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

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CHAPTER 63 • Ileoanal Anastomosis (Straight and J Pouch) 727

2.0 Vicryl suture

placed full thickness

through apical opening

of the pouch

FIGURE 63 –12

Anastomosis

completed

Pouch drawn

down to pelvis

2.0 Vicryl sutures

passed through

anal canal

FIGURE 63 –13

728 Section IX • Colon

Stapled Anastomosis

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

the proximal end of the bowel (Figures 63-14 and 63-15). A 29-mm circular intraluminal

stapler (ILS) is opened, and the anvil is placed in the lumen of the pouch, cinching the

purse-string down.

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

pled end of the bowel (Figure 63-16). The main rod is deployed so that it exits either

above or below the staple line. 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 pouch 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.

FIGURE 63 –14

FIGURE 63 –15

CHAPTER 63 • Ileoanal Anastomosis (Straight and J Pouch) 729

Ileal pouch

Anvil

Rectal pouch

Main rod

Circular intraluminal

stapler

Main rod and anvil

are connected

FIGURE 63 –16

730 Section IX • Colon

Brooke Ileostomy

◆ A protecting Brooke loop ileostomy may be created in the right lower quadrant through the

rectus abdominis muscle to protect the pouch while it heals.

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

to mark the proximal limb of the ileostomy to avoid confusion about 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 to the anterior rectus fas-

cia, 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 spigot-like protuberance that falls into the

ileostomy 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.

3. CLOSING

◆ A #10 closed suction Jackson-Pratt drain is placed in the pelvis.

◆ The omentum is moved to the side and placed in either paracolic gutter. Two Ochsner

clamps are placed at the umbilicus opposite each other. One sheet of Sepraﬁ lm is cut in half

and placed over the bowel under the incision. This minimizes adhesion formation and

makes reentry easier for future operations.

CHAPTER 63 • Ileoanal Anastomosis (Straight and J Pouch) 731

◆ The abdomen is closed using no. 1 polydioxanone (PDS) running suture.

◆ The subcutaneous tissue is irrigated with bacitracin irrigation, and the skin closed with staples.

◆ The umbilicus is reapproximated. A bacitracin-soaked cotton ball wrapped in Adaptic is

packed into the umbilicus as a bolster.

◆ A well-ﬁ tting ileostomy appliance is cut to size and placed so that skin is not visible around

the wafer. This prevents early production of sulcus from draining into the healing mucocu-

taneous wound.

STEP 4: POSTOPERATIVE CARE

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

◆ Adequate pain control is achieved using patient-controlled analgesia or epidural catheter.

◆ Consideration for stress ulcer prophylaxis should be given to patients with symptoms or

history of peptic ulcer disease.

◆ All patients should receive prophylaxis for deep venous thrombosis, using sequential com-

pression devices while in bed, and heparin 5000 U subcutaneously every 8 hours or enoxa-

parin 40 mg subcutaneously every morning, starting within 24 hours from surgery. Dosing

schedules should start on postoperative day 1, after results of morning laboratory tests are

back to ensure there is no signiﬁ cant drop in hemoglobin to suggest postoperative bleeding.

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

urimeter on the Foley bag. Adequate ﬂ uid resuscitation should be given based on the clini-

cal assessment of intravascular volume status.

◆ 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 ﬂ uids without carbonation and without a straw to

minimize accumulation of air in the intestine. This may be advanced ad lib as bowel func-

tion returns.

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

walk multiple times a day beginning on postoperative day 1 and should be encouraged to

do so frequently.

732 Section IX • Colon

◆ The umbilical bolster should be removed before the patient leaves the hospital. Skin staples

are removed in the ofﬁ ce during the postoperative visit.

◆ The ostomy care nurse should be consulted, and adequate postoperative education and

support should be given to the patient before discharge from the hospital.

◆ The closed-suction drain may be removed on postoperative day 3 or when the drainage has

decreased to less than 50 mL/day.

STEP 5: PEARLS AND PITFALLS

◆ Damage to the superior hypogastric plexus during high ligation of the IMA or to the hypo-

gastric nerves at the sacral promontory during mobilization of the upper mesorectum

results in retrograde ejaculation.

◆ Damage to the inferior hypogastric pelvic plexus may also result in urinary dysfunction due

to denervation and paralysis of the detrusor muscle.

◆ Damage to the nervi erigentes during lateral and anterior dissection in the pelvis results in

erectile dysfunction.

◆ Shortened ileocolic mesentery may preclude pouch placement in the pelvis. The patient

should be prepared to accept permanent ileostomy should this happen.

◆ Shortened small bowel mesentery or large body habitus may preclude formation of protect-

ing loop ileostomy. The right colon may be mobilized to provide additional distance.

◆ Care should be taken not to twist the small bowel mesentery when bringing out an ileos-

tomy or creating an ileoanal anastomosis. This can be done by identifying the SMA at the

root and “shaking hands” with the mesentery to feel for twists.

