CHAPTER 7 Colorectal surgery 278 Postoperative complications (cid:142)(cid:3) Anastomotic dehiscence (cid:142)(cid:3) Postop erative paralytic ileus (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Bleeding (cid:142 )(cid:3) Incisional hernia. LEFT HEMICOLECTOMY1 279 Anvil placed in distal segment Fig. 7.44 Stapled anastomosis CHAPTER 7 Colorectal surgery 280 Transverse colectomy Indications Malignant tumor of the mid transverse colon. Preparation As for left hemicolectomy. Position Supine. Incision Midline. Procedure (cid:142)(cid:3) Perform a full laparotomy to ascertain resectability of tumor, p res- ence of liver metastases, peritoneal deposits, and synchronous tumors. (cid:142)(cid:3) Separate the omentum from the stomach below the gastro-epiploic vessels. (cid:142)(cid:3) Mobilize the hepatic and splenic flexures. The latter step may not be needed if there is a long transverse colon. (cid:142)(cid:3) A wedge resection based on the middle colic vessels is then under- taken with at least 5cm clearance from a malignant tumor. (cid:142)(cid:3) Clamp, divide, a nd ligate the middle colic artery at its origin. (cid:142)(cid:3) Clamp, divide, and ligate the meso-colon and marginal vessels up to the sites of bowel resection. (cid:142)(cid:3) Restore bowel continuity by using single layer of 3/0 PDS interrupted seromuscular sutures. (cid:142)(cid:3) Leave a drain in close proximity to the anastomosis. Closure Close the abdominal wall using single layer number 1 loop PDS, skin with subcuticul ar Monocryl (or Vicryl). Postoperative complications (cid:142)(cid:3) Anastomotic dehiscence (cid:142)(cid:3) Postop erative paralytic ileus (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Bleeding (cid:142 )(cid:3) Incisional hernia. TRANSVERSE COLECTOMY1 281 Middle colic artery Fig. 7.45 Transverse colectomy Fig. 7.46 Single layer interrupted anastomosis CHAPTER 7 Colorectal surgery 282 Sigmoid colectomy Indications (cid:142)(cid:3) To palliate a sigmoid tumor (left hemicolect omy is preferred for oncological reasons) (cid:142)(cid:3) Complicated diverticular disease (cid:142)(cid:3) Sigmoid volvulus (cid:14 2)(cid:3) As part of Hartmann \200\231s procedure. Position Lloyd-Davies. Preparation As for left hemicolectomy. Incision Midline. Procedure (cid:142)(cid:3) Cover the small bowel with wet packs and keep it away from the operative field by tilting the table to the patient \200\231s right. (cid:142)(cid:3) Stand on the right side of the table. (cid:142)(cid:3) Retract the sigmoid colon medially. (cid:142)(cid:3) Ask the assistant to hold the lower left abdominal wall. (cid:142)(cid:3) Divide the peritoneum lateral to the sigmoid and descending colon along the \200\230white line \200\231 of fusion using diathermy. (cid:142)(cid:3) Develop the plane between the mesentery and retro-peritoneum. Identify and preserve the left ureter and gonadal vessels as they fall away in this dissection. (cid:142)(cid:3) The splenic flexure may need to be taken down for tension free anastomosis. (cid:142)(cid:3) Ligate the sigmoid arteries at their origin from the inferior mesenteric a rtery in malignant disease. In benign disease the mesocolon may be divided closer to the bo wel wall. (cid:142)(cid:3) Apply crushing and occlusion clamps at the descending sigmoid colon junction and at the recto-sigmoid junction. (cid:142)(cid:3) Cut the bowel between the clamps. (cid:142)(cid:3) Carry out a sutured or stapled anastomosis. (cid:142)(cid:3) Perform a leak test. (cid:142)(cid:3) Leave a drain i n close proximity to the anastomosis. Closure Single mass layer using number 1 loop PDS and subcuticular Monocryl. Postoperative complications (cid:142)(cid:3) Anastomotic dehiscence (cid:142)(cid:3) Postop erative paralytic ileus (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Bleeding (cid:142 )(cid:3) Incisional hernia. SIGMOID COLECTOMY1 283 Superior mesenteric artery Inferior mesenteric artery Fig. 7.47 Sigmoid colectomy CHAPTER 7 Colorectal surgery 284 Total colectomy Indications (cid:142)(cid:3) Inflammatory bowel disease \200\224acute sever e colitis failing to respond to medical treatment, toxic mega-colon, perforation, bleeding. (cid:142)(cid:3) Familial adenomatous polyposis. (cid:142)(cid:3) Left colonic obstruction with caecal perforation. (cid:142)(cid:3) Colonic inertia. In the emergency setting for ulc erative colitis, colectomy with ileostomy and preservation of rectal stump is the operation of choice. Subsequent restorative proctocolectomy and avoidance of permanent ileostomy is a possibility. Preparation (cid:142)(cid:3) Carry out adequate resuscitation when procedure done as an emergency (cid:142)(cid:3) Administer prophylactic antibiotics (cid:142)(cid:3) Thromboembolism proph ylaxis (cid:142)(cid:3) Catheterise (cid:142)(cid:3) Counsel patient and have ileostomy sit e marked by stoma nurse (cid:142)(cid:3) Do not give bowel preparation when carrying