Lateral internal sphincterotomy Indication Surgery is indicated when medical therapy fails. Anal dilatation has been abandoned in favor of lateral internal sphincterotomy because the latter process is more controlled and incontinence is less common. Position of patient Lithotomy. Procedure This is done as a day procedure under general anesthesia. (cid:142)(cid:3) Perfor m a digital rectal examination and sigmoidoscopy. (cid:142)(cid:3) Introduce a bivalve anal speculum. Open it gradually to put the fibers of the internal sphincter on the stretch. (cid:142)(cid:3) Ask the assistant to apply traction to perianal skin. (cid:142)(cid:3) Pal pate the intersphincteric groove in the 3 o \200\231clock position. (cid:142)(cid:3) Infilt rate local anesthetic with 1:200 000 adrenaline in the groove and make a 1cm incision along the groove. (cid:142)(cid:3) The lower border of the internal sphincter is identified as a white band. Using blunt ended scissors develop the intersphincteric and submucosal planes. Divide the i nternal sphincter to the level of the dentate line. (cid:142)(cid:3) Excise any skin tag or hypertrophied internal papilla. (cid:142)(cid:3) Ap ply pressure to achieve haemostasis. Leave the wound open. Flap repairs may be used for rec urrent fissure after sphincterotomy and where risk to continence is high. Postoperative complications (cid:142)(cid:3) Incontinence (cid:142)(cid:3) Recurrence/persi stence (cid:142)(cid:3) Bleeding/haematoma. FISSURE-IN-ANO1 227 Fig. 7.1 Lateral internal sphincterotomy Divided internal sphincter Posterior fissure Fig. 7.2 Lateral internal sphincterotomy: technique and result CHAPTER 7 Colorectal surgery 228 Hemorrhoids Degeneration of the supporting structures of the three anal cushions causes the m to prolapse leading to development of hemorrhoids. The majority of patients present with intermittent, small rectal bleeds and require no treatment other than reassurance and dieta ry advice but thorough evaluation is necessary to exclude other pathologies such as inflamm atory bowel disease and malignancies. Examination should include inspection of the perineum , digital rectal examination, proctoscopy and sigmoidoscopy, and full colonic examination m ay be required by colono- scopy or barium enema. Injection sclerotherapy Indication Persist ent haemorrhoidal bleeding or small anterior mucosal prolapses. The aim of the procedure is to cause submucosal fibrosis. Position Left lateral. Procedure Done as an outpatient proce dure. (cid:142)(cid:3) Draw up 10 \200\22315ml of 5% phenol in almond oil into a Luer lock syringe with a shouldered Gabriel needle. (cid:142)(cid:3) Pass a proctoscope and identify the left lateral, right anterior, and righ t posterior internal hemorrhoids. (cid:142)(cid:3) Inject 3 \200\2235ml of the solution under vision into the submucosa above each haemorrhoid. The correct plane of injection is indicated by elevation of the mucosa. Review the patient at six weeks and repeat the procedure if necessary. Rubber band ligation Indication Persistent haemorrhoidal bleeding and prolapsing. The aim of the procedure is t o fix the mucosa thereby preventing prolapse. Contraindication Anticoagulation and immunoco mpromise. Position Left lateral. Procedure Done as an outpatient procedure. (cid:142)(cid:3 ) Pass a proctoscope and identify the internal hemorrhoids. Non-suction banders require an assistant to keep the proctoscope in position. (cid:142)(cid:3) Grasp the mucosa above the haemorrhoid and draw it into the barrel of the loaded ligator. Suction banding frees the surgeon \200\231s left hand to hold the proctosco pe in position whilst applying suction to draw the mucosa into the bander. It is important to make sure before releasing the band that the grasping or suction on the mucosa does not cause pain. If it does, apply the banding to a more proximal position above the anorectal r ing. hemorrhoids1 229 Fig. 7.3 Equipment for injection sclerotherapy Fig. 7.4 Equipment for rubber band ligation Site for injection/rubber band ligation Fig. 7.5 Site for injection/rubber band ligation CHAPTER 7 Colorectal surgery 230 Warn the patient that it is usual to feel some rectal discomfort and a desire to defaecate for the next 2 \200\2233 days and that a small amount of bleeding or the passage of a \200 \230blackberry-like \200\231 thrombosed pile is common between 4 \200\22310 days. Review th e patient at six weeks and repeat the procedure if necessary. Haemorrhoidectomy Indication (cid:142)(cid:3) Prolapsing hemorrhoids with symptomatic external hemorrhoids (pain, swelling). (cid:142)(cid:3) Second degree hemorrhoids (reduce spontaneously) and third degree hemorrho ids (needing to be reduced manually) that do not respond to out-patient procedures. (cid:142)(cid:3) Fourth degree hemorrhoids (which remain prolapsed permanently). Position L ithotomy or prone jack-knife with general anesthetic. Procedure Usually done as an