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

Подождите немного. Документ загружается.

CHAPTER 61 • Left and Sigmoid Colectomy (Laparoscopic-Assisted) 687

pedicle. Care should be taken to avoid division of nerve ﬁ bers during high IMA division,

which results in retrograde ejaculation in male patients.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Preoperative considerations for laparoscopic left and sigmoid colectomy are similar to those

outlined in Chapter 59.

◆ Bowel continuity may or may not be restored depending on the clinical circumstances.

◆ If an ostomy is planned, the patient should be marked preoperatively for either an end sig-

moid colostomy or loop ileostomy and educated concerning the new ostomy.

◆ Indications for laparoscopic left and sigmoid colectomy include:

◆ Benign polyps or lesions not amenable to endoscopic resection

◆ Malignant lesions located in the splenic ﬂ exure, descending colon, and sigmoid colon

◆ Diverticulitis of the sigmoid colon

◆ Complicated as deﬁ ned by history of perforation and abscess formation, stricture, and

ﬁ stula

◆ In immunocompromised patients (steroid-dependent and transplant patients)

◆ In select few who had multiple episodes of recurrent simple disease

◆ Crohn’s disease

◆ Sigmoid volvulus

◆ The hand-assisted technique is particularly beneﬁ cial in difﬁ cult cases, such as complicated

diverticulitis and Crohn’s disease, allowing for improved ease of dissection under operative

conditions that are normally challenging even in the open setting.

◆ Informed consent addresses complications as outlined in Chapter 59, but should include

possibility of damage to nerves, creating sexual dysfunction such as retrograde ejaculation.

STEP 3: OPERATIVE STEPS

1. POSITIONING

◆ The patient is placed supine on the operating table on a deﬂ ated bean bag covered with two

hospital sheets.

◆ After general endotracheal anesthesia is administered, a Foley catheter is placed along with

sequential compression devices on the lower extremities.

688 Section IX • Colon

◆ During the setup, the surgeon conﬁ rms with the anesthesia team that the proper preopera-

tive prophylactic antibiotic is being administered before initiating the procedure based on

measures deﬁ ned by the Physician Quality Reporting Initiative.

◆ The patient is placed in low lithotomy position using Allen stirrups. A soft roll is placed

under the pelvis to elevate and pad the hips.

◆ The arms are padded and tucked so that the top sheet comes over and underneath the bot-

tom sheet. Care is taken to ensure that all intravenous (IV) lines are padded away from the

skin to prevent pressure necrosis. The hands are placed in slightly ﬂ exed position with cir-

cular roll to prevent intraoperative movement.

◆ The bean bag is inﬂ ated with the sides and top corners turned up. Padding is placed

between the patient’s head and the walls of the bean bag. A blue towel is placed across the

patient’s chest on which heavy tape is used to encircle the patient on the operating table.

Attention is paid to ensure that the tape is not restricting to respiration.

◆ Abdominal and pubic hair is clipped off as needed.

◆ A warmer is placed appropriately to ensure normothermia during the procedure.

◆ An orogastric tube is placed by the anesthesia team for the duration of the procedure, to be

removed upon completion of the procedure.

◆ The surgeon stands to the right of the patient, with the assistant between the patient’s legs

or next to the surgeon on the right.

◆ Monitors are placed on the upper and lower left side of the patient.

◆ Digital rectal examination is performed, followed by rigid proctoscopy. This conﬁ rms a

clean rectal vault and absence of unappreciated rectal pathologic ﬁ ndings.

◆ The abdomen is prepped and draped in standard fashion according to the surgeon’s preference.

CHAPTER 61 • Left and Sigmoid Colectomy (Laparoscopic-Assisted) 689

2. INCISION

◆ Using a marking pen, mark the midline from the pubic symphysis to the xiphoid process to

facilitate midline entry if rapid conversion to an open procedure is needed.

◆ The laparoscopic instruments are positioned accordingly on the operative ﬁ eld to include a

30-degree laparoscope, two insufﬂ ation tubing devices attached to CO

tanks, electrocautery,

suction, and consideration for harmonic scalpel or LigaSure device.

◆ Port placement

◆ Hand-assisted laparoscopic technique

◆ A vertical midline incision is made 1 cm less than the width of the hand. It is carried

through the center of the umbilicus, which will make up for the difference in length.

◆ The abdomen is entered sharply. The midline fascia is divided beyond the limit of the

skin incision both proximally and distally. Visible adhesions are taken down in stan-

dard fashion.

