Chassin's Operative Strategy in Colon and Rectal Surgery (eBook)

Preface 7
Table of Contents 8
Contributors 12
Part I Large Intestine 13
1 Concepts in Surgery of the Large Intestine 14
BENIGN CONDITIONS 14
Diverticular Disease 14
Volvulus 15
Ischemic Colitis 16
Rectal Prolapse 16
Familial Polyposis and Hereditary Colon Cancer Syndromes 17
Inflammatory Bowel Disease 18
Crohn’s Colitis 18
Ulcerative Colitis 18
Indeterminate Colitis 19
Polyps 19
MALIGNANT CONDITIONS 20
Colorectal Cancer 20
Extent of Resection 20
Colorectal Cancer with Synchronous Pathology 20
Synchronous Benign or Premalignant Conditions 20
Synchronous Cancer 21
Preoperative Evaluation 21
Neoadjuvant Therapy for Rectal Adenocarcinoma 22
Squamous Carcinoma of the Anus 22
Surgical Approach and Strategy 22
Specific Interoperative Considerations During Operations for Colorectal Cancer 24
Strategies for Complex Situations 24
Primary Anastomosis versus Staged Procedures 25
Technical Factors for Safe Anastomosis 26
Other Factors Affecting Anastomotic Healing 27
Technical Considerations and Adjuncts 27
INTESTINAL POUCH RESERVOIRS 28
INTESTINAL STOMAS 28
POSTOPERATIVE CARE 30
Management of Altered Sphincter Function 30
Urogenital Function 31
CANCER SURVEILLANCE 31
POUCH SURVEILLANCE 31
REFERENCES 32
2 Right Colectomy for Cancer 36
INDICATIONS 36
PREOPERATIVE PREPARATION 36
PITFALLS AND DANGER POINTS 36
OPERATIVE STRATEGY 36
OPERATIVE TECHNIQUE (Right and Transverse Colectomy) 40
Incision 40
Ligature of Colon Proximal and Distal to Tumor 40
Omental Dissection 40
Division of Middle Colic Vessels 40
Division of Ileocolic Vessels 41
Division of Ileal Mesentery 42
Division of Right Paracolic Peritoneum 42
Identifi cation of Ureter 44
Division of Ileum and Colon 44
Ileocolic Two-Layer Sutured End-to-End Anastomosis 44
Anastomosis by Stapling, Functional End-to-End 48
Wound Closure 48
POSTOPERATIVE CARE 48
COMPLICATIONS 52
REFERENCES 52
3 Laparoscopic Right Hemicolectomy 53
INDICATIONS 53
PREOPERATIVE PREPARATION 53
PITFALLS AND DANGER POINTS 53
OPERATIVE STRATEGY 53
OPERATIVE TECHNIQUE 54
Room Setup and Trocar Placement 54
Exploration 55
Mobilization of the Cecum 56
Mobilization of the Hepatic Flexure 56
Extracorporeal Resection and Anastomosis 57
Re-insufflflation and Inspection 58
POSTOPERATIVE CARE 60
COMPLICATIONS 60
REFERENCES 60
4 Left Colectomy for Cancer 61
INDICATIONS 61
PREOPERATIVE PREPARATION 61
PITFALLS AND DANGER POINTS 61
OPERATIVE STRATEGY 61
Extent of Dissection 61
Liberation of Splenic Flexure 61
No-Touch Technique 64
Technique of Anastomosis 64
OPERATIVE TECHNIQUE 64
Incision and Exposure 64
Liberation of Descending Colon and Sigmoid 64
Division of Renocolic Ligament 64
Splenic Flexure Dissection 66
Ligation and Division of Inferior Mesenteric Artery 69
Division of Mesocolon 69
Ligation and Division of Mesorectum 69
Insertion of Wound Protector 71
Division of Colon and Rectum 71
End-to-End Two-Layer Anastomosis, Rotation Method 72
End-to-End Anastomosis, Alternative Technique 73
Stapled Colorectal Anastomosis 76
Stapled Colocolonic Functional End-to-End Anastomosis: Chassin’s Method 81