inpatient. (cid:142)(cid:3) Prepare the skin, towel up and sha ve the perineum. Insert a bivalve anal speculum and assess the position and size of the hem orrhoids. Start with the most posterior lying haemorrhoid so that blood does not obscure vi sion. (cid:142)(cid:3) Apply artery forceps to the skin at the edge of the external haemorrhoid a nd incise the skin with cutting diathermy. (cid:142)(cid:3) Continue the dissection medially with diathermy and insert the bivalve speculum once the anal margin is reached. (cid:142)(cid:3) Continue to carefully separate the internal haemorrhoidal tissue from the white internal sphincter muscle fibers using diathermy. (cid:142)(cid:3) Achieve haemos tasis with diathermy during this dissection. (cid:142)(cid:3) Divide mucosa at the apex of the haemorrhoid with diathermy or by transfixing with 2/0 Vicryl. (cid:142)(cid:3) Repeat the procedure to excise the hemorrhoids in other positions, taking care to keep skin bridges between excisions to avoid anal stenosis. During the operation re peatedly remove and reinsert the speculum to avoid overstretching the sphincter. (cid:142)(cid:3) At the completion of the procedure an anal pack is not required. Stool softeners may aid postoperative pain. Perform digital rectal examination and proctoscopy 4 \200\2236 weeks after discharge. The above description is of an open technique using diathermy. In the closed technique the skin edges and the mucosa are sutured together. Postoperative complications (cid:142)(cid:3) Incontinence/major incontinence (cid:142)(cid: 3) Acute urinary retention (cid:142)(cid:3) Recurrence/persistence (cid:142)(cid:3) Stenosi s (cid:142)(cid:3) Bleeding/haematoma. hemorrhoids1 231 Haemorrhoid dissected off the internal sphincter Internal sphincter muscle fibers Fig. 7.6 Haemorrhoidectomy CHAPTER 7 Colorectal surgery 232 Circular stapled haemorrhoidectomy (see also p366) A new technique where a circular staplin g device introduced per-anally is used to excise a rim of rectal mucosa above the hemorrhoi ds. The result is the prolapsed haemorrhoidal tissue is drawn back into a more physiologica l position and its blood supply is interrupted. The procedure claims to be less painful and allows rapid post operative recovery. Perianal haematoma Haematoma due to rupture of an anal venule. Surgery is indicated if the patient presents early with a painful lump. Incise the skin over the swell- ing and evacuat e the clot. This can be done under local or general anesthesia. Thrombosed or strangulated hemorrhoids Conservative treatment is usually successful. Immedi ate surgery, if under- taken, should be under antibiotic cover and carried out by an experi enced surgeon. hemorrhoids1 233 Prolapsed mucous membrane drawn into the casing Fig. 7.7 Circular stapled haemorrhoidectomy \200\224insertion of stapling device Staple line Fig. 7.8 Circular stapled haemorrhoidectomy \200\224final result CHAPTER 7 Colorectal surgery 234 Fistula-in-ano The majority of fistulas-in-ano arise from a diseased anal gland in the inte r-sphincteric space. They are classified as crypto-glandular. Crohn \200\231s disease, infe ctions, hydradenitis suppurativa, and malignancy may be associated with fistulas. Preparati on Warn the patient of the possibility of further procedures if a complex or high fistula i s encountered. A phosphate enema is administered one hour prior to the procedure. Position Lithotomy. Procedure Carried out under general anesthetic usually as a day case procedure. (cid:142)(cid:3) Perform rigid procto-sigmoidoscopy. (cid:142)(cid:3) Identify the position of the external opening (or openings). Goodsall \200\231s rule is helpful in predicting th e direction of tract. It states that a fistula where the external opening is situated behin d the transverse anal line has a curved tract and opens in the posterior midline whereas an teriorly placed openings have straight tracts with an internal opening in the corresponding quadrant of the anal canal. (cid:142)(cid:3) Palpate the peri-anal skin carefully for induration. This helps to indicat e the course of the fistulous tract. (cid:142)(cid:3) Perform a digital examination of the ano-rectum to feel for the internal opening and any supra-levator induration. (cid:142)(cid:3) Insert an Eisenhammer proctoscope and look for the internal opening. (cid: 142)(cid:3) Gently insert a Lockhart \200\223Mummery fistula probe in the external opening and ascertain the direction and depth of the tract. Look for secondary tracts. Allo w the tip to exit through the internal opening. Bend the probe to bring the tip outside the anal orifice. FISTULA-IN-ANO1 235 1 2 4 3 Fig. 7.9 Types of fistula-in-ano. 1) Superficial; 2) Inter-sphincteric; 3) Trans-sphincteri c; 4) Supra-sphincteric Anterior fistulas direct Posterior fistulas curved Fig. 7.10 Goodsall \200\231s law CHAPTER 7 Colorectal surgery 236 (cid:142)(cid:3) Using diathermy cut onto the probe to lay open superficial, inter-sphincteric