out em ergency colectomy. Position Lloyd-Davies. Incision Midline. Procedure (Fig. 7.48) (cid:142)(cid:3) When carrying out emergency colectomy for inflammato ry bowel disease, insert proctoscope to deflate bowel. (cid:142)(cid:3) Make the trephine for the ileostomy before opening the abdomen. (cid:142)( cid:3) Handle bowel with care to avoid perforation. (cid:142)(cid:3) Start with mobilizing the right colon. (cid:142)(cid:3) Divide bowel at the ileo-caecal junction with a linear st apler. (cid:142)(cid:3) Continue mobilizing the colon, transfixing relevant vessels. (cid:1 42)(cid:3) Leave a long recto-sigmoid stump which can be exteriorised to form a mucous fistula or closed depending on the state of the bowel. Colectomy with ileo-rectal anastomosis can be carried out in selected cases of chronic infl ammatory bowel disease (not Crohn \200\231s disease) and for familial adenomatous polyposis . Follow the steps for colectomy. Carry out a hand sutured or stapled ileo-rectal anastomos is. Postoperative complications (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Wound infection (cid :142)(cid:3) Anastomotic dehiscence (cid:142)(cid:3) Stoma complications (cid:142)(cid:3) R ectal stump suture line breakdown. TOTAL COLECTOMY1 285 Superior mesenteric artery Right colic artery Middle colic artery Left colic artery Ileocolic artery Inferior mesenteric artery Fig. 7.48 Total colectomy CHAPTER 7 Colorectal surgery 286 Anterior resection Indication Carcinoma of the rectum, where sphincter preservation is poss ible, high anterior resection is done for tumors of the upper third of the rectum. The anas tomosis is made in the region of the junction of the mid and lower third of the rectum. Low anterior resection entails a total meso- rectal excision. The anastomosis is made at the l evel of the pelvic floor. For low anterior resections defunctioning stoma is made. Preparation As for left hemicolectomy. The stoma nurse marks the ileostomy site (for defunc tioning). Position Lloyd-Davies. Incision Long midline. High anterior resection Procedure (cid:142)(cid:3) Stand on the right side of the table. (c id:142)(cid:3) Assess the position and resectability of the tumor. Assess liver and peritoneum for metastatic deposits and colon for synchronous tumors. (cid:142)(cid:3) Keep the small bowel away from operating field by tilting the patient to the right and covering the small bowel with moist packs. (cid:142)(cid:3) Retract the sigmoid colon to the midline and have the assistant to retract the lower left abdominal wall. (cid:142)(cid:3) Using diathermy divide the peritoneum along the \200\230white line \200 \231. (cid:142)(cid:3) Develop a plane between the mesentery and retro-peritoneum. In the p rocess the gonadal vessels and ureter are swept away. Identifying and preserving these alon g with the hypogastric nerves. (cid:142)(cid:3) Lift the descending colon and its mesentery off the Gerota \200\231s fasci a. (cid:142)(cid:3) Separate the greater omentum from the distal transverse colon and continue the dissection laterally towards the flexure. (cid:142)(cid:3) Extend the dissection along the left para-colic gutter towards the splenic flexure. (cid:142)(cid:3) Grasp both limbs of the colon and under vision divide the peritoneum at th e flexure. The colon can now be brought out of its splenic bed. Take care during the mobili zation of the splenic flexure that the tip of the retractor held by the assistant does not damage the spleen and avoid undue traction on the omentum during this maneuver as the splen ic capsule can be torn. (cid:142)(cid:3) Hold the sigmoid colon and descending colon up, divide the perito- neum on the right side from the origin of the inferior mesenteric artery to the level of th e sacral promontory. (cid:142)(cid:3) Identify and preserve the right ureter. ANTERIOR RESECTION1 287 Superior mesenteric artery Inferior mesentric artery Fig. 7.49 Anterior resection Purse string in descending colon tied around shaft of anvil Trocar of stapler penetrating through staple line Trocar removed Fig. 7.50 Stapled anastomosis: after anterior resection CHAPTER 7 Colorectal surgery 288 (cid:142)(cid:3) Pass a finger under the sigmoid colon and define the origin of the inferior mesenteric artery. Apply three artery forceps and divide the vessel between the tw o proximal forceps. This allows double ligation of the artery remnant. (cid:142)(cid:3) Clamp, divide and ligate the inferior mesenteric vein below the inferior border of the pancreas. (cid:142)(cid:3) Divide the meso-colon at the descending sigmoid colon junction ligating and dividing the marginal vessels. (cid:142)(cid:3) Transect the colon at this level using a side-to-side stapler. (cid:142)(c id:3) Now pack the small bowel and mobilized colon into the upper abdomen using two large moist packs. Place a Goligher \200\231s retractor to retract the wo und edges using the central blade to hold the