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16. Removal of complete specimen, macroscopic examination: confirm diagnosis. Frozen sections of margins in case of
cancer.
17. Creation of pouch (Figure 5–12B): folding of distal ileum, apical enterotomy. Firing of 2–2
1
/
2
cartridges of 75-cm
linear stapler to create ~12 cm pouch. Free end of J to be shortened flush to inlet, approximated to afferent limb with
a series of interrupted sutures.
18. (A) Stapled ileoanal anastomosis (Figure 5–12B): purse-string suture to apical enterotomy and insertion of
largest possible circular stapler anvil. Insertion of stapler through anus and tension-free anastomosis. Assessment of
donuts and digital assessment of anastomosis.
(B) Hand-sewn ileoanal anastomosis: switch to perineal approach, guiding Babcock clamp through anus to
grasp tip of pouch, pulling through and fixation with six seromuscular anchoring stitches, maturing mucosal
junction. Removal of retractor.
19. Presacral drains according to surgeon's preference. No need for NGT.
20. For two-stage procedure: creation of loop 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
(distal limb marked) wrapped with Seprafilm and carried through abdominal wall.
21. Closure of the laparotomy incision.
22. Maturation of loop ileostomy to 3 cm nipple. Appliance.
Anatomic Structures at Risk
Both ureters, duodenum, spleen, mesenteric blood supply, gonadal vessels, hypogastric nerves, presacral vein plexus,
posterior vaginal wall.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated. Steroid
taper if needed. Ileostomy takedown > 6 weeks if clinical/radiologic evidence that pouch is healed, and if steroids are
tapered off.
Complications
Bleeding (surgeon-dependent): presacral veins, inadequate ligature of vascular stalks, splenic tear, gonadal vessels.
Anastomotic leak (4–10%): most commonly due to technical error, tension, inadequate blood supply, high-dose steroids,
malnutrition.
Pouch-anal stricture (10–14%).
Ileoanal dysfunction.
Sexual dysfunction (1–3%) and infertility (25–40%).
Ureteral injury (0.1–0.2%).
Cross-Reference
Familial adenomatous polyposis (FAP; 211.3, 235.2, V84.09) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
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Pouchitis—ileoanal dysfunction (569.60) (Ch. 4)
Mucosectomy of anal transital zone (ATZ) (Ch. 5)
Creation of end-ileostomy or -colostomy (Ch. 5)
Ileostomy takedown (Ch. 5)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
MUCOSECTOMY OF ANAL TRANSITIONAL ZONE (ATZ)
Principle
Elective excision of the residual ATZ cuff in patients with status post-ileoanal reconstruction in double-stapling technique for
ulcerative colitis. The pouch is advanced and sutured to the dentate line. Despite some inflammatory changes in the ATZ in
the majority of patients, only a minority requires excision (highly symptomatic, dysplasia).
Setting
Inpatient (selected outpatient?), OR procedure.
Alternatives
Conservative treatment of pouchitis or cuffitis.
Major revision or removal of ileoanal pouch.
Indication
ATZ cuffitis.
Ileoanal dysfunction (uncertain whether pouchitis or cuffitis): elimination of variable.
ATZ dysplasia.
Preparatory Considerations
Bowel cleansing: stay on clear liquids the day before, two Fleet enemas prior to procedure.
Prophylactic antibiotics.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages—
superior view with comfortable access for surgeon/assistant, decreased vascular congestion.
2. Pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve
relaxation of anal sphincter muscles.
3. Placement of Lone Star retractor.
4. Incision of mucosa right at dentate line and circumferential dissection and mobilization of mucosa.
5. Continuation until stapled anastomosis reached.
6. Placement of full-thickness holding sutures to pouch proximal to staple line.
7. Resection of mucosa.
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8. Placement of 4–8 full-thickness absorbable sutures from end of pouch to dentate line, consecutive tying.
9. Maturing of mucosa.
10. Removal of Lone Star retractor.
Anatomic Structures at Risk
Sphincter complex, pouch, rectovaginal septum.