and low trans-sphincteric tracts. Use self-retaining retractors to expose the tract. Curette the granulation tissue away. Send tissue from the tract for histologica l examination. Cut away any overhanging skin edges. Lay open any secondary extensions. (cid :142)(cid:3) When the exact position and level of the tract in relation to the external sphincter is not clear insert a loose Setons such as a vascular sling or non-absor bable suture. Seton can similarly be used to drain acute infection secondary to a fistula-i n-ano with definitive surgery being deferred until the acute inflammation settles. (cid:142)(cid:3) Lay open the tract outside the sphincters when you encounter a high trans- sphincteric or supra-sphincteric tract. Encircle the muscle with a Seton. Tighten it at two weekly intervals until it cuts through. This allows the gradual severance of the muscle fo llowed by fibrosis. Advancement flaps have been used as an alternative method of sphincter preservation in this situation. Emphasize proper care of open wounds to prevent superficial healing before heal ing has taken place from the depths outwards. Postoperative complications (cid:142)(cid:3) Incontinence (cid:142)(cid:3) Recurrence/persi stence (cid:142)(cid:3) Bleeding/haematoma. FISTULA-IN-ANO1 237 Fig. 7.11 Laying open of fistula tract CHAPTER 7 Colorectal surgery 238 Pilonidal sinus Pilonidal sinus occurs most commonly in the natal cleft. Enlargement of hai r follicles with ingress of exogenous hairs results in the sinus, which may be asymptomatic . Treatment is only indicated when there is symp- tomatic disease. It may present acutely w ith cellulitis or as an abscess. The former may resolve with the use of antibiotics but an abscess requires drainage of pus, which can be done under local anesthetic using a stab inc ision. The sinus is treated electively once the acute infection has settled. Surgical options Pilonidal sinus may also present as a result of chronic infection with dis charge. The options are laying open of the tracts, wide excision with or without primary mi dline closure, asymmetric closure using Karydakis or Bascome \200\231s technique and Rhombo id flaps and Z-plasty. Low recur- rence and high primary healing rates have been achieved b y techniques which result in the main wound being placed away from the midline and which ob literate the natal cleft. Bascome \200\231s cleft closure technique can be done under local anesthetic as a day case procedure. Position Prone with table jack-knifed and the buttocks separated using tapes to expose the natal cleft. Procedure (cid:142)(cid:3) Excise the affected skin in the midline and laterally. (cid:142) (cid:3) Lay open and curette the underlying sinus and chronically infected tissue. (cid:142)(cid:3) Suture the exposed fat together. (cid:142)(cid:3) Mobilize a flap of skin from the opposite side and suture it laterally over a suction drain. Postoperative complications (cid:142)(cid:3) Recurrence (cid:142)(cid:3) Wound infection an d dehiscence. PILONIDAL SINUS1 239 Fig. 7.12 Bascome \200\231s cleft closure technique CHAPTER 7 Colorectal surgery 240 Rectal prolapse Full thickness rectal prolapse can be treated by perineal and abdominal pro cedures. Delorme \200\231s procedure Position Lithotomy. Procedure (cid:142)(cid:3) Allow the rectum to prolapse to its full extent. (cid:142)(cid:3 ) Infiltrate saline containing 1 in 200 000 adrenalin in the sub-mucosal plane. (cid:142)(cid:3) Make a circumferential incision in the mucosa, 1cm proximal to the dentate line. (cid:142)(cid:3) Using diathermy carefully separate the mucosa circumferentially from muscle. Continue until the apex of the prolapse is reached. (cid:142)(cid:3) Plicate the mu scle tube using 4 \200\2238 individual absorbable sutures. (cid:142)(cid:3) Divide the muco sal cylinder in stages and approximate the mucosal ends with interrupted absorbable sutures. Postoperative complications (cid:142)(cid:3) Recurrence (cid:142)(cid:3) Bleeding, infectio n, obstruction. Laparoscopic abdominal rectopexy Position Lloyd-Davies. Procedure Catheterise the patient. (cid:142)(cid:3) Make a vertical skin incision within th e umbilicus. Expose the linea alba. Place two anchoring fascial sutures and incise linea al ba between them. (cid:142)(cid:3) Open peritoneum and insert a Hassan cannula. (cid:142)(cid:3) Create pneum operitoneum. (cid:142)(cid:3) Under laparoscopic vision insert a 5mm cannula in both iliac fossae. If necessary insert an additional 5mm suprapubic port to keep the sigmoid colon in left upper quadrant. (cid:142)(cid:3) Usually 30 \200\22340(cid:13) of head down tilt is needed to keep small bo wel out of the pelvis. Achieve this in stages to allow the anesthetist to adjust ventilation. (cid:142)(cid:3) Insert two transcutaneous straight needled sutures to encircle Fallopian tubes to elevate uterus out of the way. (cid:142)(cid:3) Grasp the recto-sigmoid junction to tense