The operation is usually performed with the patient in the Lloyd-Davies position. With the surgeon standing to the patient's left side, the abdomen is entered through a midline incision and fully explored, with particular attention paid to any signs of small-bowel Crohn's disease. Extreme care must be taken when handling the friable bowel in order to avoid colonic traction and to provide easy exposure of the colonic flexure. The entire colon is mobilised away from any retroperitoneal attachments, starting from the cecum (Fig. 3). To avoid injuries, the right spermatic vessels and the right ureter are identified through their course.
The common sites for iatrogenic perforation are the transverse colon with a thickened, highly vascu-larised omentum, and the splenic flexure, particularly in case of extreme colon dilatation. Since the omentum may be quite adherent to the colon, it may be easier to divide the gastrocolic ligament closer to the stomach than to the transverse colon, and a gentle decompression of the colon with a rectal tube may be helpful. Special attention is required during division of the thickened splenocolic ligament to avoid tearing the splenic capsule. Once the entire colon has been mobilised down to the sigmoid, the terminal ileum is divided adjacent to the ileocecal valve with a linear stapler (Fig. 4). The main ileocolic vessels supplying the terminal ileum are preserved for future pouch construction and mobilised to construct end ileostomy. Two to three centimetres of ileum can be
denuded of blood supply in preparation of ileostomy, and the mesentery is divided up to the region of the right and middle colic vessels. Individual sigmoid branches, rather than the inferior mesenteric trunk, are isolated in order for the distal sigmoid colon to reach the anterior abdominal wall without tension (Fig. 5). Terminal branches of the inferior mesenteric artery and the superior rectal artery are preserved in order to ensure a good supply to the rectal stump. When rectum-preserving total colectomy is performed, the whole colon is excised to the point of confluence of the colonic taenia at level of the sacral promontory with a stapler loaded with 4.8-mm staples. The sutured link may be oversewn with continuous or interrupted Lembert sutures. In most cases, disease activity settles down, and the rectum heals without problems. It is mandatory to leave intact the
Fig. 5. Total colectomy: preparation of left colon pelvic peritoneum and the planes of dissection in the pelvis to reduce the risk of sepsis and pelvic-nerve injuries and avoid inconvenience for other future surgical options, such as rectal excision or secondary IRA. In case of massive rectal bleeding or when the rectum is affected by deep ulceration and severe inflammation, the Hartmann pouch can be performed below the peritoneal reflection. An ultralow Hartman's closure of the rectum, at the level of the levators floor, can be performed, with future option of a delayed ileoanal reservoir or a complete proctec-tomy as a perineal procedure.
When subtotal colectomy is performed, the sigmoid colon is divided at a level where it can be brought out easily through a left lower quadrant incision or lie, without tension, in the subcutaneous plane at the lower end of the midline incision. The seromuscular layer of the bowel is usually sutured circumferentially to the peritoneum. The bowel is divided with a linear stapler or a two-layer suture closure. The skin over the bowel is partially left open or closed with sutures. The benefit of this procedure is that subcutaneous implantation of the stump avoids intraperitoneal abscess and troublesome discharging mucous fistulae. Less commonly, a particularly diseased friable sigmoid colon is brought out as a formal mucous fistula. The sigmoid stump is left protruding 3-5 cm to allow amputation at the skin level and maturation of the mucous fistula in 7-10 days. A long colonic stump is associated with higher risk of bleeding and a very foul odour.
Rectum-sparing total colectomy is a simple and quick procedure in emergency. The rationale for this operation has come from studies that have shown better inflammation and bleeding control, especially in case of severely diseased sigmoid colon [38, 39].
Another advantage of this procedure is that it can avoid parietal abscess, intra- or extrafascial faecal contamination, which is very common when the sigmoid colon is buried in the subcutaneous tissue. About 10% of all patients who have a relatively spared rectum are candidates for future straight end-to-end IRA . Of course, regular surveillance is required for the potential risk of recurrent disease and/or malignant transformation. If the sigmoid colon and rectum are so friable that a safe stapled or sutured closure cannot be obtained, an ultralow Hartman's closure of the rectum, at the level of the levators floor, may be realised. If low rectal closure cannot be performed, the anal stump may be left open, leading a drainage pelvic tube through the anal canal.
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