bowel in place. (cid:142)(cid:3) Remove the side tilt to the table and apply a head down tilt. (cid:142)(ci d:3) Move to the patient \200\231s left side to carry out the pelvic dissection. (cid:142)( cid:3) When present the uterus can be hitched up by two sutures inserted through each broad ligament. (cid:142)(cid:3) Hold the sigmoid colon up and using diathermy develop the plane behind the superior haemorrhoidal vessels. (cid:142)(cid:3) Identify and preserve the pre-sacral nerves as they cross the pelvic brim medial to the ureters. (cid:142)(cid:3) Carry on the dissection in the avascular plane between the meso-rectum and the pre-sacral fascia posteriorly. Keeping in this plane dissect the latera l aspects of the meso-rectum. (cid:142)(cid:3) Having reached the level of the peritoneal reflection assess whether further mobilization is needed. (cid:142)(cid:3) Aim for a 2cm clearance below the distal margin of the tumor and a 5cm clearance of the mesorectum. (cid:142)(cid:3) Then dissect anterior to Denonvillier \200\231s fascia, between the rectum and the bladder, seminal vesicles and prostate in men and the bladder and vagina in women. (cid:142)(cid:3) Divide mesorectum at the selected level. Do this by pinching the mesorectum between the index finger and the thumb off the rectum. Insert two right angled c lamps through this window and cut between them. Transfix the meso-rectum held in the clamps . (cid:142)(cid:3) Then apply a right angled clamp across the rectum. (cid:142)(cid:3) Irri gate the rectum with Betadine or another tumouricidal aqueous antiseptic agent using a Foley \200\231s catheter introduced per-anally. (cid:142)(cid:3) Apply another right angled clamp below the previous one. (cid:142)(cid:3) Transect the rectum between the clamps. (cid:142)(cid:3) Remove the clamp on the rectal stu mp and apply Babcock \200\231s forceps to the cut edge. Suck any Betadine from the lumen. (cid:142)(cid:3) Place a purse-string suture using 2/0 Prolene, no more than 2.5mm from the cut edge to avoid tissue bunching. (cid:142)(cid:3) Remove the staple line on the colonic end and similarly place a purse- str ing. Insert the detached anvil of an end-to-end type circular stapler into the lumen and se curely tie the purse-string around the shaft. (cid:142)(cid:3) Insert the stapler per-anall y and unwind the stapler so the rod exits completely through the open rectal end. Secure th e purse-string around the rod. ANTERIOR RESECTION1 289 (cid:142)(cid:3) Mate the central shaft of the anvil with the instrument shaft by pushing f irmly until the shaft clicks into its fully seated position. Turn the wing nut clockwise to approximate the tissue and to close the space between the cartridge and anvil. (cid:142)(cid:3) Fire the stapler when close approximation is obtained (green color appears on the window adhere to manufacturers instructions). Unwind and remove the stapler. (cid:142)(cid:3) Check to see the doughnuts are complete. (cid:142)(cid:3) Fill the pelvis with normal saline. Check for any leaks by insufflating air through a sigmoidoscope inserted into the rectum. (cid:142)(cid:3) Irrigate the peritoneal cavity. (cid:142)(cid:3) Leave a drain in close pr oximity to the anastomosis. Alternatively a hand sewn anastomosis can be performed using in ter- rupted sero-muscular extra mucosal 3/0 PDS sutures. Closure Close the abdomen in a sin gle \200\230mass \200\231 layer using number 1 loop PDS, with subcuticular Monocryl for th e skin. Stapler approximated and ready for firing Fig. 7.51 Stapled anastomosis: after approximation of end-to-end stapler CHAPTER 7 Colorectal surgery 290 Low anterior resection Procedure (cid:142)(cid:3) Continue the rectal mobilization to the p elvic floor performing a total meso-rectal excision. (cid:142)(cid:3) Cross-staple the rectum using a TA30 or 45. (cid:142)(cid:3) Carry out a B etadine washout of the rectum. (cid:142)(cid:3) Cross-staple the rectum below the previous staple line. (cid:142)(cid:3) Transact the rectum flush on the stapler. (cid:142)(cid:3) Op en and remove the stapler. (cid:142)(cid:3) Insert the anvil of end-to-end stapler in the c olon end as described above and secure its purse-string. (cid:142)(cid:3) Insert the end-to-end stapler with the sharpened point retracted into the rectal stump and bring it up to the staple line. (cid:142)(cid:3) Advance the spike so that it appears posterior to the staple line. (cid:14 2)(cid:3) Mate the central shaft of the anvil with the instrument shaft and approximate the two ends. (cid:142)(cid:3) Fire the stapler after the green spot appears in the window (check manufacturer \200\231s instructions). (cid:142)(cid:3) Check for completeness of the doughnuts. (cid:142)(cid:3) Perform a leak t est as described above. A 5cm colonic pouch can be fashioned and a colo-pouch anal anastomo sis made instead of the straight colo-anal anastomosis described. Instead of a stapled anas