the root of the mesocolon. (cid: 142)(cid:3) Dissect with harmonic scalpel over the sacral promontory. Enter the bloodless plane behind the mesorectum. (cid:142)(cid:3) Divide the peritoneum on the right and dissect down to the pelvic floor. There is no need to divide the peritoneal reflection anteriorly, but complete mobili zation on the right and posteriorly. (cid:142)(cid:3) Swing the sigmoid colon to the right and divide the peritoneum on the left. RECTAL PROLAPSE1 241 Mucosa separated circumferentially and sutures in place to plicate muscle Fig. 7.13 Delorme \200\231s procedure Muscle plicated Mucosal ends approximated Fig. 7.14 Delorme \200\231s procedure CHAPTER 7 Colorectal surgery 242 (cid:142)(cid:3) Identify the ureter and dissect medial to it. (cid:142)(cid:3) Choose the points in the mesocolon for fixation to the sacral promontory. Place a suture through the mesorectum and sacral promontory on each side. (cid:142)(cid:3) Close the defect in the sigmoid mesocolon. (cid:142)(cid:3) Leave a drain in the pelvis. (cid:142)(cid:3) Remove uterine sutures. (cid:142)(cid:3) Remove carbon diox ide and withdraw cannula. (cid:142)(cid:3) Close fascia of 10mm port site. (cid:142)(cid:3) Use Steristrips to approximate skin. (cid:142)(cid:3) Infiltrate wounds with local anesthe tic. Open abdominal rectopexy can similarly be carried out using sutures or mesh. Postoperative complications (cid:142)(cid:3) Recurrence (cid:142)(cid:3) Bleeding, infectio n, obstruction, and inadvertent bowel injury. RECTAL PROLAPSE1 243 Fig. 7.15 Port placement for laparoscopic abdominal rectopexy (two 5mm and one infra umbili cal 10mm port) CHAPTER 7 Colorectal surgery 244 Acute anorectal infection (abscess) Anorectal infection is usually linked to anal gland inf ection and is com- monly associated with a fistula. Anorectal infection may also be seen in association with Crohn \200\231s disease, hydradenitis suppurative, and malig- nancy. Pati ents with perianal abscesses present with pain and a palpable tender lump at the anal margi n. Those with an ischiorectal abscess have tenderness, induration, and fullness in the isch iorectal fossa. An inter- sphincteric or submucous abscess should be suspected in a patient with persistent anal pain and no obvious perianal abnormality. See Figs. 7.16 \200\22317. Position Lithotomy. Procedure The procedure is performed under general anesthetic. (cid:142)(cid:3) Make a cruc iate incision over the swelling and deepen it to the abscess cavity. (cid:142)(cid:3) Take a swab for bacteriology. (cid:142)(cid:3) Gently break down the fibro us septa in the ischiorectal fossa. (cid:142)(cid:3) Remove the corners of the incisions so that free drainage is provided and the final opening represents the entire floor of the ab scess cavity. (cid:142)(cid:3) Loosely pack the cavity with an alginate dressing. (cid:142)(cid:3) Do not attempt to probe for a fistula tract or to lay it open. Aftercare with loose packing and d ressing ensures that healing occurs from deep to superficial and lessons risk of a further abscess. Postoperative complications (cid:142)(cid:3) Development of fistula-in-ano (cid:142)(cid:3) Bleeding/haematoma. ACUTE ANORECTAL INFECTION (ABSCESS)1 245 5 3 1 2 4 Fig. 7.16 Spread of infection from anal gland infection. 1) Submucous; 2) Perianal; 3) Inte r-sphincteric; 4) Ischiorectal; 5) Pelvirectal Skin corner being removed after making crutiate incision Fig. 7.17 Incision and drainage of perianal abscess CHAPTER 7 Colorectal surgery 246 Appendicectomy Appendicitis is the most common major abdominal condition necessit- ating em ergency operation. The exception to this is when an appendix mass is found without evidence of general peritonitis. Preoperative preparation (cid:142)(cid:3) Give prophylactic metronidazole suppository or in travenously when the diagnosis is made. Prophylaxis with antiaerobic agent, such as a cepha losporin can be given IV at induction of anesthesia. (cid:142)(cid:3) Commence IV fluids an d naso-gastric aspiration if generalized peritonitis. Open appendicectomy Position Supine. Incision (Fig. 7.18) Lanz. Procedure (Fig. 7.18) Palpate the abdomen again with the patient anesthetized as it may hel p to locate the position of the appendix. If a circumscribed lump or a dif- fuse thickening is felt, plan the incision accordingly. (cid:142)(cid:3) Divide the aponeurosis of the ext ernal oblique in line with its fibers and split the internal oblique and transversus muscle s. Retract the muscles to expose the peritoneum. (cid:142)(cid:3) Open the peritoneum between artery forceps. If wider access is required the internal oblique and transversus muscles can be divided in line with the fiber s of the external oblique. Do this medially or laterally as required. (cid:142)(cid:3) Aspirate serous exudate or frank pus and send a sample for culture and sensitivity. (cid:142)(cid:3) Identify the caecum. Pick it up with fingers or Babcock \200\231s