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1. Patient position: supine (transverse colostomy) or modified lithotomy position (sigmoid colostomy).
2. Limited transverse eye-shaped incision around stoma, tangentially touching mucocutaneous junction at cephalad
and caudad border.
3. Division of dermis.
4. Careful dissection through all layers of abdominal wall using sharp Metzenbaum scissors, avoidance of inadvertent
injury to bowel segment (excess of traction, cautery injury), otherwise risk of inadvertent enterotomy.
5. Mobilization of bowel through fascia (and frequently through parastomal hernia sac) until peritoneal cavity is
reached.
6. Completion of dissection all the way around, again with care not to cause inadvertent enterotomies: if this is not
adequately and safely possible (10–15% of cases)
midline laparotomy and dissection from inside.
7. Once adequate mobilization of colostomy-bearing bowel loop achieved: freshening of wound edge (
preserving
back wall), or complete resection of segment (
completely fresh anastomosis).
8. Anastomosis:
a. Stapled functional end-to-end: not recommended for large bowel as giant diverticulum is created
potentially relevant functional obstacle (harder stool) + difficult to perform subsequent colonoscopies.
b. Preserved back wall: 1- or 2-layered transverse closure of bowel.
c. Freshened bowel edges: 1- or 2-layered end-to-end anastomosis, closure of mesenteric gap.
9. Return of bowel into peritoneal cavity, limited irrigation.
10. Loose approximation of rectus muscle, closure of fascia.
11. Subcuticular closure of skin (alternative: leaving skin open for healing by secondary intention).
Anatomic Structures at Risk
Enterotomies, mesenteric tears, injury to epigastric vessels.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
If loose stool expected
preemptive perianal skin care.
Complications
Bleeding (surgeon-dependent), anastomotic leak 3% ( abscess or enterocutaneous fistula formation), SBO up to 25%,
stricture, unsatisfactory function of anal function, need to recreate another colostomy, incisional hernia formation. Stoma site
infection: 20–25%.
Cross-Reference
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Complications—stoma necrosis (569.60) (Ch. 4)
Proctocolectomy, ileal J-pouch anal anastomosis (open) (Ch. 5)
Creation of loop ileostomy or colostomy (laparoscopic/open) (Ch. 5)
Low anterior resection (LAR)/total mesorectal excision (TME) (Ch. 5)
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HARTMANN REVERSAL (LAPAROSCOPIC VS OPEN)
Principle
Laparoscopic vs open reversal of a Hartmann-type end-colostomy once the patient has recovered from the acute event that
led to the performance of a discontinuous resection (perforation, acute obstruction, etc). The index event often results in
significant adhesions (peritonitis), particularly in the midline; nonetheless, a laparoscopic start is usually justifiable.
Timing of the surgery: usually not before 3–6 months after the first surgery, dependent on general recuperation and
potential priority need for adjuvant chemotherapy or chemoradiation.
Setting
Inpatient, OR procedure.
Alternatives
Leaving the colostomy: by choice, patient comorbidities, or reconnection impossible (rare).
Completion proctectomy and coloanal anastomosis (with/without temporary ileostomy).
Indication
Existing Hartmann colostomy with confirmed integrity of distal rectal stump, > 3 months after creation, normalized health
and nutritional status.
Preparatory Considerations
Full colonic evaluation (barium enema vs colonoscopy), including contrast enema or rectal stump (for assessment of its
length and configuration, see Figure 5–17).
Figure 5–17.
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Preoperative barium enema of Hartmann pouch.
Full bowel cleansing.
Enemas into rectal stump + rigid sigmoidoscopy to verify that barium is not impacted.
Prophylactic antibiotics.
Consenting process: making sure that patient understands potential risk that either takedown cannot be completed at all (
permanent colostomy) or that temporary protection by an ileostomy may again be needed.
Surgical Steps
1. Patient position: modified lithotomy position, beanbag, strapped to table, both arms tucked.
2. Access:
a. Laparoscopic: initial port placement in open port Hasson technique: off midline (eg, right midclavicular line at
level of umbilicus). Camera insertion and assessment of density of adhesions: camera lysis until sufficient space
developed to insert 2nd/3rd port above and below also on midclavicular line under direct visual control.
b. Open: midline laparotomy.