◆ Strong consideration should be made in using a loop ileostomy to protect the pouch. Most

patients with ulcerative colitis who are undergoing this procedure are malnourished, taking

high-dose steroids, and at increased risk for impaired wound healing and anastomotic leak.

The ileostomy may be reversed in 6 weeks after contrast study through the distal limb of

the loop conﬁ rms anastomotic integrity.

◆ Patients taking high-dose steroids should follow an appropriate tapering of dosage after dis-

charge from the hospital and should be cautioned on problems with wound healing.

CHAPTER 63 • Ileoanal Anastomosis (Straight and J Pouch) 733

SELECTED REFERENCES

1. Beck DE, Opelka FG: Perioperative steroid use in colorectal patients. Dis Colon Rectum 1996;39:

995-999.

2. FDA safety alert (12/11/2008): http://www.fda.gov/cder/drug/infopage/OSP_solution/default.htm

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;31:2125-31;2132 [discussion].

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

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

734

STEP 1: SURGICAL ANATOMY

◆ The mesorectum is covered by a visceral fascia and contains blood vessels, lymphatic chan-

nels, and lymph nodes.

◆ The pelvic sympathetic hypogastric nerves originate from the preaortic superior hypogastric

plexus and travel laterally and caudally, parallel to the ureters.

◆ The pelvic parasympathetic sacral splanchnic nerves originate from S3 and S4 nerve roots

and emerge from the sacral foramen to travel laterally and caudally on the pelvic side wall

before joining the hypogastric nerve.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Total mesorectal excision is indicated for all mid or low rectal cancers. Preoperative chemo-

radiation treatment is indicated for patients with T3, T4 lesions or tumors with enlarged

pelvic lymph nodes found on pelvic computed tomography (CT) scan or endorectal ultra-

sound.

◆ Appropriate bowel preparation such as GoLYTELY or four bisacodyl (Dulcolax) tablets fol-

lowed by HalfLytely should be administered the day before surgery. Preoperatively, a single

dose of broad-spectrum antibiotic (such as ertapenem) is administered.

◆ After induction of general anesthesia, the patient is placed in a lithotomy position with the

legs in padded stirrups at 30-degree abduction. A nasogastric tube is placed to prevent gas-

tric distention, and a urinary catheter is placed to decompress the bladder.

◆ Intraoperative rigid proctoscopy is performed to determine the distal extent of the cancer.

CHAPTER

Low Anterior Resection—

Total Mesorectal Excision

Tien C. Ko

CHAPTER 64 • Low Anterior Resection—Total Mesorectal Excision 735

STEP 3: OPERATIVE STEPS

1. INCISION

◆ A midline abdominal incision is made from the pubic symphysis to approximately 5 cm

cranial to the umbilicus.

◆ The midline fascia is divided with electrocautery. The peritoneum is elevated with tissue

forceps, and after ensuring that no bowel is entrapped by the graspers, the peritoneum is

incised sharply with a scalpel.

2. DISSECTION

◆ Once the peritoneum has been entered, a systematic exploration is performed to search for

metastatic diseases in the peritoneal cavity and the liver.

◆ A ﬁ xed retractor is placed to retract small bowel superiorly and laterally out of the operative

ﬁ eld. Retraction of small bowel is aided by placing the patient in a Trendelenburg position.

◆ Mobilization of the sigmoid colon is achieved by using electrocautery to incise the lateral

visceral fascia covering the mesosigmoid along the white line of Toldt, which can be easily

visualized by retracting the sigmoid colon medially. Working through this avascular plane

allows for easy identiﬁ cation of gonadal vessels and the left ureter as they course over the

left iliac vessels into the pelvis (Figure 64-1).

◆ The medial visceral fascia is incised with electrocautery, and the right ureter is visualized as

it courses over the right iliac vessels (Figure 64-2).

◆ The presacral space is entered by dividing the loose areolar tissue at the level of the sacral

promontory. The presacral space is developed sharply with electrocautery caudally toward

the levator ani muscle, under direct vision. A ﬁ ber-optic pelvic retractor is used for retrac-

tion of the bladder and the rectum to facilitate visualization in the pelvis. After the sharp

posterior pelvic dissection is completed, the distal margin can be manually evaluated

(Figure 64-3).

◆ The mesorectum is mobilized laterally toward both the right and left pelvic side wall, pre-

serving the hypogastric nerves on the sacrum. The mesorectum is divided laterally either

with clamps and sutures or with a vessel sealer device, such as LigaSure.

◆ The rectum is mobilized ventrally by dividing the rectovaginal septum or the rectovesicle

space. In males, the dissection plane is ventral to Denonvillier fascia, preserving the seminal

vesicles.

736 Section IX • Colon

Gonadal vessels

Tumor

Ureter

Iliac vessels

FIGURE 64–1