Aftercare
Regular diet as tolerated 6 hours postanesthesia. Maintenance of soft stools (fibers, antidiarrheal medication, etc) as before
the surgery.
Zinc-oxide based barrier cream regularly to perianal skin.
Complications
Bleeding (surgeon-dependent).
Infection, abscess/fistula formation.
Anastomotic dehiscence.
Stricture formation.
Formation of rectovaginal fistula
need for colostomy.
Worsening fecal incontinence.
Cross-Reference
Familial adenomatous polyposis (FAP; 211.3, 235.2, V84.09) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
Pouchitis—ileoanal dysfunction (569.60) (Ch. 4)
Creation of end-ileostomy or -colostomy (Ch. 5)
Ileostomy takedown (Ch. 5)
General perioperative management—anorectal (Ch. 7)
STRICTUROPLASTY
Principle
Restitution of unobstructed intestinal passage for symptomatic solitary or multisegmental strictures without bowel resection
to minimize the risk of immediate or long-term short-bowel syndrome. The typical scenario is for Crohn disease or recurrent
adhesions. In the presence of multiple strictures, different techniques may have to be employed during the same procedure.
Setting
Inpatient, OR procedure.
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Alternatives
Laparoscopic-assisted approach.
Segmental resection.
Indication
Crohn disease with symptomatic stricture(s).
Adhesions with symptomatic stricture(s).
Preparatory Considerations
Small bowel evaluation: small bowel follow-through, CT enterography.
Evaluation of distal bowel to rule out hidden sites of obstruction.
Bowel cleansing if tolerated.
Suppression of disease activity (eg, infliximab
4–6-week interruption prior to elective surgery).
Steroid stress dose?
Surgical Steps
1. Patient position: supine position (alternative: modified lithotomy).
2. Laparotomy, lysis of adhesions and assessment of entire intestines to define target lesions.
3. Assessment of hidden strictures: running marble (or artificial eye ball) via enterotomy through intestines.
(A) Heinecke-Mikulicz Stricturoplasty for for Short-Segment Stricture
4. Placement of holding sutures on both sides of stricture: not proximal/distal but along circumference.
5. Longitudinal antimesenteric incision of bowel through strictured area.
6. Lateral traction on holding sutures and transverse closure of enterotomy.
(B) Finney Stricturoplasty for Long-Segment Stricture (Risk: Creation of Large Atonic Pocket)
4. Longitudinal antimesenteric incision of bowel through whole length of strictured area.
5. Folding of opened bowel: may be difficult in indurated, thickened/foreshortened mesentery/bowel.
6. Closure of posterior bowel wall with continuation toward anterior wall.
(C) Isoperistaltic Side-to-Side Stricturoplasty for Very Long or Multisegmental Strictures
4. Mobilization/division of mesentery at midpoint of diseased segment and transection of bowel.
5. Moving of two ends alongside in side-to-side fashion (for as much as 30–40 cm).
6. Approximation of two loops with interrupted seromuscular sutures.
7. Longitudinal antimesenteric enterotomy on both loops, spatulation of intestinal ends to avoid blind stumps.
8. If suspicious areas of disease: biopsy and frozen sections of to rule out malignancy.
9. Two-layer closure of two bowel segments.
Anatomic Structures at Risk
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Small bowel mesentery.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Complications
Bleeding (surgeon-dependent), tearing of mesentery, anastomotic leak, recurrent stricture.
Cross-Reference
IBD—Crohn disease (555.X) (Ch. 4)
Creation of end-ileostomy or -colostomy (Ch. 5)
Medical management of Crohn disease (Ch. 6)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
ADHESIOLYSIS (LAPAROSCOPIC VS OPEN)
Principle
Laparoscopic vs open lysis of peritoneal adhesions, either as independent procedure or as part of larger operation. Adhesions
are common after previous abdominal procedures and may result in acute or recurrent SBOs, recurrent/chronic abdominal
pain, infertility, and difficult reoperative surgery. Whether a procedure is started laparoscopically or open should be based on
the surgeon's personal knowledge of an individual's extent of adhesions and the current extent of abdominal distention.