to- mosis, endo-anal colo-anal anastomosis can be performed. (cid:142)(cid:3) Leave a suction drain in the hollow of the pelvis. (cid:142)(cid:3) Washou t the peritoneal cavity. (cid:142)(cid:3) Make a trephine in the marked site in the right i liac fossa and pull out a loop of terminal ileum to act as a defunctioning stoma. Closure Close the abdomen in a single mass layer using number 1 loop PDS, with subcuticular Monocryl for the skin. Make the ileostomy as described before. Postoperative complications (cid:142)(cid:3) Anastomotic dehiscence (cid:142)(cid:3) Postop erative paralytic ileus (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Bleeding (cid:142 )(cid:3) Anastomotic stricture (cid:142)(cid:3) Urinary and sexual dysfunction (cid:142)(ci d:3) Incisional hernia. This page intentionally left blank CHAPTER 7 Colorectal surgery 292 Proctocolectomy and ileostomy Removal of the colon, rectum, and anus. Indication (cid:142)(cid:3) Ulcerative colitis where medical treatment fails or there is ma lignant transformation, performed in patients where a sphincter saving proce- dure is not d esirable or suitable. (cid:142)(cid:3) Colonic Crohn \200\231s disease. (cid:142)(cid:3) Synchronous colonic and rectal cancers. (cid:142)(cid:3) Familial adenomatous polyposis (for those with low rectal cancers). Preparation As for left hemicolectomy. Ileostomy site marked by stoma nurse. Position Lloyd-Davies with perineum protruding 5cm from lower edge of table. Incision Midline. Procedure (cid:142)(cid:3) Make the trephine for the ileostomy before opening the abdomen. (cid:142)(cid:3) Start with mobilizing the right colon. (cid:142)(cid:3) Divide the bowel a t the ileo-caecal junction with a linear stapler. (cid:142)(cid:3) Follow the steps as desc ribed in relevant chapters when mobilizing the colon. Preservation of the greater omentum is not necessary. (cid:142)(cid:3) When carcinoma or dysplasia is present perform wide clearance with high ligation of the lympho-vascular pedicle. (cid:142)(cid:3) Mobilize the rectum performing a total mesorectal excision, preserving the presacral nerves. In benign cases remove the rectum by close (peri-muscular) dissection . (cid:142)(cid:3) Do the perineal dissection by entering the inter-sphincteric plane. (cid:1 42)(cid:3) Follow the steps as mentioned in the chapter for formation of terminal ileostomy. Postoperative complications (cid:142)(cid:3) Paralytic ileus (cid:142)(cid:3) Wound infecti on (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Delayed healing of perineal wound (cid:142)(c id:3) Urinary or sexual dysfunction (cid:142)(cid:3) Ileostomy related complications. PROCTOCOLECTOMY AND ILEOSTOMY1 293 Middle colic artery Superior mesenteric artery Right colic artery Left colic artery Inferior mesenteric artery Ileocolic artery Fig. 7.52 Proctocolectomy and Ileostomy CHAPTER 7 Colorectal surgery 294 Abdomino-perineal excision of rectum Indications (cid:142)(cid:3) Low rectal carcinoma wher e adequate clearance will not be obtained by anterior resection. Other malignancies include those of the anal canal. (cid:142)(cid:3) Inflammatory bowel disease, such as severe Crohn \200\231s disease with multiple fistulae. (cid:142)(cid:3) As part of the procedure of proctocolectomy. Preparation As for left hemicolectomy. The stoma nurse marks the colostomy site in the left iliac fossa. Position Lloyd-Davies with the perineum projecting 5cm from the lower edge of the table. Incision Midline. Procedure Stand on the right side of the table. (cid:142)(cid:3) Assess the liver and perit oneum for metastatic deposits and the colon for synchronous tumors. (cid:142)(cid:3) Keep the small bowel away from operating field by tilting the patient to the right and covering the small bowel with moist packs. (cid:142)(cid:3) Retract the sigmoid colon to the midline and have the assistant retract the lower left abdominal wall. (cid:142)(cid:3) Using diathermy divide the peritoneum along the \200\230white line \200 \231. Develop a plane between the mesentery and the rectal peritoneum. In the process the g onadal vessels and ureter are swept away. Identify and preserve these along with the hypo-g astric nerves. (cid:142)(cid:3) Lift the descending colon and its mesentery off the Gerota \200\231s fasci a. (cid:142)(cid:3) The splenic flexure may need to be mobilized. (cid:142)(cid:3) Hold the sigmoid colon and descending colon up. Divide the perito- neum on the right side from the origin of the inferior mesenteric artery to the level of th e sacral promontory. (cid:142)(cid:3) Identify and preserve the right ureter. (cid:142)(cid :3) Pass a finger under the sigmoid colon and define the origin of the inferior mesenteric artery. Apply three artery forceps and divide the vessel between the tw o proximal forceps. This allows double ligation of the artery remnant. (cid:142)(cid:3) Clamp, divide, and ligate the inferior mesenteric vein. (cid:142)(cid:3) D