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LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

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INDICATIONS
Resection of the right colon is commonly indicated for carcinoma, inflamatory bowel disease,
and more rarely for tuberculosis or volvulus of the cecum, ascending colon, or hepatic flexure.
PREOPERATIVE PREPARATION
Some tumors of the right colon present as an obstruction and may require relatively urgent
operation for excessive cecal distention (

15 cm) in the presence of a competent ileal

cecal valve. Such a patient is resuscitated with correction of fluid and electrolyte imbalances.
The proximal bowel is decompressed with a nasogastric tube. Once the patient's physiologic
status is optimized, he or she will proceed to urgent operation, wherein a right colectomy can
be performed in an unprepared bowel. The left side of the colon should be decompressed
with enemas and the prudent surgeon should verify that there is not a second or
matachronous colorectal lesion. If the right colectomy is being done in an elective setting, the
entire colon should be evaluated with either colonoscopy or barium enema. Blood transfusion
may be advisable, especially in older patients with cardiovascular disease, when a silent and
unrecognized iron deficiency anemia has been created by a silent neoplasm of the right
colon. Preexisting steroid therapy is continued with intravenous replacement as the patient
prepares for surgery. Perioperative systemic antibiotics are given.
ANESTHESIA
Either general inhalation or spinal anesthesia is satisfactory.
POSITION
The patient is placed in a comfortable supine position. The surgeon stands on the patient's
right side.
OPERATIVE PREPARATION
The skin is prepared in the routine manner and a sterile plastic drape applied.
INCISION AND EXPOSURE
A liberal midline incision centered about the umbilicus is made. A transverse incision just
above the level of the umbilicus also provides an excellent exposure. The lesion of the right
colon is inspected and palpated to determine whether removal is possible. In the presence of
malignancy, the liver is also palpated for evidence of metastasis. If the lesion is inoperable, a
lateral anastomosis may be performed between the terminal ileum and the transverse colon.
After resection has been decided upon, the small intestines are walled off with gauze or
replaced partially in a plastic bag, and the cecum is exposed.
DETAILS OF PROCEDURE
An incision is made in the peritoneal reflection close to the lateral wall of the bowel from the
tip of the cecum upward to the region of the hepatic flexure (Figure 1). A liberal margin should
be assured in the region of the tumor. Occasionally, the full thickness of the adjacent
abdominal wall may require excision to include the local spread of tumor. Since the entire

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hepatic flexure is usually removed as part of a right collectomy, the hepatocolic ligament,
which contains some small blood vessels, must be divided and ligated, but there will be no
blood vessels of importance in the peritoneal attachments along the right gutter. With the
lateral peritoneal attachment divided, the large bowel may be lifted mesially with the left hand,
while the loose areolar tissue lying under it is dissected off with a moist gauze sponge over
the right index finger (Figure 2). In elevating the right colon toward the midline, the surgeon
must positively identify the right ureter and be certain that it is not injured. Care is taken also
toward the top of the ascending colon and near the hepatic flexure to avoid injury to the third
portion of the duodenum, which underlies the large bowel (Figure 3). The raw surface
remaining after the intestine has been freed and brought outside the peritoneal cavity is
covered with warm, moist gauze pads. The middle colic vessels are identified, along with the
right-hand branches heading toward the hepatic flexure and the planned zone of transection.
The mesentery of the large bowel is clamped and divided just distal to the hepatic flexure or
wherever the bowel is to be resected. The right branches or all of the middle colic vessels are
divided and doubly ligated. The bowel at the selected level for division is freed of all
mesentery, omentum, and fat on both sides. All vessels must be carefully ligated. The right
half of the greater omentum is divided near the greater curvature of the stomach and excised
along with the right colon.
The terminal ileum is prepared for resection some distance away from the ileocecal valve,
depending upon the amount of blood supply that must be sacrificed to ensure excision of the
lymph node drainage area of the right colon. After the small intestine has been prepared at its
mesenteric border, a fan-shaped excision of the mesentery to the right colon is carried out.
This usually includes part of the right branches of the middle colic vessels. In the presence of
malignancy, the lymph node dissection should descend as far as possible along the course of
the right colic and ileocolic vessels without compromising either the middle colic vessels or
the superior mesenteric vascular supply of the remaining small bowel (Figure 4). The blood
vessels of the mesentery are doubly tied (see PyloromyotomyIntussusception).
A straight vascular clamp, or some other type of straight clamp, is applied obliquely to the
small intestine about 1 cm from the mesenteric border to ensure a serosal surface for the
placement of sutures for the subsequent anastomosis. Stone, Kocher, or Pace-Potts clamps
are next applied across the large intestine, which is then divided between the clamps. The
intervening section of bowel, with its fan-shaped section of mesentery and nodes, is excised.
The divided proximal end of the small intestine is covered with gauze moistened with saline,
and closure of the stump of the large bowel is started unless an end-to-end or end-to-side
anastomosis is planned. Some surgeons prefer to use stapling devices in which case the
colon and terminal small bowel are resected using the GIA60 device. The ileum and
transverse colon may then be anastomosed in an antimesenteric side-to-side manner using
the technique shown in Resection of Small Intestine, Stapled (Alternative Methods). As
staples may not be universally available, the techniques for hand-sewn anastomoses are
shown in the next sections.

