Lower Gastrointestinal Tract Surgery (eBook)

Foreword 6
Preface 8
Acknowledgments 9
Contents 10
Contributors 12
Part I: Colon 15
1: Surgical Anatomy and Embryology 16
1.1 Introduction 16
1.2 Embryology 16
1.3 Fasciae 19
1.4 Mesocolon 21
1.5 Arterial Blood Supply 29
1.6 Venous Drainage 32
1.7 Lymphatic System 37
1.8 Autonomic Nerves 40
References 43
2: Appendectomy 44
2.1 Introduction 44
2.2 Deciding Between Open Versus Laparoscopic Approach 44
2.3 Surgical Anatomy 44
2.4 Conventional Appendectomy 46
References 57
Suggested Readings 57
3: Crohn’s Disease of the Large Bowel 58
3.1 General Principles of Surgery for Crohn’s Disease of the Large Bowel 58
3.2 Operative Options 58
3.2.1 Segmental Colectomy 61
3.2.2 Subtotal or Total Colectomy 64
3.2.3 Proctectomy 65
3.2.4 Proctocolectomy 65
References 65
4: Ulcerative Colitis 66
4.1 Introduction 66
4.2 Surgical Options for UC 66
4.3 Total Proctocolectomy with Conventional End Ileostomy (TPC) 66
4.4 Creation of Conventional End Ileostomy 67
4.5 Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA) 67
4.6 Creation of Loop Ileostomy 93
References 95
5: Benign Tumours of the Colon 96
5.1 Introduction 96
5.2 Resection of Right-Sided Tumours 96
5.3 Resection of Tumours of the Transverse and Left Colon 104
5.4 Laparoscopic Sigmoid Colectomy 116
5.5 Laparoscopic Total Colectomy 125
5.6 Laparoscopic “Rendezvous” or Laparo-Endoscopic Resection 129
References 131
6: Volvulus of the Colon 132
6.1 Caecal Volvulus 132
6.1.1 Pathophysiology 132
6.1.2 Clinical Presentation 132
6.1.3 Diagnosis 132
6.1.4 Management of Ileocaecal Volvulus 139
6.1.5 Open Versus Laparoscopic Surgery 141
6.2 Sigmoid Volvulus 141
6.2.1 Pathophysiology 142
6.2.2 Symptoms and Signs 143
6.2.3 Diagnosis 144
6.2.4 Imaging 144
6.2.5 Treatment 147
6.2.5.1 Conservative Treatment 147
6.2.5.2 Surgical Management 151
6.2.5.3 Elective Surgery 151
6.2.5.4 Non-resectional Procedures 151
6.2.5.5 Resectional Procedures 152
6.2.5.6 Emergent Procedure 152
6.2.6 Surgical Technique 156
Suggested Readings 163
7: Colon Cancer 164
7.1 Introduction 164
7.2 Embryological Planes and Mesocolic Excision 164
7.3 Lymph Node Dissection 169
7.4 Right Hemicolectomy 171
7.5 Extended Right Hemicolectomy 182
7.6 Carcinomas of the Splenic Flexure 190
7.7 Anastomosis 192
References 195
Suggested Reading 195
8: Ileostomies and Colostomies 196
8.1 Introduction 196
8.2 Loop Ileostomy 201
8.3 Loop Colostomy 211
References 219
9: Surgery for Cancer of the Left Colon 220
9.1 Introduction 220
9.2 Mobilisation of the Left Colon 220
9.3 Dissection of the Vessels, Bowel Resection and Reconstruction 227
Suggested Readings 235
Part II: Rectum 236
10: Rectum: Surgical Anatomy and Embryology 237
10.1 Introduction 237
10.2 Embryological Development of the Anorectum 237
10.3 Topographic Anatomy of the Rectum 240
10.4 Perirectal Fasciae 246
10.5 Arterial Blood Supply of the Anorectum 247
10.6 Autonomic and Somatic Nerve Supply of the Anorectum and Male Pelvic Organs 249
10.7 Dorsal, Lateral and Ventral Topography of the Rectum 250
Suggested Readings 260
11: Per Anal Excision of Benign Tumours 261
11.1 Introduction 261
