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. (cid:142)(cid:3) An appropriate sized hole is cut in the stoma bag to accommodate the rod and the looped colon. For a sigmoid loop colostomy make a left grid iron incision. Carefully identify the sigmoid colon to make sure it is not small bowel. It has no omentum but has appendices epiploicae and taenia. Orient the loop to avoid rotation. The loop may be tethered with congenital adh esions which may need to be divided. The rest of the procedure is as described for a transv erse colostomy. Postoperative complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Stomal herniation CHAPTER 7 Colorectal surgery 262 (cid:142)(cid:3) Prolapse (cid:142)(cid:3) Retraction (cid:142)(cid:3) Necrosis. Closure of loop colostomy Indication (cid:142)(cid:3) When fecal stream diversion is no lon ger required. Check for anastomotic integrity and patency using contrast radiology and endo scopic examination prior to reversal. (cid:142)(cid:3) Prepare proximal colon as for any colonic anastomosis. 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 incise the skin close to the muco-cutaneous junction. (cid:142)(cid:3) Use sharp and blunt dissection to free the colon loops from the parieties. (cid:142)(cid:3) Close the colostomy transversely using one layer interrupted sero-muscular extra-mucosal sutures. (cid:142)(cid:3) Replace the colon in the peritoneal c avity. (cid:142)(cid:3) Close the abdominal wall in one layer using interrupted PDS sutures . Close the skin with interrupted sutures or skin staples. Postoperative complications (cid:142)(cid:3) Anastomotic leakage (cid:142)(cid:3) Wound inf ection. COLOSTOMY1 263 Transverse loop colostomy Left iliac fossa colostomy Fig. 7.28 Sites of colostomy Fig. 7.29 End colostomy Fig. 7.30 Loop colostomy CHAPTER 7 Colorectal surgery 264 Bowel resection and anastomosis The essentials for any bowel anastomosis are: (cid:142)(cid :3) Tension free (cid:142)(cid:3) Adequate blood supply (pulsating mesenteric vessels) (cid :142)(cid:3) Accurate apposition using good surgical techniques (cid:142)(cid:3) Minimal lo cal spillage. Single layer interrupted seromuscular (extra-mucosal) technique Mobile anastomosis (ileo-il eal, ileo-colic anastomosis) (cid:142)(cid:3) Line up the ends of the bowel. (cid:142)(cid: 3) Ensure that the ends to be anastomosed are roughly equal in circumference. To achieve this make an incision on the anti-mesenteric aspect of the bowel or do an end-to-side anastomosis. (cid:142)(cid:3) Use non-crushing bowel clamps to prevent spillage. (cid:142)(cid:3) Isolat e the operative field using moist packs. (cid:142)(cid:3) Use 3/0 absorbable suture materia l with an atraumatic round bodied needle. (cid:142)(cid:3) Insert stay sutures at the mesenteric and anti-mesenteric borders; do not ligate them but place them in haemostats. (cid:142)(cid:3) Starting from the mesenteric aspect, place interrupted sutures along the a nterior wall of the bowel 0.5cm apart and tie as they are placed. Each suture should perfor ate the bowel from the serosal surface penetrating the muscle layer and sub-mucosa and emer ging between the mucosa and sub-mucosa. (cid:142)(cid:3) Include the sub-mucosa as this is the strongest layer of the bowel wall. ( cid:142)(cid:3) On completion, tie both stay sutures; do not cut but replace in haemostats. (cid:142)(cid:3) Use the stay sutures to reverse the bowel. The posterior wall will now lie anteriorly. (cid:142)(cid:3) Suture the new front wall in a similar manner. Ensure the angles are adequately sutured. (cid:142)(cid:3) On completion return the stay sutures to their original position and cut them. (cid:142)(cid:3) Close the mesenteric defect taking care not to damage the mesenteric vessels. Immobile anastomosis (colorectal or ileo-rectal) (cid:142)(cid:3) Insert stay sutures at th e lateral ends of the cut end of the bowel walls. Do not ligate them but place them in haemostats. (cid:142)(cid:3) Insert the posterior row of seromuscular sutures, hold suture ends in individual artery forceps. Thread the artery forceps to a forceps holder to avoid tangling. After insertion of the whole row \200\230parachute \200\231 the proximal bowel down to th e rectum. Tie the knots; they will lie on the luminal side of the anastomosis. Cut the knot tails. (cid:142)(cid:3) Perform the anterior anastomosis in a similar fashion; the knots will lie on the serosal side of the anastomosis. BOWEL RESECTION AND ANASTOMOSIS1 265 Fig. 7.31 Seromuscular