ivide the mesocolon at the descending sigmoid junction, ligating and dividing the marginal vessels. (cid:142)(cid:3) Transect the colon at this level using a side-to-side stapler. (cid:142)(c id:3) Now pack the small bowel and mobilized colon into the upper abdomen using two large moist packs. ABDOMINO-PERINEAL EXCISION OF RECTUM1 295 (cid:142)(cid:3) Place a Goligher \200\231s retractor to retract the wound edges, use the central blade to hold the bowel in place. (cid:142)(cid:3) Remove the side tilt to the table and apply a head down tilt. (cid:142)(ci d:3) Move to the patient \200\231s left side to carry out pelvic dissection. (cid:142)(cid: 3) When present the uterus can be hitched up by two stitches inserted through each broad ligament. (cid:142)(cid:3) Hold the sigmoid colon up and using diathermy develop the plane behind the superior haemorrhoidal vessels. (cid:142)(cid:3) Identify and preserve the pre-sacral nerves as they cross the pelvic brim medial to the ureters. (cid:142)(cid:3) Carry on the dissection in the avascular plane between the mesorec- tum an d pre-sacral fascia posteriorly. Keeping in this plane dissect the lateral aspects of the m esorectum. (cid:142)(cid:3) Incise the peritoneal reflection anteriorly. (cid:142)(cid:3) Dissect ante rior to the Denonvillier \200\231s fascia, between the rectum and the bladder, seminal vesi cles and prostate in men and the bladder and vagina in women. (cid:142)(cid:3) Continue the rectal mobilization to the pelvic floor, performing a total mesorectal excision. Superior mesenteric artery Inferior mesenteric artery Fig. 7.53 Abdominoperineal excision of rectum CHAPTER 7 Colorectal surgery 296 The perineal procedure can be performed at the same time as the pelvic dissection from abov e, using a combined synchronous approach. (cid:142)(cid:3) Close the anal orifice with a 0 or 1 silk purse-string suture. Apply an artery forceps to the ends of the suture which is left long. (cid:142)(cid:3) Make an elliptical incision from the mid point of the perineal body, in th e male or the posterior aspect of the vaginal introitus, in the female, to a point over the coccyx. (cid:142)(cid:3) Deepen the incision laterally into the ischio-rectal fossa. Control bleeding from the pudendal vessels. (cid:142)(cid:3) Use retractors to help dissect to the level of the levator ani. (cid:142)( cid:3) Carry the incision posteriorly to expose the anococcygeal ligament. Incise the ligament in front of the coccyx. (cid:142)(cid:3) Dissect behind the external sphincter to reach the levator muscles. (cid:1 42)(cid:3) Use the tip of the scissors to traverse the muscle, ask the abdominal operator t o help to direct the scissors tip correctly. Avoid lifting the pre-sacral fascia from the s acrum and entering the pre-sacral venous plexus. (cid:142)(cid:3) Insert a finger into the pelvis and divide the levator muscles over it on either side. (cid:142)(cid:3) Continue the dissection anteriorly making a transverse incision in anterio r decussating fibers of the external sphincter exposing the posterior fibers of the superfi cial and deep transverse perineal muscles. Deep to the latter identify the median raphe in the rectourethralis and puborectalis muscles. Follow the median raphe with blunt scissor di s- section into the pelvis with the abdominal operator guiding with his finger. Divide the remaining tissues to free the rectum and then remove it. (cid:142)(cid:3) Close the perineal wound in layers \200\224approximating levator muscles and fibro-fatty tissue in the midline. Close the skin. (cid:142)(cid:3) Irrigate the pelvis and leave a suction drain. It is not essential to reperitonise the pelvis. (cid:142)(cid:3) Make a trephine at the marked site and deliver the colon end. (cid:142)(ci d:3) Follow the steps as described for construction of colostomy. Closure In single mass layer using 1/0 PDS with subcuticular Monocryl for skin. Postoperative complications (cid:142)(cid:3) Paralytic ileus (cid:142)(cid:3) Wound infecti on (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Urinary or sexual dysfunction (cid:142)(cid:3 ) Colostomy related complications. This page intentionally left blank CHAPTER 7 Colorectal surgery 298 Restorative proctocolectomy Proctocolectomy with ileal pouch \200\224anal anastomosis. Indications (cid:142)(cid:3) Chronic ulcerative colitis where medical therapy fails and pat ient wants to avoid permanent ileostomy. (cid:142)(cid:3) As a second procedure after colectomy in patients with acute severe ulcerative colitis. (cid:142)(cid:3) Familial adenomatous polyposis. Patient should be highly motivated and hav e an adequate anal sphincter. Preparation As for left hemicolectomy. Ileostomy site marked by stoma nurse. Position Lloyd-Davies. Incision Midline. Procedure (cid:142)(cid:3) Follow the steps as for conventional procto-colectomy. (cid:142) (cid:3) Mobilize the rectum to anorectal