Setting
Inpatient, OR procedure.
Alternatives
Conservative management.
Indication
Complete SBO.
Acute nonresolving partial SBO.
Recurrent SBOs (elective setting).
Caveat: pain alone is usually not a sufficient indication for surgery and has a high likelihood of failure.
Preparatory Considerations
ALL
Prophylactic antibiotics.
Consenting process: making sure that patient understands that there is potential risk of an ostomy.
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EMERGENCY
Fluid resuscitation
NGT decompression.
(SEMI-)ELECTIVE
Full colonic evaluation (barium enema vs colonoscopy) to rule out colonic site of obstruction.
Full bowel cleansing.
Surgical Steps
1. Patient position: modified lithotomy position, beanbag, strapped to table, both arms tucked.
a. Laparoscopic: initial laparoscopic port placement in Hasson technique off previous scars—eg, midclavicular
line at level of umbilicus; camera insertion and assessment of density of adhesions—camera lysis until sufficient
space is developed to insert 2nd/3rd port above and below also on midclavicular line under direct visual control.
If adhesions are too dense or space too limited—conversion to open procedure.
b. Open: access through previous scar or new incision if it will provide better exposure; avoid electrocautery
entry until confirmed that no bowel loops are attached underneath fascia.
2. Takedown of adhesions with ultrasonic shears, scissors, careful wiping: extreme care has to be taken (a) to
improve and maintain good visibility and (b) to avoid enterotomy; if adhesions are very dense: use of saline injection
to develop plane between loops of bowel.
3. If enterotomy/ies have occurred
always repair immediately to minimize risk of leaving enterotomy unclosed.
4. Definition of surgical goals:
a. Identification of transition point local lysis, possible resection/anastomosis.
b. Running whole small bowel
freeing up of adhesions.
c. Laparoscopy: adequate visibility and progress with time if (1) adhesions too dense, (2) bowel too distended,
or (3) for other reasons no progress is made
conversion to open procedure.
5. After completion of mobilization: assessment of situation and appropriate resolution of problem areas; limited
resection/anastomosis, bypass, ostomy, etc.
6. Reevaluation of peritoneal cavity and running of whole small bowel to check for and repair possible enterotomies.
7. Port removal and/or closure of abdominal incisions.
Anatomic Structures at Risk
Enterotomies.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Continuation of NGT decompression if bowels are very distended or if extensive adhesiolysis.
Complications
Bleeding (surgeon-dependent), anastomotic leak 1–3% ( abscess or enterocutaneous fistula formation), SBO up to 25%.
Cross-Reference
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Small bowel obstruction (SBO) (Ch. 1)
Complications—postoperative ileus (546.3) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
Creation of end-ileostomy or -colostomy (Ch. 5)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
LAPAROSCOPIC COLORECTAL SURGERY
Principle
Laparoscopic surgery—once a rarity and exceptional approach—has become an established and accepted standard approach
for almost any abdominal problem. With a generation of surgeons who were brought up with laparoscopy as a routine
component of their training and more sophisticated tools, there are virtually no contraindications anymore. Even for colon
cancer, at least equivalency in oncologic outcomes has been documented after selected procedures. The only exception is
rectal cancer where data are still inadequate and to some degree of concern (higher risk of positive radial margins).
The laparoscopic approach should satisfy exactly the same principles as an open procedure but be even more
meticulous about maintaining hemostasis. One approach is to laparoscopically follow the same steps with lateral
mobilization, followed by vascular transection (lateral-to-medial approach). Because of the limited space and to take
advantage of lateral attachments for retraction, however, the opposite direction may be chosen for the dissection, ie,
medial-to-lateral approach.
The technique may be straight laparoscopically, hand-assisted laparoscopic surgery, or a hybrid surgery (eg,
laparoscopic mobilization of splenic flexure, open LAR).