forceps applied to the tinea coli and slowly and carefully draw the caecum to the surface. If the a ppendix does not come into view pass an index finger along one of the tinea to their juncti on at the appendix base and then lift it out. If delivery of the appendix is difficult then create further access between forceps and ligate it to free under vision. (cid:142)(cid:3) Hold up the appendix with tissue forceps applied around it. Divide the mes oappendix with the appendicular artery between forceps and ligate it. Identify the base of the appendix, apply artery forceps to the base to crush it then apply again more distally. Ligate the crushed appendix area more proximally. APPENDICECTOMY1 247 Umbilicus 1 Anterior superior illiac spine 2/3 2 1/3 Pubic tubercle Fig. 7.18 Incisions for appendicectomy. 1) McBurney; 2) Lanz Appendix mesentery and appendical artery ligated and divided Ligate and bury appendix stump with a purse-string suture Fig. 7.19 Appendicectomy CHAPTER 7 Colorectal surgery 248 (cid:142)(cid:3) Pass a purse-string sero-muscular suture in the caecum about 1cm from the base of the appendix using a 3/0 Vicryl. Divide the appendix flush with the under surface of the artery forceps. Place the appendix and the instruments in a dirty dish takin g care during and after division not to soil the wound or the peritoneum. (cid:142)(cid:3) Invaginate the stump and tie the purse-string suture. If the caecal wall i s oedematous and friable, this is not necessary. If the inflamed appendix is retro-caecal and cannot be delivered into the wound carry out a retrograde appendicectomy. Dividing the appendix first at its base, invaginating the stump and then dividing the meso- appendix in small segments. If the omentum is adherent to the inflamed appendix remove it with the appendix. If a mass is encountered after opening the peritoneum, surround it with moist packs and gen tly explore the mass with the finger. Aspirate any pus, isolate the appendix and remove it in the usual way. If the appendix is divided at the site of the perforation take care to re move the entire appendix. If the diagnosis of acute appendicitis was incorrect, most local abnor- malities can be dealed with by extending the incision as described above. (cid:142)(cid:3) Make an appropriate vertical laparotomy incision if exposure is still inadequate or the abn ormality lies outside the reach of the Lanz incision. (cid:142)(cid:3) If normal appendix is found search for an inflamed Meckel \200\231s diverticulum. Closure (cid:142)(cid:3) Close the peritoneum with Vicryl. (cid:142)(cid:3) Allow the split muscles to fall together. Suture the external oblique aponeurosis with Vicryl. (cid:142)(cid:3) Close the skin incision with interrupted or subcuticular sutures. Drainage is not generally used after appendicectomy. Postoperative complications (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Pelvic or abd ominal abscess (cid:142)(cid:3) Paralytic ileus (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3 ) Incisional hernia. This page intentionally left blank CHAPTER 7 Colorectal surgery 250 Laparoscopic appendicectomy Especially useful in women of child bearing age when the diagno sis of acute appendicitis is in doubt. Position Lithotomy. Procedure Empty bladder before commencing the operation. (cid:142)(cid:3) Make a vertical s kin incision within the umbilicus. Expose the linea alba. Place two anchoring fascial sutur es and incise the linea alba between them. (cid:142)(cid:3) Open peritoneum and insert Hassan cannula. (cid:142)(cid:3) Create pneumop eritoneum. (cid:142)(cid:3) Under laparoscopic vision place a 10mm and 5mm cannulae in the right and left iliac fossa respectively avoiding the inferior epigastric vessels. (cid:142)(cid:3) Table is tilted head down with left lateral position. (cid:142)(cid:3) Exp ose the appendix by displacing the ileum and caecum using atraumatic grasping forceps. (cid:142)(cid:3) Ligate or clip the mesoappendix and its artery. (cid:142)(cid:3) Apply two ligatures at the base of the appendix and transect the appendix between them. The appendix stump is not buried. (cid:142)(cid:3) Visualization of the Fallopian tubes and ovaries is aided by manipulating the uterus with fingers placed in vaginal fornices. (cid:142)(cid:3) The appendix is removed through the 10mm cannula or by placing it in an endo bag, if bulky/friable. (cid:142)(cid:3) Lavage with normal saline. (cid:142)(cid:3) Remove carbon dioxide and with draw cannula. (cid:142)(cid:3) Close fascia of 10mm port sites. (cid:142)(cid:3) Use Steris trips to approximate skin. (cid:142)(cid:3) Infiltrate wounds with local anesthetic. Postop erative complications (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Pelvic or intra-abd ominal abscess. APPENDICECTOMY1 251 Fig. 7.20 Port sites for laparoscopic appendicectomy Dissection of mesoappendix Clips applied to artery Ligation of appendix with loop Appendix divided