Special Considerations

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Drainage of the abdomen after the conclusion of each case is possible, however, not absolutely necessary. After the pelvis has been carefully irrigated, an atraumatic closed suction drain may be placed in the pelvis through the right- or left-lower-quadrant cannula site. Usually, the drain can easily be passed through the 5-mm cannula and a grasper from the opposite quadrant cannula is used to place the drain into the pelvis. The cannula is then removed.

The vascular anatomy within the mesentery of the transverse colon to the left of the middle colic vessels and in the region of the splenic flexure needs special attention here. Because this area may be difficult to expose, a fundamental understanding of the vessels that may be encountered here is extremely important. Connections between the left colic and middle colic artery are common, with two arcades in the splenic flexure mesentery seen most commonly (33%), followed in frequency by tertiary or primary ones (25% each); arcades with 4, 5, or 6 branches are exceptional (Figure 8.7.25).20 In 14.5% of specimens, an accessory left colic will arise from the superior mesenteric artery. Also, it is not unusual to find a separate unnamed vein draining from the distal transverse colon directly into the inferior mesenteric vein, or even following a separate course underneath the pancreas to the splenic vein.

When the transverse mesocolon is transected along with the middle colic vessels, entry into the lesser sac is often confusing because of congenital adhesions between the greater omentum, the stomach, and the transverse mesocolon. The omentum may usually be recognized by its fine, fatty lobulations in comparison with the smooth texture of the fat in the transverse mesocolon. The omentum may be quickly encountered superiorly after transection of the transverse mesocolon. Generally, by patiently separating the plane and lysing any congenital adhesions just behind and superior to the middle colic vessels, the lesser sac can be found.

Normally, for cancer located in the transverse colon or close to the hepatic or splenic flexures, extended right hemicolectomies or subtotal colectomies are indicated, including lymph node dissection extending to the root of the middle colic artery and vein. The following points highlight certain techniques that should be used in the rare instance that laparoscopic total abdominal colectomy is performed for cancer (e.g., two synchronous cancers in the proximal and distal colon or one cancer and synchronous large sessile adenoma):

Colic Arcades
Figure 8.7.25. Mesenteric vascular connections between the left colic and middle colic arteries. Most commonly, there are two (33% of specimens); three arcades and one arcade are less common (25% each). More than three arcades are exceptional.

•All major vessels are ligated proximally with dissection of each of the artery's root at the superior mesenteric artery or aorta and wide mesenteric resection (we use proximal mesenteric vascular division as the routine procedure).

•The transection of the ileum and its mesentery should also be performed laparoscopically. As soon as the bowel is dissected completely free, an endoscopic bowel bag should be passed into the abdominal cavity through the suprapubic cannula site, and the specimen should be immediately put into the fully opened bag that has been positioned in the pelvis. •The specimen should be carefully removed and sealed inside the bowel bag after the suprapubic cannula site has been enlarged. This way, the abdominal wall will be protected from any contamination by cancer cells.

The most difficult and also time-consuming part of the procedure is the mobilization of the transverse colon. During medial dissection, it is highly recommended to identify the branches of the middle colic artery and vein very carefully and thoroughly to avoid any unexpected vessel injury in this area of the mesocolon. Surgeon and assistant have to move their instruments very precisely; the mesocolon has to be exposed clearly but carefully. Bleeding from one of these vessels is difficult to stop and may lead to early conversion.

During the completion of the medial dissection coming up orally from the IMA area beyond the splenic flexure one always has to be prepared for another branch of the middle colic vessels to be hidden in the fatty tissue of the mesentery. Also, "tissue triangulation" of the omentum and the transverse colon (see Chapter 6) is crucial during lateral mobilization in this area to facilitate fast orientation and accelerate surgery.

When using cutting devices such as electrocautery or the harmonic scalpel, very high temperatures may be generated in the surrounding tissue leading to the destruction of proteins even several millimeters away from the spot of operation. This is why we avoid using these instruments in the immediate neighborhood of structures carrying mucosa and restrict their application to short-term use of only a few seconds without interruption.

The most important complication in the postoperative course after total abdominal colectomy is anastomotic leakage. The rate of leakage, however, may be kept low by thoroughly testing the anastomosis at the end of surgery (endoscopic and air-leak check). If it still occurs and no conservative treatment by drainage is possible, (laparoscopic) protective ileostomy formation or disconnection of the anastomosis may become necessary. Another complication is anastomotic stricture after double-stapling technique. Such a stricture may be avoided if the anastomosis is checked by rectoscopy in a time range of 4 weeks after the operation. When narrowing is present, the tissue is still soft enough to be widened by carefully pushing the blunt tip of the obturator of the rectoscope beyond the anastomosis. If a stenosis occurs later, stepwise endoscopic dilatation or incision of the scar tissue using electrocautery may be indicated. Bleeding from the anastomosis should be rare if it is checked at the end of surgery. Other complications dealing with the loss of large bowel function are chronic diarrhea, electrolyte disturbances, and dehydration. Conservative treatment replacing liquids and antidiarrheal medication are recommended. In cases of total colectomy for chronic constipation, symptoms may reoccur in the long term. Also in these cases, medical therapy is indicated first.

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