◆ The GelPort (Applied Medical) is used by placing the Alexis retractor into the wound

and rotating the outer ring inward, thus tightening the ﬁ t. A 5-mm blunt-tipped port

is placed through the GelPort, which is attached to the outer ring. Insufﬂ ation is initi-

ated on high ﬂ ow to 15 mm Hg.

◆ The left hand is introduced through the GelPort and the laparoscope through the

5-mm port.

◆ Surgeons with larger hands may consider placing the camera through a 12-mm port in

the upper midline.

◆ A 12-mm port is placed in the right lower quadrant.

◆ The patient is placed in steep Trendelenburg position and airplaned to the left.

◆ Conventional technique

◆ The Veress needle or Hassan technique may be used to access the abdomen above the

umbilicus. A 12-mm port is placed in the right lower quadrant and a 5-mm port is

placed at the lower midline. A second 5-mm port may be placed in the right upper

quadrant for traction.

◆ The liver is visualized and inspected along with the peritoneal cavity for evidence of meta-

static disease. Laparoscopic intraoperative ultrasound may be performed at this time.

690 Section IX • Colon

3. DISSECTION

◆ The small bowel is retracted out of the pelvis and to the upper right of the abdomen. The

sigmoid is pulled upward, and the base of the mesentery is exposed.

◆ A medial to lateral approach is taken to identify the left ureter (Figure 61-1). The base of

the mesosigmoid is lightly scored, and the IMA pedicle is lifted up so that the ﬁ ne areolar

tissue beneath can be dissected away. The left ureter is identiﬁ ed and freed from the overly-

ing mesentery. It is retracted laterally.

◆ For oncologic resection of curable disease, a high ligation of the IMA is performed by skel-

etonizing and ligating the artery at its base, proximal to the origin of the left colic artery,

using a white-load endoscopic gastrointestinal anastomosis (GIA) stapling device. The po-

sition of the ureter is checked before ligation. High ligation for advanced cancer provides

no survival advantage and should not be performed; this is true for benign disease, as well.

◆ The posterior attachment of the descending colon to the retroperitoneum is mobilized by

dissecting the avascular ﬁ ne areolar plane proximally.

◆ The inferior mesenteric vein is identiﬁ ed and ligated proximally at the base of the pancreas

for oncologic resections, allowing a tension-free anastomosis (Figure 61-2).

◆ The lateral peritoneal attachments of the sigmoid colon are taken down. For sigmoid colec-

tomy, the base of the mesosigmoid is entered posteriorly at the sacral promontory, in the avas-

cular areolar plane. This is taken down to a point 5 cm distal from oncologic abnormality and

to the upper rectum (as evidenced by splaying of the taenia coli) for diverticular disease.

Inferior mesenteric vein

Inferior mesenteric artery

Inferior

mesenteric

artery

Ureter

Mesentery

Aorta

Inferior

vena cava

FIGURE 61 –1

CHAPTER 61 • Left and Sigmoid Colectomy (Laparoscopic-Assisted) 691

Spleen

Descending colon

Sigmoid

colon

Transverse

colon

Spleen

Kidney

Inferior

mesenteric

vein

Stomach

Pancreas

FIGURE 61 –2

692 Section IX • Colon

Endoscopic GIA

Sigmoid colon

Rectum

FIGURE 61 –3

◆ A window is cleared between the bowel and mesentery. Use of the harmonic scalpel facili-

tates this without major blood loss. Mesentery may be divided using the harmonic scalpel

or an endoscopic GIA white vascular load stapler. The colon or upper rectum may be

divided using a reticulating endoscopic GIA blue load stapler (Figure 61-3). Care should

be taken to ensure that the bowel is laid out like a “table,” perpendicular to the staple line

to minimize an oblique division, undue thickness of the tissue, and inclusion of devascular-

ized segment in the anastomosis.

◆ The splenic ﬂ exure is mobilized for left colectomy and for creation of tension-free anasto-

mosis in sigmoid colectomy (Figure 61-4). In addition, if bowel continuity is not being

restored, mobilization will prevent tension on an end colostomy and subsequent retraction.

This is done by taking the lateral peritoneal attachment of the white line of Toldt down.

The gastrocolic ligament is divided at its colonic attachment in the distal transverse colon,

and the lesser sac is entered (Figure 61-5). The lienorenal ligament is divided, and the ret-

roperitoneal attachments are bluntly taken down.

◆ The proximal end of the anastomosis is determined according to the pattern of vascular

demarcation and location of the pathologic ﬁ nding. In diverticular disease, an area free of

thickened colon is selected despite the possible presence of proximal diverticula.

◆ Pneumoperitoneum is reversed, and the mobilized segment is exteriorized.