11.2 Transanal Resection 261
11.3 Transanal Endoscopic Microsurgery 261
11.3.1 Pre-operative Assessment 264
11.3.2 Peri-operative Care and Positioning 265
11.3.3 Equipment 265
11.3.4 Procedure 266
11.3.5 Post-operative Care 271
11.4 Transanal Minimally Invasive Surgery 272
11.5 Endoscopic Mucosal Resection 273
11.6 Endoscopic Submucosal Dissection 279
References 282
12: Rectal Cancer: Anterior Resection and Low Anterior Resection with Total or Partial Mesorectal Excision 283
12.1 Introduction 283
12.2 Embryology 283
12.3 Left Colon and Splenic Flexure Mobilisation (Fig. 12.1) 284
12.4 Ligation and Division of the Inferior Mesenteric Vessels 286
12.5 Mobilisation of the Mesorectum and Rectum 290
12.6 Posterior Dissection 290
12.7 Lateral Dissection 296
12.8 Anterior Dissection 299
12.9 Deep Posterior Dissection 300
12.10 Anterior Dissection in Low Rectal Cancer 304
12.11 Extended Resection for Cancer Adherence or Involvement Beyond the Mesorectal Fascia 304
12.12 Distal Washout and Anastomosis 305
12.13 Circular Stapled Anastomosis 308
12.14 Defunctioning a Low Anastomosis After TME 308
12.15 Partial Mesorectal Excision 309
12.16 Post-operative Assessment of the Specimen 309
References 310
13: Lateral Pelvic Lymph Node Dissection (Pelvic Sidewall Dissection) 311
13.1 Introduction 311
13.2 Indications 311
13.3 Pelvic Sidewall Dissection 312
13.3.1 Taping of the Autonomic Nerves 313
13.3.2 Taping of the Ureters 313
13.3.3 Dissection of the Common Iliac Lymph Nodes 314
13.3.4 Dissection of the External Iliac Lymph Nodes 314
13.3.5 Dissection of the Obturator Lymph Nodes with Preservation of the Obturator Nerve 315
13.3.6 Dissection of the Internal Iliac Lymph Nodes Preserving the Superior Vesical Artery 316
13.3.7 Extraperitoneal Approach 320
13.3.8 Completion of Pelvic Sidewall Dissection 321
13.3.9 Combined Resection of Distal Internal Iliac Artery 321
13.3.10 Completion of Therapeutic Pelvic Sidewall Resection 325
References 328
14: Intersphincteric Abdominoperineal Resection 329
14.1 Definition and Indications 329
14.2 Surgical Strategy 329
14.3 Evolution of Surgery 332
14.4 Surgical Technique 333
14.4.1 Abdominal Step 333
14.4.2 Anal Exposure 335
14.4.3 Anal Canal Incision 336
14.4.4 Posterior Intersphincteric Dissection 337
14.4.5 Lateral Dissection 338
14.4.6 Anterior Dissection 339
14.4.7 Connection with the Abdominal Dissection 342
14.4.8 Anal Repair 346
14.4.9 Rectal Reconstruction 346
14.5 Deciding Between ISR and APR 347
14.6 Summary of Good Surgical Practice 350
References 350
15: Colon Cancer: Multivisceral Resection 351
15.1 Introduction 351
15.2 Preoperative and Intraoperative Management 351
15.3 Operative Procedure 351
15.4 Case Presentation 353
15.5 Peritoneal Carcinomatosis 376
15.6 Reconstruction 377
15.7 Conclusion 378
References 378
16: Abdominoperineal Excision of the Rectum 379
16.1 Introduction 379
16.2 The Abdominal Part of APE 379
16.3 Omentoplasty 379
16.4 The Pelvic Part of APE 382
16.5 Inter-Sphincteric APE (Fig. 16.2) 382
16.6 Stoma Formation 383
16.7 Extra-Levator APE (ELAPE) (Fig. 16.3) 385
16.8 Ischio-Anal APE (Fig. 16.12) 396
16.9 Minimally Invasive Approaches to APE 398