junction. (cid:142)(cid:3) For stapled anastomosis apply a transverse stapler at this level. For hand-sutured anastomosis divide the bowel to leave an open anal stump. (cid:142)(cid:3) Select the point on the ileum for ileo-anal anastomosis and attempt a trial descent to the anal canal level. (cid:142)(cid:3) Make a J or W ileal reservoir. (cid:142)(cid:3) Perform a stapled pouch-an al anastomosis or a hand sutured anastomosis after mucosectomy. (cid:142)(cid:3) Fashion a defunctioning ileostomy. Postoperative complications (cid:142)(cid:3) Pelvic sepsis (cid:142)(cid:3) Stricture of th e anastomosis (cid:142)(cid:3) Intestinal obstruction (cid:142)(cid:3) Pouch \200\224vagina l, pouch \200\224perineal fistula (cid:142)(cid:3) Excessive frequency of defecation (cid:1 42)(cid:3) Failure \200\224need to remove the pouch and establish a permanent ileostomy (cid:142)(cid:3) Pouchitis. RESTORATIVE PROCTOCOLECTOMY1 299 J ileal reservoir Stapled pouchanal anastomosis Fig. 7.54 Restorative proctocolectomy CHAPTER 7 Colorectal surgery 300 Hartmann \200\231s procedure Indications A safe option when dealing with left-sided colonic emergencies (obstruc- tion, perforation). The diseased colon is resected, divided colon is brought out as an end colostomy in the left lower quadrant, the rectal stump is closed or exteriorised. The procedure is performed when con- ditions are unfavorable for immediate an astomosis (fecal peritonitis, obstruction, unprepared bowel, unstable patient, inexperience of sur- geon). Preparation (cid:142)(cid:3) Ensure adequate resuscitation (cid:142)(cid:3) Prophylactic an tibiotics (cid:142)(cid:3) Thrombo-embolism prophylaxis (cid:142)(cid:3) Cross-match blood (cid:142)(cid:3) Catheterise (cid:142)(cid:3) Forewarn the patient about colostomy and mark the site. Position Lloyd-Davies. Incision Midline. Procedure (cid:142)(cid:3) As for sigmoid colectomy and colostomy. (cid:142)(cid:3) Close t he rectal stump by cross stapling or suturing. (cid:142)(cid:3) Leave two long non-absorbab le sutures at the lateral ends to help future identification of the rectal stump. Postoperative complications (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Wound infection (cid :142)(cid:3) Breakdown of rectal stump (cid:142)(cid:3) Colostomy complications. Reversal of Hartmann \200\231s procedure Usually considered six weeks after the initial sur gery. Position Lloyd-Davies. Preparation As for left hemicolectomy. HARTMANN \200\231S PROCEDURE1 301 Procedure (cid:142)(cid:3) Mobilize colostomy and re-open laparotomy incision. (cid:142)(ci d:3) Mobilize adherent small bowel loops and identify the rectal stump. Introduce a rigid s igmoidoscope to aid identification if locating the stump is difficult. (cid:142)(cid:3) Mobilize proximal colon to bring it close to the rectum without tension. T he splenic flexure may need to be brought down. (cid:142)(cid:3) Perform a stapled or a han d sewn anastomosis as described for anterior resection. The operation can be performed laparoscopically assisted. End colostomy Rectal stump closed Sigmoid colon removed Fig. 7.55 Hartmann \200\231s procedure CHAPTER 7 Colorectal surgery 302 Procedures for large bowel obstruction Preparation (cid:142)(cid:3) Resuscitate the patient adequately. (cid:142)(cid:3) Perform a rigid sigmoidoscopy followed by water \200\223solua ble contrast enema to exclude pseudo-obstruction. (cid:142)(cid:3) Cross match two units of blood. (cid:142)(cid:3) Thrombo-embolism prophyla xis. (cid:142)(cid:3) Prophylactic antibiotics at induction. (cid:142)(cid:3) Catheterise p atient. Position Lloyd-Davies. Incision Midline. Procedures (cid:142)(cid:3) Consider decom pression of gaseous large bowel distension. Insert a 14 or 16G needle through a tinea into the lumen of the bowel and attach to suction. (cid:142)(cid:3) If obstruction is due to a right-sided lesion consider a right hemicolec- tomy or for a fixed tumor an ileo-transverse anastomosis (hand- sutured single or two layer ed anastomosis or a stapled anastomosis). (cid:142)(cid:3) If obstruction is due to left si ded lesion options are: three-stage app- roach (defunctioning loop colostomy (cid:125) rese ction and anastomosis (cid:125) closure of stoma); two-stage approach (Hartmann \200\231s p rocedure (cid:125) reversal of Hartmann \200\231s); one-stage approach (sub-total colectomy with ileo-colic or ileo-rectal anastomosis or left hemicolectomy after an on-table colonic irrigation). Choice of operation depends on patient fitness, stage of disease if malignanc y and local conditions for primary anastomosis. On-table colonic irrigation (cid:142)(cid:3) Make a colotomy proximal to the lesion causing obstruction. (cid:142)(cid:3) Insert anesthetic scavenging tubing and secure with heavy su ture around the bowel. Connect tubing into a plastic bag and place this into a bucket. (cid:142)(cid:3) Insert a large Foley catheter into caecum via appendix stump or an