Conversion rates are irrelevant (except from a financial standpoint); they are not a measure of quality.
Beginners should start with easy cases: eg, creation of colostomy, or skinny patient with palliative segmental sigmoid
resection for cancer. Diverticulitis (even though a benign condition) may occasionally be extremely challenging.
Setting
Inpatient, OR procedure.
Alternatives
Open approach.
Indication
Novice: laparoscopic creation of colostomy, sigmoid resection, ileocecal resection, right hemicolectomy.
Advanced: left hemicolectomy, resections involving mid colic artery (eg, extended right hemicolectomy), subtotal
colectomy, Hartmann reversal, rectopexy.
Experts only: proctocolectomy, rectal dissection.
Preparatory Considerations
Identical to open procedures.
Specifically for laparoscopic approach:
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– Tattooing of lesions for intraoperative identification.
– Avoidance of colonoscopy immediately prior to procedure (because gas-filled bowels limit the view).
Instrumentation:
– 5- and 10–12-mm ports (check with diameter of stapling device).
– Laparoscope, 1–2 insufflators.
– Atraumatic graspers, Babcocks, needle drivers, scissors, anvil grasper.
– Suction/irrigation device.
– Energy ligation device (eg, ultrasonic shears), clip applier, laparoscopic roticulating linear stapling devices.
– Wound protector, hand-assist port.
– Open instruments and staplers.
Surgical Steps
1. Patient position: lesion on left side modified lithotomy position; lesion on right side supine or modified
lithotomy. Patient tightly secured on the table (eg, beanbag, tapes), both arms tucked, hips straight or in 0–10
degrees of flexion: "flight test" prior to draping—patient placed in extreme Trendelenburg and lateral position to verify
adequate stabilization.
2. Equipment position such that surgeon, pathology, and monitor all are in line; adequate monitor position for
assistants.
3. Access:
a. Open Hasson technique.
b. Alternative: Veress needle technique + optical port—if no previous laparotomies.
4. Visualization and placement of working ports under visual guidance.
(A1) Right Lateral-to-Medial Approach
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. 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. Elevation of cecum and identification of ileocolic vascular stalk. Creation of window and clipping/division of individual
vessels or stapling/cutting of whole stalk.
8. Enlargement of umbilical port to 4 cm, placement of wound protector, delivery of mobilized colon.
9. Open completion of mobilization of ileal mesentery.
10. Functional end-to-end anastomosis with total of two stapler cartridges. Closure of mesenteric gap.
11. Closure of incision and ports.
(A2) Right Medial-to-Lateral Approach
5. Elevation of cecum and identification of ileocolic vascular stalk. Creation of window with clipping/division of
individual vessels or stapling/cutting of whole stalk.
6. Retroperitoneal mobilization in avascular plane up to duodenum/pancreas, mobilization of hepatic flexure from
underneath.
7. Development of lesser sac: either dissection of omentum off transverse colon (omentum sparing), or division of
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gastrocolic ligament in several steps (resection of omentum).
8. Mobilization of remaining hepatic flexure and lateral colon attachments, free ileal mesentery.
9. Enlargement of umbilical port to 4 cm, placement of wound protector, delivery of mobilized colon.
10. Open completion of mobilization of ileal mesentery.
11. Functional end-to-end anastomosis with total of two stapler cartridges. Closure of mesenteric gap.
12. Closure of the incision and ports.
(B1) Left Lateral-to-Medial Approach
5. Mobilization of left colon from its retroperitoneal attachments: incision of white line of Toldt at sigmoid colon
junction, moving along colonic gutter to splenic flexure. Landmarks: ureter, gonadal vessels (avoid injury).
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. Complete mobilization of splenic flexure.
8. Elevation of sigmoid colon and identification of vascular stalk. Creation of window: verification of ureter in remote
location, clipping/division of individual vessels or stapling/cutting of whole stalk: IMA/IMV (at origin) vs superior
hemorrhoidal stalk.
