TECNICAS DE CIERRE DE HERIDA

Indications Surgical wounds. Traumatic wounds.

Contraindications Absolute Multiple comorbidities precluding safe intervention. Active infection. Foreign body (except surgical implants). Active bleeding. Relative Impaired healing (corticosteroids, malnutrition, radiation, chronic disease).

Informed Consent Usually implied with consent for major procedure, must obtain consent otherwise. Potential Risks Scarring (normal and abnormal). Bleeding (may require reoperation or transfusion). Infection (may require antibiotics or reoperation). Failure of operation or need for secondary intention healing. Need for revision.

Equipment Instruments Appropriate instruments vary by wound type but include at a minimum a needle driver and tissue handling forceps. Sutures Consist of both a needle and suture material, each with multiple subtypes and characteristics. The needle and suture material may vary widely based on different types of wounds in different locations. Needle Table 42–1: Point characteristics. Swage: the method of attaching the suture material to the needle. Channel swage: a channel is crimped over suture material (swage diameter > body diameter). Drill swage: suture material is placed in the drill hole at the rear of needle, which is then crimped (swage diameter < body diameter). Nonswaged: eyed needle (similar to sewing needle). Closed-eye needles require suture material to be passed through the eye each time it is threaded. French eye needles have a posterior slit allowing suture to be placed in the eye without direct threading; this causes more tissue trauma and reduced suture integrity (eye > body diameter). Pop-off: swage is designed to allow suture material to be gently removed from the needle with traction. Table 42–2: Needle body characteristics. Designed to transmit the penetrating force to the point. Varied alloy characteristics can make a needle soft or firm (ductility). Diameter: gauge or thickness of needle. Table 42–1. Needle characteristics—point. Category Type Description Tissue Use Diagram   Conventional cutting Triangular point that changes to a flattened body with one cutting edge on the concave surface of the needle (surface seeking) Skin and tendon     Reverse cutting Cutting edge on convex curvature of the needle (depth-seeking) Stronger than conventional cutting Dense tissue, including skin, oral mucosa, and tendon   Cutting Side-cutting (spatula) Flat with 2 cutting edge to reduce tissue injury and improve depth control Ocular tissues     Taper-point (round needle) Stretches tissue without direct cutting action to minimize tearing Sharpness increases with taper ratio (slope) (8–12:1) and decrease with tip angle (20–35 degrees) Easily penetrated tissues, including abdominal viscera, dura, and peritoneum   Blunt Blunt Dissects through tissue rather than cutting it Friable tissue, including kidney and liver   Table 42–2. Needle Characteristics—body. Type Notes Diagram Straight Used in easily accessible tissue   Tissue is manipulated to allow passage of needle (eg, Keith needle) Curved Most common Chord length: linear distance between tip and swage (bite width)   Needle follows predicable path through tissue with even tension distribution Needle length: distance between tip and swage along curvature of needle   Radius: distance form center of arc of rotation of needle to needle itself—determines bite depth Compound Compound curved: variable radius   Used in ophthalmologic and microsurgical procedures

Patient Preparation Nothing by mouth the evening before surgery if the patient will be undergoing general anesthesia. Preoperative antibiotics per institutional policy and based on wound characteristics. Anesthesiology consultation as needed. Anesthesia Under general anesthesia, no additional preparation is necessary. In a conscious patient, local anesthetic (lidocaine, bupivacaine, etc) must be used. Wound Preparation Wound must be clean. Clean wounds may need no specific preparation prior to closure. Highly contaminated wounds should be irrigated (bulb, pulse-lavage, etc). Lacerations. May use a prefabricated syringe-mounted ocular flushing system. A saline bottle with 5–10 needle punctures provides a low-cost, effective irrigator in the acute setting. Skin edge. Complex lacerations and damaged skin edges should be resected to healthy tissue where possible. "Freshen" skin edges to allow more accurate apposition of wound margins. Hair is generally removed to fully expose wounds and reduce infection.

Patient Positioning The wound should be fully exposed and at comfortable working distance from the surgeon. A light source is often necessary in the emergency department setting.