between loops Fig. 7.21 Laparoscopic appendicectomy CHAPTER 7 Colorectal surgery 252 Excision of Meckel \200\231s diverticulum Meckel \200\231s diverticulum is the persistence of a segment of vitello-intestinal duct on the anti-mesenteric border of the ileum. It is f ound in 2% of the population within two feet of the caecum (80cm) and is generally two inch es long (5cm). Indications (cid:142)(cid:3) Acute inflammation (cid:142)(cid:3) Bleeding from ectopic gast ric mucosa (cid:142)(cid:3) Intestinal obstruction \200\224volvulus around a persistent ban d or adhesion, intussusception (cid:142)(cid:3) An incidental finding at laparotomy. Consider excision of it because of th e risk of associated pathology. A wide-mouthed, thin-walled unattached diverticulum in an a dult patient may be left alone. Position Supine. Procedure The choice is between either diverticulectomy or excision of the seg- ment of ile um carrying the diverticulum. (cid:142)(cid:3) Isolate the segment of ileum containing the diverticulum. Ligate any supplying vessels. (cid:142)(cid:3) Apply light occlusion clamps to the ileum and divide the diverticulum at i ts base and close the bowel wall transversely. The diverticulum can also be removed by a si ngle firing of a transverse stapler. (cid:142)(cid:3) Resect the segment of ileum in patients with peptic ulceration or diverticulitis affecting the base. (cid:142)(cid:3) Restore intestinal continuity by a single or two layer anastomosis. Postoperative complications (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Pelvic or int ra-abdominal abscess (cid:142)(cid:3) Ileus (cid:142)(cid:3) Incisional hernia (cid:142)(ci d:3) Anastomotic leak. EXCISION OF MECKEL \200\231S DIVERTICULUM1 253 Fig. 7.22 Excision of Meckel \200\231s diverticulum \200\224extent of excision Fig. 7.23 Anastomosis following excision CHAPTER 7 Colorectal surgery 254 Ileostomy The terminal ileum is exteriorized as a spout in the right iliac fossa. Efflu- en t is collected in a collecting bag (ileostomy bag). The ileostomy may be formed as a loop o f bowel to divert enteric contents temporarily or more permanently as an end stoma. End ile ostomy Indication After proctocolectomy for inflammatory bowel disease, rarely for patients with familial adenomatous polyposis and patients with synchronous colo- nic and rectal can cers. Preparation The ileostomy should be sited in the right iliac fossa clear of the umbil i- cus and anterior superior iliac spine and avoiding any scars or depres- sions. The optim al stoma site is identified and marked preoperatively. Position Supine or Lloyd-Davies posi tion to allow a combined abdomino-perineal procedure to be carried out. Procedure (cid:142) (cid:3) In addition to laparotomy for the major procedure, make a trephine by excising a ci rcular area of skin over the marked stoma site. Do this by picking up the skin with Littlew ood forceps and excising a disc approximately 2cm in diameter. Alternatively make a cruciat e incision and trim the edges using a cutting diathermy point. (cid:142)(cid:3) Excise a disc of sub-cutaneous fat to expose the anterior rectal sheath. Make a cruciate incision on the sheath. (cid:142)(cid:3) Use artery forceps to split the rectus abdominis muscle. Do this carefully to avoid injury to the inferior epigastric vessels. (cid:142)(cid:3) Expose the peritoneum by retracting the split muscle. Open the peritoneum between artery forceps. The trephine must admit the tips of two fingers to ensur e there will be no obstruction to the blood supply of the bowel. (cid:142)(cid:3) Divide the ileum close to the ileo-caecal junction using a linear stapler. (cid:142)(cid:3) Divide the adjacent mesentery and partially remove the mesentery of about 5cm of terminal ileum. (cid:142)(cid:3) Deliver this length of ileum through the trephine onto the skin surface. ( cid:142)(cid:3) The ileal mesentery should lie in a cephalad direction. Stitch the cut edge of the mesentery to the parietal peritoneum; it is not necessary to close the lateral gutt er. (cid:142)(cid:3) Close and cover the abdominal incision. (cid:142)(cid:3) Excise the staple line. (cid:142)(cid:3) Insert eight 4/0 Vicryl sutures through the subcuticular skin edge, the adjacent sero-muscular wall of the ileum and full thickness of the open bowel end, avoiding the vessels of the mesentery. (cid:142)(cid:3) Clip the sutures long and tie them once all have been inserted. This everts the bowel end and results in a 2.5cm spout. This permits close application of the il eostomy bag with discharge of effluent away from the skin. ILEOSTOMY1 255 Fig. 7.24 Site of ileostomy Fig. 7.25 End ileostomy CHAPTER 7 Colorectal surgery 256 Postoperative complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Parastomal herniat ion (cid:142)(cid:3) Prolapse (cid:142)(cid:3) Retraction (cid:142)(cid:3) Necrosis (cid:14 2)(cid:3) Stenosis. Loop ileostomy Indication To divert fecal stream or protect large