Lower GI Flashcards
Total colectomy for toxic megacolon
Colonoscopy
Midline incision
Abdominal exploration
Ligation of the colonic vessels (ileocolic, right colic, middle colic, left colic, sigmoid vessels)
Mobilization of the colon from retroperitoneum
Transection at the ileum and rectosigmoid junction
Removal of the colon
Bringing up the ileum and optional oversewing of rectal stump (leave rectal tube for vanc enemas x 72hrs post op)
Irrigation if contamination or perforation
Closure of incision
Maturation of ileostomy
Potential Pitfalls:
Failure to resect entire colon due to normal intra-abdominal appearance
Failure to resect entire sigmoid colon if sigmoid vessels have been ligated
Failure to oversewn rectal stump or create mucous fistula if high risk of leak
Laparoscopic sigmoid colectomy
Position the patient in lithotomy.
Place the patient in slight Trendelenburg’s position.
Maintain pneumoperitoneum and insert ports- 12mm RLQ, 5mm RUQ, periumbilical, LLQ
Inspect the four quadrants of the abdomen and pelvis.
Retract rectosigmoid and dissect along the plane behind the mesosigmoid to the level of the IMA.
Identify the left ureter and then define the vascular pedicle.
Continue medial-to-lateral dissection from the posterolateral edge of the descending colon down into the rectosigmoid.
Determine the proximal transection point. Splenic flexure may need to be mobilized. Clamp the colon and divide it at this point.
Distal transection is divided at the proximal rectum.
The mesentery of the specimen is then divided.
Remove the specimen.
Create an anastomosis and follow with an air-leak test.
Conclude with a final inspection of the abdomen. Then close the extraction site and port site.
Pitfalls:
If in there for diverticulitis and too much inflammation, divert and drain instead of resection
Hartmann’s Procedure
Place the patient in the modified lithotomy position.
Make a midline laparotomy incision.
Explore the abdomen and evacuate any free fluid.
Mobilize the colon. Incise the white line of Toldt. Carry the peritoneal incision from the rectosigmoid junction to the splenic flexure.
Blunt dissection should be used to dissect the sigmoid colon if there is severe inflammation.
Identify and protect the ureters.
After the colon is mobilized, determine the proximal and distal points of bowel transection.
Resect the diseased colon by dividing the mesenteric attachments from the colon wall. Ligate the mesenteric vessels.
Remove the specimen.
Create an end colostomy and close the rectal stump.
Irrigate the abdomen and pelvis. Close the abdomen.
Allow colostomy to mature.
Potential Pitfalls
Excessive mobilization of the colon should be avoided. This may result in a redundant stoma, and increase the risk of prolapse and parastomal hernias.
Gastrectomy with vagotomy for bleeding ulcer
Distal Gastrectomy:
Kocher maneuver.
Divide the gastrocolic ligament to enter the lesser sac.
Examine the stomach and identify the region of the ulcer to determine the appropriate extent of resection.
Divide the greater omentum along the greater curve from duodenum halfway to the GE junction.
Ligate and divide the right gastroepiploic vessels near the GDA.
Incise the gastrohepatic ligament.
Ligate and divide the right gastric artery proximally.
Divide the duodenum and stomach with a stapling device.
Oversew both staple lines, leaving a portion of the gastrotomy closure available for reconstruction.
Reestablish GI tract continuity via either Billroth I or II reconstruction.
Truncal Vagotomy:
Retract the left hepatic lobe laterally, with division of the triangular ligament as needed to expose the esophageal hiatus.
Incise the peritoneum and dissect the esophagus circumferentially.
Identify and dissect the anterior and posterior trunks of the vagus nerves.
Place proximal and distal clips ~2 cm apart on each trunk and then resect the intervening nerve segments.
Inspect the esophagus to ensure that all portions of the vagus nerves have been divided.
As needed, perform a cruroplasty to prevent hiatal hernia.
Confirm NG tube placement and then close the abdomen.
Potential Pitfalls:
Failure to identify an associated neoplasm.
Injury to the porta or inferior vena cava with Kocher maneuver and duodenal dissection.
Injury to the middle colic vessels with division of the gastrocolic ligament.
Billroth I reconstruction under tension or with inflamed duodenum.
Failure to divide all vagal branches.
Duodenal ulcer bleeding control (after failure of endo x 2, or if shock, or if req >3 blood transfusions daily)
Exploratory laparotomy through an upper midline incision.
Localization of the pylorus and duodenum.
Generous Kocher maneuver.
Longitudinal pyloroduodenotomy.
Biopsies of the ulcer bed (if not performed endoscopically previously).
Three-point ligation of the gastroduodenal artery. Assure complete hemostasis. Beware of the common bile duct posteriorly.
Approximation of the ulcer.
Transverse closure of the gastroduodenostomy (Heineke-Mikulicz pyloroplasty) in one or two layers.
Potential Pitfalls:
Persistent bleeding after ligation of the bleeding vessel. Remember to complete three-point ligation of the gastroduodenal artery.
Injury to or ligation of the common bile duct located posteriorly. If there are any questions, the duct should be probed for better identification.
Inability to close the gastroduodenotomy. Perform Finney or Jaboulay pyloroplasty.
Extended Right Colectomy (transverse colon mass)
Lithotomy positioning.
Midline incision, exploratory laparotomy (examine peritoneal surfaces, liver).
Decompressive enterotomy in right colon (if necessary).
Mobilize the right colon from lateral to medial.