suture Fig. 7.32 Interrupted seromuscular single layer anastomosis CHAPTER 7 Colorectal surgery 266 Two layer anastomosis (cid:142)(cid:3) Line up the ends of the bowel. (cid:142)(cid:3) Ensu re that the ends to be anastomosed are roughly equal in circumference. To achieve this make an incision on the anti-mesenteric aspect of the bowel or do an end-to-side anastomosis. (cid:142)(cid:3) Use non-crushing bowel clamps to prevent spillage. (cid:142)(cid:3) Isolat e the operative field using moist packs. (cid:142)(cid:3) Use 3/0 absorbable suture materia l with an atraumatic round bodied needle. (cid:142)(cid:3) Insert stay sutures at the mesenteric and anti-mesenteric borders; do not ligate them but place them in haemostats. (cid:142)(cid:3) Place a stitch between the adjacent cut edges of bowel in the middle of th e posterior wall. Continue towards one corner with full thickness over-and-over stitches. T he stitches should be less than 0.5cm apart and pick up about 0.5cm of bowel wall. To turn the corner pass the needle from the mucosa outwards on one corner to the serosa inwards on the other followed by the mucosa outwards on the same side to the serosa inwards on the oth er, thus forming a series of loops on the mucosal surface (Connell suture). (cid:142)(cid:3) Once around the corner, leave this stitch and return to the middle of the posterior wall. Using a new length of suture insert and tie a stitch close to the site of t he previous ligature. Proceed towards the opposite corner and using the technique described above turn around the corner. Oppose the anterior walls using over-and-over stitches and t ie off the ends of the suture in the middle. Remove the bowel clamps. (cid:142)(cid:3) Place a second layer of seromuscular continuous or interrupted sutures starting at one corner and going all the way round by rotating the bowel. The poste rior layer of seromuscular sutures can be placed before the full thickness layer. The anter ior seromuscular layer being completed subsequently. (cid:142)(cid:3) Close the mesenteric defect taking care not to damage the mesenteric vessels. Anastomosis using staplers is described in chapters of right hemicolec- tomy and anterior r esection. Small bowel resection and anastomosis Indications (cid:142)(cid:3) Obstruction leading to n on-viable bowel (cid:142)(cid:3) Irreducible small bowel intussusception (cid:142)(cid:3) M esenteric ischaemia (cid:142)(cid:3) Meckel \200\231s diverticulum (cid:142)(cid:3) Crohn \200\231s stricture (cid:142)(cid:3) Traumatic damage (cid:142)(cid:3) Tumors \200\224prima ry or adherent small bowel loop to large bowel tumor. Preparation In cases of small bowel o bstruction: naso-gastric aspiration, re-hydration with intravenous fluids, correction of el ectrolyte abnormality. Position Supine. BOWEL RESECTION AND ANASTOMOSIS1 267 Connell inverting suture Fig. 7.33 Two layer anastomosis Full thickness suture Inverting seromuscular Lembert suture Fig. 7.34 Two layer anastomosis CHAPTER 7 Colorectal surgery 268 Incision Midline, in case of strangulated external hernia make the appropriate incision. Procedure (cid:142)(cid:3) Inspect the bowel requiring resection and also the remaining bow el. Choose the resection margins. (cid:142)(cid:3) Transilluminate the mesentery by shining a light from behind. This may not be helpful in Crohn \200\231s disease because of thickened mesentery. (cid:142)(cid:3) Between the margins of resection divide the mesentery using diathermy or scissors, leaving the vessels to be taken between artery forceps. Cut and liga te the vessels. Clear the mesentery up to the bowel wall. In malignant disease, take a V-sh aped wedge of mesentery to remove the local lymphatic tissue which runs with the arteries. In benign disease keep close to the bowel wall. (cid:142)(cid:3) Apply crushing clamps to bowel immediately beyond the point of resection. Milk the bowel contents from the intervening section to re- duce risk of spillag e when bowel opened and apply non-crushing clamps proximal and distal to the crushing clamp s. (cid:142)(cid:3) Divide bowel flush with the crushing clamp using a knife. (cid:142)(cid:3) Anastomose the two ends in one or two layers. (cid:142)(cid:3) Close the defect in the mes entery taking care not to damage the mesenteric vessels. Closure Single layer 1/0 PDS and subcuticular Monocryl. Postoperative complications (cid:142)(cid:3) Anastomotic leak (cid:142)(cid:3) Bleeding Large bowel resection and anastomosis This is dealed with in the