3. Takedown of adhesions (ultrasonic shears, scissors, wiping).
4. Target 1: moving small bowel out of pelvis and identification/mobilization of rectal stump.
5. Target 2: identification of ostomy-baring colon, mobilization of splenic flexure.
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6. Once that is achieved: limited transverse eye-shaped incision around stoma, tangentially touching mucocutaneous
junction at cephalad and caudad border and complete mobilization of stoma-bearing bowel through all layers of
abdominal wall (including frequently present hernia sac).
7. Freshening of colonic edge, placement of purse-string suture, insertion of largest possible diameter of circular
stapler anvil; bowel dropped back to peritoneal cavity.
8. Stoma site can subsequently either be used as a hand-port, or it is air-sealed by means of axially twisted wound
protector or towel clamps.
9. The whole laparoscopic mobilization should clearly advance with time: if adhesions are too dense and no progress is
made
conversion to open procedure, eg, through midline laparotomy (see above).
10. Insertion of stapler through anus and deployment of anvil under direct visual control.
11. Completion of anastomosis
testing: submerging anastomosis under water and insufflation of pressured air
through sigmoidoscope: air bubbles yes/no?
12. Reevaluation of peritoneal cavity.
13. Port removal and/or closure of abdominal incisions.
14. Stoma site: closure of skin (alternative: leaving skin open for healing by secondary intention).
Anatomic Structures at Risk
Enterotomies, mesenteric tears, injury to epigastric vessels.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Complications
Bleeding (surgeon-dependent), anastomotic leak 3% ( abscess or enterocutaneous fistula formation), SBO up to 25%,
stricture, unsatisfactory anorectal function, need to recreate another colostomy, incisional hernia formation. Stoma site
infection: 20–25%.
Cross-Reference
Large bowel obstruction (LBO, 560.9) (Ch. 1), (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.IX) (Ch. 4)
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
LOW ANTERIOR RESECTION (LAR)/TOTAL MESORECTAL EXCISION
(TME)
Principle
Oncologic, anatomic, and specimen-oriented resection of the rectum with preservation of an intact mesorectal compartment
(Figure 5–18). Benchmark: < 10% local recurrence without adjuvant treatment.
Figure 5–18.
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TME specimen from front and back showing intact glossy fascial cover.
Two-stage: with temporary ileostomy.
One-stage: without ileostomy.
Setting
Inpatient, OR procedure.
Alternatives
Partial TME (for tumors in upper rectum).
Abdominoperineal resection.
Coloanal anastomosis, possible intersphincteric dissection.
Pelvic exenteration (advanced primary or recurrent tumor)
Local transanal excision or transanal microsurgery (TEM).
Expectant approach in case of complete clinical response after neoadjuvant chemoradiation. Laparoscopic approach.
Indication
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Rectal cancer.
Preparatory Considerations
Full colonic evaluation and histologic documentation.
Rigid sigmoidoscopy to determine level above anal verge.
Staging: ERUS, CT abdomen/pelvis, MRI.
Interdisciplinary management: neoadjuvant chemoradiation (depending on stage, level, preference).
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: modified lithotomy position.
2. Laparotomy:
a. Lower midline: infraumbilical incision sufficient if stomach and splenic flexure 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. Abdominal exploration: local resectability, secondary pathology (liver/gallbladder, colon, female organs, small
bowel), other abnormalities.
4. Installation of abdominal wall retractor (eg, Bookwalter retractor). Insertion of large surgical towel underneath
unopened supraumbilical abdominal wall keeps small bowel out of surgical field and allows free access to pelvis.
5. 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 continued into pelvis.
6. If needed: complete mobilization of splenic flexure by retraction of distal transverse and proximal descending colon
and conjoining the two in stepwise ligation. Avoid splenic tear.
7. Once mobilization is sufficient, serosal incision on right side of mesosigmoid, continuation toward peritoneal
reflection
8. Developing avascular plane posterior to superior hemorrhoidal vessels but anterior to hypogastric nerve plexus,
caudad continuation leads to avascular plane anterior to Waldeyer fascia.
