontaneous or iatrogenic perforation.
Colitis with severe malnutrition.
Treatment with high-dose steroids, possibly with infliximab.
Smoldering C difficile colitis, refractory to conservative treatment.
Preparatory Considerations
Toxic patient: short-term adequate resuscitation and monitoring.
All others: worsening or lack of improvement within 72 hours of optimal medical management, advance definition by involved
teams of deadline and criteria when to declare failure of conservative treatment.
Marking of possible stoma sites: may be impossible in emergency setting and severe abdominal distention.
Therapeutic antibiotics, possibly steroid stress dose.
Surgical Steps
1. Patient position: modified lithotomy or supine position.
2. Long midline laparotomy: good exposure needed, distended/diseased bowels often friable and not tolerating any
traction (risk of perforation).
3. Installation of abdominal wall retractor to expose whole abdomen.
4. Quick gentle abdominal exploration: additional pathology (liver/gallbladder, colon, female organs, small bowel),
other abnormalities.
5. Mobilization of right colon from its retroperitoneal attachments, starting at ileocecal junction, moving along colonic
gutter to hepatic flexure. Landmarks: ureter, duodenum (avoid injury).
6. Entry into lesser sac and division of gastrocolic ligament in several steps (alternative: omentum-sparing, ie, more
time-consuming dissection of omentum off transverse colon).
7. Retrograde dissection from sigmoid toward splenic flexure along white line of Toldt. Opening of retroperitoneum,
identification of areolar tissue. Firm pressure against sigmoid mesentery to bluntly reflect retroperitoneal tissues and
expose left ureter. Incision of peritoneum is continued into pelvis.
8. Completion of mobilization of splenic flexure by retraction of distal transverse and proximal descending colon and
conjoining the two in stepwise ligation. Avoid splenic tear.
9. Once retroperitoneal mobilization is complete from ileum to sigmoid: stepwise devascularization of colon with
clamping and transecting major vascular stalks (suture ligatures). Before dividing tissue, remote location of ureters to
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be verified.
10. Transection of terminal ileum with 75-mm linear stapler.
11. Distal resection point: stepwise division of mesentery or mesorectum between clamps and ligatures.
12. Transection at distal resection point either with reload of 75-mm linear stapler or transverse cutter/stapler:
depending on tissue quality: higher risk of stapling failure, need for hand-sewn closure of distal stump (or creation of
mucous fistula).
13. Careful removal of complete specimen, macroscopic examination: confirm diagnosis. Frozen sections if uncertain
pathology or margin.
14. Marking of rectal stump with long nonabsorbable colored monofilament suture (for later identification).
15. Creation of end ileostomy. Excision of skin disk at preoperatively marked site for ileostomy. Dissection of fat,
incision of anterior rectus sheath, splitting of muscle to create gap. Small bowel loop carried through abdominal wall.
16. Closure of the laparotomy incision.
17. Maturation of ileostomy to 3 cm nipple. Appliance.
18. Washout of rectal stump with povidone-iodine, temporary rectal drain placement (to avoid rectal blow-out).
Anatomic Structures at Risk
Both ureters, duodenum, spleen, mesenteric blood supply, gonadal vessels.
Aftercare
ICU monitoring and stabilization. Extubation per respiratory and hemodynamic parameters.
Intestinal recovery: in absence of nausea/vomiting (extubated patient) or lack of residuals in NGT
start liquids by mouth or
via enteral feeding tube, advance as tolerated.
Therapeutic antibiotics.
Steroid taper if needed.
Ileostomy takedown > 3–6 months when patient nutritionally and physically recovered and if steroids tapered off.
Complications
Bleeding (surgeon-dependent): inadequate ligature of vascular stalks, splenic tear, gonadal vessels.
Ongoing infection, sepsis, ARDS, multiorgan system failure, death.
Rectal blow-out.
Ureteral injury (0.1–0.2%).
Cross-Reference
Megacolon (Ch. 1)
Pain, abdominal (Ch. 1)
Sepsis (Ch. 1)
Ischemic colitis (557.X) (Ch. 4)
Pseudomembranous/Clostridium difficile colitis (008.45) (Ch. 4)
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IBD—ulcerative colitis (556.9) (Ch. 4)
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Creation of end-ileostomy or -colostomy(Ch. 5)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
PROCTOCOLECTOMY, ILEAL J-POUCH ANAL ANASTOMOSIS (OPEN)
Principle
Restorative proctocolectomy: oncologic resection of the whole colon and rectum with a restorative ileoanal pull-through
procedure, ie, creation of a new storage area (Figures 5–12A and 5–12B).