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The end of the colon is closed by a continuous absorbable suture on an atraumatic needle
and whipped loosely over a Pace-Potts or similar noncrushing clamp (Figure 5). Interrupted
000 silk sutures placed beneath the clamp may be used. The clamp is then opened and
removed. If a continuous suture is used, it is pulled up snugly and tied. A single layer of 000
silk Halsted mattress sutures is placed about 2 or 3 cm from the original suture line, care
being taken that no fat is included. As these sutures are tied, the original suture line is
invaginated so that serosa meets serosa (Figure 6). The surgeon must determine before
closing the ends of the colon whether an end-to-end, end-to-side, side-to-end, or lateral
anastomosis is to be carried out (Figures 14, 16, 17 and 18).
The end-to-side approximation is physiologic, simple, and safe to perform. The small
intestine, still held in its clamp, is brought up adjacent to the anterior taenia of the colon
(Figure 7). The small intestine should retain a good color and give evidence of adequate
blood supply before the anastomosis is attempted. If its color indicates an inadequate blood
supply, the surgeon should not hesitate to resect a sufficient length until its viability is
unquestionable. Next, the omentum, if not previously excised, is retracted upward, and the
anterior taenia of the transverse colon is grasped with Babcock forceps at the site chosen for
anastomosis (Figure 7). Following this, the edge of the mesentery of the small intestine
should be approximated to the edge of that of the large intestine, so that herniation of the
small intestine cannot occur beneath the anastomosis into the right gutter (Figure 14). This
opening is closed before the anastomosis is started, since on rare occasions the blood supply
may be injured by the procedure and the viability of the anastomosis jeopardized. A small,
straight crushing clamp is applied to the anterior taenia, including a small bite of the bowel
wall (Figure 8). Following this, the clamps on the terminal ileum, as well as on the anterior
taenia of the transverse colon, are so arranged that a serosal layer of interrupted 000
mattress or nonabsorbable synthetic sutures can be placed, anchoring the terminal ileum to
the transverse colon (Figure 9). The two angle sutures are not cut and serve as traction
sutures (Figure 9). An opening is made into the large intestine by excising the protruding
contents of the crushing clamp that has been applied to the anterior taenia (Figure 10). An
enterostomy clamp is then applied behind each of the crushing clamps. The crushing clamps
are removed, and the terminal ileum is opened; likewise, the crushed contents of the
transverse colon are separated. Sometimes it is necessary to enlarge the opening in the
mucosa of the colon, since the previous excision of the contents of the crushing clamp did not
provide a sufficiently large stoma for satisfactory anastomosis. The mucosa is then
approximated with a continuous locked nonabsorbable suture on atraumatic needles, which is
started in the midline posteriorly. The sutures, A and B, are continued as a Connell inverting
suture around the angles and anteriorly to ensure inversion of the mucosa (Figures 11 and
12). Interrupted fine 000 silk sutures are preferred by some for closing the mucosal layer. An
anterior row of mattress sutures completes the anastomosis. Several additional mattress
sutures may be placed to reinforce the angles (Figure 13). The patency of the stoma is
tested. It should permit introduction of the index finger. If the tension is not too great, the raw

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surface over the iliopsoas muscle may be covered by approximating the peritoneum of the
lateral abdominal wall to the mesentery.
The second method shown is a direct end-to-end anastomosis (Figures 15 and 16). The
discrepancy in the size of the terminal ileum and the transverse colon can be overcome safely
by attending to certain technical details. Added luminal circumference can be provided by
exaggerating the oblique division of the terminal ileum. During the anastomosis, slightly larger
bites are taken in the colonic side to compensate for the discrepancy between the two sides
of the anastomosis. Following completion of the anastomosis, any remaining gap between the
mesenteries is approximated. The patency of the lumen is determined by palpation.
If a side-to-end anastomosis is preferred by the surgeon, the stump of the small intestine is
closed as previously described for the large intestine. The small intestine is then brought up
to the open end of the large intestine (Figure 17), the posterior row of serosal sutures is
placed, the small intestine is opened, and the continuous mucosal suture or the inverting
sutures are placed as well as, finally, the anterior serosal sutures of interrupted 000 silk or
nonabsorbable synthetic material. Whenever this type of procedure is carried out, care should
be taken that only a very small portion of small intestine protrudes beyond the suture line,
since blind ends of bowel that are in the peristaltic line form a stagnant pouch against which
peristalsis tends to work, increasing the chance of eventual breakdown.
In the fourth method, the ends of the large and small intestines are closed, and a lateral
anastomosis is carried out. Only a small portion of small intestine should protrude beyond the
suture line. The small intestine should be anchored to the colon with interrupted sutures of
silk or nonabsorbable synthetic material, including both angles of the stoma as well as the
closed end of small bowel (Figure 18). The stapled equivalent of each of the variations can be
found in earlier chapters illustrating the use of various stapling instruments in small bowel
anastomoses.
CLOSURE
Drains are undersirable unless gross infection has been encountered. The site of
anastomosis is covered with omentum. The abdominal wall is closed in routine fashion, and a
sterile dressing is applied.
POSTOPERATIVE CARE
The patient should be in a comfortable position. Diarrhea or frequent bowel movements may
be satisfactorily controlled by medication and diet. The need for continued steroid therapy,
particularly in patients with regional ileitis, should not be overlooked in the immediate
postoperative period.

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