Procedure Suture Closure Techniques Figure 42–1: Running continuous stitch. Widely used technique to close many wounds varying from lacerations to midline laparotomy wounds. Depth of bite and layers of tissue incorporated are dependent on site and tissue characteristics. Advantages of running technique. Allows expeditious wound closure. Closure is completed with one continuous length of suture material. Achieves approximation of wound margins. Disadvantages of running technique. Less reliable than interrupted closure. Wound edge eversion is difficult and there is greater potential for misalignment of wound edges, particularly if the tissue is pliable and the wound is long. Figure 42–2: Simple interrupted suture. Most common and basic suturing technique. Depth of bite and layers of tissue incorporated are dependent on site and tissue characteristics. Advantages of interrupted technique. Closure is completed suture by suture. The depth of bite, layers of tissue incorporated, and tension on the closure can be carefully adjusted for each individual stitch. Achieves accurate approximation of wound margins with optimal control. More reliable closure than continuous stitch. Disadvantages of interrupted technique. Time consuming. Multiple knots may contribute to foreign body response and additional scarring. Additional suture material may contribute to infections in the wound (suture abscess). Mattress suture: interrupted suturing technique in which the needle is passed through tissue multiple times. Figure 42–3: Horizontal mattress technique. The initial simple suture is placed perpendicular to the wound. Instead of tying the suture, the needle is advanced parallel to the wound margin and passed back through the tissue at an equal bite depth to a point on the initial wound edge equidistant to the length of advance on the opposite wound edge. The suture is tied and now lies parallel to the wound edge. Figure 42–4: Vertical mattress technique. The initial simple suture is placed perpendicular to the wound using a large bite depth. Instead of tying the suture, the needle is returned to the side of the initial bite at a smaller bite depth and without any advancement down the length of the wound. The suture is tied and now lies perpendicular to the wound edge. Figure 42–5: Half-buried horizontal mattress technique. Similar to the horizontal mattress technique, but the suture does not pass out of the tissue on the edge opposite the initial bite. The suture remains buried. Advantages of mattress suture techniques. Tissue eversion is easily controlled. Wound tension is distributed in friable tissue to prevent the suture from tearing through the tissue. Strong closure. Disadvantages of mattress suture techniques. Can create ischemic tissue either directly under the suture (vertical mattress) or constrict tissue within the confines of each suture leading to tissue ischemia (horizontal mattress). Figure 42–6: Purse-string suture. Used to close wounds by circumferential constriction of the wound edge. Commonly used in closing the end of a hollow viscus such as bowel or appendiceal stumps, around a catheter, or in reconstructive and cosmetic surgery. Uses a running suture technique. The suture is passed in and out of tissue around the circumference of the wound without entering the lumen of the viscera. As the suture reaches the origin, it can be tightened to reduce the circumference of the initial wound in a manner similar to the leather strings on a pliable "purse." If the technique is executed properly, the viscera can be reduced into the wound as the suture is tightened, creating a seal. Advantages of purse-string technique. Provides equal wound tension distribution around the circumference of the wound. Rapid closure. Disadvantages of purse-string technique. Creates pleating, which may lead to a poor seal, unfavorable scarring, or both. When used on skin, may lead to scar-widening as tissue stretches. Figure 42–7: Subcuticular suture. Used to close superficial skin edges to achieve accurate wound margin approximation. Sutures are not placed through the epidermis, thus avoiding potential scarring related to suture placement. The suture is introduced through normal skin and brought out of the deep tissue into the epidermal-dermal junction. The suture is then passed back into tissue and out of tissue at this same level, alternating edges of the wound (the suture should not penetrate epidermis). The suture exits deep tissue through the epidermis just distal to the wound. The tails are trimmed so they may be accessed to pull the suture out after several days (some prefer to tie or bury the suture). Advantages of subcuticular technique. Excellent control of wound margins increases the likelihood of a cosmetically pleasing outcome. May help avoid transverse "railroad track" scarring since sutures do not pass through the epidermis. Suture can be pulled out of the wound to reduce inflammatory response or suture erosion through the skin (spitting). Disadvantages of subcuticular technique. Closure is more time consuming than either staples or tissue glue. Figure 42–1 Figure 42–2 Figure 42–3 Figure 42–4 Figure 42–5 Figure 42–6 Figure 42–7 Nonsuture Closure Techniques Figure 42–8: Stapled closure. Used to close superficial skin edges. Skin edges are held up and everted using tissue forceps. A staple is deployed at this site. The process is repeated down the length of the wound. Advantages of stapled closure. Rapid skin edge closure. Individual staples can be removed in the event of wound infection. Disadvantages of stapled closure. May contribute to transverse hatching of the scar in a "railroad track" pattern. Staple removal can be uncomfortable. Tissue glue. Used to close superficial skin edges to achieve close edge approximation. Skin edges are approximated manually or with pull-out sutures. The wound is cleaned of necrotic debris, foreign material, and dried blood. A bed of glue is applied down the length of the wound, typically in one pass. Advantages of tissue glue. Rapid skin edge closure. Minimal tissue handling. Disadvantages of tissue glue. Glue cannot be removed easily if need be (eg, opening an infected wound). Expensive. Figure 42–8

Postoperative Care Wound edges should remain clean. Sutures should be removed several days (typical in face) or weeks following repair, depending on the location of the wound and characteristics of the tissue. Pain control with analgesics is appropriate. Antibiotics are not necessary for most wounds but may be recommended in contaminated wounds following closure.