Closure 84
POSTOPERATIVE CARE 84
COMPLICATIONS 84
REFERENCES 84
5 Laparoscopic Left Hemicolectomy 85
INDICATIONS 85
PREOPERATIVE PREPARATION 85
Mechanical Bowel Preparation 85
Administration of Prophylactic Antibiotics 85
Other Perioperative Steps 85
PITFALLS AND DANGER POINTS 85
OPERATIVE STRATEGY 85
OPERATIVE TECHNIQUE 85
Room Setup and Patient Positioning 85
Trocar Placement 86
Mobilizing the Left Colon and Identifification of the Left Ureter 86
Dissecting the Splenic Flexure and Isolation of the Transverse Mesentery 87
Identifification and Transection of the Mesentric Vessels 89
Transection of the Distal Colon or Rectosigmoid Junction 90
Exteriorization of the Left Colon 91
Performing the Anastomosis 92
Closure of the Wound 94
POSTOPERATIVE CARE 96
COMPLICATIONS 96
REFERENCES 96
6 Low Anterior Resection for Rectal Cancer 97
INDICATIONS 97
PREOPERATIVE PREPARATION 97
PITFALLS AND DANGER POINTS 97
OPERATIVE STRATEGY 97
Prevention of Anastomotic Complications 97
Which Colorectal Anastomosis: Sutured, Circular Stapled, or Double Stapled? 98
Extent of Lymphovascular Dissection 98
Indications for Complementary Colostomy or Loop Ileostomy 98
Presacral Dissection: Prevention of Hemorrhage 98
Presacral Dissection: Preservation of Hypogastric Nerves 101
Ureteral Dissection 101
OPERATIVE TECHNIQUE 102
Incision and Position 102
Exploration and Evisceration of Small Bowel 102
Mobilization of Sigmoid 102
Lymphovascular Dissection 103
Presacral Dissection 106
Pelvic Hemostasis 107
Mobilization of Proximal Colon 107
Preparation of Rectal Stump 110
Irrigation of Rectal Stump 110
Selection of Anastomotic Technique 110
Side-to-End Low Colorectal Anastomosis (Baker) 110
Alternative to Colorectal Side-to-End Anastomosis 116
Circular Stapled Low Colorectal Anastomosis 116
Double-Stapled Technique for Very Low Colorectal Stapled Anastomosis 123
Pitfalls and Danger Points of Circular Stapled Colorectal Anastomosis 126
Wound Closure and Drainage 128
POSTOPERATIVE CARE 128
COMPLICATIONS 128
REFERENCES 129
7 Abdominoperineal Resection for Rectal Cancer 130
INDICATIONS 130
PREOPERATIVE PREPARATION 130
PITFALLS AND DANGER POINTS 130
OPERATIVE STRATEGY 130
Abdominal Phase 130
Colostomy 130
Pelvic Floor 131
Perineal Phase 131
Position 131
Closure of Perineum 131
Dissection of Perineum 132
Hemostasis 132
OPERATIVE TECHNIQUE 132
Position 132
Incision and Exploration: Operability 132
Mobilization of Sigmoid, Lymphovascular Dissection, and Presacral Dissection 132
Pelvic Hemostasis 133
Perineal Dissection 133
Management of Pelvic Floor 139
Colostomy 140
POSTOPERATIVE CARE 145
Perineal Care 145
Colostomy Care 145
COMPLICATIONS 145
REFERENCES 146
8 Laparoscopic Abdominoperineal Resection and Total Proctocolectomy with End Ileostomy 147
ABDOMINOPERINEAL RESECTION 147
INDICATIONS 147
PREOPERATIVE PREPARATION 147
PITFALLS AND DANGER POINTS 147
OPERATIVE TECHNIQUE 147
Room Setup and Trocar Placement 147
Exploration of the Abdominal Cavity 147
Mobilization of the Sigmoid/Rectosigmoid Colon 149
Division of the Inferior Mesenteric Vessels 149
Division of the Sigmoid/Descending Colon 149
