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) 697

◆ The clamp is pulled through, taking care that there are no twists in the mesentery and no

tension on the colostomy.

◆ The colostomy is matured in standard fashion after the abdomen is closed and the midline

incision is protected.

4. CLOSING

◆ Surgical gloves are changed, and the Alexis wound retractor is removed, as are all other

ports. Sepraﬁ lm is placed, 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 (50,000 U in 1 L saline).

◆ Staples are used to close the skin. A small umbilical bolster is created by placing a bacitracin-

soaked cotton ball wrapped in Adaptic into the umbilical depression. This is left in place

during the hospital stay and removed before discharge home.

◆ The orogastric tube is removed before extubation. A nasogastric tube should be placed if

there is extensive lysis of adhesions or other indication for maintenance of a nasogastric

tube postoperatively.

STEP 4: POSTOPERATIVE CARE

◆ The same principles of postoperative care followed for laparoscopic-assisted right colectomy

apply to laparoscopic-assisted left and sigmoid colectomy, and can be referred to in

Chapter 59.

STEP 5: PEARLS AND PITFALLS

◆ Division of the left colic artery may be necessary for adequate mobilization in creating a

tension-free anastomosis. The ascending branch of the left colic artery should be preserved,

allowing collateral ﬂ ow from the middle colic artery back to the ascending left colic artery

through the marginal arteries.

◆ Oncologic resection of the sigmoid colon mandates attention to preserve the meandering

artery of Riolan during high ligation of the IMA for maintaining collateral blood ﬂ ow to the

proximal left colon.

698 Section IX • Colon

◆ Consideration for placement of ureteral stents should be made for cases involving complicated

diverticulitis or large bulky tumors. Although stents have not been shown to prevent injury,

palpation of the stent may assist in timely recognition of ureteral location. In addition, injuries

may be identiﬁ ed earlier during the intraoperative period by visualization of the stent, thus

facilitating repair.

◆ The left ureter should be visualized and swept laterally before division of the IMA pedicle.

Failure to do this may involve inclusion of the ureter with the pedicle, leading to one of the

most common causes of ureteral injury during this procedure.

◆ High ligation of the IMA pedicle may injure the superior hypogatric (sympathetic) plexus

because of entrapment and division of the nerves. This results in retrograde ejaculation.

Care should be taken to identify the nerves and dissect them laterally before division of the

pedicle.

◆ A lip of omentum may be mobilized to buttress the anastomosis, a consideration to make if

the tissues are inﬂ amed or friable.

◆ The inferior epigastric artery may be visualized and avoided before making the incision for

an ostomy by transillumination of the anterior abdominal wall with the laparoscopic light.

◆ Tension on the ileostomy due to foreshortened mesentery or large abdominal pannus may

be relieved by mobilization of the right colon.

SELECTED REFERENCES

1. Aalbers AG, Biere SS, van Berge Henegouwen MI, Bemelman WA: Hand-assisted or laparoscopic-assisted

approach in colorectal surgery: A systematic review and meta-analysis. Surg Endosc 2008; 22:1769-1780.

2. Guidelines from the Joint Commission on Surgical Care Improvement Project Core Measurement Set.

Available on the Internet: www.jointcommission.org/PerformanceMeasurement.

3. 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].

699

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of the anatomy of the abdomen is critical before undertak-

ing total abdominal colectomy (Figure 62-1).

◆ The relationship of the colon to intraperitoneal and retroperitoneal attachments and struc-

tures should be fully understood.

◆ Particular attention should be paid to the location of the left ureter relative to the inferior mes-

enteric vascular pedicle. This is the most commonly injured area after vascular pedicle ligation.