Potential Complications Wound infection. Infected wounds, particularly those involving deep spaces, are typically opened to prevent systemic spread. Unfavorable scarring. Some scarring is expected, but hypertrophic scars, keloids, or wound contraction leading to functional limitation may occur, often without a known cause. Some wounds with unfavorable scarring may require scar revision. Figure 42–9: Standing cutaneous deformities ("dog ears") may be a result of individual wound length differences leading to excess tissue on one side of the wound, or occur in cases in which tissue rearrangement is necessary to achieve closure. These cutaneous deformities may persist and can often be addressed at primary closure. To remove a standing cutaneous deformity, the tissue leading to the deformity can be lifted away from the plane of tissue and resected in an elliptical fashion. If executed properly, the dimensions of the newly created ellipse will allow primary closure without a standing cutaneous deformity. Figure 42–9

Pearls and Tips Remember that not all wounds require or are well-managed by primary closure. To prevent injury to yourself and others, never handle needles directly. Returning suture by grasping the suture material instead of the needle will reduce the risk of the needle ejecting out of the needle holder. Use instruments appropriate for both the needle and the tissue you are suturing.

References Aston SJ, Beasley RW, Thorne CH, et al. Grabb and Smith's Plastic Surgery, 5th ed. Philadelphia, PA: Lippincott-Raven Publishers; 1997. Baker SR, Swanson NA. Local Flaps in Facial Reconstruction. St Louis, MO: Mosby-Year Book; 1995. Evans GRD. Operative Plastic Surgery. Stamford, CT: Appleton & Lange; 2000. Johnson & Johnson. Ethicon Wound Closure Manual, 2001. Available at: http://www.orthonurse.org/portals/0/wound%20closure%20manual.pdf. Accessed August 12, 2008. McGregor IA. Fundamental Techniques of Plastic Surgery and Their Surgical Applications, 10th ed. Edinburgh, New York: Churchill Livingstone; 2000. Sanders RJ. Subcuticular skin closure—description of technique. J Dermatol Surg. 1975;1:61–64.[PubMed: 770536] [Full Text]

MANEJO OPERATIVO DEL TUMOR RECTAL

Indications Transanal Excision of Tumor Stage T1 tumors: Mobile and < 4 cm in diameter. Involving < 40% of the rectal wall circumference. Located within 6 cm of the anal verge. Well or moderately differentiated histology only. Absence of vascular and lymphatic invasion. No evidence of nodal involvement on preoperative rectal ultrasound or MRI. Low Anterior Resection (LAR) with Total Mesorectal Excision Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained within 2 cm of the anal sphincter in moderately or well-differentiated tumors or within 5 cm for poorly differentiated tumors. Abdominoperineal Resection (APR) with Total Mesorectal Excision Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors.

Contraindications Transanal Excision of Tumor Tumors stage greater than T1N0M0. Fixed tumors. Tumors > 4 cm in diameter or involving > 40% of the circumference of the rectal wall. Tumors located > 6 cm from the anal verge. Tumors with poorly differentiated histology or angiolymphatic invasion, or those that show evidence of nodal involvement on preoperative rectal ultrasound or MRI. LAR with Total Mesorectal Excision Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors. APR with Total Mesorectal Excision Malignant lesion of the lower rectum diagnosed by evaluation of a tissue biopsy specimen showing local invasion into the pelvic sidewall or pelvis that could benefit from neoadjuvant treatment to facilitate possible curative resection.

Informed Consent Transanal Excision of Tumor Expected Benefits Removal of tumor with preservation of anus. Avoidance of radical surgery. Potential Risks Bleeding requiring reoperation. Rectal stricture. Need for further resection based on pathologic findings. Fistula to prostate or vagina. Injury to the urethra for distal anterior tumors in men. LAR or APR with Total Mesorectal Excision Expected Benefits Treatment of rectal cancer. Potential prevention of colonic obstruction, tenesmus, and invasion of adjacent pelvic structures. Potential Risks Bleeding requiring reoperation from presacral or splenic injuries (LAR or APR) or from the anastomosis (LAR). Infection, including intra-abdominal or pelvic abscesses resulting from anastomotic leaks (LAR) or infected intra-abdominal or pelvic fluid collections (LAR or APR). Fistula formation from anastomotic leak (LAR). Postoperative ileus (LAR or APR). Ureteral injury (LAR or APR). Need for a permanent or temporary stoma (LAR). Bladder or sexual dysfunction (LAR or APR). Fecal incontinence (LAR). Clustering of bowel movements (LAR).

Equipment Transanal Excision of Tumor Self-retaining (Ferguson) anoscope. Lone Star retractor (for more proximal lesions). LAR or APR with Total Mesorectal Excision Self-retaining retractors. Bookwalter abdominal retractor with a lighted St. Mark's retractor. Lone Star retractor (for perineum). Handheld lighted St. Mark's retractor and long instruments (crucial for delicate dissection in the pelvis). Gastrointestinal anastomosis (GIA) stapler. End-to-end anastomosis (EEA) stapler (LAR). Thoracoabdominal (TA) stapler (LAR).

Patient Preparation Clearance of bowel for synchronous lesions by colonoscopy. CT scan of the chest, abdomen, and pelvis to evaluate for metastatic disease of the lungs, liver, or peritoneum. Endorectal ultrasound or endorectal MRI for local staging (T and N staging). Patients with uT1N0 tumors may be appropriate candidates for transanal excision. Patients with uT3NX or uTXN+ disease should be considered for possible neoadjuvant chemoradiation therapy. Consider preoperative tattooing of the lesion with permanent ink, especially if the lesion is small or the patient will receive neoadjuvant chemoradiotherapy. Preoperative carcinoembryonic antigen level. Nothing by mouth the evening before surgery. Mechanical bowel preparation according to surgeon's preference. Preoperative antibiotics and preoperative subcutaneous heparin. Anesthesiology consultation as needed. Stoma marking by an enterostomal therapist for patients undergoing LAR or APR.