9. Ligation of vascular stalk (IMA, superior hemorrhoidal) with clamping and transection (ligature, suture ligatures).
Before dividing tissue, remote location of ureters to be verified.
10. Stepwise transection of mesosigmoid to proximal point of resection and transection of sigmoid colon with linear
stapler.
11. Continuation of nerve-sparing dissection into pelvis under direct visualization, no blunt dissection (avoid presacral
veins!).
12. Sharp anterior and lateral dissection all the way to pelvic floor, identification of seminal vesicles (males), careful
dissection of rectovaginal plane (females). Anterior or circumferential tumors: dissection with inclusion of Denonvilliers
fascia. Posterior tumors: dissection just posterior to fascia to spare autonomic nerve function.
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13. (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 to presacral space is made.
Alternatively: intersphincteric dissection by entering at dentate line, accessing intersphincteric groove, and
continuing dissection proximally until connection with abdominal dissection.
14. Removal of complete specimen, macroscopic examination (Figure 5–18), frozen section of distal resection margin.
15. Creation of colonic pouch: may be considered in all complete TMEs, but definitely recommended if diameter of
proximal colon would not allow insertion of 33-mm stapler anvil:
a. Colonic J-pouch: folding of distal colon, apical enterotomy, firing of 75-cm linear stapler to create 5–6-cm
pouch. Free end of J to be shortened flush to inlet, approximated to afferent limb with a series of interrupted
sutures.
b. Transverse coloplasty: 4-cm longitudinal anterior enterotomy ~3–4 cm proximal to distal resection end.
Transverse closure in two layers.
16. (A) Stapled anastomosis: Purse-string suture to distal colon (straight anastomosis, transverse coloplasty), or to
apical enterotomy (colonic J-pouch). 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 anastomosis: Switch to perineal approach, guiding Babcock clamp through anus to grasp end of
the bowel or tip of J-pouch and carefully pulling it through
fixation with six seromuscular anchoring stitches,
maturing mucosal junction. Removal of retractor.
17. Presacral drains according to surgeon's preference. No need for NGT.
18. For two-stage procedure: creation of loop ileostomy. Excision of skin disk at preoperatively marked site for the
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.
19. Closure of incision.
20. Maturation of loop ileostomy to 3-cm nipple. Appliance.
Anatomic Structures at Risk
Left ureter, gonadal vessels, hypogastric nerves, fascial planes, presacral vein plexus, vagina.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated. Ileostomy
takedown > 6 weeks if clinical/radiologic evidence that anastomosis healed. Takedown postponed if consolidating
chemotherapy is given priority: started after 4 weeks.
Complications
Bleeding (surgeon-dependent): presacral veins, inadequate ligature of vascular stalks, splenic tear, gonadal vessels.
Anastomotic leak (5–15%): technical error, tension, inadequate blood supply, poor tissue quality after chemoradiation.
Ureteral injury (0.1–0.2%).
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Cross-Reference
Colorectal cancer—rectal cancer (154.1) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
Creation of loop ileostomy or colostomy (laparoscopic/open) (Ch. 5)
Abdominoperineal resection (APR) (Ch. 5)
Transanal excision (polyp, cancer) (Ch. 5)
Transanal endoscopic microsurgery (TEM) (Ch. 5)
Chemotherapy protocols—curative intent (colorectal cancer) (Ch. 6)
Radiation therapy (Ch. 6)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
ABDOMINOPERINEAL RESECTION (APR)
Principle
Oncologic, anatomic, and specimen-oriented resection of the rectum in TME technique with removal of the anus and creation
of a permanent end-colostomy.
Setting
Inpatient, OR procedure.
Alternatives
Sphincter-preserving TME coloanal anastomosis for tumors above puborectalis muscle, possible intersphincteric dissection for
lower tumors?
Pelvic exenteration (advanced primary or recurrent tumor).
Local transanal excision.
Expectant approach in case of complete clinical response after neoadjuvant chemoradiation.
Indication
Rectal cancer at level of puborectalis muscle/sphincter complex.
Rectal cancer with perirectal fistula.