CHAPTER 61 • Left and Sigmoid Colectomy (Laparoscopic-Assisted) 693

Splenic flexure

Blunt dissection

of retroperitoneal

attachment of

left colon

FIGURE 61 –4

Omentum

Spleen

Splenic-flexure

Gastrocolic ligament

FIGURE 61 –5

694 Section IX • Colon

Primary Anastomosis

◆ The decision to restore bowel continuity depends on the primary diagnosis and clinical

scenario.

◆ The mesentery to the proximal end of the anastomosis is clamped, divided, and ligated. An

Ochsner bowel clamp is then placed across the bowel, and the specimen is divided and

passed off the ﬁ eld. The proximal lumen of the colon is inspected for abnormalities and irri-

gated with saline. Care is taken to ensure full sterile technique is maintained without fecal

spillage.

◆ A purse-string suture using 2-0 Prolene on an SH needle is taken circumferentially around

the proximal end of the bowel. A 29-mm circular intraluminal stapler (ILS) is opened, and

the anvil is placed in the lumen, synching the purse-string down (Figure 61-6, A).

◆ The colon is replaced into the abdomen, and a pneumoperitoneum is recreated. An anvil

grasper is used to pick up the anvil in the conventional laparoscopic technique. The left

hand is used to guide the anvil to the pelvis in the hand-assisted technique.

◆ The perineal operator places the circular stapler into the rectum and is directed to the sta-

pled end of the bowel. The main rod is deployed so that it exits either above or below the

staple line (Figure 61-6, B). The main rod and anvil are attached. The mesentery is

checked for twists and for undue tension. The circular stapler is tightened and ﬁ red. The

resulting rings are inspected for completion.

◆ A leak test is performed by introducing air into the rectum while occluding the proximal

bowel. The anastomosis is submerged in saline and placed under intraluminal air tension.

Presence of bubbles suggests an incomplete staple line and should be addressed accordingly.

◆ Loop ileostomy may be created to divert the fecal stream away from the distal anastomosis

in the presence of unhealthy tissue or a tentative anastomosis.

CHAPTER 61 • Left and Sigmoid Colectomy (Laparoscopic-Assisted) 695

Purse-string

suture

Main rod

Proximal

colon

Proximal colon

Anvil

Intraluminal stapler

Rectum

FIGURE 61 –6

696 Section IX • Colon

Protecting Loop Ileostomy

◆ The following outlined steps may be done with the open abdomen using the Alexis wound

retractor (Applied Medical) through the incision made to exteriorize the resected segment of

colon.

◆ Umbilical tape is passed between the mesentery and distal ileum. A Vicryl stitch may be

used to mark the up side of the ileostomy to avoid confusion in which side to mature.

◆ Two Ochsner clamps are placed on the anterior fascia of the rectus muscle, and an Allys

clamp is placed on the skin between the two. The assistant maintains even traction so that

all layers are parallel and aligned.

◆ An Ochsner clamp is placed on the skin over the ileostomy site and pulled up. A no. 10

blade knife is used to cut a circular disc.

◆ Electrocautery is used to cut through subcutaneous tissue down anterior rectus fascia,

which is sharply divided. Muscle ﬁ bers are spread perpendicularly, and the peritoneum is

cut longitudinally enough to snugly ﬁ t two ﬁ ngers. Injury to the inferior epigastric vessels

should be avoided.

◆ The ileostomy is wrapped in Sepraﬁ lm and brought out of the abdominal cavity through

the ostomy site on traction using the umbilical tape for a length of at least 4 cm, taking care

not to twist the mesentery. This will minimize adhesions and facilitate ease of takedown at a

later time.

◆ The proximal limb is conﬁ rmed by visualizing the suture, and a transverse incision is made

across the ileum using Bovie electrocautery.

◆ Vicryl sutures are placed through the mucosa at points equidistant from each other on the

proximal limb, then through the seromuscular layer proximally at the skin level, and then to

skin. The proximal limb is everted to form a spicket-like protuberance that falls into the ile-

ostomy bag, diverting the sulcus away from the level of the skin. The distal limb is sutured

to the inferior portion of the skin edge without eversion.

◆ The appliance is cut to ﬁ t circumferentially so that there are no gaps exposing the skin at

the end of the procedure after skin is closed.

End Colostomy

◆ A left lower colostomy site is created in a similar fashion to the aforementioned technique

for creation of a loop ileostomy.

◆ An Ochsner bowel clamp is passed through the aperture of the ostomy site and placed on

the edge of the bowel to be exteriorized.