bowel anastomosis or ileal pouch anal anastomosis. Preparation As mentioned under end ileostomy. Position Lloyd \200\223Davies position to allow stapling or suturing to be carried out per i- anally. Procedure (cid:142)(cid:3) Select a loop of terminal ileum close to the ileo-cae cal junction. This should be of sufficient length to be brought out without tension. (cid:142)(cid:3) Mark the distal limb with a suture. (cid:142)(cid:3) Make a mesenteric win dow adjacent to the wall of the ileum at the apex of the loop. Pass a Nylon tape through it. (cid:142)(cid:3) Using the tape deliver the loop through a trephine incision as described above. (cid:142)(cid:3) Remove the tape and insert a rod through the window in the mesentery used to pass the Nylon tape. (cid:142)(cid:3) Close and cover the abdominal incis ion. (cid:142)(cid:3) Make a transverse enterotomy in the distal limb at the junction with the skin using a diathermy point. (cid:142)(cid:3) Insert four to six 4/0 Vicryl sutures through the superior subcuticular skin edge, adjacent sero-muscular wall of the ileum and full thickness of the open proximal bowel end. (cid:142)(cid:3) On the distal limb open end insert a further four interrupted 4/0 Vicryl s utures through full thickness bowel and subcuticular skin so that the distal lumen is flush with the skin. (cid:142)(cid:3) Tie the sutures after all of them are in place. This forms a spout and avoids forceful grasping of the mucosa with forceps to evert the bowel. Postoperative complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Parastomal herniat ion (cid:142)(cid:3) Prolapse (cid:142)(cid:3) Retraction (cid:142)(cid:3) Necrosis. Laparo scopic loop ileostomy Indications and preparation as for open procedure Position Supine. ILEOSTOMY1 257 Fig. 7.26 End ileostomy Fig. 7.27 Loop ileostomy CHAPTER 7 Colorectal surgery 258 Procedure Empty the bladder before commencing the operation. (cid:142)(cid:3) Make a vertic al skin incision within the umbilicus and expose the linea alba. (cid:142)(cid:3) Place anchoring fascial sutures and incise the linea alba between them. (c id:142)(cid:3) Open the peritoneum and insert a Hassan cannula. (cid:142)(cid:3) Create pne umoperitoneum. (cid:142)(cid:3) A 5mm suprapubic working port is placed under vision. (cid: 142)(cid:3) The table can be tilted head down and left lateral position to facilitate visualizing the caecum. (cid:142)(cid:3) Identify the ileo-caecal junction and work proximally up the small bowel using atraumatic grasping forceps to identify a convenient loop of terminal ileum tha t will be able to be brought out easily and without tension. Orientate this loop carefully under vision so that the proximal bowel lies superiorly with the ileal mesentery lying in a cephalad direction. (cid:142)(cid:3) Make an open trephine by excising a circular area of skin over the marked stoma site. Ensure that the trephine admits two fingers to ensure there will be no obstruct ion to the blood supply of the bowel. (cid:142)(cid:3) Excise sub-cutaneous fat to expose t he anterior rectal sheath. Make a cruciate incision on the sheath and use artery forceps to split the rectus abdominis muscle. Do this carefully to avoid injury to the inferior epiga stric vessels. (cid:142)(cid:3) Expose the peritoneum by retracting the split muscle. (cid:142)(cid:3) Bef ore opening the peritoneum grasp the loop of ileum laparoscopically and hold up to the surface just away form the trephine. (cid:142)(cid:3) Open the peritoneum between artery forceps and immediately grasp and deliv er the ileal loop through the trephine incision with Babcock forceps. (cid:142)(cid:3) Remove carbon dioxide and withdraw the cannulas. (cid:142)(cid:3) Close fa scia of 10mm port sites. (cid:142)(cid:3) Use Steristrips to approximate skin. (cid:142)(ci d:3) Infiltrate wounds with local anesthetic and dress the wounds. (cid:142)(cid:3) Continu e with fashioning the loop ileostomy as for an open procedure. Postoperative complications (cid:142)(cid:3) Development of parastomal hernia (cid:142)(cid:3) Prolapse (cid:142)(cid:3 ) Retraction (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Necrosis (cid:142)(cid:3) Stenosi s (cid:142)(cid:3) Inadvertent bowel injury. Closure of loop ileostomy Indication When fecal stream diversion is no longer required. Che ck for anasto- motic integrity and patency using contrast radiology or endoscopic examinati on prior to reversal. ILEOSTOMY1 259 Position Supine. Procedure (cid:142)(cid:3) Insert four muco-cutaneous stay sutures to help in mobilization. Hold the long ends on an artery forceps. (cid:142)(cid:3) Using cutting diathermy to incise the skin circumferentially close to the mucocutaneous junction. (cid:142)(cid:3) Use sharp and blunt dissection to free the ileal loops from the parieties. (cid:142)(cid:3) Insert a finger in the peritoneal cavity and sweep it carefully around to separate adhesions and to allow withdrawal of sufficient