Patient Positioning Transanal Excision of Tumor For posterior lesions, the patient should be in a supine lithotomy position in gentle Trendelenburg using well-padded stirrups. For anterior lesions, the prone jackknife position is preferred. Sequential pneumatic compression devices should be applied. LAR or APR with Total Mesorectal Excision The patient should be in a supine lithotomy position in gentle Trendelenburg using well-padded stirrups. Sequential pneumatic compression devices should be applied. A Foley catheter and nasogastric or orogastric tube should be placed, especially if mobilization of the splenic flexure is contemplated. Consideration should also be given to the placement of a left ureteral stent if a difficult pelvic dissection is anticipated.

Procedure Transanal Excision of Tumor Regional anesthesia may be adequate, although general anesthesia is sometimes required. A self-retaining retractor is placed and a 1:100,000 epinephrine solution is infiltrated into the submucosa to facilitate dissection. Figure 24–1: Stay sutures are placed circumferentially 1 cm from the gross margin of the lesion. Figure 24–2: Full-thickness excision of the lesion is performed down to the level of perirectal fat using electrocautery. The specimen is carefully marked to delineate the correct orientation for the pathologist. Figure 24–3: The defect in the rectal wall is closed transversely with absorbable suture. Proctoscopic examination of the rectum is performed at the conclusion of the procedure to ensure patency of the rectum. Figure 24–1 Figure 24–2 Figure 24–3 LAR or APR with Total Mesorectal Excision General anesthesia is required. The patient should be in the lithotomy position with the legs elevated at approximately 15 degrees and spread at 45 degrees. Positioning of the anus and buttocks at the end of the table is important for access. A median laparotomy incision from the pubis symphysis to above the umbilicus is performed. For an LAR or APR, a self-retaining retractor is placed and the small intestine is retracted superiorly and to the right under a moistened towel. The left colon is freed from its lateral peritoneal attachments along the avascular line of Toldt, and the splenic flexure is mobilized (see Chapter 23) as needed for a tension free anastomosis. The peritoneum of the pelvic colon is opened using electrocautery. Care must be taken to identify the ureters, on the left in particular. The left ureter is identified as it crosses the pelvic brim over the left common iliac artery. Especially in patients with a significant amount of adipose tissue, widely encircling the ureter with a vessel loop can aid in safe mobilization of the distal rectum. The inferior mesenteric artery is identified at its origin and suture-ligated. The distal descending colon is then divided with a GIA-60 stapling device at least 5 cm proximal to the tumor. Figure 24–4: The distal rectum is then sharply mobilized posteriorly to remove the mesorectum intact with its fascial envelope (see also Figures 24–7A and 24–7B). The bladder is retracted superiorly and the anterior rectal wall is separated from the seminal vesicles and the posterior capsule of the prostate in a man. The lateral dissection encompasses the lateral peritoneal reflections, and middle hemorrhoidal vessels are ligated and divided. Figure 24–5: The proximal rectum is then clamped and a linear stapling device is applied across the rectum at least 2 cm distal to the tumor. The proximal rectum is divided and the specimen is removed. Figure 24–6A, B: Creation of the stapled LAR anastomosis. The staple line of the descending colon is opened and a nonabsorbable purse-string suture is placed. The anvil of a circular stapler is placed within the descending colon through the purse-string suture, and the suture is tied. The assistant then passes the circular stapler through the anus, deploying the "spike" just anterior to the staple line on the rectum. The anastomosis is completed as the surgeon marries the anvil placed in the end of the divided descending colon to the stapler exiting the rectum. The surgeon guides the end of the stapler together, taking care that no other tissue (ie, bladder or vagina) is intervening in the anastomosis, and the assistant fires the stapler. The rings of tissue ("donuts") are inspected for any defect. The assistant then inspects the integrity of the anastomosis by insufflating the rectum using a rigid sigmoidoscope, while the surgeon manually occludes the distal colon with the anastomosis submerged in sterile saline. The presence of any bubbling from the anastomosis suggests an anastomotic leak. Figure 24–4 Figure 24–5 Figure 24–6A–B Total Mesorectal Excision Care must be taken with lower lying rectal cancers to perform a total mesorectal excision to prevent leaving nodal tumor deposits behind. The superior hemorrhoidal artery is identified and ligated. Figure 24–7A-C: There should be wide incision at the peritoneal reflection and sharp division of the Waldeyer's fascia posterior to the fascia propria of the rectum, as well as incision of Denonvilliers' fascia and separation of the rectal wall from the seminal vesicles and the posterior capsule of the prostate anteriorly. Figure 24–8A, B: The correct and incorrect dissection planes for total mesorectal excision are depicted. Figure 24–7A–C Figure 24–8A–B Coloanal Anastomosis If it is not possible to obtain a distal rectal margin of at least 2 cm, a coloanal anastomosis may be contemplated. Figure 24–9A-C: The distal rectum is divided proximal to the dentate line following rectal dissection and total mesorectal incision. A 5–6-cm colonic J pouch can be fashioned using a GIA stapler. The end-to-side J pouch coloanal anastomosis is then created by sewing the full-thickness colon to the mucosa and internal sphincter of the anus. Absorbable sutures are used to create this anastomosis, and the colotomy created to allow admission of the GIA stapler when creating the J pouch is used for the anastomosis (Figure 24–9A, Figure 24–9C). If there is insufficient length for a colonic J pouch, an end-to-end anastomosis can be fashioned using a circular stapler or hand-sewn anastomosis as outlined above (Figure 24–9B, C). Figure 24–9A Figure 24–9B–C Abdominoperineal Resection for Low-Lying Rectal Cancers This procedure requires the same attention to obtaining adequate radial margins via total mesorectal excision. Figure 24–10: The sigmoid artery proximal to the takeoff of the superior hemorrhoidal artery is ligated. Figure 24–11A, B: The distal margin of resection should include the levators, as visualized from the perineal portion of the operation. Figure 24–12: The closure of the perineal incision should be in layers, beginning with the levators followed by the deep tissues and skin. Drains are placed in the deep space and are brought out through the lower abdominal wall. Figure 24–10 Figure 24–11A–B Figure 24–12