Enter lesser sac at hepatic flexure.
Remove greater omentum from stomach.
Mobilize splenic flexure.
Divide mesentery.
Ligate ileocolic vascular pedicle.
Ligate middle colic pedicle.
Ligate ascending branch of left colic artery.
Construct ileocolic anastomosis.
Close mesenteric defect (surgeon preference).
Irrigate and close abdomen.
Laparoscopic Left colectomy
Ports: RUQ and supraumbilical 5mm ports, RLQ 12 mm port, LLQ 5mm assist port
Establish pneumoperitoneum, explore abdomen laparoscopically to identify stigmata of inflamed sigmoid colon, and rule out other unexpected findings.
Place inferior mesenteric artery (IMA) on stretch, incise peritoneum underlying it, and identify left ureter from medial perspective.
High IMA ligation with vessel sealer while protecting left ureter
Mobilize lateral attachments of sigmoid, descending colon, and splenic flexure if necessary to create a tension-free anastomosis (may ligate inferior mesenteric vein at level of ligament of Treitz (inferior border of pancreas)) for further mobilization.
Thin the rectal mesentery at top of rectum (area where tinea splays) and divide with laparoscopic stapler or with open stapler through Pfannenstiel extraction
Identify soft, uninflamed sigmoid colon proximal to area of diverticulitis for area of proximal division and purse-string end-to-end anastomosis (EEA) stapler anvil into bowel edge (28mm at least)
Perform leak test using flexible sigmoidoscopy after occluding lumen proximal to anastomosis with saline filled pelvis.
Closure of fascia of trocar incisions 10 mm or greater and Pfannenstiel incision.
Potential Pitfalls:
Failure to recognize need for splenic flexure mobilization and IMV ligation for a tension-free anastomosis.
Failure to create a tension-free anastomosis with soft, well-perfused proximal sigmoid colon to uninflamed rectum with negative leak test.
Ischemic colitis operative management
Midline abdominal incision.
Determine extent of gangrenous colon.
Mobilize and resect nonviable colon.
Check for brisk bleeding at the resection margins (can also use mesenteric doppler, ICG green fluorescence, palpation)
Creation of anastomosis or stoma depending on patient stability and bowel status.
Close abdomen.
Potential Pitfalls
Inadequate resection leaving nonviable bowel.
Anastomosis should be avoided in hemodynamically unstable patients.
Ileal Pouch Anal Anastomosis
Patient is placed in the modified lithotomy position with access to the anus
Perform total proctocolectomy or completion proctectomy, dividing the mesentery near the bowel, unless cancer is a concern
Staple and divide the terminal ileum, preserving the ileocolic artery initially
For double-stapled technique, use a TA-30 or other suitable stapler to staple the anorectal junction at the level of the levator muscles
Mobilize the small bowel and its mesentery, including full lysis of adhesions and separation of the superior mesenteric artery pedicle from the duodenum
If reach is insufficient, perform lengthening procedures including divide peritoneum, selective vascular ligation, and or consideration of alternate pouch shape
Create a 15- to 20-cm long J-pouch by stapling the distal two limbs of ileum together with GIA stapler and inserting anvil of EEA stapler, if double-stapled technique planned
Perform stapled or hand-sewn anastomosis, with mucosectomy and transanal pull through if hand-sutured technique chosen
Perform diverting loop ileostomy
Potential Pitfalls
Injury to the small bowel mesentery during maneuvers to create length
Failure to separate the anal cuff from the vagina/prostate can result in fistula
Ileocolic resection
Laparoscopic port placement - 5mm ports in upper epigastrium, periumbilically, suprapubic midline, LLQ
Visual evaluation of entire small bowel.
Lateral to medial or medial to lateral mobilization of the ascending colon and mesentery and hepatic flexure
Identification of the duodenum.
Ligation and division of the ileocolic vessels.
Division of the bowel proximal and distal to grossly diseased intestines.
Anastomosis of the ileum to the ascending colon.
Potential Pitfalls
Bleeding from inflamed mesentery.
Injury to the duodenum.
Injury to the ureter.
LAR
Check for presence of metastatic disease during laparotomy/laparoscopy.
Identify ureter early in dissection.
Divide superior rectal artery or inferior mesenteric artery as appropriate to clear lymph nodes and provide length for tension-free pelvic anastomosis.
Mobilize left colon with takedown of splenic flexure and division of inferior mesenteric vein at the inferior border of pancreas if necessary to provide length for tension-free anastomosis.
Divide mesocolon onto the bowel at site selected for proximal transection.
Perform total mesorectal excision by entering plane between visceral and parietal layers of endopelvic fascia.
En bloc resection of adherent structures to provide adequate tumor clearance.
Identify distal point of transection and divide mesorectum onto rectal muscle tube.
Staple and transect distal rectum.
Transect bowel proximally and prepare proximal colonic conduit by inserting anvil, which is secured with purse-string suture.
Complete the double-stapled anastomosis under direct vision.
Perform air leak test.
Construct diverting ileostomy if necessary.
Potential Pitfalls
Failure to adequately identify left ureter, risking potential injury.
Capsular tears on spleen due to excessive retraction on tissues.
Injury to autonomic nerves posterior to superior rectal artery at pelvic inlet and laterally during pelvic dissection.
Breach of mesorectal fascia or coning in on resection specimen in vicinity of tumor.
Injury to presacral veins during pelvic dissection.
Failure to divert high-risk low anastomosis.