CHAPTER

Total Colectomy

Valerie P. Bauer

Incision

FIGURE 62–1

700 Section IX • Colon

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications for total abdominal colectomy involve both emergent and elective scenarios for

treatment of:

◆ Ulcerative colitis

◆ Crohn’s disease of the large bowel with sparing of the distal sigmoid colon and rectum

◆ Attenuated familial adenomatous polyposis

◆ Synchronous multiple cancers

◆ Perforated cecum due to distal colon cancer obstruction

◆ Constipation

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

◆ If temporary or permanent ileostomy is planned, the patient should be marked preopera-

tively for either an end or loop ileostomy and educated concerning the new ostomy.

◆ Consideration for ureteral stenting should be made based on the extent of disease and prior

abdominal operations.

◆ Aspirin, other blood thinners, and vitamin E should be stopped for 10 days before the

procedure.

◆ Preoperative laboratory and cardiac evaluations should be obtained based on patient

comorbidities.

◆ Patients taking steroids preoperatively should receive a stress dose of hydrocortisone

100 mg intravenously (IV) before the operation. This should be continued postoperatively

and tapered accordingly.

◆ Consideration toward placing an epidural catheter preoperatively should be made for post-

operative pain control and minimization of parenteral narcotic use and associated postoper-

ative ileus.

◆ Bowel preparation should include mechanical bowel preparation of the surgeon’s choice.

Sodium phosphate bowel preparations should be used with caution because of acute phos-

phate nephropathy.

◆ Appropriate preoperative antibiotics are administered parenterally within 1 hour before cut

time, according to the Surgical Care Improvement Project (SCIP) quality measures deﬁ ned

for elective colorectal operations. We use ertapenem (Invanz) 1 g IV without redosing,

because it has 24-hour duration of action.

CHAPTER 62 • Total Colectomy 701

STEP 3: OPERATIVE STEPS

1. POSITIONING

◆ Proper positioning of the patient should be directed by the primary surgeon to ensure con-

sistency and safety to the patient.

◆ The patient should be placed supine on the operating table. After administration of anes-

thesia, sequential compression devices should be placed on the legs and a Foley catheter

inserted. The legs are placed in low lithotomy position with Allen stirrups. The boots are

adjusted so that each leg rests in a ﬂ exed position without pressure on the popliteal fossa.

Padding is used to shield the skin from all hard objects.

◆ Abdominal and pubic hair is clipped off.

◆ A Bair Hugger Warmer is placed across the patient’s chest.

◆ An orogastric tube is placed, to be removed after surgery unless a nasogastric tube is indi-

cated, as in cases of extensive lysis of adhesions.

◆ Rigid proctoscopy is performed to clean the rectum of residual stool and to conﬁ rm absence

of pathologic ﬁ ndings in the rectum that may need to be addressed in the operating room.

◆ The abdomen and perineum are prepped in standard fashion according to the surgeon’s

preference. The scrotum should be positioned away from the perineum.

702 Section IX • Colon

2. INCISION

◆ The pubic symphysis and manubrial notch are palpated and marked. A line is drawn down

the entire midline in case the incision needs to be extended during the later part of the pro-

cedure (Figure 62-2).

◆ A no. 10 blade knife is used to make an incision from a point 2 cm above the umbilicus

down to the pubic symphysis.

◆ The abdomen is entered sharply. Care is taken to dissect around the bladder obliquely. The

incision is extended through the pyramidalis muscle to the pubic symphysis.

◆ The abdomen is explored for additional pathologic abnormalities. The terminal ileum is

identiﬁ ed and the entire small bowel is run proximally to the ligament of Treitz. The liver is

palpated for the presence of masses.

Transverse colon

Descending colon

Ascending colon

Sigmoid colon

Inferior mesenteric artery

Superior rectal artery

Superior mesenteric artery

Middle colic artery

Right colic artery

Left colic artery

Ileocolic artery

Sigmoid arteries

Rectum

FIGURE 62–2

CHAPTER 62 • Total Colectomy 703

3. DISSECTION

◆ A Bookwalter retractor is set up. Laparotomy pads are placed along each side of the

abdominal wall. Two ratcheted short Richardson retractors are positioned opposite each

other in lower oblique fashion, taking care not to impinge on the femoral canal.