Rectal Mobilization 149
Perineal Dissection and Specimen Removal 149
TOTAL PROCTOCOLECTOMY WITH END ILEOSTOMY 154
INDICATIONS 154
PREOPERATIVE PREPARATION 154
PITFALLS AND DANGER POINTS 154
OPERATIVE TECHNIQUE 154
Room Setup and Trocar Placement 154
COMPLICATIONS 160
POSTOPERATIVE CARE 160
9 Subtotal Colectomy with Ileoproctostomy or Ileostomy and Sigmoid Mucous Fistula 161
INDICATIONS 161
PREOPERATIVE PREPARATION 161
PITFALLS AND DANGER POINTS 161
OPERATIVE STRATEGY 161
OPERATIVE TECHNIQUE 161
Placement of Ileostomy 161
Operative Position 162
Incision 162
Evacuation of Stool 162
Dissection of Right Colon and Omentum 162
Dissection of Left Colon 162
Division of Mesocolon 162
Ileostomy and Sigmoid Mucous Fistula 165
Ileoproctostomy 167
Subtotal Colectomy Combined with Immediate Total Proctectomy 167
Needle-Catheter Jejunostomy 169
Closure of the Abdominal Incision 169
POSTOPERATIVE CARE 169
COMPLICATIONS 169
REFERENCES 169
10 Ileoanal Anastomosis with Ileal Reservoir Following Total Colectomy and Mucosal Proctectomy 170
INDICATIONS 170
CONTRAINDICATIONS 170
PREOPERATIVE PREPARATION 170
PITFALLS AND DANGER POINTS 170
OPERATIVE STRATEGY 170
Mucosectomy 170
Abdominal Dissection 171
Rectal Dissection 171
Division of Waldeyer’s Fascia 171
Temporary Loop Ileostomy and Ileostomy Closure 171
Ileoanostomy 171
Constructing the Ileal Reservoir 171
OPERATIVE TECHNIQUE 172
Mucosal Proctectomy Combined with Total Colectomy 172
Perineal Approach 172
Abdominal Incision and Exposure 173
Constructing the Ileal Reservoir 174
Ileoanal Anastomosis 177
Loop Ileostomy 178
Drainage and Closure 179
POSTOPERATIVE CARE 180
COMPLICATIONS 180
REFERENCES 180
11 Abdominoperineal Proctectomy for Benign Disease 181
INDICATIONS 181
PREOPERATIVE PREPARATION 181
PITFALLS AND DANGER POINTS 181
OPERATIVE STRATEGY 181
OPERATIVE TECHNIQUE 181
Abdominal Incision and Position 181
Mesenteric Dissection 182
Rectal Dissection 182
Perineal Incision 183
Division of Levator Diaphragm 184
Closure of Pelvic Floor 184
Ileostomy 184
Abdominal Closure 184
POSTOPERATIVE CARE 185
COMPLICATIONS 185
REFERENCES 185
12 End-Ileostomy 186
INDICATIONS 186
PITFALLS AND DANGER POINTS 186
OPERATIVE STRATEGY 186
OPERATIVE TECHNIQUE 186
Preoperative Selection of Ileostomy Site 186
Incision 186
Fashioning the Ileal Mesentery 186
Closure of Mesenteric Gap 187
Mucocutaneous Fixation of Ileostomy 190
POSTOPERATIVE CARE 190
COMPLICATIONS 190
REFERENCE 190
13 Loop Ileostomy 191
INDICATIONS 191
PITFALLS AND DANGER POINTS 191
OPERATIVE STRATEGY 191
OPERATIVE TECHNIQUE 191
POSTOPERATIVE CARE 193
COMPLICATIONS 193
REFERENCES 193
14 Cecostomy SURGICAL LEGACY TECHNIQUE 194
INDICATIONS 194
PREOPERATIVE PREPARATION 194
PITFALLS AND DANGER POINTS 194
OPERATIVE STRATEGY 194
OPERATIVE TECHNIQUE 194
Skin-Sutured Cecostomy 194
Incision 194
Exploration of Cecum 194
Cecal Fixation 194
Mucocutaneous Suture 194
Tube Cecostomy 195
POSTOPERATIVE CARE 196
COMPLICATIONS 196
REFERENCE 196
15 Transverse Colostomy 197
INDICATIONS 197
PREOPERATIVE PREPARATION 197
PITFALLS AND DANGER POINTS 197
OPERATIVE STRATEGY 197