Postoperative Care Early ambulation is encouraged and diet is advanced as soon as tolerated. Patients requiring abdominal incision receive epidural analgesia and are transitioned to oral pain medications as soon as they can tolerate solids. Patients with ileostomies may require aggressive management of fluid status after the resumption of bowel function. We promote aggressive isotonic liquid consumption by the patient, with avoidance of caffeine and chocolate, and prefer first to use fiber bulking agents, followed by the addition of the antimotility agent loperamide. Daily examination of the perineal wound is mandatory following APR, and sitting should be discouraged for the first 5 postoperative days. Walking, however, should be aggressively encouraged. Pelvic drains are generally removed on postoperative day 5.

Potential Complications Transanal Excision of Tumor As excision of the rectal wall is carried out below the peritoneal reflection, intra-abdominal leak is generally not a problem. Deep space infections can occur and should be treated by local drainage. More commonly, pathologic evaluation reveals more extensive disease than was appreciated preoperatively, necessitating further local or more radical resection. LAR and APR with Total Mesorectal Excision Postoperative ileus is common, usually lasting 2–3 days and rarely requiring nasogastric decompression. Colonic ileus lasting longer than 2–3 days after LAR should prompt suspicion of an anastomotic hematoma, mechanical obstruction, or peritonitis associated with an anastomotic leak. Anastomotic leak is a potentially devastating complication following LAR and typically occurs 5–7 days following resection. Fever, leukocytosis, ileus, and distention may be early signs of a leak. Peritonitis mandates exploration with proximal diversion if a leak is discovered. More subtle clinical presentations may require imaging with water-soluble contrast enema for identification. Intra-abdominal abscesses from breaks in surgical technique may require intravenous antibiotics, bowel rest, and percutaneous drain placement. Splenic injury can occur when mobilization of the splenic flexure is necessary to perform a tension-free anastomosis (LAR), or as necessary for the colon to be easily brought up for end colostomy (APR). Ureteral injury can result from altered rectosigmoid anatomy associated with malignancy, inflammation, and neoadjuvant radiotherapy. Bladder or sexual dysfunction can occur due to injury of the sympathetic or parasympathetic nerves in the pelvis.

Pearls and Tips Transanal Excision of Tumor Pin the specimen out on suture card or cardboard and deliver it to the pathologist with correct orientation. Perform proctoscopy at the end of the procedure to ensure that the rectal lumen has not been sutured closed. Patients are usually hospitalized overnight for observation. Fever > 38.8°C is not uncommon in the immediate postoperative period, but if fever continues through the first postoperative night, blood and urine cultures as well as plain films of the chest should be ordered to evaluate for other, treatable sources of infection. LAR and APR with Total Mesorectal Excision For low rectal anastomosis, fill the pelvis with sterile saline and insufflate the rectal stump before reanastomosis with the circular stapler. If a leak is identified in the linear staple line on the rectum, posterior dissection should extend posteriorly to the level of the coccyx to identify the site of leakage. The circular stapler can then be brought out through the defect, a purse-string suture placed around the spike, and the purse-string suture excluded after firing the circular stapler. During perineal dissection, maintain constant attention to palpation of the Foley catheter to avoid inadvertent urethral injury.

References Chang AE, Morris AM. Colorectal Cancer. In: Mulholland MW, Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific Principles & Practice, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1103–1128. Huang EH. Complications of Appendectomy and Colon and Rectal Surgery. In: Mulholland MW, Doherty GM, eds. Complications in Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:498–522.