Persistent/recurrent anal squamous cell cancer (after Nigro protocol).
Anal adenocarcinoma (eg, anal glands).
Preparatory Considerations
Full colonic evaluation and histologic documentation.
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Digital rectal exam and rigid sigmoidoscopy to determine tumor level.
Staging: ERUS, CT abdomen/pelvis, MRI.
Interdisciplinary management: neoadjuvant chemoradiation (depending on stage, level, preference).
Bowel cleansing (traditional) vs no bowel cleansing (evolving concept).
Ureteral stents for redo cases or extensive disruption of anatomy (eg, inflammation).
Marking of stoma sites.
Prophylactic antibiotics.
Surgical Steps
1. Patient position: modified lithotomy position.
2. Abdominal dissection: in TME technique (see Low anterior resection (LAR)/total mesorectal excision (TME).
3. Perineal dissection (separate instrument set, 2-team approach):
a. Closure of anus using two concentric purse-string sutures with strong suture material.
b. Marking of planned elliptic incision with pen:
(1) In women with anterior tumor: extension into vagina, ie, resection of posterior vaginal wall.
(2) All others: midperineum.
c. Landmarks of dissection:
(1) Lateral: ischioanal fossae to ischial tuberosity.
(2) Posterior: anococcygeal ligament.
(3) Anterior: transverse perinei muscle (caveat: risk of urethral injury in males).
d. Connection of perineal with abdominal dissection by entering through anococcygeal ligament.
e. Loading pelvic floor muscles on finger and slow transection with electrocautery, selective ligation of bleeding
vessels.
f. Once both posterolateral aspects are freed up: posterior delivery of abdominal specimen component and
completion of anterior dissection.
4. Removal of complete specimen, macroscopic examination, frozen section of resection margins if any doubts.
5. Closure of perineal defect:
a. Direct closure: two layers, perineal drains not needed.
b. Flap closure for larger defect
myocutaneous flap (eg, rectus abdominis muscle).
c. Internal barrier (eg, omentum patch) and perineal wound left open or covered with wound VAC.
6. Creation of end-colostomy at preoperatively marked site, internal closure of lateral aspect (bowel-abdominal wall)
to avoid internal wrapping of bowel around colostomy-bearing segment.
7. Closure of abdominal incision.
8. Maturation of colostomy. Appliance.
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Anatomic Structures at Risk
Left ureter, gonadal vessels, hypogastric nerves, fascial planes, presacral vein plexus, vagina, urethra.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Consolidating chemotherapy (if needed) started after 4 weeks.
Rare possibility: secondary abdominoperineal reconstruction after APR with pullthrough (perineal colostomy) and placement
of artificial bowel sphincter.
Complications
Bleeding (surgeon-dependent): presacral veins, inadequate ligature of vascular stalks, splenic tear, gonadal vessels.
Surgical site infection (perineal wound) in 20% of patients (particularly after neoadjuvant chemoradiation).
Ureteral injury (0.1–0.2%).
Cross-Reference
Colorectal cancer—rectal cancer (154.1) (Ch. 4)
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Creation of end-ileostomy or colostomy (Ch. 5)
Low anterior resection (LAR)/total mesorectal excision (TME) (Ch. 5)
Transanal excision (polyp, cancer) (Ch. 5)
Transanal endoscopic microsurgery (TEM) (Ch. 5)
Chemotherapy protocols—curative intent (colorectal cancer) (Ch. 6)
Radiation therapy (Ch. 6)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
TRANSANAL EXCISION (POLYP, CANCER)
Principle
Transanal full-thickness excision of circumscribed distal rectal pathology. Ideal for benign pathology; also an option for early-
stage rectal cancer, but increased risk of local recurrence even in T1 rectal cancers important patient selection. Cause for
high local recurrence rate (18–30%): risk of positive lymph nodes (for T1 lesion: 7–10%, T2 15–25%), direct implantation
of shed cancer cells into the wound closure. Discussion about role of surgery and adjuvant chemoradiation is ongoing.
Caveat: for cancer, the transanal excision should be considered an excisional biopsy until pathologic stage is obtained. T2
additional treatment, T3 full oncologic treatment/resection.
Setting