enterotomy in the terminal ileum. (cid:142)(cid:3) Infuse 2 \200\2233 litres, or more, of warm saline into caecum and manipul ate colonic contents into anesthetic tubing. Mobilize colonic flexures if necessary to achi eve this. Continue this until effluent is clear. (cid:142)(cid:3) Carry out a left hemicolectomy as described previously. There are kits ava ilable on the market for carrying out on-table colonic irrigation. Self-expanding metal stents are now being used in large bowel obstruc- tion secondary to ma lignancy either for palliation or as a temporary bridge to surgery (stent decompression (ci d:125) elective resection). PROCEDURES FOR LARGE BOWEL OBSTRUCTION1 303 Fig. 7.56 On-table colonic lavage This page intentionally left blank Chapter 8 305 Hepatobiliary surgery R. Carter and C. W. Imrie Introduction 306 Investigational procedures 308 Pancreatic mobili zation 310 Management of tumors 312 Management of pancreatic necrosis 316 Management of pse udocyst 318 Management of chronic pancreatitis 320 Common pancreatic complications 322 CHAPTER 8 Hepatobiliary surgery 306 Introduction As the morbidity and mortality associated with pancreatic surgery are amongst the highest in surgical practice, management of patients should take place within the conte xt of multi-disciplinary team and they should be in optimal condition pre-operatively. They may be suffering from exocrine failure, altered glucose tolerance, or altered coagulation due to post-hepatic biliary obstruction. All these issues should be addressed. Most surgica l procedures will require blood to be cross-matched. This page intentionally left blank CHAPTER 8 Hepatobiliary surgery 308 Investigational procedures Ultrasound The first line investigation for most patients with p ancreatico-biliary symptoms. Can detect: (cid:142)(cid:3) Cholelithiasis (cid:142)(cid:3) H epatic abnormalities. NB Image quality, especially of the pancreas, compromised by incomple te fasting or obesity. Commonly performed procedures: (cid:142)(cid:3) Targeted biopsy (cid:142)(cid:3) Drainage (cid:142)(cid:3) FNA (Fine needl e aspiration). NB Fast patient for six hours to reduce bowel gas. If intervention is planne d perform appropriate investigations (e.g. clotting screen) and exclude coagulopathy. Endoscopic ultrasound A mainstay of pancreatic investigation. Radial imaging used to: (cid: 142)(cid:3) Assess venous invasion (cid:142)(cid:3) Locate islet cell tumors. Linear array ultrasonography provides: (cid:142)(cid:3) Excellent images of the pancreatic parenchyma (c id:142)(cid:3) The opportunity for guided intervention, e.g. FNA, trucut biopsy of tumors, ultrasound guided drainage of cystic collections and celiac plexus blockade. ERCP Endoscopic retrograde cholangio-pancreatography (ERCP) is common- place in surgical pr actice. The patient lies on an X-ray table in a semi- prone position with the head turned t o the right. Venous access is via the right hand. Under conscious sedation, an endoscope is passed into the duodenum and catheters positioned within the bile or pancreatic duct for i njection of contrast and imaging. Therapeutic procedures: (cid:142)(cid:3) Sphincterotomy (cid:142)(cid:3) Stent insertion (c id:142)(cid:3) Biopsy (cid:142)(cid:3) Stone retrieval. Major complications (commonly assoc iated with therapeutic ERCP): (cid:142)(cid:3) Pancreatitis (cid:142)(cid:3) Duodenal perfo ration (cid:142)(cid:3) Post-sphincterotomy hemorrhage. MRCP Magnetic resonance cholangio-pancreatography. In many situations this is the preferred investigation. In 72 weighted images, static fluid is repre- sented as a strong white sign al. That within the common bile duct and INVESTIGATIONAL PROCEDURES1 309 pancreatic duct can be represented as an image resembling an ERCP, which can provide excell ent diagnostic information of the biliary tree in particular (NB still inferior to direct r adiology). Contraindications and problems: (cid:142)(cid:3) Intracorporeal implants (pacemakers, intra cranial vascular clips, metallic foreign bodies) (cid:142)(cid:3) Intensive care organ support (cid:142)(cid:3) Claustrophobia (cid:142)(cid :3) Lengthy image acquisition times. Staging laparoscopy Laparoscopy is commonly used to assess upper GI malignancies. Position of patient Supine. Intraperitoneal access This is achieved using a cut-down technique with the use of a Veress needle, but is associated with the risk of visceral or vascular injury. (cid:142)(cid:3) I nsert a blunt port sub-umbilically (cid:142)(cid:3) Create a pneumo-peritoneum using carbon dioxide at a pressure of 10 \200\22313mmHg. Two further subcostal ports are then inserted under direct vision. Procedure (cid:142)(cid:3) Inspect the peritoneum by starting to the left of the falciform ligament and working clockwise, examining the lower abdomen for trans- coelomic spread before return ing to the right upper quadrant. (cid:142)(cid:3) Inspect the superior and