COLECTOMIA

Indications Colon cancer. Colon polyps not amenable to colonoscopic polypectomy. Diverticular disease. Perforation of the colon for which ostomy is not needed. Inflammatory bowel disease. Volvulus. Stricture. Ischemia. Bleeding. Slow-transit constipation refractory to medical therapy.

Contraindications Widely metastatic colon cancer that is nonoperative or requires a palliative ostomy. Severe peritonitis requiring diverting ostomy, in which primary anastomosis would have an unacceptable leak rate. Hemodynamic instability requiring expeditious ostomy, making primary anastomosis inappropriate.

Informed Consent Expected Benefits Treatment of established colon cancer (or prevention of development). Relief of functional or mechanical colonic obstruction. Treatment (or prevention) of intra-abdominal sepsis secondary to colonic perforation. Treatment of colonic bleeding. Potential Risks Bleeding. Infection. Damage to adjacent structures, including ureter, bowel, spleen, and others. Need for further operations. Anastomotic leak. Need for ostomy. Unresectability. Recurrence of cancer. Cardiopulmonary or other organ failure. Death.

Equipment Bookwalter or similar self-retaining abdominal retractor. Long instruments. Gastrointestinal anastomosis (GIA), linear cutting stapler. Linear thoracoabdominal (TA) stapler. Intraluminal circular end-to-end anastomosis (CEEA) stapler. Laparoscopic equipment if procedure will be performed using laparoscopic techniques, to include: Angled laparoscope. Atraumatic bowel graspers. Laparoscopic GIA staplers. Device for dividing mesenteric vasculature (ie, GIA vascular staple load, LigaSure device, etc).

Patient Preparation Preoperative blood work: Complete blood count to rule out anemia. Type and screen. Carcinoembryonic antigen level. Examination of abdomen for prior incisions. Full colonoscopy to cecum before elective operation, and tattooing of lesions with permanent ink as appropriate. CT scan of abdomen and pelvis with oral and intravenous contrast to evaluate for liver metastasis in patients with cancer. Other diagnostic imaging as appropriate. Mechanical bowel preparation. Deep vein thrombosis prophylaxis with sequential compression devices and consideration of subcutaneous heparin dosing before induction of anesthesia, especially if the patient has been diagnosed with cancer. For patients older than 50 years, -blockade before induction of anesthesia. General anesthesia. Foley catheter. Nasogastric tube. Preoperative antibiotics covering skin and bowel flora (eg, second- or third-generation cephalosporin or penicillin derivative).

Patient Positioning The patient should be supine, with the entire abdomen prepared and draped. Consider lithotomy position if splenic flexure mobilization may be necessary, and for sigmoid colectomy.

