Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 57 • Stoma Takedown: Takedown of Loop Colostomy or Ileostomy 647

FIGURE 57 –8

Distal bowel

Proximal

bowel

FIGURE 57 –9

648 Section IX • Colon

◆ The antimesenteric and mesenteric borders of each lumen are lined up.

◆ A double-armed 4-0 Maxon monoﬁ lament suture is used to create a single-layered running

anastomosis (Figure 57-10). The serosal edge is grasped and the mucosa and submucosal

edges are reapproximated. This is done by placing the knot on the outer portion of the

bowel at the antimesenteric border. One arm of suture is passed under the knot and used to

complete half of the anastomosis, as is the other arm on the other side. The suture line is

inspected for integrity.

◆ The completed anastomosis is dropped back into the abdominal cavity (Figure 57-11).

◆ Surgical gloves are changed and the anterior rectus fascia is reapproximated using 0

polydioxanone (PDS) in ﬁ gure-of-eight interrupted sutures.

◆ The subcutaneous skin is irrigated with bacitracin antibiotic.

◆ A nylon vertical mattress suture is used to loosely close the skin, followed by placement of

Telfa wicks between each suture (Figure 57-12). A dry dressing is placed over the wicks

and changed as needed. The wicks, however, are not removed until the patient leaves the

hospital.

FIGURE 57 –10

CHAPTER 57 • Stoma Takedown: Takedown of Loop Colostomy or Ileostomy 649

FIGURE 57 –11

FIGURE 57 –12

650 Section IX • Colon

STEP 4: POSTOPERATIVE CARE

◆ Adherence to a postoperative colorectal clinical pathway ensures standardization of care.

◆ Nasogastric decompression is not necessary unless vomiting and postoperative ileus or

obstruction occurs.

◆ Adequate pain control is achieved using patient-controlled algesia.

◆ Stress ulcer prophylaxis, such as famotidine (Pepcid) 20 mg IV every 12 hours, should be

used in patients with prior peptic ulcer disease (PUD), gastroesophageal reﬂ ux disease

(GERD), or symptoms to suggest disease.

◆ All patients should receive prophylaxis for deep venous thrombosis (DVT), using sequential

compression devices while in bed and heparin 5000 U subcutaneously every 8 hours or

enoxaparin 40 mg subcutaneously every morning. Dosing schedules according to PQRI

quality measures may begin preoperatively, or, as we practice, within 24 hours from the

operation after morning laboratory test results are back, to ensure there is no signiﬁ cant

drop in hemoglobin level to suggest postoperative bleeding.

◆ Adequate intravenous ﬂ uid should be administered with monitoring of urine output via

urimeter on the Foley bag. The Foley catheter may be removed on postoperative day 1.

◆ The diet may be limited to ice chips and sips of water in the postanesthesia care unit and

on postoperative day 1. Return of bowel function is measured by the frequency and pitch of

bowel sounds, lack of abdominal distention, and the patient’s subjective will to eat. A clear

liquid diet may be offered as sips of clear liquids without carbonation and without a straw

to minimize buildup of air in the intestine. This may be advanced ad lib as bowel function

returns.

◆ Early ambulation is crucial for aid in return of bowel function. Patients should be instructed

to walk multiple times a day beginning on postoperative day 1.

◆ The incision site should be checked on postoperative day 1 and daily thereafter to ensure

absence of infection. Wicks should be removed before the patient leaves the hospital.

CHAPTER 57 • Stoma Takedown: Takedown of Loop Colostomy or Ileostomy 651

STEP 5: PEARLS AND PITFALLS

◆ Soft tissue infection can occur to varying degrees, with necrotizing fasciitis as the worst case

scenario. The ostomy site should be loosely closed and meticulous attention paid to the

appearance of the wound postoperatively. In addition, anastomotic leak may present in part

as a soft tissue infection.

◆ Wrapping a temporary ileostomy or colostomy with Sepraﬁ lm allows for easier takedown

later. This consideration should be made during the initial surgery.

SELECTED REFERENCES

1. Zeng Q, Yu Z, You J, Zhang Q: Efﬁ cacy and safety of Sepraﬁ lm for preventing postoperative abdominal

adhesion: Systematic review and meta-analysis. World J Surg 2007;31:2125-2131;2132 [discussion].

2. QualityNet: Site index. Available at www.qualitynet.org.

3. Itani KM, Wilson SE, Awad SS, et al: Ertapenem versus cefotetan prophylaxis in elective colorectal surgery.

N Engl J Med 2006;355:2640-2651.