9. Continuation of serosal incision on both sides of mesosigmoid toward peritoneal reflection.
10. Blunt dissection behind vascular stalk (avascular plane) to entry of pelvis.
11. Creation of window in mesorectum at distal point of resection. Division of bowel by means of reticulating linear
stapler (as many firings as needed). Division of mesorectum with energy ligation device.
12. Enlargement of umbilical port to 4 cm, placement of wound protector, delivery of mobilized colon.
13. Open completion of mobilization of proximal colon mesentery and bowel resection.
14. Purse-string suture to proximal end and insertion of circular stapler anvil.
15. Bowel returned to abdomen, sealing of wound protector and reinsufflation.
16. Anvil grasper to anvil and controlled anastomosis under direct visual control.
17. Testing of anastomosis: submerging under water, finger compression of bowel proximal to anastomosis, and
insufflation of air through proctoscope—oversewing and retesting if needed (laparoscopic suturing skills).
18. Drains according to surgeon's preference. No need for NGT.
19. Closure of incision and ports.
(B2) Left Medial-to-Lateral Approach
5. Elevation of sigmoid colon and identification of vascular stalk. Incision of serosa and creation of window:
identification of ureter, followed by clipping/division of individual vessels or stapling/cutting of whole stalk after
verifying ureter in remote location: IMA/IMV (at origin) vs superior hemorrhoidal stalk.
6. Retroperitoneal mobilization in avascular plane up to pancreas, mobilization of splenic flexure from underneath.
7. Development of lesser sac: either dissection of omentum off transverse colon (omentum sparing), or division of
gastrocolic ligament in several steps (resection of omentum).
8. Completion of mobilization of splenic flexure and left colon from its retroperitoneal attachments.
9. Continuation of serosal incision on both sides of mesosigmoid toward peritoneal reflection.
10. Blunt dissection behind vascular stalk (avascular plane) to entry of pelvis.
11. Creation of window in mesorectum at distal point of resection. Division of bowel by means of reticulating linear
stapler (as many firings as needed). Division of mesorectum with energy ligation device.
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12. Enlargement of umbilical port to 4 cm, placement of wound protector, delivery of mobilized colon.
13. Open completion of mobilization of proximal colon mesentery and bowel resection.
14. Purse-string suture to proximal end and insertion of circular stapler anvil.
15. Bowel returned to abdomen, sealing of wound protector, reinsufflation.
16. Anvil grasper to anvil and controlled anastomosis under direct visual control.
17. Testing of anastomosis: submerging under water, finger compression of bowel proximal to anastomosis, and
insufflation of air through proctoscope—oversewing and retesting if needed (laparoscopic suturing skills).
18. Drains according to surgeon's preference. No need for NGT.
19. Closure of incision and ports.
Anatomic Structures at Risk
Ureters, duodenum, pancreas, gonadal vessels, hypogastric nerves, fascial planes, presacral vein plexus.
Aftercare
Fast-track recovery: in absence of nausea or vomiting start of liquids on POD1, rapidly advance as tolerated.
Complications
Trocar injuries, injuries related to manipulation of small bowel or colon, collateral injuries (ureter, iliac vessels).
Conversion to open procedure is not a complication, but good judgment if lack of adequate view or progress.
Cross-Reference
Rectal prolapse—rectopexy (laparoscopic vs open) (Ch. 5)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
Left hemicolectomy (open) (Ch. 5)
(Sub-)total colectomy, ileorectal anastomosis (open) (Ch. 5)
Proctocolectomy, ileal J-pouch anal anastomosis (open) (Ch. 5)
Adhesiolysis (laparoscopic vs open) (Ch. 5)
Hartmann reversal (laparoscopic vs open) (Ch. 5)
Low anterior resection (LAR)/total mesorectal excision (TME) (Ch. 5)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
LAPAROSCOPIC PORT PLACEMENT
Principle
Adequate laparoscopic exposure and surgery depends on rational placement of the ports. If there is a need to reestablish
tactile sensation, insertion of a hand-port may facilitate and speed up the dissection.