Procedure Laparotomy is performed via a midline incision about the umbilicus. The abdomen is explored to palpate the liver for metastasis, visualize peritoneum, examine omentum and lymph nodes, and "run" the bowel. A Bookwalter retractor is placed. Figure 23–1: Vascular anatomy of the colon. The superior mesenteric artery (SMA) supplies the cecum, ascending colon, and proximal transverse colon. The SMA divides into the ileocolic artery (ICA), right colic artery (RCA), and middle colic artery (MCA). Note the hepatic (right) and left branches of the middle colic artery. The inferior mesenteric artery (IMA) supplies the distal transverse colon, splenic flexure, descending colon, sigmoid colon, and upper rectum. The IMA divides into the left colic artery (LCA) and the sigmoid artery (SA), and terminates in the superior hemorrhoidal artery. The marginal artery of Drummond provides collateral circulation along the colon. The inferior mesenteric vein (IMV) meets the splenic vein at the inferior border of the pancreas. Figure 23–2A-D: Extent of resection for colon cancer. Cecal mass: right colectomy is indicated for a mass in the cecum or ascending colon (Figure 23–2A). Transverse colon mass: transverse colectomy or extended right colectomy is indicated for a mass in the transverse colon (Figure 23–2B). Splenic flexure mass: left colectomy is indicated for a mass in the splenic flexure or descending colon (Figure 23–2C). Sigmoid colon mass: sigmoid colectomy is indicated for a sigmoid colon mass (Figure 23–2D). Right Colectomy Indicated for a mass in the cecum or right colon. Resection will include distribution of the ileocolic and right colic arteries, and the hepatic branch of the middle colic artery. Figure 23–3A, B: Lateral peritoneal reflection of the right colon. The right colon is mobilized along the retroperitoneal fold, which forms an avascular attachment of the right colon to the lateral peritoneal wall. A gauze sponge is used to dissect the underlying loose areolar tissue (Figure 23–3A). The duodenum is identified, with care taken to avoid injury. When dissection is carried out in the correct plane, the duodenum should be visualized but not elevated. A soft sponge can be used to keep the duodenum down. Care should be taken to avoid injury to the kidney or Gerota's fascia (Figure 23–3B). Figure 23–4: Transection of the right colon mesentery and named vessels. The right colon is now completely free, except for its mesentery. The right colon is elevated and the mesentery transilluminated to identify avascular tissue for cutting with Bovie electrocautery. As vessels are encountered, they should be clamped as proximally as possible, transected, and ligated. The right colic artery (if present) is ligated at its origin. If the right colic artery is absent and the ileocolic artery arises directly from the superior mesenteric artery, the ileocolic artery is ligated at its origin. The right (hepatic) branch of the middle colic artery is also ligated, sparing the main middle colic artery. Named vessels, including the ileocolic and right colic arteries, and the hepatic branch of the middle colic artery, should be tied twice on the patient's side to reduce bleeding risk. If cancer is suspected, generous mesentery is removed with the goal of achieving a maximal lymphadenectomy. Figure 23–5A-C: Two-load GIA-stapled anastomosis for right colectomy. The right colon is completely free of peritoneal and mesenteric attachments. The planned anastomosis site is now identified by bringing together 5 cm of terminal ileum proximally and the hepatic branch of the middle colic artery distally. Atraumatic bowel clamps are placed 5 cm beyond the planned anastomotic site on each end to prevent spillage. The surgeon should verify that the planned anastomosis will not be under tension when bringing together the antimesenteric border of the two bowel loops. Stay sutures are placed (Figure 23–5A), and hemostats are attached to them. A small enterotomy is made in antimesenteric side of each bowel loop. One fork of the GIA-80 stapler is introduced into each enterotomy (Figure 23–5B). The GIA-80 stapler is fired along the antimesenteric border to anastomose the bowel. Next a second load of the GIA-80 stapler is used to amputate the specimen, including the two enterotomy sites, thereby simultaneously closing the end luminal defects (Figure 23–5C). Alternatives to the two-load GIA-stapled anastomosis include a hand-sewn end-to-end anastomosis (see Figure 23–7), a hand-sewn side-to-side anastomosis, or a four-load GIA-stapled anastomosis. Closure of the resultant mesenteric defect is optional. The abdomen is irrigated with warm saline and closed in standard fashion. Figure 23–1 Figure 23–2A–D Figure 23–3A–B Figure 23–4 Figure 23–5A–C Transverse Colectomy Based on the right colectomy, the transverse colectomy or extended right colectomy for a mass in the transverse colon also includes resection of the right omentum, division of the hepatocolic ligaments, and inclusion of the entire middle colic artery in the resection. Left Hemicolectomy Indicated for a mass in the splenic flexure or descending colon. Resection includes the left colic artery and may be extended to include the sigmoid colectomy discussed later. Begin by incising the white line of Toldt (lateral peritoneal reflection) to mobilize the left colon. This mobilization is extended up to the splenic flexure. Figure 23–6A, B: Mobilization of the splenic flexure. In mobilizing the splenic flexure, the goal is to divide all colonic attachments in a safe manner while preserving the mesentery. Traditionally, the dissection proceeds retrograde. The renocolic ligament is identified and incised (Figure 23–6A). The base of the spleen should now be visible. Next the attachments between the omentum and the spleen, and between the omentum and the colon, are divided. Care should be taken to avoid excessive traction on the colon, which can cause a splenic capsule tear. The splenocolic and pancreaticocolic ligaments are identified and incised (Figure 23–6B). Alternatively, the dissection can proceed anterograde, by elevating the omentum to access the lesser sac. The attending physician may stand between the patient's legs to facilitate this dissection. The splenic flexure is freed. Similar to Figure 23–4, the left colon is elevated and its mesentery transilluminated to identify avascular tissue to be divided with the electrocautery device. As they are encountered, large vessels are clamped and divided at their origin, and ligated twice on the patient side. If cancer is suspected a broad en bloc mesenteric resection is performed to remove as many lymph nodes as possible. Figure 23–7A-E: Hand-sewn, double-layer, end-to-end anastomosis for left colectomy. The left colon specimen has been passed off the field. End-to-end hand-sewn anastomosis begins by placing atraumatic bowel clamps 5 cm past the GIA staple line to prevent spillage of stool. Next, the GIA staple lines are excised. Alignment of bowel: the mesenteric and antimesenteric portions of the remaining bowel should be aligned. Stay sutures are placed at the mesenteric and antimesenteric borders of the planned anastomosis, and hemostats are attached to them. If there is a size mismatch, a small Cheatle slit can be created in the antimesenteric border of the smaller diameter segment (Figure 23–7A). Posterior outer layer Lembert stitches: interrupted 3-0 Lembert sutures are placed in the posterior seromuscular layer to form the posterior outer layer of the anastomosis (Figure 23–7B). Inner layer running stitch: a double-armed 4-0 absorbable monofilament suture is used to create the inner layer of the anastomosis in a running fashion, with full-thickness bites. The submucosa provides the strength (Figure 23–7C, D). Anterior outer layer Lembert stitches: interrupted 3-0 Lembert sutures are placed in the seromuscular layer to form the anterior outer layer, which completes the two-layer anastomosis (Figure 23–7E). The anastomosis is examined to verify that it is widely patent, has an excellent blood supply, shows no evidence of hematoma or leak, and is not under tension. Alternatives to the hand-sewn end-to-end anastomosis include a hand-sewn side-to-side anastomosis (not shown), a two-load GIA stapled side-to-side anastomosis (see Figure 23–5), and an EEA stapled end-to-end anastomosis (not shown). Closure of the resultant mesenteric defect is optional. The abdomen is irrigated with warm saline and closed in standard fashion. Figure 23–6A–B Figure 23–7A–E Sigmoid Colectomy Indicated for a mass in the sigmoid colon or for diverticulitis. Principles are similar to those for left colectomy. Figure 23–8: Mobilization of the sigmoid colon. Particular attention must be paid to avoid damaging the left ureter, which is extremely close to the sigmoid colon as it passes over the left iliac artery. Consider preoperative placement of a ureteral stent, especially if significant inflammation or scar tissue is anticipated in the area. It may not be necessary to always mobilize the splenic flexure; however, a tension-free anastomosis must be achieved. The anastomosis may be hand sewn end to end, hand sewn side to side, stapled side to side using a GIA stapler, or stapled end to end using an EEA stapler. Figure 23–8 Laparoscopic Colectomy The patient is placed in deep Trendelenburg position, and the right side of the table is then rotated up. Consideration should be given to preoperative placement of an infrared ureteral stent, which can be seen using a special laparoscope. We prefer to approach the colon medially, thereby letting the lateral peritoneal fold provide initial retraction. Figure 23–9A-D: Laparoscopic assisted right colectomy. Port sites: 5-mm ports are placed in the midline at the epigastric and suprapubic positions, and a 12-mm port and 5-mm port are offset to the left side of the umbilicus, maintaining a hand's breadth of space between each port (Figure 23–9A). Avascular mesenteric windows are created with cautery. An endovascular stapler is then used to staple vessels, beginning with the ileocolic artery, and repeating for the right colic artery (Figure 23–9B). The lateral peritoneal reflection is divided (Figure 23–9C). Next, a 5-cm long incision is made on the right side of the abdomen. The rectus is swept medially for a rectus-sparing incision through the posterior rectus sheath. The right colon is then externalized (Figure 23–9D). A two-load GIA-stapled simultaneous colon resection and extracorporeal anastomosis is performed, as previously described (see Figure 23–5). Figure 23–9A–D