◆ The small bowel is packed upward using a moist blue towel with a radiopaque loop

attached to it, and a wide Deaver ratcheted retractor is bent and placed to maintain

exposure without compression of the aorta or inferior vena cava.

◆ In female patients, the uterus should be retracted by placing a ﬁ gure-of-eight stitch with

2-0 Vicryl through the posterior wall of the uterus as a retraction stitch. A ratcheted bladder

blade is then placed to retract the uterus and bladder.

◆ The surgeon on the right side of the patient pulls up on the sigmoid colon so that the lateral

peritoneal attachment is on tension (Figure 62-3). Electrocautery is used to divide the

attachment.

Lateral peritoneal

attachment

White line of Toldt

FIGURE 62–3

704 Section IX • Colon

◆ The recess at the base of the mesosigmoid, called the intersigmoid fossa, is identiﬁ ed and

delicately incised. The left ureter lies just deep to it and is identiﬁ ed and mobilized laterally.

The ureter courses medially and parallel to the gonadal vessels, another important land-

mark to identify (Figure 62-4).

◆ The surgeon to the left of the patient isolates the inferior mesenteric pedicle. This is done

by identifying the avascular window at the base of the mesosigmoid while tenting the mes-

entery up. The window is incised against the surgeon’s ﬁ nger from the right with electro-

cautery, and is extended proximally to the pelvic brim and distally down to the level of the

sacral promontory bilaterally.

◆ The peritoneal covering of pedicle is cut, and excess mesenteric fat is thinned in preparation

for ligation.

◆ Seurat clamps are used to divide the pedicle. A 2-0 Vicryl tie is used to ligate both the base

and specimen side of the pedicle. If the artery feels calciﬁ ed or has atherosclerotic plaque

visibly extruding from the vessel after clamping, a 2-0 Vicryl stick tie should be placed to

ensure hemostasis of the pedicle base (Figure 62-5).

◆ The rectosigmoid mesentery is sequentially clamped, divided, and ligated to the serosal

edge of the colon. The surface is cleaned of excess mesenteric and epiploic fat in prepara-

tion for division.

◆ Before division, the left colon is mobilized as much as possible by being divided from its

retroperitoneal lateral attachments upward toward the spleen (Figure 62-6).

Ureter

Gonadal vessels

FIGURE 62–4

CHAPTER 62 • Total Colectomy 705

Inferior mesentery artery

FIGURE 62–5

Spleen

Kidney

Omentum

FIGURE 62–6

706 Section IX • Colon

◆ Method of division of the rectosigmoid depends on whether intestinal continuity will be

reestablished. Either a linear stapler or division between two Ochsner bowel clamps may be

used to divide the bowel at the level of the sacral promontory (Figure 62-7). The proximal

rectosigmoid end is wrapped with a laparotomy pad and may be clamped if there is con-

cern for fecal leakage through the staple line during mobilization. The distal stump is

marked with a 2-0 Prolene suture for future recognition if reversal is a possibility.

◆ The Deaver blade is removed along with the blue towel. The transverse colon is pulled

downward, and the lesser sac entered by incising the ﬁ lmy attachment of the gastrocolic lig-

ament to the colon (Figure 62-8).

◆ The splenic ﬂ exure is mobilized by the surgeon standing on the patient’s right side. The

assistant may move to the position between the patient’s legs for improved visualization.

The splenocolic ligament is divided close to the bowel wall to avoid injury to the spleen

(Figure 62-9).

◆ Once the splenic ﬂ exure is down, the remainder of the gastrocolic ligament is detached

from the transverse colon.

◆ Attention is then turned to the right colon. The small bowel may be loosely packed away,

once again, depending on the surgeon’s preference.

Division of the

rectosigmoid

FIGURE 62–7