relevant chapters. BOWEL RESECTION AND ANASTOMOSIS1 269 Fig. 7.35 Resection of small bowel Fig. 7.36 Closure of mesentery after small bowel resection CHAPTER 7 Colorectal surgery 270 Right hemicolectomy Indications (cid:142)(cid:3) Malignant disease affecting the caecum, as cending colon, and hepatic flexure (cid:142)(cid:3) Inflammatory conditions such as Crohn \200\231s disease. Preparation (cid:142)(cid:3) Thrombo-embolism prophylaxis (cid:142)(cid:3) Antibiotics admi nistered after induction of anesthesia (cid:142)(cid:3) Urethral catheter inserted after pa tient has been anesthetized. Position Supine. Incision Midline with two-thirds of the incision above the umbilicus to ease mobi- lisation of hepatic flexure or transverse incision just above the umbilicus. Procedure (cid:142)(cid:3) Carry out a full laparotomy to assess resectability and metastat ic spread to the liver and peritoneum. Synchronous tumors should have been excluded by preoper ative colonoscopy or barium enema. If not palpate the colon carefully. (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 left. (cid:142)(cid:3) Stand on the left side of the table and retract the right colon. (cid:142) (cid:3) Using diathermy, divide the peritoneum on the right para-colic gutter from the caecum to the hepatic flexure and continue this dissection to develop the plane be tween the meso-colon and the posterior abdomi- nal wall. In doing so the ureter and gonadal vessels will safely fall away. (cid:142)(cid:3) Carefully divide the vascular omental attachments of the hepatic flexure close to the colon. (cid:142)(cid:3) Identify the duodenum behind the right colon and gently dissect this away. Do not dissect medial to the duodenal loop to avoid injury to the small vessels around the pancreas. (cid:142)(cid:3) Enter the lesser sac distal to the hepatic flexure. (cid:142)(cid:3) Divid e the greater omentum below the gastro-epiploic arcade to the junction between proximal third and distal two-thirds of the transverse colon. (cid:142)(cid:3) Now move to the right side of the table. (cid:142)(cid:3) Lift the termina l ileum and right colon. (cid:142)(cid:3) Transilluminate the mesentery and clamp, divide a nd ligate the ileo-colic and right colic vessels at their origin from the superior mesenteric. Clamp, div ide, and ligate the right branch of the middle colic artery. (cid:142)(cid:3) Clear the bowel wall at the sites of transection and apply crushing clamps. (cid:142)(cid:3) Apply occlusion clamps on the proximal small bowel and distal large bowel. RIGHT HEMICOLECTOMY1 271 Middle colic artery Right colic artery Ileocolic artery Fig. 7.37 Right hemicolectomy CHAPTER 7 Colorectal surgery 272 (cid:142)(cid:3) Divide the bowel on the crushing clamps leaving them on the specimen. (cid:142)(cid:3) An end-to-end anastomosis is commonly performed but end-to-side with closu re of the end of the colon is another option. Carry out the anastomosis either using a sing le layer of interrupted sero-muscular 3/0 Vicryl or PDS sutures or alternatively as a two l ayer suturing technique. (cid:142)(cid:3) Alternatively a stapled one stage functional end-to-end anastomosis and resection can be performed. (cid:142)(cid:3) Loop the portion of bowel to be resected and approximate the antimesenteric borders with stay sutures. (cid:142)(cid:3) Make a 1cm stab wound into the lumen of both the proximal and distal limbs and insert one fork of a GIA instrument into each lumen. (cid:142)(cid:3) Apply downward traction on the stay sutures to keep the mesentery out of the stapler. (cid:142)(cid:3) Close the instrument and fire the staples. Two double staggered rows of st aples join the bowel; simultaneously, the knife blade cuts between the two staple lines cre ating a stoma. (cid:142)(cid:3) Inspect the anastomotic staple lines for completeness and haemostasis. (ci d:142)(cid:3) Use a Babcock forceps to oppose the ends of the staple lines. (cid:142)(cid:3 ) Apply a GIA instrument across both limbs of bowel, distal to the Bab- cock forceps and fire the stapler to transect the bowel. (cid:142)(cid:3) Bury the transverse staple line using 3/0 PDS interrupted sutures. (cid:14 2)(cid:3) Close the mesenteric window, avoid taking the vessels in the bites. (cid:142)(cid :3) A drain maybe left in close proximity to the anastomosis. Closure (cid:142)(cid:3) Single layer mass closure using 1/0 PDS (cid:142)(cid:3) Skin with subcuticular Monocryl or Prolene. 