Postoperative Care Diet is advanced as tolerated after confirming flatus. A Foley catheter is inserted to monitor adequacy of urine output for the first 24 hours. -Blockade is continued if appropriate. Deep vein thrombosis prophylaxis should be continued. Patients are encouraged to be ambulatory and should be out of bed three times daily on postoperative day 1.

Potential Complications Intraoperative and Technical Injury to the ureter. Injury to the duodenum. Injury to other bowel. Small deserosalizations can be repaired with Lembert stitches. Care should be taken to avoid grasping the bowel during the operation. Epiploic appendages should be grasped instead. Injury to the spleen. A topical hemostatic agent can be applied or splenorrhaphy or splenectomy performed. Inadequate blood supply at the anastomosis. Additional bowel should be resected. Consider using Doppler ultrasound to evaluate blood flow to the anastomosis if concerned. Anastomosis under tension. Additional bowel can be mobilized. Stool spillage and tumor cell spillage, creating the potential for abscess or "drop metastases." Noncrushing bowel clamps should be used proximal and distal to the line of colonic division. Early Postoperative Period Wound infection. Staples should be removed as needed, followed by confirmation that fascia are intact. The wound should then be packed and allowed to heal by secondary intention. Anastomotic leak. In some patients, tachycardia may be the only sign; others may have prolonged ileus or appear septic. Intra-abdominal abscess. Typically diagnosed by CT scan on postoperative days 5–7. Can often be treated using a percutaneous drain placed by the radiology service. May be secondary to an anastomotic leak. Colocutaneous fistula. Late Postoperative Period Anastomotic stricture. Anastomotic recurrence of cancer. Incisional hernia. Internal hernia. Ureteral stricture from ureteral devascularization.

Pearls and Tips Take no chances with the anastomosis. Ensure that the anastomosis is widely patent, has an excellent blood supply, shows no evidence of hematoma or leak, and is not under tension. Assess visually, tactilely, and via Doppler ultrasound if necessary. Do not leave the operating room if the viability of the anastomosis is questionable. When mobilizing the splenic flexure, always avoid excessive traction on the colon to prevent tearing of the splenic capsule. Suspect intra-abdominal abscess in patients with postoperative fever, tachycardia, or prolonged ileus. Diagnose with CT scan.

References Ballantyne GH. Atlas of Laparoscopic Surgery. Philadelphia, PA: WB Saunders; 2000. Cameron JL. Current Surgical Therapy. Philadelphia, PA: Elsevier Mosby; 2004:211–216. Scott-Conner CE. Chassin's Operative Strategy in General Surgery. New York, NY: Springer; 2002:359–418. Zollinger RM Jr, Zollinger RM Sr. Zollinger's Atlas of Surgical Operations. New York, NY: McGraw-Hill; 2003:112–139.