Minilaparotomy Bowel Transection and Ileorectal Anastomosis

The patient is reversed to a regular position. The distal sigmoid colon is grasped through the right-lower-quadrant cannula, then the supra-pubic cannula site is enlarged using a muscle-splitting (small Pfannenstiel) incision and the wound protected using a plastic sleeve device.

Colon Laparoscopic
Figure 8.7.20. The hepatocolic ligament is divided from medial to lateral, completely freeing up the right colon.

Pneumoperitoneum is released and the CO2 insufflator is shut off temporarily. The sigmoid colon is exposed toward the incision and grasped with Allis clamps. The entire colon is pulled out through this wound (Figure 8.7.21). The mesentery of the terminal ileum is now divided extracorporeally toward the considered transection line of the ileum. The terminal ileum is grasped with a purse-string-suture clamp, the straight needles are applied, and the bowel is transected. The specimen is removed. The anvil and the center rod assembly of a 28 circular stapler are placed into the bowel lumen and the purse-string suture is tied in the conventional manner (Figure 8.7.22). The ileum is returned to the peritoneal cavity, and the cavity is copiously irrigated by flushing warm saline in through the suprapubic incision line and suctioning the fluid again through the same incision using a conventional sump suction system. The abdominal wall thereafter is closed with conventional running sutures in two layers (peritoneum and fascia). Pneumo-peritoneum is reestablished and the patient is positioned head and right side down again. The shaft of the circular stapler is passed transa-nally under laparoscopic guidance. The modified plastic spike of the stapler is retracted into the instrument head until the instrument is carefully and completely brought up to the rectal staple line. Then the spike is pushed through the rectal wall just adjacent to the staple line

Ileorectal Anastomosis Intestinal Tract
Figure 8.7.21. The entire colon may then be pulled out through the suprapubic incision.
Anastomosis Donuts
Figure 8.7.22. After removing the entire colon, the center rod and anvil is inserted into the end of the ileum and secured using a purse-string suture.

by turning the wing nut on the stapler handle counterclockwise (Figure 8.7.23).

A standard double-stapling technique is used to form the ileorectal anastomosis. The center rod of the staple protruding from the ileum is grasped with a right-lower-quadrant endoscopic Babcock instrument and is locked into the circular stapler protruding from the rectal stump (Figure 8.7.24). This locking action is easily performed without substantial force as long as the axis of the center rod and the axis of the center post are in a perfect line. Because the center rod is grasped with the Babcock instrument through the right lower quadrant, the tip of the center rod will tend to be directed to the right side of the pelvis. The center post protruding from the rectum should be directed to the left side of the pelvis and the center rod should enter the pelvis from the left side. This maneuver will facilitate locking the center rod into the center post. Before anastomotic formation, the ileal mesentery must be carefully scrutinized along its cut edge to be sure it is not twisted. Excellent visualization of the anastomosis before firing the stapler is

Surgical Staples Ileum

standard double-stapled technique is used for the anastomosis of ileum to rectum.

Figure 8.7.23. After passing the circular stapler up to the top of the rectum, the spike is protruded through the rectal wall adjacent to the rectal staple line.

standard double-stapled technique is used for the anastomosis of ileum to rectum.

also necessary. The tissue donuts created with the circular staplers are carefully inspected for completeness and are sent for routine pathologic evaluation if the surgeon deems it necessary.

The anastomosis is checked for leaks by filling the pelvis with saline solution, occluding the small bowel lumen several centimeters above the anastomosis applying a bowel clamp and then using a proctoscope to insufflate air into the rectum. No air bubbles should appear.

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  • aapo j
    What is transected bowel?
    7 years ago

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