4. Beck DE, Opelka FG: Perioperative steroid use in colorectal patients: Results of a survey. Dis Colon

Rectum 1996;39:995-999.

5. Law WL, Bailey HR, Max E, et al: Single-layer continuous colon and rectal anastomosis using monoﬁ la-

ment absorbable suture (Maxon): Study of 500 cases. Dis Colon Rectum 1999;42:736-740.

652

STEP 1: SURGICAL ANATOMY

◆ The right colon begins at the ileocecal valve, includes the right (ascending colon) hepatic

ﬂ exure, and ends at the mid-transverse colon; the appendix is present at the inferior aspect

of the cecum. The blood supply to this area comes from the superior mesenteric artery

through its ileocolic, right colic, and right branches of the middle colic arteries. The lym-

phatics to the right colon follow its arterial blood supply. A minimum of 12 lymph nodes

within the mesentery is considered an adequate resection when performing a right hemico-

lectomy for cancer.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications: Colon resection is performed for benign diseases, such as diverticulitis, isch-

emic colitis, volvulus, polyposis, bleeding from arteriovenous malformation, trauma,

inﬂ ammatory bowel disease, and curative treatment or palliation of malignant tumors of the

colon and rectum. The extent of resection is based on the vascular supply of the speciﬁ c lo-

cation of the tumor. Tumors at the hepatic ﬂ exure or on the proximal transverse colon can

be resected with an extended right hemicolectomy, which involves additionally taking the

blood supply and transverse colon to the left of the middle colic artery.

◆ Preoperative planning: In clinical practice throughout North America, an adequate mechan-

ical bowel preparation is generally considered desirable the day before surgical resection.

Preoperatively, intravenous antibiotics must be administered before the skin incision. A pre-

operative dose of subcutaneous heparin (5000 U) or a low-molecular-weight heparin is rec-

ommended to prevent deep venous thrombosis. Before induction of general anesthesia,

pneumatic compression boots are placed on both lower extremities and continued postop-

eratively until the patient ambulates on the ﬁ rst postoperative day.

◆ Anesthesia: General anesthesia is used.

CHAPTER

Right Hemicolectomy

Celia Chao

CHAPTER 58 • Right Hemicolectomy 653

STEP 3: OPERATIVE STEPS

1. INCISION

◆ A midline incision (Figure 58-1) is made, and a Thompson retractor is placed to retract the

anterior abdominal wall and increase exposure in the region of the right colon.

Incision

FIGURE 58 –1

654 Section IX • Colon

2. DISSECTION

◆ A standard exploration of the intra-abdominal cavity is performed to determine the extent

of disease and resectability. The peritoneal surface, liver, porta hepatis, mesenteric nodes,

and ovaries are examined. The right colon is mobilized from its retroperitoneal attachments

by incising the white line of Toldt (Figure 58-2).

◆ The cecum and ascending colon are retracted medially, exposing the right ureter and gonadal

vessels. Continuing superiorly along this retroperitoneal plane, the hepatocolic ligament is

divided to release the hepatic ﬂ exure (Figure 58-3).

◆ Posteriorly, the duodenum is identiﬁ ed and separated from the colon. The omentum is mo-

bilized off the transverse colon by dissecting along an avascular plane (Figure 58-4).

Incision of white

line of Toldt

FIGURE 58 –2

CHAPTER 58 • Right Hemicolectomy 655

Division of hepatocolic

ligament

FIGURE 58 –3

Dissection of omentum

from transverse colon

FIGURE 58 –4

656 Section IX • Colon

◆ If the omentum is adherent or close to the tumor, that portion of the omentum can be re-

moved en bloc with the resected colon. The points of transection of the terminal ileum and

transverse colon are decided based on the mesenteric blood supply (Figure 58-5).

◆ Using a gastrointestinal anastomosis (GIA) stapler, transect the terminal ileum 10 to 15 cm

from the ileocecal valve for lesions involving the cecum and approximately 5 cm for lesions

distal to the cecum (Figure 58-6).

◆ The transverse colon is divided in similar fashion with the GIA stapler just to the right of

the middle colic artery. The peritoneum to the mesentery is scored with electrocautery; the

vessels, and not the surrounding fatty tissue, can be more easily clamped and tied. The

mesentery corresponding to the points of resection are divided to the origins of the ileocolic

and right colic arteries to ensure adequate removal of the node-bearing tissue in the mesen-

tery.

Middle colic

vessels

Ileocolic

vessels

Right colic

vessels

Line of transection

Ligation of distal

ileomesenteric vascular

arcade

FIGURE 58 –5