length of small bowel for anastom osis. (cid:142)(cid:3) Separate the loops and divide the mesentery adjacent to the site cho- sen for anastomosis. (cid:142)(cid:3) Divide the ileum and carry out a single or two layered anastomosis or a stapled functional end to end anastomosis. (cid:142)(cid:3) Return the segment of bowel into the peritoneal cavity. (cid:142)(cid:3) C lose with a single layer interrupted PDS sutures. Oppose the skin margins with interrupted non-absorbable sutures or skin staples. Postoperative complications (cid:142)(cid:3) Acute obstruction (cid:142)(cid:3) Anastomotic leakage. CHAPTER 7 Colorectal surgery 260 Colostomy The colon may be exteriorized temporarily or permanently as an end or loop colost omy. Semi-solid feces is collected in a collecting bag (colos- tomy bag). End colostomy Usually formed from the sigmoid or lower descending colon, which is brought t o the surface through a trephine in the left side of the abdominal wall. Indications (cid:142)(cid:3) After abdomino-perineal excision for distal rectal cancers and some anal cancers. (cid:142)(cid:3) After a Hartmann \200\231s procedure (potentially reversible). (cid:142)(c id:3) Irremediable fecal incontinence. Preparation The patient is counseled both in electiv e and emergency situations. The optimal site is identified and marked preoperatively. It is sited in the left iliac fossa clear of the umbilicus and anterior-superior iliac spine and avoiding any scars or depressions. Procedure (cid:142)(cid:3) In addition to laparotomy for the major procedure, make a trephi ne by excising a circular area of skin over the marked stoma site. Do this picking up the s kin with Littlewoods forceps and excising a disc of skin approximately 2cm in diameter. Alt ernatively make a cruciate incision and trim the edges using a cutting diathermy point. (cid:142)(cid:3) Excise a disc of sub-cutaneous fat exposing the anterior rectal sheath. (c id:142)(cid:3) Make a cruciate incision on the anterior rectal sheath to expose the rectus abdominis muscle. (cid:142)(cid:3) Split the rectus abdominus muscle using artery forceps muscle gently to avoid injury to the inferior epigastric vessels. (cid:142)(cid:3) Retract the muscle and open the peritoneum between artery forceps. The aperture should allow the tips of two fingers through it. (cid:142)(cid:3) The divided, proximal end of mobilized colon may be brought through the ab dominal wall aperture using Babcock forceps and the lateral para-colic space closed with in terrupted absorbable sutures or an extra-peritoneal tunnel may be dissected and the colon p assed through this and out. (cid:142)(cid:3) Close and cover the main wound. (cid:142)(cid:3) Ask your assistant to ret ract the skin and sub-cutaneous tissue using two Langenbeck retractors. With your left inde x finger retract the colon. (cid:142)(cid:3) Insert four interrupted 3/0 Vicryl sutures into each quadrant to oppose th e anterior rectus sheath to the colon taking sero-muscular bites. (cid:142)(cid:3) Excise t he staple line and suture the skin edge to full thickness bowel end using interrupted 4/0 Vicryl sutures. COLOSTOMY1 261 Postoperative complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Stomal herniation (cid:142)(cid:3) Prolapse (cid:142)(cid:3) Retraction (cid:142)(cid:3) Necrosis (cid:142)(c id:3) Stenosis. Loop colostomy Is used to divert the fecal stream. The most commonly selected sites are the transverse and sigmoid colon. Should be avoided if an alternative as it is prone to so man y complications. Indications (cid:142)(cid:3) In patients with distal colonic obstruction as first part of a staged resection. (cid:142)(cid:3) As palliation for unresectable lesions. (cid:142)(cid:3 ) To defunction distal anastomosis. (cid:142)(cid:3) To protect anal operations for example anal fistula or sphincter repair. Preparation The patient is counseled regarding the stoma . The optimal site is identi- fied and marked preoperatively. Procedure A formal laparotomy may not be needed. (cid:142)(cid:3) For a transverse colostom y make a horizontal incision midway bet- ween the umbilicus and the costal margin in the right upper quadrant. (cid:142)(cid:3) Inci se all the layers of the abdominal wall. Divide the muscle fibers of the rectus abdominis. (cid:142)(cid:3) Mobilize the transverse colon from omental adhesions. Preserve the marginal vasculature. (cid:142)(cid:3) Make a window close to the bowel in the transverse meso-colon. Pass a Nylo n tape through the window. Use this to bring the loop to the surface. (cid:142)(cid:3) Replace the tape with a rod. The latter supports the loop. (cid:142)(cid:3 ) Attach the bowel to the anterior rectus sheath with interrupted absorbable sutures. (cid:142)(cid:3) If a midline incision has been made close and cover it. (cid:142)(cid:3) O pen the colon longitudinally. Suture the margin of the open colon to the adjacent skin edge with interrupted absorbable sutures.