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. Lesions of the transverse colon, splenic flexure, descending co lon can be treated by extended right hemicolectomy. RIGHT HEMICOLECTOMY1 273 Fig. 7.38 End-to-end anastomosis Fig. 7.39 Stapled anastomosis CHAPTER 7 Colorectal surgery 274 Left hemicolectomy Indications (cid:142)(cid:3) Neoplastic lesions involving distal transve rse colon, descending colon or sigmoid colon. (cid:142)(cid:3) Complex, symptomatic diverticular disease. Preparation (cid:142)(cid:3) Two units of blood are grouped and cross-matched (cid:142)(cid :3) Mechanical bowel preparation (usually with two sachets of Picolax) (cid:142)(cid:3) Thr ombo-embolism prophylaxis (cid:142)(cid:3) Prophylactic antibiotics administered after indu ction of anesthesia. (cid:142)(cid:3) Urethral catheter inserted after patient has been ane sthetized. Position Lloyd-Davies. 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) Cover the small bowel with wet packs and keep it away from operative field by tilting the table to the patient \200\231s right. (cid:142)(cid:3) Stand on the right side of the table and retract the sigmoid colon medially. (cid:142)(cid:3) Ask the assistant to retract 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 the retro-peritoneum. In the p rocess the gonadal vessels and ureter are swept away. Identify and safeguard the hypo-gastr ic 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. Continue the dissection laterally towards the flexure. For splenic flexure tumors the gastro-colic omentum is divided and the omentum removed with the specimen. (cid:142)(cid:3) Continue the incision along the left para-colic gutter upwards towards the splenic flexure. LEFT HEMICOLECTOMY1 275 Phrenicocolic ligament Inferior mesentric vein Inferior mesenteric artery Fig. 7.40 Left hemicolectomy Ureter Gonadal vessels Fig. 7.41 Mobilization of left colon CHAPTER 7 Colorectal surgery 276 (cid:142)(cid:3) Now grasp both limbs of the colon and under vision divide the peritoneum at the flexure. Bring the colon out of its splenic bed. Take care during the mob ilization of the splenic flexure that the tip of the retractor held by the assistant does n ot damage the spleen and avoid undue traction on the omentum during this maneuver as the sp lenic capsule can be torn. (cid:142)(cid:3) Lift up the sigmoid colon and divide the peritoneum on the right side from the origin of the inferior mesenteric artery down to the level of the sacral promentory. (cid:142)(cid:3) Pass a finger under the sigmoid colon and define the origin of the inferior mesenteric artery. (cid:142)(cid:3) Double clamp, divide and doubly ligate the inferior mesenteric artery. (ci d:142)(cid:3) Then clamp, divide and ligate the inferior mesenteric vein below the inferior border of the pancreas taking care not to tear this vessel. (cid:142)(cid:3) Divide the tr ansverse meso-colon at a convenient point. Isolate and ligate the marginal artery. (cid:142)(cid:3) Divide the transverse colon between occlusion and crushing clamps. (cid:14 2)(cid:3) Similarly divide the colon at the recto-sigmoid junction between Hayes clamps. (cid:142)(cid:3) Move to the left side of the table. (cid:142)(cid:3) Make sure there is no tension at the bowel ends and that it is adequately vascularised. (cid:142)(cid:3) Restore bowel continuity by using single layer of 3/0 PDS interrupted seromuscular sutures. (Fig 7.42) (cid:142)(cid:3) For a stapled anastomosis insert 2/0 Prolene purse-strings to both bowel ends. Make a colotomy through the anterior tinea and insert a circular stapler, placi ng the anvil in the distal segment. Tie the purse- strings and after approximation fire the stapler. (Fig 7.43) Alternatively a stapled anastomosis can be constructed introducing the stapler per- anally and placing the anvil in the proximal segment. (Fig 7.44) (cid:142)(cid:3) Check the donuts for completeness. (cid:142)(cid:3) Perform a leak test by insufflating air through a sigmoidoscope intro- duced per-anally and filling the peritonea l cavity with normal saline. (cid:142)(cid:3) Do a washout of the peritoneal cavity. Water is preferred for cytotoxic properties in cases of malignancy. (cid:142)(cid:3) Leave a tube drain in close proximity to the anastomosis. Closure In a single layer using number 1 loop PDS or Prolene and the skin with subcuticular Monocryl or Prolene. LEFT HEMICOLECTOMY1 277 Fig. 7.42 Interrupted seromuscular single layer anastomosis Circular stapler introduced into proximal colon through colotomy Purse string Fig. 7.43 Stapled anastomosis