Impending Rupture of Cecum 197
Diversion of Fecal Stream 197
OPERATIVE TECHNIQUE 197
Incision 197
Identification of Transverse Colon 198
Immediate Maturation of Colostomy 198
Modification of Technique Using a Glass Rod 199
POSTOPERATIVE CARE 199
COMPLICATIONS 199
REFERENCES 200
16 Closure of Temporary Colostomy 201
INDICATIONS 201
PREOPERATIVE PREPARATION 201
PITFALLS AND DANGER POINTS 201
OPERATIVE STRATEGY 201
OPERATIVE TECHNIQUE 201
Incision 201
Fascial Dissection 201
Peritoneal Dissection 202
Closure of Colon Defect by Suture 202
Closure of Colonic Defect by Staples 203
Resection and Anastomosis of Colostomy 205
Closure of Abdominal Wall 205
Management of Skin Wound 205
POSTOPERATIVE CARE 205
COMPLICATIONS 205
REFERENCES 205
17 Laparoscopic Stoma Construction and Closure 206
INDICATIONS 206
PREOPERATIVE PREPARATION 206
PITFALLS AND DANGER POINTS 206
OPERATIVE STRATEGY 206
OPERATIVE TECHNIQUE 206
Loop Ileostomy 206
Room Setup and Trocar Placement 206
Choosing a Loop of Terminal Ileum 208
Exposing the Ileum 208
Loop Sigmoid Colostomy 209
Room Setup and Trocar Placement 209
Dissecting the Left Parietocolic Attachment 209
Exteriorizing the Sigmoid Loop 209
End Sigmoid Colostomy/Mucous Fistula 213
Operating Room Setup and Trocar Placement 213
Identification of the Ureter 214
Incision of the Mesocolon and Division of the Sigmoid Colon 214
Exteriorizating the Proximal Sigmoid Colon 216
Transverse Colostmy 216
Operating Room Setup and Trocar Placement 216
Dissecting the Omentum 218
Hartmann’s Take Down 218
Operating Room Setup, Trocar Placement, and Stoma Mobilization 218
Dissecting the Rectal Stump 220
Mobilization of the Left Colon 220
Performing the Anastomosis 220
Testing the Anastomosis 222
POSTOPERATIVE CARE 222
COMPLICATIONS 222
General Complications 222
Complications Related to Stoma Construction 222
Complication Related to Stoma Closure 222
REFERENCES 222
18 Operations for Colonic Diverticulitis (Including Lower Gastrointestinal Bleeding) 223
INDICATIONS 223
PREOPERATIVE PREPARATION 223
OPERATIVE STRATEGY 223
OPERATIVE TECHNIQUE 223
Primary Resection and Anastomosis 223
Incision 223
Liberation of Sigmoid and Left Colon 223
Division of Mesocolon 224
Anastomosis 224
Abdominal Closure 224
Primary Resection with End- Colostomy and Mucous Fistula 224
Emergency Sigmoid Colectomy with End-Colostomy and Hartmann’s Pouch 225
Indications 225
Preoperative Preparation 225
Operative Technique 226
REFERENCES 227
19 Ripstein Operation for Rectal Prolapse 228
INDICATIONS 228
PREOPERATIVE PREPARATION 228
PITFALLS AND DANGER POINTS 228
OPERATIVE STRATEGY 228
OPERATIVE TECHNIQUE 228
Incision 228
Incision of Pelvic Peritoneum 229
Presacral Dissection 229
Application of Mesh 230
Closure of Pelvic Peritoneum 230
Wound Closure 230
POSTOPERATIVE CARE 233
COMPLICATIONS 233
REFERENCES 233
Part II Anus, Rectum, and Pilonidal Region 234
20 Concepts in Surgery of the Anus, Rectum, and Pilonidal Region 235
CLINICAL CONDITIONS: SYMPTOMS AND MANAGEMENT CONCEPTS 240
REFERENCES 241
21 Rubber Band Ligation of Internal Hemorrhoids 242
INDICATIONS 242
PITFALLS AND DANGER POINTS 242