Two-stage: with temporary ileostomy.
One-stage: without ileostomy possible if technically perfect and no malnutrition or high-dose steroids
Figure 5–12A.
Proctocolectomy: mobilization of the colon.
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Figure 5–12B.
Ileal J-pouch anal anastomosis.
Setting
Inpatient, OR procedure.
Alternatives
Laparoscopic approach.
Proctocolectomy with permanent ileostomy.
Indication
Ulcerative colitis (except fulminant colitis).
FAP.
Rarely: multiple synchronous cancers and/or polyps.
Crohn colitis: ileoanal pull-through procedure may be considered if there is no evidence of small bowel disease or
perianal manifestations.
Preparatory Considerations
Full colonic evaluation and histologic documentation for all elective cases, rigid sigmoidoscopy to rule out rectal cancer.
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Small bowel follow-through or CT enterography to rule out small bowel involvement.
Bowel cleansing (traditional) vs no bowel cleansing (evolving concept).
Ureteral stents for redo cases or extensive disruption of anatomy (eg, inflammation).
Marking of possible stoma sites.
Steroid stress dose, discontinuation of other immunosuppressives. Prophylactic antibiotics.
Surgical Steps
1. Patient position: modified lithotomy position.
2. Laparotomy:
a. Lower midline: infraumbilical incision sufficient if stomach can be reached, otherwise extension above
umbilicus.
b. Alternative access: transverse suprapubic (transection of rectus muscle), Pfannenstiel incision (transverse
incision to skin and anterior rectus sheath with midline rectus-saving celiotomy).
3. Dynamic abdominal wall retraction to expose right side, then left side of colon.
4. Abdominal exploration: small bowel (evidence of Crohn disease?), liver (PSC cirrhosis, gallstones?), colon (mass,
covered perforation?), other abnormalities.
5. Mobilization of right colon from its retroperitoneal attachments, starting at ileocecal junction, moving along colonic
gutter to the hepatic flexure. Landmarks: ureter, duodenum (avoid injury): Figure 5–12A.
6. Development of lesser sac: either dissection of omentum off transverse colon (omentum sparing), or division of
gastrocolic ligament in several steps (resection of omentum).
7. Retrograde dissection from sigmoid towards splenic flexure along white line of Toldt. Opening of retroperitoneum,
identification of areolar tissue. Firm pressure against sigmoid mesentery to bluntly reflect retroperitoneal tissues and
expose left ureter. Incision of peritoneum is continued into pelvis.
8. Completion of mobilization of splenic flexure by retraction of distal transverse and proximal descending colon and
conjoining the two in stepwise ligation (Figure 5–12A). Avoid splenic tear.
9. Once retroperitoneal mobilization is complete from ileum to sigmoid: stepwise devascularization of colon with
clamping and transecting of major vascular stalks (ligature, suture ligatures). Before dividing tissue, remote location of
ureters to be verified.
10. Transection of terminal ileum with 75-mm linear stapler.
11. Installation of abdominal wall retractor (eg, Bookwalter retractor) for pelvic dissection.
12. Continuation of serosal incision on both sides of mesosigmoid toward peritoneal reflection.
13. Developing avascular plane posterior to superior hemorrhoidal vessels but anterior to hypogastric nerve plexus
leads to avascular plane anterior to Waldeyer fascia. Continuation of nerve-sparing dissection under direct
visualization, no blunt dissection (avoid presacral veins!).
14. Sharp anterior and lateral dissection all the way to pelvic floor, identification of seminal vesicles (males), careful
dissection of rectovaginal plane (females).
15. (A) Double-stapling technique: transection of distal rectum at puborectalis muscle, ie, ~2–3 cm proximal to
dentate line with transverse linear stapler/cutter.
(B) Hand-sewn technique: switch to perineal approach, installation of Lone Star retractor, incision of mucosa at
dentate line, and mucosectomy up to puborectalis muscle where connection is made to presacral space.