Key principles
• Inflammatory v. oncological o Decide on purpose of procedure pre-operatively • Resect to helathy bowel • Protect ureter • Minimise retraction on spleen
Specific preoperative preparation
• Consider JJ stent in difficult cases if concern of ureteric involvement • Stoma nurse marking
Operation Details
- Positioning
- Supine
- Incision
- Large midline incision
- Technical aspects
- Inspect small bowel and retract using moist pack and self-retawining retractor
- Mobilisation
- Free colon from peritoneal attachments along line of Toldt proximally from splenic flexure to pelvic inlet
- Blunt dissection around any inflammatory mass can be helpful
- Identify ureter in normal tissue and follow into pelvis, preserving and protecting
- If required for length splenic flexure can be mobilised
- Transection
- Select proximal and distal transection points
- Linear cutting stapler
- Oncological v. inflammatory
- Inf - Peritoneum overlying mesentry scored with electrocautery and left colic/sigmoidal branches identified, double ligated and transected with division of remaining mesentry and removal of specimen
- Onc - IMA ligated near origin from aorta and all associated nodal tissue taken with specimen
- Proximal and distal end of bowel marked, sent for histology
- Prolene to stump to facilitate reversal
- Washout
- Ensure proximal colon reaches abdominal wall
- Consider abdominal wall tacking sutures
- Stoma
- Trephine, muscle splitting, two finger breadths
- Colon passed out without torsion or tension
- Closure midline over drains
- Maturation of flush stoma with 3-0 vicryl rapide on SH
Relative anatomy
• Ureter o They arise from the renal pelvis and descend towards the bladder on the anterior surface of the psoas major muscle. o The ureters cross the pelvic brim and then run posteroinferiorly on the lateral walls of the pelvis, and curve anteromedially to enter the posterior aspect of the bladder at the vesico-ureteric junction. o The ureter is divided into an abdominal part and pelvic part o The abdominal part lies behind the peritoneum, on the medial part of the psoas major muscle and is crossed by the gonadal vessels. o At its origin, the right ureter is covered by the duodenum (descending part), lies to the right of the IVC and is crossed by the right colic and ileocolic vessels. o The left ureter is crossed by the left colic vessels and passes posteriorly to the sigmoid colon and its mesentery. o It enters the pelvis by crossing the division of the common iliac vessels. The pelvic part runs downward on the lateral wall of the pelvic cavity, along the anterior border of the sciatic notch. o It lies anterior to the hypogastric artery and medial to the obturator nerve. o It inclines medially and enters the bladder at the lateral angles of the trigone. o In females, the ureters pass under the uterine arteries (‘water under the bridge’). o In males, the ureters pass under the vas deferens • Blood supply o IMA to sigmoidal and left colic branches o Watershed at splenic flexure, arc of Drummond
Intraoperative complications & challenges
• Ureter involved o JJ Stent o Urology input o Consider en bloc resection and reconstruction • Ureter damaged o JJ Stent o Spatulation repair • Splenic o Minimise risk by gentle retraction o Consider pack above spleen to take tension off o Pack first o Topical haemostatics o Progressive management from diathermy, suture through splenectomy • Not enough length on descending colon o Take down splenic flexure o Score peritoneum o Take IMA, IMV if required - Double take IMV o Bring out high descending or transverse if required
Complications
• Wound infection (most common) • Rectal stump leak • Abscesses around the rectal stump • Fistula from the rectal stump to the bowel • Retraction of the colostomy • Parastomal hernia • Skin irritation around the colostomy • Paralytic ileus • Wound dehiscence • Ureteral injury • General consequences that may occur with any operation (eg, bleeding, damage to surrounding structures, and cardiopulmonary complications) • Mortality is estimated to be about 13% if purulent peritonitis is present and may be as high as 43% if feculent peritonitis is present