16.10 Reconstruction of the Pelvic Floor 399
References 402
17: Pelvic Exenteration with Composite Pelvic Bone Resection for Malignant Infiltration 403
17.1 Introduction 403
17.2 Pelvic Bone Compartments and Their Contents (Fig. 17.1) 405
17.3 Surgical Technique of Pelvic Exenteration with En Bloc Composite Resection of the Anterior Pelvic Bone (Pubic Bone) (Fig. 17.2) 407
17.3.1 Results of Pelvic Exenteration with En Bloc Composite Resection of the Anterior Pelvic Bone (Pubic Bone) 416
17.4 Surgical Technique of Pelvic Exenteration with En Bloc Composite Resection of the Posterior Bone (Sacrectomy) 418
17.4.1 Results of Pelvic Exenteration with En Bloc Composite Resection of the Posterior Pelvic Bone (Sacrectomy) 428
17.5 Surgical Technique of Lateral Pelvic Exenteration with Composite Lateral Pelvic Bone Excision 430
17.5.1 Results of Lateral Composite Pelvic Bone Excision with Pelvic Exenteration 432
References 434
18: Flaps for Reconstruction: Vertical Rectus Abdominis Myocutaneous Flap 435
18.1 Introduction 435
18.2 Preoperative Considerations and Measures 435
18.3 Operative Procedure 439
References 450
Part III: Pelvic Floor, Anus and Anal Canal 451
19: Pelvic Floor/Anal Canal: Surgical Anatomy and Embryology 452
19.1 Introduction 452
19.2 Pelvic and Urogenital Diaphragm 452
19.3 Pelvic Floor and Anal Sphincter Muscles 457
19.4 Nerve and Vascular Supply of the Pelvic Floor 461
19.5 Topography of Pelvic Spaces 464
19.6 Anal Canal 467
Suggested Readings 473
20: Haemorrhoids 474
20.1 Introduction 474
20.2 Clinical Presentation 474
20.3 Treatment Algorithm 474
20.3.1 General Measures 474
20.3.2 Sclerotherapy 475
20.3.3 Rubber Band Ligation 475
20.4 Surgery 475
20.4.1 Indication for Surgery 475
20.5 Surgical Techniques 476
20.5.1 Milligan-Morgan’s Open Haemorrhoidectomy (Fig. 20.1a–g) 476
20.5.2 Segmental Haemorrhoid Resections with Tissue Sealing (Fig. 20.2a–j) 476
20.5.3 Supra-Anodermal Haemorrhoidopexy with the Stapler (Fig. 20.3a–j) 483
20.5.4 Haemorrhoidal Artery Ligation with/Without Anal Repair (Fig. 20.4a–d) 483
20.5.5 Submucosal Tissue Destruction 483
20.6 Individualised Therapy and Indication 484
20.7 Results (for Detailed Information See the Respective Literature) 484
20.8 Conclusion for Practical Work in Daily Routine 484
Suggested Readings 491
21: Anal Fistulas 492
21.1 Introduction 492
21.2 Diagnostic Imaging 492
21.3 Surgical Treatments 492
21.3.1 General Surgical Procedures 495
21.3.1.1 Fistulotomy 495
21.3.1.2 Core-Out Fistulectomy 496
21.3.1.3 Seton (Cutting, Loose, Chemical) 499
Seton (Cutting Technique) 499
Seton (Loose or Draining Technique) 500
21.3.1.4 Mucosal/Skin Advancement Flaps (Fig. 21.6) 501
21.3.2 Sphincter-Saving Procedures 502
21.3.2.1 Ligation of Intersphincteric Fistula Tract 503
21.3.2.2 Closure of Internal Opening with Over-the-Scope Clip (OTSC) Fistula Clip 505
21.3.2.3 Fistula Tract Filling (Glue, Paste, Plugs) 506
Glue 506
Collagen Paste 507
Plugs 507
21.3.2.4 Fistula Tract Ablation 508
FiLaC 508
VAAFT (Video-Assisted Anal Fistula Treatment) 509
21.3.2.5 Stem-Cell Therapy 509
21.4 Conclusions 511
References 511