under-surface of the liver, anterior aspect of the stomach and omentum for peritoneal metastasis. (cid:142)(cid:3) Lift the omentum allowing examination of the root of the mesentery for loc al invasion. The pancreatic head can then be assessed for mobility. (cid:142)(cid:3) Instil l 500ml of saline for cytology and also to promote an acoustic win- dow for laparoscopic ultrasound. Insert a laparoscopic ultrasound probe through the left up per quadrant port and placed along the right side of the falciform ligament, over segment f our, to identify the hepatic veins for orientation. Then examine hepatic parenchyma in segm ental fashion looking for metastasis. Then place the ultrasound probe along side the coelia c axis and superior mesenteric artery and follow the vessels proximally searching for signi ficant lymphadenopathy The pancreas is usually easily identified and the pancreatic duct fo llowed from the body towards the head of the gland. (cid:142)(cid:3) Identify the splenic veins and superior mesenteric confluents and assess them for venous involvement. (cid:142)(cid:3) Aspirate the fluid for cytology and remove the ports removed under vision to ensure there is no internal bleeding. CHAPTER 8 Hepatobiliary surgery 310 Pancreatic mobilization Elective pancreatic surgery is usually performed within specialized units. Approaching the pancreas in an unstructured manner can result in signifi- cant (par ticularly venous) hemorrhage. Most general surgeons operate on the pancreas during emergenc y trauma procedures. Nevertheless the principles of mobilization apply to all pancreatic pr ocedures and are designed to promote vascular control during procedures. Position of the patient Supine. Incision Transverse (rooftop) or midline incision. Procedure (cid:142)(cid:3) Elevate the colon and omentum and dissect the omentum from the colon to allow entry to the lesser sac. Mobilize the hepatic flexure and retract inferiorly . Open the peritoneum parallel to the duodenum to allow entry to the plane between the infe rior vena cava (IVC) and the duodenum. (cid:142)(cid:3) Extend the incision from the reflected colon up to the inferior aspect of the liver to develop the foramen of Winslow, encircling the hepato- duodenal ligament to pe rmit, if necessary, the application of a Pringle maneuver. Roll the duodenum medially expos ing the anterior aspect of the IVC, the left renal vein and the anterior aspect of the aort a. The duodenum and pancreatic head can then be held in the left hand between fingers and t humb, allowing pressure to be applied in an antero-posterior direction if significant venou s bleeding is encountered. (cid:142)(cid:3) Follow the middle colic veins downwards, often dividing a branch of the un cinate process to expose the superior mesenteric vein as it descends beneath the pancreatic neck. (cid:142)(cid:3) Expose the anterior aspect of the head of the pancreas by dividing the gas tro-epiploic vessels, which emerge from the pancreatic parenchyma close to the lower border of the pancreatic neck. (cid:142)(cid:3) Expose the portal vein as it emerges from the superior border of the pancr eatic neck by ligating the gastro-duodenal artery, divide and retract it superiorly and med ially to expose the vein. (cid:142)(cid:3) In the trauma situation, mobilize the pancreatic tail by bringing the tail and spleen forwards and medially from the posterior abdominal wall and open the lesser sac as described above and mobilize the splenic flexure and the colon and retract them inferio rly. The splenic artery can be ligated at its origin on the superior aspect of the pancreas in the midline. Divide the short gastric vessels between the stomach and spleen to expose the anterior aspect of the pancreatic tail and divide the lieno-renal ligament lateral to t he spleen, rolling the spleen and pancreas medially in the plane behind the splenic vessels . This ma- noeuvre compresses the splenic vessels and as it is performed permits vascular c ontrol to be maintained during dissection. This page intentionally left blank CHAPTER 8 Hepatobiliary surgery 312 Management of tumors Pancreatic head resection \200\224pancreatico-duodenectomy Position of the patient Supine. Incision Rooftop or midline. Procedure (cid:142)(cid:3) Mobilize the head of the pancreas as described above. Divide the omentum up to the gastro-epiploic vessels preserving the gastro- epiploic arcade down to t he level of the pylorus. Divide the lesser omentum at the level of the liver and mobilize i t down to the pylorus taking care to preserve the right gastric arcade. (cid:142)(cid:3) Transect the duodenum approximately 2cm beyond the pylorus. Per- form a retrograde cholecystectomy by exposing the anterior aspect of the common hepatic duc t and dividing it approximately 1cm below the hilar plate. Skeletalise the right side of th e hepatic artery and the portal vein down to the superior border of the pancreas.