OPERATIVE STRATEGY 242
OPERATIVE TECHNIQUE 242
POSTOPERATIVE CARE 243
COMPLICATIONS 244
REFERENCES 244
22 Hemorrhoidectomy 245
INDICATIONS 245
CONTRAINDICATIONS 245
PREOPERATIVE PREPARATION 245
PITFALLS AND DANGER POINTS 245
OPERATIVE STRATEGY 245
Avoiding Anal Stenosis 245
Achieving Hemostasis 245
Associated Pathology 246
OPERATIVE TECHNIQUE 246
Closed Hemorrhoidectomy 246
Local Anesthesia 246
Intravenous Fluids 247
Positioning the Patient 247
Incision and Dissection 247
Radical Open Hemorrhoidectomy 250
Incision 250
Excising the Hemorrhoidal Masses 250
POSTOPERATIVE CARE 253
COMPLICATIONS 253
REFERENCES 253
23 Anorectal Fistula and Pelvirectal Abscess 254
INDICATIONS 254
PREOPERATIVE PREPARATION 254
PITFALLS AND DANGER POINTS 254
OPERATIVE STRATEGY 254
Choice of Anesthesia 254
Localizing Fistulous Tracts 254
Goodsall’s Rule 254
Physical Examination 254
Injection of Dye or Radiopaque Material 255
Preserving Fecal Continence 255
Fistulotomy Versus Fistulectomy 255
Combining Fistulotomy with Drainage of Anorectal Abscess 255
OPERATIVE TECHNIQUE 256
Anorectal and Pelvirectal Abscesses 256
Perianal Abscess 256
Ischiorectal Abscess 256
Intersphincteric Abscess 256
Pelvirectal Supralevator Abscess 256
Anorectal Fistula 258
Intersphincteric Fistula 258
Transsphincteric Fistula 260
Suprasphincteric Fistula (Extremely Rare) 263
Extrasphincteric Fistula (Extremely Rare) 263
Technical Hints for Performing Fistulotomy 264
POSTOPERATIVE CARE 264
COMPLICATIONS 264
REFERENCES 265
24 Lateral Internal Sphincterotomy for Chronic Anal Fissure 266
INDICATIONS 266
PREOPERATIVE PREPARATION 266
PITFALLS AND DANGER POINTS 266
OPERATIVE STRATEGY 266
OPERATIVE TECHNIQUE 266
Anesthesia 266
Closed Sphincterotomy 266
Open Sphincterotomy 267
Removal of the Sentinel Pile 267
POSTOPERATIVE CARE 267
COMPLICATIONS 267
REFERENCES 268
25 Anoplasty for Anal Stenosis 269
INDICATIONS 269
PREOPERATIVE PREPARATION 269
PITFALLS AND DANGER POINTS 269
OPERATIVE STRATEGY 269
OPERATIVE TECHNIQUE 269
Sliding Mucosal Flap 269
Incision 269
Internal Sphincterotomy 269
Advancing the Mucosa 269
Sliding Anoderm Flap 269
Incision 269
Internal Sphincterotomy 272
Advancing the Anoderm 272
POSTOPERATIVE CARE 274
COMPLICATIONS 274
REFERENCE 274
26 Thiersch Operation for Rectal Prolapse SURGICAL LEGACY TECHNIQUE 275
INDICATIONS 275
PREOPERATIVE PREPARATION 275
PITFALLS AND DANGER POINTS 275
OPERATIVE STRATEGY 275
Selecting Proper Suture or Banding Material 275
Achieving Proper Tension of the Encircling Band 275
OPERATIVE TECHNIQUE 275
Fabricating the Encircling Band of Mesh 275
Incision and Position 275
Inserting the Mesh Band 275
Adjusting Tension 276
Closure 276
POSTOPERATIVE CARE 278
COMPLICATIONS 278
REFERENCES 278
27 Operations for Pilonidal Disease 279
INDICATIONS 279
PITFALLS AND DANGER POINTS 279
OPERATIVE STRATEGY 279
Acute Pilonidal Abscess 279
Marsupialization 279
Excision with Primary Suture 279
OPERATIVE TECHNIQUE 279
Marsupialization 280
Pilonidal Excision with Primary Suture 281
Excision of Sinus Pits with Lateral Drainage 282
POSTOPERATIVE CARE 283
COMPLICATIONS 283
REFERENCES 284
Index 285