22: Entero- and Rectocele, Rectal Prolapse 512
22.1 Introduction 512
22.2 Surgical and Functional Anatomy 512
22.3 Epidemiology, Aetiology and Pathogenesis 512
22.4 Treatment Objectives 513
22.5 Treatment Principles 514
22.6 Surgical Treatment 514
22.6.1 Transanal Approach 514
22.6.1.1 Mucosal Resection According to Rehn-Delorme 514
22.6.1.2 Rectosigmoidectomy According to Altemeier 521
22.6.1.3 Stapled Transanal Resection of the Rectum (STARR) 522
22.6.1.4 Perineal Stapled Prolapse Resection (PSP) 527
22.7 Transabdominal Surgical Approaches 528
References 533
23: Sacral Nerve Stimulation for Faecal Incontinence 534
23.1 Introduction 534
23.2 Concept 534
23.3 Anatomy 534
23.4 Indications and Contraindications 535
23.5 Surgical Technique 537
23.5.1 Patient Positioning 537
23.5.2 Use of Fluoroscopy/X-Ray 538
23.5.3 Foramen Needle Electrode Placement (Acute Percutaneous Evaluation) 541
23.5.4 Temporary Electrode Placement 545
23.5.5 Tined Lead Electrode Placement 547
23.5.6 The Pocket in the Buttock/Pulse Generator Placement 561
23.5.7 Postoperative Management 563
References 563
24: Sphincteroplasty 564
24.1 Introduction 564
24.2 Operative Technique 564
24.2.1 Preoperative Considerations 564
24.2.2 Positioning 564
24.2.3 Surgical Steps 564
24.3 Post-Operative Management 583
24.4 Outcomes 584
References 585
25: Transanal Total Mesorectal Excision (ta-TME) 586
25.1 Introduction 586
25.2 Technical Description of ta-TME 587
25.2.1 Laparoscopic Abdominal Phase 587
25.2.2 Endoscopic Transitional Phase 588
25.2.2.1 Position of the Patient 588
25.2.2.2 Placement of the Transanal Port Device 588
25.2.2.3 Purse-String Suture Below the Tumour Under Endoscopic Vision 593
25.2.2.4 Complete Transection of the Rectal Wall 594
25.2.2.5 Posterior Mesorectal Dissection 595
25.2.2.6 Anterior Mesorectal Dissection to the Peritoneal Reflection 596
25.2.2.7 Lateral Mesorectal Dissection 597
25.2.2.8 Extraction of the Surgical Specimen 599
Extraction of the Specimen by Transanal Route 599
Transabdominal Extraction 600
25.2.2.9 Preparation of the Colon to Anastomose the Bowel 601
25.3 Types of Anastomosis 602
25.3.1 Mechanical Anastomosis 602
25.3.2 Hand-Sewn Colo-Anal Anastomosis 603
25.3.3 Pull-Through Type Delayed Anastomosis 604
Suggested Readings 607
26: Multivisceral Resection for Rectal Cancer 608
26.1 Introduction 608
26.2 Preoperative Assessment 609
26.3 Total Pelvic Exenteration: The Surgical Steps 610
26.3.1 Mobilisation of the Colon and Posterior Dissection of the Rectum 610
26.3.2 Anterior Mobilisation of the Bladder 611
26.3.3 Lateral Pelvic Dissection of the Bladder’s Vascular Pedicles, the Autonomic Nerves, and Ureters 612
26.3.4 Perineal Dissection 614
26.3.5 Special Considerations 617
26.3.5.1 Extended Urethral Resection to the Base of the Penis 617
26.3.5.2 Rectal Resection with Prostatectomy, Sparing of the Bladder and Sphincter Preservation 617
26.4 Exenteration in Female Patients 619
26.4.1 Posterior Exenteration 620
26.4.2 Special Considerations 622
26.4.2.1 Total Vaginectomy 622
26.5 Lateral Pelvic Dissections 622
26.6 Extended Resections of the Pelvic Floor 625
References 625
Suggested Reading 625